Operative Techniques in Otolaryngology (2014) 25, 160–170

Inferior turbinate reduction

Deya Jourdy, MD

From the Department of Otolaryngology and Neurosurgery, New York Medical College, Valhalla, New York

KEYWORDS The inferior turbinate is an important structure serving a vital role in nasal physiology. However, inferior
Inferior turbinate turbinate enlargement can lead to decreased nasal airflow and a sensation of nasal obstruction. Chronic nasal
reduction; obstruction can substantially affect quality of life, productivity, and finances, and when medical therapies
submucous resection; fail, surgical management is often recommended. Many techniques for inferior turbinate reduction exist,
surgical technique; including outfracturing, submucosal soft tissue reduction (ie, electrocautery, radiofrequency coblation, and
turbinate outfracture; powered microdebrider), submucosal bone removal, argon plasma coagulation, laser reduction, partial
radiofrequency turbinectomy, and total turbinectomy. These techniques have demonstrated varied long-term results, and
coblation; there remains a lack of consensus as to the optimal surgical technique. However, given the important role the
microdebrider; inferior turbinates play in nasal physiology, many contemporary surgeons aim to strike a balance between
partial tubrinectomy adequate tissue resection for symptom improvement and preservation of functional turbinate tissue and its
contribution to normal nasal physiology.
r 2014 Elsevier Inc. All rights reserved.

Introduction Indications, patient selection, and workup

The inferior turbinate is an important structure, serving a
vital role in nasal physiology. It has many functions,
including the filtration, warming, and humidification of
inspired air, in addition to the regulation of nasal airflow.
However, inferior turbinate enlargement, due to hypertrophy
or edema, can lead to decreased nasal airflow, and
subsequently, a sensation of nasal obstruction. Chronic
nasal obstruction can substantially affect quality of life,
productivity, and finances.1,2 A number of medical therapies
exist to treat patients with nasal obstruction secondary to
enlarged inferior turbinates; however, when these medical
therapies fail, surgical management is often recommended.
The focus of this article is a wide variety of surgical
techniques that have been described to reduce the size of
enlarged inferior turbinates when medical management has
yielded unsatisfactory results.
Address reprint requests and correspondence: Deya Jourdy, MD,
ENT Faculty Practice, LLP, 1055 Saw Mill River Rd, Suite 101, Ardsley,
NY 10502.
E-mail address: djourdy@gmail.com
http://dx.doi.org/10.1016/j.otot.2014.02.005
1043-1810/r 2014 Elsevier Inc. All rights reserved.
Inferior turbinate reduction is one of the most commonly
performed sinonasal surgical procedure, and the most
common indication for turbinate reduction is nasal obstruc-
tion due to inferior turbinate enlargement. In addition to
relief of nasal obstruction, inferior turbinate reduction may
also play a role in the treatment of adult and pediatric sleep-
disordered breathing.3,4 There are numerous possible
etiologies for inferior turbinate enlargement. This includes
physiological, anatomical, or pathophysiological causes,
such as allergic, vasomotor, and hormonal rhinitis, as well
as systemic inflammatory diseases. As such, an assessment
for allergic and other systemic etiologies is a crucial
component of a comprehensive medical history of any
patient being evaluated for nasal obstruction. Physical
examination should include anterior rhinoscopy and nasal
endoscopy, before and after nasal decongestion, to differ-
entiate between possible bony and soft tissue contributions
to turbinate enlargement and the patient's symptoms. Before
considering surgical intervention, treatment typically con-
sists of medical therapy, which may include topical nasal
steroids, antihistamines, and nasal saline irrigations.5
Jourdy Inferior Turbinate Reduction
Anatomy
The inferior turbinate is composed of a central bony portion
that projects from the medial aspect of the maxillary and
palatine bones at varying angles, and is surrounded
medially, laterally, and inferiorly by a layer of soft tissue.
