Turbinate Laser Surgery

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INFERIOR TURBINATE: WHAT THEY ARE AND WHAT THEY DO

Inferior turbinates, whose skeleton consists of a small independent bone, are the longest and most voluminous nasal turbinates (4-5 cm). They have an oblong triangular shape, with its base at the head of the turbinate, a few millimeters from the nostril, and its posterior apex (or turbinate tail) 1 cm from the Eustachian tube outlet.

The respiratory portion of the nasal cavity, together with large sections of the olfactory portion, is covered by pink and smooth mucosa, about 2 millimeters thick in the septum area. It gets thicker, up to 5 millimeters, in the area of the inferior turbinates, as they are full of cavernosum or erectile tissue, especially around their head and tail.

Physical and chemical stimulation of the nasal mucosa is expressed in circulatory modifications – especially in the erectile tissue of the turbinates – variation of the nasal lumen, increased glandular secretions – predominantly serous and mucous.

At the same time this reflex can cause a decreased respiratory width and rate; the air can thus stay in contact with the nasal mucosa long enough to be modified in terms of temperature, humidity and purity.

The cavernosum tissue plays a particularly important role in vasomotor reactions. Since this tissue is mostly present in the inferior turbinates, these structures are essential for an adequate respiration. On the basis of these principles of anatomy and physiology, invasive surgery on inferior turbinates is progressively falling into disuse today.

Temperature and humidity of inhaled air are emblematic variables that characterize the vasomotor reaction of the inferior turbinates: cold air causes congestion of the corpus cavernosum, and so does dry hot air. On the contrary, humid hot air causes decongestion of the inferior turbinates.

Mechanical or chemical stimulation of the nasal mucosa causes an accentuated secretion of a particularly liquid, almost watery, substance.

The great secretory and vasomotor responsiveness of the nasal mucosa, which are closely related to each other, play a very important role in nasal defense.

This great responsiveness can lead from the physiological to the pathological, which means to the so-called nasal autonomic syndromes, such as hypertrophic vasomotor rhinitis of inferior turbinates.

INFERIOR TURBINATES HYPERTROPHY AND VASOMOTOR RHINITIS

Frequent viral infections and their lesions, necrotizing in particular, impair the defense mechanism in the surface of the mucosa, facilitating the penetration of both bacteria and environmental substances (antigens). In addition to being particularly widespread in the air (dust, pollen, mould), the latter, unlike bacteria, do not generate immediate local reactions (purulent rhino-sinusitis), but specific immune phenomena. They trigger the production of antibodies and when they meet, even after a certain time, they cause all the typical reactions of inferior turbinates hypertrophy (allergic rhinitis and vasomotor or pseudo allergic rhinitis).

In a healthy individual, the histamine liberated by antibody sensitization in the nose area, is almost immediately neutralized. This does not happen in those individuals who, because of genetic predisposition, have a reduced capacity to metabolize histamine, with subsequent developing of chronic inflammation of the mucosa in the inferior turbinates.

In case of allergic rhinitis due to nasal mucosa sensitization by pollen (pollinosis), animal epidermal residues (cats and dogs hair), fungus spores (mould) or environmental dust (dust mites), the nasal reactions in the corpus cavernosum of the turbinates occur only when the antigen load is sufficiently high. The reactions can thus be seasonal (grass allergic rhinitis) or perpetual (dust mites allergic rhinitis).

In simple vasomotor or pseudo allergic rhinitis, the lack of natural antihistaminic power in the nasal mucosa allows histaminic reactions every time that even non-specific stimuli (cold, heat, sunlight) cause the liberation of histamine in the inferior turbinates.

INFERIOR TURBINATES HYPERTROPHY: SYMPTOMS AND COMPLICATIONS

Nasal obstruction, more pronounced when lying or sleeping.
– Alternation of closed nasal cavity (some hours on the left side, others on the right)
– Increased mucus and phlegm production, dripping down the throat
Frequent headaches with no apparent reason
– Nasal polyps
Chronic sinusitis
– Frequent colds that heal slowly and with difficulty
– Proneness to sneezing
Sleeping apnea
Socially disturbing snoring
– Reduced sense of smell
– Muffled ear and reduced sense of hearing
– Frequent otitis
– Dry tickly cough
– Bronchial asthma
– Decongestant spray abuse and addiction (Azelastine spray, Naphazoline spray and others)

