|Year : 2020 | Volume
| Issue : 2 | Page : 160-164
Chemical cautery versus anterior inferior turbinectomy: Which is the better modality of treatment in nasal allergy?
KS Gangadhara Somayaji, Tom Koshy Jones, S Saimanohar
Department of ENT, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Submission||24-May-2020|
|Date of Decision||03-Jun-2020|
|Date of Acceptance||22-Jun-2020|
|Date of Web Publication||18-Dec-2020|
Dr K S Gangadhara Somayaji
Department of ENT, Yenepoya Medical College, Deralakatte, Mangalore - 575 003, Karnataka
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Nasal allergy is one of the most common forms of allergy seen in practice. Although medical treatment is the most commonly accepted modality of treatment, surgery also has a role. This study was aimed at the assessment of nasal symptoms and mucociliary clearance in patients with nasal allergy, before and following chemical cautery with trichloroacetic acid (TCA) in one group and anterior–inferior turbinectomy in another group and to study advantages and disadvantages of each procedure.
MATERIALS AND METHODS: This was a prospective, randomized, single-blind, controlled clinical trial conducted at a tertiary care hospital on a sample of fifty patients with a history of allergic rhinitis without a satisfactory response to medical line of treatment. Preoperative nasal airflow was assessed both subjectively and objectively using the nasal symptom score and the mucociliary clearance, respectively. One group was subjected to undergo anterior–inferior turbinectomy and the other group chemical cautery with 50% TCA. Postoperative nasal airflow was also assessed by similar methods after a duration of 1 month.
RESULTS: All the patients had significant relief from their symptoms at the end of 1 month postprocedure, irrespective of the procedure done. However, patients who underwent anterior–inferior turbinectomy had more symptomatic relief compared to the other group.
DISCUSSION: Debulking the inferior turbinate either with surgery or with cautery relives the nasal obstruction in patients with allergic rhinitis. The other symptoms of nasal allergy are also found to be less severe in these cases.
CONCLUSION: Surgical line of treatment can be used as an effective intervention to satisfactorily alleviate patient's allergic symptoms. Anterior–inferior turbinectomy is preferred for the longer symptom-free life of the patients.
Keywords: Allergic rhinitis, cautery, mucociliary clearance, surgery, turbinate
|How to cite this article:|
Gangadhara Somayaji K S, Jones TK, Saimanohar S. Chemical cautery versus anterior inferior turbinectomy: Which is the better modality of treatment in nasal allergy?. BLDE Univ J Health Sci 2020;5:160-4
|How to cite this URL:|
Gangadhara Somayaji K S, Jones TK, Saimanohar S. Chemical cautery versus anterior inferior turbinectomy: Which is the better modality of treatment in nasal allergy?. BLDE Univ J Health Sci [serial online] 2020 [cited 2021 Jan 19];5:160-4. Available from: https://www.bldeujournalhs.in/text.asp?2020/5/2/160/303970
| Introduction|| |
Allergy is a hypersensitivity disorder of the immune system of our body. Allergy tends to occur when our immune system reacts abnormally to otherwise harmless substances, present in the environment. Approximately 20%–30% of the total population suffers from of allergic disorder. Nasal allergy is one of the most common forms of the allergy seen in our practice. Nasal obstruction, watery rhinorrhea, itching in the nose and the eyes, and sneezing are the common symptoms of nasal allergy. In a multicentric study, the prevalence of allergic rhinitis was found to be 3.5% of the population in our country.
| Materials and Methods|| |
This time-bound, prospective, cross-sectional study was conducted in a tertiary care referral hospital with a sample size of fifty patients who were divided into two groups of 25 each. The study was approved by the institutional ethics committee. The patients selected were in the age group of 12–60 years. The average age of the patients who were selected in our study was 28 years. Of these patients, 64% were male and 36% female. Group A had those patients selected to undergo anterior–inferior turbinectomy (partial inferior turbinectomy [PIT]), and Group B had those in whom chemical cauterization with 50% trichloroacetic acid (TCA) was done.
