Pathology of the turbinates is one of the most frequent causes of nasal complaints. Obstructed breathing, hypersecretion, sneezing, itching, hyposmia, and pressure sensations are the most common symptoms. Remarkably, most textbooks and courses on nasal surgery pay little or no attention to turbinate pathology and its treatment. Instead they concentrate on the septum, pyramid, and lobule. Nonetheless, disorders of the turbinates are extremely common in daily rhinological practice.

Therapy of turbinate disorders should take account of the character and the cause of the pathology. Remarkably, however, specific types of turbinate pathology are rarely distinguished. Most textbooks and articles refer to “hyperplastic,” “hypertrophic,” “engorged,” or “congested” turbinates. In an attempt to provide grounds for choice of treatment, this chapter differentiates between various types of turbinate pathology.

The choice of a therapy for turbinate disorders has been a matter of dispute for over a century. What all authors do agree on is that conservative treatment—with topical steroids, antihistamines, systemic antibiotics, depending on the cause of the pathology—should be first choice. Medications are permanently effective in a limited number of cases, however. Surgical treatment—usually some kind of turbinate reduction—is then considered. When choosing a method of turbinate reduction, we must keep in mind that turbinates are very important functional structures because they enable the nose to perform its tasks. They regulate the course of the airstream; they humidify, warm, and cleanse the inspired air; and they are the main organs of defense for the upper respiratory tract. Preservation of these functions is therefore obligatory.

As previously noted, we need a workable classification of turbinate pathology. In our experience, the following types may be distinguished:

1. compensatory hypertrophy;
   
2. protrusion (i.e. abnormal medial position of the turbinate);
   
3. hyperplasia of the turbinate head;
   
4. hyperplasia of the entire turbinate;
   
5. (degenerative) hyperplasia of the turbinate tail.

As previously noted, we will first consider conservative treatment, as we would in the majority of cases of turbinate pathology. The effect of a corticosteroid spray and/or systemic or topical antihistamines should be tested in allergic or hyper-reactive patients for at least 3 months. Where infection plays a role, a course of antibiotics (sometimes in combination with antihistamines or corticosteroids) should be given first. In patients who do not respond within 3–6 months, surgery must be considered.

Procedures to reduce a turbinate should be judged by two basic criteria. The first is the efficacy of the technique in alleviating breathing obstruction, hypersecretion, recurrent infection, sneezing, and headaches. The second is an assessment of the procedure’s side effects, both in the short and the long term. It would be a mistake to focus solely on the degree of widening of the nasal passages in terms of endoscopic findings, rhinomanometry, and acoustic rhinometry. A wider nasal cavity does not necessarily mean the nose functions better. The aim of turbinate surgery must be to diminish complaints while preserving function.

Fig. 8.1 Protrusion of the inferior turbinate. There is a wide angle between the turbinate bone and the lateral nasal wall.

In terms of function, surface electrocautery is obviously a destructive procedure. It does not meet the requirement of diminishing complaints while preserving function.

Modern variations, such as submucosal bipolar diathermia and the recently propagated high-frequency diathermy, may cause less superficial damage.

The aim of turbinate surgery must be to diminish complaints while preserving function.

Chemocoagulation or chemocautery with chromic acid or trichloric acid was introduced as an alternative to electrocautery in the last decades of the 19th century. In our opinion, chemocautery of the turbinate mucosa is the worst treatment imaginable. It does not reduce the turbinate volume but causes damage to all functional elements of the mucosa. Nevertheless, the method is still used.

Turbinectomy also dates from the last decades of the 19th century. Resection of the inferior turbinate became one of the most frequently practiced rhinological surgical procedures in the first quarter of the 20th century. Special instruments were designed, such as Struycken’s scissors. Soon after its introduction, however, reports about postoperative atrophic rhinitis and “secondary” ozena appeared. This led many surgeons to use more conservative techniques such as lateralization, partial resection, and submucous resection of turbinate bone. In the 1970s and 1980s, turbinectomy was again recommended by several authors. Many of them disputed claims that it might lead to atrophic rhinitis or a “wide nasal cavity syndrome.” Noting the numerous complications, others disagreed. Stenquist and Kern coined the term “empty nose syndrome.” A review of the literature on this controversial issue was recently presented by Hol and Huizing (2000).

In our opinion, turbinectomy is a nasal crime. We feel that there is no reason (apart from malignancies) to resect more than one-third to one-half of the inferior turbinate.

