Nasal Turbinate Reduction (Conchotomy)

Conchotomy (synonyms: conchal reduction, turbinectomy) is a surgical procedure to (surgically) reduce the size of enlarged turbinates (conchae nasales). It is used as a therapeutic measure in the treatment of altered turbinates that interfere with breathing. However, conchotomy is not just a single procedure, but is a generic term for various surgical procedures that serve to correct the anatomically altered turbinate. With the help of this corrective measure there is a possibility to improve nasal breathing, which can be used especially to eliminate chronic recurrent infections. The advantage of this method is that the shape and given functions of the nose as an olfactory organ are completely preserved.

Indications (areas of application)

  • Anatomical variants of the nasal turbinates.
  • Chronic nasal dysfunction – with reflex compensatory hyperplasia of the tissue (excessive growth).
  • Hyperreflective rhinitis or vasomotor rhinopathy – severe watery secretion of the nasal mucosa due to a dysfunction triggered by external or internal factors.
  • Mucosal hyperplasia – excess of nasal mucosa.
  • Nasal septum deviation (deviation of the nasal septum) with reflex compensatory hyperplasia of the tissue.
  • Trauma (injury) to the turbinates with reflexive, compensatory hyperplasia of the tissue.
  • Enlargement of the bony portion of the turbinates.
  • Soft tissue changes, which can be, for example, chronic, drug-induced or hormonal.

Contraindications

If an infection is present, a conchotomy should not be performed under any circumstances. In particular, symptoms in the ear, nose and throat area such as rhinitis should be considered absolute contraindications.

Before surgery

  • Conchotomy should be performed under general anesthesia, because the procedure requires the exact work of the surgeon and patient movement could lead to a negative impact on the surgical outcome.
  • Furthermore, it is indispensable that there are no infections in the patient, as these could, among other things, increase the risk of anesthetic incidents. In such a case, a postponement of the surgical intervention must be made to reduce the risk of complications.
  • Discontinuation of blood-thinning medications such as acetylsalicylic acid (ASA) or Marcumar should also be done in consultation with the treating physician. By the short-term suspension of medication intake, the risk of secondary bleeding is significantly minimized, without a significant increase in risk for the patient.

The surgical procedures

Anatomical basics

The nasal cavity is divided by the septum nasi (nasal septum) and consists of the vestibule nasi (nasal vestibule) and the cavum nasi (nasal cavity). Laterally, the three conchae nasales (nasal conchae) arise: the concha inferior, the concha mediale, and the concha superior. The turbinates delimit the upper, middle and lower nasal passages. A number of causes lead to stenosis (narrowing) of these airways, and changes in the inferior concha are particularly common. Procedure sequence

In conchotomy, the course of the procedure varies depending on the choice of procedure. Basically, however, the procedure is such that parts of the mucosa are removed from the patient in a semi-recumbent position and, in addition, areas of the corpus cavernosum of varying size are removed. There is also the possibility of extracting bony parts of the nose. For the surgical access, it is in principle unimportant which parts of the nose are removed, since the nostrils serve as the primary access route. The aim of the surgical measures is to reduce the conchal tissue as gently as possible. Conventional procedures for reduction of conchal tissue:

  • Electrococclusion – In this method, surface anesthesia (anesthesia of the mucosa) is performed first, followed by decongestion of the nasal mucosa with a vasoconstrictor additive (substance that constricts the vessels, causing decongestion). This procedure is necessary so that the surgeon can examine the turbinates without swelling.In stab coagulation, a needle electrode is inserted into the mussel body and the tissue is obliterated in a precisely circumscribed area by a short electric shock. The treatment may be repeated several times if necessary.
  • Partial conchotomy – After decongestion, the nasal cavity is examined endoscopically for pathologic (abnormal) findings. The procedure can be performed under general anesthesia or with local anesthesia. The surgery involves removal of bone tissue from the os turbinale (bone of the inferior turbinate) and removal of excess mucosal flaps with conchotomy scissors (also called strip conchotomy). Care is taken to preserve healthy, functional tissue.
  • Total conchotomy – Complete surgical removal of the inferior turbinate is rarely performed because it can result in pain and drying of the nasal cavity.
  • Mucotomy – This operation is very similar to conchotomy, but no bone tissue is removed; instead, ablation of the thickened mucosa of the turbinates is performed in cases such as chronic rhinitis hypertrophicans.
  • Submucosal resection of the os turbinale – In this treatment, after anesthesia and decongestion, the mucosa is mobilized and the bone tissue is removed with forceps. The wound is then closed with the mucosal flap (mucosal flap).
  • Anterior turbinoplasty – This procedure is a modification of submucosal resection and differs in technique and performance.
  • Lateroposition of the inferior turbinate – This procedure is used to permanently fix the turbinate in a lateral position to ensure airway patency.
  • Cryoturbinectomy/Cryoconchectomy – Icing and subsequent removal of excess tissue at approximately -85°C.