The inclusion criteria included patients who were not having symptomatic relief with the medical line of treatment. Patients with gross deviated septum and patients who underwent recent nasal surgery (<1 month) were excluded from the study. However, patients with minimal septal deviation were retained in the study.
All the patients had symptoms such as nasal obstruction, sneezing, and running nose. The nasal symptom score was calculated in two ways: by calculating the mean of the subjective grade measuring complaints and by grading of each symptom depending on its severity, into Grade 0: no symptom and Grade 3: severe.
Saccharin time measurements were used for measuring. Saccharin granules were placed at the anterior end of the inferior turbinate and the time taken for the sweet taste to be appreciated in the throat was considered as the mucociliary clearance time. Similar procedure was done on the other nostril after a period of 30 min. Postoperatively, similar procedure was done, and results were compared.
In Group A, PIT was performed, under general anesthesia, with the help of turbinectomy scissors. The inferior turbinate was outfractured, and the turbinate mucosa and bone were included in the resection.
In Group B, TCA solution was applied, under local or general anesthesia, on the anterior end of the inferior turbinate with the help of a cotton-tipped Jobson Horne probe, until blanching of the mucosa was seen. The patient was called for another application after 1 week.
The results were compared with Chi-square test.
| Results|| |
Preoperatively, all the fifty patients who underwent either of the procedures complained of all the three symptoms (nasal obstruction, sneezing, and running nose). Postoperatively, 40% of the patients in Group A (PIT) had complete relief from their symptoms, whereas only 20% of the patients who underwent chemical cautery had relief from their symptoms [Table 1].
While on grading the symptoms subjectively for comparison, postoperatively, all the patients (100%) who underwent either of the procedures had a significant change from their preoperative status and were confirmed by finding out the P value which was significant.
Preoperatively, patients in Group A had improvement of nasal obstruction from 1.8 ± 0.8 to 0.32 ± 0.556, sneezing from 1.84 ± 0.687 to 0.28 ± 0.541, and symptom of running nose from 1.96 ± 0.840 to 0.12 ± 0.331. Patients in Group B had improvement of their symptoms of nasal obstruction from 2.12 ± 0.781 to 0.44 ± 0.650, sneezing from 2 ± 0.789 to 0.72 ± 0.890, and running nose from 1.88 ± 0.725 to 0.48 ± 0.770 [Graph 1].
Mucociliary clearance time was also calculated preoperatively and postoperatively after 1 month which showed a significant P value between the patients who underwent either of the procedures.
On comparing the postoperative complications on patients who underwent the procedures, it was found that 56% of the patients who underwent PIT had crusting and dryness. In those patients who underwent chemical cautery with TCA, 64% of the patients had synechiae postoperatively and 44% had burning sensation/irritation of the nose [Table 2].
| Discussion|| |
Allergic rhinitis is defined as a disorder of the nose caused by an immunoglobulin E-mediated inflammation following exposure of the nasal mucosa to an allergen. Most of the patients present with nasal obstruction, sneezing, and watery nasal discharge. Nasal obstruction is often caused by bilateral inferior turbinate hypertrophy. The possible mechanisms of inferior turbinate enlargement in nasal allergy can be due to mucosal involvement (dilatation of venous sinuses, tissue edema, and cellular hypertrophy) and osseous involvement (cellular hypertrophy and cellular hyperplasia). The treatment is the removal of the allergens and administration of antihistamines including nasal decongestants and oral or parenteral or topical steroids. Turbinate surgery is a useful treatment for chronic nasal stuffiness induced by perennial allergic rhinitis.
In the study by Unsal Tuna et al. on 54 patients, 85% of patients had relief from the symptom of nasal obstruction 1 month after TCA application, whereas in our study, of the 25 patients in Group B, 64% were relieved of their symptoms.
