1 INTRODUCTION

Nasal obstruction secondary to inferior turbinate hypertrophy is a common compounding problem for many patients with obstructive sleep apnea and/or snoring (OSA/S).

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.

2 PATIENT SELECTION

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.

3 OUTLINE OF PROCEDURE

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.

Patients are positioned upright in the procedure chair in the clinical examination room. Visualization of the anterior aspect of the nasal cavity is readily provided by a nasal speculum and headlight illumination as seen in Figure 23.1. The inferior turbinate dimensions both in terms of cross-sectional area occupied and anterior–posterior length of hypertrophy are determined. Infrequently, preoperative sedation or preoperative pre-emptive pain medication may be provided for anxious individuals. The procedure for anesthesia of the nasal cavity is a very important component of outpatient coblation inferior turbinate reduction and actually takes up much of the operative time. The nasal cavity is sequentially anesthetized, first with spray application of a lidocaine/phenylephrine mixture. After a few minutes, this is then followed by a direct contact anesthesia applied in the form of a cottonoid pledget soaked in cetaccainephenylephrine which is placed in the anterior one half of the nasal cavity, maximizing contact with the inferior turbinate. After an additional few minutes have elapsed, these pledgets are removed, an additional 2–3 ml up 2% lidocaine has infiltrated in each anterior inferior turbinate head, extending from the mucosal surface to the periosteum of the inferior concha. Additionally, we have found that further anesthetic injections just lateral to the piriform aperture, slightly anterior to the anterior head of the inferior turbinate, provide additional anesthesia to the infraorbital nerve branches to the inferior turbinate, increasing patient comfort and tolerance for the procedure. Occasionally, even after these steps with anesthesia, patients still may have some pain with the coblation procedure, especially as the middle to posterior aspects of the inferior turbinate are treated. In these patients, it is helpful to provide a sphenopalatine nerve block with a slightly bent spinal needle as indicated in Figure 23.2. For a sphenopalatine nerve block, 1–2 ml of 1% lidocaine with epinephrine are instilled just posterior and slightly inferior to the posterior attachment of the middle turbinate. This is best done with a 3 ml injection syringe coupled to a slightly bent 22-gauge spinal needle (Fig. 23.3). On occasion, endoscopic guidance may facilitate this posterior nerve block. Alternatively, a transoral, greater palatine foramen approach to the sphenopalatine ganglion for this additional nerve block may be employed.

Fig. 23.1 Anterior rhinoscopy demonstrating inferior turbinate hypertrophy and exposure for anesthesia and subsequent coblation of the inferior turbinate.

Fig. 23.2 Lateral piriform aperture and periosteal anesthesia of the inferior turbinate for coblation inferior turbinate reduction.

Fig. 23.3 Transnasal sphenopalatine nerve blockade providing additional anesthesia for inferior turbinate reduction.

For typical inferior turbinate reduction procedures, the coblation radiofrequency controller (ENTec/Arthrocare Corp., Sunnyvale, CA) is set to a power level of 6. We prefer to use this turbinate setting and conduct multiple passes rather than increasing power level for larger turbinates. Next, a small amount of nasal saline gel is placed on the tip of the coblation wand. This nasal saline gel as a conductive medium is essential to provide smooth entry into the surface of the inferior turbinate without thermally related damage. Using a small nasal speculum to dilate and protect the limen nasi, the coblation wand is placed against the anterior aspect of the inferior turbinate. The wand is activated by the foot pedal, and the probe is carefully passed into the inferior turbinate in a submucosal plane (Figs 23.4 and 23.5). Depending on the degree of turbinate hypertrophy and the desired volume of tissue reduction, anything from one to six passes may be made. The coblation wand is maintained in the active state as the wand is removed from the turbinate, thereby providing additional exit point hemostasis. For each pass, approximately 10–15 seconds are required. The same procedure is repeated for the contralateral turbinate. Again, the desired volume of tissue reduction may be achieved by adjusting the number of passes and depth of entry into the inferior turbinate. Commonly, though not always, there is a visual reduction in turbinate size immediately during the procedure (Fig. 23.6). Any minor oozing after the procedure is handled by replacement of the cottonoid pledget into the nasal cavity. We commonly leave a cottonoid pledget in the nasal cavity to be removed by the patient approximately 4–6 hours later, depending on the degree of minor mucosal oozing.

Fig. 23.4 Anterior rhinoscopy view of left inferior turbinate reduction with the coblation technique. Here, the wand is placed with three passes in a submucosal plane midway between the mucosal surface of the inferior turbinate and the inferior turbinate concha.

