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ARAŞTIRMA
Türk Rinoloji Dergisi 2008
A New Surgical Technique of
Internal Nasal Valve Collapse
Erdal SERENa
a
Clinic of Otorhinolaryngology,
Giresun State Hospital,
GİRESUN, TURKEY
Yazışma Adresi/Correspondence:
Erdal SEREN
Giresun State Hospital,
Clinic of Otorhinolaryngology,
GİRESUN, TURKEY
[email protected]
ABSTRACT Objective: I describe a new outpatient technique of internal nasal valve collapse, advocated to minimize and simplify surgery under local anesthesia with bipolar radio-frequency induced thermotherapy (RFITT). Material and Methods: 19 patients with nasal obstruction due to
inspiratuar nasal valve collapse were included in this study. RFITT was performed with the turbinate probe on the mucosal packet towards the pyriform aperture. Results: Severity of obstruction
scores improved in all patients, with the mean score improving at the left nostril from 7.9 pretreatment to 3.8 post-treatment and at the right nostril from 8.6 pretreatment to 4.3 post-treatment.
The outcomes were measured using Visual analog score (VAS) before treatment and at 16 weeks post
treatment. Improvement was shown in severity of obstruction (p<0.05). Conclusion: This new method appears to be a safe, quick, bloodless, and painless. These encouraging good preliminary results
must be confirmed by further study and long-term follow-up.
Key Words: Nasal valve, nasal valve collapse, nasal valve surgery
ÖZET Amaç: lokal anestezi altında Bipolar radyofrekanslı termoterapi (BRFTT) kullanılarak yapılan basit, minimal invazif ve ayaktan uygulanabilen internal nazal valf kollapslarında kullanılacak
olan yeni bir tekniği tanımlıyorum. Gereç ve Yöntemler: Bu çalışma inspiratuar nazal valf kollapsına bağlı nazal tıkanıklık içeren 19 hasta içermektedir. Turbinat prob ile mukozal örtüden piriform
aperturaya doğru BRFTT uygulandı. Bulgular: Tüm hastalarda obstruksiyon skorlarına düzelme
bulundu. Sol nostrilde ortalama skorlarda tedaviden önce 7.9 dan tedavi sonrası 3.8 e kadar düzelme görüldü. Sağ nostrilde ise tedavi öncesi 8.6 dan tedavi sonrası 4.3 3 kadar düzeldi. Tedavi öncesi ve tedaviden 16 hafta sonrası ölçümleri Visual analog skor kullanılarak (VAS) ölçümler yapıldı.
Obstrüksiyonun şiddetinde düzelmeler gözlendi.(p<0.05) Sonuç: Bu metod hızlı, güvenilir, kansız
ve ağrısız bir metod özelliğindedir. Ön çalışmaların verdiği bu iyi sonuçların daha fazla çalışmalar
ve uzun süreli takip sonuçları ile değerlendirilmesi gerekir.
Anahtar Kelimeler: Nazal valf, nazal valf kollapsı, nazal valf cerrahisi
Turkish J Rhinology 2008, 1:62-66
ne of the most common causes of nasal obstruction is internal valve collapse. The cross-sectional area of the internal nasal valve is
determined by the angle formed by the connection of the upper lateral cartilage with the septal cartilage. As this angle narrows, the cross-sectional area decreases. The inferior turbinate and lateral nasal soft tissue
constitutes a minor portion of the internal nasal valve.1,2
Copyright © 2008 by Türk Rinoloji Derneği
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Treatment of internal valve problems usually involves one of three
methods: scar revision, medial osteotomies, or on-lay grafting of the nasal
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A NEW SURGICAL TECHNIQUE OF INTERNAL NASAL VALVE COLLAPSE
dorsum. None of these methods is free of adverse
side-effects such as pain, bleeding, bone necrosis.3,4
Simpson and Groves5 first systematized submucosal
diathermy of the inferior turbinates with the aim of
obtaining adequate turbinate reduction with preservation of the overlying mucosa in order to avoid postoperative atrophic changes. The new bipolar
radio-frequency induced thermotherapy, RFITT,
has provided a gentler and minimal invasive therapy for turbinate hypertrophy. The effect of RFITT
is achieved by coagulation of venous sinusoids within the turbinate, leading to submucosal fibrosis.6,7
RFITT uses very low levels of radiofrequency
energy to create finely controlled necrotic lesions
in soft tissue structures. Following the general pattern of wound healing, the necrosis leads to scar
formation and retraction of tissue, resulting in an
overall reduction of volume in the treated area.7,8
The present study was conducted to elucidate
the novel applicability of RFITT method in tissue
fibrosis and retraction in patients with internal nasal valve collapse.
