Vol.2, No.11, 1287-1293 (2010)
doi:10.4236/health.2010.211191
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
A comperative clinical study of mucotomy and KTP laser
treatment of the inferior turbinate in allergic and
non-allergic subjects
Ágnes Patzkó*, Eszter Tóth, Krisztina Somogyvári, Imre Gerlinger
Department of Otorhinolaryngology, Head and Neck Surgery, University Medical School of Pécs, Hungary;*Corresponding Author:
apatzko@yahoo.com
Received 20 July 2010; revised 20 August 2010; accepted 25 August 2010.
ABSTRACT
Mucotomy is one of the most frequently applied
surgical techniques for the management of in-
ferior turbinate hyperplasia. Mucotomy guaran-
tees patent airway, however, it might lead to the
emergence of sicca syndrome. In contrast, KTP
(potassium titanyl phosphate) laser treatment
spares the medial part of the inferior turbinate
mucosa, contributing to maintenance of physio-
logical nasal function. A retrospective compara-
tive clinical study was performed to reveal the
advantages and side-effects of both surgical me-
thods in medium- and long-term in allergic rhini-
tis and non-allergic patients. Furthermore, we
wished to determine the exact indications of the
up-to-date laser treatment. Ninety-one of the 117
patients who underwent bilateral turbinate sur-
gery during an 8-year period (2000-2007) respond-
ed to our questionnaire focusing on subjective
postoperative changes. Patients were separated
into 6 groups, based on the type of operation
they underwent, the length of the follow-up and
whether they suffered from allergies. The major
complaint, nasal obstruction, improved in all 6
groups, which reached significance (p 0.05) in
4 groups. The most pronounced improvement
was observed in the group of non-allergic pa-
tients with medium-term follow-up who under-
went mucotomy. Nevertheless, a serious side-
effect: crusting also increased significantly (p
0.05) in the latter group, while it was absent in
allergic patients with medium-term follow-up,
who underwent mucotomy. These results lead
us to propose the following protocol for the
treatment of inferior turbinate hyperplasia: 1)
after unsuccessful conservative treatment, laser
treatment is suggested for non-allergic patients;
2) following unsuccessful conservative and even
repeated laser treatment in the allergic group,
mucotomy or turbinoplasty should be attempted.
Keywords: Crusting; Inferior Turbinate; KTP Laser;
Mucotomy; Turbinoplasty
1. INTRODUCTION
Complete or incomplete inferior turbinate resection
procedures are commonly used surgical techniques
worldwide in both children and adults, in out- or
in-patient settings. Most surgeons agree with the logical,
but potentially misleading idea that the patients’ com-
plaints, especially nasal obstruction will be improved if
nasal airflow is increased [1]. The most important factor
determining airway resistance is the nasal valve. The
nasal resistance is additionally influenced by the nasal
cycle, which involves the alternating congestion and
decongestion of the septal and inferior turbinate veins
every 4-6 hours. As the inferior turbinate shrinks, this
contributes to an increased nasal valve area, a decreased
nasal resistance and an improved airflow [2].
There is considerable controversy in the literature
concerning the management of inferior turbinate enlarge-
ment. The origins of this debate date back more than a
hundred years, when the routine procedure was total
turbinectomy [3,4], which was accompanied by the ad-
verse effects of serious bleeding, atrophic rhinitis and
crusting [5]. Subsequently, various types of partial tur-
binectomy gained popularity [6-9]. Some of the recent
surgical approaches, such as diathermy or cryosurgery
cause tissue necrosis, and the subsequent fibrosis has
been claimed to result in inferior turbinate reduction
[10,11]. Nevertheless, disappointing outcome was re-
ported in long-term follow-up patients, who underwent
electrocauterization [7], as well as in the case of total
inferior turbinate resection, indicating that the side-effects
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have been underestimated [12]. Treatment options util-
izing the most up-to date technology (lasers and radiof-
requency devices) are currently offered, though their out-
comes have still not been adequately analysed [13-16].
