**2.1 Extramucosal debulking procedures**

These procedures include:

1.Total turbinectomy

*Rhinosinusitis*

**Figure 2.**

**Figure 1.**

syndrome" [4].

*improvement of respiratory nasal flux.*

which technique is the best [5].

surgical indication [6].

**2. Surgical techniques**

3.Dislocation procedures

4.Submucosal procedures

1.Extramucosal debulking procedures

2.Superficial extramucosal procedures

*Rhinomanometric evaluation before (A) and after (B) application of nasal topical decongestant shows the* 

*The radiologic study with head-CT shows a normal anatomy of the turbinates and the nasosinusal system.*

The goal of turbinate surgery is to improve nasal patency by minimizing complications such us postoperative hemorrhage, crusting, foul odor, and the "empty nose

There is a variety of turbinate procedures, but there is a lack of consensus about

Turbinate hypertrophy can be divided into primary and secondary. The primary hypertrophy is related to the submucosal component, while the secondary hypertrophy is due to contralateral septal deviation and is related to the bony component of the turbinate. It is important to distinguish these two types of hypertrophy in order to decide the proper procedure to perform. The anatomic radiologic study (**Figure 1**) and the rhinomanometric evaluation (**Figure 2**) are mandatory for

Turbinate reduction techniques can be divided into four categories [7]:

**134**


#### *2.1.1 Total turbinectomy*

It is a technique that was described for the first time in the last 10 years of the nineteenth century. Jones in 1895 and Holmes in 1900 introduced the concept of total turbinectomy [8].

This technique is considered the most radical surgical technique on the inferior turbinate. After having fractured, the bone plate of the inferior turbinate (**Figure 3**), levering from the inferior meatus, with an angled scissors, the inferior turbinate is dissected for its entire length remaining adherent to the lateral wall of the nasal cavity.

For the immediate benefit that the patient obtains, it is often considered as safe and effective though its major complication is the possible bleeding, avoidable, however, both using adequate nasal swabs and avoiding to treat patients who take anticoagulants [9].

Unfortunately, this type of surgery, extremely aggressive, can later lead to dry nose syndrome or even the syndrome of the empty nose with a paradoxical obstruction. The obstructive event is due to the loss of normal nasal resistance and the formation of a laminar air column. This situation causes a poor contact between the air and the nasal walls, the mucosa, due to the absence of the sensory fibers of the inferior turbinate, shows a reduction or even a loss of the respiratory flow [6].

The altered aerodynamics pattern, due to total turbinectomy, generates many complications such as copious postoperative bleeding, quantitative reduction of the ciliary movement, mucosal dryness, and deficit of mucus clearance. All this

**Figure 3.** *Total turbinectomy.*

#### *Rhinosinusitis*

creates stagnation of secretions, crusts formations (sometimes foul-smelling), and frequent infections with gradual development of dry inflammatory forms affecting the pharynx and larynx. Precisely because of its complications, this technique has now fallen into disuse [9].

TASCA states that it is wrong to transform the nasal cavities into rigid and inanimate tubes, unable to perform the functions of congestion and decongestion, depriving them of their natural function [10]; and for Huizing and de Groot, total turbinectomy is a nasal crime, and they do not consider it useful to perform the resection of more than a third or half of the inferior turbinate unless it is a tumor [11].

#### *2.1.2 Partial turbinectomy*

The partial turbinectomy (**Figure 4**) is used to limit the large surgical resections that are performed with total turbinectomy, and consists in the removal of the mucosa and bones of the anterior third of the inferior turbinate. The degree of resection is directly proportional to the degree of hypertrophy. Initially, the mucosal and the submucosal tissue are removed, and if there is bone hypertrophy, a small bone resection is also performed. There are several partial turbinectomy techniques.

The oldest technique is the crushing and trimming introduced by Kressner in 1930. Other technique is selective mucosotomy, which consists of the removal of the anterior or/and the posterior region of the turbinate following defined section lines. The diagonal resection consists in a sagittal exeresis with the purpose of preserving the head of the turbinate and eluting the posterior region of the turbinate. The horizontal resection of the inferior edge of the turbinate avoids the risk of bleeding from the sphenopalatine artery [12], which instead occurs in the diagonal resection [7].

The degloving technique was proposed by Chevretton et al. It consists of the resection of a large part of the turbinate, leaving the bone and the periosteum intact [7, 13].

