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Vincent’s S.C.A.N.S 
Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
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Last update:  10/1/13 
EDUCATION Turbinates    & Turbinate Surgery
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
“ MY NOSE IS ALWAYS BLOCKED !”
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What are nasal turbinates ? These   are   normal   structures   projecting   from   the   sidewall   of   each   nostril.   There   are   three   turbinates   (inferior,   middle,   and   superior)   on   each   side   of the   nose   (occasionally   four   in   some   individuals,   the   fourth   being   called   the   supreme   turbinate).   Turbinates   are   covered   by   the   normal   nasal lining/mucosa   and   it   functions   to   clean,   moisten/humdify   and   warm   the   air   we   breathe   as   it   moves   through   our   noses   into   our   lungs.   On   the surface   of   this   lining,   normal   mucociliary   function   (a   blanket   of   cells   with   tails   invisible   to   the   naked   eye   moving   in   a   synchronised   orderly   pattern   to move   nasal   discharge   in   a   certain   direction)   takes   place   to   ensure   proper   clearance   of   nasal   mucus   onto   the   back   of   our   nose   and   subsequently into   the   throat.   Mucociliary   function   is   an   important   defense   mechanism   that   protects   the   respiratory   system   against   bacterial   infection   and   other foreign particles. One of the major and commonest causes of chronic nasal airway obstruction is enlargement (hypertrophy) of the inferior turbinate. Usually the lowest turbinate also known as the inferior turbinate enlarges in conditions like allergic rhinitis (AR), vasomotor rhinitis (non-allergic rhinitis) and or just simply born with an enlarged structure (compensatory hypertrophy secondary to deviated nasal septum (DNS). The middle turbinate can also be enlarged in chronic rhinosinusitis (CRS), allergic rhinitis or congenital conditions (concha bullosa).  What can it look like ? There are other conditions which may resemble enlarged turbinate. These can all be reliably differentiated using a nasal endoscopic examination in the ENT clinic.
ENT ALLERGY What is it ? Read more Read more
Can this condition be treated ? Yes, sure. Please read on… What are the aims of treatment ?  1. Reduce volume 2. Preserve function (mucosa-sparing) The   main   goal   of   turbinate   surgery   should   be   the   reduction   of   the   volume   of   tissue   over   the   enlarged turbinate therefore structurally enlarging the passageway through which air passes into the nose. However, a wider nasal cavity does not  necessarily or automatically mean the nose functions better.   It   is   also   extremely   important   to   preserve   the   normal   function   of   the   nasal   lining   to   maintain   the   normal mucociliary   function,      regulating   the   humidification   and   temperature   of   the   inspired   air.   Removal   of   too   much normal   tissue   can   predispose   to   ' empty   nose   syndrome   (ENS) '   where   the   nose   loses   its   normal   function   of humidification.   Paradoxically,   patients   with   ENS   feel   as   though   their   nose   is   always   blocked,   and   that   they cannot   take   in   sufficient   air   through   their   nose.   The   patient   may   also   complain   of   frequent   crusting   in   their nose, sometimes with a foul smell. Therefore   it   is   important   to   remove   just   enough   nasal   tissue   to   breathe   without   blockage   and   at   the   same time main normal function of the nose. At   the   same   time,   these   are   to   be   achieved   with   minimal   adverse   or side   effects,   inconvenience   and/or   complications   to   the   patient.      This include nasal bleeding, unwanted scarring. How can this condition be treated ? Many different surgical methods are currently available. Treatment    of    nasal    inferior    turbinate    hypertrophy    varies    include conservative/non-surgical   treatment,    including   using   corticosteroid nasal    sprays,    oral    antihistamines    with    decongestants    and    topical decongestant.   This   also   treats   the   underlying   allergic   condition   eg.   AR   predisposing   to   enlarged   turbinates. This   generally   takes   a   longer   duration   to   work   and   symptoms   can   likely recur. On    the    other    hand,    newer    surgical    modalities    include    microdebrider-assisted    inferior    turbinoplasty (MAIT) ,      radiofrequency   volume   reduction/ablation    or   laser   surgery .   Turbinectomy   has   also   been   used   and   the   degree   of   resection   of   the offending turbinate ranges from partial to total, depending on severity of disease/symptoms and surgeon's preference.  Microdebrider   refers   to   modern   cutting   blade   employed   to   efficiently   suck   and   cut   tissues   simultaneously.   It   is   used   in   many   ENT   surgeries   to produce   a   clean   cut   edge.   Currently   new   techniques   of   Microdebrider-assisted   inferior   turbinoplasty   (MAIT)    involves   creating   a   pocket   under the   surface   of   the   turbinates   to   removed   the   bulk   of   turbinates.   This   spares   the   mucosa   from   damage   as   compared   to   the   older   conventional techniques   of   removing   the   mucosa.   It   also   significantly   differs   from   turbinectomy   where   usually   the   turbinate   bone   is   partially   or   totally   removed together with the overlying mucosa- a more destructive or invasive procedure. Radiofrequency   tissue   reduction    is   a   modern   surgical   procedure   that   uses   radiofrequency   heating   to   induce   submucosal   tissue   (nasal   tissue underneath   the   lining,   therefore   sparing   the   mucosa)   destruction,   leading   to   the   reduction   of   tissue   volume.   It   causes   a   thermal   change   that   should occur   in   the   deep   mucosa   without   damaging   the   surface.   The   healing   process   intentionally   induces   scarring   that   leads   to   tissue   volume   reduction, thus achieving the surgical aim. Lasers   in   medicine   comes   in   many   forms,   eg.   carbon   dioxide   (CO2),   Nd-YAG,   diode,   gold   lasers   and   newer   ones   are   on   the   horizon.   In   ENT surgeries, carbon dioxide laser  is most commonly used. Currently available CO2 laser involves changes over the lining of the nose.
