Radiofrequency Turbinate Reduction
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The most common reason for nasal obstruction is mucosal hypertrophy of the inferior turbinate, followed by structural deformity of the nasal airway (septal deviation, bony inferior turbinate hypertrophy). [1] Numerous interventions are available for the treatment of nasal obstruction secondary to inferior turbinate hypertrophy including medical treatments (immunotherapy, antihistamines, intranasal corticosteroid sprays, decongestants) and surgical options (corticosteroid turbinate injections, cryosurgery, electrocautery, turbinate out-fracture, microdebrider-assisted turbinoplasty, excision and submucous resection). The goals of inferior turbinate surgery include volume reduction, a reduction in nasal obstruction, and maintenance of nasal function while minimizing complications. There is currently no consensus on the most effective technique.
Radiofrequency turbinate reduction (RFTR) is a minimally invasive surgical option that can reduce tissue volume in a precise, targeted manner. This technique uses radiofrequency to create lesions within the submucosal tissue of the turbinate, reducing tissue volume with minimal impact on surrounding tissues. [2, 3] Radiofrequency turbinate reduction differs fundamentally from traditional methods by using low-power radiofrequency energy to provide a relatively quick and painless procedure for tissue coagulation.
An explanatory video of the procedure is below.
The video below depicts RFTR being performed.
There have been multiple studies completed analyzing the outcomes of radiofrequency ablation (RFA) turbinate reduction. In 2009, Hyotnen et al completed a systematic literature review of the RFA technique and concluded that overall, the technique is well tolerated and effective. [4]
Additionally, multiple reviews comparing RFA with microdebrider-assisted inferior turbinoplasty (MAIT) have been published. Lui et al showed no statistically significant difference in outcomes between the techniques at 6 months; however, maintenance of improvement at 3 years was significantly better in the MAIT group. [5] Results also suggest that although RFA and MAIT both result in a statistically significant reduction in nasal blockage, MAIT is more effective in decreasing nasal volume. [6] Studies focusing on how RFA affects nasal histology report an increase in mucociliary times and loss of nasal sensation. [7, 8] Despite these reports of unfavorable effects, more research is needed, given the short follow-up times and earlier studies reporting no histologic changes. [9]
Overall, RFA has a low complication rate and has been shown to reduce nasal obstruction secondary to inferior turbinate hypertrophy; however, recently published studies suggest advantages to microdebrider turbinoplasty.
The lateral nasal walls contain 3 pairs each of small, thin, shell-like bones: the superior, middle, and inferior conchae, which form the bony framework of the turbinates. Lateral to these curved structures lies the medial wall of the maxillary sinus.
Inferior to the turbinates lies a space called a meatus, with names that correspond to the above turbinate, eg, superior turbinate, superior meatus. The roof of the nose internally is formed by the cribriform plate of the ethmoid. Posteroinferior to this structure, sloping down at an angle, is the bony face of the sphenoid sinus.
For more information about the relevant anatomy, see Nasal Anatomy.
Radiofrequency inferior turbinate reduction can be used in patients with the following conditions: [2, 10, 11, 12, 3, 17, 13, 14]
Nasal congestion and rhinorrhea associated with inferior turbinate mucosal hypertrophy
Nasal congestion with inferior turbinate mucosal hypertrophy with a mildly deviated septum
Sleep apnea with increased nasal resistance and difficulty wearing a nasal CPAP mask
Inferior turbinate mucosal hypertrophy undergoing septoplasty, rhinoplasty, or endoscopic sinus surgery
Rhinitis medicamentosa requiring adjunctive treatment
No absolute contraindications exist for radiofrequency turbinate reduction. However, the use of the radiofrequency turbinate reduction system is contraindicated in patients with heart pacemakers or other electronic devices unless they can be temporarily deactivated.
Patients with significant systemic comorbidities, such as hypertension or diabetes mellitus, may need special treatment adjuncts in conjunction with their primary care physician prior to undergoing radiofrequency turbinate reduction. Moreover, anticoagulant therapy cessation for 72 hours prior to treatment is necessary. [15]
Factors that may have an influence on the overall success of the radiofrequency turbinate reduction include the following:
Severe nasal and/or septal deformity
Acute allergic or infectious rhinitis
Active respiratory infection
See the list below:
When the procedure is performed with the patient awake, topical lidocaine 4% and a vasoconstrictor (eg, phenylephrine HCl) are applied via spray to each nasal cavity, followed by injection of 1 mL 1% lidocaine with 1:100,000 epinephrine into each inferior turbinate.
If the procedure is performed during another nasal procedure with the patient under general anesthesia, the topical lidocaine is omitted. [10, 15, 11]
Equipment includes the following: [15]
Handpiece
Cable
Dispersive electrode
Syringe, 3 mL
Needle, 25-30 gauge, 1.5 inch
Gauze
Nasal pledgets
Topical and local anesthetic/decongestant medications
See the list below:
For the stand-alone procedure, seat the patient comfortably in an examination chair with dispersive electrode placed over a well-vascularized muscular site (eg, lower back or lateral scapula) with full contact to the skin.
When performed in the setting of another nasal surgery, no special positioning is required.
See the list below:
Insert the handheld needle electrode into the anterior portion of the inferior turbinate, as shown.
Insert the needle electrode into the middle portion of the inferior turbinate from an inferomedial approach to deliver 350-500 joules, 2-10 watts, and 70-80 volts, with a target temperature of 80°C per lesion. The activated system usually takes 2 minutes per lesion.
The depth of insertion should be 5 mm to reduce the risk of damage to the mucosa, causing ulcerations or sloughing.
