*Corresponding Author: Lucas Ferreira Rocha, Department of OtolaryngologyLagoa’s HospitalRio de JaneiroBrazil.
Received: March 02, 2018; Accepted: March 29, 2018; Published: March 31, 2018
Citation: Thuler E (2018) Laser Submucous Turbinectomy (LST) with partial removal of the turbinate bone and Neurovascular Branches Photocoagulation (NBP): Feaseability and Safety in Outpatient Setting. Surg Res Pract 2: 06-11.
Copyright: ©2018 Thuler E. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Introduction: The Submucous Turbinectomy (ST) with Neurovascular Branches Photocoagulation (NBP) has superior functional results in the surgical treatment of the inferior nasal turbinate hypertrophy, improving nasal obstruction and reducing the vasomotor reflex. However, it is difficult to perform in an outpatient setting, mainly because of the risk of postoperative bleeding. Diode laser (980nm) finds the ideal characteristics to perform this procedure, allowing the photocoagulation of the neurovascular branches with simultaneous bleeding control. However, the feasibility and safety to perform this procedure in an outpatient setting were not described before.
Objective: Describe a Laser Submucous Turbinectomy (LST) technique with partial removal of the turbinate bone and Neurovascular Branches Photocoagulation (NBP), demonstrating its feasibility and safety as an outpatient procedure.
Methods: With REB approval we retrospectively analyzed patients submitted to this procedure in the inferior nasal turbinate hypertrophy treatment, from January 2015 to December 2015. Based on its physical interaction with the nasal mucosa, was selected the 980nm Diode Laser, applied with 7 Watts of power in pulsed mode (20hz/25ms). Patients were followed during 12 weeks after the procedure to register any possible complication.
Results: 49 patients met the inclusion criteria, average age of 36 (SD = 18), 31 male (58%) and 18 female (42%). The average energy applied was 1801 Joules (SD = 611) on the left inferior turbinate and 1563 Joules (SD = 457) on the right inferior turbinate. The average procedure time was 8’30 minutes (SD = 2’45) on the left side and 7’30 minutes on the right side (SD=1’54). All procedures were performed in outpatient setting, without the use of nasal package. There were no complications.
Conclusion: The laser submucous turbinectomy (LST) technique described with neurovascular branches photocoagulation (NBP) has demonstrated feasibility and clinical safety in outpatient setting.
Inferior nasal turbinate hypertrophy, laser turbinoplasty, intratable chronicle rhinitis, neurovascular branches photocoagulation
The nasal chamber has three turbinates in the lateral wall. The superior and middle turbinate are part of the ethmoid bone, while the inferior turbinate (IT) has a separate bone, recovered with a respiratory mucosa that plays a paramount role in filtering, warming and humidifying the air.
During the inspiration, up to two-thirds of the upper airway resistance is determined by the inferior turbinate and its hypertrophy compromises the nasal breathing and consequently the quality of life .
The allergic rhinitis has a prevalence upon to 30% [2,3], it is the main cause of IT hipertrophy, characteristically associated with chronic inflammation, characterizing the chronic hypertrophic rhinitis (CHR) . Specially, when the inferior turbinate bone is hypertrophied, this condition has poor response to drug treatment and surgical procedures may be necessary [5,6].
The most performed procedure in these cases is the parcial turbinectomy , when the IT is resected with its ciliated mucosa. Typically it is followed by electro cauterization to prevent bleeding, causing further thermal demage to the mucosa, delayng the healing process with increased risk of prolonged crust formation and functional impairment. The major postoperative complications are bleeding and excessive resection, compromising the nasal physiology and causing the empty nose symdrome (ENS) [8,9].
Several mucosal sparing techniques were described in a attempt to achieve less invasive procedures, only partially removing the IT mucosa, performed with conventional electrocautery , controlled temperature devices [11,12], microdebriders  and surgical lasers . However, recurrence of the obstructive symptoms in these procedures is higher, occuring on average two years after the procedure, specially in patients with refractary allergic rhinitis .
The submucous turbinectomy (ST) is a techinique that propitiate the best functional results , also allowing the partial resection of the inferior turbinate bone and the neurovascular branches (NBR),reducing secretion, sneezing and the vasomotor reflex in similar degree that the transnasal resection of the posterior nasal nerve (TRPNN) at the sphenopalatine foramen does . However, as the turbinate has an abundant blood supply, this procedure was originally described followed by nasal packing to avoid postoperative bleeding and performed as inpatient surgery .
According to its physical properties and tissue interaction, diode laser finds the ideal characteristics to perform this procedure in outpatient surgery, with better bleeding control and avoiding nasal package. If used with the appropriate parameters, it can also reduce the thermal damage to the mucosa and crust formation, shortening the recovery time [19,20], though its feasibility and safety in outpatient setting was never described before.
The aim of this manuscript is to describe a Laser Submucous Turbinectomy (LST) technique with partial removal of the inferior turbinate bone and Neurovascular Branches Photocoagulation (NBP), demonstrating its feasibility and safety in an outpatient setting.