Figure A: Moderately enlarged inferior turbinates (IT); Figure B: an inflammed and grossly enlarged IT; Figure C: Very enlarged middle turbinate (MT), concha bullosa with normal IT.  (S=septum)
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IT
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© Vincent Tan ENT
B
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IT
What evidence exist for the usage of the different techniques ? What are the pros and cons ? Based on medical evidence from medical journals as referenced below:
RELATED LINKS
References from Medical Journals: Based on medical evidence from medical journals as referenced below:
Figure A - A nasal video endoscopic examination of the nose using a rigid endoscope (red arrow); Figure B - A benign nasal polyp; Figure C - a vascular tumour growing out of the nose due to delayed presentation; Figure D - a nasal tumour still confined to the nose. Biopsy later confirmed its non-cancerous nature; Figure E - another nasal tumour which was confirmed as nasopharyngeal  cancer (NPC)   Vincent Tan ENT A B C D E
Figure A: Microdebrider in a nasal tumour surgery - notice the cutting edge of the blade (red arrow). In MAIT, the cutting process occurs underneath the surface (green arrow) as in Figure B: in Figures C & D: the radiofrequency probe (red arrow) in the inferior turbinate (blue arrow)- (not to worry, it is not as painful as it looks) -the scarring occurs under the surface which is spared; Figure E: CO2 laser probe yellow arrow) inducing changes over the nasal mucosa (white arrow)
© Vincent Tan ENT
1. Sapçi T, Sahin B, Karavus A, Akbulut UG. Comparison of the effects of radiofrequency tissue ablation, CO2 laser ablation, and partial turbinectomy applications on nasal mucociliary functions. Laryngoscope. 2003 Mar;113(3):514-9. 2. Hol MKS, Huizing EH. Treatment of inferior turbinate pathology: a review and critical evaluation of the different techniques. Rhinology 2000;38:157-166. 3. Wexler DB, Berger G, Derowe A, Ophir D. Long-term histologic effects of inferior turbinate laser surgery. Otolaryngol Head Neck Surg. 2001 Apr;124(4):459-63. 4. Chen YL, Tan CT, Huang HM. Long-term efficacy of microdebrider-assisted inferior turbinoplasty with lateralization for hypertrophic inferior turbinates in patients with perennial allergic rhinitis. Laryngoscope. 2008 Jul;118(7):1270-4. 5. Liu CM, Tan CD, Lee FP, Lin KN, Huang HM. Microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty. Laryngoscope. 2009 Feb;119(2):414-8. 6. Chen YL, Liu CM, Huang HM. Comparison of microdebrider-assisted inferior turbinoplasty and submucosal resection for children with hypertrophic inferior turbinates. Int J Pediatr Otorhinolaryngol. 2007 Jun;71(6):921-7. Epub 2007 Apr 5. 7. Naveen D. Bhandarkar and Timothy L. Smith. Outcomes of surgery for inferior turbinate hypertrophy. Current Opinion in Otolaryngology & Head and Neck Surgery 2010, 18:49-53
华文版 .
Examples:
RADIOFREQUENCY  VOLUME REDUCTION
MICRODEBRIDER TURBINOPLASTY
RIGHT INFERIOR TURBINATE (RIT)
LEFT INFERIOR TURBINATE (LIT)
RIGHT INFERIOR TURBINATE (RIT)
BEFORE  SURGERY
8 DAYS AFTER  SURGERY
15 DAYS AFTER  SURGERY
REMARKS:
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RIT
RIT
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LIT
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LIT
S = nasal septum
Notice the intact pinkish nasal mucosa lining preserved before and after the surgery Volume reduction of inferior turbinate is appreciated early in the postoperative period, resulting in improvement of nasal airway Surgery does not preclude the use of medication in the postoperative period in some patients, especialli to treat other symptoms. Results, however, may vary in different patients (as healing properties differ among individuals) and therefore preoperative counselling and discussion is important.
Notice the wide space in the right nostril after turbinectomy (MT = middle turbinate, IT = inferior turbinate, NP = nasopharynx, S=septum) MT IT stump S NP  Vincent Tan ENT A B C B D E
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
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ENT
D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Cert.in Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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