Chapter 23 Bipolar radiofrequency cold ablation turbinate reduction for obstructive inferior turbinate hypertrophy
As such, medical or surgical treatment of inferior turbinate hypertrophy may improve symptoms associated with OSA and/or snoring in many ways. Enhancement of nasal airflow may allow for increased nasal versus mouth breathing or improved tolerance of continuous positive airway pressure (CPAP). Given the association between allergic rhinitis alone and reduced sleep quality, improvement of nasal obstruction may also independently improve sleep quality.
When pharmacologic management of nasal obstruction secondary to inferior turbinate hypertrophy fails, surgical therapy should be considered. Many treatment modalities for inferior turbinate hypertrophy have been prescribed including partial turbinectomy (bone and soft tissue) and turbinate reduction by various modalities including electrocautery, radiofrequency ablation, laser ablation, radiofrequency cold ablation (coblation) and submucous resection. Since most of these methods have demonstrated good clinical effectiveness, those procedures that are minimally invasive with limited side effects have been recently favored including office-based radiofrequency techniques. This chapter details patient selection procedural details, perioperative management and outcomes with coblation inferior turbinate reduction.
As with any surgical procedure, patient selection has a tremendous impact on postsurgical outcomes. Although many patients with OSA and/or snoring complain of nasal obstruction or nasal congestion, the etiologies for these symptoms may be multiple and multifactorial. Conversely, a number of patients with OSA/S may complain little about symptomatic nasal obstruction but upon examination are found to have several anatomic factors that may contribute to nasal obstruction. Therefore, independent of reported symptoms, all patients with OSA/S require a detailed nasal examination, typically including fiberoptic trans-nasal endoscopy. The examiner must note the presence or absence of inferior turbinate hypertrophy, nasal septal deviation, sinonasal polyposis and adenoid hypertrophy. Other factors that may also contribute to nasal obstruction (i.e. making one or more of the above more symptomatic) but may be less anatomically evident include nasal valve collapse and the relative size of the piriform aperture.
With respect to inferior turbinate hypertrophy, the relative size of the inferior turbinate along its full length must be assessed. It is not uncommon to find patients with relatively normal-appearing anterior inferior turbinates, but with very pronounced posterior (tail) cobblestoned turbinate hypertrophy. The relationship of the inferior turbinate hypertrophy to nasal septal deviation in particular should be assessed. Some patients with septal deviation may yet still be candidates for inferior turbinate reduction alone if the turbinate component is felt to contribute substantially more to the nasal obstruction. Unfortunately, no clear-cut testing modality will define the individual contributions to nasal obstruction for these anatomic factors. However, we and others have found that a topical nasal decongestant test with neosynephrine or oxymetazoline may help identify patients more likely to benefit from inferior turbinate reduction. Patients must be cautioned that this pharmacologic turbinate reduction is supraphysiological and may exaggerate what is achievable with mechanical inferior turbinate reduction. Those patients who demonstrate an improvement in their subjective sense of nasal breathing and/or objectively demonstrate improvement in their nasal patency (as measured by acoustic rhinometry or nasal endoscopy) are more likely to achieve benefit with inferior turbinate reduction alone. We avoid mixing topical lidocaine in conjunction with topical decongestants because it may confound the patient’s subjective assessment of their nasal breathing. A small fraction of patients will have limited improvement with topical decongestion, still demonstrating large inferior turbinates. These patients often have a large bony (concha) inferior turbinate and may be better candidates for submucous resection techniques. Patients with significant nasal septal deviation (especially in the anterior or mid-nasal cavity), sinonasal polyposis or adenoid hypertrophy are often not good candidates for inferior turbinate reduction alone.
Part of patient selection is appropriate patient counseling and ensuring the patient’s understanding of the goals of the procedure as well as treatment outcomes. Patients should be informed and understand that coblation inferior to reduction may be only component in addressing nasal obstruction with further therapy being required. Further therapy may include repeated coblation inferior turbinate reduction sessions to address middle or posterior turbinate hypertrophy or further sessions to achieve the desired volume of turbinate reduction.
Patients are typically apprised of the procedure and given perioperative instructions prior to the procedure. Informed consent is obtained for all patients and includes a discussion of the risks and benefits of procedure, including the rare risk of smell disturbance as well as the infrequent risks of postoperative crusting, bleeding and/or pain.
The coblation inferior turbinate reduction procedure is most commonly performed in the outpatient setting. In patients who have isolated turbinate hypertrophy as a cause of their nasal obstruction (or minimally impacting nasal septal deviation) we prefer to perform this procedure in the outpatient setting prior to any adjunctive sleep apnea procedures. This allows patients to maintain a patent nasal airway in the immediate postoperative period after other surgical procedures for OSA. However, the procedure can be performed simultaneously with nasal septoplasty and/or other adjunctive surgical procedures for OSA in the operating room setting provided the plasma field generator is available.