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Effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life
Accepted Manuscript Effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life
Katharina Stölzel, Marie Bandelier, Agnieszka J. Szczepek, Heidi Olze, Steffen Dommerich PII: DOI: Reference:
S0196-0709(17)30517-3 doi: 10.1016/j.amjoto.2017.08.009 YAJOT 1899
To appear in: Received date: Revised date: Accepted date:
30 July 2017 ###REVISEDDATE### ###ACCEPTEDDATE###
Please cite this article as: Katharina Stölzel, Marie Bandelier, Agnieszka J. Szczepek, Heidi Olze, Steffen Dommerich , Effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life, (2017), doi: 10.1016/j.amjoto.2017.08.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life
Katharina Stölzel 1 , Marie Bandelier 1 , Agnieszka J. Szczepek 1 , Heidi Olze 1 , Steffen
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Dommerich 1
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Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin, Campus Charité
Corresponding author:
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1
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Mitte, Chariteplatz 1, 10117 Berlin, Germany
Katharina Stölzel, MD
Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin, Campus Charité
Tel.: +4930450655218
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Fax: +4930450555922
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Mitte, Charitéplatz 1, 10117 Berlin, Germany
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Email address: [email protected]
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Abstract Purpose: Chronic hyperplasia of the inferior nasal concha is accompanied by a nasal obstruction; however, there is no standardised surgical treatment for this condition. Here, we compared the outcome of three surgical techniques frequently used to treat the hyperplasia of inferior turbinates: turbinectomy with lateralization, submucosal electrocautery and laser
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cautery additional to septoplasty.
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Materials and Methods: One hundred and nine patients participated in this prospective
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randomized study upon signing written consent. The subjects were randomly assigned to one of three intervention groups: 1) submucosal turbinectomy with lateralization, 2) submucosal
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electrocautery or 3) laser cautery. All groups were followed-up for up to 6 months after surgical intervention. During the four follow-up appointments, the outcomes were measured
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with the modified German version of Sino- Nasal Outcome Test 20 questionnaire. In addition, the nasal breathing and the absolute nasal flow rates and respective mucosal component were
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determined by the anterior rhinomanometry.
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Results: Following surgery, the subjective and objective nasal obstruction decreased significantly in all three groups. Moreover, the subjective symptoms measured by modified
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Sino- Nasal Outcome Test 20 improved significantly, although there were some temporal differences between groups regarding subjective nasal obstruction, ear pressure, nasal
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discomfort, daytime fatigue, cough and dry mouth. The mucosal component of nasal congestion decreased significantly after surgery. Conclusions: All surgical techniques used to reduce the conchae mucosa led to a significant improvement in the objective and subjective nasal breathing and the quality of life. Septoplastic reduction proved to be of additional benefit.
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1. Introduction The hyperplasia of the inferior nasal turbinate is frequently accompanied by chronic nasal obstruction. The hyperplasia may be caused by an elevated number of blood vessels in
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the nasal mucosa and common venous sinusoids in the lamina propria of the inferior turbinates [1]. A study of Talaat et al. has demonstrated that the reduction in the number of
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blood vessels of inferior turbinates correlates with post-surgical clinical improvement [2]. The
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hyperplasia of inferior turbinates may be caused by chronic nasal infections [3], allergic and
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non-allergic rhinitis, chronic hypertrophic rhinitis and compensatory hypertrophic concha with septal deviation. The latter is caused by contact of nasal septum with turbinates, which
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induces swelling of inferior turbinate [4, 5].
Primary therapy of patients with hyperplastic inferior nasal turbinates includes treatment
with
nasal
sprays
containing
either
antihistamines,
α1-
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conservative
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sympathomimetic drugs or corticosteroids. However, the abuse of α1-sympathomimetic drugs frequently leads to tachyphylaxis, leaving the attending physician with no choice but surgical
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reduction of inferior nasal concha [6]. The alternative approach (acupuncture) has proved ineffective for the treatment of hyperplastic inferior nasal turbinate [7].
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Conflicting studies claiming therapeutic success for one but not the other surgical approach contributed to the present lack of consensus lines of treatment for hyperplastic inferior turbinates with and without septoplasty. Therefore, the first aim of our study was to compare the surgical outcome by using subjective and objective parameters measured in patients treated with one of the three most common surgical methods for turbinate reduction, namely the submucosal turbinectomy with lateralization, submucosal electrocautery or laser cautery. The second aim was to validate the benefit of consolidation of the two surgical procedures: septoplasty and the reduction of hypertrophic inferior nasal conchae. In order to
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better distinguish if the improvement of nasal breathing is due to septoplasty or due to the reduction of hypertrophic lower nasal conchae, we determined the mucosal component. In addition, anterior rhinomanometry was used to determine the difference in swelling of nasal mucosa before and after intervention. To assess the subjective nasal obstruction, we also included parameters such as pain or
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dryness of nose by using the modified questionnaire "Sino-Nasal outcome Test 20",
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developed to evaluate symptoms of chronic sinusitis [8].
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2. Methods
This randomized, three-arm, prospective study was approved by a local Ethics
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Committee (permit number EA1/188/13). One hundred and nine patients were initially enrolled. The inclusion criteria included age between 18 and 70 years, both genders and a
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positive diagnosis of inferior nasal concha enlargement. The exclusion criteria included
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chronic rhinosinusitis, nasal surgery prior to study, diabetes, nasal polyps, autoimmune diseases and coagulation disorders. All patients underwent surgical reduction of inferior nasal
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concha; the allocation to given surgical technique group was randomized. Complete evaluation over six months (four appointments) was possible for 75 subjects. In that group,
years).
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there were 23 women and 52 men. The subjects were on average 36 years old (range 18 to 81
All patients underwent surgical reduction of inferior nasal concha; the allocation to given surgical technique group was randomized: Group 1: lateralized submucosal turbinectomy, (19 patients) Group 2: electrocautery (26 patients)
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Group 3: laser cautery (30 patients)
The anterior rhinomanometry before and after the decongestion with measurement of the difference as a mucous membrane component was used as an objective measurement
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parameters [9]. Subjects in all three study groups received self-report questionnaires before and after
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the surgery. The questionnaire contained 18 items that were based on the German versions of
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the Sino- Nasal Outcome Test 20 [10]. The modification was done by excluding questions
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that solely regarded sinus symptoms (Tab. 1). Five answers weighted with points were offered to meet the statistical requirements of a Likert scale. A Likert scale contains several
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evaluative statements with which a patient can agree with or reject them. The method was developed for measuring personal attitudes. The unweighted values of the individual
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responses are added together to give the value of the scale. In the present study, following
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answers were used: "strongly disagree" (0 points), "disagree" (1 point), "neither agree nor disagree" (2 points), "agree" (3 points) and "strongly agree" (4 points).
