Nd:YAG laser turbinate surgery animal experimental study: Preliminary report

The chronically hypertrophic nasal turbinate is a challenging problem for otolaryngologists. Although some success has been achieved with a number of medical and surgical methods, other forms of treatment are still needed. In this study, encouraging results were achieved using the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser on canine turbinates. Clinical and histological results showed that with Nd:YAG laser surgery, coagulation occurs in the deep cavernous vessels and submucosal glands of the turbinate, while the overlying mucosa remains intact.     

Use of the Nd:YAG laser in otorhinolaryngology]

The Nd:YAG laser is suitable for the treatment of various otorhinolaryngological clinical disorders. These include the palliative reduction of tumor size in sites with difficult access, treatment of hemangiomas and reduction of hyperplastic turbinates. Within certain limits, other indications are treatment of recurrent epistaxis and recurrent polyposis. Palliative reduction of malignancies in the nasopharynx, esophagus, and bronchial system (laser power density: 1500-8000 W/cm2) must sometimes be carried out in several sessions in order to avoid complications due to the laser (i.e., perforation of the bronchial or esophageal wall, lesions of adjacent vessels or nerves). Nd:YAG laser treatment of hemangiomas (500-3000 W/cm2) can lead to excellent results. To avoid excessive thermal lesions, vascular tissue is cooled with ice cubes or with an ice-cold Ringer's solution. The laser process is continued until the onset of tissue blanching. Carbonizations of the tissue are to be avoided. In Nd:YAG laser therapy of hyperplastic lower nasal conchae (approx. 1000 W/cm2), results are based on submucous scarring in which the covering epithelium is maintained. The objective of Nd:YAG laser treatment of recurrent epistaxis in patients with Osler's disease (500 W/cm2) is to reduce the incidence of hemorrhage. Use of the laser in recurrent polyposis is best confined to patients who refuse conventional surgical revision operations. Laser light (500-3500 W/cm2) should only be applied for a short period of time (0.5 s) to avoid creating a rarefying osteitis.     

First results of the wave-guide in CO2-laser surgical reduction of the hyperplastic nasal turbinates

BACKGROUND: The CO2-laser-surgical reduction of the hyperplastic nasal turbinates represents a standard procedure in ENT-Surgery. In the presented paper, the authors introduce a new technique for the treatment of hyperplastic turbinates. METHODS: The laser beam is transmitted through a 90 degrees handpiece to the mobile "infra-guide" wave guide, which contains a 1 mm ceramic tube. By application of mirrow pieces with different angles, laser surgical reduction of those parts of the nasal turbinates is possible, which normally can not be reached by conventional, tangentially to the mucosa directed laser beams. The direction of the laser beam is controlled either optically, as in endonasal sinus surgery, or monitored through a camera. A total of 36 patients (22 women, 14 men, mean age 32.7 years) with nasal turbinate hyperplasia and either impaired nasal breathing and/or retronasal drip were treated with the new method. RESULTS: The laser wave guide represents a minimally invasive and basically complication-free method feasable on an outpatient basis. As a particular advantage, laser surgical reduction of the posterior parts of the inferior and also the middle turbinate is possible. The majority of the patients relates of an improvement of the preoperative symptoms (regarding reduction of impaired nasal breathing: 61.3 %, regarding reduction of post nasal drip 87.1 %). CONCLUSION: The laser wave-guide represents a basically complication-free, minimally invasive supplement to the different treatment modalities of the hyperplastic nasal turbinates.     

Ho:YAG laser treatment of hyperplastic inferior nasal turbinates.

OBJECTIVES: Although preliminary studies about the successful use of the Ho:YAG laser in nasal turbinate surgery have been reported, no clinical study has been performed on this procedure. The aim of this prospective clinical study was to assess the long-term effect of Ho:YAG laser in the treatment of hyperplastic inferior nasal turbinates. METHODS: Eighty-five patients with nasal obstruction who did not respond to conservative medical treatment were treated with a pulsed Ho:YAG laser (wavelength of =2080 nm). Fifty-two of these patients were included in this clinical study and were followed for 1 year. RESULTS: Within the first 2 weeks, nasal obstruction was correlated to the extent of nasal crusting. Six months after laser treatment, the mucociliary function test showed no variation compared with the preoperative measurements. One year after laser treatment 77% of the patients demonstrated improved nasal airflow on rhinomanometry and questionnaire. CONCLUSIONS: Ho:YAG-laser treatment of hyperplastic turbinates can be performed as outpatient surgery under local anesthesia and offers controllable ablation of soft tissue in a short operation time with satisfactory results and excellent patient acceptance.     

