Electron Microscopic Study of Mucosal Sparing Techniques for
Inferior Turbinate Volume Reduction
Add Helm) MD. Ahmed Dussien MD . Mohamed All MR, Mohsen Ahdel Rank MD, Mohamed Gamil MISRCH.
ENT Department Benha Faculty of Medicine Zagazig University
Abstract
Chronic nasal obstruction is a frequent symptom. In the management of nasal
obstruction, identification and treatment of inferior turbinate hypertrophy remains an
important consideration for long-term improvement of nasal breathing. Various surgical
techniques are currently performed to reduce the volume of the hypertrophied inferior
turbinate. The multitude of approaches available to the rhinologist is a testament to the
lack of a single established method. This study was conducted on 30 patients with chronic
nasal obstruction due to bilateral persistent hypertrophy of the inferior tztrbinates.
Twenty-three patients were males (76.7 %) and seven patients were females (23.3%). The
mean age ± SD of the patients was 21.3 ± 3.4 years. In our study we compare between
two mucosal sparing techniques used for inferior turbinate volume reduction;
submucosal diathermy versus coblation; clinically and ultrastructurally. Also, we
correlate between the post operative ultrastructure of the inferior turbinate mucosa and
the clinical findings after these techniques.
Patients were subjected to a sufficient evaluation which included subjective and objective
assessment by; endoscopic nasal examination, preoperative and postoperative saccharine
test and ultrastructure study of inferior turbinate mucosal biopsy one month
postoperatively.
Under local anesthesia, coblation assisted technique was performed along the right sided
inferior turbinate while electrical submucous diathermy was performed along the left
sides. Our study showed that both submucous diathermy and coblation technology are
effective methods for inferior turbinate volume reduction. However, coblation proved by
the ultrastructure study to produce less cellular damage, minimal crust, faster recovery
of normal nasal physiology , faster improvement in nasal obstruction and better
tolerability by the patients in the postoperative period. Up to our knowledge, this is the
first time to study the postoperative ultrastructure of the inferior turbinate mucosa after
coblation or submucous diathermy.
Introduction
Nasal obstruction is the presenting
complaint of a large number of patients in
otolaryngologic practice (Beckingham et al.,
1989). Chronic nasal obstruction is a
frequent symptom that can result from
persistent hypertrophy of the inferior
turbinate. The inferior turbinates are
intriguing structures of the lateral nasal wall
that are designed specifically to cause nasal
resistance and slow movement of nasal
airflow (Kelvin et al., 2001). The most
common causes of such obstruction are
allergic rhinitis, non-allergic rhinitis or
hypertrophy of the turbinate of unknown
reason (Langerholm et al., 1999).
Bhatt, (1997) stated that all patients with
turbinate dysfunction should have a trial of
medical treatment before surgical
intervention. Although medical treatments
(local corticosteroids, antihistamines,
decongestants) are frequently effective to
restore comfortable nasal breathing, nasal
obstruction is sometimes only slightly
improved, leading some patients to increase
their consumption of local decongestants
with a high risk of iatrogenic effects (Coste
et al.,2001). When conservative medical
management of symptomatically enlarged
inferior turbinate is ineffective, the
obstructing tissue may be reduced by an
intramucosal or extramucosal destructive
procedure, or by conservative surgical
resection (Mabry, 1998).
Various surgical techniques are
currently performed to reduce the volume of
the mucosal (and sometimes bony) tissues of
the inferior turbinate: total or partial
turbinectomy; turbinoplasty, laser-assisted
turbinoplasty; and chemical, electrical, or
diathermy coagulation or even cryosurgery
(Jackson and Koch 1999). Although most of
these techniques provide satisfactory results
for a more or less long period, adverse
events are frequently observed after such
treatment: postoperative bleeding, crusting,
sometimes associated with a foul odor, pain,
hyposmia, and synechia (Faulcon et al.,
1998). Controversy still exists about the best
appropriate method for surgical reduction of
the inferior turbinate. The multitude of
approaches available to the rhinologist is a
testament to the lack of a single established
method (Chang and Ries, 2004).