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The statistical analyzes were performed with the IBM SPSS Statistics version 22 for Windows. For the statistical test procedures, a significance level of 0.05 (Alpha = 5%) was
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used. For nominal features, the chi-squared test was used and for metric features - the Kruskal-Wallis test.
The treatment groups were also examined for possible differences during the course of time. Since there had been an incomplete repeated measures design (not all patients attended all three post-surgical appointments), the two-factorial experimental design with a betweensubjects factor and a within-subjects factor using the GEE (Generalized Estimating Equations) methodology has been used.
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3. Results The comparative statistical analyzes were carried out with data obtained only from subjects who presented for follow-up, and included 75 patients assigned to one of the three
3.1 Changes in the objective nasal obstruction over time
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intervention groups.
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There were no significant differences in the inspiration values (without decongestant
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nasal spray) across the three groups prior to surgery, and at 150 Pa, the values were on average 388.511ml / s (SD = 38.925).
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Following surgery, we observed a significant improvement of overall inspiration without decongestant nasal spray in all three groups (p = 0.000) after one, three and six
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months. There were no significant differences between the groups. The mucous membrane component was determined based on the difference in total inspiration
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before and after administration of decongestant nasal spray. Also here there was a significant improvement 6 months after surgery in each group (Fig.1).
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3.2 Changes in the subjective complaints over time 3.2.1 Changes in the subjective nasal obstruction over time
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Seventy-six percent of patients reported a double-sided nasal obstruction prior to surgery. Half of the study participants’ complained about a permanent nasal obstruction, 31.3% of patients said to be particularly affected at night, and 17.9 % stated difficulties with breathing under special conditions such as physical exercises. Following surgery, nasal obstruction improved significantly in all three groups (p = 0.0001). Already during the first follow-up appointment, all patients reported decrease of nasal obstruction. Three months after surgery, the grade of remaining nasal obstruction differed significantly between the submucosal electrocautery group and the laser group (p =
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0.031), with the laser group having more reduced nasal obstruction. Six months after surgery, the differences between the groups were no longer significant. 3.2.2 Significant subjective changes without significant differences between surgery techniques
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The symptoms that have not differed between the groups are listed in Table 2. These symptoms include nightly waking up, problems falling asleep, sneezing, ear pain and reduced
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concentration. All of them decreased significantly after surgical intervention (p = 0.001). The
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retrograde flow of secretion did not change significantly over time.
3.2.3 Subjective changes with significant differences between surgical techniques
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The symptoms listed in Table 3 also decreased following surgical intervention. There
3.2.4 Changes in the ear pressure
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were; however, significant differences between the groups (Tab. 3).
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All patients reported a feeling of pressure in the ears prior to surgery. Three months after surgery, there were significant differences between the groups. Patients in the
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electrocautery group had significantly stronger feeling of pressure in the ears than the patients in submucosal turbinectomy group (p = 0.031). After 6 months, all patients reported
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disappearance of the ear pressure (Tab. 3). 3.2.5 Change in cough over time Prior to surgery, cough was not a serious complaint. One to two months after the surgery, there was a significant group difference between the submucosal turbinectomy group and laser cautery group (p = 0.001), where patients from the laser cautery group did not suffer from cough. During the follow-up appointments, patients from laser cautery group retained the smallest symptom severity (Tab. 3).
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3.2.6 Change in facial pain/ pressure over time In all three intervention groups, nasal discomfort was not reported prior to surgery. Six months after the surgery, significant group differences were observed between the submucosal turbinectomy group and electrocautery group (p = 0.024) and the electrocautery
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group and laser cautery group (p = 0.011). Patients in the electrocautery group were affected by nasal discomfort to the greatest degree (Tab.3).
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3.2.7 Change of daytime sleepiness over time
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All patients reported fairly intense daytime sleepiness upon recruitment. After the
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surgery, the mean value decreased in all groups meaning that the daytime sleepiness occurred less frequently. One to two months after the surgery, the daytime sleepiness was still reported
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by the submucosal turbinectomy group still but in the other two intervention groups it was barely a complaint. After half a year, significant differences between submucosal
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turbinectomy group and electrocautery group (p = 0.041) and the submucosal turbinectomy
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group and laser cautery group (p = 0.034) were noted again. Patients from electrocautery group and laser cautery group stated that the daytime sleepiness was no longer a problem. On
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average, the surgical intervention minimized the daytime sleepiness in all groups (Tab. 3).
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3.2.8 Changes in frustration, restlessness and irritation Majority of patients reported being frustrated, restless and irritated prior to surgery. During the second follow-up visit, a significant difference between electrocautery group and laser cautery group was observed (p = 0.05) with the patients in the latter group reporting less distress. After six months, there were no differences between the groups and in all patients frustration, restlessness and irritation were reduced (Tab. 3).
Discussion
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In the year 2014, the turbinate reduction was ranked 24th of the 50 most common surgeries performed in Germany and reached total of 151,225 cases [11]. Surgical techniques used to reduce the soft tissue of turbinates’ are currently in review due to a lack of sustained improvement of nasal obstruction and because of possible necrosis of mucosa, crusting and bleeding [12, 13]. Nevertheless, these techniques are widely used because of positive long-
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term effects and hardly any complications [14, 15].
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The two goals of our study were to compare the objective and subjective outcomes
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between three surgical techniques used to treat hyperplasia of inferior turbinates and to determine their advantage in combination with septoplasty. For the comparison, we measured
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objective and subjective parameters in the patients treated.
According to Hofer et al, the mucosa-preserving reduction through the anterior
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turbinectomy should be the method of choice, since post-surgical symptoms such as dry nose can be avoided [12]. Salzano et al has also suggested partial inferior nasal turbinectomy to be
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the best method, when compared to radiofrequency ablation, high-frequency ablation and
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electrocautery. Unfortunately, the authors followed up their patients only for two months [16]. In our study, we were not able to reproduce the above observation. Possible reason for this
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discrepancy could be the difference in a follow-up times (two months in the Salzano study and three and six months in our study).
