REX MOULTON-MRRETT. MD, VICTOR PASSY, MD. DOROTHY HORLICK, MPH. CT MT. and
GEORGE RAUEL, MD, Irvine and Long Beach, California
Nasal obstruction remains a challenge to the modem day rhinologist. In the evolving climate of "cost containment" and "risk-outcome analyses", office-based inferior turbinate reduction has regained popularity. This article describes a new method to reduce nasal obstruction in patients with chronic rhinitis when conventional medical therapy has failed.
Rhinitis is chronic (CR) when symptoms of nasal obstruction, sneezing, itchy nose, and rhinorrhea persist for more than 3 months each year. CR is either infective or noninfective in origin, on the basis of the presence or respective absence of more than five polymorph leukocytes per high-power field (HPF) by nasal cytology." Infective CR is usually caused by sinusitis, whereas 48% of noninfective CR (NICR) is allergic (ACR), 15% nonallergic eosinophilic (NAECR), and 37% vasomotor (VMCR) in origin.2 The estimated incidence of allergic rhinitis in the United States is 24 million.3 One quarter of these cases are chronic,4 which implies that approximately one person in every four households has
Nasal obstruction is the most common yet the least responsive to medication of all the symptoms associated with NICR. Intranasal steroids relieve nasal obstruction in approximately 50% of patients with ACR or NAECR.5 Unfortunately, poor patient compliance in the long term limits efficacy. Ipratropium bromide, antihistamines, and cromolyn sodium have little, if any, effect over placebo on nasal obstruction in NICR.5-7 Although most patients obtain relief of nasal obstruction with oral sympathominietics, long-term usage is cautioned in view of the associated side effects.8 It follows that one half of those with the common problem of nasal obstruction from NICR may become candidates for surgical intervention.
A consistent finding in patients with NICR and nasal obstruction is engorgement of the membranous head of the inferior turbinate. In health, the isthmus nasi or "nasal valve" is the site of maximal intranasal resistance. However, in the presence of inferior turbinate hypertrophy, the head of the inferior turbinate (Cottle"s area IV), which lies immediately posterior to the nasal valve and attic (areas II and III), becomes the site of maximal intranasal resistance. Turbinate reduction decreases the cross-sectional surface area of the head of the inferior turbinate and therefore decreases intranasal resistance.9
At least 20% of patients have early complications from turbinate resection."0 No ideal surgical procedure exists for the reduction of the inferior turbinate. An ideal procedure should be inexpensive, simple, and rapid to perform in-office; require only a local anesthetic; and lead to early and long-term relief of nasal obstruction, with few if any complications.
Infrared coagulation (IC) was first developed by Nath and Kiefhaber in 1975." Light from a 15-V tungsten-halogen lamp reflects from a gold surface. The reflected light is noncoherent and multispectral, with a spectral maximum, in the infrared range, of 10,000 A. Reflected light then passes through a solid-quartz column to a 2-, 6-, or 10-mm diameter tip. On contact with tissue the tip causes injury by thermal necrosis at 1000 C without surface adhesion or carbonization. The depth of injury is determined by the duration of exposure, up to 3 seconds (Fig. 1). Depth and therefore extent of injury are easily, precisely, and reproducibly controlled." IC for mild to moderate anorectal hemorrhoids is currently regarded as preferential to banding, cryotherapy, sclerotherapy, or excision. The procedure is well tolerated by patients under topical anesthesia and is associated with mild swelling, no perianal discharge, and no bleeding, and remucosalization is noted to occur within 2 weeks."2
Because hemorrhoid tissue and the membranous head of the inferior turbinate bear a histologic similarit~ we set out to determine whether infrared coagulation of the inferior turbinate (ICIT) might provide a more ideal office-based method to reduce nasal obstruction in patients with NICR.