Laser procedure to reduce the mussel tissue:

  • Laser turbinectomy – The excess tissue is vaporized with a carbon dioxide laser or an Nd-Yag laser.
  • Laser conchotomy – Using the laser beam of a diode laser, whose wavelength is in the range of 980 nm and therefore in the infrared range, the turbinates can be reduced elegantly and almost completely painlessly. A significant advantage of this procedure over conventional conchotomy is that the use of the laser results in an almost bloodless operation, which can also significantly reduce the risk of secondary bleeding. Furthermore, this is a much gentler procedure, so that the patient’s recovery time after the operation is relatively short. Due to these characteristics of laser conchotomy, it is possible to avoid uncomfortable tamponade of the nose in the vast majority of cases. To avoid pain, the surgeon applies cotton balls to the nostrils, which have been soaked with a strong anesthetic and decongestant medication. To achieve optimal effect of the drug, it must be allowed to act in the nose for 30 minutes before the surgical intervention can begin. With the help of these measures, the risk of severe pain is minimized. However, it is possible that the operated patient may periodically experience a slight pulling or burning sensation in the surgical area. In rare cases, however, pain may occur, in which case this is an indication (indication) for the use of additional local anesthesia. This additional measure is comparable in terms of risk and expected pain to local anesthesia at the dentist. In some patients there is an additional bending of the nasal septum, so that as a consequence the airflow through one nostril continues to function worse than in the opposite nostril. Despite this anatomical anomaly, a significant improvement in symptoms can usually be observed. However, if there is a massive bending of the nasal septum, this procedure can also lead to significant symptom relief in patients who are not willing to undergo a relatively extensive procedure such as straightening of the nasal septum. If the laser treatment is not successful, the procedure can generally be repeated several times. However, the probability of success is usually reduced in such a case.

After the operation

Unfortunately, after surgery relatively often there is a problem that the mucous membrane of the mussel grows back quickly and after only a few years the effect of the operation is lost. Due to the good regenerative capacity of the mucosa, the operation can in principle be repeated as often as desired. Often the combination with a straightening of the nasal septum (septal deviation) is useful and of longer duration. Regardless of the course, postoperative cooling of the nose is recommended, as this can reduce swelling and, if necessary, postoperative bleeding.

Possible complications

Overall, both conventional and laser procedures are very low-risk procedures. However, the following complications may occur:

  • Postoperative bleeding
  • Wound infections
  • Postoperative respiratory infections
  • Headaches
  • Pain in the surgical area
  • Empty Nose Syndrome (ENS) (Synonyms: Empty Nose Syndrome, also called “Open Nose”) – This syndrome is an increased dryness in the nasal area, which may result from the removal of the conchal tissue. As a result, many patients also have crusting and suffer from shortness of breath. This seems paradoxical, since after turbinate reduction there is more space for air to flow in and out. The turbinates themselves serve to humidify the nose (air conditioning), so an increased removal of this tissue leads to the fact that the turbinates can no longer perform their task and thus the nose dries out.
  • Ozaena (stinky nose) – In very rare cases, after surgery, there may be the formation of the so-called stinky nose, which is characterized by the fact that it becomes clogged with dry crusts that are colonized by bacteria. Despite this relatively serious complication, there is a possibility of healing within a short time, because the mucous membrane of the turbinates is very capable of regeneration.