Microdebrider-assisted inferior turbinoplasty versus other surgical techniques| ACTA Otorhinolaryngologica Italica

Abstract

This meta-analysis was conducted to evaluate the effects of microdebrider-assisted inferior turbinoplasty (MAIT) versus other techniques in treating inferior turbinate hypertrophy.  The protocol was registered in PROSPERO (CRD 42019126157). Cochrane Register of Controlled Trials CENTRAL, which includes MEDLINE was searched from inception until September 2021. One hundred twenty-four records were retrieved from the search of the electronic database and other sources. Ten articles were selected and analyzed quantitatively. There was significant reduction of nasal obstruction in microdebrider compared to radiofrequency by visual analogue scale but not by objective evaluations. Microdebrider has similar effect in reducing nasal obstruction to submucosal resection and laser. There was a higher incidence of postoperative bleeding in microdebrider compared to radiofrequency but shorter operative time and lesser intraoperative blood loss compared to submucosal resection.  In conclusion, the effect of MAIT is comparable to submucosal resection, laser and radiofrequency in reducing nasal obstruction. Whilst microdebrider has a shorter operative time and less intraoperative blood loss than submucosal resection, postoperative bleeding is greater than radiofrequency.

Introduction

Chronic and refractory nasal obstruction is one of the most challenging conditions to treat ¹. Although nasal obstruction is not life-threatening, it may significantly impact the quality of life of patients ². The anterior end of the inferior turbinate is the narrowest part of the nasal airway where hypertrophied inferior turbinate may cause significant nasal obstruction ³. Turbinate hypertrophy may lead to nasal obstruction, mouth breathing, snoring and retention of secretion ⁴. First-line treatment of this disorder is pharmacological. When standard pharmacological treatment using steroids, topical decongestants and antihistamines are inadequate, surgical treatment to address the inferior turbinate hypertrophy is necessary ¹. Several surgical interventions are available, which include using microdebrider, laser argon, carbon dioxide laser, radiofrequency, cryocoagulation and submucosal ablation by electrocautery ³.

The goal of turbinate surgery is to reduce the erectile submucosal tissue volume and the bony turbinate ⁵. With volume reduction, surgery on submucosal tissue also creates scarring, which helps prevent the engorgement of the inferior turbinate ⁵. It is imperative not to cause excessive damage to the turbinate mucosa, which is associated with a higher risk of throat dryness, nasal crusting, nasal bleeding, synechia formation, osteitis, atrophic rhinitis and inadequate volume reduction ⁶. Preservation of the mucosa avoids disruption of normal nasal physiology, including maintaining the equilibrium of temperature, humidity and filtration of inhaled air. Turbinoplasty has emerged as a preferred choice to achieve volume reduction while minimising complications associated with such intervention. Microdebrider-assisted inferior turbinoplasty (MAIT) is one of the surgical techniques to address the hypertrophic turbinates ¹. We aimed to evaluate the outcomes of MAIT versus other turbinoplasty procedures in treating patients with inferior turbinate hypertrophy. The primary outcome of this meta-analysis was the reduction of nasal obstruction, while the secondary outcome was complications of the procedure.

Materials and methods

The systematic review was conducted according to a protocol published in PROSPERO with identification serial number as CRD 42019126157. The methods and reporting were based on the Cochrane Collaboration and the preferred reporting items for systematic reviews and meta-analyses statement ⁷. The evaluation was done according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines ⁸.

Eligibility criteria

We included all randomised controlled trials (RCTs) comparing MAIT with other surgical techniques for inferior turbinoplasty. We included only articles published in English. The inclusion criteria were patients of all age groups who presented with obstructive nasal symptom due to inferior turbinate hypertrophy. Exclusion criteria were nasal obstruction unrelated to inferior turbinate hypertrophy and patients who underwent other nasal or sinus surgery. Studies must have extractable data and a follow-up period of at least postoperative one-month to be included.

Search strategy

We searched the Cochrane Register of Controlled Trials CENTRAL, which includes MEDLINE from inception until December 2021. Search words used were ‘turbinoplasty’, ‘turbinate reduction’, ‘microdebrider’ in combination with ‘AND’ and ‘OR’. We applied the Cochrane Highly Sensitive Search. We checked the reference list of identified RCTs and reviewed articles to find unpublished trials or trials not identified by electronic searches. Ongoing trials were searched by using other databases when necessary.

Study selection

Two review authors (NK, NMN) screened the titles and abstracts from the searches and obtained full-text articles when they appeared to meet the eligibility criteria or insufficient information to assess the eligibility. We assessed the eligibility of the trials independently and documented the reasons for exclusion. We resolved any disagreement between the review authors by discussion.

