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Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction
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Original Article
Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction Sharanjeet Singh a, Ramiza Ramza Ramli a, Zahiruddin Wan Mohammad b, Baharudin Abdullah a,∗ a Department
of Otorhinolaryngology-Head & Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia b Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
A R T I C L E
I N F O
Article history: Received 27 October 2019 Accepted 4 February 2020 Available online xxx Keywords: Inferior turbinate hypertrophy Microdebrider assisted turbinoplasty Coblation assisted turbinoplasty
∗
A B S T R A C T
Objective: Patients suffering from persistent inferior turbinates hypertrophy refractory to medical treatments require surgical intervention where the main aim is symptomatic relief without any complications. Extraturbinoplasty is one of the preferred procedures for turbinate reduction due to its efficacy in freeing up nasal space by removing the obstructing soft tissue and bone while preserving the turbinate mucosa. We sought to evaluate the effectiveness and safety of microdebrider assisted turbinoplasty (MAT) and coblation assisted turbinoplasty (CAT) performed as an extraturbinoplasty procedure. Methods: A prospective randomized comparative trial was conducted among patients with bilateral nasal blockage secondary to inferior turbinates hypertrophy. Patients were randomly assigned to MAT or CAT. An extraturbinal medial flap turbinoplasty was performed for both techniques. Symptom assessment was based on the visual analogue score for nasal obstruction, sneezing, rhinorrhea, headache and hyposmia. Turbinate size, edema and secretions were assessed by nasoendoscopic examination. The assessments were done preoperatively, at 1st postoperative week, 2nd and 3rd postoperative months. Postoperative morbidity like pain, bleeding, crusting and synechiae were documented. The clinical outcomes of both techniques were analyzed using repeated measures ANOVA. Results: A total of 33 participants were recruited, 17 patients randomized for MAT and 16 patients for CAT. Nasal obstruction, discharge, sneezing, headache and hyposmia significantly reduced from 1st week until 3 months for both procedures. Similar significant reductions were seen for turbinate size, edema and secretions. However, there was no significant difference in symptoms and turbinate size reduction were seen between both groups at the first postoperative week, 2nd and 3rd postoperative months. There was significant longer operating time for CAT when compared to MAT (p = 0.001). The postoperative complications of bleeding, crusting and synechiae did not occur in both groups. Conclusion: Both MAT and CAT were equally effective in improving nasal symptoms and achieving turbinate size reduction in patients with inferior turbinate hypertrophy. Both MAT and
Corresponding author. E-mail address: [email protected] (B. Abdullah).
https://doi.org/10.1016/j.anl.2020.02.003 0385-8146/© 2020 Oto-Rhino-Laryngological Society of Japan Inc. Published by Elsevier B.V. All rights reserved. Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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CAT offer maximal relieve in patients experiencing inferior turbinates hypertrophy by removing the hypertrophied soft tissue together with the turbinate bone without any complications. © 2020 Oto-Rhino-Laryngological Society of Japan Inc. Published by Elsevier B.V. All rights reserved.
1. Introduction Chronic nasal obstruction secondary to inferior turbinate hypertrophy is the one of the most common problems in patients seeking treatment at an outpatient clinic. Turbinate hypertrophy is observed in various conditions, including allergic rhinitis, vasomotor rhinitis, or chronic hypertrophic rhinitis. Medical treatments such as antihistamines, topical decongestants, or topical corticosteroids are used to relieve obstruction [1]. However, some patients are refractory to these medical treatments and complain of persistent symptoms. In these cases, surgical reduction of inferior turbinate needs to be performed. Various surgical techniques are currently being done to reduce the volume of the mucosal and bony tissues of the inferior turbinate. These include cryosurgery, electrocautery, total or partial turbinectomy, turbinoplasty, and submucosal turbinectomy [2,3]. These surgical methods provide relatively satisfactory results, but adverse effects are frequently observed postoperatively such as bleeding, crust formation, pain, foul odor, synechiae, or atrophy of the inferior turbinates [3,4]. Furthermore, when these procedures are performed using headlights, hypertrophy of the posterior end of the inferior turbinate remains and the patient may complain of nasal obstruction persistently in some cases. Aggressive turbinectomy surgery may give better long-term results but has higher risk of complications [5]. To resolve these problems, less destructive endoscopic procedures using laser or radiofrequency have been introduced allowing for more precise technique. In patients with chronically hypertrophied turbinate mucosa, radiofrequency is increasingly used to reduce the volume of turbinate mucosa, and satisfactory results with fewer side effects have been achieved [6,7]. Currently the ideal tool for turbinate surgery is still unsettled. The aim is for relief of nasal obstruction and avoiding adverse effects such as bleeding, crusting and excessive pain. The ideal surgical approach should address both the erectile submucosal tissue and the bony turbinate; the bony reduction allows more intranasal space whereas the induced-scarring on the submucosal tissues minimizes the submucosal engorgement at the inferior turbinates. In addition, the preservation of the mucosa maintains the physiological function of the turbinates [8]. The surgical technique for turbinoplasty using coblation and microdebrider has been described [9,10]. Turbinoplasty is designed to remove the non-functional obstructive part of the turbinate while preserving the functional medial mucosa which plays a main role in the warming and humidification of air through the nasal passages. It has the advantage over the other turbinate procedures by preserving mucosa to avoid complications, while removing adequate obstructed tissue to improve the airway significantly. The
technique is mainly the tunneling or intraturbinal method which only removes the submucosal erectile tissue, leaving behind the bulky inferior turbinate bone which is one of the contributing factors in causing nasal obstruction. Microdebrider has been widely used when an extraturbinal procedure is desired. The extraturbinal method is a modification of inferior turbinoplasty that combines conservative sparing of the nasal mucosa offered by submucous resection which removes the obstructing soft tissue, with the removal of part of the bulky inferior turbinate bone characteristic of partial turbinate resection [11]. Coblation which uses radiofrequency energy for resection has been relatively underused as an extraturbinal procedure. Thus, the comparison of postoperative results between the 2 methods of coblation-assisted turbinoplasty (CAT) and microdebrider-assisted turbinoplasty (MAT) in addressing inferior turbinate hypertrophy has not been reported adequately. The main purpose of this study was to compare the effectiveness and safety of both MAT and CAT techniques in the treatment of inferior turbinate hypertrophy. 2. Materials and methods 2.1. Study design and patients This was a prospective, randomized, comparative surgical trial conducted at the Department of Otorhinolaryngology Head and Neck Surgery, Hospital Universiti Sains Malaysia, Kubang Kerian, Malaysia between November 2017 and March 2019. Patients age more than 18 years and less than 45 years who attended the out-patient of otorhinolaryngology clinic in Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia with nasal block secondary to inferior turbinate hypertrophy refractory to medical treatment and planned for turbinoplasty surgery were recruited. Patients with deviated nasal septum, sinusitis, concha bullosa, collapse of alar cartilage, nasal polyps or tumors of nose or paranasal sinuses, previous history of nasal surgeries and pregnancy were excluded from the study. Written informed consent was obtained from the enrolled participants or from the guardians. The study protocol was approved by the Human Medical Research and Ethics Committee (USM/JEPEM/17040196) and was performed in adherence with the Declaration of Helsinki. Patients were randomized into either Group A (microdebrider) and Group B (coblation) by drawing lots (1:1 randomization using an envelope containing 50% (B) lots and 50% (B) lots) (Fig. 1). 2.2. Operative technique Turbinoplasty was performed using either Integrated Power Console (Medtronics, USA) with a Straightshot M4
Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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Fig. 1. Methodology flowchart.