Subjective patient complaints do not necessarily cor-
relate with the objectively measured decrease in postop-
erative nasal resistance (determined by rhinomanometry,
acoustic rhinometry) as an indication of excellent result
of surgery [17-19]. Our paper assesses the outcome of
mucotomy and KTP laser treatment of the inferior tur-
binate in both medium- and long term in allergic and
non-allergic patients, with the aims of identifying the
advantages and side-effects of these techniques from the
aspect of quality of life of the patients, and of determin-
ing exact indications in order to elaborate a therapeutic
protocol.
2. PATIENTS AND METHODS
2.1. Patients
A retrospective analysis of 117 patients who under-
went bilateral turbinate surgery during an 8 year period
(2000-2007) was planned. In 97 subjects (83%) mu-
cotomy and in 20 cases (17%) laser treatment of the in-
ferior turbinates had been carried out. Ninety- one (39
female, 52 male; mean age at surgery 37 ± 13,7 years,
range: 14-73 years; 74 mucotomy, 17 KTP laser-treated)
of them (78%) responded to a questionnaire focusing on
subjective postoperative changes (Appendix). Patients
could respond with a yes, no or not sure to all questions.
For the analysis, the patients were divided into 6 groups,
based on the type of operation they had undergone, the
length of the follow-up (medium-term or long-term) and
whether they suffered from allergies (Table 1).
The indication of bilateral mucotomy or laser treat-
ment was based on the detailed medical history and
physical examination (anterior rhinoscopy and nasal
endoscopy). Objective measurements (rhinomanometry
and acoustic rhinometry) were not performed. Allergic
rhinitis was verified by means of the Prick-test and
blood test for specific IgE detection besides the typical
symptoms (itchy eyes, sneezing, nasal discharge and
blockage and headache). The most common causes of
non-allergic turbinate hyperplasia were medicamentous
rhinitis and vasomotor rhinitis. Sixty-five of the 91 pa-
tients underwent septoplasty at the same time as (63 pa-
tients, 97%) or before the turbinate surgery (2 patients,
3%), while 3 patients had a septal reoperation simulta-
neously with or before the turbinate surgery (5%). In
cases of suspected chronic rhinosinusitis, a CT scan and
nasal endoscopy facilitated the establishment of the in-
dication for surgery.
2.2. Surgical Procedures
Mucotomy: Following medialization of the turbinate,
the hyperplastic mucosa was surgically removed using
straight scissors. In cases of significant hypertrophy ex-
cessive bone was not preserved. Occasional severe bleed-
ing from the sphenopalatine artery was treated with a
nasal tamponade. If necessary, the enlarged posterior po-
le of the inferior turbinate was also resected (Figure 1).
Figure 1. Schematic illustration of mucotomy.
Table 1. Groups of patients.
Description Group abbreviation No. of patients
Medium-term follow-up of allergic patients who underwent mucotomy M2A 29
Medium-term follow-up of non-allergic patients who underwent mucotomy M2NA 29
Long-term follow-up of allergic patients who underwent mucotomy M7.5A 5
Long-term follow-up of non-allergic patients who underwent mucotomy M7.5NA 11
Medium-term follow-up of allergic patients who underwent KTP laser
treatment KTP2A 7
Medium-term follow-up of non-allergic patients who underwent KTP laser
treatment KTP2NA 10
N.B: medium-term follow up: 2.11 years (range: 1.8-2.4 years) long-term follow up: 7.48 years (range: 7.1-7.9 years)
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KTP laser treatment of the inferior turbinate: A KTP
laser (wavelength: 532 nm) has been applied for the treat-
ment of our patients regularly since 2004. This type of
laser combines ideal rhinological features of ablation,
vaporization and coagulation. Furthermore, hemoglobin
absorbs the laser light, providing a blood-free environ-
ment. The hand-piece allows the laser light beam to be
directed towards the hidden parts of the nasal cavity (Fi-
gures 2(a) and 2(b)). In the course of the operation, the
laser probe containing a 0.6 mm laser fiber was targeted
to the posterior pole of the inferior turbinate under en-
doscopic control. The laser beam, applied at 10 W was
conducted from the posterior to the anterior pole of the
inferior turbinate in about 20-40 seconds, burning a
trench into the surface of the inferior turbinate (Figure
3). In some cases, two parallel trenches were formed. In
Figure 2. Fibre-optical hand piece with a built-in sucker
(a). filter fixed to endoscope (b).
