The chronic nasal obstruction is one of the most common complaints in ENT departments. A longer lasting chronic cold causes a significant impairment of the general well-being. The chronic nasal obstruction secondarily leads to breathing through the mouth with accompanying desiccation of the mucosa in the oral cavity and the pharynx. It also results in developing tenacious mucus and an increased risk for throat infections.
A chronic nasal obstruction is very frequently the result of a chronic swelling of the mucosa of the inferior turbinates (fig. 1). The adaptation of the inferior turbinates to the physiological requirements is malfunctioning and irreversible swellings occur. As first cause for nasal obstruction allergic rhinitis must be mentioned. The seasonal allergic rhinitis is most commonly elicited by pollen. In the case of perennial allergic rhinitis an exposition to allergens occurs during the whole year. Most common allergens are house dust mites, animal epithelia as well as mold. The hyperreflector and vasomotor rhinitis can be described as a non-allergic and non-infectious permanent or acute pathological reaction of the nasal mucosa. It is the case of incapacity of the autonomous neural system to react adequately by a vasomotor response.
Due to the fact that a chronic nasal obstruction can only be alleviated for a limited period of time by conservative therapies, in many cases surgical therapy is required (see Treatment of hypertrophic inferior turbinates, part 1, link to Springer Science Online). In the last decades many therapeutic procedures and surgical techniques have been described to treat the so-called chronic cold. All surgical procedures finally have the purpose to reduce the volume of the hyperplastic inferior turbinates. Based on our extended experience we consider laser surgical procedures as the treatment option of choice in cases of mucosal hyperplasia of the inferior turbinates.
Precondition for a reasonable and successful laser surgical treatment of the hypertrophic turbinates is that the nasal obstruction is mainly due to mucosal swelling. If it is caused by an increased or enlarged bone of the inferior turbinate, conventionally surgical therapy is required. Thus all patients must undergo examination of the nose by means of rigid and flexible endoscopy in order to assess the extent of the hypertrophy of the turbinates, and also to identify further pathological alterations such as septal deviation or the formation of polyps from the paranasal sinuses.
Among the different laser systems especially the CO2 laser and the Nd:YAG laser have shown to be especially useful. The choice of the laser type used for reduction of the turbinates is based on the location of the part of the turbinate mostly obstructing nasal breathing. The CO2 laser is particularly appropriate when the nasal obstruction is due to a hypertrophied tip of the turbinate – which is most common. If it is not the tip of the turbinate but rather the total mucosa of the turbinates which are hyperplastic, we favour the Nd:YAG laser. The treatment concept is very different for both laser types because of the different tissue effects.
CO2 laser
The CO2 laser light is mainly absorbed by the cellular water and thus the penetration is less than 1 mm so that the mucosa of the turbinates is removed by means of CO2 laser in the sense of excision or vaporization. Among the different CO2 laser procedures the so-called single spot technique revealed to be the most appropriate application method. Hereby single laser spots (laser density: 2038 W/cm2, application time: 1 s) are applied under microscopic control (fig. 2) to the tip of the turbinate which leads to a shrinking of the mucosa with subsequent scarring.
The remaining intact mucosal islands allow a quick re-epithelization of the mucosa of the turbinates (fig. 3). On the other hand a moderate scarring is a desired effect, especially in cases of allergic rhinitis, in order to interrupt the allergic reactions occurring in the mucosa. The results after CO2 laser surgical reduction of the turbinates are very satisfactory.
The anterior part of the turbinate which is responsible for the nasal obstruction can be reduced effectively by means of this technique (fig. 4a+b).
Nd:YAG laser
The treatment principle of Nd:YAG laser is completely different. The Nd:YAG laser beam penetrates up to 1 cm into the tissue and is absorbed at the tumescent bodies of the inferior turbinate. This absorption induces scarring with secondary shrinking of the turbinate. Macroscopically this leads to a taut inferior turbinate which is limited in its swelling potential.
The treatment with the Nd:YAG laser is performed by means of an endoscope developed especially for endonasal laser applications (fig. 5). A flexible laser light fiber is introduced via the endoscope. All parts of the turbinates can be treated under visual control.
The laser light application is performed in the so-called non-contact mode, i.e. without contact of the optical fibers with the mucosa (fig. 6). Initially the application of low laser densities of 5-10 W only lead to a fading of the mucosa.
In the further course the mucosa of the turbinates shrinks and thus the nasal breathing is improved (fig. 7a+b). Sometimes it takes several weeks until the positive effect can be noticed.
In conclusion it can be stated that laser treatment of the hypertrophic inferior turbinates is hardly traumatizing and shows only few side effects. The treatment can be performed as an outpatient procedure in local anesthesia. In most of the cases no nasal packing is required. The therapeutic results are comparable to conventional surgery or even superior to those. The long term results are very satisfactory independently from the laser type and the applied surgical technique. The laser procedure is especially well suited for children.