Data extraction

Data were extracted using data collection forms. The reviewers independently extracted study settings, participant characteristics, methodology and duration of the follow-up. The method of assessment of nasal obstruction together with the reported complications of these procedures were also extracted.

Risk of bias assessment

We assessed the risk of bias ⁷. All trials were classified as low risk, unclear risk, or high risk depending on random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, completeness of outcome data, the selectivity of outcome reporting and other bias. We resolved any disagreements by discussion.

Grading quality of evidence

We assessed the quality of evidence for primary and secondary outcomes according to the GRADE methodology for risk of bias, inconsistency, indirectness, imprecision and publication bias that was classified as very low, low, moderate and high ⁸.

Statistical analysis

We undertook a meta-analysis using Review Manager 5.3.5 software (RevMan 2014) and used the random-effects model to pool data. The heterogeneity was interpreted as follows: 0 to 40% might not be important; 30 to 60% may represent moderate heterogeneity; 50 to 90% may represent substantial heterogeneity, and 75 to 100% would be considerable heterogeneity ⁷. We measured the treatment effect for dichotomous outcomes using risk ratio (RR), and for continuous outcomes, we used mean difference (MD) and standardised mean difference (SMD) with 95% confidence interval (CI).

Results

Study selection

We retrieved 126 records from search of the electronic databases and one record from other sources (Fig. 1). Following removal of the duplicates, 126 records were left. After screening, 98 records were excluded. We identified 28 articles as possibly meeting the review inclusion criteria. Fifteen articles were excluded, of which 11 were non-randomised trials, three articles did not report the outcomes of interes, and one article was not available in English. Thirteen articles were included in this review, all of which were analysed quantitatively.

Participants

Table I shows the characteristics of the included trials. Eleven of the 13 trials were single-centre trials ^3,9-18 and two were multicentre trials ^19,20. All the trials were in adults except for one ²⁰, which was in children with a mean age of 11.6 years.

Intervention

Nine trials ^3,9,12-18 compared MAIT with radiofrequency, and three trials ^10,11,20 compared it with submucosal resection. Three trials ^17-19 compared MAIT to diode laser. MAIT was performed under local anaesthesia in 9 trials ^{3,9,10,12-15,17,18} and under general anaesthesia in 3 trials ^16,19,20. One trial¹¹ did not state the type of anaesthesia used. All procedures were done as an endoscopic technique. The procedure of MAIT was performed by inserting a microdebrider submucosally, medial to the conchal bone from the anterior head of the inferior turbinate along its entire length until the posterior end ^3,9-12,14-20. In addition to MAIT, one trial ¹⁰ out-fractured the inferior turbinate and lateralised it. Another trial ¹³ performed MAIT by using a microdebrider to trim the redundant and hypertrophied mucosa of the anterior head and the inferomedial side of the inferior turbinate.

Similarly, radiofrequency was performed by applying a radiofrequency probe submucously at the anterior, medial and inferior portions of the inferior turbinate in an anterior to posterior direction ^3,9,12-18. A submucosal resection was performed by making an initial mucosal incision on the head of the inferior turbinate ^10,11,20. The submucosal tissue was dissected using an elevator from the medial surface and inferior edge of the concha bone along the length of inferior turbinate and subsequently removed. A laser turbinoplasty technique was performed by creating an incision at the anterior aspect of the inferior turbinate ^17-19. A bare optical fibre was inserted submucosally, and laser pulses were delivered to the turbinate via the optical fibre along its entire length.

Outcomes

Relief of nasal obstruction was measured subjectively via a visual analogue score (VAS) and subjective nasal obstruction scale (SNOS), and objectively via acoustic rhinometry and mucociliary transport time. Visual analogue score evaluated the subjective feeling of nasal obstruction based on a scale ranging from 0 (no obstruction) to 10 (complete obstruction). Subjective nasal obstruction scale quantified the severity of nasal obstruction by a 4-scale measurement where 0 is no obstruction, 1 is mild obstruction, 2 is moderate obstruction, 3 is severe obstruction and 4 is complete obstruction. All 9 trials comparing microdebrider and radiofrequency reported relief of nasal obstruction. Six trials ^{9,13,14,16-18} measured nasal obstruction using VAS; one trial¹⁵ measured using SNOS and one trial ¹² did not report it. Four trials ^9,12,14,18 evaluated mucociliary transport time and 4 trials ^13,15,17,18 evaluated via acoustic rhinometry. All trials ^10,11,20 comparing microdebrider with submucosal resection used VAS to measure the relief of nasal obstruction. Additionally, 2 trials ^11,20 evaluated it by mean total nasal resistance. Three trials ^17-19 comparing microdebrider with laser, measured relief in nasal obstruction by VAS and acoustic rhinometry.

