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Turbinate - Radiofrequency Treatment of Chronic Obstruction

Radiofrequency turbinate reduction is a fast, effective way to relieve chronic nasal obstruction due to enlarged turbinates without the pain and inconvenience associated with traditional techniques. The radiofrequency treatment is performed in an outpatient setting under local anesthesia. The procedure itself typically takes less than two minutes per turbinate with no nasal packing required and most patients do not require any kind of postoperative analgesic.

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Important Facts about Chronic Nasal Obstruction and Enlarged Turbinates

A stuffy nose is often caused by an enlargement of the inferior nasal turbinates. These are small, shelf-like structures composed of thin bone and covered by mucous membranes.  They protrude into the nasal airway and help to warm, humidify and cleanse air as it is inhaled before it reaches the lungs. Chronic stuffy nose can impair normal breathing, forcing patients to breathe through the mouth and often affecting their daily activities.

Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and Obstructive Sleep Apnea Syndrome ( OSAS ). Chronic stuffy nose is often unresponsive to medical treatment such as nasal sprays; thus surgical treatment is required. This is commonly associated with rhinitis, the inflammation of the mucous membranes of the nose. When the mucosa becomes inflamed, the blood vessels inside the membrane swell and expand, causing the turbinates to become enlarged and obstruct the flow of air through the nose.

More than 50 million Americans suffer from some type of chronic rhinitis.

The Current Treatment Regimen

The Current Treatment Regimen

Current treatments for a chronic stuffy nose range from behavioral changes such as avoiding exposure to the triggers that cause rhinitis) to invasive surgery. Medical therapy offers only temporary relief, but it can also be associated with significant side effects. Surgical treatments sometimes result in lengthy recovery periods and significant patient discomfort.

Medical Therapy

Medications designed to treat the stuffy nose, sinus complaints and the common cold make up the largest segment of the over-the-counter drug market for the U.S. pharmaceutical industry. The treatments associated with this include a variety of antihistamines, decongestants, and topical and systemic corticosteroids. These drugs provide only symptomatic improvement; they cannot cure the condition. They also can create side effects such as drowsiness, bleeding, drying and crusting.


In severe cases of allergic rhinitis, immunotherapy (allergy shots) may be recommended. With immunotherapy, a patient is injected with increasingly larger amounts of an allergen to encourage the body to build up resistance. While modestly effective in selected patients, immunotherapy can be a lengthy and expensive process, which limits patient and physician acceptance of the approach.

Surgical Therapy

Surgical treatment is indicated only after patients fail to respond to medical therapy. Turbinate surgery can be performed as an office procedure under local anesthesia or in the operating room under general anesthesia.

Cautery (burning) of enlarged turbinates can be done with an electrosurgical probe or a laser and is usually performed as an office procedure. Both electrocautery and laser surgery are performed on either the surface of the turbinate tissue or sub-mucosally.

Surface cautery results in edema and crusting in the nose that can last three weeks or longer, while sub-mucosal cautery can cause swelling for up to 10 days. Another method for improving nasal obstruction is outward fracture of the turbinate bone(s), which moves the turbinate away from its obstructive position in the airway. This approach, however, does not address the usual source of obstruction. Enlarged sub-mucosal tissue, and the fractured turbinate often returns to its previous position.
Turbinate resection (removal of the bone and/or soft tissue) and excision (removal of the soft tissue only) can be performed with surgical scissors or a laser. After the surgery the nose must be packed for several days with gauze containing antibiotic ointment.

Bleeding, which can usually be managed by packing the nose, is the greatest risk for patients undergoing standard turbinate resection. Over-resection of the turbinates has been reported as the cause of excessive, irreversible drying of the turbinates. Resection, excision and surface cautery can all be associated with prolonged crusting and healing, which occurs over a four to six-week period.

Newer Technology for Patients with Persistant Nasal Obstruction

A non-surgical, minimally invasive technique using the application of temperature controlled radiofrequency ( TCRF ) to the nasal region has been developed at our center to give significant relief for those that suffer from nasal obstruction due to allergic rhinitis (swelling of the soft tissues of the inner nose).

Overview: The Problem

The symptoms of nasal obstruction: inability to breathe, congestion, runny nose, post nasal drip and even headache are well known to most patients as signs of an acute upper respiratory infection or a reaction to environmental irritation such as allergies. However, for many individuals this obstruction is chronic and markedly affects their quality of life on a daily basis.

Causes and Conventional Treatment

Medical

Allergies can lead to symptoms by stimulating the nasal tissue to release chemicals that cause swelling and drainage. If these stimulants can be identified, avoidance may be attempted. Medications such as antihistamines, decongestants, and nasals steroids are often used and can be successful. However, some patients experience side effects and variable success rates. Finally, immunotherapy (allergy shots) is excellent for many allergy symptoms, but less effective for pure nasal obstruction. In addition, it may take a prolonged period of treatment to see benefits.