This soft tissue layer, which is thickest along the medial
aspect of inferior turbinate, is composed of erectile tissue
with seromucinous glands and venous sinusoids and is
covered by pseudostratified ciliated columnar epithelium.5,6
The venous sinusoids play a significant role in the regulation
of mucosal thickness and are controlled by sympathetically
innervated arterial resistance vessels. The inferior turbinate
has a rich, variable blood supply, mainly provided by the
posteriorly located inferior turbinate branch of the posterior
lateral nasal artery, originating from the sphenopalatine
artery.7
Inferior turbinate function
The inferior turbinates play an important role in nasal
physiology. By increasing the mucosal surface area in the
nasal cavity, the turbinates serve to warm and humidify
inspired air, and thus facilitate pulmonary alveolar gas
exchange. Furthermore, the orientation and shape of the
turbinates streamline inspired air posteriorly, while provid-
ing sufficient resistance to decrease airflow velocity and
change it from a laminar to a transitional pattern.5,8 This
increase in turbulence aids in the filtration function of the
nasal cavity, by allowing for the trapping of inspired debris
in the mucus layer of the nasal epithelium, which then
serves to remove the debris from the nasal cavity through
mucociliary clearance. When nasal resistance is abnormally
low (eg, owing to excessive inferior turbinate surgical
reduction), the altered airflow and resistance patterns may
lead to paradoxical subjective complaints of nasal obstruc-
tion, known as “empty nose syndrome.”5,9
Most people experience irregularly alternating asymmet-
ric airflow through the nose, commonly referred to as “the
nasal cycle,” due to alternating engorgement within the
nasal erectile mucosa, and especially that of the inferior
turbinates. At any given time, one side of the nasal passages
is typically more congested with a reduced amount of
secretions, whereas the contralateral nasal cavity is more
widely patent but has increased secretions from serous and
mucus glands. Despite the constant fluctuation of each
individual turbinate size and ipsilateral airway resistance,
the total resistance of the whole nasal airway has been noted
to be constant, as described by Kayser in 1895.5,10
Surgical technique
Numerous surgical techniques have been described for the
treatment of inferior turbinate hypertrophy, and there
remains a lack of consensus as to the optimal technique.
These surgical techniques differ in the amount and type of
tissue resection and preservation (Figure 1). As our
161
understanding of nasal physiology has grown, surgical
techniques have also evolved with the aim to achieve both
maximal symptom improvement and preservation of
function. Furthermore, in the current age of rising health
care costs, some of the turbinate procedures described are
now performed in the office setting using local and topical
analgesia. The following techniques are discussed in a
sequential order, starting with techniques that generally
involve the least amount of tissue removal and progressing
toward techniques with more tissue resection.
Lateralization of the inferior turbinate
Lateralization of the inferior turbinate involves an
outfracturing of the turbinate bone to decrease the angle
with which the inferior turbinate bone projects from the
maxillary and palatine bones along the lateral nasal wall
(Figures 1A and 2).11 This procedure typically begins with
an infracture of the turbinate bone by placing a Boies or
Goldman elevator lateral to the inferior turbinate in the
inferior meatus. Force is then directed medially and
superiorly in an attempt to avoid a greenstick fracture, but
rather create a fracture line near the bony attachment to
the lateral nasal wall (Figure 2A and B). This, in turn
helps to achieve maximal lateralization when the inferior
turbinate is subsequently outfractured by using the elevator
to direct force inferiorly and laterally along the turbinate's
attachment site to the lateral nasal wall (Figure 2C).
Lateralization of the inferior turbinate is generally not
considered sufficient as a stand-alone procedure for the
management of significant turbinate hypertrophy, but it can
be helpful when used in conjunction with other turbinate
reduction procedures.5
Submucosal soft tissue reduction
The submucosal soft tissue of the inferior turbinate can
be reduced using a variety of methods, including direct
tissue resection, and various thermal techniques that produce
submucosal injury (Figures 1B and 3). This leads to
submucosal fibrosis and contracture, with obliteration of
the venous sinusoids, and a reduction of the erectile
properties of the submucosal tissue.