Figure 3. A trench was burnt into the surface of the inferior
turbinate applying the laser in continuous contact mode at
10 W. (S: septum, IT: inferior turbinate, L: laser fibre-optic).
case of extreme anterior pole hyperplasia a brief addi-
tional laser treatment was applied to the submucosa. Spe-
cial care was taken to spare the medial surface of the in-
ferior turbinate. After laser treatment, there was no need
for a tamponade.
2.3. Statistical Analysis
The changes reported by the patients between the pre-
operative and postoperative conditions were analyzed by
means of the McNemar test. The answers relating to a
given symptom were analyzed with the Wilcoxon signed
rank test. We considered a probability level of p < 0.05
as significant.
3. RESULTS
Our study focused on nasal breathing, crusting, smell
detection and headache. Overall, the questions dealing
with nasal breathing revealed a significant number of pa-
tients who no longer suffered from nasal obstruction in
all the non-allergic groups and in group M2A (Figure 4).
The most pronounced improvement occurred in group
M2NA. Postoperatively, 23 of the 29 subjects (79%) of
this group regained the nasal respiratory function. Posi-
tive, though non-significant changes were observed in
groups M7.5A and KTP2A. Whereas the latter two groups
of allergic subjects reported difficulty with nasal breath-
ing preoperatively, 3 of the 7 in group KTP2A and 3 of
the 5 in group M7.5A experienced patent airways post-
operatively.
The outcomes of the two surgical procedures were
compared from the aspect of crusting. In group M2NA,
the incidence of crusting was significantly higher post-
operatively (p < 0.05): preoperatively 6 (21%), post-
operatively 16 (55%) of the 29 subjects complained of
crusting (Figure 5). We did not see such negative effects
of the surgery on crusting in group M2A. All of these
patients had undergone bilateral inferior turbinate sur-
gery and consequently significantly more of them pre-
sented with bilateral crusting. Ten (62%) of the 16 pa-
tients in group M2NA, who reported crusting experi-
enced a thick, smelly discharge from the nasopharynx, 3
(19%) complained of a watery nasal discharge, and only
3 (19%) patients reported no nasal discharge. We did not
find significant changes in crusting in the remaining 4
groups, regardless of the type of surgery.
When considering smell detection, there was a post-
operative improvement in all 6 groups, though it did not
reach the level of significance (Figure 6). The questions
concerning headache, ear pain and reduced hearing acu-
ity revealed significant differences post-operatively.
Headache of the M2NA patients was alleviated. No pa-
tients developed headaches after the operation and 6 of
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Figure 4. Improvement in nasal breathing in patients who underwent mucotomy or KTP laser treatment.
(For nomenclature, see Table 1).
Figure 5. Changes in the incidence of crusting in group M2NA. These patients displayed the most marked
improvement in nasal breathing besides the highest incidence of postoperative crusting.
Figure 6. Moderate, non-significant improvement of sense of smell in all study groups.
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the 15 patients who suffered from headaches preopera-
tively became symptom-free. Moreover, among the M2A
patients, the ear pain diminished and the hearing acuity
improved postoperatively, with 6 of the 11 patients no
longer having complaints.
5. DISCUSSION
Adequate treatment of inferior turbinate enlargement
poses a challenge for functional nasal surgery. Unfortu-
nately, detection of the underlying cause of the hyper-
plasia (allergy, medicamentous rhinitis, vasomotor rhini-
tis or compensatory hyperplasia caused by a septal de-
viation) and its conservative management do not always
result in symptomatic relief. The large variety of surgical
interventions reflects the lack of consensus (Table 2).
We believed that a study comparing the subjective out-
come following mucotomy or KTP laser treatment of the
inferior turbinate would be helpful in developing a thera-
peutic protocol resulting in the best possible quality of
life for the patient. Although rhinomanometry and acous-
tic rhinometry are mainly used for scientific purposes, in
the future these procedures should be applied both pre-
and postoperatively. Their use would allow a detailed
analysis of the correlation between objective and subjec-
tive symptoms [17].
