Primary nasal tuberculosis: a case report

We report a case of a 36 year old woman who presented a chronic rhinitis and a hypertrophy of the inferior turbinates. Primary nasal tuberculosis was discovered by chance after the inferior turbinectomy. Primary nasal tuberculosis is very rare and is more frequent in women. Symptomatology is often unilateral with nasal obstruction, anterior rhinorrhea or epistaxis. The clinical examination may discover ulceration or a polyp located generally in the nasal septum or the inferior turbinate. Diagnosis relies on the anatomopathologic and bacteriological examinations. The treatment is mainly medical based on antituberculosis drugs. In the light of this case report, a review of the literature was made.     

等离子下鼻甲部分消融术与吸切钻下鼻甲部分切除术

目的比较等离子下鼻甲部分消融术与吸切钻下鼻甲部分切除术对慢性肥厚性鼻炎患者术中、术后的影响。方法等离子组患者25例,对照组14例。等离子组用低温等离子射频消融系统连接45号刀头,行下鼻甲前、后部中隔侧的4～6通道消融。对照组用吸切钻自前向后切割下鼻甲肥厚黏膜,术后需填塞止血2日。术后患者对疼痛和鼻堵程度采用VAS评分。术前、术后1个月、3个月、6个月均由医师对每侧下鼻甲进行评分,由患者评估鼻堵程度和频度。结果等离子组术中出血较对照组明显减少,术后疼痛和鼻堵程度较轻。术后1个月等离子组和对照组的鼻堵程度、鼻堵频度和下鼻甲体积较术前均有明显改善,二者改善的程度无明显差别。术后3个月两种术式均疗效稳定且等离子组鼻堵频度进一步改善。术后6个月两种术式疗效依然稳定。结论等离子下鼻甲部分消融术创伤小,术中、术后出血少,痛苦小;术后1个月患者主观症状与客观体征均有明显改善;术后3个月患者主观症状进一步改善;术后6个月内疗效均稳定且与吸切钻下鼻甲部分切除术疗效相当。     

Inferior turbinectomy in children

BACKGROUND: Inferior turbinectomy on patients of all ages is a controversial procedure. Its effect on children has been reported little in the literature and the few studies that are available involved relatively older children, i.e., >10 years old. Nasal obstruction caused by extensive hypertrophy of the inferior turbinates is not an uncommon observation in the pediatric population. The clinical manifestations might present as snoring, noisy breathing, mouth breathing, and, possibly, sleep apnea. METHODS: In this study, we followed 227 children <10 years of age who underwent inferior turbinectomy (27 children also underwent a revision of an earlier adenoidectomy), of whom 179 children had significant relief of nasal obstruction at the 1-year follow-up. RESULTS: Nocturnal breathing was reported to be more regular and otherwise improved in the 36 children with a suspected history of sleep apnea. Forty-two of 47 children who had thick nasal secretions and did not respond to antibiotic therapy before the operation had significant relief postoperatively. Postoperative complications were few and their number did not exceed that of adults. CONCLUSIONS: A complete inferior turbinectomy should be considered in children <10 years of age who have hypertrophied inferior turbinates that cause major interference with nasal breathing.     

How we do it: Radiofrequency‐turbinectomy for nasal obstruction symptoms

? Radiofrequency energy has been reported to be effective to reduce nasal obstruction because of inferior turbinate hypertrophy. ? A total of 158 patients who had undergone such surgery are reported. ? Three to 30 months postoperatively 85% of the patients reported a marked decrease in nasal obstruction. This was irrespective of a short‐term or a long‐term follow‐up, and was applicable to patients that had septal deviations in addition. ? Radiofrequency‐turbinectomy is a simple and effective method for treatment of nasal obstruction as a result of hypertrophy of the inferior turbinates, even if combined with a moderate septal deviation.     

