Pediatric Turbinate

Hypertrophy
Nina L. Shapiro, MD
Associate Professor
Pediatric Otolaryngology
UCLA School of Medicine
Introduction: Turbinate Hypertrophy

• Chronic rhinitis leading to turbinate

hypertrophy common in both children and
adults
– 20 million people in U.S
– $2 billion annually

– Infectious or non-infectious
– Allergic or non-allergic
Turbinate hypertrophy: Children
• Smaller intranasal anatomy

• Obstruction due to turbinate hypertrophy

plays larger role in pediatric patients
relative to adults
Turbinate Anatomy
 Introduction
• Children with adenotonsillar obstruction

– Adenoidectomy or Adenotonsillectomy
alleviates obstruction in presence of
enlarged turbinates

• Surgical intervention to reduce turbinate

hypertrophy may be additional option
Adenotonsillar Hypertrophy
 Medical Management
• Antihistamines

• Decongestants

• Topical nasal steroids/nasal saline/sinus rinses

• Antibiotics if sinusitis

• Immunotherapy if allergic
 Surgical Options
• Cold-steel turbinectomy/turbinoplasty
• Lateralization/outfracture of inferior turbinate
• Diathermy (electrocautery)
• Laser
• Cryosurgery
• Powered Microdebrider
• Radiofrequency Ablation
• Coblation
 What Is Coblation?
• Bipolar configuration
• RF current through conductive
solution
– 100-300 V, 100-500 kHz
• Plasma field by RF current
– In NaCl, orange glow
• Not heat-driven
• Molecular dissociation
• Minimal thermal penetration
– Cell death (<125 mm)
 Coblation
• Low frequency
– Decreased tissue penetration
– Minimal collateral tissue damage
– Surface temperatures 40° to 70° C
• Shorter current path
– Control of energy delivery
• Volumetric tissue removal

Electrocautery
• Monopolar spark between
electrode and tissue
• Localized tissue heating
– 450° to 600° C
• Tissue desiccation and
vaporization
 Coblation® Turbinate
Wand
Needle-tip wand with contact
markers

Coblation foot pedal control

Saline gel application for each

turbinate entry ReFlex Ultra™ 45
Plasma Wand

Varying
durations/contacts/entries
 Coblation Turbinate Reduction

• Coblation shrinks submucosal tissue

– Preserves mucosal and glandular architecture
– Immediate reduction in nasal obstruction, with
greater reduction over time
– Thermal lesion remains after tissue
vaporization
– Soft tissue attenuation/contracture progresses
 Coblation Turbinate Reduction
• Operating room or in-office procedure
– Topical/Local anesthetic
– <25% require post-operative narcotic analgesic

• Fast, minimally invasive procedure

– 20-30 seconds per side
 Coblation Turbinate Reduction:
Experience in Adults
• Fast

• In-office

• Restores normal breathing immediately

• Improvement progresses over time

• Minimal side effects

 Coblation Turbinate Reduction:
Experience in Adults
• 50% reduction in nasal blockage at 1 week, 3, 6, and 12
months
– Easy to perform in OR or office
– Minimal pain; low incidence of post-op crusting
– Each lesion created in 10 seconds
– Minimal damage to surrounding tissue

Bäck LJ, Hytönen ML, Malmberg HO, Ylikoski JS. Laryngoscope. 2002;112:1806–1812.

Bhattacharyya N, Kepnes LJ. Otolaryngol Head Neck Surg. 2003;129:365–371

Clinical Effectiveness of Coblation Inferior
Turbinate Reduction

OBJECTIVE
• Determine safety and clinical efficacy of Coblation
inferior turbinate reduction
DESIGN
• 26 patients with inferior turbinate hypertrophy treated
in-office with Coblation

Bhattacharyya N, Kepnes LJ. Otolaryngol Head Neck Surg.

2003;129:365-371.
 Clinical Effectiveness of Coblation Inferior Turbinate Reduction
Bhattacharyya N, Kepnes LJ. Otolaryngol Head Neck Surg. 2003;129:365-371.

Variable Baseline D at 3 months D at 6 months

RSI domains
Facial 30.4 –11.2 –17.2*
Nasal 40.3 –10.5* –20.1*
Oropharyngeal 22.5 –4.3 –12.2*
Systemic 22.5 –7.3* –12.6*
Overall 28.5 –8.7* –15.8*
Nasal questionnaire
Nasal obstruction 3.4 –1.1* –1.5*
Time obstructed 3.5 –1.1* –1.2*
Nasal stuffiness 3.0 –0.6 –0.8*
Mucus production 2.1 –0.2 –0.3
Postnasal discharge 2.3 -0.4 –0.5
Snoring 2.8 –0.4 –0.5
Overall nasal symptoms 3.5 –1.1* –1.2*
 Clinical Effectiveness of Coblation Inferior
Turbinate Reduction

CONCLUSIONS
• Inferior turbinate reduction by Coblation is
effective for inferior turbinate hypertrophy

• Clinical benefit persists for at least 6 months

Bhattacharyya N, Kepnes LJ. Otolaryngol Head Neck Surg. 2003;129:365-371.