PATİENTS
MATERIAL AND METHODS
19 patients with nasal obstruction due to inspiratuar nasal valve collapse were included in this
study. The patients were comprised of 7 females
and 12 males whose ages ranged from 18 to 47 (mean 27 years). The preoperative evaluation included
a complete history and clinical examination. Rigid
endoscopy was performed to exclude other cases
causes of nasal obstruction (turbinate hypertrophy,
nasal polyp, septal deviation or other nasal masses).
Exclusion criteria included a history of bleeding disorders, prior radiation therapy to the nose, insulin-dependent diabetes, pregnancy, poorly
controlled hypertension with systolic pressure greater than 180 mm Hg. In all cases there was a varying degree of bilateral internal nasal valve collapse
after minimal inspiratory effort. Ethical approval
was obtained from local director of medical research, and all patients gave a written informed consent.
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Erdal SEREN
On each occasion the patients were asked the
evaluate their nasal blockage that they routinely
experienced and were asked to score their symptoms on a visual analogue scale from 0 to 10 (10 being totally blocked and 0 being no sensation of
blockage). The minimum score required for acceptance into the study was greater than or equal to 6.
SURGİCAL TECHNIQUE
The operation was performed under local anesthesia, and 4 % topical Xylocaine pledges were placed in
the nose for 5 minutes. The vestibular skin, nasofacial sulcus and alar rim were then injected with 5 cc
1% Xylocaine with 1:100,000 epinephrine. A stair
step incision (with No.15 blade) and elevation of the
soft tissues, the lateral crus on each side was everted
using a double-skin hook placed at the cephalic rim.
A mucosal packet was then created by dissecting the
vestibular mucosa from the under surface starting
from the junction of the intermediate crus towards
the pyriform aperture. RFITT was then performed
with the turbinate probe (CelonProBreathTM) and a
RFITT unit (CelonLab ENT, Celon AG Medical instruments, Berlin, Germany) .The needles of the probe were inserted the full length of the mucosal
packet towards the pyriform aperture oblique (Figure 1A). The unit was set at partially rectified current and the power was set at 10. Using the foot
switch, 10 second bursts of electrical current were
used. Every patient received (each nasal cavity) 100
Joules into mucosal packet. Diameter of coagulation
was 4.6 mm. We performed the same procedure 2
cm above and 2 cm below of this area (Figure 1B).
Then wounds were closed using 4.0 plain catgut. All
patients received 8 mg of intravenous dexamethaso-
FIGURE 1A
FIGURE 1B
FIGURE 1: A) The needles of the turbinate probe (CelonProBreathTM)
were inserted the full length of the mucosal packet towards the pyriform
apertura oblique. 1B) We performed same procedure 2 cm above and 2
cm below of this area. (The surgical areas marked three circle sign)
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ne intraoperatively. No antibiotic were given and
does not require nasal packing or expensive instrumentation.
POSTOPERATIVE FOLLOW-UP
All patients were examined weekly for 16 weeks.
Any complications related to the procedure were
registered. At the end of the follow-up period, all
patients were evaluated using nasal endoscopy and
patient questionnaire (Figure 2A, 2B).