microdebrider blade at 5000-rpm oscillating mode or Coblation II surgery system (Smith and Nephew, USA) with EVAC 70 wand set at ablation power seven. All surgical procedures were performed by a senior surgeon (BA). After the endotracheal tube intubation and general anesthesia administered, the patient was positioned and draped for endoscopic nasal surgery. Visualization throughout the procedure was obtained using a straight forward, 4-mm diameter 0° nasal endoscope (Karl Storz, Germany). Both inferior turbinates were injected with 2 to 3 ml of local anesthesia containing 1% lidocaine with 1:100,000 epinephrine. Injections were performed along the inferior and medial edges of the turbinate, blanching the turbinal mucosa. Ten minutes after the injection, the surgical procedure was performed. We performed endoscopic medial flap turbinoplasty (extraturbinal) as described by Barham et al. [11] for both procedures. In group A, patients underwent MAT. A window was created at the anterior inferior turbinate using the microdebrider blade. Using the microdebrider blade, the whole lateral aspect of the inferior turbinate mucosa and soft tissue removed in an anterior to posterior direction (Fig. 2). The turbinate bone was dissected off the soft tissue using a cottle dissector to
separate it from the medial mucosa of the inferior turbinate (medial flap) and a Blakesley forceps was used to remove it. The turbinate bone with its periosteum was removed along the vertex of the inferior meatus from the head to the posterior end. If there was any bleeding encountered, we used bipolar cautery for hemostasis. After the bone and lateral mucosa were removed the medial flap was placed in its final position curving inferolaterally to cover the remaining exposed area of the lateral inferior turbinate (Fig. 3). In group B, patients underwent CAT. A window was created at the anterior inferior turbinate using the coblation wand in ablation mode (power set at 7). Using the coblation wand, the whole lateral aspect of the inferior turbinate mucosa and soft tissue removed in an anterior to posterior direction (Fig. 4). The turbinate bone was dissected off the soft tissue using a cottle dissector to separate it from the medial mucosa of the inferior turbinate (medial flap) and a Blakesley forceps was used to remove it. The turbinate bone with its periosteum was removed along the vertex of the inferior meatus from the head to the posterior end. If there was any bleeding encountered, we used coblation wand in coagulation mode (power set at 3) for hemostasis. After the bone and lateral mucosa were removed the medial flap
Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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Fig. 2. Microdebrider blade is placed at the lateral part of the left turbinate to dissect the lateral mucosal wall and turbinate bone from anterior (A) to posterior (B) direction.
2.3. Patient assessment
Fig. 3. At the end of the microdebrider-assisted turbinoplasty, the medial flap is positioned inferolaterally to cover the exposed area of the lateral inferior turbinate.
Patients were assessed before the surgical procedure and during each postoperative visit. Symptom assessment was based on the VAS, with 0 representing no symptoms and 10 the most severe symptoms, to document nasal obstruction, sneezing, rhinorrhea, headache and hyposmia. Nasal endoscopic assessment of the inferior turbinate’s size was based on Camacho et al. [12] classification system which classifies inferior turbinate’s size as 4 grades based on its position in the total nasal airway space. When the inferior turbinate occupies 0%–25% of total airway space it is grade 1, grade 2 is 26%–50%, grade 3 is 51%–75% and grade 4 is 76%–100% (Fig. 6). Turbinate size, edema and secretions were assessed preoperatively and at the first postoperative week, second and third postoperative months by nasoendoscopic examination. Postoperative morbidity like pain, bleeding, crusting and synechiae were documented. 2.4. Statistical analysis
was placed in its final position curving inferolaterally to cover the remaining exposed area of the lateral inferior turbinate (Fig. 5). For both procedures, no nasal packing/dressing or antibiotic therapy was used after the operation. All subjects were evaluated 6 h after the procedure for the first time. The pain assessment was done by a visual analog scale (VAS) and additionally, the number of analgesics consumed was recorded. Cases of operative or postoperative nasal bleeding were evaluated for each surgical technique. Patients were discharged home 24 h after surgery as per our hospital protocol. The patients were assessed on follow-up at day 7, 2 months and 3 months. During the first follow up at day 7, nasoendoscopy and nasal toileting were performed to facilitate the healing process and was repeated during subsequent follow-up at second and third month.
The sample size required for the study was calculated based on the specific objective outcome variables. Power analysis identified at least 14 patients per group before adding 30% dropout rate to detect p value of < 0.05 with a Power of 0.8 at 0.05 significance level and mean difference set on 2.0. Statistical analysis was performed using the Statistical Program for Social Sciences (SPSS version 24). For normally distributed values, independent t-test was used, whereas for variables that are not normally distributed, the Mann–Whitney U test was utilized. Evaluation of the differences between the 2 methods over time was done by repeated measures Anova when it was normally distributed. Otherwise, Freidman analysis was used. A value of p < 0.05 was accepted as the significance level.
Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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Fig. 4. Coblation wand is placed at the lateral part of the left turbinate to dissect the lateral mucosal wall and turbinate bone from anterior (A) to posterior (B) direction.
both groups post-operatively (Table 1). Statistically significant improvement in the nasal obstruction started at 1st week and maintained at 3 months follow up. The other symptoms improvement had similar trend. Nasal discharge and sneezing symptoms significantly improved postoperatively with statistically significant decrease in headache scores compared to the preoperative values. Turbinate size, edema and secretions significantly improved in both groups with no crusting and synechiae observed throughout the visits (Table 2). There was no significant difference in both groups by symptoms and endoscopic evaluation. Consequently, both techniques were effective, but neither technique was superior to the other. 3.3. Intraoperative and postoperative complications
Fig. 5. At the end of the coblation-assisted turbinoplasty, the medial flap is positioned inferolaterally to cover the exposed area of the lateral inferior turbinate.