Parameters for argon laser surgery of the lower human turbinates. In vitro experiments

On 8 human lower turbinates in vitro, experiments were performed using an argon laser with a power of 1-10 W, a beam diameter of 0.2 and 2 mm. For clinical laser surgery of the turbinates 1-2 W is sufficient. Drilling, incision, coagulation and vaporizing experiments, were done on the tissue of the lower turbinates. The results of this laser surgery are discussed and compared with present-day surgical methods such as conchotomy, cutting of the posterior ends by slinging, and electrocautery of the lower turbinates.     

Possibility and clinical significance of reservation middle turbinate in endoscopic sinus surgery]

OBJECTIVE: To study the possibility and significance or reservation of the middle turbinate in endoscopic sinus surgery for sinusitis and/or nasal polyps. METHODS: (1) The morphology and mucosal ultrastructure of middle turbinate were observed preoperatively and postoperatively by nasal endoscopy and scanning electron microscopy in 20 cases; (2) The proportions of the septal turbinate formation and the closure of ethmoid sinus cavity were investigated postoperatively by nasal endoscopy in 60 cases with middle turbinate reserved and 60 cases with middle turbinate resected. RESULTS: (1) The morphology and mucosal ultrastructures of reserved middle turbinate were observed to have recovered postoperatively; (2) The proportions of the septal formation and the closure of ethmoid sinus cavity in the groups with middle turbinates reserved and resected were 13.3%, 18.3% and 58.3%, 51.7%, respectively (P < 0.01). CONCLUSION: It is possible that the structure of reserved middle turbinate may return to normal and it is important to save the middle turbinates to improve clinical cure rate.     

Pneumatization of turbinates

OBJECTIVES: To present unusual computed tomography (CT) findings concerning huge pneumatization of turbinates and paranasal sinuses in one patient. In current world literature the authors only found nine reports of pneumatization of inferior turbinates, which, therefore, must be considered an extremely rare anatomical finding. STUDY DESIGN: Case report and literature review. METHODS: Computed tomography findings in a 35-year-old white woman with nasal obstruction are presented; and the authors describe this additional case of pneumatization of an inferior turbinate, as well as other variants. The literature and nomenclature are reviewed. RESULTS: Besides the rare anatomical finding of a pneumatized inferior turbinate, in addition, both patient middle and superior turbinates were pneumatized bilaterally. Frontal and sphenoid sinuses were huge, with pneumatization of the crista galli and the posterior parts of the septum. The floor of the orbit presented with an orbitoethmoid (Haller) cell on one side. Thus, five of the six turbinates present were pneumatized. To the authors' knowledge, no other case of such extreme pneumatization has been published in world literature to date. CONCLUSIONS: Whereas pneumatization of the ethmoturbinals is a frequent finding on sinus computed tomography scans, pneumatization of the maxilloturbinal remains an extremely rare anatomical variant. Pneumatization of ethmoid cells and secondary sinuses is considered an active achievement of nasal and sinus mucosa during fetal development and adolescence. The underlying mechanisms of this process are not yet understood. The inferior turbinate is the least likely to present with pneumatization. In clinical practice, the pneumatization status should well be studied on the scans before any sinus and turbinate surgery is undertaken.     

