POWERED INFERIOR TURBINOPLASTY
Modified Endoscopic Turbinoplasty, Submucosal Powered Turbinoplasty, and Submucosal Electrocautery: Randomized Trials
This article describes two prospective, randomized, controlled, double-blinded trials: one comparing submucosal electrocautery (SEC) with submucosal powered turbinoplasty (SPT) and one comparing SPT with modified endoscopic turbinoplasty (MET). All patients had symptomatic nasal obstruction (allergic or nonallergic) that was unresponsive to medical therapy. The turbinate reduction method was determined randomly. Patients with odd numbers underwent SPT on the left side and those with even numbers underwent SPT on the right side. The opposite turbinate was treated with SEC or MET, depending on the trial. Patients' subjective scores for nasal obstruction and rhinorrhea were obtained 1, 4, and 12 months after surgery, as were results of clinical examinations, rhinometry, anterior rhinoscopy, and nasendoscopy conducted by examiners blinded to the treatment method.

The MET procedures included creation of a window at the anterior aspect of the inferior turbinate
to access the lateral mucosa, rather than medial fracturing of the turbinate, which can destabilize
it and make the reduction procedure more difficult. A microdebrider blade (Medtronic Xomed) was
used to remove mucosa on the lateral aspect of the inferior turbinate and expose the turbinate
bone. An elevator was employed to lift the medial mucosa away from the bone in a subperiosteal
plane, thereby allowing a sharp dissection and reduction of trauma to the mucosa.

The only postoperative complications in the study were moderate bleeding (not requiring packing), which occurred in none of the 50 patients who had SEC, 7 of the 100 patients who had SPT, and 2 of the 50 patients who had MET; crusting, which occurred in 58% SEC, 2% SPT, and no MET patients; and pain, which occurred in 22% SEC, 9% SPT, and 14% MET patients.
In the SEC vs SPT trial, both procedures initially improved subjective nasal obstruction symptoms
effectively in at least 92% of cases. Over time, however, regular use of decongestants increased
in both treatment groups, suggesting a deterioration in the benefit the therapy. The examiner
assessments revealed a significantly higher rate of improvement in nasal patency in the SPT group.

In the SPT vs MET trial, both procedures initially improved subjective nasal obstruction symptoms
effectively in at least 96% of cases. In the SPT group, however, regular use of decongestants
increased from 1 to 12 months postoperatively. In the MET group compared with the SPT group,
significantly more patients had relief of nasal obstruction with only occasional or no use of
decongestants at the 4- and 12-month assessments. The rate of change between the objective
examiner scores comparing SPT to MET was not statistically significant. None of the three
procedures decreased rhinorrhea significantly. 

The authors conclude that powered turbinoplasty provides an effective, reliable, long-term
improvement in nasal airway patency and relief of nasal obstruction, with minimal complications.
They also comment that powered turbinoplasty is cost-effective and technically straightforward.
Sacks R, Thornton MA, Boustred RN. Modified endoscopic turbinoplasty—long-term results compared to submucosal electrocautery and submucosal powered turbinoplasty. Presented at: American Rhinologic Society Spring Meeting; May 13-16, 2005; Boca Raton, FL.

Inferior Turbinate Reduction with the Microdebrider
This article describes the microdebrider (Medtronic ENT) submucosal procedure for reducing
the nasal turbinates in children with sleep disordered breathing (SDB) associated with turbinate
swelling refractory to medical treatment. The author notes that there are a variety of techniques
for reducing turbinate size, but the ideal procedure spares the mucosal lining, thereby promoting a quicker recovery and possibly decreasing the likelihood of excessive bleeding and the development of atrophic rhinitis. For these reasons, the author terms the Medtronic ENT inferior turbinate blade to be an ideal instrument for performing the procedure.

