Turbinate Slides 2003 0312

7/28/2019 Turbinate Slides 2003 0312

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Turbinate Dysfunction

Shashidhar S. Reddy, MD, MPH

Matthew Ryan, MDMarch 2003


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Overview

Focus on Nasal Obstruction

Anatomy

Histology and Physiology

Evaluation of Nasal Obstruction

Turbinate Disorders Medical Management

Surgical Management


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Anatomy

Inferior Turbinate:

An inferior infolding of

the lateral nasal wall. 60 mm in anterior to

posterior direction.

Forms an important

component of thenasal valve.

Derived from themaxilloturbinal ridge.


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Anatomy

Middle Turbinate

Lies medial to the anteriorethmoid air cells, the

maxillary sinus ostium, thenasofrontal duct, and theuncinate process.

Length of 40 mm andmean height of 14.5 mm

anteriorly and 7 mmposteriorly.

Develops from the secondethmoturbinal.


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Anatomy

Superior Turbinate

Meatus drains the

posterior ethmoid aircells.


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Anatomy

Nasal Valve

External Nasal Valve

Boundaries include: lower lateral

cartilages

Soft tissue alae

Membranous septum

Sill of the nostril Can be site of

obstruction (e.g. s/prhinoplasty)


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Anatomy

Internal Nasal Valve Boundaries include:

Septum

Upper lateral cartilages

Anterior end of inf.Turbinate

1.3cm from nares

Accounts for 50% ofairway resistance

Inferior turbinate canaffect this area greatly


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Histology

Three layers ofTurbinates

Medial thin mucosa Bone

Lateral thick mucosa

From: Berger: Laryngoscope, Volume111(12).December 2000.2100-2105


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Histology

Mucosa

Pseudostratified columnar ciliated respiratory

epithelium Goblet cells produce salts, glycoproteins,

polysaccharides, lysozymes.

Complex array of arteries, veins, and venoussinusoids.

Lamina Propria contains the above tissue.


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Physiology

Functions of the Nose Related toTurbinates:

Airway

Filtration most particles > 30m

Heating to 31-37 degrees

Humidification to 95%


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Physiology

Chemical or microbial irritation leads to rapidinflammatory response.

Nasal cycle lasts 2-6 hrs, occurs in 20-80% ofpeople.

Sympathetic nervous system increases vascularresistance

Parasympathetic nervous system (vidian nerve)relaxes capacitance vessels.

Sensory receptors = temperature receptors


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Evaluation of Patients

History nasalobstruction symptoms

Physical exam Look for dynamic and

structural cause ofnasal obstruction.

Check before and afterdecongestion.


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Evaluation of Patients

Rhinomanometry

Anterior pressure sensorin one nostril, flow meter in

a mask. Posterior pressure sensor

in the mouth, flow meter ina mask.

Ohms Law: R=P/V

Normal is .15 to .3 Pa/cm3

>.3 is usually associatedwith symptoms.


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Evaluating Patients

Acoustic Rhinometry Measures cross-

sectional area (CSA)

Minimal CSA beforeconsistent reporting ofnasal obstruction is.3cm2 or less.

Above .3cm2

, reliabilityto predict gradation ofsymptoms iscontroversial.


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Evaluating Patients

Other tests:

Olfaction tests

Nasal smear

Tests of humidity and heating


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Turbinate Disorders

Allergic rhinitis

Histologic turbinate findings: mast cellabundance, seromucous gland

hyperplasia, interstitial fibrosis,eosinophils on smear.

Probably the most frequent cause ofturbinate-related nasal obstruction.

Acute rhinosinusitis Exam similarto AR

Leukocytes on nasal smear.


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Turbinate Disorders

Chronic Rhinosinusitis

Leads to longstanding changes in mucosa.

Fibrosis, polyposis.

Vasomotor Rhinitis

Nasal congestion, rhinorrhea only

Drug Induced Rhinitis


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Turbinate Disorders

Nasal Polyposis

Etiology unclear -?denervated mucosa

Samters Triad

Atrophic Rhinitis

Progressive slow atrophy of

nasal mucosa

Questionable associationwith aggressive turbinateresection


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Turbinate Disorders

Anatomic

Septal Deviation

Concha Bullosa

From:

BaylorGrandRoundsArchive


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Turbinate Disorders

Anatomic

Paradoxical middle turbinate curvature in 10-

29% Synechiae, polypoid changes


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Medical Management

Allergic Rhinitis Nasal steroids with oraland/or topical antihistamines, systemic

decongestants. Drug induced rhinitis cessation of topical

medicine and switch to steroids.

Nasal Polyposis systemic steroids, topicalsteroids.

Rhinosinusitis: Antibiotics


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Surgical Management

Total inferior Turbinectomy

Benefits:

Most effective in terms of LONG TERMimprovement of airway

Ophir et alfollowed 186 patients for 10 years andshowed that 82% showed subjective improvement,

95% had widely patent airways


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Surgical Management

Total Inferior Turbinectomy

Disadvantages

Postoperative hemorrhage rate of 5-8% Nasal crusting, sometimes lasting for months, up to 15% at

one year, in a study by Mabry et al(40pts. followed for oneyear)

Synechiae 6-12% of the time

Atrophic rhinitis? Classic study by Moore shows rate of 66%in group of 18 pts at 3-5 years. Six ENTs in Australiareported none in 17,000 cases. (Fry et al1992)


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Surgical Management

Partial Turbinectomy

Anterior portion, at

nasal valve, isresected.

