INTRODUCTION

Nasal cavities are the guardians of the lower respiratory tract and their main function is to condition the inspired air. Nasal mucosa, and submucous layer that presents characteristic vascularization, especially in the nasal conchae, is adapted to homeostasis and conditioning of nasal air flow3-5.

Nasal obstruction is one of the most frequent complaints in Otorhinolaryngology and it is associated with rhinosinusal chronic inflammations, as well as structural abnormalities of the septum and lateral wall of the nose. Allergic, reaction and eosinophilic non-allergic rhinitis, when not treated or unbalanced, may progress into a hypertrophic chronic rhinitis.

Hypertrophic chronic rhinitis is histologically characterized by chronic inflammatory process, with fibrous and grandular hyperplasia and deposit of collagen on sub-epithelial basal lamina. Modifications such as these, which affect mainly the nasal conchae, are irreversible and do not have possibility of clinical therapeutic success10-11. Of the structural alterations, in addition to nasal septum deformities, morphological variations of inferior and middle conchae induce chronic nasal obstruction. Medialized inferior concha and bullous and paradoxical middle conchae are prevalent examples of nasal obstruction from structural cause.

Currently, nasosinusal surgery enables simultaneous treatment of these affections, aiming at optimizing nasal permeability. The development of surgical nasosinusal instruments have evolved significantly, especially videoendoscopy and nasal microdebrider, enabling detailed access to nasal structures and tissue resection techniques that are more precise and elaborate1, 7, 9. Turbinectomy of inferior and middle nasal conchae is one of the most frequently performed and most controversial procedures because of complications and results. Among the most common complications are nasal hemorrhage, formation of synechia and even chronic maxillary sinusitis2, 6, 10, 11.

The purpose of this study was to show the surgical technique and our short-term experience of turbinectomy of middle and inferior nasal conchae assisted by videoendoscopy and microdebrider, in patients who have nasal chronic obstruction and required this surgery In addition to nasosinusal surgery.

MATERIAL AND METHOD

We analyzed 41 adult patients, both sexes, submitted to turbinectomy of inferior and middle nasal conchae associated or not with other intranasal procedures, whose main complaint was chronic nasal obstruction, in the period between January 1999 and June 2000.

Patients underwent the surgical procedure under general anesthesia and complementation of local anesthesia in the nasal conchae to be resected, using 1.8 to 2.5 ml de 2% xylocaine and norepinephrine 1:200,000.

The endoscope we used was 4mm, 0° and/or 30°, coupled to a microcamera Stortz Telecom SL NTSC, with monitor Sony HR Trinitron and light source Dyonics Dyobrite 3,000. Zero degree endoscope provides ampler field for visualization compared to the one of 30°, making the procedure easier. Turbinectomy was conducted with a microdebrider Xomed XPS 2.000, and with a 4mm cutting probe. This equipment enables irrigation with sterile solution and aspiration of resected material and blood in real time, maintaining the endoscopic visualization field clean and clear. Inferior concha turbinectomy was normally conducted from caudal to cephalic direction, on both medial and lateral faces, until it reached the bone portion and exposed it. Depending on the volume of the bone structure, it could be resected precisely and judiciously, with angled scissors. Middle concha turbinectomy was done similarly, until the apparent origin of the structure in the ethmoid cells; by doing so, we avoid exposing the cells of ethmoid bullous and posterior ethmoid cells, located posterit orly to the basal lamella of the ethmoid. Occasional hemorrhage points may be controlled with electrocoagulation.

In order to avoid synechiae between the bloody turbinate area and the nasal septum, we used in all cases a nasal splint of Neiman, made of silastic and fixed on the nasal septum, in the area of the atrium, with mononylon 4-0 and 1,95 cm cutting needle. The nasal splint was maintained until the 10`h postoperative day, when it was finally removed. Anterior nasal packing was done with gauze soaked in Omcylon AM® cream, and removed in the second postoperative day, when the patient was discharged.

In the three first postoperative weeks, we recommended nasal irrigation with isotonic saline solution 3 to 4 times a day, in order to prevent accumulation of hematic crusts in the nasal cavity. The first postoperative routine visit was scheduled for the 10th day, in which the Neiman's nasal splint was removed, together with the excess of hematic crusts.

RESULTS

Turbinectomies were bilateral and carried out to complement or not other intranasal procedures, in 41 patients who had nasal chronic obstruction. Distribution of surgical procedures is shown in Table 1 and Graphs 1 and 2.

There were no surgical cases of isolate turbinectomy; they were all bilateral and associated with other intranasal procedures: 51% (21/41) septoplasty, 32% (13/41) FESS according to Messerklinger technique and 17% (7/41) to both procedures.

Most of the turbinectomies were carried out on the inferior conchae, in 63% (26/41) of the cases. Inferior concha turbinectomies were mainly associated with septoplasty of Cotle-Guillen, in 73% (19/26) of the cases. Turbinectomies of middle conchae were mainly associated with Messerklinger technique of FESS, in 87% (13/15) of the cases.





Turbinectomy assisted by videoendoscopy and microdebrider takes about 15 minutes (for each concha) and visualization and control of the surgical field are very precise. Intraoperatory bleeding is small.

