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.     

The site and function of the nasal valve

Previous observers have suggested that the main site of respiratory airflow resistance is localized to the vestibular region of the nose. This resistive segment of the airway was investigated using a “head-out” body plethysmograph in subjects with anatomically normal noses (a) untreated, (b) congested and (c) decongested. In all three conditions, 2/3 of the total nasal airflow resistance was found within the bony cavum in the vicinity of the pyriform aperture and about 1/3, in the cartilaginous vestibule. As might be expected, caval resistance changed proportionately with the degree of mucosal congestion; but, more surprisingly, vestibular resistance changed similarly. This was due in part to the observed forward expansion of the anterior ends of the inferior turbinates with congestion. EMG recordings in subjects breathing through both nostrils demonstrated a gradation of inspiratory alar dilator muscle activity with increased minute ventilation and with mucosal congestion, and there was no evidence of inspiratory alar collapse. But with elevated ventilation through one nostril only, or when the alar muscles were paralyzed by lidocaine block of the VIIth nerve, alar collapse occurred. These findings are of importance in the management of the congested but anatomically normal nose and in surgery of the nasal tip.     

Anterior turbinectomy. A new surgical approach to turbinate hypertrophy: a review of 220 cases

Surgical correction of mechanical nasal airway obstruction is commonly treated by septoplasty. The nasal airflow, however, is often inadequate postoperatively. The inferior turbinates are responsible for nasal obstruction more often than is realized. Recent studies have confirmed that the main site of respiratory resistance is located at the level of the anterior ends of the inferior turbinates. A new turbinectomy approach in which the anterior end of the inferior turbinate is resected with a specially modified forceps is described. A large series of patients, along with their follow-up data, are described. The advantages of the anterior turbinectomy are discussed.     

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.     

Septal cartilage graft for nasal valve incompetence associated with deviated septum

BACKGROUND: The nasal valve is one of the major factors contributing to nasal airflow obstruction. Physiologically, the nasal valve offers the greatest resistance to nasal airflow and generally functions as an inflow device controlling nasal airflow and resistance. Many patients who have complaints of breathing impairment are affected by alterations of the nasal septum, the turbinates, the columellar base, the vestibule floor, or the lateral wall of the nose but may have associated incompetence of the nasal valve, which is too often undervalued by nasal surgeons. The aim of this study was to propose a relatively easy surgical technique to correct most nasal valve impairments associated with nasal septum deviation whether or not there also is inferior turbinate hypertrophy. METHODS: Between May 2004 and September 2006, 68 patients (26 women and 42 men; mean age, 37 years; range, 16-71 years) underwent primary or secondary functional nasal surgery, because of a nasal respiratory obstruction caused by nasal septal deviation eventually associated with inferior turbinates hypertrophy, and also demonstrated nasal valvular incompetence. A septal cartilage graft was used to correct the valvular incompetence. RESULTS: On postoperative visits almost all of the patients (with one exception) showed a remarkable improvement in the stiffening of the valvular region and had only minimal depression of the nostril during deep inspiration. CONCLUSION: This study indicated that septal grafts were useful in the surgical management of nasal respiratory impairment because of nasal valve incompetence, where there had been flaccid mobile collapse of the ala of the nose associated with septal alterations.     

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.     

Endoscopic carbon dioxide laser turbinoplasty

In the present work we describe the management of hypertrophied inferior turbinates using CO(2) laser in the UniPulse mode. The laser beam is delivered through the nasal probe delivery system, and the procedure is performed using the 0 degrees endoscope. The UniPulse mode allowed fine-tuned, char-free tissue ablation, and the nasal probes allowed delivery of laser energy to the posterior parts of the inferior turbinates. The procedure was performed on 149 patients. The one-year post-operative follow-up period revealed good functional results in 131 patients (88 per cent). The minimal nasal cross sectional area increased significantly from 0.52 cm(2) to 0.81 cm(2). The average decongestive effect, on the other hand, decreased from 0.26 cm(2) to 0.07 cm(2) indicating significant laser-induced fibrosis. The operation can be performed as an out-patient procedure with little or no morbidity.     

Human respiratory airflow through an artificial nasal model: pressure/flow relationship

Nasal airflow and differential pressure at peak flow were measured by Rhinorheograph MPR-1100 made by Nihon Kohden Co., Ltd. with human resting respiratory airflow through an artificial nasal model. In the healthy nasal model, it was assumed that nasal resistance was produced mainly in the vicinity of the pyriform aperture. Reduction of air space in the nasal model due to various simulated diseases led to decrease airflow and increased differential pressure with consequent increase of nasal resistance. Severe diffuse swelling of the inferior turbinate was the most important cause of marked elevation of resistance, nasal secretion also was an important factor which increased nasal resistance.     