Wedge turbinectomy: a new combined photocoagulative Nd:YAG laser technique

OBJECTIVES: To demonstrate that Nd:YAG laser photocoagulation using a combination of interstitial and contact approaches in the surgical treatment of inferior turbinate hypertrophy yields improved results in terms of postoperative nasal patency, complications, and relapse. STUDY DESIGN: A group of 121 patients with symptoms of nasal obstruction due to hypertrophied inferior turbinates were treated between January 1994 and December 1997 at the Otolaryngology-Head and Neck Surgery Unit of the Main Military Hospital of Rome using the wedge turbinectomy, a new endonasal laser technique. METHODS: This is a combined photocoagulative procedure performed under local anesthesia. In the first surgical step we perform interstitial photocoagulation using Nd:YAG laser and in the second step we use a contact approach, making two strips of photocoagulated mucosa running side by side from the tail to the head of turbinate. RESULTS: At 1-year follow-up, the complication rate in all our patients treated with this laser technique was very low and we achieved a steady improvement in nasal patency in 104 patients (85.9%). The relapse rate was approximately 14%, but we observed that 65% of the patients who experienced long-term failure were affected by allergic rhinitis. CONCLUSIONS: An accurate preoperative evaluation of the cause of the turbinate hypertrophy is fundamental to achieving better results after laser turbinectomy and reducing the risk of relapse.     

Comparative morphological investigation on the rabbit's auricle after exposure to CO2- and Nd:YAG-laser radiation

By comparing the effects of CO2- and Nd:YAG-laser radiation (mainly differing in wave-length by a factor of 10), a surgical instrument suitable for Otorhinolaryngology had to be found. The studies were performed on the rabbit's auricle in order to examine the effect of the laser irradiation mainly on the cartilage. The CO2-laser was found to be more efficient in cutting and caused less extended tissue damage than the Nd:YAG-laser. The latter seems to be more suitable for soft tissue surgery.     

内窥镜鼻窦手术保留中鼻甲的可能性及其临床意义

目的探讨鼻窦炎和／或鼻息肉内窥镜鼻窦手术中保留中鼻甲的可能性及其临床意义。方法①应用鼻内窥镜和扫描电镜分别观察２０例手术前、后中鼻甲形态和粘膜表面超微结构;②应用鼻内窥镜观察中鼻甲保留组和中鼻甲切除组各６０例的术后中隔鼻甲和筛窦术腔闭塞的发生率。结果①肿胀型、息肉样变型和息肉形成型的中鼻甲形态和粘膜表面超微结构术后呈良性转归;②中鼻甲保留组和中鼻甲切除组中隔鼻甲出现率分别为１３．３％和５８．３％,筛窦术腔闭塞率分别为１８．３％和５１．７％（Ｐ＜０．０１）。结论内窥镜鼻窦手术中经适当处理保留的中鼻甲有恢复正常的趋向,并对术后术腔恢复和提高临床治愈率有积极作用。     

8 years' laser surgery of the inferior turbinates in vasomotor rhinopathy in the form of laser strip carbonization

Between 1976 and 1984 more than 2000 patients with nasal obstruction due to vasomotor rhinitis were treated with the argon laser. The inferior turbinate was treated by laser-strip carbonisation over an area 3 to 5 cm long, 2 mm wide and 1 to 3 mm deep, surrounded by a 2 mm broad coagulation zone. 700 patients were invited to attend follow up and 411 turned up. The observation period was up to 5 years. 80% of the patients obtained a significantly improved or completely free nasal breathing. This result could be improved by 6% by further surgery. Advantages of the laser-strip carbonisation of the inferior turbinate are that it is a bloodless procedure which can be carried out accurately under vision, without nasal packing and it can be performed under local anesthesia without pain. Disadvantages are a longer healing period and temporary crust formation as in conchotomy, the high technical effort and cost of the laser. The end result after laser-strip carbonisation on the inferior turbinates was achieved after 1 1/2 to 2 years.     