RESULTS
One patient developed very marked oedema in spite
of steroid administration. Then this oedema resolves
with oral dexamethasone therapy. No postoperative
bleeding occurred. Postoperative discomfort or headache was virtually nonexistent, as no packing was
required. Also, there was no incidence of atrophic
changes of mucosa or vestibular skin.
Statistical analysis of the improvements in nasal airway performance for the right nostril at 16
weeks showed that the improvement achieved was
significant (p<0.005) (Table 1). Similar statistically
significant results were also seen with the left nostril (Table 2). Severity of obstruction scores improved in all patients, with the mean score improving
for the left nostril from 7.9 pre-treatment to 3.8
post-treatment and for the right nostril from 8.6
pre-treatment to 4.3 post-treatment. These improvements were all statistically significant.
STATISTICAL ANALYSIS
Visual analog scales (VAS) scores for pre-treatment
and post-treatment visits were compared using the
FIGURE 2A
FIGURE 2B
FIGURE 2: A) Preoperative frontal view of a patient. This patient has nasal
valve collapse on mild nasal inspiration. 2B) Postoperative frontal view of
the patient 16 weeks after surgery. She has a normal subjective nasal airway posoperatively.
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A NEW SURGICAL TECHNIQUE OF INTERNAL NASAL VALVE COLLAPSE
VAS Scores
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10
9
8
7
6
5
4
3
2
1
0
Right nose
Pre treatment
Post treatment
0.95 Conf. Intraval
Mean
TABLE 1: Mean scores of the right nose.
VAS Scores
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9
8
7
6
5
4
3
2
1
0
Left nose
Pre treatment
Post treatment
Mean
± 0.95 Conf. Intreval
TABLE 2: Mean scores of the left nose.
paired t test and statistical significance was defined
as p< 0.05. All analysis were performed by using
Statistica 6.0 software (StatSoft, Inc., USA). Statistical analysis of the improvements in nasal airway
performance for right nostril at 8 weeks showed
that the improvement achieved was significant
(p<0.05). Similar statistically significant results were also seen with the left nostril.
DISCUSSION
Nasal valve collapse is commonly overlooked and
must be considered in the complete evaluation of
the patient with nasal obstruction. Certain elements of the history may prompt the rhinologist to
give special consideration to the possibility of nasal
valve collapse. The internal nasal valve and the nasal valve area play a critical role in nasal resistance.9
In the absence of other causes of nasal obstruction,
the internal nasal valve and nasal valve area constitute the flow-limiting segment of the nose. The
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A NEW SURGICAL TECHNIQUE OF INTERNAL NASAL VALVE COLLAPSE
internal nasal valve refers to the cross-sectional
area bordered by the junction of the caudal portion of the upper lateral cartilage and the nasal septum, circumscribing an angle of 9° to 15° in the
normal Caucasian nose.2
Inspiratory collapse of the lateral nasal sidewalls with normal inspiratory negative pressure
suggests inadequate rigidity of nasal supporting
structures. Inspiratory collapse at the external valve is visible on examination and is indicative of
flaccid soft tissue in this location. Similarly, inspiratory collapse may compromise function at the internal nasal valve. The patient’s nose should be
observed for collapse on normal inspiration.3,4
There are a number of surgical approaches
available to treat nasal valve collapse. Selection of
the appropriate surgical intervention depends on
proper identification of the anatomic cause of the
collapse. Generally, treatment of internal valve
problems usually involves one of three methods:
scar revision, medial osteotomies, or on-lay grafting of the nasal dorsum. But this method includes
some complications. Main complications include
the following:10,11
Bleeding
Infection
Poor cosmetic outcome
Continued valve insufficiency
Too-large graft with extrusion or external
deformity
Poorly sized pocket with graft migration.