With the approval of the Research Ethics Board (REB) NP 268.734, we retrospectively analyzed the electronic medical records from patients submitted to this procedure from January 2015 to December 2015.
The procedure was proposed to patients with nasal obstruction secondary to chronical hypertrophy of the inferior turbinates, nonresponsive to at least three months of treatment with topical corticosteroids (Mometasone). Were also included procedures in association with sectorial septoplasty. Patients with other causes of nasal obstruction and those who were not properly followed postoperatively were excluded.
Based on previous studies regarding laser physical interaction with the nasal mucosa, was selected the 980nm Diode Laser (DMC, Brazil) with 7 watts of power in a pulsatile mode (20 Hz/ 25msg) [21,22], applied using a 600 micrometers optic fiber attached to a thin metal angled tip with the aid of a zero degree nasal endoscope coupled to a video system, to allow more control and precision.
Accordingly to our institutional protocol for outpatient surgery, the procedures were performed in the surgical theater after antibiotic profilaxia (Cefazolin 2 grams), under propofol intravenous anesthesia and discharging home after six hours.
The LST technique starts using the laser to perform a longitudinal incision along the inferior turbinate lower edge (Figure 1 and 2), followed by sub periosteal dissection of the turbinate bone preserving the underlying mucosa (Figure 3).
Figure 1. Laser submucous reduction.
Figure 2. Inferior turbinate incision.
Figure 3. subperiostal dissection.
After the subperiosteal dissection, two neurovascular branches are clearly visualized in the internal side of the turbinate bone, coming from its tail along the superior and inferioredges. Before removing the turbinate bone, these branches are photocoagulated using the laser (Figure 4) and finally is repositioned the mucosa with its integrity preserved, welding the incision edges also with the laser (Figure 5). As the histological documentation of the turbinate neurovascular branches have not been done before, we preserved and sent to immune histochemical analysis part of the resected branches.
Figure 4. Bone ressection and Neurovascular photocoagulation.
Figure 5. Final aspect.
During the posopersative care, topical oxymetazoline was prescribed in the first 72 hrs to reduce the risk of bleeding and aiming the early identifation of any surgical complication all patients were evaluated after three days, two weeks, four weeks, eight weeks and twelve weeks. Nasal irrigation with hypertonic saline solution (3% Sodium Chloride) was also recommended during the first two weeks.
Figure 6. Actine smooth muscle immunohistochemical analisys - jpg_preview.
Figure 7. Glial cell immunohistochemical analisys.
In regard to the postoperative data, was gently aspirated any secretion or clots from the nasal cavity in the first evaluation, without removing the crusts over the incision, observing mild edema of the inferior turbinate mucosa that re-absorved completely within 2 weeks. The healing has occurred within 4 weeks.
Increased secretion with infectious aspect was present in 2 (4%) of the cases between the first and second week, successfully treated with oral antibiotic (Amoxacilin) for seven days. There were no major complications, such as bleeding, persistent crust formation, nasal synechiae or atrophic rhinitis with empty nose syndrome.
Generally, allergic patients have the worse response to the turbinate surgery with recurrence of the symptoms related to the vasomotor reflex as congestion, secretion and sneezing. The transnasal resection of the posterior nasal nerve (TRPN) at the sphenopalatine foramen is capable to reduce the recurrence of these symptoms, as the afferent sensory fibers to the nasal mucosa are ressected, improving sneezing and nasal secretion and reducing the local citokines released. However, it is more invasive and presents increased risk of postoperative bleeding [17,25].
The selective resection of the peripheral posterior nasal nerve is an option less invasive and it can be performed during the submucosal removal of the turbinate bone, since the peripheral branches of the posterior nasal nerve are within the vascular branches, between the bone and the lateral turbinate mucosa, achieving the same results than the TRPN . However, as the postoperative bleeding risk is still high, it is performed with nasal packing in an inpatient setting.
Although many studies have been published proposing the use of laser to reduce the inferior turbinate in outpatient surgery, it is always applied removing the mucosa, without the partial resection of the turbinate bone [14,26].
The Laser techniques described, beside good initial clinical results, has about 20% of recurrence rate in two years follow up [27-29] and it is controversial among rhinologists, mainly because the laser is applied to vaporize the mucosa, with epithelial destruction and physiology impairment [5,8,16].
Differently from other procedures described using the laser, in the present technique it was selected the 980 Diode Laser to perform the incision in the inferior turbinate and to photocoagulate the neurovascular branches, providing precision and more control over this critical step of the procedure, based in an electron microscopy analysis in the nasal mucosa that demonstrated better physical interaction for incision and coagulation .
The pulsatile mode, in a low frequency, is able to provide good hemostasis with less thermal damage to the adjacent tissue , increasing the preservation of the mucosa, contributing to better healing process, reducing the postoperative bleeding risk and allowing an outpatient setting.