www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Effects
of
turbinoplasty
versus
outfracture
and
bipolar
cautery
on
the
compensatory
inferior
turbinate
hypertrophy
in
septoplasty
patients
夽
Aykut
Bozan
a,
Hüseyin
Naim
Eris
¸
b,
Denizhan
Dizdar
a,∗,
Sercan
Göde
c,
Bahar
Tas
¸delen
d,
Hayrettin
Cengiz
Alpay
aaIstanbulKemerburgazUniversity,MedicalFaculty,DepartmentofOtorhinolaryngology,Tarsus,Turkey bMedicalParkTarsusHospital,Radiology,Tarsus,Turkey
cEgeUniversity,MedicalFaculty,DepartmentofOtorhinolaryngology, ˙Izmir,Turkey dMersinUniversity,MedicalFaculty,Biostatistics,Mersin,Turkey
Received20December2017;accepted17April2018 Availableonline18May2018
KEYWORDS Turbinate; Hypertrophy; Outfracture; Turbinoplasty Abstract
Introduction:Themostcommoncauseofseptoplastyfailureisinferiorturbinatehypertrophy thatisnottreatedproperly.Severaltechniqueshavebeendescribedtodate:totalorpartial tur-binectomy,submucosalresection(surgicalorwithamicrodebrider),withturbinateoutfracture beingsomeofthose.
Objective: Inthisstudy,wecomparedthepre-andpostoperativelowerturbinatevolumesusing computed tomography inpatients who hadundergone septoplastyandcompensatory lower turbinateturbinoplastywiththosetreatedwithoutfractureandbipolarcauterization. Methods:Thisretrospectivestudyenrolled66patients(37men,29women)whowereadmitted toourotorhinolaryngologyclinicbetween2010and2017becauseofnasalobstructionandwho wereoperatedonfornasalseptumdeviation.Thepatientswhounderwentturbinoplastydue tocompensatorylowerturbinatehypertrophyweretheturbinoplastygroup;Outfractureand bipolarcauterizationwereseparatedastheoutfracturegroup.Compensatorylowerturbinate volumes ofallpatientsparticipatinginthestudy (meanage34.0±12.4years,range17---61 years) were assessed by preoperative and postoperative 2 month coronal and axial plane paranasalcomputedtomography.
夽 Pleasecitethisarticleas:BozanA,Eris¸HN,DizdarD,GödeS,Tas¸delenB,AlpayHC.Effectsofturbinoplastyversusoutfractureand
bipolarcauteryonthecompensatoryinferiorturbinatehypertrophyinseptoplastypatients.BrazJOtorhinolaryngol.2019;85:565---70.
∗Correspondingauthor.
E-mail:denizhandizdar@hotmail.com(D.Dizdar).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2018.04.010
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Results:Thetransverseandlongitudinaldimensionsofthepostoperativeturbinoplastygroup weresignificantlylowerthanthoseoftheout-fracturegroup(p=0.004).In bothgroupsthe lowerturbinatevolumesweresignificantlydecreased(p=0.002,p<0.001inorder).The postop-erativevolumeoftheturbinateonthedeviatedsideofthepatientswassignificantlyincreased: tubinoplastygroup(p=0.033).
Conclusion:Both turbinoplasty and outfracture are effective volume-reduction techniques. However,theturbinoplastymethod resultsinmorereductionofthelowerturbinatevolume thanoutfractureandbipolarcauterization.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Concha; Hipertrofia; Fraturalateral; Turbinoplastia
Efeitosdaturbinoplastiaversusfraturalateralecauterizac¸ãobipolarnovolumeda conchainferiorhipertróficacompensatóriaempacientessubmetidosaseptoplastia
Resumo
Introduc¸ão:Acausamaiscomumdefalhadaseptoplastiaéahipertrofiadasconchasinferiores nãotratadaadequadamente.Diversastécnicasforamdescritasatéomomento:turbinectomia totalouparcial,ressecc¸ãodasubmucosa(cirúrgicaoucommicrodebridador)eafraturalateral. Objetivo:Nesteestudo,comparamososvolumespréepós-operatóriodaconchainferiorcom hipertrofiacompensatóriacomousodetomografiacomputadorizadaentrepacientes submeti-dosaseptoplastiaeturbinoplastiaoufraturalateralcomcauterizac¸ãobipolar.