Therefore, we developed a new technique for
internal nasal valve collapse. This study was designed to evaluate efficacy of RFITT for the treatment
of nasal valve collapse. Electrocautery, one of the
earliest uses of electricity in surgery, was originally
defined as the application of an electrically heated
probe to tissue. In this approach, the probe itself is
heated by a current flowing through a heater element in its tip. The heat is transferred conductively
from the probe to the tissue and no current flows
into the patient from the probe. Later developments led to the use of radiofrequency (RF) energy
to pass high frequency electrical current through
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the patient, making the patient part of a complete
electrical circuit.12
Radiofrequency is a procedure in which tissue are destroyed by electrical energy. This energy is
converted to heat as a result of tissue resistance, but
unlike electrocautery the heat is generated in the
tissues themselves and the actual electrodes remains cold. The bipolar probe destroys more tissues
than the originally described monopolar probe.
Tissue destruction is limited to area between the
needles of the probe. This minimizes risk of avascular necrosis.8
This procedure (RFITT) is repeated several times in order to achieve an optimal reduction of the
tissue. RFITT is particularly safe and gentle to patient on account of the bipolar probe construction
(no neutral electrode, no current flowing through
the patient’s body) and impedance regulated power
supply (no risk of carbonization).
On a cellular level, the tissue damage and recovery from RFITT demonstrates the body’s typical pattern of tissue injury, followed by scar
formation and retraction of tissue. The lesion site
one hour after the treatment shows the typical effects of tissue coagulation; the destroyed cells have
a structure less, homogenous appearance, and there is edema and congestion within the tissues. At
three weeks, the lesion is white and glossy, with
well formed scar tissue.6,8
In this study, we evaluate the safety of RFITT
for treatment of nasal obstruction due to nasal valve collapse. There were no significant complications and minimal morbity. Furthermore, our study
demonstrated statistically significant improvement
in symptoms of nasal obstruction compared with
pretreatment and post-treatment.
The VAS was chosen as the measurement tool
in this study because it has been used effectively to
evaluate patients treated with Radiofrequency treatment.13-15 Maxwell16 describes VAS as easy to use,
sensitive, and accurate when testing differences
within subject comparisons. Lund17 has also described the use of linear visual scales in the office evaluation of nasal obstruction, noting they are of great
value for comparing sequential evaluations. Objec65
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tive testing with acoustic rhinometry and rhinomanometry was considered but not used due to
their questionable reliability and reproducibility.18
Acoustic rhinometry results in distortion of the nasal valve area during testing, and rhinomanometry
has up to 50% day-to-day variation in results.18
Therefore these objective measurements were not
included in this study.
CONCLUSION
RFITT appears to be a safe and effective procedure
that is easily performed in an office setting. This
application results in statistical improvement of nasal obstruction in patients with nasal valve collapse.
The advantages of our methods are:
1.
2.
3.
4.
5.
6.
7.
66
Cole P. The four components of the nasal
valve. Am J Rhinol 2003; 17: 107-10.
Wexler DB, Davidson TM. The nasal valve: a
review of anat-omy,imaging, and physiology.
Am J Rhinol 2004; 18:143-50.
Grupta A, Brooks D, Stager S, et al. Surgical
accesss to internal nasal valve. Arch Facial
Plastic Surg 2003; 5:155-8.
Orten SS, Hilger PA. Surgical solution: Nasal
valve collapse. Arch Facial Plast Surg 1999;1:
55-7.
Simpson JF, Groves J. Submucosal
diathermy of the inferior turbinates. L laryngol
Otol 1958; 72: 292-301.
Elwany S, Gaimaee R, Abdel Fattah H. Radiofrequency bipolar submucosal diathermy of
the inferior turbinates. Am J Rhinol 1999; 13:
145-9.
Smith TL, Smith JM. Radiofrequency Electrosurgery. Operative techniques in Oto-
A NEW SURGICAL TECHNIQUE OF INTERNAL NASAL VALVE COLLAPSE
Gentle, repeatable treatment
Precise and reproducible thermo-lesions
sia
dure
Outpatient procedure under local anestheShort treatment time
Minimal pain during and after the proce-
Low risk of bleeding
Minimal invasive procedure
Less morbidity
Lower medical cost
Faster return to full activity
The benefits are sustained at 16 weeks after
treatment, but long term efficacy is still unclear.
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