In recent years, inferior turbinate
reduction has regained popularity on
outpatient basis using local anesthesia. One
of the recent methods is using coblation
technology (high frequency cold plasma
ablation) which is introduced submucosally,
creating focal lesion with no damage to the
adjacent structures as the temperature
delivered to the tissues is considerably low
(40-70°C) (Coste et al., 2001). Coblation
technology is based on an ionic
"bombardment" of the biological tissue at
the intervention site, which leads to ruptures
of intermolecular cohesions (Sergeev and
Belov; 2003).
Submucous diathermy of the inferior
turbinate is a widely practiced procedure.
The effect of submucosal diathermy is
achieved by coagulation of the venous
sinusoids within the turbinate, leading to
submucosal fibrosis (Jones and Lancer,
1987).
The aim of this work is to compare
between two mucosal sparing techniques
used for inferior turbinate volume reduction;
submucosal diathermy versus coblation, and
to correlate bctween the past operative
2
uhrastructure of the inferior turbinate
',Waisa and the clinical findings after these
techniques.
Patients and Method
The present study was conducted on 30
patients who were complaining of persistent
bilateral nasal obstruction due to bilateral
inferior turbinates hypertrophy. Patients in
whom the nasal obstruction was due to other
causes were excluded. Every patient was
submitted to two different operative
procedures; the right sided inferior turbinate
was submitted to volume reduction by
coblation assisted technique while the left
sided inferior turbinate was submitted to
volume reduction by electrical submucous
diathermy in the same session. The 30
patients (60 inferior turbinates) were divided
into two equal groups according to the
operative procedure assigned for each
group:
Group I: coblation side (right sided inferior
turbinates); this includes 30 inferior
turbinates.
Group II: diathermy side (left sided inferior
turbinates); this includes 30 inferior
turbinates.
All patients were submitted to the
following:
I- Preoperative evaluation:
1-Saccharin test: Nasal epithelial function
was evaluated preoperatively by saccharin
test. Saccharin transient time (normally 10-
15 min) was measured after deposition of a
saccharin tablet on the floor of the nasal
fossa at the level of the head of the inferior
turbinate. The patient was asked to swallow
every 30 seconds until he tasted sweaty
sensation in his throat. Time is calculated by
the examiner from placing of the tablet till
the sweaty sensation of the patient. The
other side is done on the same way.
2- Endoscopic nasal examination: using 0
degree rigid endoscope to detect the
presence of any other causes of nasal
obstruction as deviated septum, nasal
masses, or polyposis. Patients with any
pathology other than inferior turbinate
hypertrophy were excluded from the study.
3 -Corona! C. T. scans of the paranasal
sinuses were done to determine whether the
hypertrophy is mucosal only or with bone
hypertrophy. Only patients with mucosal
hypertrophy were included in the study
(Figure A).
II- Operative procedure:
Anesthesia:
The procedure was done under local
anesthesia; by placing cotton nasal pack
soaked with xylocaine cream 5% for
approximately 20 minutes, and then the
anterior head of the inferior turbinate was
injected with 2 to 3m1 of mixture of
adrenaline I /200000 and xylocaine 10%.
Technique:
Right side:
The Coblation radiofrequency controller
(ENTec/Arththrocare Corp, Sunnyvale,CA)
with a voltage range of 96 to 312 voltage
root mean-square (Vnns) value and the
3
ENTec coblation wand (Reflex Ultra 45
wand).An amount of saline is placed on the
tip of the coblation wand . Coblation power
level of 5 (168-182 Vrms) delivering bipolar
energy (100 kHz) with temperature between
40-70°C was used.With 0 degree endoscopic
guidance, the Coblation wand is applied first
into the base of the anterior part of the
inferior turbinate, wand is then activated by
the foot pedal, and the probe is carefully
passed into the submucosal plane of the
turbinate. The Coblation wand is maintained
in an active state for 15 seconds and then it
is removed at the coagulation mode. The
process is repeated in medial part of the
inferior turbinate and its superior part. Dry
cotton pack is placed in the nose to control
any minor bleeding for 10 minutes (Figure
B).
