Making a successful transition to office-based inferior turbinate hypertrophy (ITH) surgery depends on proper coding and other financial concerns. But a more basic question first needs to be considered before breaking out the calculator: What is the optimal technique for performing the surgery?
Explore This IssueNovember 2013
As with so many chronic, common conditions, there are myriad options. Indeed, according to one of the first widely cited comprehensive reviews of the ITH literature, by Hol and Huizing (Rhinology. 2000;38:157-166), there have been at least 13 different techniques developed for the condition, ranging from the very aggressive, mucosal-damaging thermal coagulation and electrocautery methods that dominated the early days of ITH surgery to later, more precise mucosal-sparing approaches such as radiofrequency (RF) ablation. Based on the horrific side effects of the earlier interventions, including mucosal atrophy, tissue necrosis and crusting that essentially obliterated the functional structures of the nose, the authors concluded that the best surgical approach is the one that “achieves optimal [turbinate] volume reduction with preservation of function.”
Unfortunately, that criterion still leaves multiple surgical techniques currently in use, which is one of the reasons why a leading otolaryngologist decided to conduct a more up-to-date literature review. The study, by Pete S. Batra, MD, co-director of the Comprehensive Skull Base Program in the department of otolaryngology-head and neck surgery at the University of Texas Southwestern Medical Center in Dallas, employed evidence-based medicine to assess the evidence (Laryngoscope. 2009;119:1819-1827). Why take that approach? “It’s our fiduciary responsibility to scrutinize all of the relevant literature; you don’t want to look at just one uncontrolled study and use that as the basis for how you manage patients,” Dr. Batra told ENTtoday. In the case of ITH, that is especially important, he noted, because new technology tends to drive the ITH literature, where the latest device is evaluated in an uncontrolled, often short-term study, and in some cases touted as practice changing.
One of the most ground-breaking studies included in his EBM review was by Passali and colleagues, Dr. Batra noted, and he gave it high marks because it was randomized, it included a large number of patients (382), and it compared the most commonly used ITH surgical techniques (turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal resection and submucosal resection with outfracture.) “The study also followed the patients for six years,” Dr. Batra noted. “That type of long-term follow-up is critical for assessing the utility of these surgical interventions.”
The study showed that submucosal resection (SMR) plus outfracture (also known as lateral displacement [LD]) achieved the best balance between long-term symptom relief “and an acceptable risk profile,” Dr. Batra said. Specifically, at year six, SMR + LD patients achieved an average symptom score of 10 (range, 5 to 30). Although that may seem modest compared with the higher scores of other procedures such as electrocautery, which had a 26 score at the six-year follow-up, the rate of side effects (e.g., crusting, bleeding and mucosal atrophy) were telling: electrocautery patients had a complication score of 39 (range, 0 to 50), versus a score of 10 for the SMR + LD group.
Based on those findings, the authors of the Passali study concluded that SMR + SD should be considered “the first-choice technique for the treatment of nasal obstruction due to hypertrophy of the inferior turbinates.”
Dr. Batra said SMR +LD is his own treatment of choice for managing patients with turbinate hypertrophy. “This is what the data tell us, so I have incorporated these findings into my practice—provided there is evidence that patients have not responded to an adequate course of medical therapy,” he said.
Several additional studies published shortly after the accrual date for Dr. Batra’s evidence-based review also concluded that SMR offers the best outcomes for patients with ITH, he said. In one, by Liu and colleagues, 120 patients were treated with either a coblation or microdebrider procedure (Laryngoscope; 2009;119:414-418). After approximately one year of follow-up, both techniques were equally effective in relieving symptoms based on visual analog scores, acoustic rhinometry tests and other measures of sinus function, Dr. Batra noted. Between one and three years of follow-up, however, “the microdebrider group had significantly better outcomes,” he noted.
Interestingly, despite relatively poor support in the literature, some surgeons are still performing invasive procedures for ITH such as a partial or even complete resection of the inferior turbinates, Dr. Batra noted. He explained that this aggressive approach “fundamentally alters the nasal environment” by destroying the turbinates’ ability to filter out potentially harmful organisms. “This may result in colonization with opportunistic gram-negative bacteria and could set up patients with long-term chronic infections, crusting and bleeding,” he said. “So the only time I really do this in my practice is for patients who have a benign tumor or a malignancy involving the inferior turbinate.”
On the flip side, overly light-handed approaches such as thermal-only techniques, “where you just do surface cautery or even submucosal cautery, and frankly lasers,” are not optimal. “Yes, the risk for side effects may be lower, but long-term, the clinical benefits are just not there, as the literature details.”
The ideal balance, he said, “is to use a submucosal resection technique, either with a powered microdebrider or RF abalation or coblation, or you can just do it by raising a flap and removing that segment of the turbinate bone” to address chronic hypertrophy and congestion. “That approach places you somewhere in the middle of the risk-versus-benefit equation, and that’s really where you want to be with these patients.”