A systematic review of the nasal septal turbinate- An overlooked surgical target.pdf

Am J Otolaryngol 40 (2019) 102188 Contents lists available at ScienceDirect...

Am J Otolaryngol 40 (2019) 102188 Contents lists available at ScienceDirect Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto A systematic review of the nasal septal turbinate: An overlooked surgical T target William J. Mossa,b, , Farhoud Farajib, Aria Jafarib, Adam S. DeCondeb ⁎ a Commonwealth Health Center, Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, Saipan, CNMI, United States of America b University of California, San Diego, Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, San Diego, CA, United States of America ARTICLE INFO ABSTRACT Keywords: Objective: The nasal septal turbinate (NST) is a conspicuous structure located in the anterior nasal cavity that Nasal septal turbinate impacts the internal nasal valve. Its structure and function is often thought to be poorly characterized, and it is Nasal swell body rarely addressed surgically. The authors perform a systematic review in an attempt to synthesize what has been Intumescentia septi nasi anterior learned of this structure and to evaluate its potential as a treatment target. Methods: A query of the Medline, Embase, Web of Science and Cochrane databases was undertaken in search of studies evaluating the NST. This qualitative systematic review was performed in accordance with PRISMA guidelines. Study quality and risk of bias were assessed with established criteria. Results: Of the initial 1069 hits from the four databases, 16 articles were ultimately included in the review, which varied in quality and risk of bias. The included articles consisted predominantly of radiographic and histopathologic studies. Four studies evaluated NST treatment outcomes. The NST represents a fusiform-shaped region of erectile tissue, similar in structure and function to that of the inferior turbinates. Preliminary treatment outcomes suggest the NST represents an important surgical target in nasal airway surgery. Conclusion: When evaluating nasal obstruction patients, surgeons should assess the NST and consider addressing it surgically. 1. Introduction guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), which are a standardized and widely utilized The nasal septal turbinate (NST) is a widened, fusiform-shaped re- criterion for performing effective systematic reviews. Using the gion of the septum located in the anterior nasal cavity. The central search terms, “nasal/nose septal turbinate(s) OR nasal/nose septal body portion of the NST contains septal cartilage and bone however the (ies) OR nasal/nose septal swelling(s) OR nasal/nose swell body(ies) majority of its three-dimensional volume consists of soft tissue; mucosa, OR intumescentia septi nasi anterior OR Kiesselbach's body/ridge OR erectile tissue, vasculature and secretory glands (Fig. 1). A variety septal cavernous body,” a query of the Medline, Embase, Web of Sci- of nomenclature has been used to refer to this structure over the years ence and Cochrane databases was performed for articles evaluating the including the nasal septal body, septal swell body and the in- nasal septal turbinate. Two authors performed the review in- tumescentia septi nasi anterior [3,4,5]. Despite being a conspicuous dependently and corroborated the search results (WM, AJ). The date of structure that impacts the internal nasal valve, the NST is rarely in- the final search was August 20, 2018. Prospective and retrospective tervened on surgically. The authors perform a systematic review of studies were considered, including anatomic, radiographic and histo- studies evaluating the NST in an effort to summarize what has been pathologic studies. Studies including five or fewer patients were ex- learned about this structure and to evaluate its potential as a treatment cluded. Foreign language articles, animal studies and narrative reviews target. were excluded. Extracted data was compiled and manipulated using Microsoft Excel (Microsoft, Seattle, WA). The quality of articles was 2. Methods assessed by assigning a score using the methodological index for non- randomized studies (MINORS). The MINORS criteria represent a This systematic review was performed in accordance with the validated instrument for assessing non randomized studies. Non- ⁎ Corresponding author at: Commonwealth Health Center, Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, 1 Hinemlu Rd., Garapan, Saipan, Northern Mariana Islands, 96950, United States of America. E-mail address: [email protected] (W.J. Moss). https://doi.org/10.1016/j.amjoto.2019.03.003 Received 31 January 2019 0196-0709/ © 2019 Elsevier Inc. All rights reserved. Descargado para Anonymous User (n/a) en University of Guadalajara de ClinicalKey.es por Elsevier en febrero 01, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. W.J. Moss, et al. Am J Otolaryngol 40 (2019) 102188 bias of good, fair or poor was assigned as defined by the Cochrane Collaboration. A level of evidence score of one through five was assigned to each article using the criterion from the Oxford Center of Evidence-Based Medicine. This study was designed to be a de- scriptive systematic review and as such, meta-analysis statistics were not attempted. 3. Results The systematic review schema used to identify eligible articles is shown in Fig. 2. Of the 1069 initial hits, 1045 were excluded based on the title, abstract or redundancy. Of the 24 unique full-length manu- scripts that were reviewed, three were excluded for having an in- sufficient number of patients. Two foreign language articles were ex- cluded. Two were found to describe histology of erectile tissues of the nasal cavity without a focus on the NST and were thus excluded. One narrative review was excluded. This resulted in 16 manuscripts that met inclusion criteria with a collective 1964 patients (Tables 1–3) [10–25]. 