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1 Braz J Otorhinolaryngol. 2018;xxx(xx):xxx---xxx
2

3 Brazilian Journal of

OTORHINOLARYNGOLOGY
www.bjorl.org

ORIGINAL ARTICLE

4 Effects of turbinoplasty versus outfracture and bipolar

5 cautery on the compensatory inferior turbinate
6 hypertrophy in septoplasty patients夽
7 Q2 Aykut Bozan a , Hüseyin Naim Eriş b , Denizhan Dizdar a,∗ , Sercan Göde c , Bahar Taşdelen d ,
8 Hayrettin Cengiz Alpay a

a
9 Istanbul Kemerburgaz University, Medical Faculty, Department of Otorhinolaryngology, Tarsus, Turkey
b
10 Medical Park Tarsus Hospital, Radiology, Tarsus, Turkey
c
11 Ege University, Medical Faculty, Department of Otorhinolaryngology, İzmir, Turkey
d
12 Mersin University, Medical Faculty, Biostatistics, Mersin, Turkey

13 Received 20 December 2017; accepted 17 April 2018

14 KEYWORDS Abstract
15 Turbinate; Introduction: The most common cause of septoplasty failure is inferior turbinate hypertrophy
16 Hypetrophy; that is not treated properly. Several techniques have been described to date: total or partial tur-
17 Outfracture; binectomy, submucosal resection (surgical or with a microdebrider), with turbinate outfracture
18 Turbinoplasty being some of those.
19 Objective: In this study, we compared the pre- and postoperative lower turbinate volumes using
20 computed tomography in patients who had undergone septoplasty and compensatory lower
21 turbinate turbinoplasty with those treated with outfracture and bipolar cauterization.
22 Methods: This retrospective study enrolled 66 patients (37 men, 29 women) who were admitted
23 to our otorhinolaryngology clinic between 2010 and 2017 because of nasal obstruction and who
24 were operated on for nasal septum deviation. The patients who underwent turbinoplasty due
25 to compensatory lower turbinate hypertrophy were the turbinoplasty group; Outfracture and
26 bipolar cauterization were separated as the out fracture group. Compensatory lower turbinate
27 volumes of all patients participating in the study (mean age 34.0 ± 12.4 years, range 17---61
28 years) were assessed by preoperative and postoperative 2 month coronal and axial plane
29 paranasal computed tomography.

30

夽 Please cite this article as: Bozan A, Eriş HN, Dizdar D, Göde S, Taşdelen B, Alpay HC. Efeitos da turbinoplastia versus fratura lat-

eral e cauterização bipolar no volume da concha inferior hipertrófica compensatória em pacientes submetidos a septoplastia. Braz J
Otorhinolaryngol. 2018. https://doi.org/10.1016/j.bjorl.2018.04.010
∗ Corresponding author.

E-mail: denizhandizdar@hotmail.com (D. Dizdar).

https://doi.org/10.1016/j.bjorl.2018.04.010
1808-8694/© 2018 Published by Elsevier Editora Ltda. on behalf of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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31 Results: The transverse and longitudinal dimensions of the postoperative turbinoplasty group
32 were significantly lower than those of the out-fracture group (p = 0.004). In both groups the
33 lower turbinate volumes were significantly decreased (p = 0.002, p < 0.001 in order). The postop-
34 erative volume of the turbinate on the deviated side of the patients was significantly increased:
35 tubinoplasty group (p = 0.033).
36 Conclusion: Both turbinoplasty and outfracture are effective volume-reduction techniques.
37 However, the turbinoplasty method results in more reduction of the lower turbinate volume
38 than outfracture and bipolar cauterization.
39 © 2018 Published by Elsevier Editora Ltda. on behalf of Associação Brasileira de Otorrino-
40 laringologia e Cirurgia Cérvico-Facial. This is an open access article under the CC BY license
41 (http://creativecommons.org/licenses/by/4.0/).

