Secret in mangement of turbinate hypertrophy

Dr.essam Behairy
‫اعرف عدوك واعرف نفسك‬
‫تستطيع أن تكسب مائة ‪x‬مائة‬
‫دون هزيمة واحدة‪ ،‬وحين‬
‫تكون جاهال بالعدو وعارفا‬
‫بنفسك فان فرص النصر‬
‫والهزيمة تكون متساوية‪ ،‬أما‬
‫ان كنت جاهال بعدوك وجاهال‬
‫بنفسك فمن المؤكد أنك ستهزم‬
‫في كل المعارك هزيمة نكراء‬
 SECRET 1 Morphology
lined by respiratory •
epithelium on only 10% of
its surface.
stratified epithelia: •
squamous (8.2%), columnar
ciliated (13.6%), and
cuboidal (46.6%). Thus
cuboidal epithelium is the
most widespread and
presents variable features.
characteristics were found •
in transitional zones on
21.6% of the surface.
Type I, lamellar •
Type II, compact •
; Type III, combined type •
(compact with spongious
component)
; Type IV, bullous. •
The distribution was as •
follows: 352 (62.19%)
lamellar, 50 (8.83%)
compact, 162 (28.63%)
combined, and 2(0.35%)
bullous type.
 NORMAL& ABNORMAL

MACRO.
MICRO
CYCLE …UP DOWN CRACTERS..SPOILING
 of Nasal cycle lasts 2-6 hrs, occurs in 20-80
people.Sympathetic nervous system increases
vascular resistance Parasympathetic nervous
system (vidian nerve)relaxes capacitance
vessels. Sensory receptors temperature
receptors

Cycles of swelling and constriction of the

venous sinuses of the inferior turbinate and
the nasal septum (Richard Kayser1895)
 Secret 2) Air flow splitter
Function Dysfunction
1) Regulate airflow, and to •
and humidify warm
the air . Dysfunction of any of these •
2) filtering inspir ed air • systems can lead to
3)immunologic defense by • symptoms of nasal
bringing inspired air in dysfunction (eg,congestion,
contact with mucous-coated postnasal drainage, facial
membranes that contain pressure, headaches, sinus
immunoglobulin A (IgA).
infections).
4)sense of smell, which is •
intimately associated with the
taste sensation..
External Nasal Valve
Boundaries include
lower lateral cartilages
Soft tissue alae
Membranous septum
Sill of the nostril
Can be site of obstruction (e.g. s/p rhinoplasty
A) swelling of the mucosa due to various forms of
rhinitis
B)thickened or abnormally positioned turbinate bones
TYPE
DEGREE
 3rd secret ;Evaluation of Patients
History nasal obstruction •
symptoms
Physical exam •
Look for dynamic and •
structural cause of nasal
obstruction.
Check before and after •
decongestion.
Rhinomanometry •
Anterior pressure sensor •
in one nostril, flow
meter in a mask.
Posterior pressure sensor •
in the mouth, flow
meter in a mask.
Ohms Law RP/V •
Normal is .15 to .3 •
Pa/cm3
gt.3 is usually associated •
with symptoms.
Grade-1 Posterior wall of nasopharynx can be
seen through ≥ 50% of posterior choana
(Score = 1)
Grade-2 Posterior wall of nasopharynx can be
seen through < 50% of posterior choana
(Score = 2)
Grade-3 Posterior wall of nasopharynx not
visible at all (Score = 3).
 ,

Endoscopic grading of turbinate size relative to visibility

of the posterior choana. 1 = grade 1; 2 = grade 2;
3 = grade 3
; T = inferior turbinate; S = septum; ab = imaginary line dividing ipsilateral
choana in midline
 Evaluating PatientsOther tests
Evaluating PatientsAcoustic •
Rhinometry Olfaction tests •
Measures cross-sectional • Nasal smear •
area (CSA) Tests of humidity and •
Minimal CSA before • heating
consistent reporting of
nasal
obstruction is .3cm2 or less.
Above .3cm2, reliability to •
predict gradation of
symptoms is controversial.
•
 Histology
. .
Three layers of Turbinates •
Medial thin mucosa •
Bone •
Lateral thick mucosa •
Mucosa •
Pseudostratified columnar •
ciliated epitheliumGoblet cells
produce salts, glycoproteins,
polysaccharides, lysozymes. •
arteries, veins, and venous •
sinusoids.Lamina Propria
contains the above tissue.
•
 Secret 4 Etiology of Turbinate
Disorders.
Allergic rhinitis • Leads to longstanding changes in mucosa. •