Submucosal electrocautery
Monopolar electrocautery and bipolar electrocautery can be
used to produce submucosal thermal injury. This technique
involves the use of a single needle electrode (Figure 3A), or
bipolar forceps with needle tips. After the administration of
local anesthetic, the electrode can be pressed against the
head (anterior portion) of the inferior turbinate and activated
for a short period to produce a devascularized zone. The
needle electrode is then inserted into the submucosa through
this zone and advanced toward the tail of the inferior
turbinate while taking care to stay close to the turbinate
bone. The electrocautery is then activated as the needle is
slowly withdrawn to inflict the thermal injury near the tip of
162 Operative Techniques in Otolaryngology, Vol 25, No 2, June 2014

Figure 1 Surgical techniques for inferior turbinate reduction differ in the amount and type of tissue resected. The maxillary sinus is
labeled with an asterisk for orientation purposes, and the tissue typically removed for each technique is demarcated. (A) Lateralization of the
inferior turbinate with outfracture. (B) Submucosal soft tissue reduction (ie, submucosal electrocautery, radiofrequency coblation, and
microdebrider). (C) Resection of the inferior turbinate bone. (D) Resection of the inferior turbinate bone and lateral mucosa. (E) Partial
mucosal and soft tissue resection or ablation (ie, laser turbinectomy). (F) Total turbinectomy.

the electrode. Preference regarding the power and duration
of electrocautery, as well as the optimal number of passes, is
surgeon dependent.1,12,13
Submucosal radiofrequency coblation
Radiofrequency tissue reduction involves the direct applica-
tion of a high-frequency current to the targeted tissue, leading
to submucosal injury from friction between ions. This
technique differs from the electrocautery technique in several
ways; although it still generates enough thermal energy to
cause the desired submucosal injury, the maximal temperature
generated (typically less than 851C), and dissipation of the
heat within the tissue, is significantly lower than that with
electrocautery (which can reach up to 8001C).5,14 This is one
of the reasons the technique has become popular in the office
setting under local anesthesia. There are numerous radio-
frequency devices designed with both monopolar and bipolar
delivery of energy. Much like the electrocautery technique, the
turbinate is first infiltrated with local anesthetic, which can
expand the submucosal tissue making the procedure easier to
perform. The wand tip is then coated in saline gel or another
conductive media and activated at the head of the turbinate to
produce a devascularized zone. The wand is then inserted
through this zone and advanced toward the tail of the turbinate
submucosally (Figure 3B). It is then activated for a short
period (eg, 10 seconds), and then partly withdrawn and
Jourdy Inferior Turbinate Reduction 163

Figure 2 Lateralization of the inferior turbinate begins with an infracture of the turbinate bone toward the nasal septum (A) to create a
fracture line near the attachment to the lateral nasal wall (B). This is followed by a lateral outfracture away from the nasal septum (C).

activated again. As with submucosal electrocautery, prefer-
ence regarding the power and duration of coblation, and the
optimal number of passes, is surgeon dependent. Typically,
settings of 751C-851C, 10-15 W, and 300-500 J, or a coblation
setting of 4-5, have been reported in the literature depending
on the system used.