42 PALAVRAS-CHAVE Efeitos da turbinoplastia versus fratura lateral e cauterização bipolar no volume da

43 Concha; concha inferior hipertrófica compensatória em pacientes submetidos a septoplastia
Hipertrofia;
44 Resumo
Fratura lateral;
45 Introdução: A causa mais comum de falha da septoplastia é a hipertrofia das conchas inferiores
Turbinoplastia
46 não tratada adequadamente. Diversas técnicas foram descritas até o momento: turbinectomia
47 total ou parcial, ressecção da submucosa (cirúrgica ou com microdebridador) e a fratura lateral.
48 Objetivo: Neste estudo, comparamos os volumes pré e pós-operatório da concha inferior com
49 hipertrofia compensatória com o uso de tomografia computadorizada entre pacientes submeti-
50 dos a septoplastia e turbinoplastia, ou fratura lateral com cauterização bipolar.
51 Método: Este estudo retrospectivo incluiu 66 pacientes (37 homens e 29 mulheres) internados
52 em nosso serviço de otorrinolaringologia entre 2010 e 2017 por obstrução nasal e submetidos
53 à cirurgia por desvio de septo nasal. Os pacientes submetidos à turbinoplastia devido à hiper-
54 plasia compensatória da concha inferior formaram o grupo turbinoplastia; aqueles submetidos
55 à fratura lateral e cauterização bipolar foram separados, formando o grupo fratura lateral. Os
56 volumes compensatórios da concha inferior de todos os pacientes que participaram do estudo
57 (idade média de 34,0 ± 12,4 anos, faixa etária de 17 a 61 anos) foram avaliados por tomografia
58 computadorizada dos seios paranasais nos planos axial e coronal no pré-operatório e aos 2 meses
59 do pós-operatório.
60 Resultados: As dimensões transversais e longitudinais do grupo turbinoplastia no pós-operatório
61 foram significantemente menores do que as do grupo de fratura lateral (p = 0,004). Em ambos
62 os grupos, os volumes da concha inferior diminuíram significantemente (p = 0,002, p < 0,001,
63 respectivamente). O volume pós-operatório da concha do lado do desvio aumentou significan-
64 temente no grupo turbinoplastia (p = 0,033).
65 Conclusão: Tanto a turbinoplastia como a fratura lateral são técnicas efetivas de redução de
66 volume. No entanto, a turbinoplastia causa maior redução do volume da concha inferior do que
67 a fratura lateral com cauterização bipolar.
68 © 2018 Publicado por Elsevier Editora Ltda. em nome de Associação Brasileira de Otorrino-
69 laringologia e Cirurgia Cérvico-Facial. Este é um artigo Open Access sob uma licença CC BY
70 (http://creativecommons.org/licenses/by/4.0/).

71 Introduction radiofrequency application, argon plasma treatment, and 83

cryosurgery.4 84

72 The most common cause of chronic nasal obstruction is sep- None of the turbinate surgical techniques performed 85

73 tum deviation and lower turbinate pathologies.1 Inferior with or without septoplasty are perfect. Short- and long- 86

74 turbinate hypertrophy is frequently seen in allergic rhini- term complications, such as bleeding, bruising, and atrophy, 87

75 tis, vasomotor rhinitis, and as compensatory hypertrophy are frequent.5 Ideally, turbinate surgery should be done 88

76 in septum deviation. Lower turbinate hypertrophy on the without damaging the mucosal surface. This ensures preser- 89

77 concave side of the nasal septum is called compensatory vation of normal lower turbinate function, rapid healing, 90

78 hypertrophy.2 The most common cause of septoplasty fail- and inhibition of atrophic rhinitis.6 Despite the increasing 91

79 ure is inferior turbinate hypertrophy that is not treated number of lower turbinate surgical procedures, turbino- 92

80 properly.3 Several techniques have been described to date: plasty, outfracture, and bipolar cautery methods have been 93

