Available online at www.sciencedirect.com
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 537 – 540 www.elsevier.com/locate/amjoto
Bipolar scissor turbinectomy: a new technique for day-case turbinectomy Ahmed Atef, MD⁎ Department of Otolaryngology, Faculty of Medicine, ENT Clinic, Cairo University, Egypt Received 27 August 2010
Abstract
Hypothesis: The study aimed to assess the efficacy of bipolar scissor in the treatment for patients with inferior turbinate hypertrophy. Materials and Methods: A prospective cohort clinical study was conducted on 10 adult patients who were chosen with a diagnosis of turbinate hypertrophy. Results: Ninety percent of our cases were satisfied with the procedure, there were significant drops in the sensation of nasal obstruction, the average duration of the procedure was 20 minutes for both sides, and only a single case was complicated with a small burn on the vestibule. Discussion: Bipolar scissor could be applied safely in turbinate surgery to perform a rapid effective turbinectomy without packing or overnight hospital stay. © 2011 Elsevier Inc. All rights reserved.
1. Introduction Chronic nasal obstruction is one of the most common human problems and a very frequent symptom in the ear, nose, and throat field. Hypertrophy of the inferior turbinate is the most frequent cause and may be related to allergy, pseudoallergy, nonallergic rhinitis with eosinophilia syndrome, and iatrogenic rhinopathy [1,2]. When medical treatment fails, patients often benefit from surgical reduction of the inferior turbinate. Various techniques have been described including turbinectomy, submucosal turbinectomy, microdebrider submucosal resection, cryotherapy, submucous electrosurgery, and laser turbinectomy. Each technique has some inherent weakness including lack of efficacy and early and late complications (bleeding, crusting, mucosal tears, atrophic rhinitis, and significant cost and recovery times) [3,4]. The ideal surgical technique has yet to be demonstrated. Bipolar electrosurgical scissor is a new instrument that was originally designed for open surgery using a dual function that cuts and coagulates at the same time [5]. Bipolar scissor appears to combine the best of cold scissor dissection and electrosurgical techniques, allowing rapid ⁎ Department of Otolaryngology, Faculty of Medicine, ENT Clinic, 123 Hassan Mamoun St, Nasr City, Cairo, Egypt. E-mail address:
[email protected] (A. Atef). 0196-0709/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2010.11.006
removal with minimal bleeding and desirable tissue effects [6]. Bipolar scissor has been studied extensively in tonsillectomy [5], but to our knowledge, no author tried to study the efficacy of this relatively new instrument in turbinate surgery. The purpose of this study is to prospectively assess the efficacy of bipolar scissor in the treatment for patients with inferior turbinate hypertrophy. 2. Materials and methods 2.1. Study design A prospective cohort clinical study was conducted on 10 adult patients who were chosen with a diagnosis of turbinate hypertrophy. All of these 10 patients had symptoms and signs of nasal obstruction and stuffiness related to enlarged turbinates and were treated between May 2008 and September 2009. Patients gave their written informed consents before being included in the study, which was approved by the local ethics committee. All procedures were performed by one author (A.A.). Patients with previous turbinate surgery, septal deformities, nasal polyps or tumor, nasal radiotherapy, or recurrent sinusitis were excluded. Coagulation disorders, cardiac pacemaker, and uncontrolled hypertension were additional exclusion criteria.