Left side:
Electrical diathermy device is set to a
power level of 5. A grounding pad was
applied to the patient's flank. A spinal metal
needle is passed with 0 degree endoscopic
guidance into the submucosal plane of the
base of the anterior part of the inferior
turbinate. Then, the hand piece is activated
using a foot pedal, and touched to the spinal
needle to conduct electrical current (2000
kHz) through the turbinate. Electrical
current is kept for 15 seconds and during its
removal. The process is repeated in medial
part of the inferior turbinate and its superior
part. Dry cotton packs was placed in the
nose to control any minor bleeding for 10
minutes (Figure B).
Figure A. C. T. scan showing mucosal
hypertrophy of the inferior nasal turbinates.
Figure B: Diagram showing 3 marked sites
Jar the insertion of Coblation wand and the
spinal needle
III —Postoperative evaluation:
1- Saccharine test was done one week, two
weeks and one month post operatively for
each nasal side.
2- Endoscopic nasal examination for
assessment of the surgical site on weekly
bases for one month.
3- Electron microscopic study of biopsy
from the inferior turbinate of 10 patients (20
4
inferior turbinate biopsies; 10 from right and
10 from left sides).
Legal consent was obtained after the
nature of the work had been fully explained.
A tiny biopsy is taken one month
postoperatively from the inferior turbinates
under local anesthesia, using 5% xylocaine
without adrenaline. The biopsies were
processed using scanning electron
microscopy (done in Ain Shams Specialty
Hospital Electron Microscope Unit).
The results of the electron microscopic
study of each side were compared
considering cilia, goblet cells, fibrosis and
inflammatory cells and documented
photographically.
Results
Thirty patients presented to the outpatient
clinic of ENT Department in Benha
University Hospital with persistent bilateral
nasal obstruction of variable duration
ranging from I year to 10 years during the
period from September 2003 to September
2004.
Twenty-three patients were males (76.7 %)
and seven patients were females (23.3%).
The mean age ± SD of the patients was 21.3
3.4 years.
Pre-operative saccharine test was done for
all patients. All patients showed prolonged
time ranging from 16 minutes to 32 minutes
with a mean duration ± SD 21.7 ± 4.9
minutes (Table I).
Number of patients Duration in minutes
19 20-> 30 min.
II
16-20 min.
Mean duration
2I.7min.
Table ( I ). Preoperative saccharine test
duration.
Postoperative clinical results:
In the early postoperative period; in the
coblation side, 3patients (10%) showed
minor bleeding in the first 6 hours. This
bleeding was controlled by ephedrine packs.
In the diathermy side, 5 patients (16.7%)
showed minor bleeding in the first 6 hours
which was also controlled by ephedrine
packs with no significant difference between
both sides. Pain was only recorded in the
first day of follow up with no significant
difference between both sides.
There was improvement in nasal obstruction
with significant difference in the benefit of
coblation side in the first week of follow up
as, (27 patients 90%) from coblation side
improved, while in diathermy side (onlyl 1
patients 36.7% improved) (p<0.001). After
two weeks and one month, all patients
(100%) of the coblation side showed
improvement while only 26 patients (86.7%)
of the diathermy side showed improvement
with non significant difference between both
sides 0)>0.05),In the diathermy side 4
patients (13.3%) still complaining of mild to
moderate nasal obstruction.
Nasal crust was more in the diathermy side
in the all postoperative follow up visits with
5
highly significant difference between it and
the coblation side; in the diathermy side, 20
patients (66.7%) showed large amounts of
crusts and 10 patients (33.3%) showed
moderate amounts of crusts, while in
coblation side, 25 patients (83.3%) showed
few crusts and 5 patients (16.7%) showed
moderate amounts of crusts (p<0.001).
There was increase in the duration of the
saccharine test after one week post
operatively with no significant difference
between both sides (coblation side; ±SD
26.4±15.57, diathermy side; ±SD
29.93±4.83). However, there was a decrease
in the duration of saccharine test after two
weeks and one month with significant
difference between both sides in benefit of
the coblation side (coblation side; ±SD
9.83±4.6, diathermy side; ±SD 14.5±3.6)
(p<0.001).