Diode laser treatment of hypertrophic inferior turbinates and evaluation of the results with acoustic rhinometry

Inferior turbinate hypertrophy is the most common cause of chronic nasal obstruction. When conservative medical treatment options fail in patients with inferior turbinate hypertrophy, reduction of the inferior turbinate can be performed using surgical techniques. Laser-assisted turbinate surgery has the advantages of limited tissue trauma and reduced bleeding. We evaluated the effectiveness and outcomes of using a diode laser (λ?=?980?nm) in turbinate reduction. Our study included 62 patients with symptoms of nasal obstruction due to hypertrophic inferior turbinates, who did not respond to medical treatment (≥1?year). Patients were treated with diode laser between January 2009 and December 2010 in our ENT (ear, nose, and throat) department. Subjective outcome of severity of nasal obstruction was assessed on a standard 10-cm visual analog scale (VAS). Acoustic rhinometry was used to measure nasal patency. The cross-sectional areas 1, 2, and 3 and the volumes between 2.5 and 5.5?cm were measured. VAS scores and acoustic rhinometry measurements were performed preoperatively and 1, 6, and 12?months after surgery. The mean follow-up was 13.1?±?1?months. The mean operation time was 3?min per turbinate; no nasal packing was necessary. We did not observe any major complications. Both subjective and objective evaluations showed significant improvement. VAS scores improved, the mean MCA2, MCA3, and V2–5 measurements increased significantly 1?year after surgery. In the first year after surgery, 53 of 62 (85.4%) patients reported marked improvements in nasal breathing. Our results showed that, objectively and subjectively, the success rates in diode laser-assisted turbinate reduction were satisfactory. The diode laser, being one of the most portable and least expensive of the lasers available for turbinate surgery, makes it possible for turbinate reduction to be performed under topical anesthesia within a short period of time with excellent patient acceptance.     

Unilateral inferior turbinate agenesis: a case report

Many common anatomic variations in the nasal cavity have been observed, including paradoxical turbinates and pneumatization of the inferior, middle, and superior turbinates. We describe a case of a rare anomaly-unilateral inferior turbinate agenesis-in a 65-year-old man who had presented with epistaxis. During evaluation, anterior rhinoscopic examination revealed the absence of the right inferior turbinate; this finding was confirmed on computed tomography. The patient had never undergone nasal or sinus surgery, and he denied ever having expelled anything of significance from his nasal cavity. This case merits attention because of the rarity of reports on turbinate agenesis.     

Giant concha bullosa containing another concha bullosa inside: unique anatomic variation of the middle turbinate

Detailed knowledge of the anatomical variations of the lateral nasal wall is crucial for both the surgeon who is performing endoscopic sinus surgery and the radiologist who is involved in the preoperative work-up. Preoperative recognition of these variations will avoid possible complications during the surgery. In this report, we present a unique anatomical variant of the middle turbinate, a large concha bullosa inside a giant concha bullosa, which has never been reported before. Furthermore, we comment on the differential diagnosis of the variations of the middle turbinate and on the embryology of the nasal turbinates. This report also supplies additional aspects to rhinologists in the scope of middle turbinate pneumatization.     

鼻内窥镜术后鼻腔粘连对疗效的影响

目的 :探讨鼻腔粘连对鼻窦内窥镜手术疗效的影响。方法 :应用Storz硬性鼻内窥镜 ,根据不同的病变部位 ,参照Messerklinger鼻内窥镜手术方法 ,行鼻内窥镜手术 84 5例 (15 5 8侧 ) ,术后定期随访 1年以上。结果 :治愈 12 80侧 ,总治愈率为 82 .2 %。其中Ⅰ型病例治愈率达 91%以上 ;Ⅱ型 1期和 2期分别为 98.9%和82 .8% ,3期为 75 .0 % ;Ⅲ型治愈率为 6 1.2 %。在 2 78侧无效病例中鼻腔粘连 15 1侧 ,占 5 4 .3%。结论 :鼻窦内窥镜术后鼻腔粘连以中鼻甲与其周围结构为主 ,导致鼻窦引流不畅 ,以致影响疗效 ,因此 ,减少术后局部粘连是提高手术疗效的关键。术中对中鼻甲的适当处理有助于减少术后粘连 ,提高手术效果     