81 total or partial turbinectomy, submucosal resection (surgi- used frequently for the last three decades.7 Turbinoplasty is 94

82 cal or with a microdebrider), outfracture, electrocautery, more difficult and has a higher complication rate than the 95

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96 outfracture method, despite its high success rate. Lower Patient evaluation 148

97 turbinate outfracture and bipolar cauterization can be

98 applied in the same order and more quickly.8 The compensatory turbinatel volume of all subjects was 149
99 In this study, we compared the pre- and postoperative assessed pre- and postoperatively using coronal and axial 150
100 lower turbinate volumes using computed tomography (CT) plane paranasal CT performed in 1 mm sections from 151
101 in patients who had undergone septoplasty and compen- anterior (nares) to posterior (choana). The volumetric eval- 152
102 satory lower turbinate turbinoplasty with those treated with uations were performed by the same radiologist. 153
103 outfracture and bipolar cauterization. The lower turbinate volumes were calculated in 154

mm3 using the ellipse formula: longitudinal dimen- 155

sion (mm) × transverse dimension (mm) × anteroposterior 156

dimension (mm) × 0.52. The longitudinal and transverse 157

104 Methods turbinate dimensions were calculated from the cross-section 158

through the coronal plane after the uncinate processes. The 159

105 Patient selection longest dimension of the lower turbinate was set as the 160

anteroposterior dimension in the axial plane. 161

106 This retrospective study enrolled 66 patients (37 men, 29

107 women) who were admitted to our otorhinolaryngology Statistical analysis 162
108 clinic between 2010 and 2017 because of nasal obstruction
109 and who were operated on for nasal septum deviation. CT
Statistical analysis was performed using STATA/MP 11. The 163
110 showed septum deviation and contralateral compensatory
data were summarized as means and standard deviation. 164
111 lower turbinate hypertrophy. The patients were divided
Pre- and postoperative comparisons were made using paired 165
112 into two groups. The turbinoplasty group included patients
t-tests within each group. The independent t-test was used 166
113 who underwent septoplasty and turbinoplasty; the outfrac-
to compare preoperative groups, while analysis of covari- 167
114 ture group underwent septoplasty with compensatory lower
ance (ANCOVA) was used to compare postoperative groups 168
115 turbinate outfracture and bipolar cauterization.
using the preoperative values as covariates. The indepen- 169
116 Patients with maxillofacial trauma, paranasal sinus
dent t-test was used to compare relative postoperative 170
117 tumors, nasal polyps, septal perforations, acute or chronic
changes (%) between groups. Statistical significance was 171
118 rhinosinusitis, S type nasal septum deviation, turbinate bul-
taken as p < 0.05. 172
119 losa, or previous nasal or paranasal surgery were excluded
120 from the study. Ethics committee approval was obtained
121 from Istanbul University, Cerrahpaşa Medical Faculty, Ethical Results 173
122 Committee (n◦ 61328).
Endoscopic hemorrhage control was performed because of 174

hemorrhage development on postoperative 4th and 6th days 175

in postoperative period in only 2 patients in the group 176

123 Surgical procedure of turbinoplasty. In the other 64 patients, there were no 177

complications such as postoperative hemorrhage, synechia 178

124 All patients were operated by the same surgeon under or infection. Nasal endoscopic examinations were performed 179

125 general anesthesia. First, a septoplasty was performed. at 2 months postoperatively. No signs of septum deviation, 180

126 Thirty-two patients (19 men, 13 women; mean age, turbinate hypertrophy, or atrophic rhinitis were observed in 181

127 36.6 ± 15.0 years, range: 19---61 years) in the turbinoplasty the follow-up examinations, and there were no complaints 182

128 group underwent compensatory lower turbinate turbino- of nasal obstruction. 183

129 plasty. A superior-to-inferior incision was made on the The differences in the pre- and postoperative parameters 184