with enlarged turbinate bone, which can be a major contributor
to turbinate enlargement (Figures 1C and 5). Depending on the
thickness of the inferior turbinate bone, it may be possible
to resect a portion of it using the submucosal powered

Powered submucosal turbinate reduction

Similar to the submucosal thermal techniques described, the
intention of powered submucosal resection is to reduce
the amount of submucosal erectile tissue, while leaving the
overlying epithelium unharmed. With the recent advent of a
smaller (2.0-2.9 mm), specifically designed inferior turbi-
nate microdebrider blade, with an incorporated tip elevator,
this procedure has been made easier (Figure 3C). The
inferior turbinate is first infiltrated with local anesthetic,
typically with epinephrine, to limit hemorrhage and expand
the targeted submucosal soft tissue. The tip of the
specialized microdebrider blade, or a scalpel, is then used
to perform a stab incision in the head of the inferior
turbinate (Figure 4A). The microdebrider blade is then
advanced (with the cutting surface facing laterally) and used
to create a submucosal pocket on the inferomedial surface of
the turbinate bone, using the flat tip as an elevator
(Figure 4B). If a specialized turbinate blade is not available,
the flap dissection can be performed using a Cottle or Freer
elevator.5 The microdebrider blade is then rotated toward
the submucosal soft tissue and activated, typically at speeds
of up to 3,000 rpm in oscillating mode. Care must be taken
to avoid flap perforation, while targeting the anterior and
inferomedial submucosal soft tissue that contributes most
significantly to nasal airflow obstruction.6 Submucosal
resection can be carried all the way to the tail of the
turbinate posteriorly; however, this does carry an increased
risk of bleeding owing to injury to vascular contributions
from the posterior lateral nasal and sphenopalatine arteries.
Figure 3 Submucosal soft tissue reduction targets the erectile
Inferior turbinate bone resection tissue under the epithelium. This can be accomplished using a
similar submucosal tunnel using electrocautery (A), radiofre-
Submucosal resection of the inferior turbinate bone is quency coblation (B), or a powered microdebrider with a
another technique that can be especially effective in patients specialized flat tip elevator (C).
164
Figure 4 The microdebrider can be used to reduce submucosal soft tissue. The flat tip is first used to make an incision in the head of
inferior turbinate (A) and then to create a submucosal pocket where the microdebrider is activated (B).
microdebrider technique previously described, with the blade
turned laterally against the turbinate bone. Alternatively, a
more comprehensive resection of the bone can be performed
using a more traditional submucosal dissection. For this
technique, a larger anterior incision is made and extended
posteriorly along the inferior edge of the turbinate (Figure 5A).
A Cottle or Freer elevator is then used to raise a
mucoperiosteal flap medially off the underlying turbinate bone
(Figure 5B). Another mucoperiosteal flap can then be raised
off the lateral surface of the turbinate bone, and the 2 flaps can
be apposed after the bone is resected with a through-cutting
instrument (Figure 5C and D). Alternatively, as described by
Mabry,15 the lateral turbinate mucosa can be resected along
with the turbinate bone, and the remaining flap of medial and
inferior mucosal tissue can be rolled up on itself, from medial
to lateral, to form a neoturbinate with 2 apposing inverted raw
surfaces, and an external mucosal surface (Figure 1D).16 Using
a novel approach, Greywoode et al17 recently described the use
of an ultrasonic bone aspirator to remove inferior turbinate
bone. This device uses ultrasonic waves to emulsify bone, with
concurrent irrigation and microsuction of bone particles
producing a clean surgical field; this reportedly enables
removal of the inferior turbinate bone without thermal or
mechanical injury to the surrounding soft tissue or mucosa.
Mucosal sacrificing techniques
Numerous mucosal sacrificing techniques have been
reported describing different degrees of inferior turbinate
resection. However, prevailing knowledge of the important
role that the inferior turbinate and its epithelium play in nasal
physiology has led many surgeons to steer away from more
aggressive full-thickness resection techniques and those
involving extensive resection of the turbinate epithelium.
