Arganbright JM, Jensen EL, Mattingly J, Gao D, Chan KH. Utility of Inferior Turbinoplasty for the Treatment of Nasal Obstruction in ChildrenA 10-Year Review. JAMA Otolaryngol Head Neck Surg. 2015;141(10):901-904. doi:10.1001/jamaoto.2015.1560
Inferior turbinoplasty (IT) in pediatric patients is a common procedure used to treat childhood nasal obstruction. Most of the published IT studies in this population did not control for concurrent airway procedures.
To assess postoperative outcomes in pediatric patients undergoing isolated IT.
Design, Setting, and Participants
Ten-year retrospective review of the medical records of 1770 children (aged <18 years) undergoing an IT procedure at Children’s Hospital Colorado from August 1, 2003, through August 1, 2013. Patients with simultaneous procedures involving the upper airway were excluded. The review identified demographic and clinical information, operative technique, and postprocedural follow-up data. The last follow-up was completed on April 21, 2014. A telephone questionnaire was administered to parents to obtain long-term outcome data. Data were analyzed from March 10 to July 23, 2014.
Main Outcomes and Measures
Demographics, complications, postoperative outcomes, the need for revision surgery and continued use of medication, and overall parent satisfaction with the procedure. Outcomes were assessed with a 5-point Likert scale of parental perception of their child’s ability to breathe through the nose (nasal patency) preoperatively and currently (1 indicates extremely poor; 5, extremely well) and their overall satisfaction rating for the procedure (1 indicates extremely dissatisfied; 5, extremely satisfied).
Of the 1770 children, 107 underwent isolated IT. The mean age of the cohort was 10.5 (range, 1.2-17.9) years. The IT procedures included radiofrequency ablation (72 [67.3%]), microdebridement (19 [17.8%]), and partial turbinate resection (21 [19.6%]). No major complications were observed. Eight revision ITs for persistent nasal symptoms were performed independently of the initial surgical procedure, including 4 of 72 radiofrequency ablations (5.6%), 1 of 19 microdebridements (5.3%), and 3 of 21 partial turbinate resections (14.3%), with no difference among the 3 techniques (P = .10). The parents of 63 patients completed the telephone questionnaire with a mean follow-up of 4.55 (range, 0.63-10.68) years. The combined parental satisfaction on a 5-point Likert scale for the extremely satisfied and satisfied categories was 44 (69.8%), and the nasal patency score improved significantly from 2.0 to 3.4 (95% CI, 1.03-1.65; P < .001), independently of surgical techniques. Thirty-four patients (54.0%) continued to require medical management owing to persistent nasal symptoms. Patients with a history of allergic rhinitis had a greater improvement of nasal patency (2.1 to 3.9; P = .02) and a higher postoperative use of medical therapy (13 of 34 patients [38.2%] vs 21 of 73 [28.8%]; P = .01).
Conclusions and Relevance
Inferior turbinoplasty showed overall utility and was safe and effective in the treatment of nasal obstruction in children for whom medical management had failed. No differences between surgical techniques were found in patient satisfaction, improvement of nasal patency, and recurrence, likely related to sample size. More than half of the patients continued to use medical therapy postoperatively, suggesting that inferior turbinate hypertrophy should not be considered solely as a surgical disease. Allergic rhinitis was identified as a significant comorbidity.
Nasal obstruction caused by inferior turbinate hypertrophy is a common complaint among the pediatric population.1,2 Symptoms include mouth breathing, snoring or obstructive sleep apnea, and nasal drainage. Medical treatments include inhaled nasal corticosteroids, nasal irrigation, systemic medications (eg, leukotriene receptor antagonists, second-generation antihistamines), and immunotherapy. When medical therapy has failed, surgical reduction of the inferior turbinates has become a popular option.3- 5 Goals for the ideal inferior turbinoplasty (IT) include maximizing nasal airflow while limiting crusting and synechiae formation by preserving the turbinate mucosa.2,4
Current surgical techniques for IT include radiofrequency ablation (RFA), microdebridement, and partial turbinectomy, although no consensus on a superior method or device has been established. Despite the popularity of IT in the pediatric population,3 few published data have defined success and failure of this procedure in children.5 Of the prior studies showing a benefit of IT in the pediatric population, most did not control for concurrent airway procedures, making it difficult to assess the efficacy of the turbinate reduction alone.1,2,6- 9 A few studies10- 13 have limited their study population to children undergoing inferior turbinate reduction alone, but these studies have small sample sizes and short follow-up. The present study aimed to assess the outcomes of pediatric patients undergoing isolated IT. Our study goals were to identify possible differences in surgical techniques, establish the overall satisfaction rate, and explore the success and failure rates of this procedure.
