*2.4.1 Submucous resection*

Submucous resection was first described by Spielberg in 1924 [54] and then elaborated by Howard House in 1951 [32]. It consists of removing the inferior turbinal bone and the submucosal erectile tissue with preservation of the overlying mucosa [55]. A premedication with vasoconstrictors and local anesthetics is used for both the medial and lateral surfaces of the turbinal mucosa. The Freer knife is used to perform incision over the head of turbinate and is inserted to the previously exposed anterior edge of the conchal bone. The mucosa is separated from the bone by repeated small cutting strokes. The mucoperiosteum is separated from the medial and the lateral surfaces of the bone for a distance of 1.5 cm. The thick

**Figure 5.** *Inferior turbinate outfracture.*

**143**

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

anterior portion of the turbinal bone is grasped with the Takahashi forceps, rotated and then removed. The remaining 2/3 of the bones are very thin, so there is no need to remove it. Sutures are not necessary [32]. By maintaining the mucosal flaps, the normal nasal function is preserved. There is a minimum risk for crusts formation, except for the incision site. There is a low risk for postoperative bleeding, but postoperatively nasal packing is necessary. This technique is particularly effective in cases of prominent bony hypertrophy. A mucosal shredding in inexperienced hands may occur [55]. The submucosal resection leads to fibrosis of the submucosal tissue from the deep layers of the turbinate with the reduction of the immunocompetent cells and IgE. The resection also provokes a damage of the postnasal nerve fibers resulting in the reduction of sneezing and rhinorrhea in allergic patients [56, 57].

Turbinoplasty was first described by Mabry in 1982 (**Figure 7**). According to Mabry's technique, a No. 15 blade is used to make an incision from the inferior tip of the turbinate, down to the level of conchal bone, until the posterior edge of the turbinate. A mucosal flap is prepared and elevated from the medial surface. The inferior and lateral part of the turbinate (including bone, soft tissue and lateral mucosa) are then removed with forceps. The residual mucosal-covered soft tissue

Powered microdebrider-assisted turbinoplasty is an effective technique with fewer

This technique was first introduced by Beck in 1930. It is performed using an Abbey needle at 20 W of power. Under endoscopic guidance, the needle is introduced in the anterior tip of the inferior turbinate until the posterior edge. A second pass is performed along the inferior medial edge and a third pass midway between the previous passes. This technique is associated with more complications, such as postoperative bleeding, crusts formation, mucosal dryness, edema, and avascular necrosis [60, 61].

Laser treatment of the inferior turbinates is generally used as extra mucosal technique. Potassium-titanyl-phosphate (KTP) laser has been applied directly inside the turbinate to reduce the vascular tissue. KPT laser energy is well absorbed by hemoglobin and pigmented tissue. Thus, the engorged vessels strongly absorb

complications of crusting and similar favorable outcomes to manual submucosal resection [55]. It is performed under endoscopic guidance. Local infiltration is given in the inferior turbinate. A vertical incision is made in the anterior tip of the inferior turbinate. The microdebrider is then introduced through the incision and by rotating continuously in a circular fashion it removes all stromal tissue [59]. Finally, anterior nasal packing is kept in nasal passages for 48 h [1]. Microdebrider offers preservation of both the mucosa and the anatomy/physiology of the turbinate. However, this

technique is associated with a major risk of postoperative bleeding [55].

*2.4.3.1 Submucosal electrocauterization (Diathermy)*

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

*2.4.2.1 Cold turbinoplasty with manual instrumentation*

flap is then curled upon itself to form a "neoturbinate" [58].