Operative Techniques in Otolaryngology, Vol 25, No 2, June 2014
Partial turbinectomy
Anterior turbinectomy removes a small portion (1.5-2.0 cm) of
full-thickness tissue at the head of the inferior turbinate in the
region of the internal nasal valve. Limiting partial turbinate
resection to this portion of the inferior turbinate allows the
surgeon to address the region of greatest nasal airway resistance,
while lowering the risk of hemorrhage secondary to injury to the
posterior vascular supply.7,18,19 Further, tissue is sometimes
resected from the “scroll” region of the turbinate, inferior to the
bone. The tissue to be resected can first be clamped for a short
period and injected with anesthetic with epinephrine to decrease
the risk of bleeding. The resection can then be performed with a
through-cutting instrument or a microdebrider.
Argon plasma coagulation
Argon plasma coagulation allows for contact-free thermo-
coagulation of tissue by using a current that is conducted
through ionized argon gas, which forms an arc of current
between the handpiece and the tissue. The energy delivered
to the tissue with this technique is limited to 1-2 mm of
penetration.1 It was first applied in the field of otolaryngol-
ogy for the treatment of juvenile laryngeal papillomatosis
and epistaxis secondary to hereditary hemorrhagic telan-
giectasias.20 When used for the treatment of inferior
turbinate hypertrophy, the handpiece applicator is used to
pass the argon plasma coagulation beam slowly over the
entire length of the lower one-third to one-half of the
inferior turbinate in 3-4 parallel lines (Figure 6). Direct
contact of the applicator tip with the turbinate tissue is
avoided because it prevents the desired effects.20
Laser
Lasers produce a precise beam of coherent light that may be
accurately delivered, producing minimal damage beyond the
Jourdy Inferior Turbinate Reduction 165

Figure 5 Submucosal bone resection begins with an anterior incision that is extended posteriorly along the inferior edge of the turbinate
(A). Medial and lateral mucoperiosteal flaps are then raised (B), and the underlying bone is resected leaving the 2 flaps (C). The raw surfaces
of the flaps are then placed together and lateralized (D).

area requiring treatment. Tissue absorption of the energy is
dependent on the wavelength of the laser light, which can be
delivered in either a pulsed mode or a continuous mode. The
use of a laser for inferior turbinate reduction has been
around since the late 1970s and is particularly useful when
soft tissue hypertrophy predominates.21,22 A number of
lasers have been used for this technique, including the argon
laser, the carbon dioxide (CO2) laser, the diode laser, the
holmium: yttrium aluminum garnet laser, the potassium
titanyl phosphate (KTP) laser, and the neodymium: yttrium
aluminum garnet (Nd:YAG) laser. Given the considerable
differences in the various laser beam properties, such as
the degree of hemostasis, tissue ablation, and depth of
penetration, the laser systems can be used in a variety of
methods to achieve turbinate reduction. This ranges from
simple tissue ablation, to laser mucotomy (excision of
superficial mucosa), to partial or total turbinectomy with the
laser used as a cutting instrument (Figure 1E).
Degloving
Degloving of the inferior turbinate is a technique whereby
the soft tissue and epithelium overlying the turbinate bone is
resected along the whole length of the turbinate.23 Despite
results that suggest sustained improvement in nasal
obstruction up to 2 years after surgery, this technique is
not commonly used owing to fear of tissue overresection,
166
Figure 6 Argon plasma coagulation of the inferior turbinate
delivers an arc of current to the lower one-third to one-half of the
inferior turbinate along the entire length of the turbinate.
destruction of the important pseudostratified ciliated colum-
nar epithelium, and the possible deleterious effects on
normal nasal physiology.