 Coblation vs. Microdebrider
• 60 patients randomized/not blinded
• 30 coblation/30 microdebrider
• 3,6, 12 month follow-up
• Improvement at all time points in both
groups
– Nasal obstruction
– Postnasal drip
 Coblation vs. Microdebrider
• Symptoms of nasal obstruction and nasal
cavity better in microdebrider group at 12
months
• HOWEVER, only one coblation needle
pass, unknown contact duration anteriorly

Lee JY, Lee JD. Laryngoscope 116:729-734, 2006.

Radiofrequency vs. Submucous resection

• 75 patients
• 25 submucous resection/25 radiofrequency/
25 controls (medical management)
• Followed 1 week, 1 month, 3 months
• Both techniques equally effective in short-
term follow period
– Nasal obstructive symptoms, rhinomamometry
 Radiofrequency vs. submucous
resection: RF benefits
• Local anesthesia
• Preserves nasal epithelium
• No increased secretions or crusting
• No nasal packing
• Sooner return to work/activities; minimal pain;
in-office
– May outweigh increased cost of RF wand
Cavaliere M, Mottola G, Iemma M. Otolaryngol Head Neck Surg 133(6): 972-978,
2005.
 Radiofrequency vs. placebo
• 32 adult patients
• In-office/local anesthesia
• RF probe with or without energy delivery
• Results:
– Treatment group improved over placebo group at 8
wks/ 6mo follow-up
• Frequency/severity of nasal obstruction
• Ability to breathe through nose

Nease CJ, Krempl GA. Otolaryngol Head Neck Surg 2004; 130:291-299.
 Radiofrequency vs. Placebo
• RF group at 2 years follow-up
• Same improvement in symptoms
– Frequency/severity of nasal obstruction
– Ability to breathe through nose
• Statistically significant at 8 weeks and 2
years follow-up (p<0.05) compared with
pre-op with sustained benefit.
Porter MW, Hales NW, Nease CJ, Krempl GA. Laryngoscope 116:554-557, 2006.
 Pediatric Patient Selection
• Children with nasal obstruction alone
– History of allergic/non-allergic rhinitis with non-
response or non-compliance to medical therapy
• Children with turbinate hypertrophy secondary to
other problems
– Turbinate reduction in conjunction with other
procedures such as sinus surgery or T&A
• Pediatric OSA?
• Previous/concurrent adenoidectomy?
 Pediatric Patient Selection
• Typically treat children >6 years that have
failed trial of medical therapy

– Most children <3 years not yet truly diagnosed

with allergies

– Young children have other sources of airway

obstruction such as adenoid hypertrophy
 Pre- op Evaluation

• History/physical
• Nasal endoscopy
• Acoustic rhinometry
• Sinus CT Scan to rule out concomitant
anatomic abnormalities/sinus disease/polyps
• Prior medical management: poor
outcome/compliance
Pediatric Coblation Turbinate Reduction:
Surgical Technique
• 0-degree endoscope
• Turbinate injection with 1% lidocaine or
saline
– 2-3 cc per side
• Turbinate wand channeling
• Topical cottonoids with oxymetazoline
 Coblation Pediatric Turbinate
Reduction Technique
• Create two anterior lesions within the bulk
of the turbinate
– One superior, one inferior

• 10 seconds per lesion

• Coblation setting of 6
 Inferior Turbinate Channeling
• Before each insertion, apply saline gel
or other conductive media to ensure
formation of plasma field

• Activate controller foot pedal as

advance wand tip into the inferior
turbinate (power setting 4-6 coblate
based on user preference)
 Inferior turbinate channeling
• Stop insertion at appropriate visualization marker
and continue to hold coblation pedal for 10
seconds to create lesion
– First marker for anterior turbinate
– Last marker for posterior turbinate

• Withdraw inactivated wand to additional markers and

repeat ablation

• When last ablation complete, remove inactivated wand

• Repeat steps to create additional channels

 Post-op Evaluation
• Follow-up at 3-6 weeks, 6 months, 12 months

• Physical exam/symptom improvement/reduction

in medical therapy

• Acoustic rhinometry

• Allergy follow-up as needed

 Adult vs. Pediatric Techniques
• Similar settings (4-6 coblate)
• Similar duration of contact (10 seconds)