The effect of inferior turbinate outfracture on nasal resistance to airflow in vasomotor rhinitis assessed by rhinomanometry

Twenty-eight patients with nasal obstruction due to vasomotor rhinitis were assessed using anterior rhinomanometry before and six weeks after the operation of out-fracture and amputation of the posterior ends of the inferior turbinates. It was found that the operation did not significantly improve the nasal airway. Though just over half the patients had an objective improvement in nasal airflow, only half of this group reported a subjective improvement in their symptoms.     

Changes in nasal resistance and quality of life after endoscopic microdebrider-assisted inferior turbinoplasty in patients with perennial allergic rhinitis

OBJECTIVE: To assess objective and subjective outcomes in patients with perennial allergic rhinitis who had undergone endoscopic microdebrider-assisted inferior turbinoplasty. DESIGN: Prospective study. SETTING: Tertiary referral center. PATIENTS: Fifty patients with perennial allergic rhinitis who had substantial mucosal hypertrophy of the inferior turbinates and who underwent endoscopic microdebrider-assisted inferior turbinoplasty with follow-up 1 year after surgery. INTERVENTION: A newly designed microdebrider blade incorporated with an elevator was used to perform this procedure in the clinical setting with the patient under local anesthesia and with 30 degrees endoscopic guidance. MAIN OUTCOME MEASURES: Both objective outcome evaluated by total nasal resistance at anterior rhinomanometry and subjective outcome assessed with the Rhinoconjunctivitis Quality of Life Questionnaire were analyzed before and 1 year after surgery. RESULTS: The median total nasal resistance in 50 patients decreased from 0.45 Pa/cm(3) per second preoperatively to 0.28 Pa/cm(3) per second 1 year postoperatively, a statistically significant difference (P<.001). Compared with preoperative scores, the postoperative scores of these patients significantly improved in both 7 separate domain scores and overall Rhinoconjunctivitis Quality of Life Questionnaire scores (P<.005). CONCLUSION: Our results suggest that endoscopic microdebrider-assisted inferior turbinoplasty is effective for decreasing nasal resistance and improving quality of life in patients with perennial allergic rhinitis who have substantial nasal congestion.     

Effect of submucosal diathermy to the inferior turbinates on unilateral and total nasal airflow in patients with rhinitis

The efficacy of the controversial treatment of submucosal diathermy to the inferior turbinates (SMDIT) was evaluated objectively. Twenty-seven patients with chronic rhinitis were investigated by hourly posterior rhinomanometry to assess changes in total and minimum (Fmin) and maximum (Fmax) unilateral nasal airflow over 5 h, before and 2-3 months after standardized SMDIT treatment. Nasal airflow was recorded at a sample pressure of 75 Pa and the results are reported as medians with interquartile range. Whilst SMDIT caused a significant 51% increase (p < 0.0001) in total nasal airflow from 246 cm3/s (131) to 371 cm3/s (133) the changes in unilateral airflow provided further evidence which strongly supported the benefits of this operation. Unilateral Fmin significantly increased by 136% (p < 0.0001) from 69 cm3/s (82) to 163 cm3/s (74) and Fmax significantly increased by 23% (p < 0.0001) from 171 cm3/s (74) to 211 cm3/s (59). The effect of surgery was to "splint" to the turbinate in a state of relative vasoconstriction. Our findings therefore provide functional evidence of submucosal fibrosis following SMDIT. The greater percentage change in unilateral Fmin suggests that this parameter is a more sensitive index of the effect of nasal surgery than total nasal airflow measurements. The importance of considering the nose as two separate airways in the evaluation of nasal treatments is emphasized.     

正常和病理状态下鼻气道阻力在鼻腔中的分布

目的探讨正常和病理状态下鼻瓣区的确切位置。方法研究正常成人鼻黏膜减充血前、后以及慢性鼻炎和鼻中隔偏曲手术前、后鼻气道阻力（nasal airway resistance,NAR）在鼻腔中的分布。结果正常成人鼻黏膜减充血前,NAR最大部位位于梨状孔,而在减充血后,则位于内孔区。慢性鼻炎患者手术前、后NAR最大部位分别位于梨状孔和内孔区。鼻中隔偏曲矫正术前、后则分别位于偏曲部位和梨状孔。结论鼻瓣区在正常情况下位于梨状孔和下鼻甲前端,当鼻腔存在阻塞性病变时则位于病变部位。鼻瓣区的部位不是固定不变的,而是和鼻黏膜舒缩状态以及鼻腔的开放程度密切相关。     

Influence of lateral osteotomies in the dimensions of the nasal cavity.

