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190
S. Leong et al.
turbinate; medialization of the turbinate may be required for appropriate access
[10]. A Cottle elevator is then used to dissect the medial mucosa from underlying
bone; the bone may be removed with a long Stevens tenotomy scissor. The medial
mucosal ap is rotated laterally to cover the exposed part of the inferior turbinate.
For intraturbinoplasty, a #15 blade is used to incise the anteromedial portion of the
inferior turbinate; the microdebrider is then inserted into the submucosal pocket and
used to debride soft tissue and turbinate bone [11]. Direct inspection with a 0 degree
endoscopic is used to assess for bleeding; suction cautery may be used to achieve
hemostasis. The incision into the inferior turbinate may be left open or closed with
a simple interrupted suture. Complications of bleeding, crusting, and synechiae formation are minimal in both techniques, and symptomatic control is achieved in the
vast majority of cases.
Coblation (Video 18.2)
Coblation is an ablative technique that uses bipolar radiofrequency in combination with saline irrigation to vaporize soft tissue [8]. Coblation can be used to
perform intraturbinoplasty or extraturbinoplasty in a similar fashion to microdebrider resection. Coblation also produces postoperative brosis within the inferior turbinate, which prevents future hypertrophy by anchoring mucosa to the
periosteum [8]. In multiple studies, coblation-mediated submucosal resection
achieved symptomatic control in the vast majority of patients with minimal complications, and patients remained asymptomatic for durations of time exceeding
32months [8]. Unlike microdebrider resection, traditional coblation cannot be
used to resect turbinate bone; however, the Turbinator wand attachment was
developed to add a cutting effect in addition to the thermal energy produced by
traditional coblation [8]. Using the Turbinator wand, turbinate bone may be
resected in addition to soft tissue, thereby allowing for signicant reduction in
turbinate size.
Radiofrequency Ablation (Video 18.3)
Radiofrequency energy is delivered submucosally to the inferior turbinate via a
needle on a handheld device, ablating tissue with heat desiccation created by frictional energy. As the turbinate heals, the submucosal necrosis created by the ablation is replaced by broblasts and normal wound contraction leads to a reduction in
turbinate volume. Temperatures range from 60° to 90° C in radiofrequency ablation
as opposed to up to 800°C with electrocautery or laser techniques [4]. A prospective, randomized, single-blinded, placebo-controlled trial in 32 patients conducted
by Nease and Krempl showed that radiofrequency ablation is more effective in
treating inferior turbinate hypertrophy than placebo [12]. Performance-wise, radiofrequency ablation is a comparable technique to coblation, but does not employ
saline irrigation, and instead uses a radiofrequency electrode to directly heat soft
18 Inferior Turbinate Reduction
191
tissue to 60–90° [13]. The efcacy of radiofrequency ablation is comparable to
microdebrider resection, and the radiofrequency electrode produces a more targeted
effect than coblation [8]. Like microdebrider resection, complications of bleeding,
crusting, and synechiae are typically minimal.
Ultrasound Turbinoplasty
Ultrasound turbinoplasty is achieved with an ultrasonic nasal probe that is inserted
submucosally. The low frequency ultrasound disrupts cavernous and connective tissue in the turbinate, thereby reducing the bulk of the soft tissue of the turbinate [14].
The technique can be performed under local anesthesia and is comparable in
improving nasal obstruction to other techniques such as coblation, monopolar cautery, and radiofrequency turbinoplasty for at least 6months from surgery [14]. This
technique is well-tolerated under local anesthesia and has minimal complications,
primarily consisting of pain and nasal discharge. Post-operative bleeding and synechiae are rare with this technique.
Tips and Pearls
• Surgical resection of the inferior turbinate may be performed for refractory infe-
rior turbinate hypertrophy.
• A variety of techniques have been described, the most effective of which tend to
be submucosal techniques given high efcacy with low complication rates.
• Submucosal techniques can be performed under local or general anesthesia as
sole therapies or adjunctive procedures.
• Under local anesthesia, patient education and careful patient selection are neces-
sary to set expectations and provide successful outcomes.
References
1. Berger G, Balum-Azim M, Ophir D. The normal inferior turbinate: histomorphometric analysis and clinical implications. Laryngoscope. 2003;113(7):1192–8. https://doi.
org/10.1097/00005537- 200307000- 00015.