3. Results 3.1. Participant characteristics A total of 33 participants were recruited for this study with 17 patients in group A (MAT) and 16 in group B (CAT). The main presenting symptom was nasal obstruction in all patients, with mean VAS score between 7 and 10 which was severe and confirmed by nasoendoscopic grading of grade 3 to 4. Rhinorrhea and sneezing were present in 95% of patients with moderate severity ranges between 4 and 7, hyposmia in 15% and headache present in 21%. The mean age of the participants was 31.45 (SD 11.10). Predominantly, there were 96.3% male patients compared to female. 3.2. Efficacy All patients had symptomatic improvement with statistically significant decrease in all symptoms VAS score for
There was significant difference for duration of surgery between the 2 groups (Table 3), with CAT group consumed longer duration of surgery with mean time taken 20.67 min when compared to MAT mean time of 17.15 min (p = 0.001). There was no significant difference of intraoperative bleeding between MAT and CAT (P = 0.365) (Table 3) with no uncontrolled bleeding observed during or after the procedure and no nasal packing required for both techniques. VAS pain score 6 h post-operatively, was below 5 for both techniques that was considered as tolerable and on day 7, the average pain score was 2.65 for MAT and 2.19 for CAT that was considered as mild (Table 3). Besides the longer operative time in CAT, there was no difference in the intraoperative and postoperative bleeding and pain score between both groups. 4. Discussion Since it was first introduced, most surgeons prefer using powered instruments endoscopically to surgically reduce inferior turbinates hypertrophy [13]. The extent of resection includes bone, submucosa, and lateral or inferior mucosa in most studies [14]. However, surgeons prefer to resect both bone and soft tissue and tend to avoid extensive mucosal resection which favours the turbinoplasty procedure.
Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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Fig. 6. Nasoendoscopic grading system of inferior turbinate hypertrophy; grade 1 is 0%–25% of total airway space occupied (A), grade 2 is 26%–50% occupied (B), grade 3 is 51%–75% occupied (C) and grade 4 is 76%–100% occupied (D).
Furthermore, several studies demonstrated that turbinoplasty technique is a superior technique for the management of inferior turbinate hypertrophy, producing a lasting and adequate decrease in turbinate size with low morbidity [15–17]. Endoscopic MAT is one of the preferred surgical techniques in turbinoplasty [18–20]. When compared with older surgical treatment such as turbinectomy, endoscopic MAT has the advantages of being minimally invasive, allowing the preservation of physiological nasal mucosa, and relatively a painless procedure [4]. On the other hand, coblation is an instrument that uses radio frequency energy for soft tissue surgery in otolaryngologic procedures [21]. By using radio frequency in a bipolar mode with a conductive solution such as saline, coblation energizes the ions in the saline to form a small plasma field. The healing process induces fibrosis, with wound contraction leading to tissue volume reduction and the decreased thermal effect of coblation subsequently has led to less pain and faster recovery for cases where tissue is excised [10]. A study by Di Rienzo Businco et al. [22] on 220 patients that underwent CAT as an intraturbinal method reported similar improvement in both objective and subjective outcomes of nasal airway resistance and blockage. Objective outcomes were measured by basal rhinomanometry and nasal provocation test rhinomanometry while subjective assessment was performed using symptom VAS score. By preserving the nasal mucosa, none of their patients experienced any major side effects during or after the procedure such as bleeding,
synechia formation, and rhinitis sicca while post operatively inferior turbinate size showed apparent reduction in size. Similarly, our patients that underwent CAT as an extraturbinal method had similar improvements without any major adverse events. The median VAS score for nasal obstruction improved significantly in both CAT and MAT groups with concomitant marked reduction of the turbinate size at 3rd month postoperatively. However, there was no significant difference in relieving nasal obstruction and reducing the inferior turbinates size between both techniques. Our results demonstrated that both techniques have similar effects in improving nasal symptoms and reducing the size of turbinate hypertrophy. There was no significant bleeding noted postoperatively for both techniques and no nasal packing was required in all patients. Intraoperatively, both techniques have minimal blood loss with CAT documented slightly lower intraoperative bleeding compared to the MAT method. However, the difference was not statistically significance. Krouse et al. [23] reported a non-randomized non-blinded study of 250 patients who underwent MAT and compared them with 225 patients who had undergone traditional endoscopic surgery. They found that surgical bleeding was reduced by more than half in the MAT group attributed to its precise resection of tissues which minimizes inadvertent tissue trauma and stripping. In our study, we have shown CAT has similar advantage of precise resection as the cutting only occurs at the tip of its
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Table 1 Comparison of visual analogue scale between microdebrider and coblation-assisted turbinoplasty. p∗
Symptoms
No of patients having symptoms (%)
VAS score (Mean ± SD) MAT
CAT
Nasal obstruction Post-op 1st week 2nd month 3rd month p∗
30(95.3)
Rhinorrhea Post-op 1st week 2nd month 3rd month p∗
30(95.3)
Sneezing Post-op 1st week 2nd month 3rd month p∗
31(95.7)
Headache Post-op 1st week 2nd month 3rd month p∗
7(21.3)
HyposmiaPost-op 1st week 2nd month 3rd month p∗
15(45.4)
8.50 ± 1.03 4.13 ± 0.85 2.18 ± 1.13 1.59 ± 1.00 < 0.001 6.72 ± 2.14 1.53 ± 0.64 1.50 ± 0.63 1.38 ± 0.50 < 0.001 6.89 ± 2.20 1.33 ± 0.49 1.20 ± 0.41 1.27 ± 0.46 < 0.001 4.53 ± 1.74 1.50 ± 0.58 1.25 ± 0.50 0.75 ± 0.50 0.001 3.242 ± 3.13 0.57 ± 0.79 1.57 ± 0.53 1.00 ± 0.00 0.003
8.68 ± 1.05 4.81 ± 0.83 1.56 ± 1.03 1.94 ± 0.85 < 0.001 6.22 ± 2.03 1.60 ± 0.74 1.33 ± 0.49 1.27 ± 0.46 < 0.001 6.69 ± 2.10 1.47 ± 0.64 1.33 ± 0.49 1.33 ± 0.79 < 0.001 4.20 ± 1.53 1.33 ± 0.58 0.67 ± 0.58 0.83 ± 0.76 0.001 3.032 ± 3.22 0.63 ± 0.52 1.00 ± 0.00 0.88 ± 0.35 0.002
0.711 0.344 0.521 0.601 0.775 0.793 0.420 0.535 0.657 0.526 0.426 0.702 0.654 0.721 0.211 0.867 0.543 0.688 0.630 0.351
Abbreviations: MAT, microdebrider-assisted turbinoplasty; CAT, coblation-assisted turbinoplasty; VAS, visual analog scale; SD, standard deviation. ∗ p < 0.05 was considered significant.