OBJECTIVES: To elucidate the importance of placement of lateral osteotomy in rhinoplasty at a level above or below the insertion of the inferior turbinate at the pyriform aperture. STUDY DESIGN: Controlled lateral osteotomies were performed in 16 cadaver noses. Eight of the lateral ostetomies were placed below (low) and eight were placed above (high) the insertion of the inferior turbinate. In all 16 noses medial osteotomies were performed. Dimensions of the nasal cavity were measured by acoustic rhinometry before and after the osteotomies. METHODS: The total minimum cross-sectional area (TMCA) and the cross-sectional area at the pyriform aperture (TCA-3.3) were calculated and the preoperative and postoperative values were analyzed statistically. RESULTS: There was no significant difference in the reduction of cross-sectional area in the group that underwent high lateral osteotomy compared with the group the underwent low lateral osteotomy. In both groups the TMCA was reduced, with 12% of the value (P = .001) before osteotomy, and the TCA-3.3 was reduced, with 15% of the value before osteotomy (P = .000). CONCLUSIONS: After lateral and medial ostetomies a significant decrease in the anterior dimensions of the nose is observed. The decrease following osteotomy does not seem to be due to the placement of the lateral osteotomy at the pyriform aperture but rather to the detachment of the bony vault from the surrounding structures.     

Congenital pyriform aperture stenosis: surgery and evaluation with three-dimensional computed tomography

OBJECTIVE: We described the surgical efficacy of congenital pyriform aperture stenosis by measuring the width of the nasal pyriform aperture with three-dimensional computed tomography. METHODS: Six patients with congenital pyriform aperture stenosis accepted surgical intervention. Three-dimensional computed tomography was performed for preoperative and postoperative evaluation of nasal pyriform aperture width. We marked the midpoint between the tip of nasal bone and the anterior nasal spine. The distances between the bilateral nasal processes of the maxilla and between the lateral rims of the pyriform aperture were measured by crossing the midpoint horizontally. RESULTS: Among the six patients (three male and three female patients), the mean age was 76.2+/-23.9 days. Silicon stents were removed 6 to 7 days after operation. During 9 months of follow-up, there were no cases of restenosis, respiratory failure, or cyanosis. The mean preoperative and postoperative interprocess distances were 4.5+/-0.84 and 8.7+/-1.37 mm, respectively, and data were statistically significant at a confidence level of P <.05. The mean preoperative and postoperative interwall distances were 9.8+/-0.75 and 10.8+/-1.5 mm, respectively. CONCLUSIONS: Congenital pyriform aperture stenosis should be suspected whenever there is both severe nasal obstruction and difficulty in passing a small catheter or nasogastric tube through the anterior nasal valve. Operation is the most extreme treatment, but it is effective for congenital pyriform aperture stenosis. Nasal stenting for 7 days seemed to be adequate. The use of three-dimensional computed tomography to evaluate preoperative and postoperative nasal pyriform aperture is effective and reliable.     

A dynamic and direct visualization model for the study of nasal airflow.

OBJECTIVE: To evaluate nasal airflow characteristics during physiologic breathing in normal and pathologic conditions. DESIGN: The choana of an anatomical human model was connected to a pump that simulated physiological pressure changes in the upper airway system. Normal ambient air was used as medium. The airstream was marked with aerosolized water particles, and was observed through an exact but translucent replica of the original nasal septum. RESULTS: In physiologic conditions the airflow is mixed. Turbulence is clearly visible even with low flow velocities. There is less turbulence with lower flow rates. The nasal airflow follows a triphasic pattern of acceleration, near-steady state, and deceleration. Turbulence is prominent in the first and third phases. The main flow stream passes through the middle meatus at all rates. Hypertrophic mucosal membranes and turbinates increase the proportion of air passing the middle meatus. With decongested turbinates, flow distribution is more even. After turbinectomy there is a significant amount of airflow passing along the floor of the nose. The olfactory region is aerated only toward the end of inspiration and during the entire expiration phase. CONCLUSIONS: This model allows the investigation of airflow distribution and turbulence under physiologic conditions and the examination of the influence of pathologic conditions on these parameters. Overzealous trimming of turbinates results in an unphysiologic distribution of airflow.     