Comparison of the effects of radiofrequency tissue ablation,CO2 laser ablation,and partial turbinectomy applications on nasal mucociliary functions

OBJECTIVES: One of the major causes of chronic nasal airway obstruction is disease of the inferior turbinate. However, there is no agreement on how to deal with this problem. Comparison was made of the nasal functions after treatment by radiofrequency tissue ablation, laser ablation, and partial turbinectomy using subjective symptom scores and objective tests. STUDY DESIGN: Prospective, randomized clinical trial. METHODS: The study was conducted on three groups of 45 adult volunteer patients with symptoms and signs of nasal obstruction and stuffiness related to enlarged turbinates. In group A, laser ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group B, radiofrequency tissue ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group C, patients who were not treated by any surgical techniques were the control subjects. Clinical examinations, visual analogue scales, rhinomanometry, and isotopic study of nasal mucociliary transport time were used to assess treatment outcomes. RESULTS: At 12 weeks after surgery, the nasal mucociliary transport time results were compared in the same patients. The average time was 25.60 minutes on the side where laser ablation was applied and 11.40 minutes on the side where partial turbinectomy (PT) was applied. In the patients on whom radiofrequency tissue ablation and partial turbinectomy were applied, the average nasal mucociliary transport time was 10.33 minutes on the radiofrequency tissue ablation side, whereas it was 11.33 minutes on the partial turbinectomy side. Rhinomanometric measurements demonstrated a significant decrease in nasal resistances at 12 weeks in both sides in groups A and B. CONCLUSIONS: In the study it was demonstrated that radiofrequency tissue ablation to the turbinate is effective in improving nasal obstruction objectively and in preserving nasal mucociliary function. Laser ablation of the turbinate is effective in improving the nasal obstruction; however, it disturbs the mucociliary function significantly. With the partial turbinectomy technique, results obtained were similar to the results with the radiofrequency tissue ablation technique.     

Laser inferior turbinectomy under local anaesthetic: a well tolerated out-patient procedure

The suitability of performing laser inferior turbinectomy under local anaesthesia in an out-patient setting was assessed, regarding its effectiveness and patients' toleration of the procedure. Prospective data collection was undertaken from 129 patients undergoing laser inferior turbinectomy over four years. Patients were assessed, pre-operatively, operatively and at two weeks and three months post-operatively, for pain, complications and symptoms, using the sino-nasal assessment questionnaire. All patients had hypertrophied inferior turbinates. Ninety-eight patients complained of nasal obstruction and 67 had the procedure as part of treatment for snoring. One hundred and twenty-one of the patients had treatment to both inferior turbinates. There were no cases of intra-operative haemorrhage. The average pre-operative sino-nasal assessment questionnaire score was 18.22, which improved to 10.68 at the three month post-operative assessment (p<0.001). Five patients had significant intra-operative pain. This study shows that laser inferior turbinectomy under local anaesthesia is well tolerated and that good results can be achieved when performing the procedure in the out-patient department.     

A comparison of anterior and radical trimming of the inferior nasal turbinates and the effects on nasal resistance to airflow

A study of 18 patients with chronic rhinitis who underwent anterior or radical trimming of the inferior turbinates is presented. Radical trimming produced a significant decrease in both total nasal resistance to airflow and subjective nasal obstruction (P less than 0.005). Anterior trimming produced a significant decrease in total nasal resistance to airflow (P less than 0.05), but had no significant effect on subjective nasal obstruction. These results suggest that the main site of nasal resistance in patients with chronic rhinitis is the same as in the normal nose. On the basis of this study, adoption of anterior trimming in place of radical trimming of the inferior turbinates cannot be recommended.     

Trimming of the inferior turbinates: a prospective long-term study

The aim of this study was to determine whether the initial benefits of radical trimming and anterior trimming of the inferior turbinates on nasal airflow persisted in the long term. Radical trimming significantly reduced nasal resistance at 2 months following operation (n = 12) (P less than 0.005). There was no significant change in nasal resistance over the next 20 months. Symptom scores for nasal obstruction also showed a significant reduction (n = 16) (P less than 0.005), at 2 months, and did not change significantly over the next 20 months. Radical trimming of the inferior turbinates is a highly effective operation in patients with hypertrophy of the inferior turbinates with few initial complications. However, further analysis of the data revealed that up to 20% of patients lose the initial subjective benefit of relief of nasal obstruction within 2 years of follow-up. Late onset crusting occurs in some patients though this is not directly attributable to an increase in nasal airflow. This study also concludes that anterior trimming of the inferior turbinates cannot be recommended as a form of treatment.     