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Using all three surgical techniques: electrocautery, submucosal turbinectomy and laser cautery, we have observed sustainable improvement in the nasal breathing and a low complication rate, confirming earlier results of Kizilkaya et al. and Prokopaki et al.[17, 18]. Kizilkaya et al. compared radiofrequency ablation with a submucosal reduction by the microbrider, as both being purely soft tissue-reducing methods (n = 30). Subjective (visual analog scale) and objective (acoustic rhinomanometry) measures have not detected the differences between the groups 6 months after surgery. Prokopakis et al. included 2983 patients to compare three different types of the inferior turbinates surgery (electrocautery,
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radiofrequency or CO2 Laser) and have demonstrated sustained significant improvement in the nasal breathing for up to one year [18]. This also suggests that the purely soft-tissuereducing methods of turbinectomy are equally effective. In a prospective randomized long-term study including 382 patients, Passalli et al. compared the submucosal resection with and without lateralization, turbinectomy,
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submucosal electrocautery, laser cautery and cryotherapy. The study was conducted over a
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period of 6 years, with approximately 63 participants per group. The best long-term outcome
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of the surgical procedure, as measured with acoustic and anterior rhinomanometry, mucociliary transport and the secretion of IgA, were obtained by using submucosal resection
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with lateralization [19]. In another study, Gindroz et al. have studied 60 patients with nasal obstruction of non-allergic origin. The ultrasound technology and the submucosal
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electrocautery or the ultrasound technology and radiofrequency therapy side were applied separately. After six months, the best outcomes (indicated by anterior rhinomanometry,
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acoustic rhinomanometry and by visual analog scale measuring nasal obstruction) were
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determined in a group of patients treated with the ultrasound technique, followed by radiofrequency ablation. However, the results obtained in a group of patients treated with
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unilateral electrocautery did not differ significantly [20]. In our study, in order to measure the rate of improvement, we determined the mucosal
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component, which is a novel outcome measure in the surgery of hypertrophic lower nasal conchae. The differences before and after swelling demonstrated significant decrease of the hypertrophy of the nasal mucosal membranes after the intervention. Our findings corroborate the results of Devresen et al., Grymer et al. and Hilberg et al. [21-23]. We have not observed mucosal hypertrophy of the septum. Yu et al. showed that three months after the reduction of hypertrophic lower nasal conchae with the Microdebrider with and without reduction of the septum (n = 26 and 25, respectively), a significant improvement was noted in patients who underwent a reduction of septum [24].
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It is generally accepted that the surgical reduction of hypertrophic lower nasal conchae accompanied by nasal breathing problems is performed together with the septoplasty [22, 25, 26]. Scientific data regarding the improvement of nasal breathing by septoplasty with and without additional reduction of the hypertrophic lower nasal conchae are scarce. The first study that included 80 patients using acoustic rhinomanometry revealed that the nasal
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breathing improved after an additional reduction of the hypertrophic lower nasal conchae
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[22]. After 5 years follow-up, no statistical differences were found between the two groups
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with and without additional reduction of the hypertrophic inferior nasal conchae neither by using questionnaires (n = 50) nor by acoustic rhinomanometry (n = 37) [25]. Also Nunez et al.
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have not found differences between the groups by means of anterior rhinomanometry or questionnaire (n = 26 patients); however, the data were collected eight weeks after
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intervention [27]. Opposite results were delivered by Devseren et al. who demonstrated a significant improvement six months after the surgery in a group of patients who underwent an
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additional reduction of the hypertrophic inferior nasal conchae. In that study, to measure the
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outcomes, the authors used anterior and acoustic rhinomanometry and questionnaires [21]. The questionnaires measuring various aspects of health, well-being as well as the
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health-related quality of life have become a popular outcome measurement in the field of otorhinolaryngology. We used such questionnaire to measure the subjective parameters and
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found that patients had the least subjective complaints when the laser cautery was used. The laser cautery is certainly the least invasive; however, the sustainability of its results has often been put in question [28]. During the six months of follow-up period, we determined remission among the patients treated with laser cautery and the strongest positive effect indicated by subjective nasal obstruction was found after 3 months after surgery. All patients reported continuous improvement in the subjective complaints after surgery. The group of patients who underwent electrocautery, predominantly complained about the facial pain and pressure, whereas the group which underwent the submucosal
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resection complained significantly more about the daytime sleepiness than the other two groups.
Conclusions
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Nasal mucosa-reducing techniques used for the inferior turbinate surgery lead to
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significant improvement of objective and subjective outcome measures. The technique of
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laser cautery induces the least post-surgical discomfort. However, none of the methods studied was significantly superior to the others. In addition, we find that septoplasty
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significantly contributes to the additional reduction of hypertrophic inferior turbinates.
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References
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1 Farmer SE, Eccles R. Chronic inferior turbinate enlargement and the implications for surgical intervention. Rhinology 2006;44(4):234-8. 2 Talaat M, el-Sabawy E, Baky FA, Raheem AA. Submucous diathermy of the inferior turbinates in chronic hypertrophic rhinitis. The Journal of laryngology and otology 1987;101(5):452-60. 3 Berger G, Gass S, Ophir D. The histopathology of the hypertrophic inferior turbinate. In. Arch Otolaryngol Head Neck Surg. United States; 2006:588-94. 4 Larrabee YC, Kacker A. Which inferior turbinate reduction technique best decreases nasal obstruction? Laryngoscope 2014;124(4):814-5. 5 Baumann I, Baumann H. A new classification of septal deviations. Rhinology 2007;45(3):2203. 6 Graf P, Juto JE. Sustained use of xylometazoline nasal spray shortens the decongestive response and induces rebound swelling. Rhinology 1995;33(1):14-7. 7 Albrecht T, Wu S, Baumann I, Plinkert PK, Sertel S. Measurable impact of acupuncture on mucosal swelling of inferior turbinates: a prospective, randomized, controlled study. Acta otolaryngologica 2015;135(2):169-76. 8 Andrews P, Poirrier AL, Lund VJ, Choi D. Outcomes in Endoscopic Sinus Surgery : Olfaction, NOSE scale and Quality of Life in a Prospective Cohort Study. Clin Otolaryngol 2016. 9 Uecker FC. HNO in Frage und Antwort. München: Der Urban & Fischer Verlag (Imprint der Elsevier GmbH); 2014. 10 Baumann I, Blumenstock G, DeMaddalena H, Piccirillo JF, Plinkert PK. [Quality of life in patients with chronic rhinosinusitis: validation of the Sino-Nasal Outcome Test-20 German Adapted Version]. HNO 2007;55(1):42-7. 11 DRG related hospital statistics (DRG statistics), diagnoses and procedures of inpatient patients in hospitals, Federal Statistical Office, Federal Health Monitoring System, 11/23/2015). 2015. 12 Hofer M, Dacho A, Dietz A. [Surgery of the nose and paranasal sinuses]. Laryngorhinootologie 2016;95(1):51-65; quiz 6-7. 13 Mlynski G. [Impaired function of the upper respiratory tract. Restorative procedures for upper airway dysfunction, nasal breathing]. Laryngorhinootologie 2005;84 Suppl 1:S101-17. 14 Egeli E, Demirci L, Yazycy B, Harputluoglu U. Evaluation of the inferior turbinate in patients with deviated nasal septum by using computed tomography. Laryngoscope 2004;114(1):113-7. 15 Rohrich RJ, Krueger JK, Adams WP, Jr., Marple BF. Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution. Plast Reconstr Surg 2001;108(2):53644; discussion 45-6. 16 Salzano FA, Mora R, Dellepiane M, et al. Radiofrequency, high-frequency, and electrocautery treatments vs partial inferior turbinotomy: microscopic and macroscopic effects on nasal mucosa. Archives of otolaryngology--head & neck surgery 2009;135(8):752-8. 17 Kizilkaya Z, Ceylan K, Emir H, et al. Comparison of radiofrequency tissue volume reduction and submucosal resection with microdebrider in inferior turbinate hypertrophy. Otolaryngology-head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2008;138(2):176-81. 18 Prokopakis EP, Koudounarakis EI, Velegrakis GA. Efficacy of inferior turbinoplasty with the use of CO(2) laser, radiofrequency, and electrocautery. American journal of rhinology & allergy 2014;28(3):269-72. 19 Passali D, Passali FM, Damiani V, Passali GC, Bellussi L. Treatment of inferior turbinate hypertrophy: a randomized clinical trial. Ann Otol Rhinol Laryngol 2003;112(8):683-8. 20 Gindros G, Kantas I, Balatsouras DG, Kaidoglou A, Kandiloros D. Comparison of ultrasound turbinate reduction, radiofrequency tissue ablation and submucosal cauterization in inferior turbinate hypertrophy. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies 2010;267(11):1727-33.
