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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5226_Библиотеки_им_академика_М_И_Перельмана.pdf
180
N. N. Patel and P. A. Loftus
Table 17.1
Indications Contraindications
• Chronic rhinitis (allergic, non-allergic, or
mixed) for >3months
• Dissatisfaction with medical management
• Age>18years
• Response to anti-cholinergic drugs
Indications and contraindications for posterior nasal nerve ablation
• Anatomical obstruction (septal deviation,
polyps, tumor)
• Severe epistaxis within the past 3months
• Rhinitis medicamentosa
• Prior radiation that included the treatment
area
• Intolerance to anesthetic agents
• Open intranasal wounds
• Impaired mucosal wound healing (e.g.,
small vessel vasculitis)
Indications forPNN Ablation
Cryoablation and radiofrequency ablation are considered in patients with chronic
rhinitis who have either failed medical management or are unable to comply with
medical therapy. Because topical nasal regimens require long-term usage and often
twice daily application, a signicant cohort of patients fail medical therapy due to
medication adherence alone. Indications for this intervention include adult patients
who have medically refractory perennial rhinitis, moderate to severe chronic runny
nose and/or nasal congestion, non-allergic chronic rhinitis, mixed allergic and nonallergic chronic rhinitis, and patients who demonstrate a response to anti- cholinergic
drugs (Table17.1).
Contraindications are primarily anatomical, as access to the sphenopalatine area
is vital for correct treatment administration. Furthermore, given that the procedure
is mostly performed in the ofce setting, tolerance of adequate topical analgesia and
decongestion is necessary. Patients who are poor candidates for this intervention
include those with anatomical obstruction (i.e., septal deviation), severe epistaxis,
rhinitis medicamentosa, prior radiation, open nasal wounds, and intolerance to
anesthetic/ decongesting agents (Table17.1). In patients undergoing cryotherapy
specically, prior studies have excluded patients who have cold-temperature induced
systemic disease, such as cryoglobulinemia, paroxysmal cold hemoglobinuria, cold
urticaria, and Raynaud’s disease [1].
Surgical Technique
This procedure is intended for clinic-based delivery with the use of local anesthesia,
but can be performed under anesthesia as an adjunct procedure or sole procedure in
select patient populations. Patients are seated in an upright position in a clinic chair
with their head positioned on the headrest. The procedure is performed under endoscopic guidance using a 0-degree rigid scope, camera tower, and one of the devices
available on the market which enable minimally invasive PNN ablation with cryotherapy or radiofrequency ablation (Fig.17.2).
ab
n = 77
n = 39
Percent of rTNSS Responders
17 Cryoablation andRadiofrequency Ablation ofPosterior Nasal Nerve
181
To begin, topical anesthesia, such as 4% lidocaine, and nasal decongestion, such
as neo-synephrine or oxymetazoline, are applied topically to the middle meatus and
anterior nasal cavity bilaterally with pledgets. Additional local anesthetic, such as
1% lidocaine with 1:100,000 epinephrine, is injected into the basal lamella, axilla of
the middle turbinate, and/or the area of the sphenopalatine foramen. If cryotherapy
is being used, pre-medication with gabapentin one hour prior to the start of the procedure has been shown to reduce acute headaches associated with this therapy [17].
The probe is introduced into the nasal cavity and guided to the target area
(Fig.17.3). The PNN is located in the posterior middle meatus, where the middle
turbinate attaches to the lateral nasal wall. The treatment is delivered according to
the device manufacturer protocol. With both types of ablation, multiple areas of the
lateral nasal wall/sphenopalatine area may be targeted. An example video demonstrating in-ofce cryotherapy is included (Video 17.1)as well as a video depicting
radiofrequency ablation of the PNN and posterior portion of the inferior turbinate
(Video 17.2).