VASOMOTOR RHINITIS AND TURBINATES HYPERTROPHY DIAGNOSIS

Stage one necessary expert analysis:
Digital video fibroscopy of nasal cavities, nasopharynx and larynx
– Micro video otoscopy
Skin Prick Testing for inhalant allergy
Additional examinations if the specialist identifies any specific risk factor for specific complications or were there any diagnostic uncertainty:
– Maxillofacial CT without contrast (useful for the study of nasopharyngeal polyps and some forms of hyperplastic chronic rhino-sinusitis)
Home digital Polysomnography (recommended when nasal obstruction is part of a respiratory obstructive sleep apnea syndrome)
– Rhinomanometry (useful to understand if a nasal obstruction is not due to the turbinates, but to nasal bone deviation)
– Spirometry (In patients suffering also from bronchial asthma)
– Nasal cytology (refinement of diagnosis in case of vasomotor allergic rhinitis)

SIMPLE VASOMOTOR RHINITIS DRUG THERAPY

Cortisone based nasal spray (recommended for therapy cycles of no less than three weeks. An excessive use could thin the respiratory nasal mucosa, causing frequent and abundant bleeding and dry nose)
Systemic administration of antihistaminic pills (drugs of this category can cause, to varying degrees, day sleepiness and slow reflexes)
– Nasal cavities washing with sterile saline solutions
– Inhalation therapy at thermal baths
– Local or general antibiotic therapy (when, together with inferior turbinates hypertrophy, a bacterial infection is also identified)
– Nasal strip (recommended as night nasal obstruction adjuvant)
– Decongestant sprays or endonasal vasoconstrictor (their frequent use, or even abuse, can cause an additional disease: drug induced rhinitis, which is incurable because the corpus cavernosum of the turbinates loses its flexibility and becomes permanently obstructed)

TURBINATE SURGERY TO CURE VASOMOTOR RHINITIS

Surgical treatment of turbinate hypertrophy involves operating under general anesthesia with nasal tampon, or ambulatory treatment under local anesthesia without nasal tampon, which can be considered a good innovation in nasal surgery.

According to the specialist’s diagnosis a procedure will be recommended, either in surgery or ambulatory.

Treatments under general anesthesia (surgery):
Inferior turbinates reduction with CO2 laser
Inferior turbinates reduction with Nd:YAG laser
Inferior turbinates reduction with diodes laser
Computerized radio-frequency decongestion of inferior turbinates sub-mucosa
– Inferior turbinates reduction with Argon Plasma

INFERIOR TURBINATES DECONGESTION AND REDUCTION WITH LASER

Inferior turbinates laser surgery is an ambulatory procedure:
under local anesthesia (Applying an anesthetic spray, only the inner part of the nose is anesthetized for about 30 minutes)
painless

– without bleeding (no nasal tampon is thus applied)
– respecting and preserving all nasal mucosa functions (olfactory, defensive, respiratory)
– with no risk of infection (no antibiotics are necessary prior to or following the treatment)
with fast recovery and no convalescence (on average the turbinates regain their natural volume and the patient is able to breath freely within 3 days from the treatment)
– can be repeated
effective even in patients suffering from allergic rhinitis (pollen, dust, mould and other allergens) and heavy smokers

The choice of the type of laser to be used is made by the ENT surgeon according to endoscopic findings, data and recommendation of international scientific literature and considering the personal medical history of the patient.

In order to perform the right therapeutic choice for each patient and avoid applying the same therapy to very different patients, an ENT laser surgery ambulatory must be able to use several laser types (and computerized radio-frequency devices too).

CO2 (carbon dioxide) laser is one of the safest, most versatile and widely used lasers in otorhinolaryngology: it is chosen to reduce inferior turbinates hypertrophy, especially at the head of the turbinates, i.e. the front: it emits point-shaped pulse light which ensures high precision in the areas to be treated. The direct impact of the CO2 laser on the turbinates surface, from outside the mucosa, immediately vaporizes excess tissue. The following healing of the treated area leads to a quick and conspicuous retraction of the turbinates, which actually “deflate”, leaving more respiratory space in both nasal cavities

On the other hand Nd:YAG laser operates via optical fiber from outside the mucosa or, when the structure of the turbinates allows its insertion under the surface, from under the mucosa: light penetrates the corpus cavernosum by diffusion and not by direct impact as for CO2 laser. This procedure is especially recommended for the correction of longitudinal hypertrophy in the inferior turbinates, i.e. a swelling going from the head to the tail.

Finally, diodes laser has a similar application to Nd:YAG laser, presenting however a significantly slower recovery.