We undertook a retrospective review of the medical records for patients younger than 18 years who underwent an isolated inferior turbinate reduction procedure from August 1, 2003, through August 1, 2013, at Children’s Hospital Colorado. The initial patient list was generated to include all patients undergoing turbinate reduction within the specified 10-year period. All patients who underwent simultaneous procedures involving the upper airway (ie, septoplasty, sinus surgery, adenoidectomy, and tonsillectomy) were excluded to generate the final cohort (follow-up completed on April 21, 2014). This study was approved by the institutional review board of Children’s Hospital Colorado. Informed consent was waived and data were deidentified.
Data analysis was conducted from March 10 to July 23, 2014. Clinical records were reviewed for demographic data, comorbidities (history of allergic rhinitis and/or asthma), preoperative symptoms, and operative technique. Primary outcome measures included persistent symptoms that required continued postoperative medical treatment, the need for revision surgery, and surgical complications. To obtain long-term outcome data, we administered a telephone survey to the parents of the patients. We used a 5-point Likert scale to obtain parental perception of their child’s ability to breathe through the nose (nasal patency) preoperatively and postoperatively (1 indicates extremely poor; 5, extremely well) and their overall satisfaction rating for the procedure (1 indicates extremely dissatisfied; 5, extremely satisfied). The survey also addressed whether the patients continued the use of medical therapy.
We used logistic regression to evaluate the relationship between IT techniques and the outcome variables, the χ2 test to assess the possible association between IT technique and overall satisfaction score, and the paired t test to evaluate whether the postoperative nasal patency scores improved significantly compared with the preoperative score. The patients with allergic rhinitis and asthma underwent review as subcohorts, and we compared outcomes and satisfaction scores among patients with and without these comorbidities.
We identified a total of 1770 patients who underwent IT during the 10-year study period. Of these, 107 patients underwent isolated IT and were included. The mean patient age was 10.5 (range, 1.2-17.9) years. Boys constituted most of the patient population (68 [63.6%]). The most common preoperative symptoms were nasal obstruction, mouth breathing, nasal drainage, and snoring. Comorbidities documented in the patients’ clinical records included allergic rhinitis (34 patients [31.8%]) and asthma (36 [33.6%]); of these patients, 13 (12.1%) were documented as having both comorbidities. All patients had documented trial and failure of medical treatment (intranasal corticosteroid therapy with or without the use of an oral antihistamine) before IT. The IT techniques included RFA (72 patients [67.3%]), microdebridement (19 patients [17.8%]), and partial turbinate resection, which involved removal of the inferior one-third of the inferior turbinate (21 patients [19.6%]). All procedures were accompanied with outfracture of the inferior turbinates. No major complications were documented. Bleeding was the most common minor complication in 8 patients. One of these 8 patients subsequently visited the emergency department; none required surgical intervention.
Revision IT was performed in 8 patients (7.5%). The techniques used for revision IT included RFA (4 of 72 patients [5.6%]), partial inferior turbinate resection (3 of 21 [14.3%]), and microdebridement (1 of 19 [5.3%]). All patients who needed revision IT for persistent nasal symptoms underwent RFA as their initial procedure. Revision surgery rates were similar among the 3 surgical techniques (P = .10). Age was not statistically associated with the need for revision surgery (P = .72), and no patient required a second revision surgery.
Parents of 63 patients (58.9%) were available for completion of the telephone survey. The median time of the telephone survey follow-up, defined as the time from the surgical date to the date of the telephone interview, was 4.55 (range, 0.63-10.68) years. The technique distribution for survey responders was similar to that for the complete study population. Overall satisfaction scores based on the 5-point Likert scale showed that 24 respondents (38.1%) were extremely satisfied, 20 respondents (31.7%) were satisfied, 13 respondents (20.6) were neutral, and 5 respondents (7.9%) were dissatisfied or extremely dissatisfied with the procedure. Surgical technique was not statistically associated with the overall satisfaction score. The mean preoperative nasal patency score was 2.0 and improved to 3.4 at the time of the questionnaire. This improvement was statistically significant (95% CI, 1.03-1.65; P < .001). The nasal patency scores were not associated with surgical technique. More than half the patients (34 [54.0%]) continued to require medical management for persistent nasal symptoms. Medications included intranasal corticosteroid spray (n = 13), oral antihistamine (n = 10), or both (n = 11).
Similar comparisons were made with respect to the presence or the absence of comorbid allergic rhinitis and asthma. Thirty-four patients (31.8%) in the allergic rhinitis group reported a greater degree of improvement in their nasal patency scores (2.1 to 3.9; P = .02); however, patients with allergic rhinitis required continued use of medical therapy significantly more often than those without (13 of 34 patients [38.2%] in the allergic rhinitis group and 21 of 73 [28.8%] in the nonallergic rhinitis group; P = .01). Asthma as a comorbidity (documented in 36 patients [33.6%]) was found not to influence outcomes. When the comorbidities of allergic rhinitis and asthma were combined, we noted a significant improvement in nasal patency scores (2.0 to 3.6; P = .03).