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21 Devseren NO, Ecevit MC, Erdag TK, Ceryan K. A randomized clinical study: outcome of submucous resection of compensatory inferior turbinate during septoplasty. Rhinology 2011;49(1):53-7. 22 Grymer LF, Illum P, Hilberg O. Septoplasty and compensatory inferior turbinate hypertrophy: a randomized study evaluated by acoustic rhinometry. The Journal of laryngology and otology 1993;107(5):413-7. 23 Hilberg O, Grymer LF, Pedersen OF, Elbrond O. Turbinate hypertrophy. Evaluation of the nasal cavity by acoustic rhinometry. Archives of otolaryngology--head & neck surgery 1990;116(3):283-9. 24 Yu MS, Kim JY, Kim BH, Kang SH, Lim DJ. Feasibility of septal body volume reduction for patients with nasal obstruction. Laryngoscope 2015;125(7):1523-8. 25 Illum P. Septoplasty and compensatory inferior turbinate hypertrophy: long-term results after randomized turbinoplasty. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies 1997;254 Suppl 1:S89-92. 26 Balcerzak J, Lukawska I, Grzanka A, Niemczyk K. [Comparative analysis of the treatment results of the nasal obstruction using septoplasty and septokonchoplasty]. Otolaryngol Pol 2014;68(3):129-34. 27 Nunez DA, Bradley PJ. A randomised clinical trial of turbinectomy for compensatory turbinate hypertrophy in patients with anterior septal deviations. Clin. Otolaryngol. Allied Sci. 2000;25(6):4958. 28 Sapci T, Sahin B, Karavus A, Akbulut UG. Comparison of the effects of radiofrequency tissue ablation, CO2 laser ablation, and partial turbinectomy applications on nasal mucociliary functions. Laryngoscope 2003;113(3):514-9.
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Figure 1
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Figure Legend
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Mean mucous membrane component as difference of total inspiration in ml/s at 150 Pa before and after decongestion with a topical nasal decongestant xylometazoline over the time.
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Table 1 Questionnaire based on the German versions of the Sino-Nasal Outcome Test 20 German Adapted Version (SNOT-20 GAV)
10. Dizziness
2. Sneezing
11. Facial pain, pressure in the face
3. Runny nose
12. Problems falling asleep
4. Postnasal discharge
13. Nightly waking up
5. Thick nasal discharge
14 Daytime sleepiness
6. Cough
15. Reduced performance
7. Ear fullness
16. Concentration weakness
8. Ear pain
17. Frustration / Restlessness / Irritability
9. Smell reduction
18. Sadness
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1. Need to blow out
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Significant changes in the overall averages of the item scores (p = 0.001) measured by
the modified questionnaire Sino-Nasal Outcome Test 20 German Adapted Version (SNOT-20 GAV) Likert Scale 1 - 5 Before
One month
Three months
Six months
Surgery
after Surgery
after Surgery
after Surgery
1,74
0,60
0,89
0,66
Nightly waking up
1,99
0,60
0,89
0,88
Sneezing
1,62
0,80
0,92
0,92
Postnasal discharge
1,62
0,80
Ear pain
0,55
0,34
Reduced
1,53
1,08
Problems falling
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Item
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Concentration
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asleep
0,92
0,92
0,22
0,27
0,78
0,82
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Subjective changes over time with significant differences between surgical techniques
(marked are significant differences p= 0.05); based on questionnaire Sino-Nasal Outcome Test 20
Item
Ear pressure
Surgery
Before
One month
Three months
Six months
technique
surgery
after Surgery
after surgery
after Surgery
0,63
0,79
0,17
0,58
Electrocautery
1,00
0,62
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German Adapted Version (SNOT-20 GAV), Likert scale 1-5
0,82
Lasercautery
1,00
0,36
Submucosal
1,21
1,16
Submucosal
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Cough
0,31 1,10
0,90
0,69
0,76
0,78
0,38
0,47
0,52
1,58
Lasercautery
1,13
Facial pain/
Submucosal
0,93
0,53
0,13
0,16
pressure
turbinectomy
1,11
0,62
0,51
0,64
0,83
0,25
0,46
0,23
2,79
2,05
1,81
1,84
Electrocautery
2,15
1,31
1,20
1,08
Lasercautery
2,37
1,40
1,44
1.12
1,42
1,05
0,83
0,63
Electrocautery
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Lasercautery Submucosal
sleepiness
turbinectomy
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Daytime
Frustration,
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Electrocautery
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turbinectomy
0,66
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turbinectomy
Submucosal
restlessness and
turbinectomy
irritation
Electrocautery
1,85
0,99
0,74
0,53
Lasercautery
1,37
0,55
0,44
0,71
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Fig. 1
Katharina Stölzel, Marie Bandelier, Agnieszka J. Szczepek, Heidi Olze, Steffen Dommerich PII: DOI: Reference:
S0196-0709(17)30517-3 doi: 10.1016/j.amjoto.2017.08.009 YAJOT 1899
To appear in: Received date: Revised date: Accepted date:
30 July 2017 ###REVISEDDATE### ###ACCEPTEDDATE###
Please cite this article as: Katharina Stölzel, Marie Bandelier, Agnieszka J. Szczepek, Heidi Olze, Steffen Dommerich , Effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life, (2017), doi: 10.1016/j.amjoto.2017.08.009
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ACCEPTED MANUSCRIPT 1
Effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life
Katharina Stölzel 1 , Marie Bandelier 1 , Agnieszka J. Szczepek 1 , Heidi Olze 1 , Steffen
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Dommerich 1
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Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin, Campus Charité
Corresponding author:
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Mitte, Chariteplatz 1, 10117 Berlin, Germany
Katharina Stölzel, MD
Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin, Campus Charité
Tel.: +4930450655218
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Fax: +4930450555922
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Mitte, Charitéplatz 1, 10117 Berlin, Germany
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Email address: [email protected]
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Abstract Purpose: Chronic hyperplasia of the inferior nasal concha is accompanied by a nasal obstruction; however, there is no standardised surgical treatment for this condition. Here, we compared the outcome of three surgical techniques frequently used to treat the hyperplasia of inferior turbinates: turbinectomy with lateralization, submucosal electrocautery and laser
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cautery additional to septoplasty.