130 anterior surface of the lower turbinate with a n◦ 15 blade, were significant in the turbinoplasty and outfracture groups 185

131 working under a 0◦ endoscopic video image, and this inci- (Table 1). 186

132 sion was extended posteriorly along the inferior surface. The transverse and longitudinal dimensions of the lower 187

133 The medial side of turbinate was elevated. The turbina- turbinate in the turbinoplasty group were significantly lower 188

134 tel mucosa and turbinate were excised while preserving the than in the outfracture group (p = 0.004). The postoperative 189

135 medial flap. Bleeding was controlled with bipolar cauteri- lower turbinate volumes decreased significantly in both the 190

136 zation. The flap was replaced, packing was placed in both turbinoplasty and outfracture groups. In the turbinoplasty 191

137 nasal cavities, and the operation completed. Nasal packing group, the mean lower turbinate volume was 4523.5 mm3 192

138 was removed after 48 h. preoperatively and 1492.2 mm3 postoperatively (p = 0.002), 193

139 The outfracture group comprised 44 patients (18 men, versus 4282.2 mm3 preoperatively and 2699.9 mm3 postop- 194

140 16 women; mean age, 31.4 ± 9.5 years, range: 17---49 years) eratively (p < 0.001) in the outfracture group. Comparing 195

141 who underwent turbinate outfracture and bipolar cauter- the turbinoplasty and outfracture groups, the postoperative 196

142 ization. Using an elevator, the lower turbinate was first volume was significantly lower in the turbinoplasty group 197

143 mobilized medially and laterally. Posterior anterior bipo- (p = 0.019) (Table 2). In the between-group comparison, the 198

144 lar cauterization was then applied to the inferomedial face volume reduction was greater in the turbinoplasty group 199

145 of the lower turbinate. Both nasal cavities were filled with (p = 0.037) (Table 2). 200

146 nasal cuffs and the operation completed. Nasal packing was The transverse and longitudinal dimensions of the 201

147 removed after 48 h. lower turbinate decreased more in the turbinoplasty group 202

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Table 1 Compensatory turbinate preoperative and postoperative values.

Turbinoplasty Out fracture

Preop. Postop. p Preop. Postop. p

A-P (mm) 48.1 ± 4.8 39.4 ± 4.9 0.009 43.7 ± 6.6 38.2 ± 6.6 0.001
Transverse (mm) 11.4 ± 2.2 6.2 ± 1.5 <0.001 12.1 ± 2.2 9.6 ± 2.7 <0.001
Longitudinal (mm) 17.8 ± 2.9 11.5 ± 2.5 <0.001 14.9 ± 2.8 12.8 ± 2.6 0.005
Volume (mm3 ) 4523.5 ± 1548.2 1492.2 ± 594.8 0.002 4282.6 ± 2094.2 2699.9 ± 1942.1 <0.001
Mean and standard deviation were defined for each subgroup. Statistically significant results are shown in bold.
A-P, Anterior-Posterior; Preop preoperative, Postop postopertative; mm, milimeter.

Table 2 Changes in turbinate measures.

Turbinoplasty Out fracture p
Preop A-P (mm) 48.1 ± 4.8 43.7 ± 6.6 0.188
Postop A-P (mm) 39.4 ± 4.9 38.2 ± 6.6 0.490
Decrease longitudinal (mm) 0.17 ± 0.11 0.13 ± 0.05 0.336
Preop transvers (mm) 11.4 ± 2.2 12.1 ± 2.2 0.576
Postop transvers (mm) 6.2 ± 1.5 9.6 ± 2.7 0.004
Decrease transvers (mm) 0.45 ± 0.12 0.22 ± 0.08 0.001
Preop longitudinal (mm) 17.8 ± 2.9 14.9 ± 2.8 0.08
Postop longitudinal (mm) 11.5 ± 2.5 12.8 ± 2.6 0.004
Decrease longitudinal (mm) 0.36 ± 0.09 0.14 ± 0.08 <0.001
Preop volüm (mm3 ) 4523.5 ± 1548.2 4282.6 ± 2094.2 0.811
Postop volüm (mm3 ) 1492.2 ± 594.8 2699.9 ± 1942.1 0.019
Decrease volüm (mm3 ) 0.63 ± 0.34 0.41 ± 0.12 0.037
Mean and standard deviation were defined for each subgroup. Statistically significant results are shown in bold.
A-P, Anterior-Posterior; Preop preoperative, Postop postopertative; mm, milimeter.