TASCA et al. reported that the only appropriate techniques are "Crushing with remodeling" and "Resection of the tail." It is preferable to perform a resection of the posterior region of the inferior turbinate, because the elimination of the head of turbinate causes a great functional damage. It creates a deficit of the mucociliary clearance and the inferior turbinate loses its function of directing the inspiring currents [10].

**137**

Ravikumar et al. [20].

avoided [15].

*Turbinate Surgery in Chronic Rhinosinusitis: Techniques and Ultrastructural Outcomes*

trophic tissue is excessive, avoiding to remove it in a single time [14].

ibly, it is removed using long angled scissors or a loop [14].

the nasal mucosa or underlying sensibility nerves [18].

turbinate, up the superficial layer to the periosteum [19].

Crushing with remodeling is indicated if the hypertrophy is both anterior and posterior and allows to respect the functional capacity of the remaining portion of the turbinate. The turbinate is compressed using specific pliers and then reduced by cutting parallel or slightly diagonal strips starting from the lower edge. After the medial fracture of the turbinate performed with a smooth and chamfered instrument (the handle of a Cottle chisel can be used), it is squeezed with modified-Kressner tongs both anteriorly and posteriorly. The size of the turbinate is reduced by removing a strip from its rather flaccid bottom edge with Heymann-type scissors. If necessary, a part of bone is removed. Finally, the turbinate remaining laterally is repositioned. It is advised to perform a second surgical time if the hyper-

Resection of degenerated tissue: if a part of the turbinate is damaged irrevers-

Even if partial inferior turbinectomy is a simple and effective surgical procedure, it is equally troublesome if not performed correctly. Excessive resection of the inferior turbinate can lead to peri- or postoperative bleeding, from medial and inferior surface of the inferior turbinate, synechiae with the nasal septum and floor of nasal cavity, frequent post nasal blood drip, nasal crusting, and atrophic rhinitis. By using appropriate tools and limiting demolition, these complications can be

A study by Passali et al. demonstrated how the partial turbinectomy technique performed at the level of the inferior turbinate resolves most of the nasal obstruction. This technique however, even if minimally, causes damage to the nasal mucosa and therefore it is necessary that the surgeon is experienced to avoid complications [1, 16]. Sapci et al. reported that the use of radiofrequency to reduce hypertrophy of turbinates leads to an improvement of nasal obstruction and does not alter the ciliary mucus clearance. With the partial turbinectomy technique, the results obtained were similar to those of results with the radiofrequency tissue ablation technique [1, 17]. Salzano et al. enrolled four groups of patients each treated with radiofrequency, high-frequency electrocautery treatments, and lower partial turbinotomy to reduce the hypertrophied lower turbinates. They show that the partial inferior nasal turbinectomy is the best method of treatment, because it does not cause damage to

In the 1996, the microdebrider was first used by Davis and Nishioka to remove both medial and inferior redundant mucosal tissue and hypertrophied cavernous sinusoid of the inferior turbinate and the anterior head region of the inferior

This procedure is performed under the endoscopic guidance using an 0° endoscope 4-mm diameter. The microdebrider is a device that consist of a handpiece on which is positioned a rotating blade protected by a blunt end that sucks and removes the hypertrophic tissue. The surgeon moves the blade of the microdebrider,

with 2300–3000 rev/s speed of oscillation, along the inferior turbinate from posterior to anterior region and with continuous suction. It is suggested to proceed in posteroanterior direction to obtain a clean field, free of blood. The timing of

Generally, if the microdebrider-assisted turbinoplasty is limited to the decongestion of the turbinates only, the patient undergoes local anesthesia with vasoconstrictive drugs to create a large ischemia avoiding intraoperative bleeding. General anesthesia is necessary in the event that a septal or paranasal sinus surgery is also associated. In our experience, the local anesthesia is performed using soaked gauzes with Xylocain hydrochloride 5% and naphazoline 0.02% set on the nasal floor and on the medial wall of the inferior turbinate. We have left the infiltration of the turbinate and given the possible neurovegetative complications described by

*DOI: http://dx.doi.org/10.5772/intechopen.84506*

**Figure 4.** *Partial turbinectomy.*

#### *Turbinate Surgery in Chronic Rhinosinusitis: Techniques and Ultrastructural Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84506*

Crushing with remodeling is indicated if the hypertrophy is both anterior and posterior and allows to respect the functional capacity of the remaining portion of the turbinate. The turbinate is compressed using specific pliers and then reduced by cutting parallel or slightly diagonal strips starting from the lower edge. After the medial fracture of the turbinate performed with a smooth and chamfered instrument (the handle of a Cottle chisel can be used), it is squeezed with modified-Kressner tongs both anteriorly and posteriorly. The size of the turbinate is reduced by removing a strip from its rather flaccid bottom edge with Heymann-type scissors. If necessary, a part of bone is removed. Finally, the turbinate remaining laterally is repositioned. It is advised to perform a second surgical time if the hypertrophic tissue is excessive, avoiding to remove it in a single time [14].