Most turbinate reductions for SDB are done in conjunction with an adenotonsillectomy, which
is performed first. At the beginning of the reduction procedure, a nasal decongestant spray is
applied and the anterior aspect of the inferior turbinate is injected with lidocaine with epinephrine.
The blade of the microdebrider (which has an elongated flat surface on one side that facilitates
dissection) is positioned at the anterior-inferior edge of the inferior turbinate. The blade is then
bluntly inserted at a 45-degree angle until it touches the turbinate bone. The microdebrider is set
in oscillating mode at 1000 cycles per second, and the blade is pushed posteriorly along the bone for about 2 cm; going further may violate the mucosal lining and cause excessive bleeding. Once a pocket has been developed between the turbinate bone and submucosal layer, the blade is rotated to face the mucosa lining and the submucosal layer is resected. The author believes that the use of a lower cycle-per-second setting helps maintain the integrity of the lining. Postoperatively, minor oozing may occur for a few hours or days. The author states that the role of nasal obstruction in sleep-disordered breathing is often overlooked by clinicians, and concludes that turbinate reduction with the microdebrider is a simple and safe technique.
Friedman NR. Inferior turbinate reduction: an application for the microdebrider. Oper Tech Otolaryngol 2005;16:232-4.

Intraturbinate Stroma Removal with the Microdebrider in Chronic Hypertrophic Rhinitis
The author describes the microdebrider technique he uses for reduction of hypertrophic turbinates and briefly reviews his results in 63 patients. Under visualization through a rigid endoscope or surgical microscope, an anesthetic and vasoconstricting agent is infiltrated into the head of the inferior turbinate. An incision is made on the inferior and lateral border of the head, a plane is created along the turbinate, and the microdebrider tip is inserted into it. The microdebrider speed is set to 1800 rpm, with the suction indicator set to low. The tip is moved in a circular motion to remove stroma. The entire procedure takes only a few minutes. Nasal packing material soaked in oxymetazoline is kept in place for a few hours postoperatively. If a very enlarged turbinate tail is present, the reduction procedure can be performed in front of or over its body to debride stroma from the site. In the author's series, no nasal bleeding occurred after the microdebrider procedure. Postoperative problems were minor and consisted of nasal congestion in 47 patients at 1 week after surgery, 18 patients at 2 weeks, and 3 patients at 1 month. Postoperative burning or itching and rhinorrhea occurred in a maximum of two and four patients, respectively. Pain was not reported by any patient. No problems were reported after 1 month. Among the 63 patients treated, 57 had improvements in subjective symptoms by 4 weeks after surgery, 61 by 2 months, 62 by 6 months, and all by 1 and 2 years. The author concludes that the microdebrider method is safe and reliable. In addition, because it is a mucosa-sparing technique, mucociliary flow patterns are not disturbed, so protection, filtration, and humidification processes continue and iatrogenic atrophic rhinitis is unlikely to develop. In contrast, many common methods for treating turbinate hypertrophy, including cauterization, diathermy, cryotherapy, total or partial resection, and laser treatment, are destructive.
Yáñez C. New technique for turbinate reduction in chronic hypertrophic rhinitis: intraturbinate stroma removal using the microdebrider. Oper Tech Otolaryngol Head Neck Surg 1998;9:135-7.

Powered Instrumentation for Submucous Resection of the Inferior Turbinates
The authors note that submucous resection of the inferior turbinates is a conventional technique
for decreasing turbinate size to alleviate airway obstruction. Several methods have been used to
reduce the turbinates, including turbinectomy, submucous turbinectomy, inferior turbinoplasty,
cryotherapy, submucous electrosurgery, and carbon dioxide laser turbinoplasty. None of these
techniques is perfect, and each has been associated with complications such as excessive resection resulting in atrophic rhinitis, postoperative bleeding, and crusting. Most also involve destruction of the mucosa, which affects nasal physiology, yet the main goal of inferior turbinate surgery should be preservation of mucosal surfaces while reducing submucosal and bony tissue. In an effort to achieve this goal, the authors began to use powered microdebrider instrumentation. This article describes their results with this technique in a prospective study enrolling 120 patients with symptoms and signs of nasal obstruction and stuffiness related to enlarged turbinates.

The microdebrider procedure begins with an incision in the anterior aspect of the bony turbinate and the creation, by sharp dissection, of a submucosal pocket on its medial surface. The microdebrider is inserted into this pocket. The bony turbinate and some of the submucosal tissue are debrided with the device set in 3000-cps oscillating mode. Hemostasis is achieved by using suction electrocautery under direct visualization. The incision is not closed. The reduction in turbinate size is immediately apparent.

Preoperatively and 6 weeks postoperatively in this series, anterior rhinoscopy and nasal endoscopy were used to grade the size of the turbinates. Patients also completed questionnaires about their nasal symptoms before and 6 weeks after surgery.