4500
Pre
Discussion 212
Post
4000
A compensatory turbinate develops to protect the more- 213
3500
involved nasal passage from cold, dry air. The most common
Volumemm3

214

3000 site is the inferior turbinate. There is thickening of the 215

turbinate bones, and an increase in the spongiform struc- 216

2500
ture and orientation to the midline. Mucosal hypertrophy 217

2000 is also present.9 Many techniques have been described 218

to reduce the volume in lower turbinate hypertrophy. In 219

1500
some of these techniques, the aim is only to decrease the 220

1000 mucosal volume, while in others the mucous membrane 221

Turbinoplasty Out-fractur and bone volume are both reduced.10 There is no consen- 222

sus regarding the best lower turbinate reduction technique. 223

Figure 1 Preoperative and postoperative volume changes of
Although less invasive methods have become popular over 224
the groups.
the last 20 years, more invasive procedures, such as turbino- 225

plasty, remain important because of their high success 226

rates. 227

Many studies have examined the effectiveness of 228

203 compared with the outfracture group (p = 0.001 and radiofrequency application in lower turbinate surgery,10---12 229
204 p < 0.001, respectively) (Table 2). and other techniques have been evaluated in non- 230
205 In the turbinoplasty group, the turbinate volume had an septoplasty patients.13---15 Veit et al. did not evaluate lower 231
206 average reduction of 56% and 36% in the out-fracture group turbinate volumes despite comparing lower turbinate reduc- 232
207 (Fig. 1). tion methods during septoplasty.16 233
208 The lower turbinate volumes on the side of the devia- We measured the turbinate volume using CT and 234
209 tion were significantly increased in both the turbinate and compared the volume after outfracture and bipolar cauteri- 235
210 out-fracture groups postoperatively (p = 0.0002, p = 0.0297, zation, which caused only mucosal volume loss, with that of 236
211 respectively) (Table 3). turbinoplasty, which resulted in mucosal and bone volume 237

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Q4 Table 3 Lower turbinate volumes on deviated side.

Turbinoplasty Out fracture

Preop. Postop. p Preop. Postop. p

Volume (mm ) 3
1967.8 ± 426.1 2070. ± 413.8 <0.0002 1725.2 ± 327.2 1791.1 ± 340.3 <0.0297

238 loss during septoplasty. Other studies have measured the after turbinoplasty, these effects are not observed after 291

239 volume using CT (10) or magnetic resonance imaging.13,17 outfracture and bipolar cauterization. In addition, turbino- 292

240 Turbinoplasty is a successful method despite postopera- plasty is suitable for bleeding control under an endoscopic 293

241 tive synechia, drying, and nasal discharge problems.16,18 In view. Consequently, turbinoplasty takes longer to perform 294

242 our study, postoperative desiccation and nasal discharge was than outfracture and bipolar cauterization. In our series, no 295

243 not followed up in the turbinoplasty patients. peri- or postoperative complications were recorded in either 296

244 Büyüklü and Zhang19,20 reported that the outfracture group, but this may be due to the small number of subjects. 297

245 method was effective for expanding the nasal passages in In a comparison of the pre- and postoperative lower 298

246 lower turbinate hypertrophy. With turbinate bipolar cauter- turbinate volumes of patients who underwent radiofre- 299