Resection of degenerated tissue: if a part of the turbinate is damaged irreversibly, it is removed using long angled scissors or a loop [14].

Even if partial inferior turbinectomy is a simple and effective surgical procedure, it is equally troublesome if not performed correctly. Excessive resection of the inferior turbinate can lead to peri- or postoperative bleeding, from medial and inferior surface of the inferior turbinate, synechiae with the nasal septum and floor of nasal cavity, frequent post nasal blood drip, nasal crusting, and atrophic rhinitis. By using appropriate tools and limiting demolition, these complications can be avoided [15].

A study by Passali et al. demonstrated how the partial turbinectomy technique performed at the level of the inferior turbinate resolves most of the nasal obstruction. This technique however, even if minimally, causes damage to the nasal mucosa and therefore it is necessary that the surgeon is experienced to avoid complications [1, 16].

Sapci et al. reported that the use of radiofrequency to reduce hypertrophy of turbinates leads to an improvement of nasal obstruction and does not alter the ciliary mucus clearance. With the partial turbinectomy technique, the results obtained were similar to those of results with the radiofrequency tissue ablation technique [1, 17].

Salzano et al. enrolled four groups of patients each treated with radiofrequency, high-frequency electrocautery treatments, and lower partial turbinotomy to reduce the hypertrophied lower turbinates. They show that the partial inferior nasal turbinectomy is the best method of treatment, because it does not cause damage to the nasal mucosa or underlying sensibility nerves [18].

In the 1996, the microdebrider was first used by Davis and Nishioka to remove both medial and inferior redundant mucosal tissue and hypertrophied cavernous sinusoid of the inferior turbinate and the anterior head region of the inferior turbinate, up the superficial layer to the periosteum [19].

Generally, if the microdebrider-assisted turbinoplasty is limited to the decongestion of the turbinates only, the patient undergoes local anesthesia with vasoconstrictive drugs to create a large ischemia avoiding intraoperative bleeding. General anesthesia is necessary in the event that a septal or paranasal sinus surgery is also associated. In our experience, the local anesthesia is performed using soaked gauzes with Xylocain hydrochloride 5% and naphazoline 0.02% set on the nasal floor and on the medial wall of the inferior turbinate. We have left the infiltration of the turbinate and given the possible neurovegetative complications described by Ravikumar et al. [20].

This procedure is performed under the endoscopic guidance using an 0° endoscope 4-mm diameter. The microdebrider is a device that consist of a handpiece on which is positioned a rotating blade protected by a blunt end that sucks and removes the hypertrophic tissue. The surgeon moves the blade of the microdebrider, with 2300–3000 rev/s speed of oscillation, along the inferior turbinate from posterior to anterior region and with continuous suction. It is suggested to proceed in posteroanterior direction to obtain a clean field, free of blood. The timing of

*Rhinosinusitis*

now fallen into disuse [9].

*2.1.2 Partial turbinectomy*

creates stagnation of secretions, crusts formations (sometimes foul-smelling), and frequent infections with gradual development of dry inflammatory forms affecting the pharynx and larynx. Precisely because of its complications, this technique has

TASCA states that it is wrong to transform the nasal cavities into rigid and inanimate tubes, unable to perform the functions of congestion and decongestion, depriving them of their natural function [10]; and for Huizing and de Groot, total turbinectomy is a nasal crime, and they do not consider it useful to perform the resection of more than a third or half of the inferior turbinate unless it is a tumor [11].

