What is the treatment for significant inferior turbinate hypertrophy?

Treatment of Significant Inferior Turbinate Hypertrophy

For significant inferior turbinate hypertrophy, a stepwise approach is recommended, starting with medical management using intranasal corticosteroids and saline irrigation, followed by surgical intervention only after failed medical therapy, with microdebrider-assisted turbinoplasty being the preferred surgical technique due to its lower complication rate. 1, 2

Medical Management

Medical therapy should be the first-line treatment for inferior turbinate hypertrophy:

1. Initial Medical Therapy (minimum 4-week trial) 1
   • Intranasal corticosteroids (e.g., fluticasone propionate)
   • Saline nasal irrigation
   • Antihistamines (second-generation preferred to reduce sedation)
   • Anticholinergic nasal sprays

Fluticasone propionate has been objectively shown to reduce turbinate size in CT studies, with significant reductions in the mucosal area of the lower turbinates and thickness of the nasal mucosa after 3 months of treatment 3.

Important Note: Intranasal corticosteroids have been shown to be safe for long-term use with no evidence of atrophy or deleterious pathological changes to the nasal mucosa even after 1-5 years of therapy 4.

Surgical Management

Surgical intervention should only be considered after failed maximal medical management (minimum 4-week trial) 1:

1. Preferred Surgical Options:

   • Microdebrider-assisted turbinoplasty (MAT) - lowest complication rate (26.5%) with complications primarily limited to postnasal drip 2
   • Radiofrequency ablation (RFA) - second-lowest complication rate (30.1%), with complications including bleeding and postnasal drip 2
   • Submucosal resection - preserves mucosal function while decreasing nasal resistance 5

2. Less Preferred Options:

   • Electrocautery - higher complication rate (37.5%) including postnasal drip and infections 2
   • Cryotherapy - fails to provide long-term results 5
   • Total turbinectomy - higher rates of crusting and epistaxis 5

Caution: Intraturbinate injection of corticosteroids, sometimes used by otolaryngologists, carries a risk of permanent vision loss (0.006% of patients) due to cavernous vein thrombosis. Nasal and oral corticosteroids are safer alternatives 4.

Special Considerations

1. Short-term Oral Corticosteroids:

   • A short course (5-7 days) of oral corticosteroids may be appropriate for very severe or intractable nasal symptoms 4
   • Should not be administered as therapy for chronic rhinitis except in rare cases with severe intractable symptoms 4
   • Parenteral corticosteroid administration is not recommended due to potential long-term side effects 4

2. Turbinate Outfracture:

   • Should only be considered in combination with tissue-reduction procedures, not as a standalone treatment 5

3. Novel Techniques:

   • One-point-three-side plasma turbinate reduction has shown promising results with minimal invasion and fewer complications 6

Monitoring and Follow-up

• Regular follow-up with endoscopic evaluation is necessary to monitor the patient's condition after surgery 1
• Post-surgical care should include continued intranasal corticosteroids and saline irrigation 1

Complications to Watch For

• Common surgical complications include bleeding, infection, and synechiae (bridging scar formation) between the turbinate and lateral nasal wall or septum 1
• Serious but rare complications include atrophic rhinitis ("empty nose syndrome"), which can be minimized by performing submucous resection rather than total turbinectomy 1

By following this algorithmic approach, clinicians can effectively manage significant inferior turbinate hypertrophy while minimizing complications and maximizing quality of life outcomes for patients.