Hipertrofia de cornetes inferiores: revisión sobre técnicas quirúrgicas actuales / Inferior turbinate hypertrophy: review of current surgical techniques

La obstrucción nasal es un motivo de consulta habitual en otorrinolaringología, siendo una de las causas más frecuentes la hipertrofia de cornete inferior, la que se puede manejar con cirugía cuando falla el tratamiento médico. En las últimas décadas se han desarrollado múltiples técnicas quirúrgicas y tecnología asociada, sin embargo, no hay un consenso establecido sobre cuál es la mejor opción para el manejo de esta patología. Se realizó revisión bibliográfica, se enuncian los métodos quirúrgicos disponibles, teniendo en cuenta beneficios, complicaciones probables y resultados de cada uno. La cirugía de cornete inferior tiene resultados favorables en pacientes con cornetes hipertróficos que no responden a manejo médico. Hasta la fecha la turbinoplastía con microdebridador ha mostrado superioridad en cuanto a resultados a largo plazo y menor tasa de complicaciones. La evidencia disponible hasta la fecha carece de homogeneidad en cuanto a métodos de selección de pacientes, medición de resultados y tiempo de seguimiento, por lo que se necesitan a futuro estudios prospectivos controlados para reevaluar los métodos descritos.

Nasal obstruction is a common complaint, one of the most frequent causes being inferior turbinate hypertrophy, which can be managed with surgery when medical treatment fails. In the last decades, multiple surgical techniques and associated technology have been developed, however, there is no established consensus on what is the best option for the management of this pathology. Literature review, the available surgical methods are stated, taking into account benefits, probable complications and results of each technique. The surgery of inferior turbinate has favorable results in patients with hypertrophic turbinates that do not respond to medical management. To date, microdebrider turbinoplasty has shown superiority in terms of long-term results and lower complication rates. The evidence available to date lacks homogeneity in terms of patient selection methods, measurement of results and follow-up time, so prospective controlled studies are needed in the future to reassess the described methods.

Flow and air conditioning simulations of computer turbinectomized nose models.

Air conditioning for the human respiratory system is the most important function of the nose. When obstruction occurs in the nasal airway, turbinectomy is used to correct such pathology. However, mucosal atrophy may occur sometime after this surgery when it is overdone. There is not enough information about long-term recovery of nasal air conditioning performance after partial or total surgery. The purpose of this research was to assess if, based on the flow and temperature/humidity characteristics of the air intake to the choana, partial resection of turbinates is better than total resection. A normal nasal cavity geometry was digitized from tomographic scans and a model was printed in 3D. Dynamic (sinusoidal) laboratory tests and computer simulations of airflow were conducted with full agreement between numerical and experimental results. Computational adaptations were subsequently performed to represent six turbinectomy variations and a swollen nasal cavity case. Streamlines along the nasal cavity and temperature and humidity distributions at the choana indicated that the middle turbinate partial resection is the best alternative. These findings may facilitate the diagnosis of nasal obstruction and can be useful both to plan a turbinectomy and to reduce postoperative discomfort. Graphical Abstract ᅟ.

Minimizing Septectomy for Endoscopic Transsphenoidal Approaches to the Sellar and Suprasellar Regions: A Cadaveric Morphometric Study.

The purpose of this study was to evaluate the effect of posterior septectomy size on surgical exposure and surgical freedom during the endoscopic transsphenoidal approach to the sella and parasellar region. Dissections were performed on 10 embalmed cadaver heads. Dissections started with wide bilateral sphenoidotomies, lateralization of middle turbinates, and a 5-mm posterior septectomy. The posterior septectomy was increased in 5-mm increments to a maximum of 35 mm, followed by bilateral middle turbinectomies. Surgical exposure was defined as the distance between the ipsilateral and contralateral limit of exposure as allowed by the posterior septum along a midsphenoid horizontal meridian. Surgical freedom was defined as the angle between the ipsilateral and contralateral limit. The mean baseline width of the posterior sphenoid sinus was 29.4 ± 3.7 mm. With a 5-mm septectomy, the mean width of surgical exposure was 21.1 ± 2.8 mm. The surgical exposure increased significantly with progressively larger posterior septectomy until a 20-mm posterior septectomy, after which no further increase in surgical exposure or freedom was obtained. Bilateral lateral opticocarotid recesses were accessible with a 15-mm posterior septectomy. The addition of bilateral middle turbinectomies did not significantly increase lateral exposure within the sphenoid sinus compared with middle turbinate lateralization.