247 ization, superficial thermal ablation creates scar tissue and quency ablation of the lower turbinate, Bahadır et al.10 300

248 fibrosis, and obliterates the venous sinuses. In one study, the stated that the postoperative volumes of six lower turbinate 301

249 results at 2 months after bipolar cauterization were success- were increased, which might have been due to the stage of 302

250 ful in 76% of the cases.14 In our study, the lower turbinate the nasal cycle. In our study, the significant increase in the 303

251 volume in the outfracture group decreased significantly and volume of the uninvolved lower turbinate (p = 0.033) on the 304

252 the patients’ complaints of nasal obstruction disappeared. deviated side in the turbinoplasty group might have been 305

253 In both groups, the improvement in the nasal obstruction due to a process other than the nasal cycle following cor- 306

254 was likely related to both the lower turbinate reduction and rection of the deviation. 307

255 correction of the septum deviation.

256 Various studies have compared the effectiveness of lower Conclusion 308
257 turbinate surgical techniques using objective tests such as
258 acoustic rhinomanometry, mucociliary function tests, and
Both turbinoplasty and outfracture are effective volume 309
259 acoustic rhinometry.15,21,22
reduction techniques. However, the turbinoplasty method 310
260 Can et al.13 have studied the effects of radiofrequency
causes more reduction of the lower turbinate volume of the 311
261 ablation in patients undergoing lower turbinate submucosal
than outfracture and bipolar cauterization 312
262 resection and found that the volume reduction was signifi-
263 cant in both groups, but it was greater with radiofrequency
264 ablation. In our study, the postoperative axial, transverse, Ethical approval 313

265 and longitudinal lower turbinate dimensions were decreased

266 significantly in both groups. All procedures performed in studies involving human parti- 314

267 Changes in lower turbinate volume have been assessed cipants were in accordance with the ethical standards of the 315

268 after applying different reduction methods. Demir et al.12 institutional and/or national research committee and with 316

269 found that the lower turbinate volume decreased by 25% the 1964 Helsinki declaration and its later amendments or 317

270 after thermal radiofrequency ablation. Can et al.13 reported comparable ethical standards. 318

271 a 42.4% volume reduction after submucosal resection. We

272 observed greater volume reduction in the turbinoplasty Informed consent 319
273 group (67.1%) than the outfracture group (36.9%), indi-
274 cating that hypertrophic mucosa and bone formation with Informed consent was obtained from all individual partici- 320
275 compensatory hypertrophy constitutes a significant volume. pants included in the study. 321
276 Furthermore, the decrease in the transverse and longitu- The English in this document has been checked by at least 322
277 dinal dimensions of the lower turbinate was significantly two professional editors, both native speakers of English. 323
278 (p < 0.001) greater in our turbinoplasty group compared with For a certificate, please see: http://www.textcheck.com/ 324
279 the outfracture group, and the loss in the turbinoplasty certificate/eqNE75. 325
280 group could be attributed to bone tissue loss. Turbino-
281 plasty method results in a greater volume decrease and
282 can be selected for lower turbinate in which the bone mass Conflicts of interest 326

283 produces a significant volume, while outfracture and bipo-

284 lar cauterization, which has a lower risk of complications, The authors declare no conflicts of interest. 327

285 can be performed in patients with more moderate lower

286 turbinate hypertrophy. References 328
287 Lower turbinate outfracture and bipolar cauterization
288 are less invasive than turbinoplasty, while the risk of periop- 1. Nease CJ, Krempl GA. Radiofrequency treatment of tirbunate 329
289 erative bleeding is greater than with turbinoplasty.18 While hypertrophy: a randomized, blinded, placebo-controlled clini- 330
290 hemorrhage, synechiae, and mucosal discharge can occur cal trial. Otolaryngol Head Neck Surg. 2004;130:291---9. 331

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S. Comparison of submucosal resection and radiofrequency

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