Table 2 Comparison of nasal endoscopic findings between microdebrider and coblation-assisted turbinoplasty. Method Inferior turbinate size (using the nasoendoscopic MAT grading system by Camacho et al. [12]) CAT Edema MAT CAT Secretion MAT CAT
Preoperative 1st week 2nd month 3rd month p∗ postoperative postoperative postoperative 3.24 ± 0.66 3.31 ± 0.70 1.1 ± 0.3 1.0 ± 0.1 0.7 ± 0.2 0.6 ± 0.3
2.36 ± 0.55 2.56 ± 0.51 1.0 ± 0.1 1.1 ± 0.2 1.0 ± 0.2 1.1 ± 0.1
1.48 ± 0.68 1.30 ± 0.3 1.81 ± 0.75 1.44 ± 0.51 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
< 0.001 < 0.001 0.002 0.003 0.001 0.002
Abbreviations: MAT, microdebrider-assisted turbinoplasty; CAT, coblation-assisted turbinoplasty; VAS, visual analog scale. ∗ p < 0.05 was considered significant.
Table 3 Comparison of operative time, intraoperative bleeding and pain between microdebrider and coblation-assisted turbinoplasty. Variables Operative time (minutes) Intraoperative bleeding (ml) Pain assessment (VAS score) Six hours postoperative First week postoperative
Right Left Total
MAT Mean (SD)
CAT Mean (SD)
t-statistics
Mean difference (95% CI)
p∗
8.59(0.91) 8.54(0.78) 17.15(1.45) 49.41(10.8)
10.40(1.74) 10.17(1.67) 20.67(3.11) 45.63(12.6)
−3.75(22.31) −3.64(20.98) −4.20(20.96) 0.92(31)
−1.80 −1.63 −3.52 3.79
0.001 0.002 0.001 0.365
4.47(1.51) 2.65(1.27)
4.53(0.99) 2.19(1.42)
0.887 0.335
Abbreviations: MAT, microdebrider-assisted turbinoplasty; CAT, coblation-assisted turbinoplasty; VAS, visual analog scale; SD, standard deviation. ∗ p < 0.05 was considered significant. Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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wand and control of bleeding could be done simultaneously when coagulation mode is chosen. There was a statistically significant difference in the operative time between CAT and MAT. The average duration of surgery was longer in CAT when compared to MAT. The difference could be explained by the property of the two handpieces of MAT and CAT. Both microdebrider and coblation handpieces are provided with an integrated continuous suction channel to remove resected tissue after dissection. Microdebrider blade is cylindrically shaped and integrated with a suction irrigation channel for continuous suction. This allows resected tissue to be cleared away from the surgical field efficiently. In contrast, coblation is equipped with a cylindrical wand that has a smaller diameter continuous suction channel which frequently got obstructed by larger pieces of tissue contributing to delay in clearing of surgical field. Interestingly, there was no significant difference in the operative time between CAT and MAT in a study by Lee and Lee [24]. However, in their study the technique was a tunneling or intraturbinoplasty method where the inferior turbinate bone was not removed. Van delden et al. [25] reported that they achieved overall success rate of 93% using MAT, and although 17 patients had complications such as bleeding, crust formation, and synechia, they were temporary and there were no permanent complications. In our study, there was no postoperative synechiae and crusting seen in both CAT and MAT. We acknowledge that the small study cohort and the lack of objective evaluation of the symptomatic improvement may be regarded as shortcomings of this study. However, it has been shown that subjective VAS score evaluation corresponds well with acoustic rhinometry findings, which is an objective assessment tool to measure the nasal volumes and crosssectional areas in the nasal cavity [26]. Moreover, nasoendoscopic assessment is commonly used and acceptable as an objective assessment of severity and improvement of inferior turbinate hypertrophy [27]. Additionally, most surgeons decide on the medical treatment and surgical intervention based on the severity of symptoms and nasoendoscopic evaluation. 5. Conclusion Our results showed that both MAT and CAT were equally effective and safe in relieving nasal obstruction and enabling optimal volume reduction with preservation of function of the inferior turbinate. Both MAT and CAT remove the hypertrophied soft tissue together with part of the turbinate bone which gives maximal relieve in patients experiencing inferior turbinates hypertrophy without any post-operative complications. Declaration of Competing Interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study. References [1] Aslan G. Postnasal drip due to inferior turbinate perforation after radiofrequency turbinate surgery: a case report. Allergy Rhinol Provid 2013;4(1):e17–20. [2] Huizing EH, de Groot JAM. Surgery of the nasal cavity- turbinate surgery. Functional reconstructive nasal surgery. 2nd ed. Thieme: Stuttgart; 2003. p. 276–82. [3] Bergmark RW, Gray ST. Surgical management of turbinate hypertrophy. Otolaryngol Clin North Am 2018;51(5):919–28. [4] Friedman M, Tanyeri H, Lim J, Landsberg R, Caldarelli D. A safe, alternative technique for inferior turbinate reduction. Laryngoscope 1999;109(11):1834–7. [5] Sinno S. Assessing approaches to the inferior turbinate in rhinoplasty. Plast Reconstr Surg 2014;134(4S–1):133–4. [6] Vijay Kumar K, Kumar S, Garg S. A comparative study of radiofrequency assisted versus microdebrider assisted turbinoplasty in cases of inferior turbinate hypertrophy. Indian J Otolaryngol Head Neck Surg 2014;66(1):35–9. [7] Utley DS, Goode RL, Hakim I. Radiofrequency energy tissue ablation for the treatment of nasal obstruction secondary to turbinate hypertrophy. Laryngoscope 1999;109(5):683–6. [8] Passali D, Lauriello M, Anselmi M, Bellussi L. Treatment of hypertrophy of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy. Ann Otol Rhinol Laryngol 1999;108(6):569–75. [9] Cingi C, Sayın I, Civelek S. Use of microdebriders in common rhinologic disorders. Expert Rev Med Devices 2010;7(3):389–94. [10] Farmer SE, Quine SM, Eccles R. Efficacy of inferior turbinate coblation for treatment of nasal obstruction. J Laryngol Otol 2009;123(3):309–14. [11] Barham HP, Knisely A, Harvey RJ, Sacks R. How I do it: medial flap inferior turbinoplasty. Am J Rhinol Allergy 2015;29(4):314–15. [12] Camacho M, Zaghi S, Certal V, Abdullatif J, Means C, Acevedo J, et al. Inferior turbinate classification system, grades 1 to 4: development and validation study. Laryngoscope 2015;125(2):296–302. [13] Liu CM, Tan CD, Lee FP, Lin KN, Huang HM. Microdebrider-assisted versus radiofrequency assisted inferior turbinoplasty. Laryngoscope 2009;119(2):414–18. [14] Bielamowicz S, Hawrych A, Gupta A. Endoscopic inferior turbinate reduction: a new technique. Laryngoscope 1999;109(6):1007–9. [15] Puterman MM, Segal N, Joshua BZ. Endoscopic, assisted, modified turbinoplasty with mucosal flap. J Laryngol Otol 2012;126(5):525–8. [16] Marks S. Endoscopic inferior turbinoplasty. Am J Rhinol 1998;12(6):405–7. [17] Hamerschmidt R, Hamerschmidt R, Moreira AT, Tenório SB, Timi JR. Comparison of turbinoplasty surgery efficacy in patients with and without allergic rhinitis. Braz J Otorhinolaryngol 2016;82(2):131–9. [18] Romano A, Orabona GD, Salzano G, Abbate V, Iaconetta G, Califano L. Comparative study between partial inferior turbinotomy and microdebrider-assisted inferior turbinoplasty. J Craniofac Surg 2015;26(3):e235–8. [19] Huang TW, Cheng PW. Changes in nasal resistance and quality of life after endoscopic microdebrider-assisted inferior turbinoplasty in patients with perennial allergic rhinitis. Arch Otolaryngol Head Neck Surg 2006;132(9):990–3. [20] Chen YL, Tan CT, Huang HM. Long-term efficacy of microdebrider-assisted inferior turbinoplasty with lateralization for hypertrophic inferior turbinates in patients with perennial allergic rhinitis. Laryngoscope 2018;118(7):1270–4.