Método: Esteestudoretrospectivoincluiu66pacientes(37homense29mulheres)internados emnossoservic¸odeotorrinolaringologiaentre2010e2017porobstruc¸ãonasalesubmetidos àcirurgiapordesviodeseptonasal.Ospacientessubmetidosàturbinoplastiadevidoà hiper-plasiacompensatóriadaconchainferiorformaramogrupoturbinoplastia;aquelessubmetidos àfraturalateralecauterizac¸ãobipolarforamseparados,formaramogrupofraturalateral.Os volumescompensatóriosdaconchainferiordetodosospacientesqueparticiparamdoestudo (idademédiade34,0±12,4anos,faixade17a61anos)foramavaliadosportomografia com-putadorizadadosseiosparanasaisnosplanosaxialecoronalnopré-operatórioeaosdoismeses dopós-operatório.
Resultados: Asdimensõestransversaiselongitudinaisdogrupoturbinoplastianopós-operatório foramsignificantementemenoresdoqueasdogrupodefraturalateral(p=0,004).Emambos osgrupos,osvolumes daconchainferiordiminuíramsignificantemente(p=0,002,p<0,001, respectivamente).Ovolumepós-operatóriodaconchadoladododesvioaumentou significan-tementenogrupoturbinoplastia(p=0,033).
Conclusão:Tantoaturbinoplastiacomoafraturalateralsãotécnicasefetivasdereduc¸ãode volume.Noentanto,aturbinoplastiacausamaiorreduc¸ãodovolumedaconchainferiordoque afraturalateralcomcauterizac¸ãobipolar.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Themostcommoncauseofchronicnasalobstructionis sep-tum deviation and lower turbinate pathologies.1 Inferior
turbinate hypertrophy is frequently seen in allergic rhini-tis,vasomotor rhinitis, and as compensatory hypertrophy in septum deviation. Lowerturbinate hypertrophy onthe concave side of the nasal septum is called compensatory hypertrophy.2 Themostcommoncauseofseptoplasty
fail-ure is inferior turbinate hypertrophy that is not treated properly.3Severaltechniqueshavebeendescribedtodate:
totalor partialturbinectomy,submucosalresection (surgi-calor witha microdebrider), outfracture,electrocautery,
radiofrequency application, argon plasma treatment, and cryosurgery.4
None of the turbinate surgical techniques performed with or without septoplasty areperfect. Short- and long-termcomplications,suchasbleeding,bruising,andatrophy, are frequent.5 Ideally, turbinate surgery should be done
withoutdamagingthemucosalsurface.Thisensures preser-vation of normal lower turbinate function, rapid healing, and inhibitionof atrophic rhinitis.6 Despitethe increasing
number of lower turbinate surgical procedures, turbino-plasty,outfracture,andbipolarcauterymethodshavebeen usedfrequentlyforthelastthreedecades.7Turbinoplastyis
outfracture method, despite its high success rate. Lower turbinate outfracture and bipolar cauterization can be appliedinthesameorderandmorequickly.8
In this study,we comparedthe pre-and postoperative lowerturbinate volumesusingcomputedtomography (CT) in patients who had undergone septoplasty and compen-satorylowerturbinateturbinoplastywiththosetreatedwith outfractureandbipolarcauterization.
Methods
Patientselection
This retrospective study enrolled66 patients (37men, 29 women) who were admitted to our otorhinolaryngology clinicbetween2010and2017becauseofnasalobstruction andwhowereoperatedonfornasalseptumdeviation.CT showed septumdeviation and contralateralcompensatory lower turbinate hypertrophy. The patients were divided intotwogroups.Theturbinoplastygroupincludedpatients whounderwentseptoplastyandturbinoplasty;the outfrac-turegroupunderwentseptoplastywithcompensatorylower turbinateoutfractureandbipolarcauterization.
Patients with maxillofacial trauma, paranasal sinus tumors,nasalpolyps,septalperforations,acuteorchronic rhinosinusitis,Stypenasalseptumdeviation,turbinate bul-losa,orprevious nasalorparanasalsurgerywereexcluded from the study. Ethics committee approval was obtained fromIstanbulUniversity,Cerrahpas¸aMedicalFaculty,Ethical Committee(n◦61328).