A randomised clinical trial of turbinectomy for compensatory turbinate hypertrophy in patients with anterior septal deviations

Turbinectomy is performed at the time of nasal septal surgery by many otolaryngologists. One reason given for this procedure is the presence of a hypertrophied contralateral inferior turbinate. A randomised trial was undertaken to evaluate the relief of nasal obstruction following contralateral turbinectomy with septal surgery. Patients presenting with nasal obstruction who had a unilateral septal deviation and contralateral inferior turbinate enlargement were prospectively randomized to contralateral turbinectomy or no turbinate surgery at the time of septal surgery. Questionnaires and active anterior rhinomanometry were used for evaluation. Twenty-six patients (mean age 31 years) demonstrated a reduction in subjective and objective measures of nasal obstruction (P < 0.05) 8 weeks after operation. There was no intergroup difference, the median total decongested nasal resistance postoperatively in the non-turbinectomized patients was 0.17 kPal-1 s and 0.21 kPal-1 s in the turbinectomized patients. Contralateral inferior turbinectomy does not add to the relief of nasal obstruction beyond that attained by septal surgery in these patients.     

Histopathological verification of clinical indications to partial inferior turbinectomy.

Surgical treatment in cases where disturbances of the nasal patency causes changes in the nasal inferior turbinates is controversial. The authors performed light- and electron microscopy and morphometric examinations of the mucous membrane of the nasal inferior turbinates obtained after partial inferior turbinectomy in patients with vasomotor and perennial allergic rhinitis and compensation hypertrophy of the nasal inferior turbinate accompanied by nasal deviation of the septum. In specimens obtained from patients with vasomotor rhinitis, a small number of glands and fibrosis of the lamina propria was observed. In specimens obtained from perennial allergic rhinitis patients, plenty of glands and large oedema was observed. In the group with compensatory hypertrophy of the inferior turbinate, normal glands and fibred areas around the vessels were observed. The largest histopathological changes of degeneration and hypertrophy of the nasal mucosa were observed in vasomotor rhinitis patients. Histopathological examination of nasal mucosa slides confirmed the usefulness of a partial inferior turbinectomy, but only in vasomotor rhinitis patients.     

Inferior turbinectomy: comparison of four techniques

As yet, there is not totally satisfactory means for treating hypertrophied turbinates and the proper management of turbinate dysfunction remains in question. In the present series, four of the widely practiced surgical procedures for the reduction of the size of the inferior turbinates were evaluated and compared. In all cases turbinectomy was performed as an isolated procedure. Eighty patients with chronic non-allergic rhinitis and hypertrophied inferior turbinates were selected, randomly divided into four groups, and followed up post-operatively for one year. Study of the results indicated that the beneficial effect of the operation is mainly mechanical by reduction of the resistance to nasal airflow. The post-operative improvement in smell acuity correlated positively with the increased patency of the nasal airway. None of the procedures had a deleterious effect on olfactory acuity. In contrast, the operation failed to enhance the mucociliary clearance rate or significantly decrease nasal drainage. Partial inferior turbinectomy and laser turbinectomy improved nasal breathing in 77 per cent of patients, and enhanced olfactory acuity in 78 per cent of patients who had pre-operative hyposmia. The results of turbinoplasty and cryoturbinectomy were less favourable. The surgical technique, advantages, and drawbacks of each of these procedures are discussed.     