*2.4.2.2 Cold turbinoplasty with electronic tools (microdebrider)*

*2.4.2 Cold turbinoplasty*

*2.4.3 Thermal turbinoplasty*

*2.4.3.2 Laser surgery*

**Figure 6.** *Multiple submucosal outfracture.*

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

anterior portion of the turbinal bone is grasped with the Takahashi forceps, rotated and then removed. The remaining 2/3 of the bones are very thin, so there is no need to remove it. Sutures are not necessary [32]. By maintaining the mucosal flaps, the normal nasal function is preserved. There is a minimum risk for crusts formation, except for the incision site. There is a low risk for postoperative bleeding, but postoperatively nasal packing is necessary. This technique is particularly effective in cases of prominent bony hypertrophy. A mucosal shredding in inexperienced hands may occur [55]. The submucosal resection leads to fibrosis of the submucosal tissue from the deep layers of the turbinate with the reduction of the immunocompetent cells and IgE. The resection also provokes a damage of the postnasal nerve fibers resulting in the reduction of sneezing and rhinorrhea in allergic patients [56, 57].

#### *2.4.2 Cold turbinoplasty*

*Rhinosinusitis*

v.Ultrasound

*2.4.1 Submucous resection*

vi.Quantic molecular resonance

vii.Submucosal corticosteroids injection

Submucous resection was first described by Spielberg in 1924 [54] and then elaborated by Howard House in 1951 [32]. It consists of removing the inferior turbinal bone and the submucosal erectile tissue with preservation of the overlying mucosa [55]. A premedication with vasoconstrictors and local anesthetics is used for both the medial and lateral surfaces of the turbinal mucosa. The Freer knife is used to perform incision over the head of turbinate and is inserted to the previously exposed anterior edge of the conchal bone. The mucosa is separated from the bone by repeated small cutting strokes. The mucoperiosteum is separated from the medial and the lateral surfaces of the bone for a distance of 1.5 cm. The thick

**142**

**Figure 6.**

**Figure 5.**

*Inferior turbinate outfracture.*

*Multiple submucosal outfracture.*

#### *2.4.2.1 Cold turbinoplasty with manual instrumentation*

Turbinoplasty was first described by Mabry in 1982 (**Figure 7**). According to Mabry's technique, a No. 15 blade is used to make an incision from the inferior tip of the turbinate, down to the level of conchal bone, until the posterior edge of the turbinate. A mucosal flap is prepared and elevated from the medial surface. The inferior and lateral part of the turbinate (including bone, soft tissue and lateral mucosa) are then removed with forceps. The residual mucosal-covered soft tissue flap is then curled upon itself to form a "neoturbinate" [58].

#### *2.4.2.2 Cold turbinoplasty with electronic tools (microdebrider)*

Powered microdebrider-assisted turbinoplasty is an effective technique with fewer complications of crusting and similar favorable outcomes to manual submucosal resection [55]. It is performed under endoscopic guidance. Local infiltration is given in the inferior turbinate. A vertical incision is made in the anterior tip of the inferior turbinate. The microdebrider is then introduced through the incision and by rotating continuously in a circular fashion it removes all stromal tissue [59]. Finally, anterior nasal packing is kept in nasal passages for 48 h [1]. Microdebrider offers preservation of both the mucosa and the anatomy/physiology of the turbinate. However, this technique is associated with a major risk of postoperative bleeding [55].

#### *2.4.3 Thermal turbinoplasty*

#### *2.4.3.1 Submucosal electrocauterization (Diathermy)*

This technique was first introduced by Beck in 1930. It is performed using an Abbey needle at 20 W of power. Under endoscopic guidance, the needle is introduced in the anterior tip of the inferior turbinate until the posterior edge. A second pass is performed along the inferior medial edge and a third pass midway between the previous passes. This technique is associated with more complications, such as postoperative bleeding, crusts formation, mucosal dryness, edema, and avascular necrosis [60, 61].

#### *2.4.3.2 Laser surgery*

Laser treatment of the inferior turbinates is generally used as extra mucosal technique. Potassium-titanyl-phosphate (KTP) laser has been applied directly inside the turbinate to reduce the vascular tissue. KPT laser energy is well absorbed by hemoglobin and pigmented tissue. Thus, the engorged vessels strongly absorb

#### **Figure 7.**

*Cold turbinoplasty with manual instrumentation (Mabry's technique) (A) incision from the inferior tip of the turbinate, (B) mucosal flap, (C and D) the bone and soft tissue of the inferior and lateral part of the turbinate lateral mucosa removal. (E) Residual mucosal curled upon itself to form a "neoturbinate."*

the laser energy resulting in shrinkage of the vessels and submucosal tissue. The procedure is conducted as described: an 18-gauge needle is inserted into the submucosa of the inferior turbinate from its anterior edge to about 2 cm. KTP laser is delivered by inserting the fiber through lumen of the needle previously applied, the needle is removed and a retrograde photocoagulation is performed. Results seem to be good with the respect of the mucosa. Patients complain about the long period they have to wait for healing [62, 63].