Postoperative bleeding necessitating a return to the operating room occurred in two patients
(1.6%) early in the series; subsequently, a modification in cautery technique was made and no
additional bleeding complications occurred. Mucosal tears were observed in 55% of patients, but
there was no loss of mucosa. Synechia developed in 5%. No patient had crusting, foul odor, or
nasolacrimal duct injury. The questionnaire data showed that the number of patients with severe
bilateral nasal obstruction or stuffiness decreased from 100 preoperatively to none postoperatively. Ninety patients had no nasal obstruction or stuffiness after surgery. Reduction of the inferior turbinates was observed in all patients.

The authors note that the microdebrider allows precise and incremental tissue removal, thereby
preventing many of the complications associated with inferior turbinate surgery. They believe
that the ability to debulk the turbinate while preserving the mucosa is the major advantage of the
powered procedure. The authors conclude that microdebrider submucous resection of the inferior turbinates is a safe method for achieving turbinate size reduction in patients with nasal obstruction due to inferior turbinate hypertrophy.
Friedman M, Tanyeri H, Lin J, Landsberg R, Caldarelli D. A safe, alternative technique for inferior
turbinate reduction. Laryngoscope 1999;109:1834-7.

Mucosal-Sparing Techniques for Office Treatment of Inferior Turbinate Hypertrophy
Each of the three authors describes a different, innovative office procedure for inferior turbinate
hypertrophy. The authors note that there are many methods for reducing the inferior turbinates.
Most improve the nasal airway, but the structures that remain postoperatively may be unable to
regulate airflow adequately, and morbidity (bleeding, crusting, and pain) varies considerably. The
three new approaches described all have mucosal preservation as one of their basic goals.

The first approach, radiofrequency volumetric tissue reduction, uses radiofrequency (RF) heating
to induce submucosal tissue destruction that results in a decrease in tissue volume. The procedure employs an RF generator (Somnus Medical Technologies) connected to a single-use delivery tip and handpiece. Under direct visualization, the RF electrode is placed in the anterior inferior portion of the turbinate and RF energy is delivered at maximum settings of 10 W, 75°C, and 500 J for about 90 seconds. A topical vasoconstrictor is applied to minimize bleeding. The author has found this procedure to be quick and associated with high patient satisfaction and tolerance. A 70% to 80% subjective improvement can be expected. Disadvantages include the equipment cost and risk of mucosal ulceration and epistaxis. The technique also has limitations with respect to precise control of the degree of tissue reduction and obtaining access to the posterior aspect of the inferior turbinate.

The Coblation® method (ENTec Arthrocare) uses RF energy between electrodes in a saline medium to create a field of ionized sodium molecules capable of ablating tissue. The author uses the bipolar wand to make four to six tunnels on each inferior turbinate. In each tunnel, the wand is advanced along the underlying bone with the Coblation mode activated and then withdrawn slowly with the cautery mode activated. Bleeding from the puncture sites is common, so topical oxymetazoline is applied. The author concludes that the Coblation procedure allows rapid, aggressive reduction of the entire inferior turbinate, which retains its ability to function as a filter and humidifier. Patients recover quickly, with minimal pain and nasal problems.

Microdebrider-assisted turbinate reduction involves excision of the erectile soft tissue of the inferior turbinate with preservation of the overlying mucosa. A stab incision to the level of the turbinate bone is made at the anterolateral surface of the inferior turbinate, and a supraperiosteal
plane of elevation is developed. A suction elevator is inserted to clear blood from the operative
field. The active face of the microdebrider blade is positioned outward toward the mucosal surface. Soft tissue is then resected under endoscopic visualization. Areas of dissection and stroma removal should include the turbinate surface and the lateral wall, lateral and superior to the turbinate attachment. The author mentions several advantages of the microdebrider approach. First, in contrast to thermoreductive techniques, it allows definitive, controlled volume reduction. Second, the resection can be tailored to individual anatomical variations. Third, the turbinate mucosa is preserved, allowing rapid healing and preservation of the humidification and mucociliary transport properties of the turbinate. Finally, the approach can be done either in the operating room as an adjunct to other procedures or in the clinic as the sole procedure. The risk of postoperative bleeding after microdebrider treatment is higher than that after thermoablative procedures, but packing is effective in minimizing the risk. Also, care must be taken to avoid perforating the mucosal turbinate flap during resection using the microdebrider.
Lee KC, Hwang PH, Kingdom TT. Surgical management of inferior turbinate hypertrophy in the office: three mucosal sparing techniques. Oper Tech Otolaryngol Head Neck Surg 2001;12:107-111.