Reported Outcomes
Both cryotherapy [18] and radiofrequency ablation [19, 20] have been studied in
patient-blinded, multicenter randomized controlled trials (RCTs) and have demonstrated clinical benet. Due to minimal morbidity, a unique feature of cryoablation
and radiofrequency ablative techniques is the ability to perform sham-controlled
trials. In these patient-blinded, sham-controlled RCTs, both cryotherapy and radiofrequency ablation demonstrated improvement in chronic rhinitis symptoms as
assessed by relative Total Nasal Symptom Score (rTNSS). In both RCTs, results
were reported as percent of responders, dened as greater than or equal to 30%
reduction of rTNSS from baseline at 3 months (Fig. 17.4). Using cryotherapy,
100
90
80
70
60
50
40
30
20
10
0
Fig. 17.4 Results of two sham-controlled, randomized controlled trials. Both trials dened
greater than or equal to 30% reduction in rTNSS from baseline as the primary outcome measure,
and both studies followed patients for 3months. (a) Cryotherapy treatment (N=64 treatment,
N=63 sham) [18] (b) Radiofrequency ablation (N=77 treatment, N=39 sham) [20]
73.4
Active
p<0.001
36.5
Sham
100
80
60
40
Responders (%)
20
0
treatment
67.5
Active
p = .009
41.0
Sham
control
182
N. N. Patel and P. A. Loftus
73.4% versus 36.5% were identied as responders in the treatment versus sham
groups, respectively (p<0.001) [18]. Similarly, in a separate RCT, radiotherapy
demonstrated 67.5% versus 41% responders in the treatment versus sham group,
respectively (p=0.009). For both technologies, other validated quality of life surveys have been reported as secondary outcomes and also demonstrated statistically
signicant improvement with treatment [21–23]. Of note, no study to date has performed a head-to-head comparison of these two technologies to determine superior
therapeutic effect.
Both technologies enrolled similar patient populations in their studies, primarily
utilizing rTNSS to identify those with long-standing rhinitis symptoms.
Radiofrequency ablation trials additionally included patients with complaints of
post-nasal drip and chronic cough, which are not included in the rTNSS.The RCTs
of radiofrequency ablation determined that these two symptoms decreased after
treatment [24]. Given that peripheral nerves have the ability to regrow, there is the
concern that non-invasive PNN ablation may only provide transient relief. Thus far,
studies in both cryoablation [25] and radiofrequency [24] PNN neurolysis have
demonstrated a lasting response for up to 1–3 years [26].
In terms of adverse events, both technologies are well tolerated. The most commonly reported adverse events in a 2018 systematic review of PNN cryotherapy
included epistaxis, nasal obstruction, nasal crusting, and ear blockage, none of
which were reported as serious [27]. At the time of cryoablation, some patients
complain of acute headache and/or tooth pain, akin to the colloquial “brain freeze”
or “ice-cream headache,” which can be alleviated with administration of gabapentin
prior to cryotherapy [17]. In studies of radiofrequency ablation, adverse events were
similarly mild, and include transient mild-to-moderate oropharyngeal pain, nasal
soreness, epistaxis, and tooth pain [28]. Overall, there were no severe adverse events
in the reported literature for either technology class.
Tips and Pearls
• For prevention of cryotherapy induced headache, premedicate with 600mg of
gabapentin at least 1h in advance of the procedure and warn patients of possible
transient “ice cream headache.”
• Ensure complete release of cryotherapy from surrounding tissues prior to
removal, and remove the probe slowly. Nasal breathing after administration may
aid in release of the probe tip through warming.
• Avoid excess gel at the stylus tip for the radiofrequency ablation as this can
impede visualization.
• Warn patients that radiofrequency ablation can result in transient burning smell
during treatment.
• For both, ensure the nasal cavity is appropriately anesthetized prior to device
introduction and insert the probe facing laterally so as to avoid trauma to nearby
structures.
• Stop advancing the device when it reaches the basal lamella, an area which can
provide immediate haptic feedback of target location.
17 Cryoablation andRadiofrequency Ablation ofPosterior Nasal Nerve
183
• Warn patients that symptoms or rhinorrhea may worsen transiently during recov-
ery prior to improvement.
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N. N. Patel and P. A. Loftus
Inferior Turbinate Reduction
18
StephenLeong, MichelleYu, andAshutoshKacker
Key Points
• Nasal congestion is a common ailment that, while typically benign, can seriously
detract from quality of life.
• The most common cause of chronic nasal congestion is enlargement of the erec-
tile tissue of the inferior turbinates.
• Therapies such as topical or systemic corticosteroids, antihistamines, and decon-
gestants can alleviate symptoms, but in cases of failure, surgical treatment of the
inferior turbinate may be an option.
• Multiple techniques to reduce the turbinates have been developed, each with
their own risks and benets.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_18.
