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Wise et al.

Page 119

must, therefore, rely upon less scientifically rigorous data when deciding upon surgery for AR patients.

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The role of septoplasty for the treatment of nasal obstruction in AR is poorly understood. The nasal septum is not a major contributor to allergic disease because it does not experience the extent of dynamic change the turbinate tissue does, and therefore, there is a paucity of literature investigating septoplasty alone to improve nasal patency in AR. The nasal septal swell body may serve to alter nasal airflow and humidification, but no literature exists to implicate a role in AR. 1553 Karatzanis et al. 1554 found that subjective improvement in patients undergoing septoplasty was higher in those without AR than those with it. For this reason, a cautious approach to the management of nasal septal deviation in AR is warranted. On the other hand, Kim et al. 1555 found that AR patients undergoing septoplasty with turbinoplasty felt more relief of nasal obstruction then those undergoing turbinoplasty alone (Table IX.C). In contrast to the septum, the inferior turbinates are a prime target of allergic effects, characterized by vasodilation of capacitance vessels leading to engorgement, in turn causing nasal obstruction and congestion. Although surgery will not eliminate the inflammatory origins of AR, additional patency of the nasal cavity reduces the effects of edematous mucosa. From a surgical standpoint, inferior turbinate reduction is the most beneficial treatment for nasal obstruction in AR refractory to medical therapy. 1552 The inferior turbinate consists of 3 primary components: a mucosal covering, a submucosal layer (containing the capacitance vessels), and a bony center. Surgery is typically aimed at the submucosa or bone, or total/partial turbinectomy which involves removal of all 3 components. The submucosal tissue can be reduced through direct removal (eg, submucous bony resection or microdebrider submucosal resection) or energy applied to damage tissue with subsequent remodeling (eg, cautery, radiofrequency, laser, Coblation™). These various techniques have substantial support in the literature. Mori et al. 1556 reported on long-term outcomes on patients undergoing submucous bony resection over a 5-year follow-up period and noted a significant improvement in symptoms and nasal allergen responses. Additionally, QOL was enhanced in postoperative patients and maintained long term. Microdebrider submucous reduction targets the cavernous tissue surrounding the bony turbinate. Advantages include real-time suction with precise tissue removal. Compared to submucosal bony resection, data suggests improved mucociliary time due to less tissue trauma. 1557 Laser turbinate reduction seeks to induce scarring in the submucosa, though the overlying superficial mucosal layer is transgressed in the process. Caffier et al. 1558 reported on the effects of diode laser turbinoplasty in 40 patients with AR. Statistically significant improvements occurred in rhinomanometry and nasal obstruction, rhinorrhea, sneezing, and nasal pruritus. The improvement in nasal obstruction was sustained at 2 years. 1558

In radiofrequency ablation (RFA) for nasal obstruction, a probe is inserted directly into the inferior turbinate to deliver a low-frequency energy, causing ionic agitation of tissues. 1559

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.