Ultrastructure Results:
Left side (diathermy side) showed:
Ciliated cells: In all specimens, no cilia
were detected in the epithelial cells by low
or high power magnification of the electron
microscope; some cells were covered only
by branched microvilli (Fig.1).Many of the
cells showing apoptosis, most of cell
junctions were lost and there was marked
edema in between the cells. Few cells were
still reaching the basal membrane(Fig. 1,2).
Goblet cells: No goblet cells were found in
any of the specimens from the left side by
high or low power magnification of the
electron microscope.
Intermediate cells: Many of the intermediate
cells showed apoptosis, loss of intercellular
junctions; few attached to the basal lamina
with marked intracellular edema in between
the cells (Figure 1).
Basal cells: Many cells showed apoptosis
and few were attached to the basal lamina.
Figure (1): A region of human nasal mucosa
from the left inferior nasal turbinate
processed by scanning electron microscope/
low power 2800. Section showing apical part
of mucosa with apoptotic epithelium(E) with
no cilia marked intracellular edema in
between intermediate cells (0) and no
attachment to the basement membrane (B)
Figure (2): A region of human nasal mucosa
from the lefi inferior nasal turbinate
processed scanning electron
microscope/loy• power 2800. Section
showing epithelial cells (E) with no cell
junctions, 170 till(1, no Goblet cells.
Apoptosis (APP) and intraccIlulor edema
(01.
6
The subepithelial layer: Showed many
inflammatory cells; (lymphocytes, eosinoph
i I is and macrophages,) fibroblasts,
collagen bundles and marked edema (Figure
3). Some blood capillaries showed active
platelets thrombosis (Figure 4). Some
submucous glands showed red blood cells in
their lumen (Figure 5).
Figure (3): Basal part of figure II showing
fibroblasts (F), lymphocytes (L),
Eosinophilis (EO), Collagen bundles (CO),
Macrophages (M) and edema (0).
Figure (4): .4 high power .v 4600 section in
submucosa of the inferior turbinate
.chows a platelet thrombus in a capillary.
Figure (5): A low power x 2800 section of a
submucous gland (SGL) showing RBC inside
its lumen
Right side (Coblation side) showed:
Ciliated cells: In all specimens, no cilia were
detected in the epithelial cells by low power
magnification of the electron microscope
(Figure 6). However, by the high power
magnification, short cilia and apical
secretary granules were detected in the
epithelial cells (Figure 7).Some epithelial
cells showed moderate damage and
moderate loss of cell junctions with some
ulceration in the surface. Few apoptotic cells
were seen (Figure 8).
Goblet cells: Few non-functioning goblet
cells were seen in the epithelium by the low
power magnification (Figure 6).
Intermediate cells: Showed to some extent
intact cell junctions and no intracellular
edema. Few cells showed apoptosis (Figure
9).
Basal cells: Few apoptotic cells were seen,
most of cells were attached to the basal
lam rano.
Subepithelial laver: Showed few
inflammatory cells and few intracellular
edema.
7
Figure (6): A region of human nasal mucosa
from the right inferior nasal turbinate
processed by scanning electron microscope/
low power x 2800. Section showing
superficial epithelial cells (E) with no
apparent cilia and apparent non-functioning
Goblet cells (G). Lymphocytes are also
present in this section (L)
Figure (8): A region of human nasal mucosa
from the right inferior nasal turbinate
processed by scanning electron microscope/
high power x 4800. Section showing
epithelial cells with moderate damage (E),
apoptotic epithelial cell (APP), ulcer (U)
and moderate loss of cell junctions (Arrow).
Figure (7): A region of human nasal mucosa
from the right inferior nasal turbinate
processed by scanning electron
microscope/high power x 8000. Section
showing epithelial cells with short cilia (C)
and apical secretary granules (SG).