#### *2.4.3.3 Radiofrequency ablation of the inferior turbinate (RFAIT)*

Among the thermal techniques, radiofrequency ablation of the inferior turbinate is one the most performed because of its simple utilization, the possibility to be performed even only under local anesthesia, and its rare complications [64, 65].

This method works generating a high frequency, but low intensity energy. The instrument consists of a monopolar or bipolar generator and a handpiece (probe) that contains electrodes [66]. The electrodes do not get heated themselves [67]. They induce an ionic stirring, and collision between ions and tissue molecules gives out heat over the surrounding submucosal layer of the turbinates (2–4 mm around the active portion of the electrode), preserving overlying mucosal integrity within its mucociliary function. The temperature achieved is always controlled (60–90°C) and carbonization phenomena are excluded [68].

The tip of the electrodes can be introduced in front part (or "head") of the inferior turbinate in one time and pushed across all its length (single insertion site technique) or in three steps (head, body, tail of turbinate), ideally under endoscopic guide. Some authors usually manage just the anterior hypertrophy of the turbinate, as responsible of most nasal resistances [69].

The reduction of the volume of the turbinate is visible just during the surgery, but long term results cannot be estimated during the procedure.

In the first 24–48 h, nasal obstruction can get worse because of the edematous reaction [69], to improve in the following 2–3 weeks, in which the original tissue is replaced by scar tissue, which has a lower thickness. The shrinkage of turbinates enhances with the partial subsequent reabsorption of the scar tissue and the submucosal fibrosis [68] that join the mucosa to the periosteum of the inferior nasal concha. Blood flow is reduced too. Intraoperative and postoperative complications (such as hemorrhage) are rare, and usually there is no need in nasal cavity packing [68].

This surgical option is repeatable and its repetition can stabilize results over time [68].

#### *2.4.3.4 Radiofrequency coblation technique*

A different type of radiofrequency bipolar technique is the so-called coblation (term that derives from the union of the words "Cold" and "Ablation") that consists

**145**

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

of a bipolar wand and a standard electrosurgical unit. The thermal lesion of the submucosal tissue is caused by the ionic agitation of an electrically conductive fluid (normal saline) added in the space between the electrode and the tissue. This ionic agitation determines a molecular disintegration that is minimal because of the minimum distance between the active and passive electrodes. For the turbinate surgery, two probes are available: the "Reflex Ultra 45 wand" and the "Hummingbird

The surgeon, using the wand, under optical guidance, can create a tissue channel or more, depending on the size of the inferior turbinate to be reduced. In this technique, which can be conducted even under local anesthesia, the infiltration of the turbinate with saline solution is important. Radiofrequency energy promotes a submucosal fibrosis process, which leads to the dimensional reduction of the turbinate, in the absence of involvement of the mucosal lining and/or of the mucociliary

In the short-term postoperative period, often it is usual to observe a "rebound swelling" of the turbinate, due to the tissue edema, that can last even 10 days, to resolve its self in about 6 weeks. As the common radiofrequency technique or even more frequently, additional therapeutic sessions can be necessary, because of a gradual recurrence of symptoms after some time. Patients with the lowest preoperative nasal conductance of airflow gain greatest objective benefit from turbinate coblation. This means that patient selection with objective measurements is very

The mechanism of action of this technique consists of the transformation of low frequency ultrasounds (44 + 4.4 KHz) into mechanical oscillations, induced by an acoustic transducer, through a piezoelectric phenomenon. The probe, introduced into the turbinate submucosa through the creation of two parallel intraparenchymal tunnels, ultimately produces a process of ultrasonic disintegration, particularly evident at the level of the cavernous and connective tissue, with reduction of the volume of the turbinate due to the formation of abundant intramural fibrotic tissue. A histopathological analysis with an electronic microscope showed regeneration of respiratory epithelium (ciliary regeneration), after 3 months reduction of hyperplasia; decrease in the number of goblet cells and glandular elements; and restoration of a normal pseudo-layered ciliated epithe-