Seven of the 9 trials ^{3,9,12,13,16-18} comparing microdebrider with radiofrequency reported the complications related to the procedures. Three trials ^3,13,16,17 stated the operative time difference, and 2 trials ^3,12 reported the incidence of recurrent nasal obstruction between microdebrider and radiofrequency. All trials ^10,11,20 comparing microdebrider with submucosal resection reported on complications related to the procedures. One trial ¹¹ stated the operative time difference between microdebrider and submucosal resection. Two trials ^17,18 comparing microdebrider with diode laser reported crusting post-operation. One trial ¹⁹ evaluated the operative time difference and amount of blood loss, but did not report the values.

Risk of bias in included studies and quality of evidence

Four trials ^9,17-19 described the randomisation method that was assessed as low risk of bias. Three trials ^10,12,17 did not elaborate on the randomisation method, which was assessed as high risk, and it was not reported in the other five trials ^3,11,13-16, which was assessed as unclear risk. Allocation concealment was mentioned in one of the trials ¹⁹, assessed as low risk, but was unclear in 12 trials ^3,9-18,20 and assessed as unclear risk. All 13 trials measured the primary outcome and were included in the meta-analysis. Eleven trials ^{3,9,11-13,15-20} measured the primary outcome at 2 to 12 months with no patient lost during follow-up. Two other trials ^10,14 measured outcomes for up to 3 years with less than 20% of patients lost to follow-up. All the trial protocols were not provided, but all trials reported the outcomes specified in their respective methodology. We detected no other potential sources of bias.

Comparisons and effects of interventions

Primary outcomes

MICRODEBRIDER VERSUS RADIOFREQUENCY

All trials ^3,9,12-18 comparing microdebrider with radiofrequency reported the relief of nasal obstruction. Seven trials ^9,13-18 measured reduction of nasal obstruction subjectively using continuous data. A significant reduction of nasal obstruction was achieved with microdebrider compared to radiofrequency (Fig. 2, Tab. II). Four trials ^9,12,14,18 evaluated the mucociliary transport time. There was no significant difference in mucociliary transport time between microdebrider and radiofrequency (Supplementary Fig. 1, Tab. II). Four trials ^13,15,17,18 reported evaluation by acoustic rhinometry. There was no significant difference between microdebrider and radiofrequency by acoustic rhinometry (Fig. 3, Tab. II).

MICRODEBRIDER VERSUS SUBMUCOSAL RESECTION

All trials ^10,11,20 comparing microdebrider with submucosal resection reported relief of nasal obstruction using VAS. Two of the trials ^10,20 were continuous data. There was no significant difference between microdebrider with submucosal resection (Fig. 2, Tab. III). Another trial ¹¹ using dichotomous data showed no significant difference between microdebrider and the submucosal resection (Tab. III).

MICRODEBRIDER VERSUS DIODE LASER

Two trials ^17,18 reported that the relief of nasal obstruction using VAS as continuous outcomes demonstrated no significant difference between groups (Fig. 2, Tab. IV). One trial ¹⁹ reported using dichotomous data showed no significant difference between groups by VAS (Tab. IV). There was no significant difference between microdebrider and diode laser by acoustic rhinometry (Fig. 3, Tab. IV).

Secondary outcomes

Microdebrider had a higher incidence of postoperative bleeding compared to radiofrequency ^12,13,17 (Fig. 4, Tab. II). Three trials ^16-18 comparing microdebrider with radiofrequency reported no difference in the incidence of crusting (Fig. 5, Tab. II). Similarly, no different was found in the incidence of crusting between microdebrider and submucosal resection ^10,11 (Fig. 5, Tab. III). Postoperative pain was identical between microdebrider and submucosal resection ¹¹ (Tab. III).

The incidence of recurrent nasal obstruction was equivalent between microdebrider and radiofrequency ^3,12 (Supplementary Fig. 2, Tab. II). Likewise, there was no difference in the operative time between microdebrider and radiofrequency ^3,13,16,17 (Fig. 6, Tab. II). A shorter operative time was observed in microdebrider compared to submucosal resection ¹¹ in addition to less intraoperative blood loss ¹¹ (Tab. III). No significant difference was seen in the incidence of crusting between microdebrider and diode laser ^17,18 (Fig. 5, Tab. IV).