Surgicalprocedure
All patients were operated by the same surgeon under general anesthesia. First, a septoplasty was performed. Thirty-two patients (19 men, 13 women; mean age, 36.6±15.0years,range:19---61years)intheturbinoplasty group underwent compensatory lower turbinate turbino-plasty. A superior-to-inferior incision was made on the anteriorsurfaceofthelowerturbinatewithan◦ 15blade, workingundera0◦ endoscopicvideo image,andthis inci-sion was extended posteriorly along the inferior surface. The medial side of turbinate was elevated. The turbina-telmucosaandturbinatewereexcisedwhilepreservingthe medialflap.Bleedingwascontrolledwithbipolar cauteri-zation.Theflapwasreplaced, packingwasplacedinboth nasalcavities,andtheoperationcompleted.Nasalpacking wasremovedafter48h.
The outfracturegroup comprised 44patients (18 men, 16women;meanage,31.4±9.5years,range:17---49years) who underwentturbinate outfracture andbipolar cauter-ization. Using an elevator, the lower turbinate was first mobilized medially and laterally. Posterior anterior bipo-larcauterizationwasthenappliedtotheinferomedialface ofthelowerturbinate.Bothnasalcavitieswerefilledwith nasalcuffsandtheoperationcompleted.Nasalpackingwas removedafter48h.
Patientevaluation
The compensatory turbinatel volume of all subjects was assessedpre- and postoperativelyusing coronal and axial plane paranasal CT performed in 1mm sections from anterior(nares)toposterior(choana).Thevolumetric eval-uationswereperformedbythesameradiologist.
The lower turbinate volumes were calculated in mm3 using the ellipse formula: longitudinal dimen-sion (mm)×transverse dimension (mm)×anteroposterior dimension (mm)×0.52. The longitudinal and transverse turbinatedimensionswerecalculatedfromthecross-section throughthecoronalplaneaftertheuncinateprocesses.The longest dimension of the lower turbinate was set as the anteroposteriordimensionintheaxialplane.
Statisticalanalysis
Statisticalanalysiswasperformed usingSTATA/MP 11.The data were summarized as means and standard deviation. Pre-andpostoperativecomparisonsweremadeusingpaired
t-testswithineachgroup.Theindependentt-testwasused tocomparepreoperative groups, while analysis of covari-ance(ANCOVA)wasusedtocomparepostoperativegroups usingthepreoperative valuesascovariates.The indepen-dent t-test was used to compare relative postoperative changes (%) between groups. Statistical significance was takenasp<0.05.
Results
Endoscopichemorrhagecontrolwasperformedbecauseof hemorrhagedevelopmentonpostoperative4thand6thdays in postoperative period in only 2 patients in the group of turbinoplasty. In the other 64 patients, there were no complicationssuchaspostoperativehemorrhage,synechia orinfection.Nasalendoscopicexaminationswereperformed at2monthspostoperatively.Nosignsofseptumdeviation, turbinatehypertrophy,oratrophicrhinitiswereobservedin thefollow-upexaminations,andtherewerenocomplaints ofnasalobstruction.
Thedifferencesinthepre-andpostoperativeparameters weresignificantintheturbinoplastyandoutfracturegroups (Table1).
Thetransverseandlongitudinaldimensionsofthelower turbinateintheturbinoplastygroupweresignificantlylower thanintheoutfracturegroup(p=0.004).Thepostoperative lowerturbinatevolumesdecreasedsignificantlyinboththe turbinoplastyandoutfracture groups.In theturbinoplasty group,the mean lowerturbinate volume was4523.5mm3 preoperativelyand1492.2mm3postoperatively(p=0.002), versus4282.2mm3preoperatively and2699.9mm3 postop-eratively (p<0.001) in the outfracture group. Comparing theturbinoplastyandoutfracturegroups,thepostoperative volumewas significantly lowerin the turbinoplasty group (p=0.019)(Table2).Inthebetween-groupcomparison,the volume reduction was greater in the turbinoplasty group (p=0.037)(Table2).
The transverse and longitudinal dimensions of the lowerturbinatedecreasedmoreintheturbinoplastygroup
Table1 Compensatoryturbinatepreoperativeandpostoperativevalues.