Unlike the other existing technologies, which base their operating principle on a transfer of thermal energy (heat generated by the passage of current), the molecular quantum resonance scalpel suitably modulated to produce tissue separation not by thermal vaporization, but as a consequence of the "resonance" effect at the cellular level. The energetic quanta, opportunely calibrated for the tissue to be treated, are able to break the molecular bonds inside the cell, without increasing the kinetic energy and, therefore, without increasing the temperature. The result is an extremely precise and delicate biological result, in the absence of damage necrosis. The temperature reached does not exceed 45°C. For the coagulation process, the frequencies are slightly modified, so as to make the molecules vibrate inside the cell and induce a modest rise in temperature (up to about 63°C), which in turn allows to obtain the coagulation of the tissue affected by fibrinogen protein decline. Submucosal decongestion of the turbinate is performed by means of insertion with

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

transport system. Nasal packing is not required [70].

wand" [70, 71].

important [72].

*2.4.3.5 Ultrasound*

lium, after 6 months [73, 74].

*2.4.3.6 Molecular quantum resonance (QMR)*

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

of a bipolar wand and a standard electrosurgical unit. The thermal lesion of the submucosal tissue is caused by the ionic agitation of an electrically conductive fluid (normal saline) added in the space between the electrode and the tissue. This ionic agitation determines a molecular disintegration that is minimal because of the minimum distance between the active and passive electrodes. For the turbinate surgery, two probes are available: the "Reflex Ultra 45 wand" and the "Hummingbird wand" [70, 71].

The surgeon, using the wand, under optical guidance, can create a tissue channel or more, depending on the size of the inferior turbinate to be reduced. In this technique, which can be conducted even under local anesthesia, the infiltration of the turbinate with saline solution is important. Radiofrequency energy promotes a submucosal fibrosis process, which leads to the dimensional reduction of the turbinate, in the absence of involvement of the mucosal lining and/or of the mucociliary transport system. Nasal packing is not required [70].

In the short-term postoperative period, often it is usual to observe a "rebound swelling" of the turbinate, due to the tissue edema, that can last even 10 days, to resolve its self in about 6 weeks. As the common radiofrequency technique or even more frequently, additional therapeutic sessions can be necessary, because of a gradual recurrence of symptoms after some time. Patients with the lowest preoperative nasal conductance of airflow gain greatest objective benefit from turbinate coblation. This means that patient selection with objective measurements is very important [72].

#### *2.4.3.5 Ultrasound*

*Rhinosinusitis*

**Figure 7.**

they have to wait for healing [62, 63].

the laser energy resulting in shrinkage of the vessels and submucosal tissue. The procedure is conducted as described: an 18-gauge needle is inserted into the submucosa of the inferior turbinate from its anterior edge to about 2 cm. KTP laser is delivered by inserting the fiber through lumen of the needle previously applied, the needle is removed and a retrograde photocoagulation is performed. Results seem to be good with the respect of the mucosa. Patients complain about the long period

*lateral mucosa removal. (E) Residual mucosal curled upon itself to form a "neoturbinate."*

*Cold turbinoplasty with manual instrumentation (Mabry's technique) (A) incision from the inferior tip of the turbinate, (B) mucosal flap, (C and D) the bone and soft tissue of the inferior and lateral part of the turbinate* 

Among the thermal techniques, radiofrequency ablation of the inferior turbinate

is one the most performed because of its simple utilization, the possibility to be performed even only under local anesthesia, and its rare complications [64, 65]. This method works generating a high frequency, but low intensity energy. The instrument consists of a monopolar or bipolar generator and a handpiece (probe) that contains electrodes [66]. The electrodes do not get heated themselves [67]. They induce an ionic stirring, and collision between ions and tissue molecules gives out heat over the surrounding submucosal layer of the turbinates (2–4 mm around the active portion of the electrode), preserving overlying mucosal integrity within its mucociliary function. The temperature achieved is always controlled (60–90°C)