Surgical treatment of inferior turbinate hypertrophy with argon plasma: a long-term follow-up in 157 patients

Surgical treatment of the inferior turbinate in patients with chronic hypertrophic rhinitis that does not respond to medical treatment is a well established procedure. CO2 laser, YAG laser, KTP laser, conventional electrocautery, cryotherapy, chemosurgery and turbinectomy or submucosal turbinectomy have been performed for the removal of nasal obstruction. Argon Plasma Coagulation (APC) is a new, innovative technique in Otorhinolaryngology which is based on high-frequency electrocoagulation with an argon-gas source. The shorter surgical times, the absence of hemorrhagic complications and, in rhinosurgery, not requiring any kind of nasal packing are remarkable. Between March and November 2000, a group of 157 patients with symptoms of nasal obstruction due to hypertrophic inferior turbinates were treated using APC, at the Otorhinolaryngology Surgical Department of the Hospital of Dolo (Venice). The follow-up period was 24 months. Rhinomanometry was performed to objectively measure the nasal obstruction and to verify the postoperative improvement. The Student t-test was used for statistical data. After 24 months, 87% (p < 0.001) of patients reported to have a better nasal airflow than before the operation. None of the patients needed a nasal packing after APC surgery. We review and discus the indication, advantages, complications, controversies and long-term results of the treatment with APC in rhinosurgery.     

Long-term results of trimming of the inferior turbinates

The long-term benefit of trimming of the inferior turbinates for nasal obstruction is unclear and our aim was to assess this. Fourteen patients who had had pre-operative nasal symptom scores and anterior rhinomanometry prior to inferior turbinate resection were reassessed at least 7 years post-operatively. Both nasal symptom scores for obstruction and nasal resistance had increased significantly in the intervening time period. Nasal crusting and hypertrophy of the cut inferior turbinate are considered to be responsible for this. Patients should be warned some degree of nasal obstruction may recur post-operatively.     

Dehiscence of the greater palatine nerve. A risk factor in inferior turbinectomy?

Inferior turbinectomy, often combined with septal surgery, is frequently performed in the surgical treatment of nasal obstruction. A patient with post-operative greater palatine anaesthesia occurring after this procedure prompted a study of the anatomy of the greater palatine nerve in the region of the inferior turbinate. Sixty-four lateral nasal walls were examined in cadavers. A dehiscence rate of 22% was noted, and in an additional 55% there was only a minimal bony covering to the nerve. Dehiscences occurred exclusively in the inferior meatus, anterior to the posterior bony end of the inferior turbinate. The narrow antero-posterior extent of the dehiscence, the hard dense lateral nasal wall bone and the lateral position of the nerve in the canal help to protect the nerve from surgical trauma during turbinate surgery.     

Laser-turbinectomy: long-term results

Hypertrophy of the inferior turbinates is a common cause of nasal obstruction. Many cases respond to medical treatment with topical steroids or antihistamines. In some patients, however, this therapy is not sufficient and through the years many surgical procedures have been used to reduce the size of the inferior turbinates, but without any satisfactory long-term results. Furthermore, these procedures have often been painful to the patient and post-operative complications such as bleeding and crusting have not been uncommon. However, instead of conventional surgery of the turbinates, laser-surgery can be used to reduce their size. In order to investigate the long-term effect of such gross reduction of the turbinates we investigated the post-operative condition of 78 patients who had undergone CO2-laser-turbinectomy due to symptoms of nasal obstruction. Twenty-four to 36 months post-operatively three quarters of all the patients reported a marked decrease in nasal obstruction as well as a reduced frequency of nasal and sinus infections. No complications were reported and the procedure was without any discomfort to the patient. Thus, laser-turbinectomy seems to be an effective, simple and painless method for treatment of nasal obstruction due to hypertrophy of the inferior turbinates.     

Complications following total inferior turbinectomy: facts or myths?

Various surgical procedures have been described for the relief of chronic nasal obstruction due to inferior turbinate hypertrophy, but none has been consistently satisfactory. We have performed total inferior turbinectomy for this condition for 5 years. Of the 39 patients followed for at least 2 years, 90% were relieved permanently of nasal obstruction. However, only 36% and 61% of patients with rhinorrhoea and anosmia respectively were relieved of these symptoms. Complications were minimal. It is concluded that even in a dry, dusty tropical climate, inferior turbinectomy does not appear to disturb the function of the nasal cavity appreciably.     