Turbinoplasty Outfracture
Preop. Postop. p Preop. Postop. p
A-P(mm) 48.1±4.8 39.4±4.9 0.009 43.7±6.6 38.2±6.6 0.001
Transverse(mm) 11.4±2.2 6.2±1.5 <0.001 12.1±2.2 9.6±2.7 <0.001 Longitudinal(mm) 17.8±2.9 11.5±2.5 <0.001 14.9±2.8 12.8±2.6 0.005 Volume(mm3) 4523.5±1548.2 1492.2±594.8 0.002 4282.6±2094.2 2699.9±1942.1 <0.001
Meanandstandarddeviationweredefinedforeachsubgroup.Statisticallysignificantresultsareshowninbold. A-P,Anterior-Posterior;Preoppreoperative,Postoppostopertative;mm,milimeter.
Table2 Changesinturbinatemeasures.
Turbinoplasty Outfracture p
PreopA-P(mm) 48.1±4.8 43.7±6.6 0.188 PostopA-P(mm) 39.4±4.9 38.2±6.6 0.490 Decreaselongitudinal(mm) 0.17±0.11 0.13±0.05 0.336 Preoptransvers(mm) 11.4±2.2 12.1±2.2 0.576 Postoptransvers(mm) 6.2±1.5 9.6±2.7 0.004 Decreasetransvers(mm) 0.45±0.12 0.22±0.08 0.001 Preoplongitudinal(mm) 17.8±2.9 14.9±2.8 0.08 Postoplongitudinal(mm) 11.5±2.5 12.8±2.6 0.004 Decreaselongitudinal(mm) 0.36±0.09 0.14±0.08 <0.001 Preopvolüm(mm3) 4523.5±1548.2 4282.6±2094.2 0.811 Postopvolüm(mm3) 1492.2±594.8 2699.9±1942.1 0.019 Decreasevolüm(mm3) 0.63±0.34 0.41±0.12 0.037
Meanandstandarddeviationweredefinedforeachsubgroup.Statisticallysignificantresultsareshowninbold. A-P,Anterior-Posterior;Preoppreoperative,Postoppostopertative;mm,milimeter.
4500 4000 3500 3000 2500 2000 1500 1000 V olumemm 3 Turbinoplasty Out-fractur Pre Post
Figure1 Preoperativeandpostoperativevolumechangesof thegroups.
compared with the outfracture group (p=0.001 and
p<0.001,respectively)(Table2).
Intheturbinoplastygroup,theturbinatevolumehadan averagereductionof56%and36%intheout-fracturegroup (Fig.1).
The lowerturbinate volumes onthe side ofthe devia-tionweresignificantlyincreasedinboththeturbinateand out-fracturegroupspostoperatively(p=0.0002,p=0.0297, respectively)(Table3).
Discussion
A compensatory turbinate develops to protect the more-involvednasalpassagefromcold,dryair.Themostcommon site is the inferior turbinate. There is thickening of the turbinate bones,andan increase inthe spongiform struc-ture and orientation to the midline.Mucosal hypertrophy is also present.9 Many techniques have been described
to reduce the volume in lower turbinate hypertrophy. In someofthesetechniques,theaimisonly todecreasethe mucosal volume, while in others the mucous membrane andbone volumeareboth reduced.10 Thereis no
consen-susregardingthebestlowerturbinatereductiontechnique. Although lessinvasivemethods havebecomepopularover thelast20years,moreinvasiveprocedures,suchas turbino-plasty, remain important because of their high success rates.
Many studies have examined the effectiveness of radiofrequency applicationin lowerturbinate surgery,10---12
and other techniques have been evaluated in non-septoplastypatients.13---15Veitetal.didnotevaluatelower
turbinatevolumesdespitecomparinglowerturbinate reduc-tionmethodsduringseptoplasty.16
We measured the turbinate volume using CT and comparedthevolumeafteroutfractureandbipolar cauteri-zation,whichcausedonlymucosalvolumeloss,withthatof turbinoplasty,which resultedin mucosalandbonevolume
Table3 Lowerturbinatevolumesondeviatedside.
Turbinoplasty Outfracture
Preop. Postop. p Preop. Postop. p
Volume(mm3) 1967.8±426.1 2070.±413.8 <0.0002 1725.2±327.2 1791.1±340.3 <0.0297
Statisticallysignificantresultsareshowninbold.
loss during septoplasty. Other studies have measured the volumeusingCT(10)ormagneticresonanceimaging.13,17
Turbinoplastyisasuccessfulmethoddespite postopera-tivesynechia,drying,andnasaldischargeproblems.16,18 In
ourstudy,postoperativedesiccationandnasaldischargewas notfollowedupintheturbinoplastypatients.