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S. Singh, R.R. Ramli and Z. Wan Mohammad et al. / Auris Nasus Larynx xxx (xxxx) xxx [21] Simeon R, Soufflet B, Souchal Delacour I. Coblation turbinate reduction in childhood allergic rhinitis. Eur Ann Otorhinolaryngol Head Neck Dis 2010;127(2):77–82. [22] Di Rienzo Businco L, Di Rienzo Businco A, Lauriello M. Comparative study on the effectiveness of coblation-assisted turbinoplasty in allergic rhinitis. Rhinology 2010;48(2):174–8. [23] Krouse HJ, Parker CM, Purcell R, Krouse JH, Christmas DA. Powered functional endoscopic sinus surgery. AORN J 1997;66(3):405–14. [24] Lee JY, Lee JD. Comparative study on the long-term effectiveness between coblation-and microdebrider-assisted partial turbinoplasty. Laryngoscope 2006;116(5):729–34.
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[25] Van delden MR, Cook PR, Davis WE. Endoscopic partial inferior turbinoplasty. Otolaryngol Head Neck Surg 1999;121(4):406–9. [26] Shah AN, Brewster D, Mitzen K, Mullin D. Radiofrequency coblation versus intramural bipolar cautery for the treatment of inferior turbinate hypertrophy. Ann Otol Rhinol Laryngol 2015;124(9):691–7. [27] Mehta N, Mehta S, Mehta N. Coblation-Assisted turbinoplasty: a comparative analysis of reflex ultra and turbinator wand. Ear Nose Throat J 2019;98(6):E51–7.
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Auris Nasus Larynx xxx (xxxx) xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Original Article
Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction Sharanjeet Singh a, Ramiza Ramza Ramli a, Zahiruddin Wan Mohammad b, Baharudin Abdullah a,∗ a Department
of Otorhinolaryngology-Head & Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia b Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
A R T I C L E
I N F O
Article history: Received 27 October 2019 Accepted 4 February 2020 Available online xxx Keywords: Inferior turbinate hypertrophy Microdebrider assisted turbinoplasty Coblation assisted turbinoplasty
∗
A B S T R A C T
Objective: Patients suffering from persistent inferior turbinates hypertrophy refractory to medical treatments require surgical intervention where the main aim is symptomatic relief without any complications. Extraturbinoplasty is one of the preferred procedures for turbinate reduction due to its efficacy in freeing up nasal space by removing the obstructing soft tissue and bone while preserving the turbinate mucosa. We sought to evaluate the effectiveness and safety of microdebrider assisted turbinoplasty (MAT) and coblation assisted turbinoplasty (CAT) performed as an extraturbinoplasty procedure. Methods: A prospective randomized comparative trial was conducted among patients with bilateral nasal blockage secondary to inferior turbinates hypertrophy. Patients were randomly assigned to MAT or CAT. An extraturbinal medial flap turbinoplasty was performed for both techniques. Symptom assessment was based on the visual analogue score for nasal obstruction, sneezing, rhinorrhea, headache and hyposmia. Turbinate size, edema and secretions were assessed by nasoendoscopic examination. The assessments were done preoperatively, at 1st postoperative week, 2nd and 3rd postoperative months. Postoperative morbidity like pain, bleeding, crusting and synechiae were documented. The clinical outcomes of both techniques were analyzed using repeated measures ANOVA. Results: A total of 33 participants were recruited, 17 patients randomized for MAT and 16 patients for CAT. Nasal obstruction, discharge, sneezing, headache and hyposmia significantly reduced from 1st week until 3 months for both procedures. Similar significant reductions were seen for turbinate size, edema and secretions. However, there was no significant difference in symptoms and turbinate size reduction were seen between both groups at the first postoperative week, 2nd and 3rd postoperative months. There was significant longer operating time for CAT when compared to MAT (p = 0.001). The postoperative complications of bleeding, crusting and synechiae did not occur in both groups. Conclusion: Both MAT and CAT were equally effective in improving nasal symptoms and achieving turbinate size reduction in patients with inferior turbinate hypertrophy. Both MAT and
Corresponding author. E-mail address: [email protected] (B. Abdullah).
https://doi.org/10.1016/j.anl.2020.02.003 0385-8146/© 2020 Oto-Rhino-Laryngological Society of Japan Inc. Published by Elsevier B.V. All rights reserved. Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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CAT offer maximal relieve in patients experiencing inferior turbinates hypertrophy by removing the hypertrophied soft tissue together with the turbinate bone without any complications. © 2020 Oto-Rhino-Laryngological Society of Japan Inc. Published by Elsevier B.V. All rights reserved.
