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Turbinate - Radiofrequency Treatment of Chronic Obstruction
Due to the partially insulated electrode and the controlled temperature used in treatment, the delicate mucosa is preserved and patients experience minimal, if any, crusting and bleeding.The procedure itself typically takes less than two minutes per turbinate. No nasal packing is required and most patients do not require any kind of postoperative analgesic. Important Facts about Chronic Nasal Obstruction and Enlarged TurbinatesChronic nasal obstruction, or a stuffy nose, is often caused by enlargement of the inferior nasal turbinates. The nasal turbinates- Chronic enlargement (hypertrophy) of the turbinates and the accompanying symptom of nasal obstruction affect people throughout the day, as well as during sleep. A 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), as the nasal airway is the normal breathing route during sleep. Chronic turbinate hypertrophy is often unresponsive to medical treatment such as nasal sprays; thus surgical treatment is required. Chronic turbinate hypertrophy and nasal obstruction are 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. According to several large population surveys, approximately 20% of the population, or more than 50 million Americans, suffer from some type of chronic rhinitis. The Current Treatment RegimenCurrent treatments for the chronic stuffy nose range from behavioral changes (i.e., avoiding exposure to the triggers that cause rhinitis) to invasive surgery.Current treatments for the chronic stuffy nose range from behavioral changes (i.e., avoiding exposure to the triggers that cause rhinitis) to invasive surgery. While avoidance of irritants in the environment is a key factor in managing chronic rhinitis, patient compliance is difficult. Medical therapy offers only temporary relief of chronic nasal obstruction due to enlarged turbinates, but it can also be associated with significant side effects. Surgical treatments sometimes result in lengthy recovery periods and significant patient discomfort. Medical Therapy
Antihistamine drugs, such as Benadryl™, Claritin™ and Chlor-Trimeton™, block the action of histamine, the agent responsible for symptoms of sneezing and a runny nose. While antihistamines reduce these symptoms, they do little to alleviate nasal obstruction. Antihistamines can cause drowsiness and they are not recommended for daytime use by people who must drive or operate equipment. Newer antihistamines have fewer sedative effects, but are more expensive. Decongestants cause constriction of the blood vessels in swollen mucous membranes, forcing blood out so that the membranes shrink and air passages open. Typical decongestants include nasal sprays such as Neo-Synephrine™ and pills such as Sudafed™ and Actifed™. Decongestants are chemically related to adrenaline, a natural decongestant that is also a stimulant. One side effect of this type of drug is a jittery or nervous feeling that can cause insomnia. Decongestants can also increase a patient's blood pressure and pulse rate. Decongestants should not be used by patients who have an irregular pulse, high blood pressure, heart disease or glaucoma. Also, certain decongestant drugs such as pseudo-ephredine should not be used by patients who suffer from benign prostate hyperplasia (approximately 13 million men in the United States) because the drug can aggravate prostate enlargement. There are a variety of decongestant nasal sprays available over the counter. These medicines can produce significant, temporary symptomatic relief of nasal obstruction; however, they can also become addictive as rebound nasal congestion occurs with overuse. Several corticosteroid therapies, most in the form of a nasal spray or inhaler, have been developed to treat chronic nasal obstruction. Intranasal corticosteroids are available only by prescription, and they can be very effective. However, they are associated with side effects such as bleeding, drying and crusting. Patients must take care not to overuse corticosteroid preparations. Although the drugs are applied topically, some systemic absorption of the agent occurs, which can disrupt the body's steroid balance. Steroids can also be injected directly into the turbinates; however, their effectiveness lasts only three to six weeks. Intranasal cromolyn is another type of drug therapy. It is a preventive medication and can be very effective in preventing a hypersensitivity allergic reaction in the turbinates (but only if used before exposure to irritants). Although side effects are unusual, cromolyn can produce nasal burning, headaches and sneezing. 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 TherapySurgical treatment of enlarged turbinates that cause chronic nasal obstruction is indicated only after patients fail to respond to 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 which 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 ObstructionA non-surgical minimally invasive technique using the application of temperature controlled radiofrequency (TCRF) to the nasal region has been developed at our center and has been found to give significant relief for those that suffer from nasal obstruction due to allergic rhinitis (swelling of the soft tissues of the inner nose). A summary of this problem and a discussion of this radiofrequency technology are presented below. Overview: The Problem
Causes and Conventional TreatmentMedicalAllergies 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. SurgicalAs 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 TechnologyThe 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:
Diagrams of the Temperature Controlled Radiofrequency Procedure to Relieve Chronic Nasal Obstruction
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--small, shelf-like structures composed of thin bone and covered by mucous membranes (mucosa) ---protrude into the nasal airway and help to warm, humidify and cleanse air as it is inhaled, before it reaches the lungs.
medical therapy. Turbinate surgery can be performed as an office procedure under local anesthesia or in the operating room under general anesthesia.
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