The partial turbinectomy (**Figure 4**) is used to limit the large surgical resections that are performed with total turbinectomy, and consists in the removal of the mucosa and bones of the anterior third of the inferior turbinate. The degree of resection is directly proportional to the degree of hypertrophy. Initially, the mucosal and the submucosal tissue are removed, and if there is bone hypertrophy, a small bone resection is also performed. There are several partial turbinectomy techniques. The oldest technique is the crushing and trimming introduced by Kressner in 1930. Other technique is selective mucosotomy, which consists of the removal of the anterior or/and the posterior region of the turbinate following defined section lines. The diagonal resection consists in a sagittal exeresis with the purpose of preserving the head of the turbinate and eluting the posterior region of the turbinate. The horizontal resection of the inferior edge of the turbinate avoids the risk of bleeding from the sphenopalatine artery [12], which instead occurs in the diagonal resection [7]. The degloving technique was proposed by Chevretton et al. It consists of the resection of a large part of the turbinate, leaving the bone and the periosteum intact [7, 13]. TASCA et al. reported that the only appropriate techniques are "Crushing with remodeling" and "Resection of the tail." It is preferable to perform a resection of the posterior region of the inferior turbinate, because the elimination of the head of turbinate causes a great functional damage. It creates a deficit of the mucociliary clearance and the inferior turbinate loses its function of directing the inspiring

**136**

**Figure 4.**

*Partial turbinectomy.*

currents [10].

#### *Rhinosinusitis*

surgery necessary to accomplish the procedure is about 1–2 min long for each nasal cavity [3, 20]. At the end of the surgery, nasal packing of variable length between 8 and 10 cm are placed.

Nasal packing are used to prevent postoperative bleeding and to fill the dead space inside the nasal cavity [21], where it remains only for 48 h and does not change the functional recovery of the mucosa [3]. The patient is advised to instill nasal drops containing vitamin A and Vaseline oil for about a month after surgery [3].

Microdebrider technique is mainly discussed because of its supposed interference on mucociliary clearance.

According to Lee and Lee [21], the microdebrider causes minimal mucosal damage that does not significantly modify the ciliary mucus transport time. In fact, the entire respiratory epithelium of the nasal cavities, and not only the mucosa of the inferior turbinate, is responsible for this physiological mechanism.

According to a study conducted by our University Clinic in the 2012, the microdebrider does not damage the respiratory epithelium, but rather stimulated its regeneration. Studies conducted on animal models have shown that basal cells move the bare mucosa forward after a mechanical injury. The cells undergo transient squamous metaplasia, and then they differentiate both goblet and ciliated cells. This mechanism has also been demonstrated in human nasal cavities. The debridement of the mucosa leads to an improvement in nasal obstruction, rhinorrhea, hyposmia, headaches, snoring, and postnasal drip. It is never associated with consequences such as dryness, crusts, or nasal irritation or with alteration of mucosal function [3].

According to a study conducted by Van et al. [22], the use of the microdebrider technique allowed a success of 93% and only 17 patients presented temporary complications such as bleeding, crusting, and synechia [21]. Lee and Lee have demonstrated, through a 2006 study, that the use of the microdebrider is more effective than the group of patients who have been treated with coblation in obstructive symptomatology and in reducing the volume of the mucosa of the head of the inferior turbinate 12 months after the intervention [21]. It has been defined as the best technique for the treatment of inferior turbinates hypertrophy [3].

## **2.2 Superficial extramucosal procedures**

Superficial extramucosal procedures include


### *2.2.1 Laser-assisted ablation*

Argon laser has been the first application of laser surgery for inferior turbinate, and has been performed by Lenz et al. in 1977 [23], even if was popularized only in the 1990s [24].

**139**

all lasers [33].

*2.2.2 Electrocautery*

*2.2.3 Chemosurgery*

*Turbinate Surgery in Chronic Rhinosinusitis: Techniques and Ultrastructural Outcomes*

anesthesia, with slow risk of bleeding, with high compliance of patient.

to preserve healthy portions of mucous for the rapid epithelization [26].

obstruction, for this reason its use has greatly reduced over time [28].

excess mucus occurred, whereas cilia were present [30].

significant nasal obstruction reduction [35].

phosphate (KTP) with a wavelength similar to Argon laser [25].