In the study conducted by Unsal Tuna et al., 26% of the 54 patients who had complained of preoperative sneezing, only one had persistent symptom after 1 month, whereas in our study, out of the 25 patients who complained of sneezing in Group B, 76% of patients were relieved from their symptoms. 32% of the patients in group B in our study had persistent running nose even after one month. Unsal Tuna et al reported 90% relief from the running nose [Table 3].
The mucus blanket in the nose is the primary defense mechanism, wherein the mucus secreted into the airway traps inhaled particulate matter and transports it to the pharynx, where it is swallowed. Although delicate, this mechanism is strong enough to entrap and remove the particles.
Chemical agents used mainly for topical therapy have been silver nitrate and TCA. Although effective, the chemical treatment method had been neglected for many years and hence, we thought of trying TCA which acts by causing produces local mucosal constriction. Its application to the anterior mid-part of the inferior turbinate was based on this site being reported to be a trigger area for sneezing and rhinorrhea. The decrease in the volume of the inferior turbinate and the reduction in the secretory activity of the mast cells after TCA application could be the cause for the reduction in the symptoms. The mucociliary function improves in the long term with the normalization of the mucosa.
In Group A patients, the mean of the mucociliary clearance time of the right nostril preoperatively was seen to be 10.84 min which when compared postoperatively improved to 5.24 min. On doing a paired t-test, P value was found to be <0.05 indicating its improvement. While in the left nostril, the mean was seen to be 9.4 min preoperatively improved to 4.12 min after 1 month of PIT showing a significant P value on paired t-test.
In Group B patients, mucociliary clearance in the left nostril preoperatively was seen to be 9.76 min, whereas postoperatively, only a narrow reduction to 7.28 min was seen, still giving a significant P value on paired t-test. Mucociliary clearance in the left nostril showed a mean of 8.88 min preoperatively and postoperatively 6.84 min, giving a significant P value < 0.05.
Comparison was done between the postoperative mucociliary clearance time between Group A and Group B to find the better procedure. The mean of the mucociliary clearance in the right nostril was seen to be 5.24 min and in patients under Group B to be 7.28 min. Unpaired t-test was done to find the significance, and P < 0.05 was attained proving its significance. Comparison between the postoperative mucociliary clearance time in the left nostril also yielded a significant P value < 0.05.
In the study done by Azevedo et al., wherein chemical cautery of the inferior turbinates was done with TCA in 17 patients who had complained of nasal obstruction. All of them reported some degree of improvement, and almost all the patients reported reduction of rhinorrhea postoperatively. The symptoms were evaluated with a visual analog scale.
These results were further substantiated in our study wherein all the patients who underwent chemical cautery and who were subjected to the evaluation of nasal symptoms under nasal symptom score, reported a significant improvement in their symptoms postoperatively.
In the study done by Al-Anbaki and Al-Sarhan, on 160 patients who were evaluated for rhinorrhea and sneezing after local application of TCA, sneezing improved in 89.5% of the cases, and rhinorrhea was better in 85.7% of the cases, whereas in our study, postoperatively, after 1 month, 76% of the cases had relief in their symptom of sneezing and 68% had relief from rhinorrhea.
The complications which might arise following either of the procedures include bleeding, infection, adhesions, crusting, septal perforation, and epiphora. However, all these are reported mostly with turbinate resection. Most of the complications such as nasal crusts and synechiae could be avoided if the patient does regular saline nasal douching. Patients who underwent chemical cautery with TCA were more prone to nasal synechiae, nasal pain, and itching/burning sensation of the nose. However, the advantage of the TCA application is that it can be done on outpatient basis under local anesthesia.
Imad et al. in their study on 25 patients who underwent PIT, 84% of the patients developed nasal crusting postoperatively, whereas in our study, 76% of the patients had moderate nasal crusting [Table 4].
