Chapter 23 Bipolar radiofrequency cold ablation turbinate reduction for obstructive inferior turbinate hypertrophy
As such, medical or surgical treatment of inferior turbinate hypertrophy may improve symptoms associated with OSA and/or snoring in many ways. Enhancement of nasal airflow may allow for increased nasal versus mouth breathing or improved tolerance of continuous positive airway pressure (CPAP). Given the association between allergic rhinitis alone and reduced sleep quality, improvement of nasal obstruction may also independently improve sleep quality.
When pharmacologic management of nasal obstruction secondary to inferior turbinate hypertrophy fails, surgical therapy should be considered. Many treatment modalities for inferior turbinate hypertrophy have been prescribed including partial turbinectomy (bone and soft tissue) and turbinate reduction by various modalities including electrocautery, radiofrequency ablation, laser ablation, radiofrequency cold ablation (coblation) and submucous resection. Since most of these methods have demonstrated good clinical effectiveness, those procedures that are minimally invasive with limited side effects have been recently favored including office-based radiofrequency techniques. This chapter details patient selection procedural details, perioperative management and outcomes with coblation inferior turbinate reduction.
As with any surgical procedure, patient selection has a tremendous impact on postsurgical outcomes. Although many patients with OSA and/or snoring complain of nasal obstruction or nasal congestion, the etiologies for these symptoms may be multiple and multifactorial. Conversely, a number of patients with OSA/S may complain little about symptomatic nasal obstruction but upon examination are found to have several anatomic factors that may contribute to nasal obstruction. Therefore, independent of reported symptoms, all patients with OSA/S require a detailed nasal examination, typically including fiberoptic trans-nasal endoscopy. The examiner must note the presence or absence of inferior turbinate hypertrophy, nasal septal deviation, sinonasal polyposis and adenoid hypertrophy. Other factors that may also contribute to nasal obstruction (i.e. making one or more of the above more symptomatic) but may be less anatomically evident include nasal valve collapse and the relative size of the piriform aperture.
With respect to inferior turbinate hypertrophy, the relative size of the inferior turbinate along its full length must be assessed. It is not uncommon to find patients with relatively normal-appearing anterior inferior turbinates, but with very pronounced posterior (tail) cobblestoned turbinate hypertrophy. The relationship of the inferior turbinate hypertrophy to nasal septal deviation in particular should be assessed. Some patients with septal deviation may yet still be candidates for inferior turbinate reduction alone if the turbinate component is felt to contribute substantially more to the nasal obstruction. Unfortunately, no clear-cut testing modality will define the individual contributions to nasal obstruction for these anatomic factors. However, we and others have found that a topical nasal decongestant test with neosynephrine or oxymetazoline may help identify patients more likely to benefit from inferior turbinate reduction. Patients must be cautioned that this pharmacologic turbinate reduction is supraphysiological and may exaggerate what is achievable with mechanical inferior turbinate reduction. Those patients who demonstrate an improvement in their subjective sense of nasal breathing and/or objectively demonstrate improvement in their nasal patency (as measured by acoustic rhinometry or nasal endoscopy) are more likely to achieve benefit with inferior turbinate reduction alone. We avoid mixing topical lidocaine in conjunction with topical decongestants because it may confound the patient’s subjective assessment of their nasal breathing. A small fraction of patients will have limited improvement with topical decongestion, still demonstrating large inferior turbinates. These patients often have a large bony (concha) inferior turbinate and may be better candidates for submucous resection techniques. Patients with significant nasal septal deviation (especially in the anterior or mid-nasal cavity), sinonasal polyposis or adenoid hypertrophy are often not good candidates for inferior turbinate reduction alone.
Part of patient selection is appropriate patient counseling and ensuring the patient’s understanding of the goals of the procedure as well as treatment outcomes. Patients should be informed and understand that coblation inferior to reduction may be only component in addressing nasal obstruction with further therapy being required. Further therapy may include repeated coblation inferior turbinate reduction sessions to address middle or posterior turbinate hypertrophy or further sessions to achieve the desired volume of turbinate reduction.
Patients are typically apprised of the procedure and given perioperative instructions prior to the procedure. Informed consent is obtained for all patients and includes a discussion of the risks and benefits of procedure, including the rare risk of smell disturbance as well as the infrequent risks of postoperative crusting, bleeding and/or pain.
The coblation inferior turbinate reduction procedure is most commonly performed in the outpatient setting. In patients who have isolated turbinate hypertrophy as a cause of their nasal obstruction (or minimally impacting nasal septal deviation) we prefer to perform this procedure in the outpatient setting prior to any adjunctive sleep apnea procedures. This allows patients to maintain a patent nasal airway in the immediate postoperative period after other surgical procedures for OSA. However, the procedure can be performed simultaneously with nasal septoplasty and/or other adjunctive surgical procedures for OSA in the operating room setting provided the plasma field generator is available.
Patients are positioned upright in the procedure chair in the clinical examination room. Visualization of the anterior aspect of the nasal cavity is readily provided by a nasal speculum and headlight illumination as seen in Figure 23.1. The inferior turbinate dimensions both in terms of cross-sectional area occupied and anterior–posterior length of hypertrophy are determined. Infrequently, preoperative sedation or preoperative pre-emptive pain medication may be provided for anxious individuals. The procedure for anesthesia of the nasal cavity is a very important component of outpatient coblation inferior turbinate reduction and actually takes up much of the operative time. The nasal cavity is sequentially anesthetized, first with spray application of a lidocaine/phenylephrine mixture. After a few minutes, this is then followed by a direct contact anesthesia applied in the form of a cottonoid pledget soaked in cetaccainephenylephrine which is placed in the anterior one half of the nasal cavity, maximizing contact with the inferior turbinate. After an additional few minutes have elapsed, these pledgets are removed, an additional 2–3 ml up 2% lidocaine has infiltrated in each anterior inferior turbinate head, extending from the mucosal surface to the periosteum of the inferior concha. Additionally, we have found that further anesthetic injections just lateral to the piriform aperture, slightly anterior to the anterior head of the inferior turbinate, provide additional anesthesia to the infraorbital nerve branches to the inferior turbinate, increasing patient comfort and tolerance for the procedure. Occasionally, even after these steps with anesthesia, patients still may have some pain with the coblation procedure, especially as the middle to posterior aspects of the inferior turbinate are treated. In these patients, it is helpful to provide a sphenopalatine nerve block with a slightly bent spinal needle as indicated in Figure 23.2. For a sphenopalatine nerve block, 1–2 ml of 1% lidocaine with epinephrine are instilled just posterior and slightly inferior to the posterior attachment of the middle turbinate. This is best done with a 3 ml injection syringe coupled to a slightly bent 22-gauge spinal needle (Fig. 23.3). On occasion, endoscopic guidance may facilitate this posterior nerve block. Alternatively, a transoral, greater palatine foramen approach to the sphenopalatine ganglion for this additional nerve block may be employed.
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