The Journal of Laryngology & Otology (2012), 126, 525–528.

SHORT COMMUNICATION
© JLO (1984) Limited, 2012
doi:10.1017/S0022215112000163

Endoscopic, assisted, modified turbinoplasty with

mucosal flap

M M PUTERMAN, N SEGAL, B-Z JOSHUA

Department of Otolaryngology – Head and Neck Surgery, Soroka University Medical Center, Ben-Gurion
University of the Negev, Beer-Sheva, Israel

Abstract
A variety of surgical methods have been developed to reduce the volume of the inferior turbinates, in order to create a more
patent nasal airway. We describe a technique used in our department since February 2002 for all patients undergoing
inferior turbinectomy. We resect with endoscopic assistance the lateral mucosa and bony inferior turbinate. This
technique can reduce a large volume of the turbinate while preserving the mucosal continuity and the submucosa by
covering the raw surface with a mucosal flap. We believe our method minimises post-operative side effects and
complications such as dryness, infection, bleeding and pain.

Key words: Endoscopic Surgical Procedure; Nasal Mucosa; Pedicled Flap; Nasal Concha

Introduction a computed tomography scan when chronic sinusitis was

Nasal obstruction due to inferior turbinate hypertrophy is a suspected.
common problem. Hypertrophy of the turbinate is caused
by either allergic or non-allergic chronic rhinitis, and is
due to glandular submucosal hypertrophy, vascular conges- Surgical technique
tion and collagen deposition. Nasal obstruction due to turbi- The procedure was performed under either local anaesthesia
nate hypertrophy significantly impairs patients’ quality of alone or combined local and general anaesthesia. Local
life. anaesthesia was delivered via nasal neurosurgical cotton
Over the past century or more, a variety of surgical gauze (American Surgical company, Lynn, MA, USA)
methods have been developed to reduce the volume of the soaked with lidocaine and 2 per cent adrenaline 1:10 000 sol-
inferior turbinates, creating a more patent nasal airway. ution and packed around the inferior turbinate, the inferior
These include ‘standard’ turbinectomy (excision using scis- meatus and the nasal cavity. After extraction of the soaked
sors), a variety of methods for submucosal resection of the cotton gauze, the inferior turbinates were infiltrated with an
turbinate, vidian neurectomy, electrocautery (either monopo- intra-thecal 22 gauge needle delivering lidocaine 2 per cent
lar, using a spinal needle, or bipolar), cryotherapy, laser and 1:100 000 adrenaline solution, for additional anaesthesia
cautery (using several different types of laser), radiofre- and haemostasis.
quency reduction (e.g. coblation) and endoscopic procedures A standard 0° sinus endoscope was used in all turbino-
(including the use of a debrider). plasty procedures.
Surgical methods are associated with varying degrees of A longitudinal incision was made running inferiorly from
morbidity, and the outcome of the various procedures the caudal end of the inferior turbinate up to the anterior
described is variable. portion (Figure 1), using a sickle knife, and completed with
micro-scissors if necessary. The medial mucoperiosteal
Material and methods layer of the turbinate was elevated from the bony part of the
We performed an endoscopic, assisted, modified turbino- turbinate in an antero-posterior direction, and from the inferior
plasty technique with mucosal flaps on adult and adolescent to the superior border of the turbinate, using a Freer elevator
patients who complained of nasal obstruction and were diag- and the tip of the suction tube. In cases in which the inferior
nosed with hypertrophied inferior turbinates. The procedure incision failed to completely release the mucoperiosteal
was carried out with or without other endoscopic procedures flap, we additionally used turbinate micro-scissors.
for the treatment of concomitant sino-nasal pathology, such After elevation of the flap, the turbinate bone was denuded
as deviated nasal septum and chronic sinusitis. We operated on its medial surface (Figure 2). Micro-scissors were intro-
only on patients who failed to respond to medical therapy. duced perpendicular to the dissected inferior turbinate and
All patients underwent evaluation, including a thorough progressively excised an adequate volume of the turbinate,
history of prior medical or surgical treatment, physical exam- working in an antero-posterior direction. After partial exci-
ination including anterior rhinoscopy, nasal endoscopy, and sion of the turbinate bone with its attached lateral mucosa,

Accepted for publication 26 July 2011 First published online 2 March 2012
526 M M PUTERMAN, N SEGAL, B-Z JOSHUA