Multiple techniques have been proposed for IT; the most commonly reported among pediatric otolaryngologists are RFA and microdebridement.3 A study by Chen et al4 is the only publication that has compared microdebridement and RFA directly within the pediatric population. They concluded that both techniques were effective at improving nasal obstruction in children with inferior turbinate hypertrophy but that the microdebridement was superior to RFA in its ability to preserve mucosa. In the present study, the 3 surgical techniques used included RFA, microdebridement, and partial inferior turbinate resection. This study failed to show a difference between techniques in terms of complications, the need for continued medical therapy, the need for revision surgery, subjective improvement in nasal patency, or overall satisfaction rating. We believe that the failure to see any difference between the surgical techniques is likely driven by sample size.
Within the current literature, the success and failure rates of pediatric inferior turbinate reduction surgery have not been defined or discussed. We found that success and failure are based on the definitions used. If we define a failed IT procedure as one that requires a revision surgery, then this study reports a 7.5% failure rate and thus a 92.5% success rate. Only a few studies have reported the percentage of patients requiring revision IT, which ranged from 6% to 8%.2,14 We assert that this definition is influenced by many factors, including parental interpretation of quality of life and the surgeon’s desire to pursue revision, both of which are subjective. If we define a failed IT procedure as one that requires the continued use of medical therapy postoperatively, then we show a 54.0% failure rate and only a 46.0% success rate. This finding would discourage the concept of inferior turbinate hypertrophy as a purely surgical disease. Discussion with patients and families as to the likelihood of the continued need for medical therapy after surgery is essential. To our knowledge, no prior studies have addressed long-term maintenance therapy for symptoms requiring postoperative medical therapy in the pediatric population.
A significant underlying comorbidity of this population is allergic rhinitis, which likely is a major driver of this disease. Our study showed an increased need for postoperative medical therapy in patients with allergic rhinitis. A single study has specifically looked at the effectiveness of IT in patients with allergic rhinitis: Siméon et al11 examined isolated IT using the coblation technique in 9 pediatric patients with allergic rhinitis. The authors concluded that inferior turbinate coblation is recommended in patients with allergic rhinitis and medically refractory nasal obstruction. The percentage of patients who required continued medical therapy postoperatively was not discussed. Larger studies are needed to determine the true significance of allergic rhinitis on IT outcomes and to determine whether this subset of patients should be treated as a separate cohort when considering pediatric IT. Although a history of asthma alone failed to influence patient postoperative satisfaction, patients with a history of allergic rhinitis and asthma showed improved nasal patency. This finding suggests that a history of asthma might have a minor role in symptom reduction.
Limitations include the sample size for isolated IT. In addition, the telephone survey was at risk for recall, response, and reporting bias, and objective outcome measures for determining nasal airway patency were not used.
Our methods for performing IT involve determining whether the turbinates can be decongested in the office setting. If so, RFA or microdebridement turbinoplasty is chosen as the first-line surgical procedure based on surgeon’s preference. If the turbinates do not decongest, partial turbinectomy is considered. For revision surgery, a partial turbinectomy is preferred.
This study supports the overall utility of IT as an effective treatment option for children with nasal obstruction and inferior turbinate hypertrophy in whom medical therapy has failed. No differences between surgical techniques were found in patient satisfaction, improvement of nasal patency, and recurrence, likely related to sample size. A large percentage of patients continued to use medical therapy postoperatively, which suggests that inferior turbinate hypertrophy should not be considered solely as a surgical disease. Allergic rhinitis was identified as a significant comorbidity in this disease process.
Submitted for Publication: March 4, 2015; final revision received May 18, 2015; accepted June 30, 2015.
Corresponding Author: Kenny H. Chan, MD, Department of Pediatric Otolaryngology, Children’s Hospital Colorado, 13123 E 16th Ave, Mailbox B-455, Aurora, CO 80045 (firstname.lastname@example.org).
Published Online: September 3, 2015. doi:10.1001/jamaoto.2015.1560.
Author Contributions: Ms Jensen and Dr Chan had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Arganbright, Chan.
Acquisition, analysis, or interpretation of data: Arganbright, Jensen, Mattingly, Gao.
Drafting of the manuscript: Arganbright, Chan.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Jensen, Gao.
Administrative, technical, or material support: Jensen, Mattingly.
Study supervision: Arganbright, Chan.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported in part by grant UL1 RR025780 from the Colorado Clinical and Translational Sciences Institute,National Institutes of Health (NIH)/National Center for Research Resources.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents are the authors’ sole responsibility and do not necessarily represent the official views of the NIH.
Previous Presentation: This paper was presented at the Spring 2014 Annual Meeting of the American Society of Pediatric Otolaryngology; May 17, 2014; Las Vegas, Nevada.