Laser surgery has been described with many different procedures such as interstitial, contact, or noncontact. This technique has been performed in topical

Many types of lasers have been used for turbinate reduction. They differ in wavelength: CO2 (λ: 10,600 nm), diode (λ: 940 nm), Ho:YAG laser (λ: 2080 nm), Nd:YAG laser (λ: 1064 nm), argon-ion (λ: 488–514 nm), and potassium-titanyl-

The CO2 laser, Nd:YAG laser, and diode laser has been the light source most used [10] in surgery. Pulsed light mode has been safer than continuous light mode with

The application of light can be straight as longitudinal strip (laser-strip carbonization) with cross-light beams (cross hatched) and in "single-spots" at a range of 1–2 mm. The most used is the laser strip carbonization. Many studies showed that the best use of this kind of laser for the turbinate is "single-spots," because to be able

The CO2 laser has a high cutting precision and superficial vaporization, but is not more maneuverable; above all, for the posterior section of the inferior turbinate, indeed it does not have a flexible optical fiber. CO2 laser has worse capacity of coagulation, higher price, and worse handling than Ho:YAG, argon-ion, Nd:YAG, and KTP lasers. Diode laser has been used for the turbinate surgery because it has a good capacity of coagulation of soft tissue with minimal risk to damage the periosteum [27]. YAG laser has a good capacity of penetration of deep tissue respecting the superficial epithelium with a good intraoperative hemostasis but in literature has been reported the presence of post operatory edema with an initial respiratory

Potassium titanyl phosphate (KTP) laser is an efficient method to treat a tissue with a high vascularity, as the inferior turbinate had a wavelength that is selectively absorbed by endogenous chromophore as melanin and hemoglobin [29]. In this way, it has a selective action toward submucosal tissue, sparing surface mucosa. Tissue sample treated with KTP surgery is evaluated macroscopically and histologically: necrotizing sialometaplasia, cartilage destruction, and dilated glands with

Many authors agree that laser surgery produces permanent histologic changes in turbinate soft tissue [31]: reduction of gland serum mucous and damage of the superficial epithelium with reduction of mucociliary transport [32]. All these change have implications for the postoperative period with presence of scabs and dry mucous. Despite its first listed disadvantages, CO2 laser is the least damaging of

This method uses the heat to clot the soft tissue, causing necrosis and fibrosis with volume reduction of the turbinate. The risk of intra- and postoperative bleeding is uncommon, but the presence of scab and scarring is frequent. Due to the high temperature achieved, this technique is destructive on the mucous and can reduce the efficiency of mucociliary transport [34]. The electrocautery exist in two modalities: monopolar and bipolar. The use of bipolar mode is safer and more effective for

In 1926, Denker and Kahler described the use of trichloroacetic acid [36] (TCA) solution to the inferior turbinate in the hypertrophic rhinitis. The effect of TCA

*DOI: http://dx.doi.org/10.5772/intechopen.84506*

lesser local damage.

#### *Turbinate Surgery in Chronic Rhinosinusitis: Techniques and Ultrastructural Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84506*

Laser surgery has been described with many different procedures such as interstitial, contact, or noncontact. This technique has been performed in topical anesthesia, with slow risk of bleeding, with high compliance of patient.

Many types of lasers have been used for turbinate reduction. They differ in wavelength: CO2 (λ: 10,600 nm), diode (λ: 940 nm), Ho:YAG laser (λ: 2080 nm), Nd:YAG laser (λ: 1064 nm), argon-ion (λ: 488–514 nm), and potassium-titanylphosphate (KTP) with a wavelength similar to Argon laser [25].

The CO2 laser, Nd:YAG laser, and diode laser has been the light source most used [10] in surgery. Pulsed light mode has been safer than continuous light mode with lesser local damage.

The application of light can be straight as longitudinal strip (laser-strip carbonization) with cross-light beams (cross hatched) and in "single-spots" at a range of 1–2 mm. The most used is the laser strip carbonization. Many studies showed that the best use of this kind of laser for the turbinate is "single-spots," because to be able to preserve healthy portions of mucous for the rapid epithelization [26].

The CO2 laser has a high cutting precision and superficial vaporization, but is not more maneuverable; above all, for the posterior section of the inferior turbinate, indeed it does not have a flexible optical fiber. CO2 laser has worse capacity of coagulation, higher price, and worse handling than Ho:YAG, argon-ion, Nd:YAG, and KTP lasers.

Diode laser has been used for the turbinate surgery because it has a good capacity of coagulation of soft tissue with minimal risk to damage the periosteum [27].

YAG laser has a good capacity of penetration of deep tissue respecting the superficial epithelium with a good intraoperative hemostasis but in literature has been reported the presence of post operatory edema with an initial respiratory obstruction, for this reason its use has greatly reduced over time [28].