2. 125395. Clinical Indicators: Inferior Turbinate Surgery. American Academy of OtolaryngologyHead and Neck Surgery (AAO-HNS). Accessed June 25, 2022. https://www.entnet.org/
resource/clinical- indicators- inferior- turbinate- surgery/
3. Passàli D, Passàli FM, Damiani V, Passàli GC, Bellussi L.Treatment of inferior turbinate
hypertrophy: a randomized clinical trial. Ann Otol Rhinol Laryngol. 2003;112(8):683–8.
https://doi.org/10.1177/000348940311200806.
4. Larrabee YC, Kacker A.Which inferior turbinate reduction technique best decreases nasal
obstruction? Laryngoscope. 2014;124(4):814–5. https://doi.org/10.1002/lary.24182.
5. Rao SUP, Basavaraj P, Yempalle SB, Ramachandra AD.A prospective study of different methods of inferior turbinate reduction. J Clin Diagn Res JCDR. 2017;11(5):MC01–3. https://doi.
org/10.7860/JCDR/2017/24861.9850.
6. Manji J, Nayak JV, Thamboo A.The functional and psychological burden of empty nose syndrome. Int Forum Allergy Rhinol. 2018;8(6):707–12. https://doi.org/10.1002/alr.22097.
192
7. Janda P, Sroka R, Baumgartner R, Grevers G, Leunig A.Laser treatment of hyperplastic inferior nasal turbinates: a review. Lasers Surg Med. 2001;28(5):404–13. https://doi.org/10.1002/
lsm.1068.
8. Abdullah B, Singh S. Surgical interventions for inferior turbinate hypertrophy: a comprehensive review of current techniques and technologies. Int J Environ Res Public Health.
2021;18(7):3441. https://doi.org/10.3390/ijerph18073441.
9. Hol M, Huizing E.Treatment of inferior turbinate pathology: a review and critical evaluation
of the different techniques. Rhinology. 2001;38:157–66.
10. Bielamowicz S, Hawrych A, Gupta A.Endoscopic inferior turbinate reduction: a new technique.
Laryngoscope. 1999;109(6):1007–9.
11. Friedman M, Tanyeri H, Lim J, Landsberg R, Caldarelli D. A safe, alternative technique for inferior turbinate reduction. Laryngoscope. 1999;109(11):1834–7. https://doi.
org/10.1097/00005537- 199911000- 00021.
12. Nease CJ, Krempl GA. Radiofrequency treatment of turbinate hypertrophy: a randomized,
blinded, placebo-controlled clinical trial. Otolaryngol—Head Neck Surg. 2004;130(3):291–9.
https://doi.org/10.1016/j.otohns.2003.11.003.
13. Utley DS, Goode RL, Hakim I.Radiofrequency energy tissue ablation for the treatment of
nasal obstruction secondary to turbinate hypertrophy. Laryngoscope. 1999;109(5):683–6.
https://doi.org/10.1097/00005537- 199905000- 00001.
14. Gindros G, Kantas I, Balatsouras DG, Kaidoglou A, Kandiloros D.Comparison of ultrasound turbinate reduction, radiofrequency tissue ablation and submucosal cauterization in
inferior turbinate hypertrophy. Eur Arch Otorrinolaringol. 2010;267(11):1727–33. https://doi.
org/10.1007/s00405- 010- 1260- 9.
https://doi.org/10.1097/00005537- 199906000- 00030.
S. Leong et al.
Radiofrequency andBioabsorbable
Nasal Implantation forTreatment
ofNasal Valve Obstruction
19
GregE.Davis andCraigMiller
Key Points
• The nasal valve is a major component of nasal airway obstruction in many
patients.
• Multiple devices are available on the market that surgically treat narrowing of the
nasal valves, bypassing the need for patients to undergo reconstructive
rhinoplasty.
• With recent advances, nasal valve compromise can be treated either in the oper-
ating room or in the ofce setting under local anesthesia.
• Patient selection and method of local anesthetic control are critical to performing
a successful procedure.
Background
The internal nasal valve is an anatomically dynamic and complex area of the nasal
cavity. This area is the narrowest region in the upper airway that can account for up
to 70% of nasal respiratory resistance [1]. Anatomically, it is composed of the dorsal
septum, upper lateral cartilage, and head of the inferior turbinate (Fig.19.1). Both
static (xed) and dynamic (motion) challenges lead to nasal airway resistance.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_19.