538
A. Atef / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 537–540
Among our patients, there were 8 men and 2 women, the mean age was 32.2 years (±5.4 years). 2.2. Surgical procedure All surgical procedures were performed by the same surgeon (A.A.). The surgical interventions were carried out with the patient under general hypotensive anesthesia. After adequate anesthesia, the inferior turbinate was infiltrated with combined 2% xylocaine and 1:100 000 epinephrine, patients were postured with semi–sitting position and draped for operation. All surgical procedures were performed under the direct vision of straight, 4-mm diameter, 0° endoscope (Karl Storz, Tuttlingen, Germany). The technique involves fracture of the turbinate bone toward the midline and cutting along its lateral attachment using PowerStar Bipolar scissor (Ethicon Ltd, Edinburgh, United Kingdom) (Fig. 1). The bipolar scissor is a modified 7-in Metzenbaum scissor with 2 blades that are insulated from each other by applying a ceramic coat to the inner surface of one blade and clear surface hardening to the other blade. The handles and part of the outer surface of the blades are covered with plastic. Antibiotic therapy with amoxicillinclavunate and analgesia with acetaminophen were given for 5 days postoperatively. Patients visited our office twice a week for 4 weeks after operation where nasal clearance was done, and patients were asked to use saline irrigation twice daily for 3 weeks after the procedure. 2.3. Evaluations Subjective symptom (severity of nasal obstruction) was measured by a standard 10-cm visual analog scale (VAS). A score of zero represented no obstruction and no episodes of nasal obstruction, and a score of 10 indicated complete nasal obstruction and constant, unremitting nasal obstruction. Questionnaires were performed before the procedure and 3 months after operation, respectively. The subtract score between postoperative and preoperative
symptom scores was calculated, and we thought that subjective improvement of symptom is greater when the positive value is larger. The patient's satisfaction about the postoperative symptom relief was also asked. We compared the preoperative VAS score with those of 3 months after operation and evaluated the degree of improvement. We also reported the pure operative time, duration of crust formation, and postoperative bleeding. Duration of crust formation was estimated as the period from the operation to the point of disappearance or detachment of major crust from the turbinate with the healed underlying mucosal surface. Postoperative bleeding was defined as a condition that required the temporary nasal packing with Vaseline gauze or Merocel (XOMED Surgical Products, Jacksonville, FL). 2.4. Statistics Postoperative improvement in our patient group was evaluated with Wilcoxon signed rank test. P values less than .05 were considered significant.
3. Results 3.1. Subjective changes of symptoms In our small group of patients, preoperative VAS score of nasal obstruction was 7.20 ± 1.27, and it was improved to 1.70 ± 1.02 at 3 months; these improvements were statistically significant. The number of patients who answered that they were satisfied with the results of the operation was 9 (90%) at 3-month period. 3.2. Operative time, duration of crust formation, and frequency of postoperative bleeding The average operative time was 20 ± 6.4 minutes, the average duration of crust formation was 14 ± 5.4 days, and
Fig. 1. PowerStar bipolar scissors.
A. Atef / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 537–540
there was no single case of primary or secondary post– turbinectomy bleeding. 3.3. Need for packing and postoperative hospital stay None of our small cohort of patients required nasal packing postoperatively, and all of them were discharged on the same postoperative day. 3.4. Operative complications One single case in our study population (second case) was complicated with a small burn of the skin of the nasal vestibule that healed rapidly without any sequel or stenosis.
4. Discussion Inferior turbinate surgery is advocated for relief of symptoms in patients with chronic nasal congestion. Numerous reports substantiate the usefulness of inferior turbinate surgery [7]. The ideal turbinate surgery should be limited to the erectile submucosal tissue and to the bony turbinate. Reduction of bone creates more space, whereas surgery on submucosal tissue creates scarring that minimizes the engorgement of the inferior turbinates of patients with vasomotor rhinitis [8]. Inferior turbinate reduction can be performed by various techniques that resect, displace, or decrease the volume of the turbinate. Turbinate resection, total or partial using the cold scissor, was once the surgical treatment of choice for turbinate hypertrophy. However, because of concerns about postoperative crusting, bleeding, and atrophic rhinitis, the treatment fell out of favor. Although very few studies actually demonstrated the validity of these concerns, the procedure became less popular with the development of other techniques [9]. Bipolar scissor is a newly introduced instrument that cuts and coagulates at the same time. The bipolar scissor is a modified 7-in Metzenbaum scissor with 2 normal blades that have been modified to allow bipolar electrocautery without excessive collateral damage. The inner surface of one blade is covered with a ceramic coat; the other blade is coated with a clear surface hardening material. The handles and part of the outer surface of the blades are covered with plastic. Some have modified the instrument further to bring the outer plastic coating to within 10 mm of the tip of the scissors. A diathermy machine is used to supply the electrical current [10]. Bipolar scissors, like bipolar forceps, are as effective as monopolar cautery but offer less lateral tissue injury and do not interfere with cardiac pacemakers or joint prostheses. Bipolar scissors and forceps have recently been coupled into one automatic unit that is linked to a computer and turns on when touched to tissues. It stops working automatically once coagulation has taken place and before desiccation or fulguration occurs [11].