Following the above-mentioned procedure, we did not

encounter immediate post-operative bleeding requiring
additional intervention. Occasionally, after tamponade
removal there was a short and minimal bleeding episode,
which was always controlled by local pressure. We did not
encounter any late bleeding (i.e. over 24 hours after
surgery), in contrast to standard inferior turbinectomy, fol-
lowing which there is occasionally severe bleeding from
the posterior turbinate requiring haemostasis
We encountered some nasal crusting between one to two
weeks after surgery. This was treated with nasal irrigation.
Rarely, small synechiae were encountered, following
FIG. 1
surgery incorporating septoplasty in addition to partial
Diagram showing the initial longitudinal incision (dotted line)
running inferiorly from the caudal end of the inferior turbinate up
inferior turbinectomy. These synechiae were between the
to the anterior portion. residual inferior turbinate and the septum. They were
usually asymptomatic and easily treated.
Empty nose symptoms, such as dryness and post-nasal
the posterior end of the turbinate was cauterised to avoid late drip, are occasionally encountered following other turbinect-
bleeding. omy techniques. No such symptoms were seen following our
The previously elevated medial mucosal flap was then lat- procedure.
erally rotated and repositioned to cover the remaining
denuded turbinate bone and mucosal stump (Figure 3).
Discussion
This mucosal flap was secured in place by the introduction
The primary goal of performing surgery on hypertrophied
of a standard 8-cm nasal tampon (Merocel, Mystic,
inferior nasal turbinates is to maximise the nasal airway for
Connecticut, USA), which had previously been inserted
as extended a period as possible, while minimising compli-
into and sutured to a disposable glove finger, the glove
cations such as excessive nasal drying, crusting, haemorrhage
finger fenestrated with scissors (Figure 4) and the whole
and pain. The advantages, disadvantages, complications and
unit smeared with synthomycin 5 per cent ophthalmic oint-
controversies of each form of treatment have been reviewed
ment. The tampon was inserted after the flap had been
and discussed by many authors. Wight et al.1 reported that
retracted laterally by an elongated nasal speculum. The
anterior trimming of the inferior turbinates cannot be rec-
tampon was removed after 24 hours.
ommended as a form of treatment, as the initial improvement
This technique has been used since February 2002 for
in nasal airflow does not persist in the long term. Their con-
more than 400 patients undergoing inferior turbinectomy.
clusion, together with our observation of some unsatisfactory
All patients were instructed to perform nasal irrigations
results of the non-endoscopic technique (caused by hypertro-
with saline solution for a period of up to two weeks after
phy of the posterior part of the inferior turbinate), led us to
removal of packing. Patients were followed up for between
develop our endoscopic technique.
six months and eight years, in either community or hospi-
The technique we describe is similar to that previously
tal-based out-patient clinics. Although we have not formally
reported by Kawai et al.2 but uses endoscopic instrumenta-
researched the effectiveness of this treatment compared with
tion, which allows an improved view, greater precision,
standard turbinectomy, we have observed excellent results
access to the inferior turbinate tail, and accurate mucosal
regarding nasal obstruction, with fewer side effects and com-
flap handling and positioning.
plications than the standard procedure. The great majority of
In our experience, the healing process is simpler than in
our patients have reported improved nasal breathing;
cases in which bone and mucosa are left denuded, with sec-
however, it is difficult to assess in all patients what part of
ondary crusting and inflammation. Removal of the tampon,
their improvement is due to other concomitant procedures
prepared as described, is usually painless and bloodless.
such as septoplasty and, occasionally, endoscopic sinus
Hol and Huizing3 reviewed 13 surgical treatments for
surgery.
inferior turbinate pathology, including electrocautery, che-
Commonly reported complications of turbinectomy include
mocautery, cryosurgery, (subtotal) turbinectomy, laser
bleeding, crusting, synechiae and empty nose symptoms.
surgery and radiofrequency. They concluded that these
methods may have destructive effects on mucosal and sub-
mucosal physiology, and that, judging from this perspective,
they should not be used.
Jackson and Koch4 stated that although most procedures
are technically easy to perform, there is variable long-term
success and significant risks, including necrosis of conchal
bone, eschar formation and haemorrhage.
Passali et al.5 reported long-term results in 382 patients ran-
domly assigned to receive electrocautery, cryotherapy, laser
cautery, submucosal resection or turbinectomy. In this study,
improvement in nasal airflow following resection of the
inferior turbinate was accompanied by a clinically significant
FIG. 2 loss of humidification, decreased efficiency of mucociliary
Clinical photograph showing the excised portion of the inferior tur- transport and reduced secretory immunoglobulin A defence
binate; note that the medial aspect of the bone is denuded. activities. Objective tests indicated that submucosal resection
ENDOSCOPIC TURBINOPLASTY 527

FIG. 3
Diagram of the right nose, coronal plane, showing the three consecutive surgical steps: (a) incision (dotted line); (b) mucosal flap creation and
partial turbinate excision; and (c) mucosal flap repositioning over the turbinate stump.