G. E. Davis (*)
Otolaryngology, Proliance Surgeons, Seattle and Puyallup, WA, USA
C. Miller
Otolaryngology, Virginia Mason Franciscan Health, Seattle, WA, USA
© 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_19
193
194
Fig. 19.1 Base view of
the nose showing the
internal nasal valve. Image
courtesy of Aerin Medical
G. E. Davis and C. Miller
Static abnormalities include deviated nasal septum, inferior turbinate hypertrophy,
and malpositioned (narrow) upper lateral cartilage. Dynamic abnormalities impact
nasal resistance during active nasal inspiration when the sidewalls of the nose collapse due to weak upper lateral cartilages. This condition highlights Bernoulli’s
principle describing that as uid velocity increases in a tube due to narrowing, the
pressure in that tube must decrease. This decrease in pressure is akin to a vacuum
effect and pulls in the surrounding inadequately supported tissue of the lateral nasal
wall. The pathology of this event is called Nasal Valve Compromise (NVC), also
called nasal valve collapse, and primarily relates to the internal nasal valve [2].
Dynamic nasal valve collapse attributed to weakness of the upper lateral cartilages can be managed via surgical and non-surgical techniques. Non-surgical techniques are typically temporary and consist of external nasal splints to support the
cartilage collapse, such as breathe-right strips, or insertable devices to help stent
open the nasal valve, such as nosecones or nasal dilators. Historically, invasive management of nasal valve collapse has consisted of surgical procedures to strengthen
the upper lateral cartilages such as batten grafts and lateral crural strut grafts. These
complex surgeries are predominantly performed by surgeons who obtained additional training in facial plastics or cosmetic fellowship programs [3]. Implanted
nonabsorbable alloplastic grafts have been used; however these have increased risks
of infection, extrusion, and high rates of revision surgery [4].
More recently, the development of two novel techniques to improve NVC has
created simplied and effective options to treat NVC and lateral wall insufciency
that areavailable for the general otolaryngologist and rhinologist. The LATERA®
(Stryker, Inc., Kalamazoo, MI) implant, a lateral nasal sidewall implant and the
Vivaer® (Aerin Medical, Mountainview, CA) radio frequency (RF) device for nasal
19 Radiofrequency and Bioabsorbable Nasal Implantation for Treatment of Nasal…
195
valve remodeling are currently readily available, low-morbidity treatment options
for patients with NVC.
Surgical Technique
Bioabsorbable Nasal Sidewall Implant (LATERA)
LATERA is a bioabsorbable nasal implant used to support both the upper and lower
lateral cartilages during inspiration. The implant is a 70:30 blend of poly(L-lactide)
and poly(D-lactide) (Fig.19.2). It is produced in two sizes, 24 and 20mm. It is
introduced via an endonasal insertion technique using a delivery device. This
implant targets the caudal lateral region of the lateral crus of the lower lateral cartilage, a critical region for maintaining strength of the lateral nasal wall.
The implant consists of a forked end, which is positioned on the frontal process
of the maxilla, and a body with a balled end, which extends caudally toward the alar
region (Fig.19.3). The implant conforms to the natural curvature of the lateral wall
against the upper and lower lateral cartilages to provide support and strength to the
lateral wall without change to the nasal aesthetic. Early prospective trials using the
device found that 30 patients with dynamic NVC had improvement in their Nasal
Obstruction Symptom Evaluation (NOSE) scores by an average of 42 points,
improving from a mean pretreatment NOSE score of 65 to a 12-month posttreatment average of 23 points [4]. Additionally, there were no reports of signicant
change to cosmesis, implant migration, or associated infection. A recent systematic
review and meta-analysis, reviewing ve studies assessing NOSE scores and quality
of life metrics following LATERA placement, concluded similar effectiveness and
improvement in nasal breathing scores compared to sham surgery [5]. Histological
analysis of LATERA at 24months after implantation showed that the implant provides long-term structural support as it is replaced by brous tissue [6]. Long-term
studies with 2-year follow-up demonstrated long-term stability [7, 8].
This procedure can be performed in the operating room either as an isolated
procedure or in conjunction with septoplasty and inferior turbinate reduction. The
minimally invasive technique and delivery system does allow for this to also be
performed in the ofce setting under local anesthesia. Appropriate patient selection
Fig. 19.2 Latera implant
(permission to use image
from Stryker)
196
Fig. 19.3 Placement of
Latera implant (permission
granted to use image from
Stryker)
G. E. Davis and C. Miller
and optimizing local anesthetic techniques improve patient experience and
satisfaction.