OTHER INFERIOR TURBINOPLASTY TECHNIQUES
Randomized, Long-Term Trial of Six Treatments for Inferior Turbinate Hypertrophy
In this 6-year study, 382 patients with nasal obstruction due to turbinate hypertrophy unresponsive to medical therapy were randomly assigned to undergo one of six surgical procedures to reduce the turbinates: turbinectomy, carbon dioxide laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateral displacement. The submucosal resection technique in this paper appears to describe a manual version of the powered removal of stromal tissue. Turbinectomy involved medial and upward fracture and resection by angled scissors along the insertion close to the lateral nasal wall. Electrocautery employed a high-frequency current delivered at a constant power to coagulate the medial surface of the inferior turbinate. For cryotherapy, a standard nasal probe was applied along the free edge and medial face of the inferior turbinate. In submucosal resection, an incision was made on the head of the inferior turbinate, submucosal tissue was dissected from the medial surface and inferior edge of the bone with an elevator, excess cavernous tissue was resected with a Hartmann forceps, and the posterior end of the turbinate was resected. Submucosal resection with lateral displacement included out-fracture and lateral displacement of bone.

Postoperatively, the turbinectomy, laser cautery, electrocautery, and cryotherapy groups had
chronic crusting in 34, 40, 39, and 40 cases, respectively, with synechiae developing more
frequently in the electrocautery group (21 cases). Bleeding occurred only in patients treated
with turbinectomy (25 cases), submucosal resection (10 cases), or submucosal resection with
displacement (8 cases). Patients underwent yearly postoperative examinations for up to 6 years.
A significant initial postoperative improvement in nasal resistance values (on rhinomanometry
and nasal volume assessments) occurred in all treatment groups (P < 0.001), but there were
significant differences among groups in improvement duration. Patients given turbinectomy or
submucosal resection had normal, sustained nasal patency during follow-up. In contrast, patients who underwent electrocautery or cryotherapy had a progressive, significant worsening of nasal resistance (P < 0.005) and nasal volume values (P < 0.001). After laser treatment, nasal resistance improved and remained normal, but nasal volumes decreased dramatically during the 6 follow-up years (P < 0.001). Only patients who had a submucosal procedure achieved normal mucociliary transport times and secretary IgA concentrations (P < 0.001), with those who also underwent lateral displacement having the best results.

The authors note that the ideal surgical approach to inferior turbinate hypertrophy should be
limited to the erectile submucosal tissue and bony turbinate because the reduction in bone size will create more respiratory space, the surgical maneuvers on the submucosal tissues will create scars that can minimize submucosal engorgement in patients with allergic rhinitis, and the preservation of the mucosa will minimize interference with physiologic functions. The authors conclude that submucosal resection with lateral displacement comes closest to this ideal and recommend it as the first-choice treatment for nasal obstruction due to inferior turbinate hypertrophy.
Passàli D, Passàli FM, Damiani V, Passàli GC, Bellussi L. Treatment of inferior turbinate hypertrophy: a randomized clinical trial. Ann Otol Rhinol Laryngol 2005;112:683-8.

Coblation® Inferior Turbinate Reduction
This prospective study investigated the safety and clinical effectiveness of the Coblation
radiofrequency technique (ENTec Arthrocare) for inferior turbinate reduction in 26 adult patients with soft-tissue inferior turbinate hypertrophy unresponsive to medical therapy. The patients completed the Rhinosinusitis Symptom Inventory (RSI) and a short-form nasal questionnaire before and 3 and 6 months after treatment. Two patients (8%) had marked epistaxis after the procedure; one required nasal packing for 24 hours. At both the 3- and 6-month follow-up assessments, there were significant improvements over preoperative RSI and nasal-questionnaire scores for nasal symptoms, systemic symptoms, overall sinonasal symptoms, degree of nasal obstruction, and amount of time with nasal obstruction. There were no significant improvements in mucus production, postnasal discharge, or snoring. The authors conclude that the Coblation method is quick and yields good, persisting clinical results. Moreover, as a submucosal technique, it preserves overall nasal physiologic features and is therefore preferred to turbinectomy or surface methods. Coblation radiofrequency is not appropriate for patients with primarily bony turbinate hypertrophy or extremely narrow piriform apertures. The authors note that a disadvantage of the Coblation technique is that patients sometime feel the thermal effect during deep or more posterior turbinate reductions.
Bhattacharyya N, Kepnes LJ. Clinical effectiveness of coblation inferior turbinate reduction. Otolaryngol Head Neck Surg 2003;129:365-71.