1. Introduction Chronic nasal obstruction secondary to inferior turbinate hypertrophy is the one of the most common problems in patients seeking treatment at an outpatient clinic. Turbinate hypertrophy is observed in various conditions, including allergic rhinitis, vasomotor rhinitis, or chronic hypertrophic rhinitis. Medical treatments such as antihistamines, topical decongestants, or topical corticosteroids are used to relieve obstruction [1]. However, some patients are refractory to these medical treatments and complain of persistent symptoms. In these cases, surgical reduction of inferior turbinate needs to be performed. Various surgical techniques are currently being done to reduce the volume of the mucosal and bony tissues of the inferior turbinate. These include cryosurgery, electrocautery, total or partial turbinectomy, turbinoplasty, and submucosal turbinectomy [2,3]. These surgical methods provide relatively satisfactory results, but adverse effects are frequently observed postoperatively such as bleeding, crust formation, pain, foul odor, synechiae, or atrophy of the inferior turbinates [3,4]. Furthermore, when these procedures are performed using headlights, hypertrophy of the posterior end of the inferior turbinate remains and the patient may complain of nasal obstruction persistently in some cases. Aggressive turbinectomy surgery may give better long-term results but has higher risk of complications [5]. To resolve these problems, less destructive endoscopic procedures using laser or radiofrequency have been introduced allowing for more precise technique. In patients with chronically hypertrophied turbinate mucosa, radiofrequency is increasingly used to reduce the volume of turbinate mucosa, and satisfactory results with fewer side effects have been achieved [6,7]. Currently the ideal tool for turbinate surgery is still unsettled. The aim is for relief of nasal obstruction and avoiding adverse effects such as bleeding, crusting and excessive pain. The ideal surgical approach should address both the erectile submucosal tissue and the bony turbinate; the bony reduction allows more intranasal space whereas the induced-scarring on the submucosal tissues minimizes the submucosal engorgement at the inferior turbinates. In addition, the preservation of the mucosa maintains the physiological function of the turbinates [8]. The surgical technique for turbinoplasty using coblation and microdebrider has been described [9,10]. Turbinoplasty is designed to remove the non-functional obstructive part of the turbinate while preserving the functional medial mucosa which plays a main role in the warming and humidification of air through the nasal passages. It has the advantage over the other turbinate procedures by preserving mucosa to avoid complications, while removing adequate obstructed tissue to improve the airway significantly. The
technique is mainly the tunneling or intraturbinal method which only removes the submucosal erectile tissue, leaving behind the bulky inferior turbinate bone which is one of the contributing factors in causing nasal obstruction. Microdebrider has been widely used when an extraturbinal procedure is desired. The extraturbinal method is a modification of inferior turbinoplasty that combines conservative sparing of the nasal mucosa offered by submucous resection which removes the obstructing soft tissue, with the removal of part of the bulky inferior turbinate bone characteristic of partial turbinate resection [11]. Coblation which uses radiofrequency energy for resection has been relatively underused as an extraturbinal procedure. Thus, the comparison of postoperative results between the 2 methods of coblation-assisted turbinoplasty (CAT) and microdebrider-assisted turbinoplasty (MAT) in addressing inferior turbinate hypertrophy has not been reported adequately. The main purpose of this study was to compare the effectiveness and safety of both MAT and CAT techniques in the treatment of inferior turbinate hypertrophy. 2. Materials and methods 2.1. Study design and patients This was a prospective, randomized, comparative surgical trial conducted at the Department of Otorhinolaryngology Head and Neck Surgery, Hospital Universiti Sains Malaysia, Kubang Kerian, Malaysia between November 2017 and March 2019. Patients age more than 18 years and less than 45 years who attended the out-patient of otorhinolaryngology clinic in Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia with nasal block secondary to inferior turbinate hypertrophy refractory to medical treatment and planned for turbinoplasty surgery were recruited. Patients with deviated nasal septum, sinusitis, concha bullosa, collapse of alar cartilage, nasal polyps or tumors of nose or paranasal sinuses, previous history of nasal surgeries and pregnancy were excluded from the study. Written informed consent was obtained from the enrolled participants or from the guardians. The study protocol was approved by the Human Medical Research and Ethics Committee (USM/JEPEM/17040196) and was performed in adherence with the Declaration of Helsinki. Patients were randomized into either Group A (microdebrider) and Group B (coblation) by drawing lots (1:1 randomization using an envelope containing 50% (B) lots and 50% (B) lots) (Fig. 1). 2.2. Operative technique Turbinoplasty was performed using either Integrated Power Console (Medtronics, USA) with a Straightshot M4
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Fig. 1. Methodology flowchart.
microdebrider blade at 5000-rpm oscillating mode or Coblation II surgery system (Smith and Nephew, USA) with EVAC 70 wand set at ablation power seven. All surgical procedures were performed by a senior surgeon (BA). After the endotracheal tube intubation and general anesthesia administered, the patient was positioned and draped for endoscopic nasal surgery. Visualization throughout the procedure was obtained using a straight forward, 4-mm diameter 0° nasal endoscope (Karl Storz, Germany). Both inferior turbinates were injected with 2 to 3 ml of local anesthesia containing 1% lidocaine with 1:100,000 epinephrine. Injections were performed along the inferior and medial edges of the turbinate, blanching the turbinal mucosa. Ten minutes after the injection, the surgical procedure was performed. We performed endoscopic medial flap turbinoplasty (extraturbinal) as described by Barham et al. [11] for both procedures. In group A, patients underwent MAT. A window was created at the anterior inferior turbinate using the microdebrider blade. Using the microdebrider blade, the whole lateral aspect of the inferior turbinate mucosa and soft tissue removed in an anterior to posterior direction (Fig. 2). The turbinate bone was dissected off the soft tissue using a cottle dissector to
separate it from the medial mucosa of the inferior turbinate (medial flap) and a Blakesley forceps was used to remove it. The turbinate bone with its periosteum was removed along the vertex of the inferior meatus from the head to the posterior end. If there was any bleeding encountered, we used bipolar cautery for hemostasis. After the bone and lateral mucosa were removed the medial flap was placed in its final position curving inferolaterally to cover the remaining exposed area of the lateral inferior turbinate (Fig. 3). In group B, patients underwent CAT. A window was created at the anterior inferior turbinate using the coblation wand in ablation mode (power set at 7). Using the coblation wand, the whole lateral aspect of the inferior turbinate mucosa and soft tissue removed in an anterior to posterior direction (Fig. 4). The turbinate bone was dissected off the soft tissue using a cottle dissector to separate it from the medial mucosa of the inferior turbinate (medial flap) and a Blakesley forceps was used to remove it. The turbinate bone with its periosteum was removed along the vertex of the inferior meatus from the head to the posterior end. If there was any bleeding encountered, we used coblation wand in coagulation mode (power set at 3) for hemostasis. After the bone and lateral mucosa were removed the medial flap
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Fig. 2. Microdebrider blade is placed at the lateral part of the left turbinate to dissect the lateral mucosal wall and turbinate bone from anterior (A) to posterior (B) direction.
2.3. Patient assessment
Fig. 3. At the end of the microdebrider-assisted turbinoplasty, the medial flap is positioned inferolaterally to cover the exposed area of the lateral inferior turbinate.