In a study conducted by Anil and Mahjabeen on fifty patients, 12% of the patients complained of nasal pain postoperatively following PIT and 8% complained of wound infection and nasal crusts. In our study, complications were seen in both the procedures. Fifty-six percent of the patients who underwent PIT presented with nasal crusts postoperatively, and 64% of the patients who underwent chemical cautery presented with nasal synechiae postoperatively.
Although there were disadvantages with the anterior–inferior turbinectomy procedure such as bleeding, infection, nasal crusting, dryness, and the need for general anesthesia, there was an early and better symptomatic relief in these patients. The alleviation of symptoms was long standing. The key for the success is removal of both the bone and mucosa the anterior end of the inferior turbinate.
| Conclusion|| |
With the comparison of both the procedures by evaluating the nasal symptom score and the mucociliary clearance time, we can reach to a conclusion that both the procedures give symptomatic relief, although with PIT, the relief is immediate, better, and long standing.
The complications that can arise from the procedure should be always kept in mind, and appropriate care should be taken preoperatively, intraoperatively, and postoperatively. Complications such as nasal crusts and synechiae can be avoided if patient knows the correct technique of saline nasal douching and does it without fail postoperatively.
Although there are advantages and disadvantages regarding the procedures, considering the subjective symptomatic relief of the patients, PIT can be opted as a better intervention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kumar SP, Prasad K, Shenoy K, D'souza M, Kumar VK. Systematic reviews on palliative sedation: What do they tell us? Indian J Palliat Care 2013;19:198-9.
] [Full text]
Farmer SE, Eccles R. Chronic inferior turbinate enlargement and the implications for surgical intervention. Rhinology 2006;44:234-8.
Gill BS. Intraturbinate use of steroids in nasal allergy. J Laryngol Otol 1966;80:506-10.
Mori S, Fujieda S, Igarashi M, Fan GK, Saito H. Submucous turbinectomy decreases not only nasal stiffness but also sneezing and rhinorrhea in patients with perennial allergic rhinitis. Clin Exp Allergy 1999;29:1542-8.
Unsal Tuna EE, Ozbek C, Koç C, Ozdem C. Evaluation of nasal symptoms and mucociliary function in patients with allergic rhinitis treated with chemosurgery using trichloroacetic acid. Am J Otolaryngol 2008;29:37-41.
Cohen NA. Sinonasal mucociliary clearance in health and disease. Ann Otol Rhinol Laryngol Suppl 2006;196:20-6.
Mahakit P, Pumhirun P. A preliminary study of nasal mucociliary clearance in smokers, sinusitis and allergic rhinitis patients. Asian Pac J Allergy Immunol 1995;13:119-21.
Burton MJ, Eisenberg LD, Rosenfeld RM. Extracts from The Cochrane Library: Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Otolaryngol Head Neck Surg 2007;137:532-4.
de Azevedo AF, Martins DA, Cardoso CG, de Moraes IF, Michel LM, Leite LH. Chemical cautery of the inferior turbinates with trichloroacetic acid. Arquivos Internacionais de Otorrinolaringologia 2011;15:475-7.
Al-Anbaki F, Al-Sarhan H. Evaluation of treatment of sneezing and rhinorrhoea by local application of Trichloroacetic acid in patients with non infective rhinitis. Iraqi J Community Med 2009;22:192-6.
Dawes PJ. The early complications of inferior turb?inectomy. J Laryngol Otol 1987;101:1136-9.
Imad H, Javad K, Ullah S. Comparison of submucosal diathermy with partial inferior turbinectomy: A fifty case study. J Postgrad Med Inst 2012;26:91-5.
Anil HT, Mahjabeen B. Comparative study between partial inferior turbinectomy and submucosal diathermy in the management of inferior turbinate hypertrophy. International J Sci Res 2014;3:323-5.
[Table 1], [Table 2], [Table 3], [Table 4]