Submucosal Diathermy for Chronic Nasal Obstruction Due to Turbinate Enlargement
This study was a retrospective review of the medical records of 91 patients who underwent
submucosal diathermy (SMD) for nasal obstruction due to inferior turbinate hypertrophy that had
been unresponsive to common medical treatments for at least a year. In all patients, SMD was
the only procedure used. Patients were questioned before the procedure about nasal obstruction, chronic nasal discharge, snoring, headaches, and hyposmia or anosmia. An anterior and posterior rhinoscopic assessment and an airflow measurement using a Gertner-Podoshin nasal plate were performed preoperatively in each patient. The operation involved insertion of a diathermy needle into the anterior end of the inferior turbinate, advancement of the needle submucosally until the posterior end of the turbinate was reached, and withdrawal of the needle over a 30-second period with the current applied. The patients were evaluated 2 months and 1 year postoperatively by means of a questionnaire about breathing through the nose, rhinoscopic assessments, and airflow measurements using the nasal plate. There were no complications from the SMD procedure. At the 2-month examination, 64 of the 91 patients (70.3%) had subjective improvement in nasal breathing and 73 (80.2%) had good nasal breathing on the nasal-plate assessment. During the first postoperative year, a second operation was performed in 16 patients because of unsatisfactory results from the initial procedure; these patients were excluded from the second evaluation. At 1 year postoperatively, 65 of the remaining 75 patients (86.7%) were symptom free with respect to nasal breathing, and 67 (89.3%) had good nasal breathing on the nasal-plate assessment. The authors note that SMD requires only local anesthesia, that it can performed in the office, and that it does not require expensive equipment. The authors conclude that SMD is a safe and effective technique for improving nasal breathing for both the short and long term in patients with chronically obstructive inferior turbinates.
Fradis M, Malatskey S, Magamsa I, Golz A. Effect of submucosal diathermy in chronic nasal obstruction due to turbinate enlargement. Am J Otolaryngol 2002;23:332-6.

Biopolar Radiofrequency Cold Ablation for Inferior Turbinate Hypertrophy
In this prospective study, the Coblation radiofrequency (ENTec Arthrocare) technique (set to a
power of 6 and used for 1 to 6 passes of 10 to 20 seconds each) was used to reduce the inferior
turbinates in 31 adult patients with symptomatic inferior turbinate hypertrophy unresponsive to
medical management. In one patient, treatment was terminated prematurely because of pain;
another patient had epistaxis requiring overnight packing. Postoperative pain was minimal; 12
patients said they had none. Most patients required minor debridement of crusting at the anterior
turbinate head at their 2-week postoperative visit; no bleeding occurred after this procedure and
no patient had substantial granulation tissue. Six weeks and 3 months after surgery, scores on the Rhinosinusitis Symptom Inventory were significantly lower than preoperative scores (P < 0.025) for all nasal symptoms except nasal congestion. One patient had recurrence of nasal obstruction. The authors note that the Coblation technique has the following advantages over electrocautery or monopolar radiofrequency reduction: the immediate tissue reduction allows the surgeon to assess the degree of turbinate reduction and further tailor the treatment approach; collateral tissue damage may be minimal, especially compared with that associated with conventional electrocautery; and the procedure is rapid and well tolerated. The authors also comment that the Coblation technique has a definite learning curve and that, in their series, adjustment of anesthesia practices was required to prevent pain during treatment. Moreover, some oozing from the turbinate entry point can be expected, and this led to their case of epistaxis.
Bhattacharyya N, Kepnes LJ. Bipolar radiofrequency cold ablation turbinate reduction for obstructive inferior turbinate hypertrophy. Oper Tech Otolaryngol Head Neck Surg 2002;13:170-4.