Lateralization by outfracturing the turbinate was introduced as early as 1904 by Killian, among others. This conservative function-preserving method is still widely used, particularly as a flanking procedure along with septoplasty. Since its effect is rather limited, several variations have been suggested, such as lateral fixation (“lateropexia”) or partial dislocation of the turbinate into the maxillary sinus after resection of part of the lateral nasal wall. Understandably, these methods did not have much of a following.

Submucosal resection of the turbinate bone was presented by several authors in the years 1906–1911, as an alternative to the more aggressive techniques previously discussed. Despite its attractivity, this procedure gained only limited popularity. In 1951, Howard House revived the method. The anterior part of the bony lamella, together with some of the parenchyma, is resected through an incision at the head of the turbinate (Freer 1911). Mabry (1982, 1984) refined the technique and introduced the term “turbinoplasty.” As the mucosa and submucosa are preserved, the method meets our requirement of “volume reduction with preservation of function.” In the recent comparative study by Passali et al.(1999), this technique came out as the best method.

Crushing and/or trimming was recommended as a less destructive alternative to turbinectomy in the early 1930s. The turbinate is first crushed in an effort to damage and thus reduce the amount of the parenchyma and, at the same time, to leave the mucosal surface intact. It is then trimmed to size. In trimming or partial resection, various techniques have been employed: horizontal or diagonal resection of the inferior margin; resection of the posterior part; and resection of the anterior part. From the viewpoint of preserving function, all of the above variations appear to be acceptable, provided they are performed in a conservative way. Personally, we prefer the crushing and trimming technique in cases where submucosal turbinate reduction is not appropriate. Although this method is certainly not ideal, it seems to represent the best compromise between desired results and side effects. Total turbinectomy is a “nasal crime”.

Injection of a long-acting corticosteroid solution was introduced in 1952. Many authors reported beneficial results. The effect lasted only a few months, however. Later, the method was discouraged after reports of acute homolateral blindness appeared.

Injection of sclerosing agents was suggested for the first time in 1953. The method did not come into general use because of its unpredictable results and complications.

Vidian neurectomy was introduced by Golding Wood in 1961 as a completely different approach to the problem of turbinate hypertrophy and hypersecretion. Parasympathetic innervation was severed by cutting the nerve fibers in the Vidian canal through a transantral approach or endonasal coagulation of the sphenopalatine ganglion. Usually, some decrease of hypersecretion was obtained. The effect on blockage was poor. Since the effects appeared to be temporary, the method was abandoned in the 1970s.

Cryosurgery was the next step in the long history of treatment of inferior turbinate hypertrophy. It was widely used in the 1970s, but its popularity soon declined. The amount of reduction appeared to be rather unpredictable.

Powered instruments like “shavers” have recently come into use in turbinate surgery. These instruments are used on the turbinate surface as well as intraturbinally, often in combination with an endoscope. Use of a powered instrument appears to be a matter of personal preference. The results depend less on the instrument that is used than on the surgical concept.

High-frequency diathermy is the most recent technique for reducing turbinate hypertrophy. Again it makes a difference whether it is used superficially or endoturbinal. See the discussion above.

In conclusion:

When accepting that the aim of turbinate surgery must be to diminish complaints while preserving function, we have to come to the conclusion that only three of the methods discussed above are acceptable:

1. submucosal turbinoplasty,
   
2. lateralization, and
   
3. (crushing and) trimming.
   
4. When part of the mucosa is irreversibly degenerated, local resection is allowed.

Lateralization (lateral displacement) of the inferior turbinate by outfracturing the turbinate bone is the most conservative method to address turbinate obstruction. It is mostly used in combination with another procedure as lateralization alone is rarely effective enough. It is often combined with septal surgery or one of the volume-reducing techniques described in the followong text.

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Fig. 8.2b A medially based mucosal flap is dissected.

Fig. 8.2c The anterior or the anteroinferior part of the turbinate bone is resected together with some of the parenchyma as required.

Fig. 8.2d The mucosal flap is repositioned.

Fig. 8.3 Lateralization of a protruding or hyperplastic inferior turbinate is performed using the flat, blunt end of a Cottle chisel.

When the inferior turbinate is hypertrophic both anteriorly and posteriorly, crushing and trimming would be the best compromise between reduction and preservation of function. The whole turbinate is first compressed using a special forceps and then reduced by resecting a parallel or slightly diagonal strip from its inferior margin. The technique respects the functional capacity of the remaining part of the turbinate.

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