Büyüklü and Zhang19,20 reported that the outfracture
methodwaseffective for expandingthe nasalpassagesin lowerturbinatehypertrophy.Withturbinatebipolar cauter-ization,superficialthermalablationcreatesscartissueand fibrosis,andobliteratesthevenoussinuses.Inonestudy,the resultsat2monthsafterbipolarcauterizationwere success-fulin76%ofthecases.14 Inourstudy,thelowerturbinate
volumeintheoutfracturegroupdecreasedsignificantlyand thepatients’complaintsofnasalobstructiondisappeared. In both groups, theimprovement in the nasalobstruction waslikelyrelatedtoboththelowerturbinatereductionand correctionoftheseptumdeviation.
Variousstudieshavecomparedtheeffectivenessoflower turbinatesurgical techniquesusingobjectivetestssuchas acoustic rhinomanometry, mucociliaryfunction tests, and acousticrhinometry.15,21,22
Can etal.13 havestudied theeffectsofradiofrequency
ablationinpatientsundergoinglowerturbinatesubmucosal resectionandfoundthatthevolumereductionwas signifi-cantinbothgroups,butitwasgreaterwithradiofrequency ablation.Inourstudy,thepostoperativeaxial,transverse, andlongitudinallowerturbinatedimensionsweredecreased significantlyinbothgroups.
Changes inlower turbinatevolumehave been assessed afterapplyingdifferentreductionmethods. Demiretal.12
found that the lower turbinate volume decreased by 25% afterthermalradiofrequencyablation.Canetal.13reported
a42.4% volumereductionafter submucosalresection.We observed greater volume reduction in the turbinoplasty group (67.1%) than the outfracture group (36.9%), indi-catingthat hypertrophicmucosaand boneformation with compensatoryhypertrophyconstitutesasignificantvolume. Furthermore, the decrease in the transverse and longitu-dinal dimensions of the lower turbinate was significantly (p<0.001)greaterinourturbinoplastygroupcomparedwith the outfracture group, and the loss in the turbinoplasty group could be attributed to bone tissue loss. Turbino-plasty method results in a greater volume decrease and canbeselectedforlowerturbinateinwhichthebonemass producesasignificantvolume,whileoutfractureand bipo-larcauterization,whichhasalowerriskofcomplications, can be performed in patients withmore moderate lower turbinatehypertrophy.
Lower turbinate outfracture and bipolar cauteriza-tion are less invasive than turbinoplasty, while the
risk of perioperative bleeding is greater than with turbinoplasty.18Whilehemorrhage,synechiae,andmucosal
discharge can occur after turbinoplasty, these effects are not observed after outfracture and bipolar cauteri-zation. In addition, turbinoplasty is suitable for bleeding controlunder an endoscopic view. Consequently, turbino-plasty takes longer to perform than outfracture and bipolar cauterization. In our series, no peri- or post-operative complications were recorded in either group, but this may be due to the small number of sub-jects.
In a comparison of the pre- and postoperative lower turbinate volumes of patients who underwent radiofre-quency ablation of the lower turbinate, Bahadır et al.10
statedthatthepostoperativevolumesofsixlowerturbinate wereincreased,whichmighthavebeenduetothestageof thenasalcycle.Inourstudy,thesignificantincreaseinthe volumeoftheuninvolvedlowerturbinate(p=0.033)onthe deviated sidein the turbinoplastygroup might have been duetoa processotherthanthenasalcycle following cor-rectionofthedeviation.
Conclusion
Both turbinoplasty and outfracture are effective volume reductiontechniques. However, the turbinoplastymethod causesmorereductionofthelowerturbinatevolumeofthe thanoutfractureandbipolarcauterization
Ethical
approval
Allproceduresperformedinstudiesinvolvinghuman parti-cipantswereinaccordancewiththeethicalstandardsofthe institutionaland/ornationalresearchcommitteeandwith the1964 Helsinkideclarationanditslateramendmentsor comparableethicalstandards.
Informed
consent
Informedconsentwasobtainedfromallindividual partici-pantsincludedinthestudy.
TheEnglishinthisdocumenthasbeencheckedbyatleast twoprofessionaleditors, both native speakers of English. Fora certificate,pleasesee: http://www.textcheck.com/ certificate/eqNE75.
Conflicts
of
interest
References
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