Individuals without true allergies may also suffer from nasal obstruction. In these cases environmental stimuli such as a change in humidity or temperature, or even a reaction to some foods cause swelling through a slightly different mechanism. Unfortunately for the patient, the symptoms are the same and the treatments are generally similar but less effective.

Although some patients may have anatomic abnormalities such as a deviated septum, the main cause of the majority of nasal obstruction is enlargement of structures known as turbinates. The turbinates are on the lateral walls on each side of the nose. They are made up of tiny layers of bone much like a sponge and are covered with a very vascular layer of soft tissue. These essential structures provide a necessary function in the warming and humidification of the air entering the airway. However, when chronically stimulated the soft vascular tissues surrounding the spongy bone of the turbinates enlarge and actually block nasal airflow. Anyone that has ever suffered a stuffy nose from a common cold has experienced nasal obstruction and a runny nose as a result of turbinate swelling.

Surgical

As mentioned above, conservative treatments such as medications can be attempted, however if unsuccessful, direct reduction of the turbinates may be required to relieve the symptoms. Surgical turbinate reduction where the leading one-third to one-half of the turbinate is actually removed is effective but invariably results in crusting and bleeding from the nose during the recovery period. It is also commonly performed in an operating room. Other treatments such as laser reduction still have similar side effects.

Newer Non-Surgical Technology

The Solution:

Temperature Controlled Radiofrequency is a recently developed non-surgical approach researched and developed by our group. It uses a tiny electrode to heat the turbinate tissue from within, eventually causing reduction of the size of the turbinate as the body reabsorbs the treated tissue. Since no “cutting” of the tissue is done, there is little or no bleeding, crusting, or pain. The use of radiofrequency is not new to medicine, as it has been used for decades in the fields of neurology, cardiology, urology and surgery. However, it was not previously used for the shrinkage of soft tissue in the upper airway until our group scientifically investigated this technology and added special thermocouples to the electrodes to monitor temperature delivery. These temperature control applications allowed for a safe delivery of energy and the ability to precisely select and treat the delicate tissues of the nose. Temperature controlled radiofrequency is minimally invasive and can be done in the office with only local anesthesia (much like your dentist would use) and the patient can resume normal activity almost immediately. This method also preserves the normal function of the turbinate, but usually results in excellent airflow to the patient.

Although this method of treatment can be very effective, a thorough evaluation and examination is performed to correctly confirm the suspected diagnosis and to determine the appropriateness of this choice. For questions regarding this treatment, or to schedule an appointment for evaluation please contact our office at (650) 328-0511.

References on research completed in this area:

1. Powell NB, Zonato AI, Weaver EM, Li KK, Troell RJ, Riley,RW, Guilleninault C. Radiofrequency Treatment of turbinate Hypertrophy in Subjects Using Continuous Positive Airway Pressure: A Randomized, Double Blind, Placebo-Controlled Clinical Pilot Study. Laryngoscope 2001; 111:1783-1790

2. Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Radiofrequency tissue reduction for treatment of turbinate hypertrophy: a pilot study. Otolaryngology Head and Neck Surgery 1998;119:569-573

3. Johnson JT, Pollack GL, Wagner RL. Transoral radiofrequency treatment of snoring. Otolaryngology Head and Neck Surgery 2002; 127: 235-237

4. Coste A, Yona L, Blumen M, et al. Radiofrequency is a safe and effective treatment of turbinate hypertrophy. Laryngoscope 2001; 111: 894-899

5. Rhee CS, Kim DY, Won TB, et al. Changes of nasal function after temperature controlled radiofrequency tissue volume reduction for the turbinate. Laryngoscope 2001;111:153-158

6. Utley DS, Goode RL, Hakim I. Radiofrequency energy tissue ablation for the treatment of nasal obstruction secondary to turbinate hypertrophy. Laryngoscope 1999; 109:683-686

7. Smith TL, Correa AJ, Kuo T, Reinisch L. Radiofrequency tissue ablation of the inferior turbinates using a thermocouple feedback electrode. Laryngoscope 1999 Nov: 109(11):1760-1765

Diagrams of the Temperature Controlled Radiofrequency Procedure to Relieve Chronic Nasal Obstruction

Submucosal Delivery of TCRF  
Energy In this outpatient procedure, the patient receives a local anesthetic. Using direct vision, the physician inserts the SP 1100 electrode into the inferior turbinate. The radiofrequency generator delivers energy beneath the mucosa.
Creation of Coagulative Lesion  
Tissue is heated in a limited area around the electrode, creating a submucosal coagulative lesion. The patient does not feel discomfort during the procedure, and the mucosa is protected from thermal damage.
Tissue Volume Reduction  
The lesion is naturally re-absorbed by the body, leading to tissue volume reduction and relief of nasal obstruction. This can be an effective treatment for patients who suffer from chronic turbinate hypertrophy enlargement.