Surgery for chronic hyperplastic rhinosinusitis

Davison pointed out in 1953 that his purpose in treating sinusitis was to utilize the smallest amount of surgery that would produce permanent relief of symptoms. By 1963 he had become convinced that extensive disease required extensive surgery. Hyperplastic rhinosinusitis is treated by a variety of surgical techniques including polypectomy, turbinate cautery, submucous resection of the turbinates or nasal septum, anterior ethmoidectomy, and spheno-ethmoidectomy. Sixty-eight patients are presented who have undergone bilateral spheno-ethmoidectomy between January, 1969, and January, 1974. These patients were predominantly allergic, with a high percentage of previous polypectomies and desensitization which failed to control their recurring nasal polyps. Ten patients were lost to follow-up. Forty-seven of 68 patients have had no recurrence of polyps in from 12 to 60 months. All patients continued to have mucosal manifestations of allergy or infection, but the recurrence of late polyps was limited to 11 patients. The spheno-ethmoidectomy technique is utilized, stressing complete removal of the middle turbinate. Kidder has shown an improved rate of polyp control in patients following ethmoidectomy with middle turbinate removal rather than with partial or total preservation of the middle turbinate. Complete resection of the middle turbinate with opening of the sphenoid air sinus permits a thorough exenteration of the ethmoid labyrinth and better control of chronic disease. A complication rate of 5.9 percent is presented and is deemed acceptable, since there were no disabling complications or complications related to poor visualization.     

Concha bullosa surgery and the distribution of human olfactory neuroepithelium

In bullous middle turbinate surgery, controversy exists over which side of the bullous middle turbinate should be removed, as the distribution of human olfactory neuroepithelium is unclear. This study evaluated whether the middle turbinate tissue of patients undergoing endoscopic concha bullosa surgery contains functional olfactory epithelium. This prospective clinical study was conducted in tertiary referable center. It detected 70 conchae bullosa in 48 patients with sinonasal symptoms, who underwent paranasal computed tomography (CT) that showed pneumatization of the middle concha. All samples were obtained under general anesthesia. Three samples were obtained from each bullous middle turbinate: one each from the anterior, medial, and lateral portions. The mucosa from each sample was stained with olfactory marker protein (OMP). In total, 210 middle turbinate samples were taken from 48 patients during endoscopic surgery for conchae bullosa. The patients were 22 females and 26 males. Of the 70 conchae bullosa, OMP-stained nerve tissue was found in the lateral, anterior and medial aspects of 57 (81.4 %), 42 (60.0 %) and 23 (32.8 %) of the bullous middle turbinates, respectively. OMP-stained nerve tissue was found in 122 (58.1 %) of the 210 bullous middle turbinate tissue samples. OMP-stained nerve tissue was found on the lateral surface of the bullous middle turbinate more often than the medial surface. Therefore, during the concha bullosa surgery, OMP-stained nerve tissue found at least in the medial part of concha, suggested that the opening of the medial part of middle concha.     

A case of chondronecrosis of the epiglottis after laser chordotomy

A 30-year-old Caucasian female patient suffering from bilateral vocal-fold immobility developed a necrosis of the epiglottis with severe respiratory distress 35 days after fiber-guided Nd:YAG-laser chordotomy on the right side. Twenty-two years prior to surgery, she had received a high-dose radiotherapy, which had caused severe scarring of the whole neck and the larynx. This necrosis is more likely an inflammatory complication than a direct side effect of the laser surgery in the radiation-altered laryngeal tissue. It underlines the importance of carefully considering the indications for laser surgery of an irradiated larynx.     

Trends in turbinate surgery literature: a 35-year review

A MEDLINE search was used to identify articles involving all forms of turbinate surgery over a 35-year period. Five hundred and sixty-one papers were identified. Of these, 283 specifically detailed turbinate surgery. These demonstrated a marked increase in the number of papers detailing endoscopic and laser turbinate surgery in the last 5 years. No randomised controlled studies were identified describing inferior turbinate surgery for nasal obstruction or middle turbinate surgery for any cause. The evidence supporting the efficacy of these procedures remains debatable. Research in this field appears to be driven by technological advancement rather than by establishment of patient benefit. Properly conducted randomised controlled trials are required to establish whether there is a long-term patient benefit from these commonly performed operations.     

'Two-stage turbinectomy': sequestration of the inferior turbinate following submucosal diathermy

Submucous diathermy of the inferior turbinates is a widely practised procedure. Three cases are presented in which surgery was complicated by avascular necrosis of the turbinate bone. Each patient required a debridement procedure before healing and recovery of normal mucociliary function could take place.