We emphasize that both mucotomy and KTP laser
treatment significantly relieved the nasal obstruction,
which was the major complaint of our patients. After the
interventions, 71% of the subjects questioned, 56% of the
total patient cohort reported a full restoration of their na-
sal respiratory function. In group M2NA, where the im-
provement of nasal obstruction was most pronounced,
the incidence of postoperative crusting increased signi-
ficantly. Most of these patients complained of a thick,
smelly nasal discharge and required regular nasal lavage,
complaints indicative of the emergence of atrophic rhini-
tis. Atrophic rhinitis and the consequent sicca syndrome
are unpleasant consequences of mucotomy and cause a
deterioration of the quality of life. Oezena was not ob-
served among our patients. Fifty-five per cent of the
questioned M2NA patients (43% of the total patient co-
hort) developed crusting. Surprisingly, crusting was not
reported to be considerably more frequent in the long-
term follow-up groups who underwent mucotomy (M7.5A
and M7.5NA). There may be several reasons that explain
this finding: the patients might have become used to
their symptoms and applied nasal ointment or paraffin
oil to their nose, the allergic patients could have received
medication, or mucosal regeneration could have oc-
curred. Despite the lack of symptoms referring to atro-
phic rhinitis, we realize the importance of an even longer
follow-up [12]. The M2A patients did not present with
the negative features of atrophic rhinitis and the inter-
vention did mitigate the nasal obstruction in these pa-
tients. In our opinion, the abundant secretion of the re-
maining nasal mucosa protected them against atrophic
changes. In the future histological examination could
confirm this hypothesis.
Table 2. Types of interventions on the inferior turbinate.
Surgery Advantages Disadvantages
Mechanical Intervention
Medialization of the Inferior Turbinate easy to perform, low risk, can be combined with
other techniques
little symptomatic relief, mucosa remains
hyperplastic
Destructive Interventions
Cryosurgery easy to perform, local an aesthesia is sufficient, no
need for tamponade
symptomatic relief may occur several months
later, bleeding, adhesions, no long-term relief,
crusting
Electrocautery local anesthesia, good haemostasis, relatively ef-
fective
only short-term symptomatic relief (up to 1-2
years)? crusting, adhesion, bleeding, infection
Lasers local anesthesia, good haemostasis, relatively ef-
fective in medium-term (2 years)
adhesion, expensive equipment, training need-
ed
Radiosurgery no adhesion, good hemostasis, relatively effective
in medium-term (2 years)
high cost, limited experience
Resection
Mucotomy easy to perform, long-lasting results bleeding, tamponade, crusting, infection
Partial Turbinectomy easy to perform, long-lasting results crusting
Total Turbinectomy easy to perform crusting, bleeding, tamponade
Submocosal Resection preserves mucosal function, effective, prevents
atrophic rhinitis
tamponade, frequent recurrence of symptoms,
persistent rhinorrhoea
Vidian Neurectomy rhinorrhoea ceases, symptomatic
relief for years
dry eyes; intermittent eye or facial pain; pala-
tal, dental and facial numbness
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The number of M2NA patients suffering from head-
ache was significantly lower postoperatively. All of the
patients whose headache ceased had presented with a
septal deviation and underwent simultaneous septal sur-
gery. We suggest that the remission of the headache was
due to the removal of the septal spine, which penetrated
the inferior turbinate and resulted in ganglion sphenopa-
latine neuralgia. We do not regard the symptomatic relief
as a consequence of the inferior turbinate surgery, but as
a coincidence, for the percentage of patients who under-
went simultaneous septal surgery was extremely high in
this group (86%). We observed that the preoperative ear
pain, fullness sensation and decreased hearing acuity
improved significantly in the M2A patients. These pa-
tients could have exhibited swelling of the mucosa in the
upper respiratory tract, due to allergy, resulting in chro-
nic inflammation of the Eustachian tube. The symptoma-
tic relief was probably due to the appropriate treatment
of allergies. Mucotomy markedly reduces the mucosal
surface and may result in a mucociliary dysfunction in-
creasing the susceptibility to infections. In spite of this,
an increased infection rate was not seen in any of the
groups. A rare, but severe complication of the treatment
of inferior turbinate enlargement is a deterioration of vi-
sual acuity, linked to retrograde embolism or retinal va-
sospasm [20]. One of the mucotomy patients reported a
permanent severe visual loss.