Figure (9): A region of human nasal 177LICOSa
from the right inferior nasal turbinate
processed by scanning electron
microscope/high pmver x 3600. Section
showing intermediate epithelial cellsa) with
intact cell junctions U) with no intracellular
edema and normal cytoplasmic organelles.
Some cells showing apomosis (APP).
8
Discussion
Nasal obstruction is one of the oldest and
most common human complaints. While it
may be a mere nuisance to some people, to
others it is a source of considerable
discomfort and it distracts from the quality
of their lives. Hypertrophy of the inferior
turbinate is a common cause of chronic nasal
obstruction. Many cases respond to
conventional medical management. In some
patients, this therapy is not sufficient, and
many surgical procedures have been used to
reduce the size of inferior turbinates. This
has led to search for effective, yet minimally
invasive techniques for reducing the inferior
turbinates (Elwany and Harrison, 1990).
In our study we compare between two
mucosal sparing techniques used for inferior
turbinate volume reduction; submucosal
diathermy versus coblation; clinically and
ultrastructurally.
The technique of submucosal diathermy of
inferior turbinates was similar to the
technique described by Talaat, (1987).
The technique of coblation reduction was
similar to the techniques described by
Kelvin et al., (2001) , Bhattacharyya and
Kepens, (2002) and Leif et al., (2002).
In our study, all patients showed
preoperative prolongation of saccharine
transient time with mean duration ± SD
(21.7± 4.9) as expected due to disturbed
mucociliary Ihnction. These results are in
accordance with saccharine test result
obtained by Coste et al., (2001).
In our study, bleeding from the entry sites
of the reflex wand of the coblation device
and the spinal needle was minimal; 3
patients (10%) from the coblation side and 5
patients (16.7%) from the diathermy side.
The difference between the two sides most
probably due to the coagulation option in the
coblation device, which enables coagulation
at the entry sites.
These results are equal to the results
obtained by Bhattacharyya and Kepens,
(2002) for the coblation side (10%) but
slightly more than Leif et al., (2002) who
reported no postoperative bleeding. As for
the diathermy side our results are slightly
more than results obtained by Talaat, (1987)
who reported 10% postoperative bleeding.
In our study, all patients showed moderate
to severe pain recorded only in the first
postoperative day of follow up with no
significant difference between both sides.
These results coincide with that obtained by
Bhattacharyya and Kepens, (2002) and Leif
et al., (2002).However; Pain was not
mentioned by Talaat, (1987) for submucous
diathermy of inferior turbinate.
There is significant improvement in nasal
obstruction in the first week in the coblation
side in 27 patients (90%) with gradual
improvement in the last follow up visit in all
patients ( I 00%). These results are in
accordance with Bhattachary a and Kepens.
(2002), Leif et al., (2002) and Kelvin et al.,
(2001). However, in diathermy side, there is
gradual decrease in nasal obstruction in the
first week of follow up in I I patients
9
(36.7%), with improvement after two weeks
and in the last follow up visit in only 26
patients (86.7%). These results agreed with
the results obtained by Talaat, (1987).
There is no significant crusting in the
coblation side along the whole postoperative
follow up period. These results agree with
Bhattacharyya and Kepens, (2002), Leif et
al., (2002) and Kelvin et al., (2001).
However, there are crusting in the diathermy
side which started to decrease mostly after
two weeks in the follow up period. These
results go in hand with Fradis et al., (2000).
There is increase in the duration of
saccharine test after one week with no
significant difference between both sides.
However, saccharine test duration showed
significant decrease in the coblation side
after two weeks and continued to decrease
till the last post operative follow up visit.
These results matched the results obtained
by Coste et al., (2001), Leif et al., (2002),
also by Sapci et al., (2003). The diathermy
side showed also decrease in the duration of
saccharine test but with a much slower rate
than right side. These results coincide with
Woodhead et al., (1989).
A tiny biopsy was taken from the right
and left inferior turbinates in the last follow
up visit, and then processed by scanning
electron microscope for the cellular
ultrastructure.