Síndrome de nariz vacía / Empty nose syndrome

El síndrome de nariz vacía es una enfermedad de reciente descripción, que no tiene una definición clínica clara. Se puede originar como complicación de la cirugía de resección de cornetes, en especial del inferior. La fisiopatología no está del todo definida, pero es probable que posterior a la resección de cornetes se altere la permeabilidad nasal, interfiriendo con los mecanismos neurosensitivos y con las funciones de los cornetes. Su síntoma principal, es la obstrucción nasal paradójica. El diagnóstico es clínico, basado en los síntomas con los hallazgos de una cavidad nasal amplia posterior a la cirugía nasal. El tratamiento es difícil por lo subjetivo de los síntomas, prefiriendo en un comienzo el tratamiento médico y reservando la cirugía para casos más severos. Lo más importante es la prevención, realizando cirugías lo más conservadora posibles de la anatomía de la cavidad nasal.

The Empty Nose Syndrome is a recently described disease, which has no clear clinical definition. It is a rare complication of turbinate surgery especially in the inferior turbinectomy. The pathophysiology is unclear, but after turbinectomy the nasal patency could be affected and this can interfere with neurosensory mechanisms and functions of the turbinates. The most common symptom is the paradoxical nasal obstruction. The diagnosis is clinical, based on symptoms with the discovery of a wide nasal cavity after nasal surgery. Treatment is difficult because of the subjective symptoms, initially preferring medical treatment and surgery is reserved for more severe cases. Most important is the prevention, being as conservative as possible with the nasal cavity.

Rinitis atrófica / Atrophic rhinitis

La rinitis atrófica es una enfermedad crónica y progresiva de etiología desconocida. Se caracteriza por atrofia de la mucosa nasal y hueso subyacente, dilatación anormal de las cavidades nasales, obstrucción nasal paradójica, y formación de secreciones viscosas y costras secas; produciendo fetidez. Sus manifestaciones clínicas más frecuentes son obstrucción nasal, secreción purulenta, costras nasales y mal olor nasal. Se ha separado en dos entidades: primaria y secundaria. El tratamiento es principalmente conservador, y se han propuesto diversas terapias farmacológicas y quirúrgicas. La rinitis atrófica unilateral es una condición infrecuente, con escasos reportes en la literatura científica. Se puede asociar a la desviación septal, por lo que su corrección quirúrgica es una alternativa terapéutica disponible.

Atrophic rhinitis is a chronic disease of unknown etiology. This condition is characterized by progressive nasal mucosal and underlyng bone atrophy, abnormal widening of the nasal cavities, paradoxical nasal congestion and formation of viscid secretions and dried crusts, leading to a characteristic fetor (ozaena). The main clinical manifestations include nasal obstruction, purulent discharge, daily nasal crusting, nasal dryness and foul smell. It has been divided into two separate entities; primary and secondary. Treatment is mostly conservative, although pharmacological and surgical therapies have been proposed. Unilateral atrophic rhinitis is an uncommon condition, with few reports in the scientific literature. It is associated with septum deviation, so surgical correction is one of the therapeutic options available.

Estudo clínico e ultraestrutural pós-turbinectomia inferior parcial / Clinical and ultrastructural study after partial inferior turbinectomy

O presente trabalho refere-se ao estudo dos resultados clínicos e histológicos obtidos após a turbinectomia inferior parcial (TIP), cirurgia indicada no tratamento da obstrução nasal crônica causada pela hipertrofia das conchas nasais inferiores. MATERIAL E MÉTODOS: Foram estudados vinte pacientes, divididos em dois grupos de dez cada (grupos A e B), submetidos à TIP, associada à septoplastia ou não. Os pacientes foram reavaliados clinicamente e histologicamente (com biópsia das áreas regeneradas das conchas inferiores), em dois períodos pós-operatórios diferentes: um grupo após oito a doze meses (grupo A) e outro após dois anos de TIP (grupo B). RESULTADOS: Os resultados clínicos mostraram-se satisfatórios para o alívio da obstrução nasal no grupo A, e insatisfatórios no grupo B. Entretanto, melhores resultados histológicos, com maior recuperação e diferenciação epitelial da mucosa regenerada das conchas inferiores após a TIP foram observados no grupo B, com sua ultraestrutura ciliar normal. CONCLUSÕES: A cirurgia revelou ser eficaz a curto, mas não em médio prazo, apesar da recuperação histológica ter sido importante.

We report clinical and histological results obtained after partial inferior turbinectomy (PIT), surgery indicated for the treatment of chronic nasal obstruction. METHODS: Twenty patients were divided into two groups submitted to PIT plus septoplasty and PIT alone. The patients were reassessed clinically and histologically by means of a biopsy of the regenerated areas in the inferior turbinates at two different times after PIT, i.e., after 8 to 12 months (group A) and after two years (group B). RESULTS: The clinical results proved to be satisfactory for the relief of nasal obstruction in group A and unsatisfactory in group B. However, better histological results with better recovery and epithelial differentiation of the regenerated mucosa of the inferior turbinates after PIT were observed in group B. CONCLUSION: Surgery proved to be effective on a short-term but not on a long-term basis, and histological recovery did not accompany improvement of clinical signs and symptoms.