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Materials and Methods: One hundred and nine patients participated in this prospective
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randomized study upon signing written consent. The subjects were randomly assigned to one of three intervention groups: 1) submucosal turbinectomy with lateralization, 2) submucosal
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electrocautery or 3) laser cautery. All groups were followed-up for up to 6 months after surgical intervention. During the four follow-up appointments, the outcomes were measured
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with the modified German version of Sino- Nasal Outcome Test 20 questionnaire. In addition, the nasal breathing and the absolute nasal flow rates and respective mucosal component were
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determined by the anterior rhinomanometry.
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Results: Following surgery, the subjective and objective nasal obstruction decreased significantly in all three groups. Moreover, the subjective symptoms measured by modified
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Sino- Nasal Outcome Test 20 improved significantly, although there were some temporal differences between groups regarding subjective nasal obstruction, ear pressure, nasal
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discomfort, daytime fatigue, cough and dry mouth. The mucosal component of nasal congestion decreased significantly after surgery. Conclusions: All surgical techniques used to reduce the conchae mucosa led to a significant improvement in the objective and subjective nasal breathing and the quality of life. Septoplastic reduction proved to be of additional benefit.
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1. Introduction The hyperplasia of the inferior nasal turbinate is frequently accompanied by chronic nasal obstruction. The hyperplasia may be caused by an elevated number of blood vessels in
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the nasal mucosa and common venous sinusoids in the lamina propria of the inferior turbinates [1]. A study of Talaat et al. has demonstrated that the reduction in the number of
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blood vessels of inferior turbinates correlates with post-surgical clinical improvement [2]. The
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hyperplasia of inferior turbinates may be caused by chronic nasal infections [3], allergic and
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non-allergic rhinitis, chronic hypertrophic rhinitis and compensatory hypertrophic concha with septal deviation. The latter is caused by contact of nasal septum with turbinates, which
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induces swelling of inferior turbinate [4, 5].
Primary therapy of patients with hyperplastic inferior nasal turbinates includes treatment
with
nasal
sprays
containing
either
antihistamines,
α1-
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conservative
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sympathomimetic drugs or corticosteroids. However, the abuse of α1-sympathomimetic drugs frequently leads to tachyphylaxis, leaving the attending physician with no choice but surgical
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reduction of inferior nasal concha [6]. The alternative approach (acupuncture) has proved ineffective for the treatment of hyperplastic inferior nasal turbinate [7].
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Conflicting studies claiming therapeutic success for one but not the other surgical approach contributed to the present lack of consensus lines of treatment for hyperplastic inferior turbinates with and without septoplasty. Therefore, the first aim of our study was to compare the surgical outcome by using subjective and objective parameters measured in patients treated with one of the three most common surgical methods for turbinate reduction, namely the submucosal turbinectomy with lateralization, submucosal electrocautery or laser cautery. The second aim was to validate the benefit of consolidation of the two surgical procedures: septoplasty and the reduction of hypertrophic inferior nasal conchae. In order to
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better distinguish if the improvement of nasal breathing is due to septoplasty or due to the reduction of hypertrophic lower nasal conchae, we determined the mucosal component. In addition, anterior rhinomanometry was used to determine the difference in swelling of nasal mucosa before and after intervention. To assess the subjective nasal obstruction, we also included parameters such as pain or
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dryness of nose by using the modified questionnaire "Sino-Nasal outcome Test 20",
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developed to evaluate symptoms of chronic sinusitis [8].
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2. Methods
This randomized, three-arm, prospective study was approved by a local Ethics
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Committee (permit number EA1/188/13). One hundred and nine patients were initially enrolled. The inclusion criteria included age between 18 and 70 years, both genders and a
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positive diagnosis of inferior nasal concha enlargement. The exclusion criteria included
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chronic rhinosinusitis, nasal surgery prior to study, diabetes, nasal polyps, autoimmune diseases and coagulation disorders. All patients underwent surgical reduction of inferior nasal
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concha; the allocation to given surgical technique group was randomized. Complete evaluation over six months (four appointments) was possible for 75 subjects. In that group,
years).
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there were 23 women and 52 men. The subjects were on average 36 years old (range 18 to 81
All patients underwent surgical reduction of inferior nasal concha; the allocation to given surgical technique group was randomized: Group 1: lateralized submucosal turbinectomy, (19 patients) Group 2: electrocautery (26 patients)
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Group 3: laser cautery (30 patients)
The anterior rhinomanometry before and after the decongestion with measurement of the difference as a mucous membrane component was used as an objective measurement
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parameters [9]. Subjects in all three study groups received self-report questionnaires before and after
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the surgery. The questionnaire contained 18 items that were based on the German versions of
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the Sino- Nasal Outcome Test 20 [10]. The modification was done by excluding questions
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that solely regarded sinus symptoms (Tab. 1). Five answers weighted with points were offered to meet the statistical requirements of a Likert scale. A Likert scale contains several
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evaluative statements with which a patient can agree with or reject them. The method was developed for measuring personal attitudes. The unweighted values of the individual
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responses are added together to give the value of the scale. In the present study, following
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answers were used: "strongly disagree" (0 points), "disagree" (1 point), "neither agree nor disagree" (2 points), "agree" (3 points) and "strongly agree" (4 points).
