Turbinate surgery

What repeats

Five findings that hold across the literature.

Reducing the turbinate adds to what a septoplasty does

Twelve randomised trials enrolling 775 adults compared septoplasty alone with septoplasty plus reduction of the inferior turbinate. Reducing the enlarged turbinate on the wider side gave better NOSE scores. In a separate trial, 40 patients with a deviated septum and stubborn allergic rhinitis had septoplasty alone and 40 had septoplasty with bilateral turbinoplasty; NOSE scores were better with the added turbinoplasty at every follow-up, while days off work and clinic visits were the same in both groups.

Rests on: Bin Lajdam et al., turbinate meta-analysis · Ghosh et al., bilateral turbinoplasty · and septoplasty.

Methods that spare the lining hold up over years

Nineteen patients had powered turbinoplasty on one side and submucosal cauterisation on the other and were followed to five years. Powered turbinoplasty was better on every measure, and cauterisation was followed by the turbinates enlarging again. In 60 patients randomised to coblation or microdebrider, symptom improvement and acoustic rhinometry at 12 months favoured the microdebrider. Pooling seven randomised trials, the microdebrider gave better nasal obstruction scores early and late, and better rhinomanometry at long-term follow-up.

Rests on: Joniau et al., five-year comparison · Lee and Lee, coblation versus microdebrider · Mirza et al., pooled randomised trials.

No single method wins on every outcome

A network meta-analysis set six methods against submucosal resection. Microdebrider-assisted turbinoplasty performed strongly on symptom reduction and cross-sectional area and ranked lower on mucociliary transit time. Radiofrequency preserved mucociliary function best and had the lowest rate of mucosal tearing. Coblation, radiofrequency and submucosal diathermy all reduced bleeding risk against the reference, and partial inferior turbinectomy raised it. Submucosal diathermy was significantly less effective at relieving obstruction at 12 months, and laser ranked low in most domains.

Rests on: Kim et al., network meta-analysis.

Taking out too much causes empty nose syndrome

Empty nose syndrome follows total or near-total resection of the inferior turbinate. The patient feels blocked while the airway measures wide open, with dryness and crusting. Diagnosis uses a validated questionnaire and the office cotton test. Three meta-analyses covering more than 1500 cases report sustained quality-of-life gains after reconstruction, alongside heterogeneity that the reviewers call substantial. Prevention is minimising how much inferior and middle turbinate is lost in the first operation.

Rests on: Talmadge et al., postsurgical empty nose syndrome · Aguirre-Peña et al., meta-analysis of meta-analyses · Chhabra and Houser, diagnosis and management.

Smell improves on the side that was blocked

Forty-seven patients with a deviated septum, enlarged turbinates or both were tested against 20 healthy controls with a smell test given in each nostril separately. Before surgery every measured characteristic was worse on the narrow side than the wide side. Twelve months after septoplasty, turbinoplasty or both, smell function and quality of life had improved significantly.

Rests on: Mackers et al., smell after nasal surgery.

By how the turbinate is reduced

The methods, and what each one is measured to do.

Radiofrequency, inside the turbinate

A needle heats the tissue under intact lining and the turbinate shrinks as it heals. Nineteen patients from a placebo-controlled trial were followed to two years with the benefit in frequency of obstruction, severity of obstruction and overall ability to breathe maintained and no complications. In 150 patients randomised to a bipolar or a monopolar device, both improved symptoms from the first month and nothing separated them from month three to month 20.

Rests on: Porter et al., two-year results · Cavaliere et al., monopolar and bipolar.

Microdebrider, under a flap of lining

The lining is lifted, the swollen tissue underneath is removed with a powered blade and the lining is laid back. This is the method that carried the long-term comparisons above. Against quantum molecular resonance in seventy patients, the microdebrider gave better symptom scores from the first month and more post-operative bleeding and swelling, with turbinate size the same at long-term follow-up.

Rests on: Mirza et al. · Maniaci et al., submucosal turbinoplasty trial.

Coblation, at lower temperature

In 108 patients having septoturbinoplasty, 55 with a medial flap turbinoplasty and 53 with a coblation turbinator, both groups improved on symptom scores, NOSE and SNOT-22, and the coblation group improved more on NOSE and SNOT-22.

Rests on: Nguyen et al., 108 cases · Kim et al..

Cautery and diathermy, the older methods

Submucosal cauterisation was the losing side of the five-year split-nose comparison, followed by the turbinates enlarging again. In the network analysis, submucosal diathermy was significantly less effective at relieving obstruction at 12 months.

Rests on: Joniau et al. · Kim et al..

Anterior turbinoplasty and laser, in a three-arm trial

Sixty patients having septoplasty were randomised to anterior turbinoplasty, radiofrequency ablation or submucous radial diode laser. Breathing improved in all three arms at every visit. The gain in the volume between the nasal valve and the body of the turbinate was significant for anterior turbinoplasty and radiofrequency at three months and two years, and the laser arm reached significance at no visit.