• Consider fewer passes/fewer contact points

in children
• No data on pediatric outcomes
Surgical Reduction of Inferior Turbinates with
Coblation in Children: Multi-center Trial

• Prospective/Controlled Study
(CHSD/MEEI/UCLA)

• Assess nasal obstructive symptom reduction

in children following Coblation turbinate
reduction (12 month follow-up)
 Pediatric turbinate reduction:
CHSD/MEEI/UCLA
• Pediatric turbinate reduction patients
• Selection criteria
– Allergic/Non-allergic rhinitis
– Prior medical therapy failure
– Nasal endoscopy/photos
– Acoustic rhinometry
– CT Scan
– Absence of adenotonsillar hypertrophy
• Surgical intervention
• Follow-up at 4 weeks, 6 months, 12 months
 Pediatric turbinate reduction:
CHSD/MEEI/UCLA
• Medical management
– Topical nasal steroids, oral antihistamines,
immunotherapy, environmental controls where possible
• Surgical intervention
– Coblation turbinate reduction (without concomitant
procedure)
• Follow-up examination, endoscopic photos,
questionnaire, acoustic rhinometry
 Pediatric turbinate reduction:
CHSD/MEEI/UCLA
• Clinical outcomes assessment
– Does coblation turbinate reduction improve
nasal obstruction in children with allergic and
non-allergic rhinitis?
– Does coblation turbinate reduction obviate need
for medical therapy?
– Are the benefits long-lasting?
 Coblation Turbinate Reduction
• Stand-alone procedure
– Normal tonsils/adenoids
– Poor response to medical therapy

• Combined procedure
– T&A with significant turbinate hypertrophy
– Endoscopic sinus surgery
 Coblation Use
• When is it indicated to combine T&A
or Adenoidectomy with turbinate
reduction?
– Allergic patients with ATH
– Severe turbinate hypertrophy with ATH
– Severe OSA
– One anesthetic– get it all done!
 Coblation Use
• Indications to perform separately
– Turbinates alone– non-invasive, minimal
recovery, small tonsils/adenoids
– Especially if surgeon does not coblate
tonsils/adenoids
• T&A, Adenoid alone– younger child,
small turbinates
 Otolaryngologist Objections

• Cost
–Minimal morbidity and long-
term benefits outweigh wand
cost
 Otolaryngologist Objections
• Reluctance to change technique
• Submucosal reduction
• Ease of performance
• Patient satisfaction
• Surgeon satisfaction
• Ancillary staff satisfaction
 Otolaryngologist Objections

• Reluctance to perform in children

–Safety/efficacy/minimize
medical therapy
–Just as OSD under-recognized,
Turbinate hypertrophy under-
recognized
 Conclusions
• Nasal obstruction due to turbinate
hypertrophy is common in adults and
children
• Coblation turbinate reduction is safe,
effective, and long-lasting in adults
• Clinical experience is promising in children
• Prospective data is forthcoming
 Studies
1. Pang YT, Willatt DJ. Laser reduction of inferior turbinates in children. Singapore Med
J 1995; 36(5):514-516.
2. Weider DJ, Sulzner SE. Inferior turbinate reduction surgery in children. Ear Nose
Throat J 1998; 77(4):304-2, 314.
3. Hol MK, Huizing EH. Treatment of inferior turbinate pathology: a review and critical
evaluation of the different techniques. Rhinology 2000; 38(4):157-166.
4. Coste A, Yona L, Blumen M et al. Radiofrequency is a safe and effective treatment of
turbinate hypertrophy. Laryngoscope 2001; 111(5):894-899.
5. Bäck LJ, Hytonen ML, Malmberg HO et al. Submucosal bipolar radiofrequency
thermal ablation of inferior turbinates: a long-term follow-up with subjective and
objective assessment. Laryngoscope 2002; 112(10):1806-1812.
6. Segal S, Eviatar E, Berenholz L et al. Inferior turbinectomy in children. Am J Rhinol
2003; 17(2):69-73.
7. Bhattacharyya N, Kepnes LJ. Clinical effectiveness of coblation inferior turbinate
reduction. Otolaryngol Head Neck Surg 2003; 129(4):365-371.
8. Chang CW, Ries WR. Surgical treatment of the inferior turbinate: new techniques.
Curr Opin Otolaryngol Head Neck Surg 2004; 12(1):53-57.
9. Rejali SD, Upile T, McLellan D et al. Inferior turbinate reduction in children using
Holmium YAG laser-a clinical and histological study. Lasers Surg Med 2004;
34(4):310-314.