cell Histologic turbinate findings mast • Fibrosis, polyposis. •

abundance, seromucous gland hyperplasia,
interstitial fibrosis, eosinophils on smear. Vasomotor Rhinitis •
Probably the most frequent cause of • Nasal congestion, rhinorrhea only •
turbinate-related nasal obstruction.
Acute rhinosinusitis Exam similar to AR • Drug Induced Rhinitis •
Leukocytes on nasal smear. • •
• 18
Chronic Rhinosinusitis
Questionable association with
aggressive
turbinate resection
 SEC 5 Associated factor…
19 • . •
Turbinate DisordersAnatomic
Septal Deviation •
Concha Bullosa •
•
Turbinate DisordersAnatomic
Paradoxical middle turbinate •
curvature in
Synechiae, polypoid changes •
•
 Medical Management
Allergic Rhinitis Nasal steroids • Medical Management •
with oral Antihistamines •
and/or topical antihistamines,
systemic
decongestants. Decongestants •
Drug induced rhinitis cessation •
of topical Topical nasal steroids/nasal •
medicine and switch to saline/sinus rinses
steroids.
Nasal Polyposis systemic • Antibiotics if sinusitis •
steroids, topical Immunotherapy if allergic •
steroids.
Rhinosinusitis Antibiotics •
•
 At least 13 surgical techniques to treat
hypertrophy of the inferior turbinate
. .
Cold-steel turbinoplasty •
Lateralization/outfracture •
of inferior turbinate
Diathermy •
(electrocautery)
Laser •
Cryosurgery •
Microdebrider •
Radiofrequency Ablation •
Coblation •
Thermal coagulation,
Electrocautery1845-1880
Chemocoagulation, Chemotherapy
1869-1890 +
Turbinectomy 1882 +
Lateralization, Lateropexia 1904 +
Submucous resection of the
turbinate bone 1906-1911 +
Crushing + trimming, partial
resection 1930-1953 +
Injection of corticosteroids 1952 +
Injection of sclerosing agents 1953
+
Vidian neurectomy 1961 +
Cryosurgery 1970 +
Turbinoplasty 1982 +

Laser surgery 1977

Powered instruments 1994
 .
Microdebrider Cold-steel
 .
Coblation Laser
 Controversy
turbinoplasty
1)Reduce the size of the •
inferior turbinate through
exuberant bone removal
with high mucosal
preservation.
2)recommended for
patients with or without
allergic rhinitis and those
showing irreversible
hypertrophy of inferior
turbinates.
Turbinectomy :Partial &total.
CONCLUSION: •
The efficacy of inferior •
turbinoplasty was
confirmed not only for
obstructive symptoms, but
also for non-obstructive
symptoms in patients with
and without allergic rhinitis.
 Surgical Management
Total inferior Turbinectomy
Benefits •
Most effective in terms of •
LONG TERM improvement
of airway
Partial Turbinectomy
Anterior portion, at nasal •
valve, is resected.
Advantages •
Addresses nasal valve •
Disadvantages •
Similar to total, but less •
severe
 Surgical Management
•
‫ز‬ •
Total Inferior Turbinectomy
Disadvantages •
Postoperative hemorrhage rate •
of 5-8
Nasal crusting, sometimes lasting •
for months, up
to 15 at one year, in a study
by Mabry et al •
(40pts. followed for one year)
Synechiae •
Atrophic rhinitisyears. Six •
 Submucous Resection
•
SuAdvantages
Decreased risk of hemorrhage •
Preserves mucociliary clearance and air •
conditioning
Disadvantages •
Technical difficulty •
Tendency to relapse 25 in a 1988 study by •
Mabry et al
•
26
Surgical ManagementMucosal Lesion-
Producing techniques
Electrocautery, Cryosurgery, Laser Surgery •
Advantages •
Local Anesthesia, Easy, low hemorrhage risk •
Disadvantages •
Extensive post-op crusting, probable •
regrowth of
lesions
 laser
27 •
Surgical ManagementLaser
Illustrations
•
28
Surgical ManagementSubmucous
Lesions
Radiofrequency unipolar or •
bipolar
Study by by Back et al on twenty •
patients showed
improvement in nasal cross-
sectional area by
acoustic rhinometry at one year
KTP, Argon, and CO2 have all •
been shown to be
effective.
detachment of the entire mucosa above the incision,
creating a mucosal flap
the turbinate was incised in the anterior-posterior direction
using turbinectomy scissors
the bone spicules were removed with a chisel
thereby removing most of the bone and all its
lateral mucosa
 .
In our opinion, the • . From that perspective, it •
seems that electrocautery,
purpose of chemocautery, (subtotal)
turbinectomy, cryosurgery,
surgically reducing and laser surface surgery
the inferior should not be used, as
these techniques are too
turbinates should destructive.
Intratubinal turbinate •
be to diminish reduction (intraturbinal
complaints while turbinoplasty) would seem
to be the method of choice.
preserving
function
 CONCLUSION
When analysing the advantages,
the disadvantages, and the
complications of the various •
methods to treat inferior
turbinate
hypertrophy, it is difficult to draw
firm conclusions.
We realize how difficult it is to •
meet with all these re-
quirements. However, we would
all agree that only studies of
this type would really help us to
find answers to the many still
remaining questions •
• : prospective and comparative •
patients should be randomly •
assigned to the study groups and
all should suffer from the same
disease
• preopera-tive and postoperative •
parameters should include
patient symp-toms (VAS score),
function tests (breathing,
• mucociliary trans-port, nasal
defence etc.), complications, and
follow-up until 3-5
• years. •