REX MOULTON-MRRETT. MD, VICTOR PASSY, MD. DOROTHY HORLICK, MPH. CT MT. and
GEORGE RAUEL, MD, Irvine and Long Beach, California
Nasal obstruction was present from 1 to 10 years (mean, 3.1 years) in the 15 patients studied (12 men and 3 women), who ranged in age from 18 to 78 years old (mean, 45 years). All patients complained of mouth breathing at night and had received at least 4 weeks (mean, 10 months) of intranasal beclomethasone. Three patients with known obstructive sleep apnea thought that nasal continuous-positive airway pressure aggravated or may have caused nasal obstruction. No new medications were started during the study, and two patients continued receiving oral terfenadine throughout the study. VMCR was diagnosed in nine (60%), NAECR in one (7%), and ACR in five (33%) patients.
The mean symptom score of nasal obstruction was 3.2, indicating bilateral recumbent congestion and unilateral complete blockage in the upright position. Turbinate examination revealed a grade score between 2 and 4 (mean, 2.7), indicating moderately to severely enlarged inferior turbinates. In agreement with this, the mean grade for diminished intranasal airflow was 2.5, indicating a moderate to severe reduction in airflow. The mean exposure time was 1.5 seconds, mean number of exposures per treatment was 7.8, and mean total number of treatments per patient was 1.5. Follow-up varied from 2 to 21 months (mean, 8 months), and five patients were seen at the clinic for 18 months after ICIT.
After ICIT, nasal obstruction was initially worse in 14 of the 15 patients, especially during the first day. Improvement in nasal obstruction was then witnessed in 14 patients: 12 by the fourth day and 2 by the second week. Eight patients reported a maximal improvement in nasal obstruction in less than 4 weeks and 6 in less than 2 to 3 months, and 1 patient reported no benefit after ICIT. The mean grade for improvement in nasal obstruction 2 months after ICIT was 2.7, indicating patients believed they were moderately better to much improved. Preliminary results from posterior rhinometry (on 7 patients not included in this study) revealed a 65% ± 5% reduction in intranasal resistance tested 3 and 6 weeks after ICIT. Symptomatic improvement continued in 4 of 5 patients in this study who were followed for more than 18 months, including an 18-year-old patient with ACR who, after one ICIT treatment, had complete resolution of bilateral upright nasal obstruction and mouth breathing. Another patient with ACR reported a moderate improvement of nasal obstruction for only 2 months after ICIT, and 4 months later he underwent potassium-titanyl phosphate laser turbinate reduction in the operating room. Potassium-titanyl phosphate laser therapy was also associated with symptomatic improvement for only 2 months.
All complications from ICIT occurred immediately or within the first week. One patient had a vasovagal episode during turbinate injection, five patients reported bloody nasal discharge for less than 4 days, and two patients had frontal headaches for less than 5 hours after ICIT. No patients refused to have ICIT repeated, and all felt that the anesthesia was adequate. Examination 2 weeks after ICIT was significant for nonobstructing crusts over the eschars in virtually all patients. By 4 weeks after ICIT most of the crusts had disappeared. Deep and confluent eschars appeared to produce more crusting. The least amount of crusting was seen with exposure times of 1.5 seconds or less, limited to six nonconfluent eschars per turbinate.
The profile of depth of injury to duration of exposure for cadaveric inferior turbinate in this study supports use of an exposure time of 1.5 seconds or less. A 1.5-second exposure caused injury three quarters the distance from mucosa to the inferior turbinate (0.75-mm depth), whereas a 2-second exposure led to mucosal carbonization and damage to the inferior turbinate bone (greater than 1-mm depth).