The impact of septorhinoplasty and anterior turbinoplasty on nasal conditioning

BACKGROUND: Septorhinoplasty and turbinoplasty is a frequently performed operation in facial plastic surgery. The aim of this study was to investigate nasal conditioning after septorhinoplasty and inferior turbinoplasty in patients with internal and external nasal deformities and hypertrophy of the inferior turbinates and to determine its relation to nasal patency. METHODS: Ten patients and 10 volunteers as controls were enrolled into this study. Measurement of nasal conditioning and active anterior rhinomanometry were performed before and 4-6 months after functional-esthetic septorhinoplasty and inferior turbinoplasty. RESULTS: Nasal airflow was significantly higher postoperatively than preoperatively. The preoperative nasal temperature (TEMP) and heat increase (HI) was lower in the patients compared with the controls. The postoperative TEMP, HI, total water content, and water gradient were significantly higher than the preoperative values. CONCLUSION: Based on this relatively small series, functional-esthetic septorhinoplasty in combination with inferior turbinoplasty may be associated with improved nasal conditioning.     

Treatment of allergic and vasomotor rhinitis by the local application of different concentrations of silver nitrate.

In 1980, Bhargava et al. reported a new treatment of allergic and vasomotor rhinitis by the local application of 15 per cent silver nitrate. The results of further studies of the treatment by using different concentrations of silver nitrate ranging from 5 per cent to 25 per cent and normal saline as placebo are presented here; 15 per cent has been found to be the most effective concentration giving successful results in 75.7 per cent of cases. It is applied to the anterior portion of both inferior turbinates and the anterior part of the nasal septum once a week on five occasions. Best relief was obtained from the most annoying symptoms of sneezing and rhinorrhoea. Asthma was controlled in 50 per cent of such patients who had attacks of allergic rhinitis followed by asthma. For this widely prevalent disease, the treatment was found to be simple, easy and useful, with negligible side-effects.     

Long-term results of inferior turbinate reduction with argon plasma coagulation

OBJECTIVES: Surgical reduction of the inferior turbinates is a commonly used therapy in patients with hyperplastic inferior turbinates when medical management remains ineffective. Current surgical methods have disadvantages (e.g., necessity of nasal packing, extended postoperative swelling, and high costs). Theoretical considerations render argon plasma coagulation (APC) a promising new therapeutic approach. STUDY DESIGN: In a prospective study, 121 patients with chronic nasal obstruction were treated for inferior turbinate reduction with APC. Hyperplasia of the nasal turbinates was diagnosed rhinoscopically and endoscopically and confirmed rhinomanometrically. The mean follow-up period was 12 months, ranging from 10 to 16 months. The treatment results were evaluated by a questionnaire, rhinomanometric findings, and electron microscopic studies of the nasal mucosa. In 50 patients a ciliary function test was performed preoperatively and postoperatively. METHODS: Argon plasma coagulation, a high-frequency electrosurgery, has been used for volume reduction of the inferior turbinate in local anesthesia. RESULTS: Seventy-six percent of the patients reported an improvement of the postoperative swelling within the first week. After 6 weeks, macroscopically the turbinates were re-epithelialized by normal mucosa in 63% of the patients. Electron microscopic studies after 3 months verified normal cilia. After 12 months, 83% of the patients stated that they had a better nasal airflow than preoperatively. Crust formation was minimal. No bleeding or impaired ciliary function occurred. Ninety-five percent of the patients were willing to undergo the same operation again. CONCLUSION: The long-term results have proved APC to be an effective and easy-to-perform alternative for inferior turbinate reduction with comparable results to other established surgical methods.     

Turbinate hypertrophy in habitual snorers and patients with obstructive sleep apnea: Findings of acoustic rhinometry

Forty-five habitual snorers (mean respiratory disturbance index = 6) and 22 patients with obstructive sleep apnea syndrome (mean respiratory disturbance index = 36) were examined by polysom-nography, radiocephalometry, rhinomanometry, na-sopharyngeal videoendoscopy, and acoustic rhinometry. In 97% of these patients, hypertrophy of the inferior nasal turbinates was found by acoustic rhinometry, while increased nasal resistance of various degrees was measured in 93% of all patients by active anterior rhinomanometry. Acoustic rhinometry demonstrated that the most resistive segment was located in the anterior parts of the nasal cavity and was built up by two compartments: the region of the isthmus nasi and the region of the head of the inferior turbinate. In our snoring patients, the cross-sectional areas at the head of the inferior turbinate were always smaller than the cross-sectional areas in the isthmus nasi, which in normal controls presented the minimal cross-sectional values of the whole nasal cavity. While rhinomanometry can only measure the amount of nasal resistance, acoustic rhinometry can clearly determine the exact size and location of the different stenoses in the nasal cavity that contribute to the increased nasal resistance.