Potassium titanyl phosphate (KTP) laser is an efficient method to treat a tissue with a high vascularity, as the inferior turbinate had a wavelength that is selectively absorbed by endogenous chromophore as melanin and hemoglobin [29]. In this way, it has a selective action toward submucosal tissue, sparing surface mucosa. Tissue sample treated with KTP surgery is evaluated macroscopically and histologically: necrotizing sialometaplasia, cartilage destruction, and dilated glands with excess mucus occurred, whereas cilia were present [30].

Many authors agree that laser surgery produces permanent histologic changes in turbinate soft tissue [31]: reduction of gland serum mucous and damage of the superficial epithelium with reduction of mucociliary transport [32]. All these change have implications for the postoperative period with presence of scabs and dry mucous. Despite its first listed disadvantages, CO2 laser is the least damaging of all lasers [33].

#### *2.2.2 Electrocautery*

*Rhinosinusitis*

and 10 cm are placed.

mucosal function [3].

ence on mucociliary clearance.

surgery necessary to accomplish the procedure is about 1–2 min long for each nasal cavity [3, 20]. At the end of the surgery, nasal packing of variable length between 8

Nasal packing are used to prevent postoperative bleeding and to fill the dead space inside the nasal cavity [21], where it remains only for 48 h and does not change the functional recovery of the mucosa [3]. The patient is advised to instill nasal drops containing vitamin A and Vaseline oil for about a month after surgery [3]. Microdebrider technique is mainly discussed because of its supposed interfer-

According to Lee and Lee [21], the microdebrider causes minimal mucosal damage that does not significantly modify the ciliary mucus transport time. In fact, the entire respiratory epithelium of the nasal cavities, and not only the mucosa of the

According to a study conducted by Van et al. [22], the use of the microdebrider

Argon laser has been the first application of laser surgery for inferior turbinate, and has been performed by Lenz et al. in 1977 [23], even if was popularized only in

technique allowed a success of 93% and only 17 patients presented temporary complications such as bleeding, crusting, and synechia [21]. Lee and Lee have demonstrated, through a 2006 study, that the use of the microdebrider is more effective than the group of patients who have been treated with coblation in obstructive symptomatology and in reducing the volume of the mucosa of the head of the inferior turbinate 12 months after the intervention [21]. It has been defined as the

best technique for the treatment of inferior turbinates hypertrophy [3].

**2.2 Superficial extramucosal procedures**

1.Laser-assisted ablation

2.Electrocautery

3.Chemosurgery

4.Cryoturbinectomy

6.Infrared coagulation

*2.2.1 Laser-assisted ablation*

5.Argon plasma coagulation

Superficial extramucosal procedures include

According to a study conducted by our University Clinic in the 2012, the microdebrider does not damage the respiratory epithelium, but rather stimulated its regeneration. Studies conducted on animal models have shown that basal cells move the bare mucosa forward after a mechanical injury. The cells undergo transient squamous metaplasia, and then they differentiate both goblet and ciliated cells. This mechanism has also been demonstrated in human nasal cavities. The debridement of the mucosa leads to an improvement in nasal obstruction, rhinorrhea, hyposmia, headaches, snoring, and postnasal drip. It is never associated with consequences such as dryness, crusts, or nasal irritation or with alteration of

inferior turbinate, is responsible for this physiological mechanism.

**138**

the 1990s [24].

This method uses the heat to clot the soft tissue, causing necrosis and fibrosis with volume reduction of the turbinate. The risk of intra- and postoperative bleeding is uncommon, but the presence of scab and scarring is frequent. Due to the high temperature achieved, this technique is destructive on the mucous and can reduce the efficiency of mucociliary transport [34]. The electrocautery exist in two modalities: monopolar and bipolar. The use of bipolar mode is safer and more effective for significant nasal obstruction reduction [35].

#### *2.2.3 Chemosurgery*

In 1926, Denker and Kahler described the use of trichloroacetic acid [36] (TCA) solution to the inferior turbinate in the hypertrophic rhinitis. The effect of TCA

#### *Rhinosinusitis*

consists in protein degeneration [37]. This action on turbinate mucosa is aggressive and damages the mucociliary function. We can study the mucociliary function with the "saccharine time" (ST) [36]: when a saccharine granule is adhered to the nasal mucosa it is dissolved within 1 min, the molecules are then transported to the nasopharynx where the patient recognizes the sweet taste, if the ST is short there is an efficient mucociliary function. In 2008, many authors showed that the "saccharine time" (ST) has been reduced in the early and late period after the TCA application. TCA treatment can induce inhibition of Th2 cell infiltration, a condition typical of allergic rhinitis [38].