Radiofrequency for Turbinate Hypertrophy
In a prospective study in 14 patients with chronic nasal obstruction unresponsive to medical
treatment and no septic deformity, the authors used radiofrequency tissue reduction (S215 system; Somnus Medical Technologies) to treat inferior turbinate hypertrophy. Patients were placed under local anesthesia, and three punctures were made in each turbinate. The maximum values for temperature, power, local energy, and procedure duration were 85°C, 8 W, 350 J, and 2.5 minutes, respectively. Three patients had pain during the procedure; in two, treatment had to be stopped. None of the patients took any analgesic medication postoperatively. Patients were evaluated before and on days 3, 7, and 60 after the procedure. Compared with preoperative findings, the abundance of secretions was increased significantly on day 3 and decreased significantly on day 60; turbinate edema was increased significantly on both day 3 and day 60. Assessments using a visual analogue scale showed a significant decrease in both daytime (P < 0.0005) and nighttime (P < 0.00001) nasal obstruction. Acoustic rhinometry showed a significant postoperative reduction in turbinate hypertrophy. Saccharine transit times decreased significantly by day 60, whereas values for ciliary beat frequency were not significantly different from those observed before surgery. The authors conclude that the radiofrequency method is a useful alternative for reducing turbinate volume while preserving the integrity and function of the surface epithelium. Patients should be informed preoperatively about the temporary nasal blockage, rhinorrhea, and inflammatory reaction that may occur after the procedure.
Coste A, Yona L, Blumen M, Louis B, Zerah F, Rugina M, Peynègre R, Harf A, Escudier E. Radiofrequency is a safe and effective treatment of turbinate hypertrophy. Laryngoscope 2001;111:894-9.

Radiofrequency Treatment of Turbinate Hypertrophy: Randomized Trial
This randomized, single-blinded clinical trial compared radiofrequency volumetric tissue reduction (RFVTR) with a placebo procedure in the treatment of nasal obstruction in 32 patients with inferior turbinate hypertrophy. In patients assigned to the treatment arm, local anesthetic agents were administered, the RFVTR probe was inserted into the anterior end of the inferior turbinate until the active tip was submucosal, and delivery was accomplished with the setting of a target temperature of 75°, 15 W, and 500 J (Somnus Medical Technologies). The patients in the placebo group underwent the same procedure, including application of local anesthetics, but no energy was delivered. The sounds of the machine were preserved to simulate treatment. The results of treatment were evaluated with use of a visual analogue scale (VAS) completed by the patients before and 8 weeks and 6 months after the procedure. Each patient also responded to a survey about complications, including pain and bleeding, and underwent a nasal examination. Preoperatively, the treatment and placebo groups (n = 16 each) were comparable with respect to gender, race, age, allergy characteristics, and VAS scores. There were no major complications during or after any procedure. Four patients (two in each group) had mild to moderate pain during and shortly after the procedure; this was relieved by acetaminophen. Follow-up examinations showed no evidence of crusting, ulceration, or surrounding mucosal damage. The inferior turbinates were appreciably smaller in most patients given RFVTR. Analysis of the preprocedure and 8-week VAS scores showed that both the treatment and placebo groups had significant postprocedure improvements in the three outcome measures analyzed: frequency of obstruction, severity of obstruction, and overall ability to breathe. However, the amount of improvement was significantly greater in the treatment arm than in the placebo group with respect to severity of obstruction and ability to breathe. Moreover, 100% of the patients in the treatment arm but only 44% in the placebo arm had improvements in all three outcome measures. Six months after RFVTR, the mean VAS scores for the treated patients assessed (including 12 from the placebo arm who chose to undergo RFVTR after the 8-week evaluation) were significantly better than the pretreatment VAS scores for all three outcome measures. The authors conclude that their study confirmed that RFVTR is a safe procedure that is easily performed in an office setting and that produces improvements in nasal obstruction significantly better than those provided by placebo. Nease CJ, Krempl GA. Radiofrequency treatment of turbinate hypertrophy: a randomized, blinded, placebo-controlled clinical trial. Otolaryngol Head Neck Surg 2004;130:291-9.