Fig. 23.5 Sagittal view of multiple passes of the coblation wand in the inferior turbinate for inferior turbinate reduction. Multiple passes may be made as required depending on the depth and volume of turbinate reduction required.

Fig. 23.6 Optimal appearance of the left inferior turbinate after left inferior turbinate coblation reduction. Typically a visible reduction in the turbinate size is almost immediately evident after coblation treatment.

As noted, the coblation inferior turbinate reduction procedure may be performed as a stand-alone procedure (i.e. in the office-based setting) or it may be conducted in concert with other obstructive sleep apnea surgical procedures, more typically done concurrently in the operating room. There is no contraindication to simultaneous performance of nasal septoplasty, nasal polypectomy, adenoidectomy with coblation inferior turbinate reduction. Furthermore, we commonly combine inferior turbinate reduction with palatal implant placement (i.e. the pillar procedure) for the treatment of obstructive sleep apnea and/or snoring (approximately 20% of cases). Patients tolerate simultaneous procedures quite well and prefer a single sitting for their procedures rather than separate office visits. Coblation inferior turbinate reduction also serves a useful purpose in addressing recurrent or persistent inferior turbinate virtually after nasal septoplasty in the office-based setting.

4 POSTOPERATIVE MANAGEMENT AND COMPLICATIONS

For patients undergoing office-based coblation inferior turbinate reduction, postoperative morbidity and management requirements are minimal. For most patients, postoperative analgesia is provided by acetaminophen or acetaminophen with codeine. Usually by the third postoperative day, pain scores are quite minimal. Patients are instructed not to blow their nose for the first 24–48 hours to prevent hemorrhage. Minor venous oozing after the coblation procedure is typically handled with over-the-counter application of oxymetazoline or phenylephrine spray during the first 3 days.

Patients should be warned to expect approximately 7–10 days of increasing nasal congestion due to intranasal new coastal swelling. Many patients do not experience this, but patients should plan for some increased congestion and possibly adverse effects on sleep in the first week after procedure. Oxymetazoline spray may be used sparingly for nighttime nasal obstruction within the first postoperative week.

Complications after coblation inferior turbinate reduction are quite rare. Approximately 2–4% of patients will have some venous bleeding typically handled with self-application of nasal decongestant sprays. Rarely, temporary packing with a dissolvable material such as Gelfoam is required. Because of the risk of postoperative bleeding, patients should refrain from strenuous exercise or lifting for approximately 7 days after the procedure. We have not seen any significant cases of postoperative nasal crusting requiring substantial débridement after the coblation inferior turbinate reduction procedure.

As with any procedure, the amount of inferior turbinate reduction must be judged carefully. Excessively superficial passes in a submucosal plane will result in loss of nasal mucosa and thereby promote crusting and bleeding in the early postoperative phase. In addition, unusually deep passes close to the periosteum or bone of the inferior concha run the risk of turbinate necrosis and excessive perioperative and/or postoperative pain. It is generally better to treat (reduce) somewhat conservatively and have the patient return for a second round of inferior turbinate reduction rather than attempting to produce all of the benefit in a single sitting.

5 SUCCESS RATE OF PROCEDURE AND WHAT TO DO IF THE PROCEDURE FAILS

Success of inferior turbinate reduction may be measured on many scales including degree of relief in terms of structuring, time spent with nasal obstruction, nasal stuffiness, mucus production, postnasal discharge, snoring and overall symptoms. With follow-up ranging from 6 months and beyond, the vast majority of patients perceive significant benefit from coblation inferior turbinate reduction with statistically and clinically significant decreases in most nasal symptoms. For example, nasal obstruction, the amount of time spent with nasal obstruction and nasal stuffiness decreased by 43%, 35% and 27% after a single treatment with coblation inferior turbinate reduction. Overall nasal symptoms decreased by 34% at 6 months follow-up. Overall, seven out of 10 patients can expect overall perceived clinical success with one treatment, and an additional two patients out of 10 will obtain substantial clinical improvement after a second treatment (Fig. 23.7).

Fig. 23.7 Individual nasal symptoms before and after coblation inferior turbinate reduction.

In cases of failure, patients may be treated with additional coblation treatments. Most commonly, this involves treatment of more distal posterior turbinate hypertrophy. In select cases, the size of the bony concha may be a substantial portion of the problem. These patients are best served with a submucous resection of a portion of the bony inferior turbinate. As the nasal mucosa is dynamic and changes over time, the inferior turbinate is no exception. Patients sometimes require a secondary or supplementary procedure at a 1 year interval or beyond. Thus far, in cases of subsequent turbinate hypertrophy after initial treatment, the coblation procedure has been repeatable with very similar subjective patient benefit without a higher rate of supplementary treatment side effects or complications.