resulted in the greatest increase in airflow and nasal respiratory turbinectomy, and observed a decreased number and activity
function with the lowest risk of long-term complications. of seromucinous glands, fibrosis of the connective tissue
Wexler et al.6 studied the long-term histological effects of stroma, and a reduction in the number and congestion of
inferior turbinate laser surgery, and found near-total elimin- cavernous blood spaces.
ation of the seromucinous gland in the region of laser treat- Sapci et al.8 concluded that although laser ablation of the
ment, with a connective tissue regenerative response, turbinate was effective in improving nasal obstruction, it sig-
together with marked reduction in venous sinusoids. nificantly disturbed mucociliary function.
Elwany and Abdel-Moneim,7 conducted an electron Berger et al.9 studied histopathological changes after
microscopy study following carbon dioxide laser coblation of the inferior turbinates, and found significant
fibrosis, glandular and venous sinusoid depletion, and
partial epithelial shedding.
Our technique combines the advantages of the submucosal
and standard resection techniques. It consists of removal of
hypertrophied bone and mucosa, while avoiding the undesir-
able depletion of important submucosal histological struc-
tures, and the harmful effects of leaving raw surfaces, by
using the mucosal flap to cover the stump.
Our method usually enables resection of approximately
half the turbinate volume, including both mucosa and
bone. Performing this procedure endoscopically enables
improved precision, better visualisation during mucosal
flap incision and dissection, and precise placement of the
mucosal flap and tampon. It also allows bipolar cauterisation
of the inferior turbinate tail, as it enables the surgeon to
approach the remote area of the tail, which often constitutes
both the last obstacle to air passage and a source of secondary
failure (in cases in which non-endoscopic surgery is used).
Our method can reduce a large volume of the turbinate
while preserving the mucosal continuity and submucosa by
covering the raw surface with a mucosal flap. We believe
that our method is rarely associated with post-operative
side effects and complications such as dryness, infection,
bleeding and pain.

Conclusion
Every reported surgical treatment for hypertrophied inferior
turbinates has been noted to have advantages and drawbacks.
FIG. 4 We believe that our endoscopic, assisted, modified turbi-
Prepared nasal tampons: inserted into and sutured to a disposable noplasty technique provides effective control of airway
glove finger which has been fenestrated with scissors. obstruction without overly interfering with the physiology
528 M M PUTERMAN, N SEGAL, B-Z JOSHUA

of the turbinates. Furthermore, by leaving the mucosal lining 6 Wexler DB, Berger G, Derowe A, Ophir D. Long-term histologic
continuity and submucosa intact, our technique reduces the effects of inferior turbinate laser surgery. Otolaryngol Head Neck
Surg 2001;124:459–63
incidence of undesirable side effects and complications associ- 7 Elwany S, Abdel-Moneim MH. Carbon dioxide laser turbinect-
ated with alternative procedures. We recommend this tech- omy. An electron microscopic study. J Laryngol Otol 1997;
nique in view of its described hypothetical advantages, 111:931–4
although we acknowledge the greater surgical skill and instru- 8 Sapci T, Sahin B, Karavus A, Akbulut UG. Comparison of the
mentation required. effects of radiofrequency tissue ablation, CO2 laser ablation,
and partial turbinectomy applications on nasal mucociliary func-
Additional studies are required in order to compare this tions. Laryngoscope 2003;113:514–19
technique to previously described procedures with regards 9 Berger G, Ophir D, Pitaro K, Landsberg R. Histopathological
to operating time, adverse effects and post-operative surgical changes after coblation inferior turbinate reduction. Arch
success. Otolaryngol Head Neck Surg 2008;134:819–23

References
1 Wight RG, Jones AS, Beckingham E. Trimming of the inferior Address for correspondence:
turbinates: a prospective long-term study. Clin Otolaryngol Dr Marc Puterman,
Allied Sci 1990;15:347–50 Department of Otolaryngology – Head and Neck Surgery,
2 Kawai M, Kim Y, Okuyama T, Yoshida M. Modified method Soroka University Medical Center,
of submucosal turbinectomy: mucosal flap method. Acta Box 151,
Otolaryngol Suppl 1994;511:228–32 Beer-Sheva 84101, Israel
3 Hol MK, Huizing EH. Treatment of inferior turbinate pathology:
a review and critical evaluation of the different techniques.
Rhinology 2000;38:157–66 Fax: +972 8 640 3037
4 Jackson LE, Koch RJ. Controversies in the management E-mail: [email protected]
of inferior turbinate hypertrophy: a comprehensive review. Plast
Reconstr Surg 1999;103:300–12
Dr M Puterman takes responsibility for the integrity of the
5 Passali D, Passali FM, Damiani V, Passali GC, Bellussi L.
content of the paper
Treatment of inferior turbinate hypertrophy: a randomized clinical
Competing interests: None declared
trial. Ann Otol Rhinol Laryngol 2003;112:683–8