Advantages

Addresses nasal valve

Courtis showed 92%

satisfaction at >2 years

Disadvantages

Similar to total, but lesssevere


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Surgical Management

Mucosal Lesion-Producing techniques: Electrocautery,

Cryosurgery, LaserSurgery

Advantages Local Anesthesia, Easy,

low hemorrhage risk Disadvantages

Extensive post-opcrusting, probableregrowth of lesions


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Surgical Management

Laser Illustrations


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Surgical Management

Submucous Lesions Radiofrequency

unipolar or bipolar Study by by Back et al

on twenty patientsshowed improvement innasal cross-sectionalarea by acousticrhinometry at one year

KTP, Argon, and CO2have all been shown tobe effective.


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Surgical Management

CorticosteroidInjection

Advantagesminimally invasive, lowcost, cost effective

Disadvantages -Effects wear off by 6weeks

Microdebrider


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Surgical Management

Vidian Neurectomy Ligate vidian nerve, thus cutting

parasympathetic supply. Transantral, Transseptal, Transpalatal.

Good immediate relief (Fernandes et al)reports 88% of 139 patients reported

improvement in rhinorrhea. Can have high complication rate including

bleeding


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Surgical Management

Middle Turbinate

Concha Bullosa

Indications

Complications


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Surgical Management

Middle Turbinate:

Medialization aftersinus surgery

Prevents synechiaeformation?


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Surgical Management

Resection of the normal middle turbinate?

Havas, et al. show clear benefit in reducing

synechiae requiring revision at osteomeatalcomplex after partial resection of middleturbinate (15% without resection vs. 7.1%with) in a randomized trial of >1000 patients.


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Conclusion

Anatomy

Histology/Physiology

Evaluation of Nasal Obstruction

Turbinate Disorders

Medical Management

Surgical Management

Controversial


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Bibliography:McCaffrey, Thomas V., Nasal Function and Evaluation, Byron J. Baileys Head and Neck Surgery Otolaryngology, Third Edition, pgs 261-271. Lippincott Williams and Wilkins Philadelphia, 2001.

Lindemann, Jorg, MD Impact of Unilateral Sinus Surgery with Resection of the Turbinates by Means of MidfacialDegloving on Nasal Air Conditioning, Laryngoscope, 112(11), pgs. 2062-2066.

Jafek, Bruce W. et al Nasal Obstruction,Head and Neck Surgery Otolaryngology, Third Edition, pgs 293-308. Lippincott Williams and Wilkins Philadelphia, 2001.

Dowley, A.C. et alThe effect of inferior turbinate hypertrophy on nasal spray distribution to the middle meatus,Clinical Otolaryngology 26(6) pgs 488-490.

Ophir, D. et al, Total inferior turbinectomy for nasal airway obstruction, Archives of Otolaryngology 111:93, 1985. Courtiss, E.H. et alResection of obstructing inferior turbinates: a 6 year follow-up, Plastic Reconstructive Surgery

72: 913, 1983.Jackson, Lance E et alControversies in the Management of Inferior Turbinate Hypertrophy: A Comprehensive

Review, Lippincott Williams and Wilkins, Plastic and Reconstructive Surgery 103(1) pgs 300-312.Leunig, Andread, MD et alHo: YAG Laser Treatment of Hyperplastic Inferior Nasal Turbinates, Laryngoscope

109(10) pgs 1690-1695.Havas, TE; Lowinger, DSG, Comparison of functional endonasal sinus surgery with and without partial middle

turbinate resection, Annals of Otolgoy, Rhinology, Laryngology, 109:634-640 pp 113-119.10. Fisher, E.W. Acoustic Rhinometry Reproducibility and Reliablity, Clinical Otolaryngology, 22(4) pp 307-317.

Hanif, J et al, The nasal cycle in health and disease. Clinical Otolaryngology and Allied Sciences, 25(6) pp 461-467.Mygin, N. Nasal Polyposis, Eosinophil dominated inflammation, and Allergy, Thorax 55(supplement 2) pp s79-s83.

Berger, Gilead et al, Histopathology of the inferior turbinate with compensatory hypertrophy in patients with

deviated nasal septum, Laryngoscope 111(12) pp 2100-2105.Saunders, M.W. et al,Parameters of nasal airway anatomy on magnetic resonance imaging correlate poorly withsubjective symptoms of nasal patency Clinical Otolaryngology & Allied Sciences 24(5) pp 431-434.Howard, et alUnderstanding the Nasal Airway: Principles and Practice, Plastic and Reconstructive Surgery, 109(3) pp 1128-

1146.Thornton, Robert S., Middle Turbinate Stabilization Technique in Endoscopic Sinus Surgery Arch OtolaryngolHead Neck Surg.1996;122:869-872Dogru, Harun. Tuz, Mustafa. Uygur, Kemal. Cetin, Meltem, A New Turbinoplasty

Technique for the Management of Concha Bullosa: Our Short-Term Outcomes,Laryngoscope. 111(1):172-174,January 2001.Backet al, Sumucosal Bipolar Radiofrequency thermal ablation of inferior turbinates: A long-term

follow-up with subjective and objective assessment, Laryngoscope 112(10) pp 1806-1812.

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