Patients were assessed before the surgical procedure and during each postoperative visit. Symptom assessment was based on the VAS, with 0 representing no symptoms and 10 the most severe symptoms, to document nasal obstruction, sneezing, rhinorrhea, headache and hyposmia. Nasal endoscopic assessment of the inferior turbinate’s size was based on Camacho et al. [12] classification system which classifies inferior turbinate’s size as 4 grades based on its position in the total nasal airway space. When the inferior turbinate occupies 0%–25% of total airway space it is grade 1, grade 2 is 26%–50%, grade 3 is 51%–75% and grade 4 is 76%–100% (Fig. 6). Turbinate size, edema and secretions were assessed preoperatively and at the first postoperative week, second and third postoperative months by nasoendoscopic examination. Postoperative morbidity like pain, bleeding, crusting and synechiae were documented. 2.4. Statistical analysis
was placed in its final position curving inferolaterally to cover the remaining exposed area of the lateral inferior turbinate (Fig. 5). For both procedures, no nasal packing/dressing or antibiotic therapy was used after the operation. All subjects were evaluated 6 h after the procedure for the first time. The pain assessment was done by a visual analog scale (VAS) and additionally, the number of analgesics consumed was recorded. Cases of operative or postoperative nasal bleeding were evaluated for each surgical technique. Patients were discharged home 24 h after surgery as per our hospital protocol. The patients were assessed on follow-up at day 7, 2 months and 3 months. During the first follow up at day 7, nasoendoscopy and nasal toileting were performed to facilitate the healing process and was repeated during subsequent follow-up at second and third month.
The sample size required for the study was calculated based on the specific objective outcome variables. Power analysis identified at least 14 patients per group before adding 30% dropout rate to detect p value of < 0.05 with a Power of 0.8 at 0.05 significance level and mean difference set on 2.0. Statistical analysis was performed using the Statistical Program for Social Sciences (SPSS version 24). For normally distributed values, independent t-test was used, whereas for variables that are not normally distributed, the Mann–Whitney U test was utilized. Evaluation of the differences between the 2 methods over time was done by repeated measures Anova when it was normally distributed. Otherwise, Freidman analysis was used. A value of p < 0.05 was accepted as the significance level.
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Fig. 4. Coblation wand is placed at the lateral part of the left turbinate to dissect the lateral mucosal wall and turbinate bone from anterior (A) to posterior (B) direction.
both groups post-operatively (Table 1). Statistically significant improvement in the nasal obstruction started at 1st week and maintained at 3 months follow up. The other symptoms improvement had similar trend. Nasal discharge and sneezing symptoms significantly improved postoperatively with statistically significant decrease in headache scores compared to the preoperative values. Turbinate size, edema and secretions significantly improved in both groups with no crusting and synechiae observed throughout the visits (Table 2). There was no significant difference in both groups by symptoms and endoscopic evaluation. Consequently, both techniques were effective, but neither technique was superior to the other. 3.3. Intraoperative and postoperative complications
Fig. 5. At the end of the coblation-assisted turbinoplasty, the medial flap is positioned inferolaterally to cover the exposed area of the lateral inferior turbinate.
3. Results 3.1. Participant characteristics A total of 33 participants were recruited for this study with 17 patients in group A (MAT) and 16 in group B (CAT). The main presenting symptom was nasal obstruction in all patients, with mean VAS score between 7 and 10 which was severe and confirmed by nasoendoscopic grading of grade 3 to 4. Rhinorrhea and sneezing were present in 95% of patients with moderate severity ranges between 4 and 7, hyposmia in 15% and headache present in 21%. The mean age of the participants was 31.45 (SD 11.10). Predominantly, there were 96.3% male patients compared to female. 3.2. Efficacy All patients had symptomatic improvement with statistically significant decrease in all symptoms VAS score for
There was significant difference for duration of surgery between the 2 groups (Table 3), with CAT group consumed longer duration of surgery with mean time taken 20.67 min when compared to MAT mean time of 17.15 min (p = 0.001). There was no significant difference of intraoperative bleeding between MAT and CAT (P = 0.365) (Table 3) with no uncontrolled bleeding observed during or after the procedure and no nasal packing required for both techniques. VAS pain score 6 h post-operatively, was below 5 for both techniques that was considered as tolerable and on day 7, the average pain score was 2.65 for MAT and 2.19 for CAT that was considered as mild (Table 3). Besides the longer operative time in CAT, there was no difference in the intraoperative and postoperative bleeding and pain score between both groups. 4. Discussion Since it was first introduced, most surgeons prefer using powered instruments endoscopically to surgically reduce inferior turbinates hypertrophy [13]. The extent of resection includes bone, submucosa, and lateral or inferior mucosa in most studies [14]. However, surgeons prefer to resect both bone and soft tissue and tend to avoid extensive mucosal resection which favours the turbinoplasty procedure.
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Fig. 6. Nasoendoscopic grading system of inferior turbinate hypertrophy; grade 1 is 0%–25% of total airway space occupied (A), grade 2 is 26%–50% occupied (B), grade 3 is 51%–75% occupied (C) and grade 4 is 76%–100% occupied (D).
Furthermore, several studies demonstrated that turbinoplasty technique is a superior technique for the management of inferior turbinate hypertrophy, producing a lasting and adequate decrease in turbinate size with low morbidity [15–17]. Endoscopic MAT is one of the preferred surgical techniques in turbinoplasty [18–20]. When compared with older surgical treatment such as turbinectomy, endoscopic MAT has the advantages of being minimally invasive, allowing the preservation of physiological nasal mucosa, and relatively a painless procedure [4]. On the other hand, coblation is an instrument that uses radio frequency energy for soft tissue surgery in otolaryngologic procedures [21]. By using radio frequency in a bipolar mode with a conductive solution such as saline, coblation energizes the ions in the saline to form a small plasma field. The healing process induces fibrosis, with wound contraction leading to tissue volume reduction and the decreased thermal effect of coblation subsequently has led to less pain and faster recovery for cases where tissue is excised [10]. A study by Di Rienzo Businco et al. [22] on 220 patients that underwent CAT as an intraturbinal method reported similar improvement in both objective and subjective outcomes of nasal airway resistance and blockage. Objective outcomes were measured by basal rhinomanometry and nasal provocation test rhinomanometry while subjective assessment was performed using symptom VAS score. By preserving the nasal mucosa, none of their patients experienced any major side effects during or after the procedure such as bleeding,