Up to our knowledge. this is the first lime to
study the postoperative uhrastructure of the
inferior turbinate mucosa alter cohlation or
submucous (limbo-um
Bruce et al. (1983) reported that the
ciliated cells are the predominant cells of
human nasal respiratory epithelium. The
most striking feature is the cilia which are
150-200 per cell. Biopsies from the
coblation side showed no cilia by the low
power magnification of the electron
microscope, however, short cilia are
detected by the high power magnification of
the electron microscope. These indicate
moderate cellular damage. Biopsies from the
diathermy side showed no cilia either by low
or by high power magnification of the
electron microscope. These indicate severe
cellular damage. These findings may explain
the significant decrease in saccharine test
duration in the coblation side.
Normally there are no apoptotic cells
among the ciliated cells (Bruce et al., 1983).
Biopsies from coblation side showed few
apoptotic cells among the ciliated cells.
These indicate moderate cellular damage.
Biopsies from diathermy side showed many
apoptotic cells. These indicate severe
cellular damage.
The goblet cells are actually columnar
epically and tapered basally similar to the
adjacent ciliated cells. Their striking feature
is the electron-lucent mucous droplets which
coalesce towards the apical surface of the
cell to bulge into the lumen of the nasal
cavity prior to discharge (Bruce et al., 1983).
Biopsies from coblation side showing few
non-functioning goblet cells by the low
power electron microscope with no electronlucent
mucous droplets which indicate
10
moderate damage to the cells, while in
diathermy side no goblet cells are found by
low or high power electron microscope,
which indicate severe damage to the cells up
to cell death. These findings may explain the
significant difference in crusting between
both sides.
The intermediate cells are elongated or
pyramidal cells with their base resting on the
basal lamina (Bruce et al., 1983). Biopsies
from coblation side showed intermediate
cells with some extent intact cell junctions,
no intercellular edema, few cells showed
apoptosis and most of cells are resting on the
basal lamina. These findings indicate very
mild cell injury. As for the diathermy side,
many cells showed apoptosis, loss of
intercellular junctions, and few cells are
attached to the basal lamina with marked
intracellular edema. These findings indicate
severe cellular injury. These findings may
explain the increased incidences in nasal
obstruction in the diathermy side.
As regarding basal cells; according to
Bruce et al., (1983), they are small
polyhedral or triangular stem cells resting
directly on the basement membrane.
Biopsies from coblation side showed few
cells with apoptosis and most of cells are
attached to the basement membrane. These
indicate very mild cellular injury to the basal
cells. In the diathermy side, many cells
showed apoptosis and few cells are attached
to the basal lamina. These indicate severe
cellular damage.
Bruce et al., (1983), reported that the
subepithelial layer is formed of collagen
bundles, blood capillaries and submucous
glands. Biopsies from coblation side showed
that, it was within normal with few
inflammatory cells and few intracellular
edema. As for diathermy side, it showed
many inflammatory cells with some blood
capillaries showing active thrombosis and
some submucous glands showing red blood
cells in their lumen. These findings indicate
reaction to severe cellular injury and may
explain the increased incidences of the
postoperative bleeding of the diathermy
side.
Elwany and Hesham (1997), in their study
on 10 patients who had undergone carbon
dioxide laser turbinectomy and followed by
ultrastructure study of biopsies from their
inferior turbinate mucosa one month
postoperatively reported that; fast healing
had been always an advantage of laser
turbinectomy. However, the clinical
assessment of their results was beyond the
scope of their research. In our study we
correlate between the post operative
ultrastructure of the inferior turbinate
mucosa and the clinical findings.
Conclusion
Submucous diathermy and coblation
technology are effective methods for volume
reduction of the inferior turbinate. Coblation
technology proved by the ultrastructure
study to produce less cellular damage,
minimal crust and faster recovery of normal
•
nasal physiology with faster improvement in
nasal obstruction with better tolerability by
patients in the postoperative period.
Up to our knowledge it is the first time to
study the correlation between the
postoperative ultrastructure of the inferior
turbinate mucosa and the clinical findings
after these techniques.
References:
I. Bahtt NJ: Surgical techniques for
turbinates. Endoscopic sinus surgery
(New horizon) Bhatt NJ (Ed);
Singular Publishing Group Inc. PP:
70-83, 1997.