Our observations lead to suggest KTP laser therapy
for non-allergic patients. We assume that submucosal
scarring prevents the fast swelling and shrinkage of the
mucosa. Furthermore, laser treatment alters the autono-
mous nervous system control, impacts on the nasal cycle
and reduces the number and the function of the muci-
nous glands [21]. Two previous studies noted the limited
success of the laser treatment of allergic patients as
compared with non-allergic patients [14,15]. The reason
for this outcome might be that after the operation the
patients return to their usual allergen-contaminated en-
vironment, which results in chronic inflammation of the
mucosa. It is suggested that these patients should be of-
fered more radical treatment options. The small sample
size allows us to draw only limited conclusions from our
study. We consider that, as the first step, allergic patients
should be offered laser treatment, since it is minimally
invasive and can easily be adjusted to the patients’ needs.
It gives comparable or even better results than conven-
tional inferior turbinate surgery. It can be performed at
out-patient clinics and does not require the unpleasant
tamponade of the nose. Janda et al. concluded that the
different types of lasers used in nasal surgery can pro-
vide equally beneficial results if correctly set and applied
[11]. The long-term effectiveness of laser treatment de-
pends greatly on the level of postoperative care. We re-
commend that patients should regularly perform nasal
lavage in order to prevent synechiae formation, inflam-
mation and atrophic rhinitis. However, it is indispensable
to explore the possible long-term side-effects of laser
treatment.
The primary advantage of more invasive procedures
(turbinectomy, turbinoplasty and resection techniques) is
the achievement of the long-term airway patency. Un-
fortunately, radical operations may trigger the appea-
rance of the sicca syndrome. The best approach appears
to be the stepwise treatment of inferior turbinate hyper-
plasia. Following unsuccessful conservative therapy, la-
ser treatment should be offered to both allergic and non-
allergic patients, though long-term benefits are apprecia-
bly less likely for allergic patients. In the event of un-
successful repeated laser treatment, we suggest that pa-
tients should be selected for turbinoplasty. In the future,
several other new treatment options (e.g. radiofrequency
treatment) could be considered [16].
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Appendix: Questionnaire
After the questions in this questionnaire, you will find several possible answers. Please, circle the correct response!
1 Did material run into your mouth from the back of your nose before the operation? Yes No I am not sure
2 If it did what was this material like? Thick Thin Watery
3 If it did, did it have an unpleasant taste? Yes No I am not sure
4 If it did run into your mouth, what colour was it? Yellow Green White Brown
5 Does material run into your mouth from the back of your nose since the operation? Yes No I am not sure
6 If it does, what is this material like? Thick Thin Watery
7 If it does, does it have an unpleasant taste? Yes No I am not sure
8 If it does run into your mouth, what colour is it? Yellow Green White Brown
9 Could you breathe at all through your nose before the operation? Yes No I am not sure
10 Can you breathe at all through your nose since the operation? Yes No I am not sure
11 Did you notice crusty material in your nose before the operation? Yes No I am not sure
12 Have you noticed crusty material in your nose since the operation? Yes No I am not sure
13 Did your acquaintances ever mention an unpleasant smell coming from your nose
before the operation? Yes No I am not sure
14 Have your acquaintances ever mentioned an unpleasant smell coming from your nose
since the operation? Yes No I am not sure
15 Did you notice a change in your sense of smell before the operation? Yes No I am not sure
16 Have you noticed a change in your sense of smell since the operation? Yes No I am not sure
17 Did you often have headache before the operation? Yes No I am not sure
18 Do you often have headache since the operation? Yes No I am not sure
19 Did you have blurred vision before the operation? Yes No I am not sure
20 Have you had blurred vision since the operation? Yes No I am not sure
21 Did you notice any hearing loss or ear pain before the operation? Yes No I am not sure
22 Have you noticed any hearing loss or ear pain since the operation? Yes No I am not sure