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The statistical analyzes were performed with the IBM SPSS Statistics version 22 for Windows. For the statistical test procedures, a significance level of 0.05 (Alpha = 5%) was
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used. For nominal features, the chi-squared test was used and for metric features - the Kruskal-Wallis test.
The treatment groups were also examined for possible differences during the course of time. Since there had been an incomplete repeated measures design (not all patients attended all three post-surgical appointments), the two-factorial experimental design with a betweensubjects factor and a within-subjects factor using the GEE (Generalized Estimating Equations) methodology has been used.
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3. Results The comparative statistical analyzes were carried out with data obtained only from subjects who presented for follow-up, and included 75 patients assigned to one of the three
3.1 Changes in the objective nasal obstruction over time
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intervention groups.
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There were no significant differences in the inspiration values (without decongestant
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nasal spray) across the three groups prior to surgery, and at 150 Pa, the values were on average 388.511ml / s (SD = 38.925).
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Following surgery, we observed a significant improvement of overall inspiration without decongestant nasal spray in all three groups (p = 0.000) after one, three and six
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months. There were no significant differences between the groups. The mucous membrane component was determined based on the difference in total inspiration
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before and after administration of decongestant nasal spray. Also here there was a significant improvement 6 months after surgery in each group (Fig.1).
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3.2 Changes in the subjective complaints over time 3.2.1 Changes in the subjective nasal obstruction over time
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Seventy-six percent of patients reported a double-sided nasal obstruction prior to surgery. Half of the study participants’ complained about a permanent nasal obstruction, 31.3% of patients said to be particularly affected at night, and 17.9 % stated difficulties with breathing under special conditions such as physical exercises. Following surgery, nasal obstruction improved significantly in all three groups (p = 0.0001). Already during the first follow-up appointment, all patients reported decrease of nasal obstruction. Three months after surgery, the grade of remaining nasal obstruction differed significantly between the submucosal electrocautery group and the laser group (p =
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0.031), with the laser group having more reduced nasal obstruction. Six months after surgery, the differences between the groups were no longer significant. 3.2.2 Significant subjective changes without significant differences between surgery techniques
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The symptoms that have not differed between the groups are listed in Table 2. These symptoms include nightly waking up, problems falling asleep, sneezing, ear pain and reduced
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concentration. All of them decreased significantly after surgical intervention (p = 0.001). The
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retrograde flow of secretion did not change significantly over time.
3.2.3 Subjective changes with significant differences between surgical techniques
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The symptoms listed in Table 3 also decreased following surgical intervention. There
3.2.4 Changes in the ear pressure
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were; however, significant differences between the groups (Tab. 3).
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All patients reported a feeling of pressure in the ears prior to surgery. Three months after surgery, there were significant differences between the groups. Patients in the
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electrocautery group had significantly stronger feeling of pressure in the ears than the patients in submucosal turbinectomy group (p = 0.031). After 6 months, all patients reported
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disappearance of the ear pressure (Tab. 3). 3.2.5 Change in cough over time Prior to surgery, cough was not a serious complaint. One to two months after the surgery, there was a significant group difference between the submucosal turbinectomy group and laser cautery group (p = 0.001), where patients from the laser cautery group did not suffer from cough. During the follow-up appointments, patients from laser cautery group retained the smallest symptom severity (Tab. 3).
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3.2.6 Change in facial pain/ pressure over time In all three intervention groups, nasal discomfort was not reported prior to surgery. Six months after the surgery, significant group differences were observed between the submucosal turbinectomy group and electrocautery group (p = 0.024) and the electrocautery
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group and laser cautery group (p = 0.011). Patients in the electrocautery group were affected by nasal discomfort to the greatest degree (Tab.3).
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3.2.7 Change of daytime sleepiness over time
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All patients reported fairly intense daytime sleepiness upon recruitment. After the
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surgery, the mean value decreased in all groups meaning that the daytime sleepiness occurred less frequently. One to two months after the surgery, the daytime sleepiness was still reported
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by the submucosal turbinectomy group still but in the other two intervention groups it was barely a complaint. After half a year, significant differences between submucosal
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turbinectomy group and electrocautery group (p = 0.041) and the submucosal turbinectomy
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group and laser cautery group (p = 0.034) were noted again. Patients from electrocautery group and laser cautery group stated that the daytime sleepiness was no longer a problem. On
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average, the surgical intervention minimized the daytime sleepiness in all groups (Tab. 3).
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3.2.8 Changes in frustration, restlessness and irritation Majority of patients reported being frustrated, restless and irritated prior to surgery. During the second follow-up visit, a significant difference between electrocautery group and laser cautery group was observed (p = 0.05) with the patients in the latter group reporting less distress. After six months, there were no differences between the groups and in all patients frustration, restlessness and irritation were reduced (Tab. 3).
Discussion
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In the year 2014, the turbinate reduction was ranked 24th of the 50 most common surgeries performed in Germany and reached total of 151,225 cases [11]. Surgical techniques used to reduce the soft tissue of turbinates’ are currently in review due to a lack of sustained improvement of nasal obstruction and because of possible necrosis of mucosa, crusting and bleeding [12, 13]. Nevertheless, these techniques are widely used because of positive long-
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term effects and hardly any complications [14, 15].
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The two goals of our study were to compare the objective and subjective outcomes
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between three surgical techniques used to treat hyperplasia of inferior turbinates and to determine their advantage in combination with septoplasty. For the comparison, we measured
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objective and subjective parameters in the patients treated.
According to Hofer et al, the mucosa-preserving reduction through the anterior
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turbinectomy should be the method of choice, since post-surgical symptoms such as dry nose can be avoided [12]. Salzano et al has also suggested partial inferior nasal turbinectomy to be
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the best method, when compared to radiofrequency ablation, high-frequency ablation and
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electrocautery. Unfortunately, the authors followed up their patients only for two months [16]. In our study, we were not able to reproduce the above observation. Possible reason for this
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discrepancy could be the difference in a follow-up times (two months in the Salzano study and three and six months in our study).