Several options are available to create lesions within the inferior turbinate in order to achieve technique options (see corresponding images below). [15]
Single anterior lesion
Anterior and mid lesions
Stacked anterior lesions
Stacked anterior lesions, mid lesion, and posterior lesion
Anterior, mid, and posterior lesions (4-lesion procedure)
See the list below:
Placement of the needle too superficially may result in damage to the mucosa, including ulceration or sloughing of mucosal tissue.
If the lesion takes more than 2 minutes to form, the needle electrode may be too close to the conchal bone.
If the turbinate is enlarged in the anterior and mid-portion, 4 row lesions are recommended.
See the list below:
Patients may experience mild to moderate pain during treatment of the posterior inferior turbinate. This can be controlled with additional local anesthetic injection.
Mild-to-moderate edema with subsequent nasal obstruction and thick mucus formation can be expected for the first week after the procedure.
If mucosal erosion is present, the risk of postoperative bleeding and adherent crust formation increases. [16]
If performed along with a septoplasty, scar tissue may form between the turbinate and the septum.
Goode RL. Diagnosis and Treatment of Turbinate Dysfunction: A Self-Instructional Package. American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc.; 1977.
Coste A, Yona L, Blumen M, et al. Radiofrequency is a safe and effective treatment of turbinate hypertrophy. Laryngoscope. 2001 May. 111(5):894-9. [Medline].
Ercan C, Imre A, Pinar E, Erdogan N, Umut Sakarya E, Oncel S. Comparison of submucosal resection and radiofrequency turbinate volume reduction for inferior turbinate hypertrophy: evaluation by magnetic resonance imaging. Indian J Otolaryngol Head Neck Surg. 2014 Sep. 66(3):281-6. [Medline]. [Full Text].
Hytönen ML, Bäck LJ, Malmivaara AV, Roine RP. Radiofrequency thermal ablation for patients with nasal symptoms: a systematic review of effectiveness and complications. Eur Arch Otorhinolaryngol. 2009 Aug. 266(8):1257-66. [Medline].
Liu CM, Tan CD, Lee FP, Lin KN, Huang HM. Microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty. Laryngoscope. 2009 Feb. 119(2):414-8. [Medline].
Gindros G, Kantas I, Balatsouras DG, Kaidoglou A, Kandiloros D. Comparison of ultrasound turbinate reduction, radiofrequency tissue ablation and submucosal cauterization in inferior turbinate hypertrophy. Eur Arch Otorhinolaryngol. 2010 Nov. 267(11):1727-33. [Medline].
Berger G, Ophir D, Pitaro K, Landsberg R. Histopathological changes after coblation inferior turbinate reduction. Arch Otolaryngol Head Neck Surg. 2008 Aug. 134(8):819-23. [Medline].
Salzano FA, Mora R, Dellepiane M, Zannis I, Salzano G, Moran E. Radiofrequency, high-frequency, and electrocautery treatments vs partial inferior turbinotomy: microscopic and macroscopic effects on nasal mucosa. Arch Otolaryngol Head Neck Surg. 2009 Aug. 135(8):752-8. [Medline].
Bhandarkar ND, Smith TL. Outcomes of surgery for inferior turbinate hypertrophy. Curr Opin Otolaryngol Head Neck Surg. 2010 Feb. 18(1):49-53. [Medline].
Utley DS, Goode RL, Hakim I. Radiofrequency energy tissue ablation for the treatment of nasal obstruction secondary to turbinate hypertrophy. Laryngoscope. 1999 May. 109(5):683-6. [Medline].
Porter MW, Hales NW, Nease CJ, Krempl GA. Long-term results of inferior turbinate hypertrophy with radiofrequency treatment: a new standard of care?. Laryngoscope. 2006 Apr. 116(4):554-7. [Medline].
Yildirim B, Uysal IO, Polat C, Gok C. [The efficacy of radiofrequency ablation technique in patients with inferior turbinate hypertrophy]. Kulak Burun Bogaz Ihtis Derg. 2008 Mar-Apr. 18(2):90-6. [Medline].
Casale M, Bottaro V, Sabatino L, Frari V, Bressi F, Vespasiani U, et al. The efficacy of radiofrequency volumetric tissue reduction of hypertrophied inferior turbinate in simple snoring. Eur Rev Med Pharmacol Sci. 2014. 18(15):2160-8. [Medline].
Assanasen P, Choochurn P, Banhiran W, Bunnag C. Radiofrequency inferior turbinate reduction improves smell ability of patients with chronic rhinitis and inferior turbinate hypertrophy. Allergy Rhinol (Providence). 2014 Mar. 5(1):12-6. [Medline]. [Full Text].
Temperature controlled radiofrequency [package insert]. Bartlett, TN: Gyrus ACMI-ENT.
Kezirian EJ, Powell NB, Riley RW, Hester JE. Incidence of complications in radiofrequency treatment of the upper airway. Laryngoscope. 2005 Jul. 115(7):1298-304. [Medline].
Belachew Tessema, MD Assistant Clinical Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut School of Medicine; Co-Director, The Connecticut Sinus Institute
Belachew Tessema, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic Society
Disclosure: Nothing to disclose.
Seth M Brown, MD, MBA, FACS Clinical Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut School of Medicine; Consulting Physician, Department of Neurosurgery, Hartford Hospital; Director, The Connecticut Sinus Institute
Seth M Brown, MD, MBA, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society, North American Skull Base Society
Disclosure: Nothing to disclose.
Amy L Hughes, MD Fellow in Pediatric Otolaryngology, Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Images and video are used in agreement with GYRUS ACMI-ENT.
Medscape Reference also thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for assistance with the video contribution to this article.
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