3.1. Radiographic studies Nine studies evaluated the anatomy of the NST radiographically, which was the most common type of study (Table 1). Four of the studies were prospective and with a low risk of bias. All studies presented level II or III evidence. Typically described as fusiform in shape, the average Fig. 1. Coronal CT image of the anterior nasal cavity. *The nasal septal turbi- maximal width of the NST was estimated at 10–12 mm [14,15,24]. nate (NST) is delineated by the dashed lines and consists of cartilage, bone and Costa performed perhaps the most complete measurements of the NST soft tissue. IT = inferior turbinate. MT = middle turbinate. dimensions and estimated an average height of 19.6 mm and length of 28.4 mm. The maximal width of the NST was estimated at comparative studies are assessed in eight domains and comparative 24.8 mm from the nasal floor in a region directly anterior to the heads studies have an additional four domains. Each domain is scored from of the middle turbinates. Similar to compensatory inferior turbinate zero to two. The optimal score is therefore 16 for non-comparative hypertrophy, the soft tissue of the NST was found to be more prominent studies and 24 for comparative studies. For the purposes of this review, when contralateral to a septal deviation [15,19,23]. The NST was found a value below 11 was considered to represent a high risk of bias for non- to decrease in size with age and was noted to correlate with inferior comparative studies. A value below 16 was considered to represent a turbinate size [11,18,24,25]. Gelera found that the soft tissue compo- high risk of bias for comparative studies. For randomized trials, a risk of nents of the NST were larger in patients with a history of sinonasal Fig. 2. Systematic review flowchart. 2 Descargado para Anonymous User (n/a) en University of Guadalajara de ClinicalKey.es por Elsevier en febrero 01, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. W.J. Moss, et al. Am J Otolaryngol 40 (2019) 102188 allergies. Evidencec 3.2. Histopathologic studies III III III III III II II II II Four studies evaluated the histopathology of the NST via cadaver or living patient specimens (Table 2). All of the studies were prospective, (H) (H) (H) (H) (H) (L) (L) (L) (L) with a low risk of bias, and presented level II evidence. The NST tissue 12/16 12/16 10/16 10/16 10/16 10/16 12/16 10/16 12/16 Biasb was found to have thicker mucosa and more abundant mucous glands and vascular sinusoids relative to other nasal mucosa [12,13,14,16]. Although the exact proportions of these structures varied between studies, the NST was universally concluded to be an erectile tissue that is larger when contralateral to a deviation and inversely correlates with inferior and middle turbinate size regulates humidification and airflow, similar to the turbinates. 3.3. Treatment studies Four studies evaluated NST treatment outcomes in patients under- going surgery for nasal obstruction (Table 3). Three of the studies were prospective, two of which were with a low risk of bias. Collectively, level I,II and IV evidence was presented. Haight performed a pro- spective non-randomized study where 28 patients underwent inferior dimensions are comparable between patients with and without allergies turbinate reduction alone and 28 underwent inferior turbinate reduc- tion in conjunction with NST reduction. Cryosurgery and cautery were both utilized and at 10–16 weeks post operatively, they found no difference in patient symptoms or rhinometry between the two patient groups. Catalano performed a prospective trial of in-office radio- is larger in patients with allergies and shrinks with age frequency ablation of the NST in 60 patients who had failed a prior septoplasty and turbinate reduction. Statistically significant re- ductions in NOSE scores from 41.6 pre-treatment to 17 and 21 at three is larger when contralateral to a deviation is larger when contralateral to a deviation and six months respectively were calculated. The authors also found is larger in males and decrease with age is larger in males and shrinks with age correlates with inferior turbinate size statistically significant improvements in endoscopic findings based on middle turbinate visualization. They reported three minor infections, one small, asymptomatic septal perforation and five patients required multiple treatments. Kim retrospectively reviewed nasal obstruction scores in eight patients who underwent in-office NST coblation. On a visual analog scale, an average pre-treatment obstruction score of 7.63 was reduced to 3.88, 4.16 and 4.63 at three, six and twelve months respectively. No complications were reported. Yu performed a pro- dimensions Score per MINORS criteria, “H” and “L” denote high and low risk of bias respectively. spective randomized controlled trial of 51 patients in which 25 un- derwent a microdebrider submucous turbinate reduction alone and 26 Findings underwent a concurrent NST reduction. All surgeries were per- NST NST NST NST NST NST NST NST NST formed under a general anesthetic. At three months post-operative, there were multiple statistically significant advantages in the NST group. Specifically, the authors found a larger nasal obstruction score Retrospective CT Retrospective CT Retrospective CT Retrospective CT Retrospective CT Prospective MRI improvement (2.02 vs. 1.43, p < 0.05). They also found a more pro- Prospective CT Prospective CT Prospective CT nounced improvement in total nasal volume on rhinometry (0.83 mL vs. 0.36 mL, p < 0.05). Other metrics such as olfaction, rhinorrhea and Design sneezing were similar between both treatment groups. The authors evaluated for hematoma, synechiae, perforation, and infection and there were no complications found related to NST reduction. 