S. Leong
Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center,
New York, NY, USA
e-mail: sl3793@cumc.columbia.edu
M. Yu (
*)
Department of Otolaryngology—Head & Neck Surgery, NewYork-Presbyterian/Weill Cornell
Medicine/Columbia University Irving Medical Center, New York, NY, USA
e-mail: miy7005@nyp.org
A. Kacker
Department of Otolaryngology– Head & Neck Surgery, New York-Presbyterian/Weill
Cornell Medicine, New York, NY, USA
e-mail: ask9001@med.cornell.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee et al. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_18
185
186
++++
++++
S. Leong et al.
• Submucous resection generally has more lasting effects on nasal obstruction than
extramucosal methods but preferred technique depends on surgeon preference,
cost, resource availability, ease of use, and risk of postoperative complications.
Background
The inferior turbinates are scroll-like, mucosal structures attached to the lateral
nasal wall that serve to lter, warm, and humidify air upon entry into the nasal cavity [1]. Inferior turbinate hypertrophy (ITH) is the most common cause of chronic
nasal obstruction and has various etiologies including allergic rhinitis, vasomotor
rhinitis, and rhinitis medicamentosa [1]. The rst-line treatment for ITH is medical
therapy with topical and/or oral antihistamines, corticosteroids, and/or decongestants; when these agents fail, surgical reduction is indicated [1].
The American Academy of Otolaryngology—Head and Neck Surgery recommends surgical inferior turbinate reduction (ITR) upon fulllment of four criteria:
(1) chronic nasal obstruction due to ITH, (2) failure of directed medical management with continued nasal symptoms, (3) failure of medical management of rhinitis
medicamentosa, and (4) symptoms of obstructive sleep apnea [2]. In this chapter,
we aim to review the different techniques for surgical ITR, and assess their relative
pros, cons, and indications (Table18.1).
Table 18.1 Pros and cons of listed techniques
Technique Cost DifficultyOverall efficacyDuration of
Complete
turbinectomy
Laser cautery +++ ++ ++ +
Electrocautery
Cryotherapy ++ +++
Turbinate
lateralization
Microdebrider
turbinoplasty
Coblation ++ ++ +++ +++
Radiofrequency
ablation
Ultrasound
turbinoplasty
+++++ +++
+ ++ +++ ++
++ ++ +++ ++
++ ++ +++ ++
effect
18 Inferior Turbinate Reduction
187
Extramucosal Surgical Techniques
The techniques described in this section achieve symptomatic control by either
resecting inferior turbinate mucosa or reducing nasal obstruction without tunneling
under the mucosa (i.e., turbinate lateralization). These techniques range from highly
efcacious with high risk of complications (i.e., complete turbinectomy) to mostly
ineffective with no signicant complications (i.e., turbinate lateralization, cryotherapy). There is evidence to show that submucosal techniques have better long-term
results than extramucosal techniques; overall many of the extramucosal techniques
that will be discussed below have fallen out of favor and are no longer routinely
used for ITR.However, some techniques, such as inferior turbinate lateralization,
are used in conjunction with submucosal techniques for an additive effect on symptomatic control [3, 4].
Complete Turbinectomy
A complete turbinectomy may be performed using curved turbinate scissors and
complete excision of all inferior turbinate tissue, leading to resolution of symptoms
in the vast majority of cases [5]. However, complete turbinectomy is associated with
unfavorable complications such as synechiae formation, signicant postoperative
pain, bleeding, and crusting [5]. Additionally, complete turbinectomy has been
associated with empty nose syndrome (ENS), an iatrogenic condition where removal
of turbinate tissue causes paradoxical nasal obstruction, impaired air sensation, and
nasal dryness [6]. Because of the potentially signicant functional burden of ENS,
as well as the frequency of other complications following complete turbinectomy,
this technique has largely fallen out of favor.
Laser Cautery
The most commonly used lasers for ITR are diode and CO2 lasers; other lasers that
may be used are argon, potassium-titanyl-phosphate (KTP), neodynium: YAG
(Nd:YAG), and holmium: YAG (Ho:YAG) lasers [7]. Each laser type has specic
pros and cons for ITR, which are beyond the scope of this chapter. Diode and CO2
lasers are preferred for ITR because they accurately ablate tissue while producing
hemostasis; these lasers are appropriate for use in endoscopic sinus surgery (ESS)
as well [8]. Laser cautery of the inferior turbinates achieves symptomatic control
through selective ablation of mucosa on the medial surface of the turbinate, thereby
producing mucosal atrophy and turbinate reduction. The complications of laser cautery are relatively minimal due to its hemostatic, highly selective effect; bleeding
and crusting have been observed in a small minority of patients [8]. Although
188
symptom control may be achieved in the majority of patients, laser cautery does not
appear to be as effective as other techniques, including submucosal techniques,
because a relatively small amount of tissue is removed [7]. Laser cautery appears to
be particularly ineffective for allergic rhinitis [7].