Discussion

Summary of main results

This meta-analysis concluded that MAIT is a promising surgical intervention for inferior turbinate hypertrophy with a favourable effect. There was a significant reduction of nasal obstruction with a microdebrider compared to radiofrequency by VAS and SNOS measurements. However, there was no difference in the two techniques based on objective evaluations using rhinometry and mucociliary transit time. In addition, the effect of microdebrider on the reduction of nasal obstruction commensurate with those of submucosal resection and diode laser. In terms of complications, microdebrider has a higher incidence of postoperative bleeding compared to radiofrequency but a smaller amount of intraoperative blood loss and shorter operative time compared to submucosal resection. The microdebrider demonstrated no difference in recurrent nasal obstruction, operative time, or crusting compared to radiofrequency and a similar effect to submucosal resection in the incidence of crusting and postoperative pain.

Quality of evidence

Using GRADE, the level of evidence that contributed to this review was assessed as low to moderate quality. The quality of evidence for the primary outcome was low to moderate in the comparison of microdebrider versus radiofrequency, low for microdebrider versus submucosal resection and low to moderate for microdebrider versus diode laser. For the secondary outcomes, comparisons of microdebrider with radiofrequency, submucosal resection and diode laser ranged from low to moderate quality of evidence. Overall, most of the trials have a small number of patients and high heterogeneity, which could be attributed to surgeons with varying levels of expertise performing the surgical procedure. The high heterogeneity could also be contributed to the different techniques being performed with a microdebrider, such as submucosal tunnelling and extraturbinal resection coupled with lateralisation of the inferior turbinate.

In general, all studies had low to unclear risk of bias in all domains except in blinding of participants and personnel. There was no evidence of selective reporting bias in all reported trials. Loss during follow-up was less than 20% in all included trials, and all the trials performed intention-to-treat analysis. Due to the low to moderate quality of evidence, the results should be interpreted cautiously. Further randomised controlled trials with a greater number of participants and robust objective evaluation might provide a better quality of evidence. Additionally, trials with extended follow-up period could evaluate the long-standing outcomes of the technique.

Potential biases in the review process

We eliminated publication bias by checking the reference lists of all related trials for further references and searching multiple databases without language restriction. We could not construct a funnel plot to detect bias or heterogeneity due to an insufficient number of trials contributing to each outcome.

Agreements and disagreements with other reviews

A review by Acevedo et al. ²¹ comparing microdebrider and radiofrequency showed that the two methods are equally effective in reducing nasal obstruction. In contrast, a more recent meta-analysis by Mirza et al. ²² reported that a microdebrider has better outcomes compared to to radiofrequency in reducing nasal obstruction, but has a higher rate of postoperative bleeding. Although the present meta-analysis found a microdebrider is superior to radiofrequency in reducing nasal obstruction subjectively, this effect was not supported by objective evaluations. Though two previous meta-analyses ^21,22 have evaluated the effects of microdebrider compared to radiofrequency, to the best of our knowledge there is no meta-analysis assessing the effects of microdebrider compared to submucosal resection and laser. Thus, the present meta-analysis contributes to the existing literature by providing a comprehensive overview of the overall effects and complications of MAIT in comparison with other surgical techniques.

Conclusions

Microdebrider-assisted inferior turbinoplasty is an effective surgical technique with an effect comparable to radiofrequency, submucosal resection and laser in reducing nasal obstruction in patients with inferior turbinate hypertrophy. While MAIT provides greater reduction of subjective nasal obstruction, the effect is not demonstrable by objective evaluation, and has a higher incidence of postoperative bleeding compared to radiofrequency. Among its advantages in comparison to submucosal resection are shorter operative time and less intraoperative blood loss.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

NK, NMN and BA made a substantial contribution to the conception and design of the article, to the acquisition, analysis and interpretation of data. SSAH critically revised the article and gave the final approval of the version to be published.

Ethical consideration

The systematic review and meta-analysis design of this article does not require ethical approval from our institution.

This article does not involve generation of new data from human or animal and no consent is necessary.

Figures and tables

Figure 1.Flow diagram of study selection.

Figure 2.Relief of nasal obstruction based on the visual analogue scale: (A) microdebrider versus radiofrequency; (B) microdebrider versus submucosal resection; (C) microdebrider versus diode laser.

Figure 3.The acoustic rhinometry assessment between: (A) microdebrider and radiofrequency; (B) between microdebrider and diode laser.

Figure 4.The incidence of post-operative bleeding between microdebrider and radiofrequency.

Figure 5.The incidence of crusting between: (A) microdebrider and radiofrequency; (B) microdebrider and submucosal resection; (C) microdebrider and diode laser.

Figure 6.The operative time between microdebrider and radiofrequency.

Supplementary Figure 1.The mucociliary transport time between microdebrider and radiofrequency.

Supplementary Figure 2.The incidence of recurrent nasal obstruction between microdebrider and radiofrequency.

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