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Using all three surgical techniques: electrocautery, submucosal turbinectomy and laser cautery, we have observed sustainable improvement in the nasal breathing and a low complication rate, confirming earlier results of Kizilkaya et al. and Prokopaki et al.[17, 18]. Kizilkaya et al. compared radiofrequency ablation with a submucosal reduction by the microbrider, as both being purely soft tissue-reducing methods (n = 30). Subjective (visual analog scale) and objective (acoustic rhinomanometry) measures have not detected the differences between the groups 6 months after surgery. Prokopakis et al. included 2983 patients to compare three different types of the inferior turbinates surgery (electrocautery,
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radiofrequency or CO2 Laser) and have demonstrated sustained significant improvement in the nasal breathing for up to one year [18]. This also suggests that the purely soft-tissuereducing methods of turbinectomy are equally effective. In a prospective randomized long-term study including 382 patients, Passalli et al. compared the submucosal resection with and without lateralization, turbinectomy,
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submucosal electrocautery, laser cautery and cryotherapy. The study was conducted over a
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period of 6 years, with approximately 63 participants per group. The best long-term outcome
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of the surgical procedure, as measured with acoustic and anterior rhinomanometry, mucociliary transport and the secretion of IgA, were obtained by using submucosal resection
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with lateralization [19]. In another study, Gindroz et al. have studied 60 patients with nasal obstruction of non-allergic origin. The ultrasound technology and the submucosal
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electrocautery or the ultrasound technology and radiofrequency therapy side were applied separately. After six months, the best outcomes (indicated by anterior rhinomanometry,
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acoustic rhinomanometry and by visual analog scale measuring nasal obstruction) were
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determined in a group of patients treated with the ultrasound technique, followed by radiofrequency ablation. However, the results obtained in a group of patients treated with
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unilateral electrocautery did not differ significantly [20]. In our study, in order to measure the rate of improvement, we determined the mucosal
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component, which is a novel outcome measure in the surgery of hypertrophic lower nasal conchae. The differences before and after swelling demonstrated significant decrease of the hypertrophy of the nasal mucosal membranes after the intervention. Our findings corroborate the results of Devresen et al., Grymer et al. and Hilberg et al. [21-23]. We have not observed mucosal hypertrophy of the septum. Yu et al. showed that three months after the reduction of hypertrophic lower nasal conchae with the Microdebrider with and without reduction of the septum (n = 26 and 25, respectively), a significant improvement was noted in patients who underwent a reduction of septum [24].
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It is generally accepted that the surgical reduction of hypertrophic lower nasal conchae accompanied by nasal breathing problems is performed together with the septoplasty [22, 25, 26]. Scientific data regarding the improvement of nasal breathing by septoplasty with and without additional reduction of the hypertrophic lower nasal conchae are scarce. The first study that included 80 patients using acoustic rhinomanometry revealed that the nasal
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breathing improved after an additional reduction of the hypertrophic lower nasal conchae
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[22]. After 5 years follow-up, no statistical differences were found between the two groups
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with and without additional reduction of the hypertrophic inferior nasal conchae neither by using questionnaires (n = 50) nor by acoustic rhinomanometry (n = 37) [25]. Also Nunez et al.
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have not found differences between the groups by means of anterior rhinomanometry or questionnaire (n = 26 patients); however, the data were collected eight weeks after
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intervention [27]. Opposite results were delivered by Devseren et al. who demonstrated a significant improvement six months after the surgery in a group of patients who underwent an
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additional reduction of the hypertrophic inferior nasal conchae. In that study, to measure the
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outcomes, the authors used anterior and acoustic rhinomanometry and questionnaires [21]. The questionnaires measuring various aspects of health, well-being as well as the
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health-related quality of life have become a popular outcome measurement in the field of otorhinolaryngology. We used such questionnaire to measure the subjective parameters and
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found that patients had the least subjective complaints when the laser cautery was used. The laser cautery is certainly the least invasive; however, the sustainability of its results has often been put in question [28]. During the six months of follow-up period, we determined remission among the patients treated with laser cautery and the strongest positive effect indicated by subjective nasal obstruction was found after 3 months after surgery. All patients reported continuous improvement in the subjective complaints after surgery. The group of patients who underwent electrocautery, predominantly complained about the facial pain and pressure, whereas the group which underwent the submucosal
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resection complained significantly more about the daytime sleepiness than the other two groups.
Conclusions
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Nasal mucosa-reducing techniques used for the inferior turbinate surgery lead to
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significant improvement of objective and subjective outcome measures. The technique of
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laser cautery induces the least post-surgical discomfort. However, none of the methods studied was significantly superior to the others. In addition, we find that septoplasty
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significantly contributes to the additional reduction of hypertrophic inferior turbinates.
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References
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1 Farmer SE, Eccles R. Chronic inferior turbinate enlargement and the implications for surgical intervention. Rhinology 2006;44(4):234-8. 2 Talaat M, el-Sabawy E, Baky FA, Raheem AA. Submucous diathermy of the inferior turbinates in chronic hypertrophic rhinitis. The Journal of laryngology and otology 1987;101(5):452-60. 3 Berger G, Gass S, Ophir D. The histopathology of the hypertrophic inferior turbinate. In. Arch Otolaryngol Head Neck Surg. United States; 2006:588-94. 4 Larrabee YC, Kacker A. Which inferior turbinate reduction technique best decreases nasal obstruction? Laryngoscope 2014;124(4):814-5. 5 Baumann I, Baumann H. A new classification of septal deviations. Rhinology 2007;45(3):2203. 6 Graf P, Juto JE. Sustained use of xylometazoline nasal spray shortens the decongestive response and induces rebound swelling. Rhinology 1995;33(1):14-7. 7 Albrecht T, Wu S, Baumann I, Plinkert PK, Sertel S. Measurable impact of acupuncture on mucosal swelling of inferior turbinates: a prospective, randomized, controlled study. Acta otolaryngologica 2015;135(2):169-76. 8 Andrews P, Poirrier AL, Lund VJ, Choi D. Outcomes in Endoscopic Sinus Surgery : Olfaction, NOSE scale and Quality of Life in a Prospective Cohort Study. Clin Otolaryngol 2016. 9 Uecker FC. HNO in Frage und Antwort. München: Der Urban & Fischer Verlag (Imprint der Elsevier GmbH); 2014. 10 Baumann I, Blumenstock G, DeMaddalena H, Piccirillo JF, Plinkert PK. [Quality of life in patients with chronic rhinosinusitis: validation of the Sino-Nasal Outcome Test-20 German Adapted Version]. HNO 2007;55(1):42-7. 11 DRG related hospital statistics (DRG statistics), diagnoses and procedures of inpatient patients in hospitals, Federal Statistical Office, Federal Health Monitoring System, 11/23/2015). 2015. 12 Hofer M, Dacho A, Dietz A. [Surgery of the nose and paranasal sinuses]. Laryngorhinootologie 2016;95(1):51-65; quiz 6-7. 13 Mlynski G. [Impaired function of the upper respiratory tract. Restorative procedures for upper airway dysfunction, nasal breathing]. Laryngorhinootologie 2005;84 Suppl 1:S101-17. 14 Egeli E, Demirci L, Yazycy B, Harputluoglu U. Evaluation of the inferior turbinate in patients with deviated nasal septum by using computed tomography. Laryngoscope 2004;114(1):113-7. 15 Rohrich RJ, Krueger JK, Adams WP, Jr., Marple BF. Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution. Plast Reconstr Surg 2001;108(2):53644; discussion 45-6. 16 Salzano FA, Mora R, Dellepiane M, et al. Radiofrequency, high-frequency, and electrocautery treatments vs partial inferior turbinotomy: microscopic and macroscopic effects on nasal mucosa. Archives of otolaryngology--head & neck surgery 2009;135(8):752-8. 17 Kizilkaya Z, Ceylan K, Emir H, et al. Comparison of radiofrequency tissue volume reduction and submucosal resection with microdebrider in inferior turbinate hypertrophy. Otolaryngology-head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2008;138(2):176-81. 18 Prokopakis EP, Koudounarakis EI, Velegrakis GA. Efficacy of inferior turbinoplasty with the use of CO(2) laser, radiofrequency, and electrocautery. American journal of rhinology & allergy 2014;28(3):269-72. 19 Passali D, Passali FM, Damiani V, Passali GC, Bellussi L. Treatment of inferior turbinate hypertrophy: a randomized clinical trial. Ann Otol Rhinol Laryngol 2003;112(8):683-8. 20 Gindros G, Kantas I, Balatsouras DG, Kaidoglou A, Kandiloros D. Comparison of ultrasound turbinate reduction, radiofrequency tissue ablation and submucosal cauterization in inferior turbinate hypertrophy. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies 2010;267(11):1727-33.