Total resection
Total or “radical” turbinectomy involves the complete
resection of the inferior turbinate using heavy scissors to
detach it directly at its site of attachment to the lateral nasal
wall (Figure 1F). This technique can reduce the nasal
resistance up to 50%.24 It was commonly used in first half of
the twentieth century but eventually fell out of favor with
many surgeons owing to concerns for severe long-term
complications such as atrophic rhinitis and ozaena.1 These
complications likely develop secondary to the loss of the
inferior turbinate's contribution to nasal physiology and are
associated with excessive mucosal drying, scarring, foul
smelling nasal discharge, and recurrent epistaxis.25 Fur-
thermore, this technique has been associated with a higher
risk of hemorrhage and pain in the immediate postoperative
period.26-28 However, despite these factors, some surgeons
still support this technique as a safe and effective method for
treating nasal obstruction.29
Complications
The complications of inferior turbinate reduction include
postoperative hemorrhage, short- and long-term nasal dry-
ness and crusting, scarring, atrophic rhinitis, ozaena, and
“empty nose syndrome.” The reported rates of each of these
complications vary from one technique to another.5 As
previously mentioned, many of these complications may be
attributed to aggressive tissue resection and alteration of
normal nasal physiology. Many authors have observed that
patients who have a total resection of the inferior turbinates
can have a paradoxical sensation of nasal congestion, a
condition commonly referred to as “empty nose syndrome.”
The etiology of this condition is unknown but may be
related to the loss or alteration of the normal sensation of
breathing through the nose, including the loss of sensory
input from the turbinates themselves.25
Operative Techniques in Otolaryngology, Vol 25, No 2, June 2014
Given the important role the inferior turbinates play in
nasal physiology, many contemporary surgeons aim to strike
a balance between adequate tissue resection and preservation
of as much functional turbinate tissue as possible. This
objective has led some researchers to examine the effect that
different techniques in inferior turbinate reduction have on
mucociliary clearance, as well as the histopathologic features
of the turbinate. To date, results have been mixed with a
general trend toward better results with radiofrequency and
partial resection techniques and worse effects with electro-
cautery and laser techniques.30-38 A consensus based on
these results cannot be reached at this time.
Discussion
The optimal surgical technique for inferior turbinate
reduction is quite controversial. The existence of the
numerous surgical techniques is in itself indicative of
the lack of consensus regarding the best method to reduce
the inferior turbinates. Fortunately, the body of literature
assessing outcomes in inferior turbinate surgery has
improved in quality in recent years, and with continued
outcomes research, clinical decision making can be guided
increasingly by the reported data.
Outfracture
Lateralization of the inferior turbinate is generally
considered to have short-lived therapeutic success, owing
to the tendency toward remedialization over time. Goode26
indicates that not only does the turbinate tend to eventually
return to its original position, but the procedure also fails to
deal with the primary cause of its enlargement. This notion
has been partly challenged by Aksoy et al11 whose data
demonstrated a sustained reduction in the angle and distance
between the inferior turbinate bone and the lateral nasal wall
up to 6 months postoperatively. Nevertheless, most
surgeons consider this technique to be an adjuvant
procedure that works well only in combination with other
turbinate reduction techniques, but not alone.
Submucosal electrocautery
Much like the outfracturing technique, the submucosal
electrocautery technique is generally considered to have
short-lived therapeutic success. Fradis et al39 demonstrated
an improvement in nasal breathing in 76% of patients treated
with submucosal electrocautery 2 months after surgery.
However, Jones and Lancer40 showed that these results are
transitory with no significant difference between the nasal
resistances before surgery, and 15 months after surgery.
Similarly, Warwick-Brown and Marks41 demonstrated a
subjective improvement in only 54% of patients at 1 year
postoperatively, whereas Lippert and Werner42 demonstrated
an overall success rate of only 36% 2 years postoperatively.
Joniau et al43 also demonstrated an improvement in nasal
Jourdy Inferior Turbinate Reduction
breathing and a reduction in turbinate size at 3 months and 1
year after surgery, however, 5-year follow-up data revealed
that nasal obstruction and hypertrophy recurred.