Argon plasma surgery for treatment of inferior turbinate hypertrophy: a long-term follow-up in 157 patients

Chronic nasal obstruction is a common disorder, mostly caused by hypertrophic inferior turbinates. In cases of nonresponse to conservative medical management, the surgical reduction of the inferior turbinates is often required. Surgical techniques for the reduction of hyperplastic nasal turbinates include monopolar or bipolar coagulation, partial or total reduction of the turbinates with a conchotome or scissors and laser surgery with Nd:YAG, CO(2) or KTP. Argon plasma coagulation (APC) is a new, innovative technique in otorhinolaryngology which is based on high-frequency electrocoagulation with an argon gas source. The fast and short surgery times, the absence of hemorrhagic complications and, in rhinosurgery, the complete abstention from any kind of nasal packing are remarkable. Between March and November 2000, a group of 157 patients with symptoms of nasal obstruction due to hypertrophic inferior turbinates were treated using APC, at the Otorhinolaryngology Surgery Department of the Hospital of Dolo (Venice). The follow-up period was 24 months. Rhinomanometry was performed to objectively measure the nasal obstruction and to verify the postoperative improvement. The Student t test was used for statistical data. After 24 months, 87% (p < 0.001) of the patients reported to have a better nasal airflow than before the operation. None of the patients needed a nasal packing after APC surgery. The indication, advantages, complications, controversies and long-term results of the treatment with APC in rhinosurgery are reviewed and discussed.     

Treatment of the obstructive nose by CO2-laser reduction of the inferior turbinates: technique and results

In our department we treat chronically enlarged inferior turbinates (not responding to adequate medical therapy) with the CO2-laser or by partial inferior turbinoplasty. In this work the technique is described and short- and long-term results are evaluated. We divided our study group into two populations: one group with a follow-up of 18 months for which we could obtain objective measurements of the nasal patency by means of a preoperative and postoperative active anterior rhinomanometry, and another group with a follow-up of more than 15 years, for which (because of the absence of a pre-operative rhinomanometry) we could only obtain a subjective evaluation of the results by means of a questionnaire. Relief of nasal obstruction was reported by 88.5% of the patients until 5 years after laser surgery on the inferior turbinates. There seems to be no functional impairment on the nasal mucosa after this kind of surgery. The advantages and drawbacks of this technique are discussed.     

Die Behandlung der hypertrophen unteren Nasenmuschel. Teil 2

The surgical management of enlarged inferior turbinates has been actively debated for more than a century. The second part of this review describes the following techniques: laterofracture, submucous turbinectomy, concho-antropexy, partial turbinectomy, anterior turbinectomy, inferior turbinoplasty, total turbinectomy, and vidian neurectomy. Indications, advantages, disadvantages, complications, and controversies of each treatment modality are reviewed and discussed. Partial or submucosal resection should be preferred, because there are moderate side effects and the amount of turbinate excised can be altered according the degree of symptomatology. Total turbinectomy or vidian neurectomy are indicated if all other treatment attempts do not succeed.     

Radiofrequency volumetric tissue reduction (RFVTR) of inferior turbinates: a new method in the treatment of chronic nasal obstruction

Twenty-two Caucasians (16 male and 6 female) with chronic bilateral nasal obstruction due to hypertrophic inferior turbinates were followed up over a three-month period. They were assessed by clinical examination, as active anterior rhinometry, and acoustic rhinometry before and after topical decongestion, preoperatively and three months after surgery. All patients were treated by application of radiofrequency-volumetric-tissue reduction (RFVTR, or somnoplasty) to both inferior turbinates. Initial postoperative edematous response disappeared during the first week after RFVTR. Three months postoperatively 20 of 22 patients (91%) reported subjective improvement of nasal patency. The average cross-sectional area for both sides of the nasal cavity (measured at the head of the inferior turbinate (C-Notch) before decongestion) increased in 15 of 22 patients (68.2%). This means a significant improvement from 1.24 to 1.49 cm2 for both sides of the nasal cavity (p = 0.0054). We conclude that RFVTR can safely reduce turbinate volume in a precise manner in patients with nasal obstruction due to hypertrophic inferior turbinates.