595 100 150 199 405 54 70 70 50 Na 4. Discussion Level of evidence per OCEBM criteria. Collectively, the NST studies included in this review provide a North America North America considerable amount of prospective data with a relatively low risk of Middle East Middle East Middle East Location bias. A wealth of evidence from radiographic and histopathologic stu- Europe dies has shown that the NST is a dynamic, fusiform-shaped structure Asia Asia Asia Summary of radiographic studies. located in the anterior nasal cavity that encroaches the internal nasal Number of study subjects. valve. Centrally, it contains septal cartilage and bone. Laterally, it consists of erectile, mucous-producing soft tissue similar to that of the 2017 2018 2004 2010 2011 2014 2014 2015 2017 Year turbinates. As such, its role in the nasal cavity appears to be that of air flow regulation and humidification. The preliminary evidence evaluating the NST as a treatment target Demirci is encouraging. Three of the four treatment studies found significant Gelera Arslan Setlur Costa Akil San San benefits in favor of NST interventions [20,21,22]. All of these studies Yu Author Table 1 used objective nasal symptom scores in their analysis and collectively, b a they supported NST reduction as both an adjunct and isolated c 3 Descargado para Anonymous User (n/a) en University of Guadalajara de ClinicalKey.es por Elsevier en febrero 01, 2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados. W.J. Moss, et al. Am J Otolaryngol 40 (2019) 102188 Table 2 Summary of histopathologic studies. Author Year Location Na Design Findings Biasb Evidencec Wexler 2006 Middle East 14 Prospective living patient NST is glandular, erectile tissue 12/16 (L) II Elwany 2008 Africa 30 Prospective cadaver NST dimensions, the NST is glandular, erectile tissue 12/16 (L) II Costa 2010 North America 10 Prospective cadaver NST is glandular, erectile tissue 12/16 (L) II Sisman 2014 Europe 50 Prospective cadaver NST is glandular, erectile tissue 14/16 (L) II a Number of study subjects. b Score per MINORS criteria, “H” and “L” denote high and low risk of bias respectively. c Level of evidence per OCEBM criteria. Table 3 Summary of treatment studies. Author Year Location Na Design Findings Biasb Evidencec Haight 1989 North America 48 Prospective trial No benefit with NST cautery or cryosurgery 13/24 (H) II Catalano 2015 North America 60 Prospective case series NST radiofrequency ablation is safe and effective 14/16 (L) II Kim 2015 Asia 8 Retrospective case series NST coblation is safe and effective 10/16 (H) IV Yu 2015 Asia 51 Prospective randomized controlled trial NST submucous reduction is safe and effective Fair I a Number of study subjects. b Score per MINORS criteria, “H” and “L” denote high and low risk of bias respectively , Cochrane Risk of Bias tool used for the randomized, controlled Yu study. c Level of evidence per OCEBM criteria. procedure. The Yu study is noted for being the only prospective ran- adjunct procedure are indicated. domized controlled trial, which showed considerable symptom im- provement with NST treatment. Of note, the one study that did not 5. Conclusions conclude NST treatment to be effective was the most outdated study included in the review and carried the highest risk of bias relatively The NST is a fusiform-shaped region of the septum located in the. This study was non-randomized and has been critiqued for using anterior nasal cavity that encroaches the internal nasal valve. The NST multiple treatment modalities. Complications were collectively minimal is similar in structure and function to the inferior turbinates. amongst the four treatment studies. Preliminary data has shown that surgical treatment of the NST as both The results of this review encourage a re-evaluation of our assess- an isolated and adjunct procedure is very promising. Surgeons should ment of nasal obstruction to include an evaluation of the NST. A tra- assess the NST when evaluating nasal obstruction patients and consider ditional septoplasty corrects only underlying cartilage and bone, which addressing this site surgically. fails to address the abundant soft tissue of the NST. Due to its en- croachment of the internal nasal valve, the site of rate-limiting nasal air Acknowledgements flow, this may be one of the higher yield regions of the septum in nasal obstruction patients [1,2]. In patients being treated for turbinate hy- None. pertrophy, addressing the NST may greatly improve results. As an easily accessible structure, treatment of the NST should minimally affect the Disclosures overall procedure time and would impose minimal risk to the patient. Given what has been learned from turbinate surgery, controlled sub- Adam S. DeConde is a consultant for Intersect ENT, Olympus and mucous reductions are advised so as to preserve NST function and avoid Stryker Endoscopy. potential complications such as empty nose syndrome or other injuries. For patients with refractory rhinitis, the NST, given its abundance of Conflict of interest erectile and mucous glands, may be a high yield target for injection therapies [26,27]. From a billing perspective, as this structure is both None. turbinate tissue and a part of the nasal septum, the Current Procedural Terminology (CPT) codes for either “septoplasty” (30520) or “inferior References turbinate reduction” (30802) could be implemented if this structure is addressed procedurally. A specific CPT code for “nasal septal turbinate Bridger GP. Physiology of the nasal valve. Arch Otolaryngol 1970;92(6):543–53. reduction” currently does not exist. Wexler DB, Davidson TM. The nasal valve: a review of the anatomy, imaging, and physiology. Am J Rhinol 2004;18(3):143–50. 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