Submucosal radiofrequency coblation
On the whole, inferior turbinate reduction by means of
radiofrequency coblation has shown encouraging short- and
long-term results. Several studies have demonstrated a
decrease in nasal obstruction up to 3 months after surgery,
including Fischer et al46 who demonstrated a subjective
improvement in 91% of patients.44,45 Nease and Krempl49
showed an improvement in nasal obstruction that was
sustained up to 6 months in a prospective, blinded,
randomized, placebo-controlled study, while additional
data reported by Bhattacharyya and Kepnes,47 as well as
Kizilkaya et al48 have also demonstrated a significant
decrease in nasal obstruction at this time interval. Longer-
term follow-up has revealed a sustained improvement.
Harsten50 reported an improvement in symptoms in 82% of
patients on short-term follow-up (4-9 months), and 78% of
patients on long-term follow-up (21-30 months). Mean-
while, Cavaliere et al51 demonstrated an improvement in
turbinate edema and nasal obstruction 20 months after
surgery with both monopolar and bipolar radiofrequency
coblation, and Porter et al52 showed continued benefits with
the overall ability to breathe 2 years after surgery in a
prospective, single blinded, randomized, placebo-controlled
trial. This decrease in nasal obstruction has been demon-
strated to last up to 5 years after surgery.53,54
Powered submucosal turbinate reduction
As with radiofrequency coblation, overall encouraging
short- and long-term results have been reported with
powered submucosal inferior turbinate reduction. In a
prospective study, Ozcan et al55 showed a significant
improvement in nasal obstruction, headaches, and nasal
dryness 6 months postoperatively. Friedman et al56 also
reported sustained improvement in nasal obstruction between
6 and 12 months of follow-up, with 75% of patients
reporting no nasal obstruction and 25% of patients reporting
only mild nasal obstruction after surgery. Huang and
Cheng57 found a significant decrease in nasal resistance as
well as improvements in quality of life measures, nasal
obstruction, rhinorrhea, sneezing, and postnasal drip 1 year
after surgery. A much longer 10-year follow-up study by
Yanez and Mora58 demonstrated that 91% of patients
reported no nasal obstruction, with only a 3% recurrence
rate of nasal obstruction. Furthermore, endoscopy, anterior
rhinomanometry, and mucociliary transit time measurements
revealed long-term improvements in this study as well.
Partial resection
Techniques that involve partial resection of the inferior
turbinate vary in the amount and location of tissue removal,
167
and consequently, demonstrate varied outcomes that are
difficult to compare. Wright et al demonstrated that although
trimming of the head of the inferior turbinate resulted in a
significant decrease in total nasal resistance to airflow, there
was no significant effect on subjective nasal obstruction.
Furthermore, up to 20% of patients had a reversal of their
initial improvement in nasal obstruction within 2 years of
follow-up.59,60 This is in contrast to the results reported by
Fanous18 who showed an improvement after anterior
turbinectomy in patients followed up for 6 months to 4
years after surgery.
Wexler and Braverman demonstrated good short-term
results in a prospective, nonrandomized study of the
resection of the medial and inferior portions of the inferior
turbinates. The patients in this study had a significant
improvement in nasal obstruction and sense of smell, with
subepithelial fibrosis and regenerated epithelium at least
4 months after surgery.61 Gupta et al62 used a similar
technique and found the improvement in symptoms held
true for patients between 6 and 40 months after surgery.
Using the technique whereby the turbinate bone and
attached lateral mucosa is resected, and the medial mucosa
is rolled into a neoturbinate, Mabry63 demonstrated a
marked improvement in nasal symptoms, including nasal
crusting and dryness. Joniau et al43 used a similar technique
and demonstrated a significant improvement in nasal
breathing and nasal discharge at 1 week, 3 months, and 1
year after the surgery. Reporting on a longer follow-up
period, Passali et al compared 6 different inferior turbinate
reduction techniques over a 6-year follow-up period in a
prospective randomized trial; a similar technique of partial
bone and lateral mucosa resection (with and without lateral
displacement of the remaining neoturbinate) produced the
best results with significantly improved nasal resistance,
nasal volume, and quality of life measures that remained
true through the 6-year follow-up period. Furthermore, only
this technique achieved normalized mucociliary transport
times.64
Chevretton et al studied the “degloving” technique
whereby the medial and inferior mucosa is removed down
to bone in a prospective study. They found a significant
improvement in peak inspiratory flow, and an overall
improvement in patient satisfaction with nasal symptoms
and obstruction up to 2 years after surgery, with no
significant change in postnasal drip and saccharin clear-
ance.23
Argon plasma coagulation
Inferior turbinate reduction by means of argon plasma
coagulation has generally demonstrated encouraging results.