synechia formation, and rhinitis sicca while post operatively inferior turbinate size showed apparent reduction in size. Similarly, our patients that underwent CAT as an extraturbinal method had similar improvements without any major adverse events. The median VAS score for nasal obstruction improved significantly in both CAT and MAT groups with concomitant marked reduction of the turbinate size at 3rd month postoperatively. However, there was no significant difference in relieving nasal obstruction and reducing the inferior turbinates size between both techniques. Our results demonstrated that both techniques have similar effects in improving nasal symptoms and reducing the size of turbinate hypertrophy. There was no significant bleeding noted postoperatively for both techniques and no nasal packing was required in all patients. Intraoperatively, both techniques have minimal blood loss with CAT documented slightly lower intraoperative bleeding compared to the MAT method. However, the difference was not statistically significance. Krouse et al. [23] reported a non-randomized non-blinded study of 250 patients who underwent MAT and compared them with 225 patients who had undergone traditional endoscopic surgery. They found that surgical bleeding was reduced by more than half in the MAT group attributed to its precise resection of tissues which minimizes inadvertent tissue trauma and stripping. In our study, we have shown CAT has similar advantage of precise resection as the cutting only occurs at the tip of its
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Table 1 Comparison of visual analogue scale between microdebrider and coblation-assisted turbinoplasty. p∗
Symptoms
No of patients having symptoms (%)
VAS score (Mean ± SD) MAT
CAT
Nasal obstruction Post-op 1st week 2nd month 3rd month p∗
30(95.3)
Rhinorrhea Post-op 1st week 2nd month 3rd month p∗
30(95.3)
Sneezing Post-op 1st week 2nd month 3rd month p∗
31(95.7)
Headache Post-op 1st week 2nd month 3rd month p∗
7(21.3)
HyposmiaPost-op 1st week 2nd month 3rd month p∗
15(45.4)
8.50 ± 1.03 4.13 ± 0.85 2.18 ± 1.13 1.59 ± 1.00 < 0.001 6.72 ± 2.14 1.53 ± 0.64 1.50 ± 0.63 1.38 ± 0.50 < 0.001 6.89 ± 2.20 1.33 ± 0.49 1.20 ± 0.41 1.27 ± 0.46 < 0.001 4.53 ± 1.74 1.50 ± 0.58 1.25 ± 0.50 0.75 ± 0.50 0.001 3.242 ± 3.13 0.57 ± 0.79 1.57 ± 0.53 1.00 ± 0.00 0.003
8.68 ± 1.05 4.81 ± 0.83 1.56 ± 1.03 1.94 ± 0.85 < 0.001 6.22 ± 2.03 1.60 ± 0.74 1.33 ± 0.49 1.27 ± 0.46 < 0.001 6.69 ± 2.10 1.47 ± 0.64 1.33 ± 0.49 1.33 ± 0.79 < 0.001 4.20 ± 1.53 1.33 ± 0.58 0.67 ± 0.58 0.83 ± 0.76 0.001 3.032 ± 3.22 0.63 ± 0.52 1.00 ± 0.00 0.88 ± 0.35 0.002
0.711 0.344 0.521 0.601 0.775 0.793 0.420 0.535 0.657 0.526 0.426 0.702 0.654 0.721 0.211 0.867 0.543 0.688 0.630 0.351
Abbreviations: MAT, microdebrider-assisted turbinoplasty; CAT, coblation-assisted turbinoplasty; VAS, visual analog scale; SD, standard deviation. ∗ p < 0.05 was considered significant.
Table 2 Comparison of nasal endoscopic findings between microdebrider and coblation-assisted turbinoplasty. Method Inferior turbinate size (using the nasoendoscopic MAT grading system by Camacho et al. [12]) CAT Edema MAT CAT Secretion MAT CAT
Preoperative 1st week 2nd month 3rd month p∗ postoperative postoperative postoperative 3.24 ± 0.66 3.31 ± 0.70 1.1 ± 0.3 1.0 ± 0.1 0.7 ± 0.2 0.6 ± 0.3
2.36 ± 0.55 2.56 ± 0.51 1.0 ± 0.1 1.1 ± 0.2 1.0 ± 0.2 1.1 ± 0.1
1.48 ± 0.68 1.30 ± 0.3 1.81 ± 0.75 1.44 ± 0.51 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
< 0.001 < 0.001 0.002 0.003 0.001 0.002
Abbreviations: MAT, microdebrider-assisted turbinoplasty; CAT, coblation-assisted turbinoplasty; VAS, visual analog scale. ∗ p < 0.05 was considered significant.
Table 3 Comparison of operative time, intraoperative bleeding and pain between microdebrider and coblation-assisted turbinoplasty. Variables Operative time (minutes) Intraoperative bleeding (ml) Pain assessment (VAS score) Six hours postoperative First week postoperative
Right Left Total
MAT Mean (SD)
CAT Mean (SD)
t-statistics
Mean difference (95% CI)
p∗
8.59(0.91) 8.54(0.78) 17.15(1.45) 49.41(10.8)
10.40(1.74) 10.17(1.67) 20.67(3.11) 45.63(12.6)
−3.75(22.31) −3.64(20.98) −4.20(20.96) 0.92(31)
−1.80 −1.63 −3.52 3.79
0.001 0.002 0.001 0.365
4.47(1.51) 2.65(1.27)
4.53(0.99) 2.19(1.42)
0.887 0.335
Abbreviations: MAT, microdebrider-assisted turbinoplasty; CAT, coblation-assisted turbinoplasty; VAS, visual analog scale; SD, standard deviation. ∗ p < 0.05 was considered significant. Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003
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wand and control of bleeding could be done simultaneously when coagulation mode is chosen. There was a statistically significant difference in the operative time between CAT and MAT. The average duration of surgery was longer in CAT when compared to MAT. The difference could be explained by the property of the two handpieces of MAT and CAT. Both microdebrider and coblation handpieces are provided with an integrated continuous suction channel to remove resected tissue after dissection. Microdebrider blade is cylindrically shaped and integrated with a suction irrigation channel for continuous suction. This allows resected tissue to be cleared away from the surgical field efficiently. In contrast, coblation is equipped with a cylindrical wand that has a smaller diameter continuous suction channel which frequently got obstructed by larger pieces of tissue contributing to delay in clearing of surgical field. Interestingly, there was no significant difference in the operative time between CAT and MAT in a study by Lee and Lee [24]. However, in their study the technique was a tunneling or intraturbinoplasty method where the inferior turbinate bone was not removed. Van delden et al. [25] reported that they achieved overall success rate of 93% using MAT, and although 17 patients had complications such as bleeding, crust formation, and synechia, they were temporary and there were no permanent complications. In our study, there was no postoperative synechiae and crusting seen in both CAT and MAT. We acknowledge that the small study cohort and the lack of objective evaluation of the symptomatic improvement may be regarded as shortcomings of this study. However, it has been shown that subjective VAS score evaluation corresponds well with acoustic rhinometry findings, which is an objective assessment tool to measure the nasal volumes and crosssectional areas in the nasal cavity [26]. Moreover, nasoendoscopic assessment is commonly used and acceptable as an objective assessment of severity and improvement of inferior turbinate hypertrophy [27]. Additionally, most surgeons decide on the medical treatment and surgical intervention based on the severity of symptoms and nasoendoscopic evaluation. 5. Conclusion Our results showed that both MAT and CAT were equally effective and safe in relieving nasal obstruction and enabling optimal volume reduction with preservation of function of the inferior turbinate. Both MAT and CAT remove the hypertrophied soft tissue together with part of the turbinate bone which gives maximal relieve in patients experiencing inferior turbinates hypertrophy without any post-operative complications. Declaration of Competing Interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the
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Please cite this article as: S. Singh, R.R. Ramli and Z. Wan Mohammad et al., Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction, Auris Nasus Larynx, https:// doi.org/ 10.1016/ j.anl.2020.02.003