Patient Selection
The ideal candidate for the LATERA procedure has mild to moderate dynamic nasal
valve collapse with inspiration, a positive Cottle maneuver (improved breathing),
mild to moderate inferior turbinate hypertrophy, and none or mild nasal septal deviation. A patient with severe septal deviation likely needs a septoplasty performed in
conjunction with the LATERA procedure. Similarly, an inferior turbinate that is
completely blocking the nasal space may benet from a turbinate reduction either in
addition to LATERA placement or in a separate procedure. An additional consideration should include the surgeon’s perception of a patient’s tolerance for an in-ofce
versus an in-operating room procedure as this can signicantly impact satisfaction
during the procedure.
Local Anesthesia
Both topical and local anesthesia are necessary to provide optimal patient comfort.
Local anesthesia injection, specically lidocaine with epinephrine, can serve to
decrease bleeding during the procedure, improve patient tolerance, and provide a
hydro-dissected plane to improve device placement. The addition of 10% volume of
19 Radiofrequency and Bioabsorbable Nasal Implantation for Treatment of Nasal…
197
8.4% sodium bicarbonate to the local anesthetic can decrease the irritation caused
by the acidic solution. Injection should proceed from the planned mucosal insertion
and then in the tissue plane supercial to the upper and lower lateral cartilages along
the planned trajectory of the device.
Surgical Technique
Apply a nasal decongestant, such as oxymetazoline spray, one hour before the procedure or as soon as is feasible prior to the procedure. This will aid in pain management and improve the visualization of the surgical eld. Apply topical anesthesia
with pledgets to numb the nasal ala. Use caution with direct inltration of local
anesthetic in the area as this may impair visualization due to local edema effects of
the anesthetic.
Begin by marking the point of maximal lateral wall collapse with a skin marker
during dynamic inspiration. This point will be the caudal aspect of the device. This
point should not sit caudal to the alar crease, as this skin is thin and can lead to cosmetic concerns or device extrusion. Using the measuring tool, place a mark at the
cephalad portion of the device. This must sit over the nasal bones. Lateral displacement of the forked end towards the medial canthus in patients who wear glasses can
provide improved comfort during the healing process. Leaving the measuring tool
in place, place a mark at the nasal rim corresponding to the vertical line of the
planned device placement. This will provide a visual point in which to make the
vestibular puncture.
Following an acceptable amount of time (usually 10–15min), inject local anesthetic with a 27g needle. Consider using 1% lidocaine with 1:200,000 epinephrine
to minimize the cardiovascular and anxiety-inducing effect of epinephrine. Warning
the patient of the potential brief tachycardia and anxiety associated with epinephrine administration can greatly reduce patient discomfort. Additionally, adding 10%
volume of 8.4% sodium bicarbonate solution to the anesthetic mixture will decrease
the sting of the solution. The local anesthetic agent should be injected into the nasal
rim in the area of the planned insertion and then along the trajectory of the implant.
Using a sharp double prong skin hook, pull the ala laterally and place the delivery device at the caudal aspect of the lower lateral cartilage corresponding to the
area where one would place a marginal incision. Directing the device towards the
septum, pierce the mucosa. Once the cannula has pierced the nasal mucosa, direct
this laterally to follow a supercial plane over the upper and lower lateral cartilages.
Continue to follow the planned trajectory until the cannula reaches the cephalic
mark at the nasal bones. Deploy the device by pressing the large green button in the
center of the cannula and advancing the delivery component into the cannula component. It is important not to advance the cannula while doing this. Place a nger
gently at the region where the device was deployed to anchor this in place and gently withdraw the cannula. Conrm that there is no aspect of the device that has
extruded through the mucosal puncture point (Video 19.1).
Inform patients that it can take up to 3months for the full effect of the procedure
to be noticeable. Patients need to avoid manipulating the lateral nasal wall for the
rst 2weeks so as not to dislodge the implant. Patients should be counseled that
198
G. E. Davis and C. Miller
complications have been reported, including extrusion/need for retrieval of the
device (4%, 22/543 implants), implant show or palpable on nasal surface (1%, 7/543
implants), and infection (1% 7/543 implants) [8].
Tips and Pearls
• Optimize the procedure room environment with distractions for the patient
including playing music or a video monitor playing non-surgical images.
• A surgical headlight is helpful for visualization.
• Lateral displacement of the forked end towards the medial canthus in patients
who wear glasses can provide improved comfort during the healing process.
• If there is bleeding from the mucosal penetration site, place gentle pressure along
the nasal dorsum for a few minutes until the bleeding abates.