Radiofrequency Volumetric Tissue Reduction for Turbinate Hypertrophy
This prospective pilot study done at Stanford University evaluated the safety and effectiveness of radiofrequency volumetric tissue reduction (RFVTR) in the treatment of 22 patients (43 turbinates) with nasal obstruction and associated turbinate hypertrophy refractory to medical therapy. The study design limited application of RFVTR to the anterior third of the inferior turbinate. Preoperatively, all patients underwent anterior rhinoplasty with direct visual inspection of the anterior nasal cavity and grading (on a 5-point scale) of the severity of nasal obstruction at the anterior end of the inferior turbinate. Visual analogue scales (VASs) were used to evaluate nasal breathing and snoring preoperatively and to assess nasal breathing, snoring, pain, and patient satisfaction the day after treatment, 2 or 3 days after treatment, and 1, 4, and 8 weeks postoperatively. During the RFVTR procedure, a radiofrequency (RF) needle electrode was inserted submucosally into the anterior head of the anterior turbinate under direct vision. RF was delivered 8 at 465 kHz for 60 to 90 seconds with a custom electrode, an RF generator, and a computercontrolled algorithm (Somnus Medical Technologies). Topical oxymetazoline was applied for hemostasis. Four patients (19%) had mild discomfort during the treatment, and two had numbness of the teeth. No bleeding, crusting, dryness, or foul odor occurred. Mild edema was observed on the first postoperative day and lasted up to 48 hours; it was not severe enough to block the airway but was correlated with a worsening of nasal obstruction for up to 48 hours after surgery. Postoperative pain was nonexistent or mild in 20 patients (91%); 3 patients required postoperative analgesia (acetaminophen). By 8 weeks after treatment, subjective nasal breathing had improved in 21 of the 22 patients and patient satisfaction with the therapy was high. There were also significant improvements in VAS scores for the degree and frequency of nasal obstruction and in the extent of obstruction determined by clinical examinations (P < 0.0001 for all differences between preoperative and postoperative findings). Snoring decreased in 12 of 13 patients and worsened in one. The authors note that RFVTR is safer than submucous diathermy or electrocautery partly because the tissue temperatures, power levels, and voltage required are much lower. They conclude that RFVTR has minimal side effects and achieves subjective improvement in patients with symptoms of nasal obstruction and that future investigations of this technique for managing turbinate hypertrophy are warranted and needed.
Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Radiofrequency volumetric tissue reduction for treatment of turbinate hypertrophy: a pilot study. Otolaryngol Head Neck Surg 1998;119:569-73.

Submucosal Bipolar Radiofrequency Ablation of Inferior Turbinates
The aim of this prospective, nonrandomized study was to assess the efficacy and morbidity of
bipolar radiofrequency thermal ablation (bRFTA; Coblation system; ENTec Arthrocare) of the
inferior turbinates in 20 adult patients with nasal obstruction caused by turbinate hypertrophy.
The ablation therapy was delivered at 100 kHz with a voltage root-mean-square value of 168 to 182. Preoperative and postoperative (1 week and 3, 6, and 12 months) nasal functions were evaluated with use of visual analogue scale (VAS) scores (for subjective results), olfactory thresholds, saccharine transit time, rhinomanometry, and acoustic rhinometry. No patient had mucosal edema, bleeding, or adherent crust formation after bRFTA treatment, although pain and nasal discharge commonly occurred for the first 2 days postoperatively. There were no adverse effects on nasal epithelial clearance time or olfactory functions. VAS scores for nasal discharge, itching, sneezing, and crusting showed a significant decrease after bRFTA (P < 0.001), whereas VAS scores pertaining to effectiveness (less frequent and less extensive nasal obstruction) and patient satisfaction increased significantly (P < 0.001). There were no significant differences between preoperative and postoperative rhinomanometry or vasoconstrictive-effect results or between preoperative and long-term postoperative acoustic rhinometry results. The authors conclude that bRFTA is a safe, minimally invasive procedure for reducing turbinate volume without altering nasal mucosa or causing more than minimal pain. They note that their results were comparable to those achieved with other surgical treatments but that the "ideal" treatment for hypertrophied turbinates remains unclear. In contrast to bRFTA, laser cautery, cryocautery, and electrocautery require general anesthesia and can cause prolonged rhinorrhea, worsening of nasal obstruction due to edema, and crusting, all of which probably result from the depth of tissue injury, which is unpredictable with these methods.
Bäck LJJ, Hytönen ML, Malmberg HO, Ylikoski JS. Submucosal bipolar radiofrequency thermal ablation of inferior turbinates: a long-term follow-up with subjective and objective assessment. Laryngoscope 2002;112:1805-12.