Surgery of the turbinates and "empty nose" syndrome

Abstract

Surgical therapy of the inferior and/or middle turbinate is indicated when conservative treatment options have failed. The desired goal is a reduction of the soft tissue volume of the turbinates regarding the individual anatomic findings, whilst simultaneously conserving as much mucosa as possible. As the turbinates serve as a functional entity within the nose, they ensure climatisation, humidification and cleaning of the inhaled air. Thus free nasal breathing means a decent quality of life, as well.Regarding the multitude of different surgical techniques, we confirm that no ideal standard technique for turbinate reduction has been developed so far. Moreover, there is a lack of prospective and comparable long-term studies, which makes it difficult to recommend evidence-based surgical techniques. However, the anterior turbinoplasty seems to fulfil the preconditions of limited tissue reduction and mucosa-preservation, and therefore it is the method of choice today.Radical resection of the turbinates may lead to severe functional disturbances developing a secondary atrophic rhinitis. The "empty nose" syndrome is a specific entity within the secondary atrophic rhinitis where intranasal changes in airflow result in disturbed climatisation and also interfere with pulmonary function. Results deriving from an actual in vivo study of climatisation and airflow in "empty nose" patients are presented.

Keywords: inferior turbinate; laser surgery; middle turbinate; pediatric surgery of turbinates; turbinate surgery; “empty nose” syndrome.

Figure 1. Coronary paranasal sinus computer tomography. Pronounced angled variants of the left os turbinale with simultaneous hypertrophy as a result of the convex deviation of the septum. Sinusitis maxillaris et ethmoidalis, right.

Figure 2. Lateroposition of the lower turbinate

Figure 3. Total turbinectomy

Figure 4. Subtotal turbinectomy

Figure 5. Submucosal turbinectomy

Figure 6. (Inferior) anterior turbinoplasty

Figure 7. Electrocoagulation of the inferior turbinate

Figure 8. Laser surgery of the inferior turbinate

Figure 9. Figure 9 a–d: Treatment of both hypertrophic inferior turbinates with the diode laser (Biolitec AG, Jena, Germany). Laser settings: 10 watt, continuous wave, laser fibre: 400 µm, treatment energy: 279.16 joules, treatment time: 28.05 secs.

a: right inferior turbinate preoperative; b: left inferior turbinate preoperative; c: right inferior turbinate at 6 weeks postoperative; d: left inferior turbinate at 6 weeks postoperative (Pictures courtesy Prof. Lindemann/ENT-Dept. Ulm University).

Figure 10. Coronary computer tomography representation of a patient with ENS. Both the inferior and middle turbinates have been resected, only vestiges of the turbinate have been preserved.

Figure 11. Side-differentiated presentation of flow simulation during inspiration with a representative healthy test person.

The volume flow is 200ml/sec. The main flow occurs mainly in the middle section of the nose; the nasal floor and roof of the nose are significantly less strongly flowed through. Turbulence is observed in the nasal valve region and at the posterior apertures of nose.

Figure 12. Side-differentiated presentation of flow lines during inspiration with a representative ENS patient.

The volume flow is 200 ml/s. The main flow occurs mainly in the upper and middle section of the nose; the nasal floor and the inferior turbinate are less strongly flowed through. Turbulence is observed in the maxillary sinuses.

Figure 13. Simulated pressure-profile representation in a healthy subject (pressure measured in Pa).

It can be seen that the highest pressure values on the mucosa are measured at the entrance to the nose and the nasal valve area, and continuously decrease in posterior direction.

Figure 14. Exemplary simulated pressure-profile representation in an ENS patient (pressure measured in Pa).

It can be seen that the highest pressure values on the mucosa are measured at the entrance to the nose and the nasal valve area, and continuously decrease in posterior direction. The decline of pressure values happens much faster than with the healthy subject. The pressure gradient between anterior and posterior nasal section is higher.