Radiofrequency Remodelling oftheLower Lateral
Cartilage (Vivaer)
The Vivaer device became commercially available in the United States in 2018. This
device uses RF energy at low temperature (60°C) deployed by a temperature controlled bipolar device to reshape the cartilage of the lower lateral cartilage. It can
also be used on soft tissue such as turbinate tissue or the septal swell body to supercially decrease the size of these structures. The initial research study reported on
50 patients who had nasal valve treatment and improved their NOSE scale scores by
69%; improving from a baseline average of 79.9 to a 26-week post-treatment average of 24.7 [9]. A two-year follow-up study on 39 of those subjects showed longevity of improvement with an average NOSE score of 26.5 (66.5% improvement from
baseline) [10]. Finally, a long-term study of 29 subjects in the initial cohort who
continued in the study reported their 48-month post-treatment NOSE score to be
25.7 (68.3% improvement compared to baseline) [11]. Perhaps the most interesting
report was a prospective multi-center randomized controlled sham trial involving
117 subjects, 77 who received RF energy during the procedure compared to 40 who
received the procedure without the deployment of RF energy [12]. The primary
outcome measure was improvement in NOSE score > 20% or improvement in
greater than or equal to 1 category of NOSE score severity compared to baseline. In
the active treatment cohort, 88.3% responded favorably versus 42.5% in the sham
treatment arm (p<0.001).
The Vivaer procedure is effective in treating NVC.In addition, patient satisfaction was reported to be quite high on ve questions queried in the initial study, ranging from 7.3 to 8.7 out of 10 [9]. Given that this procedure can be done under local
anesthesia or also under general anesthesia, there are some techniques to be implemented to aid in patient satisfaction.
19 Radiofrequency and Bioabsorbable Nasal Implantation for Treatment of Nasal…
199
Patient Selection
The ideal candidate for the Vivaer procedure has mild to moderate dynamic nasal
valve collapse with inspiration, a positive Cottle maneuver (improved breathing),
mild to moderate inferior turbinate hypertrophy and none or mild nasal septal deviation. A patient with severe septal deviation likely needs a septoplasty performed in
conjunction with the Vivaer procedure. Similarly, an inferior turbinate that is completely blocking the nasal space may benet from a more aggressive turbinate
reduction procedure rather than the supercial procedure that the Vivaer provides.
An additional consideration should include the surgeon’s perception of a patient’s
tolerance for an in-ofce versus an in-operating room procedure as this can signicantly impact satisfaction during the procedure.
Local Anesthesia
The anterior nasal cavity, including the internal nasal valve, receives innervation
from both the rst and second branches of the trigeminal nerves. The rst branch
innervates the nasal skin and ala whereas the second branch innervates the internal
lining of the nose. A combination of topical and locally injected anesthetic agents is
often adequate to obtain exceptional anesthesia.
Surgical Technique
Similar to the Latera, patients can apply a nasal decongestant (such as oxymetazoline spray) an hour before the procedure or as soon as is feasible prior to the procedure to aid in pain management and improve the surgical eld. A topical anesthetic,
typically 4% lidocaine-soaked cotton or a 10% tetracaine gel can also be applied to
the caudal nares. Following an acceptable amount of time (usually 10–15min),
inject local anesthetic with a 27 g needle. Consider using 1% lidocaine with
1:200,000 epinephrine and 10% volume of 8.4% sodium bicarbonate to minimize
the cardiovascular and anxiety-inducing effect of epinephrine and to minimize the
sting from the anesthetic. Some surgeons nd it less painful to the patient if they
apply a tapping motion to the ipsilateral infraorbital region during these injections.
The local anesthetic agent should be injected into the inferior turbinate head,
septal swell body (if being treated) and then into the nasal side of the ala and lateral
nasal wall junction targeting the lower lateral cartilage (Fig.19.4). This last injection is the most pain inducing and is best done last after giving the turbinate injection 30–60s to take effect. Additional anesthesia can be obtained by performing an
infraorbital block. If this is going to be performed, prior to the injection, place viscous lidocaine-soaked cotton in the maxillary gingival sulcus to help minimize the
pain of the injection.
Use the Vivaer device as indicated in non-overlapping areas. When applying the
device to the internal nasal valve, use your contralateral hand to apply gentle pressure with a nger on the outside of the nasal sidewall to help straighten out any
inward bowing cartilage. Several non-overlapping treatments can be applied to the
length of the inferior turbinate and the septal swell body.
Post-operatively, we recommend patients use nasal gel or antibiotic ointment
applied to the nostrils 2–3 times daily for the rst 2 weeks to help minimize