S. Leong et al.
Electrocautery
Monopolar or bipolar cautery may be used to ablate turbinate tissue either on the
mucosal surface or in a submucosal plane [5]. Typically, electrocautery is used on
the mucosal surface because the amount of tissue damage is difcult to gauge when
the electrode is inserted below the mucosa [8]. Both mucosal and submucosal cauterization are not highly effective in improving airow, and both are associated with
higher incidence of complications including crusting and synechiae formation [8].
Thus, inferior turbinate electrocautery is typically not performed as an isolated technique, but may be used in tandem with other submucosal techniques, and often with
a more minimal, mucosal-sparing method.
Cryotherapy
Cryotherapy for inferior turbinate reduction utilizes nitrous oxide or liquid nitrogen
to rapidly cool the turbinate, thus inducing necrosis and scarring in a minimally
invasive fashion [8]. Though symptom control may be achieved in the short term,
these effects do not persist; thus, this technique has largely been abandoned.
Turbinate Lateralization
Using a at elevator or long nasal speculum, the turbinates may be fractured and
pushed laterally to increase airow within the nasal cavity [9]. Although the procedure is straightforward and associated with minimal morbidity, it has not been
shown to reduce symptom burden when performed independently [9]. However,
when performed in tandem with septoplasty or other methods of turbinate reduction, it may produce an added benet in the relief of obstructive symptoms. Notably,
turbinate lateralization is often performed in conjunction with submucosal resection; this technique will be discussed in following sections.
Submucosal Techniques
The goal of submucosal resection is removal of obstructive tissue while preserving
the mucosal function of the inferior turbinate [8]. Thus, submucosal resection is typically not associated with nasal dryness or ENS.Two types of submucosal resection
are used for ITR: intraturbinoplasty and extraturbinoplasty [8]. Both are performed
under local anesthesia with lidocaine and epinephrine or neosynephrine.
Video 3 –ITR Radio Frequency
18 Inferior Turbinate Reduction
Table 18.2 Complication risk of listed techniques
189
Technique Minor
Complete
turbinectomy
Laser cautery ++++ ++ ++
Electrocautery+ + ++ ++ ++ ++ ++
Cryotherapy ++++ ++ ++
Turbinate
lateralization
Microdebrider
turbinoplasty
Coblation +++++++
Radiofrequency
ablation
Ultrasound
turbinoplasty
bleeding
+++ ++ +++ ++++ +++ +++
+++++++
++ ++++++
+++++++
+++++++
Major
bleeding
Pain Crusting Necrosis Nasal
dryness
Synechiae
Intraturbinoplasty is achieved by tunneling devices into the inferior turbinate anteriorly and resecting erectile tissue along the length of the turbinate under endoscopic
guidance [8]. Intraturbinoplasty is the most commonly used form of conventional
turbinoplasty, and may be performed with a variety of tools including microdebrider,
ultrasound, radiofrequency, and coblation. These specic techniques will be discussed in the following sections. Extraturbinoplasty is achieved by resecting the lateral erectile tissue and mucosa, elevating a medial mucosal ap, and rotation of the
ap laterally to cover the exposed part of the inferior turbinate [8]. Both techniques
achieve symptomatic control at high rates with relatively low complication rates; the
most common side effects are bleeding and crusting (Table18.2). Intraturbinoplasty
is preferred over extraturbinoplasty because it is relatively easier to perform successfully. Additionally, turbinate lateralization may be performed in conjunction with
intraturbinoplasty, and has an additive benet in relief of nasal obstruction.
Microdebrider Turbinoplasty (Video 18.1)
The microdebrider is a critical tool in ESS, allowing for continuous suction with
precise tissue removal [8]. Given its widespread use, the microdebrider is the most
commonly employed tool for ITR following an ESS case. The microdebrider may
be used for both intraturbinoplasty and extraturbinoplasty. For extraturbinoplasty,
the microdebrider is used to resect the inferior and lateral aspects of the inferior