In our sample, there were no cases of post-op epistaxis, neither immediately after nor later on (considering up to 2 to 3 weeks post-op). Undesirable synechiae between the septum and the body of the middle nasal concha were present in 5% (2/41). They were 2 to 3mm thick and 5mm long, and were later corrected.

Alb, patients accepted and performed nasal irrigation with isotonic saline solution, most of them 3 times a day. In the first routine post-op visit, we observed the common complaint of nasal obstruction, associated with formation of hematic crusts and fibrin in the nasal atrium at the level of the suture of Neiman's splint. After removal of splint, we observed that most of the crusts and fibrin were adhered to it; therefore, after removing the splint, nasal fossae became permeable and there was a significant relief of nasal obstruction. Formation of crusts on the nasal conchae submitted to turbinectomy partially remained for 3 to 6 weeks, during healing. After the 6th week post-op, bone structure of the nasal conchae was recovered by macroscopically health nasal mucosa.

DISCUSSION

Turbinectomy techniques date backs to the 19th century, described by Hartmann, in 1890, and the first procedures were partial turbinectomy on the caudal portion of the inferior conchae, resected with cold loop1010, 11. Currently, in addition to the conventional technique with scissors, there are techniques that depend on the equipment employed, such as electrocautery, electric knife and electrocoagulation, radiofrequency, laser and microdebrtierh1, 6, 7, 9, 10, 11.

Most of these types of equipment enable resection of the soft part of the nasal conchae, providing satisfactory results in the middle and long run in 80% to 100% of the cases11. One of most feared complications of turbinectomy is hemorrhage, normally of the caudal portion of the inferior turbinate and originated at the inferior turbinate artery, with a prevalence ranging from 0.5% to 10%6, 8, 10 ,11.

Turbinectomy assisted with videoendoscopy and microdebrider was proposed by Davis and Nishioka, in 19944. Microdebrider enables cut and smashing of tissues, reducing bleeding of the wide vascular network of the nasal submucosa during the surgical act. The removal of the whole submucosa includes sinusoid vascular spaces, which do not contract and potentially produce post-op hemorrhage. The exposure of the bone framework of the concha enables a more precise resection. Final hemostasis is done with electrocoagulation in the larger vessels close to the bone structure of the concha.

In our sample, inferior turbinectomies were associated with septoplasty in 73% of the cases, generally because of hyperplasia of submucous and sometimes associated with inferior concha bone structure that is extremely medialized. Middle turbinectomies were associated with FESS, with ostiomeatal block. In these cases, the most frequent structural alterations were bullous middle concha and/or paradoxical middle concha. The action of the microdebrider was on the medial face of the middle nasal concha, followed by medialization of the lateral face, stimulating in this case the formation of synechia between the middle concha and the nasal septum, aiming at expanding the free area of the middle meatus.

The surgical procedure is significantly longer to perform when compared to classical turbinectomy consisting of medial luxation of concha and turbinectomy with angled scissors. Procedures using endoscopic access and microdebrider are normally slower, but it is compensated by more precision in the turbinectomy and more effective hemostasis, reducing the risks of the feared post-op nasal hemorrhage.

The formation of fibrin and hematic crusts partially obstructs the nasal fossae, but they may be alleviated by irrigation with isotonic saline solution. Maintenance of Neiman's splint until the 10th post-op day avoids the use of repetitive post-op nasal dressings and prevents the formation of synechia between the septum and the nasal conchae. In our experience, the removal of Neiman's splint on the 10th day, removing crusts and fibrin adhered to it, relives significantly and permanently nasal obstruction.

In our series, we did not detect cases of immediate post-op nasal hemorrhage, maybe because of the reduced number of subjects in the sample (N=41). It is likely that this technique provides low prevalence of this complication. Synechiae between septum and middle nasal concha were prevalent in 5% (2/ 41) of the cases, and they were formed in the uncovered area of the nasal splint. They were removed between the 3rd and 6rd post-op months using out-patient procedures and without complications. Late removal of synechia is advantageous because there is a significant reduction of vascularization after the third post-op month and due to low incidence of recurrence.

CONCLUSION

Turbinectomy assisted by endoscopy and microdebrider provided more effective control of the structures to be removed and therefore, the procedure become easier because of (1) partial preservation of concha, relieving the symptom of nasal obstruction without interfering in the respiratory function; (2) control of hemostasis, preventing post-op hemorrhage. The technique proposed here does not exclude the existing techniques and we would like to point out that good surgical results rely on the precise indication of the surgical procedure and the common sense applied during its performance.

REFERENCES

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* Joint Professor of the Clinic of Otorhinolaryngology at Santa Casa de Sao Paulo.
** Instructing Professor and Master in Otorhinolaryngology at the Clinic of Otorhinolaryngology at Santa Casa de Sao Paulo.
*** Post-Graduate studies under course at the Clinic of Otorhinolaryngology at Santa Casa de Sao Paulo.

Study conducted at the Clinic of Otorhinolaryngology at Santa Casa de Sao Paulo. , Article submitted on August 7, 2000. Article accepted on September 14, 2000.