Rests on: Veit et al., three-arm randomised trial.

Cutting part of the turbinate away

A 1991 series of 308 cases set conservative turbinoplasty against the more destructive turbinotomies and reported both as good in skilled hands. In the modern network analysis, partial inferior turbinectomy sat in the middle for symptoms and carried higher bleeding risk.

Rests on: Galetti et al., 308 cases · Kim et al..

What to ask about turbinate surgery

Questions the evidence supports asking.

How much of the turbinate stays

The methods that keep the lining and remove tissue underneath are the ones with five-year data behind them, and total resection is the route to empty nose syndrome. Ask whether the operation is submucosal, and what proportion of the turbinate remains.

Rests on: Joniau et al. · Talmadge et al. · Chhabra and Houser.

Is this being done with a septoplasty or on its own

Most of the randomised evidence sits inside septoplasty trials. Ask which side is being reduced and why, since the pooled benefit came from reducing the enlarged turbinate on the wider side.

Rests on: Bin Lajdam et al. · and septoplasty.

Will it need doing again

Cautery was followed by the turbinates enlarging again in the five-year comparison, while powered reduction held. Radiofrequency held to two years in one series and to 20 months in another. Ask the surgeon what their own repeat rate is for the method they use.

Rests on: Joniau et al. · Porter et al. · Cavaliere et al..

What does the nose do that the turbinate is responsible for

The turbinate warms, humidifies and directs air, and the sensation of a clear nose depends on airflow receptors as well as on the size of the passage. Ask what is being traded for a wider airway.

Rests on: Hsu and Suh, anatomy and physiology · and nasal airway obstruction.

The terms, defined

The words used about this operation.

• Inferior turbinate: the lowest of the shelves on the side wall of the nose, and the one reduced in this operation. [29941182]
• Turbinate hypertrophy: enlargement of that shelf, one of the common anatomic causes of a blocked nose. [29941182]
• Turbinoplasty: reduction that keeps the lining and the bone framework. [2011375]
• Turbinectomy: removal of part or all of the turbinate. [41094220]
• Submucosal: done under the lining, with the surface left intact. [35076746]
• Radiofrequency volumetric tissue reduction: heat applied inside the turbinate through a needle. [16585858]
• Coblation: a bipolar radiofrequency device used to reduce turbinate tissue. [16652079]
• Microdebrider: a powered rotating blade used to remove tissue under a lifted flap. [16652079]
• Mucociliary transit time: how long the lining takes to move mucus back through the nose, used as a measure of whether the lining still works. [41094220]
• Acoustic rhinometry: sound reflection used to measure cross-sectional area and volume inside the nose. [16652079]
• Empty nose syndrome: the feeling of blockage in a wide-open nose after too much turbinate has been removed, with dryness and crusting. [31587766]
• ENS6Q: the six-item questionnaire validated to identify empty nose syndrome. [40461852]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess in the airway before operating and what belongs in the record afterwards.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries two chapters covering this operation and the instruments used for it. They are written for surgeons and go further into technique than a patient page should.

• Septoplasty and Turbinate Surgery
• Powered Instrumentation for Rhinoplasty and Septoplasty

The reference summaries

Three StatPearls chapters on the National Library of Medicine's Bookshelf cover the turbinate and the two medical causes of its swelling, in full text at no charge.

• Anatomy, Head and Neck, Nasal Concha, the turbinate itself.
• Nonallergic Rhinitis (Vasomotor Rhinitis).
• Rhinitis Medicamentosa, swelling caused by decongestant spray.

The societies

• ENT Health, the patient site of the American Academy of Otolaryngology, on turbinate hypertrophy.
• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Devices and anaesthesia for turbinate reduction are under test in registered trials.

• Post-Market Clinical Study to Evaluate the Safety and Effectiveness of REFLEX ULTRA 45 for Coblation Inferior Turbinate Reduction in China, recruiting, 105 participants.
• Turbinate Volume Reduction Under Local Anesthesia: Randomized Clinical Trial, completed, 90 participants.
• Evaluation of the Outcome of Septoplasty With or Without Inferior Turbinate Reduction, not yet recruiting, 40 participants.

What is not settled

• Rankings change with the outcome chosen. The method best for symptoms is not the method best for mucociliary function or for bleeding. [41094220]
• In children the evidence is thin. Eleven studies covering 730 cases used outcome measures varied enough that they could not be compared, and long-term effects on airflow and nasal physiology remain unstudied. [19818515]
• Empty nose syndrome has a contested definition, and the meta-analyses behind its surgical treatment overlap in their primary data. [40461852] [31587766]
• The comparative trials are small. The five-year comparison had 19 patients and the two-year radiofrequency series had 19. [16954990] [16585858]
• Whether the older destructive procedures are acceptable in experienced hands was argued in a series of 308 cases and has not been retested against modern outcome measures. [2011375]