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21 Devseren NO, Ecevit MC, Erdag TK, Ceryan K. A randomized clinical study: outcome of submucous resection of compensatory inferior turbinate during septoplasty. Rhinology 2011;49(1):53-7. 22 Grymer LF, Illum P, Hilberg O. Septoplasty and compensatory inferior turbinate hypertrophy: a randomized study evaluated by acoustic rhinometry. The Journal of laryngology and otology 1993;107(5):413-7. 23 Hilberg O, Grymer LF, Pedersen OF, Elbrond O. Turbinate hypertrophy. Evaluation of the nasal cavity by acoustic rhinometry. Archives of otolaryngology--head & neck surgery 1990;116(3):283-9. 24 Yu MS, Kim JY, Kim BH, Kang SH, Lim DJ. Feasibility of septal body volume reduction for patients with nasal obstruction. Laryngoscope 2015;125(7):1523-8. 25 Illum P. Septoplasty and compensatory inferior turbinate hypertrophy: long-term results after randomized turbinoplasty. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies 1997;254 Suppl 1:S89-92. 26 Balcerzak J, Lukawska I, Grzanka A, Niemczyk K. [Comparative analysis of the treatment results of the nasal obstruction using septoplasty and septokonchoplasty]. Otolaryngol Pol 2014;68(3):129-34. 27 Nunez DA, Bradley PJ. A randomised clinical trial of turbinectomy for compensatory turbinate hypertrophy in patients with anterior septal deviations. Clin. Otolaryngol. Allied Sci. 2000;25(6):4958. 28 Sapci T, Sahin B, Karavus A, Akbulut UG. Comparison of the effects of radiofrequency tissue ablation, CO2 laser ablation, and partial turbinectomy applications on nasal mucociliary functions. Laryngoscope 2003;113(3):514-9.
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Figure 1
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Figure Legend
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Mean mucous membrane component as difference of total inspiration in ml/s at 150 Pa before and after decongestion with a topical nasal decongestant xylometazoline over the time.
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Table 1 Questionnaire based on the German versions of the Sino-Nasal Outcome Test 20 German Adapted Version (SNOT-20 GAV)
10. Dizziness
2. Sneezing
11. Facial pain, pressure in the face
3. Runny nose
12. Problems falling asleep
4. Postnasal discharge
13. Nightly waking up
5. Thick nasal discharge
14 Daytime sleepiness
6. Cough
15. Reduced performance
7. Ear fullness
16. Concentration weakness
8. Ear pain
17. Frustration / Restlessness / Irritability
9. Smell reduction
18. Sadness
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1. Need to blow out
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Significant changes in the overall averages of the item scores (p = 0.001) measured by
the modified questionnaire Sino-Nasal Outcome Test 20 German Adapted Version (SNOT-20 GAV) Likert Scale 1 - 5 Before
One month
Three months
Six months
Surgery
after Surgery
after Surgery
after Surgery
1,74
0,60
0,89
0,66
Nightly waking up
1,99
0,60
0,89
0,88
Sneezing
1,62
0,80
0,92
0,92
Postnasal discharge
1,62
0,80
Ear pain
0,55
0,34
Reduced
1,53
1,08
Problems falling
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Item
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Concentration
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asleep
0,92
0,92
0,22
0,27
0,78
0,82
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Subjective changes over time with significant differences between surgical techniques
(marked are significant differences p= 0.05); based on questionnaire Sino-Nasal Outcome Test 20
Item
Ear pressure
Surgery
Before
One month
Three months
Six months
technique
surgery
after Surgery
after surgery
after Surgery
0,63
0,79
0,17
0,58
Electrocautery
1,00
0,62
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German Adapted Version (SNOT-20 GAV), Likert scale 1-5
0,82
Lasercautery
1,00
0,36
Submucosal
1,21
1,16
Submucosal
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Cough
0,31 1,10
0,90
0,69
0,76
0,78
0,38
0,47
0,52
1,58
Lasercautery
1,13
Facial pain/
Submucosal
0,93
0,53
0,13
0,16
pressure
turbinectomy
1,11
0,62
0,51
0,64
0,83
0,25
0,46
0,23
2,79
2,05
1,81
1,84
Electrocautery
2,15
1,31
1,20
1,08
Lasercautery
2,37
1,40
1,44
1.12
1,42
1,05
0,83
0,63
Electrocautery
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Lasercautery Submucosal
sleepiness
turbinectomy
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Daytime
Frustration,
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Electrocautery
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turbinectomy
0,66
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turbinectomy
Submucosal
restlessness and
turbinectomy
irritation
Electrocautery
1,85
0,99
0,74
0,53
Lasercautery
1,37
0,55
0,44
0,71
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Fig. 1