539
Recently, this new technique has been studied extensively in the literature for tonsillectomy as described by Isaacson and Szeremeta [12] and Saleh et al [10]. These scissors allow for simultaneous cutting and electrocoagulation. The use of bipolar scissors has been approached with caution because some authors questioned the safety and efficacy of these scissors particularly in causing mucosal burns [13], but comparing the technique of bipolar scissor tonsillectomy with the standard technique of cold dissection tonsillectomy proved it to be a fast, effective, and safe technique. Raut et al [14] reported a significant reduction in the intraoperative blood loss and operative time with bipolar scissor tonsillectomy compared to the classical cold dissection method without a statistically significant difference for the primary hemorrhage between the 2 groups. In this article, we are conducting a preliminary pilot study on a small nonrandomized cohort of patients to use this relatively new instrument (bipolar scissor) in conducting turbinectomy instead of the classic scissor. Bipolar scissor has never been studied in the literature before in nasal surgery, and so, our work, although on a limited number of patients, could be valuable and should be augmented in the future with more studies on larger number of patients in a randomized comparative fashion. In this work, using bipolar scissor to perform surgical turbinectomy, the procedure proved very fast (average time was nearly 20 minutes for both sides) and very effective in improving nasal obstruction, and the healing process was nearly the same as cold scissor turbinectomy. No cases of hemorrhage (primary or secondary) occurred in our small number of patients, and all our patients were discharge from operating room without a pack in their nose and were discharged from the hospital on the same day, decreasing the cost of the procedure. Although one case of skin burn occurred in our series, yet it happened with our second case, and with more cases, our technique was improved, and no cases of burns occurred again, the safety of the procedure should be discussed on a larger number of cases. 5. Conclusion Bipolar scissor could be applied safely in turbinate surgery to perform a rapid effective turbinectomy without packing or overnight hospital stay. These preliminary data should be augmented in the future with further studies on larger number of patients in a randomized comparative fashion with longer follow-up period. 6. Summary 1. Bipolar scissor is a new instrument that can be used in rhinology.
540
A. Atef / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 537–540
2. Bipolar scissor turbinectomy is safe, rapid, and could be done on day-case basis. 3. Bipolar scissor turbinectomy needs more studies to confirm efficacy, validity, and, particularly, safety. References [1] Lippert BM, Werner JA. Nd:YAG laser light–induced reduction of nasal turbinates. Laryngorhinootologie 1996;75:523-8. [2] Ottaviani F, Capaccio P, Cesana BM, et al. Argon plasma coagulation in the treatment of nonallergic hypertrophic inferior nasal turbinates. Am J Otolaryngol 2003;24:306. [3] Sapci T, Sahin B, Karavus A, et al. Comparison of the effects of radiofrequency tissue ablation, CO2 laser ablation and partial turbinectomy applications on nasal mucociliary functions. Laryngoscope 2003;113:514-9. [4] Dawes PJ. The early complications of inferior turbinectomy. [review, 10 refs] J Laryngol Otol 1987;101:1136-9. [5] Kirazli T, Bilgen C, Midilli R, et al. Bipolar electrodissection tonsillectomy in children. Eur Arch Otorhinolaryngol 2005;262:716-8.
[6] Winslow CP, Burke A, Bartels S, et al. Bipolar scissors in facial plastic surgery. Arch Facial Plast Surg 2000;2:209-12. [7] Salam MA, Wengraf C. Concho-antropexy or total inferior turbinectomy for hypertrophy of the inferior turbinates: a prospective randomized study. J Laryngol Otol 1993;107:1125-8. [8] Friedman M, Tanyeri H, Lim J, et al. A safe, alternative technique for inferior turbinate reduction. Laryngoscope 1999;109:1834-7. [9] Nurse L, Duncavage JA. The surgery of inferior and middle turbinate. Otolaryngol Clin N Am 2009;42:295-309. [10] Saleh HA, Cain AJ, Mountain RE. Bipolar scissor tonsillectomy. Clin Otolaryngol 1999;24:9-12. [11] Stenquist BC, Holt PJ, Motley RJ. Computerized bipolar diathermy with scissors and forceps in cutaneous surgery. Dermatol Surg 2002;28:601-2. [12] Isaacson G, Szeremeta W. Pediatric tonsillectomy with bipolar electrosurgical scissors. Am J Otolaryngol 1998;19:291-5. [13] Sood S, Strachan DR. Bipolar scissor tonsillectomy. [letter] Clin Otolaryngol 1999;24:465. [14] Raut VV, Bhat N, Sinnathuray AR. Bipolar scissors versus cold dissection tonsillectomy: a prospective, randomized, multi-unit study. Laryngoscope 2001;111:2178-82.