2. Beckingham E, Jones As and Weight
RE: Radical trimming of the inferior
turbinates and its effect on nasal
resistance to airflow. J Laryngol Otol
102: 694- 696, 1998.
3. Bhattacharyya and Kepens: Bipolar
radiofrequency cold ablation turbinate
reduction for obstructive inferior
turbinate hypertrophy: operative
techniques in otolaryngology- Head
and Neck surgery; 13: 170-174, 2002.
4. Bruce, Jafek Denver: Ultrastructure
of human nasal mucosa.
Laryngoscope 93:1576-1599, 1983.
5. Chang and Ries: Surgical treatment of
inferior turbinate: new teehnohigv.
C'urr Opin Otolarvngol Head Neck
Sing /2;( 1):53-7, 2004.
6. Coste A. Yana L. BIUMell Al. Louis B.
Zerah F. Rugina M. Pcvnegre R. Hail
A. Escudier E: Rculigfrequencv is a
scffe and effective treatment cif
turbinate hypertrophy. Laryngoscope
1/1: 894-899, 2001.
7 Elwin?), S and Harrison R: inferior
turbinectomy: comparison of four
techniques. J Laryngol Otol 104: 206-
209, 1990.
8. Elwany S and Hesham 41: Carbon
dioxide laser turbinectomy.An
electron microscopic study. The
Journal of Laryngology and Otology
/11:931-934, 1997.
9. Faulcon P. Amanou L, Bonfils P:
Treatment of nasal obstruction with
subtotal inferior turbinectomy in
chronic rhinitis: a retrospective study
on 50 patients. Ann Otolaryngol Chir
Cervicofac 1998; 115:228-233.
10. Fradis M, Golz A, Dannino P Inferior
turbinectomy versus submucous
diathermy for inferior turbinate
hypertrophy. Otolo Rhino! Laryngol
109: 1040-1045, 2000.
11.Jackson LE, Koch RJ: Controversies
in the management of inferior
turbinate hypertrophy; a
comprehensive review .Plast Reconstr
Surg, 103:300-312, 1999.
12. Jones A and Lancer J: Does
submucosal diathermy to the inferior
turbinates reduce nasal resistance to
air flow in the long term? Journal
larvintologv and Otology 101: 448-
451. 1987.
13. Kelvin C. Peter H. Todd T: Surgical
management of inferior turbinate
12
hypertrophy in the office: three
mucosal sparing techniques.
Operative techniques in
otolaryngology- head and neck
surgery, (12), 2; 107-111, 2001.
14. Langerholm S. Harsten G, Emgrad P
and Olsson B: Laser turbinectomy:
long term results. J Laryngol Otol.
113: 529-531, 1999.
15. Leif J, Maya L,Henrik 0, Malmerg P.
Ylikoski j :Submucosal bipolar
radiofrequency thermal ablation of
inferior turbinates: A long term
follow-up with subjective and
objective assessment. Laryngoscope
112, (10); 1806-1812, 2002.
16. Mabry RL: Inferior turbinoplasty:
patients selection, technique, and
long-term consequences Otolatyngol
Head neck surgery; 98 (1):60-6,1998
17. Sergeev V, Belov S: A New method of
high frequency electrosurgery
(coblation technology). Med Tekh I;
21-3, 2003.
18. Sapci T, Sahin B, Karavus A, Akbulut
U: Comparison of the effects of
radiofrequency tissue ablation, CO
laser ablation, and partial
turbinectomy applications on nasal
mucocilithy functions. Laryngoscope,
113 (3): 514-9, 2003.
19. Talaat Al, El- Sabawy E, A bdel Baky
F. Abdel Raheem A, : Submucous
diathermy of the inferior turhinates in
chronic hypertrophic rhinitis: The
Journal of laryngology and otology,
101,452-460,1987.
20. Woodhead C Wickham M. Smelt G.
MacDonald A: Some observations on
submucous diathermy: J Laryngol
Otot 103 (11): 1047-9, 1989.
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