The tip of the electrodes can be introduced in front part (or "head") of the inferior turbinate in one time and pushed across all its length (single insertion site technique) or in three steps (head, body, tail of turbinate), ideally under endoscopic guide. Some authors usually manage just the anterior hypertrophy of the turbinate,

The reduction of the volume of the turbinate is visible just during the surgery,

In the first 24–48 h, nasal obstruction can get worse because of the edematous reaction [69], to improve in the following 2–3 weeks, in which the original tissue is replaced by scar tissue, which has a lower thickness. The shrinkage of turbinates enhances with the partial subsequent reabsorption of the scar tissue and the submucosal fibrosis [68] that join the mucosa to the periosteum of the inferior nasal concha. Blood flow is reduced too. Intraoperative and postoperative complications (such as hemorrhage) are rare, and usually there is no need in nasal cavity packing [68].

This surgical option is repeatable and its repetition can stabilize results over time [68].

A different type of radiofrequency bipolar technique is the so-called coblation (term that derives from the union of the words "Cold" and "Ablation") that consists

*2.4.3.3 Radiofrequency ablation of the inferior turbinate (RFAIT)*

and carbonization phenomena are excluded [68].

as responsible of most nasal resistances [69].

*2.4.3.4 Radiofrequency coblation technique*

but long term results cannot be estimated during the procedure.

**144**

The mechanism of action of this technique consists of the transformation of low frequency ultrasounds (44 + 4.4 KHz) into mechanical oscillations, induced by an acoustic transducer, through a piezoelectric phenomenon. The probe, introduced into the turbinate submucosa through the creation of two parallel intraparenchymal tunnels, ultimately produces a process of ultrasonic disintegration, particularly evident at the level of the cavernous and connective tissue, with reduction of the volume of the turbinate due to the formation of abundant intramural fibrotic tissue. A histopathological analysis with an electronic microscope showed regeneration of respiratory epithelium (ciliary regeneration), after 3 months reduction of hyperplasia; decrease in the number of goblet cells and glandular elements; and restoration of a normal pseudo-layered ciliated epithelium, after 6 months [73, 74].

#### *2.4.3.6 Molecular quantum resonance (QMR)*

Unlike the other existing technologies, which base their operating principle on a transfer of thermal energy (heat generated by the passage of current), the molecular quantum resonance scalpel suitably modulated to produce tissue separation not by thermal vaporization, but as a consequence of the "resonance" effect at the cellular level. The energetic quanta, opportunely calibrated for the tissue to be treated, are able to break the molecular bonds inside the cell, without increasing the kinetic energy and, therefore, without increasing the temperature. The result is an extremely precise and delicate biological result, in the absence of damage necrosis. The temperature reached does not exceed 45°C. For the coagulation process, the frequencies are slightly modified, so as to make the molecules vibrate inside the cell and induce a modest rise in temperature (up to about 63°C), which in turn allows to obtain the coagulation of the tissue affected by fibrinogen protein decline. Submucosal decongestion of the turbinate is performed by means of insertion with

a headpiece, activated by a QMR machine, so-called Quantum (Telea, Sandrigo-Vicenza, Italy), for a total of 20–30 s, at an intensity force of 3.5, with immediate causes a shrinkage of the mucosa. Since this is a substantially new technique, even if a special dedicated bipolar electrode exists and it is already operating regularly, there are only a few references in the current literature [6, 75].

#### *2.4.3.7 Submucosal corticosteroids injection*

The injection of a "long acting" steroid solution is a minimally invasive method, which still guarantees a rather limited benefit over time (it is maximum after 1 week and generally lasts for no longer than a month). It is performed by a slow submucosal injection of triamcinolone acetonide at the level of the turbinate head. A possible complication, even if extremely rare, consists of a transient or permanent loss of sight, which is thought to derive from a retinal vasospasm or a retrograde embolization affecting the retinal circulation (devastating retinal thromboses can also occur) [6, 76, 77].