In an initial study, Bergler et al65 reported an improvement
in nasal airflow in 67% of patients the first week after
surgery and 86% of patients after 3 months. Similarly,
Gierek and Jura-Szoltys66 reported an improvement in
nasal obstruction in 88% of patients 3 months after surgery
and 73% of patients after 12 months. In a subsequent
168
prospective study with a mean follow-up period of 12
months, Bergler et al20 again reported improved nasal
breathing in 76% of patients after 1 week, and 83% after 12
months, while histologic examination demonstrated
re-epithelialization in 63% of the patients at 6 weeks and
normal cilia after 3 months. Similarly, Ferri et al67 reported
improved nasal airflow in 87% of patients 2 years after
inferior turbinate reduction with argon plasma coagulation.
Laser techniques
Given the numerous laser types (ie, wavelength),
parameters (ie, power and energy), and application modal-
ities (ie, contact, noncontact, interstitial, and superficial) that
have been used, it is difficult to assess and compare the
efficacy of this technique for inferior turbinate reduction on
the whole. A review by Janda et al68 determined that laser
treatment of hyperplastic inferior nasal turbinates achieves
comparable results to most conventional techniques in the
short term, but seems to be less effective in the long term.
However, some authors have published encouraging results.
Katz et al69 reported a relief of nasal obstruction in 89%
of patients up to 5 years after treatment with the CO2 laser,
but a review of the literature reveals a wide range of long-
term success rates between 50% and 100% for this
technique.1 Lenz70 reported on his experience with the
argon laser and demonstrated an 80% patient satisfaction rate
at 5 years, whereas Vagnetti et al71 used the Nd:YAG laser
and reported an improvement in nasal breathing in 86% of
patients 1 year after treatment. Meanwhile, Kunachak et al72
reported on their use of the KTP laser, with 81% of patients
reporting good to excellent subjective improvement with 12-
20 months of follow-up. Orabi et al73 also reported
acceptable inferior turbinate reduction with the KTP laser
in 83% of patients, although they reported that 28% of
patients required medication again to aid in symptom
control. Reporting on their experience with the diode laser,
Janda et al74 reported a significant improvement in nasal
airflow and volume, with a subjective improvement in nasal
breathing in 86% of the patients at 6 months, and 76% of
patients 1 year after laser treatment; other studies have
reported similar success.75,76 However, despite the seem-
ingly encouraging results for many of the laser techniques
discussed, they are contradicted by studies like that of
DeRowe et al77 who reported a 1-year improvement of nasal
obstruction in 41% (diode laser), 47% (Nd:YAG laser) and
57% (CO2 laser) of patients. The holmium: yttrium
aluminum garnet laser has also demonstrated mixed results.
Although Leunig et al78 reported improved nasal breathing
in 77% of patients after 1 year, Serrano reported only a 52%
success rate with a mean follow-up of 16 months.
Conclusions
Surgical reduction of the inferior turbinates is an effective
treatment modality for patients with chronic nasal obstruction
due to inferior turbinate enlargement. Numerous effective
Operative Techniques in Otolaryngology, Vol 25, No 2, June 2014
techniques exist, but there is a lack of consensus regarding
the best one. Most surgeons, however, agree that a balance
must be struck between symptom improvement and
preservation of normal nasal physiology. Future surgical
decision making will undoubtedly be guided by the
continuously growing body of quality outcomes research.
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