Treatment to Reduce Nasal Turbinates (sleep problems)

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Turbinate --Radiofrequency Treatment of Chronic Nasal Obstruction

Radiofrequency turbinate reduction is a fast, effective way to relieve chronic

nasal obstruction due to enlarged turbinates without the pain and inconvenience

associated with traditional techniques. Unlike standard electrosurgical or laser

approaches, radiofrequency treatment has continuous temperature, power, and

impedance monitoring to provide the surgeon with complete control over the

procedure. The radiofrequency treatment is performed in an outpatient setting

under local anesthesia. Due to the partially insulated electrode and the

controlled temperature used in treatment, the delicate mucosa is preserved and

patients experience minimal, if any, crusting and bleeding. The procedure itself

typically takes less than two minutes per turbinate. No nasal packing is

required and most patients do not require any kind of postoperative analgesic.

Important Facts about Chronic Nasal Obstruction and Enlarged turbinates

Chronic nasal obstruction, or a stuffy nose, is often caused by enlargement of

the inferior nasal turbinates. The nasal turbinates---small, shelf-like,

structures compose of thin bone, covered by mucous membranes (mucosa)---protrude

into the nasal airway and help to warm, humidify and cleanse air as it is

inhaled and before it reaches the lungs.

Chronic enlargement (hypertrophy) of the turbinates and the accompanying symptom

of nasal obstruction affect people throughout the day, as well as during sleep.

A chronic stuffy nose can impair normal breathing, force patients to breathe

through the mouth and often affects their daily activities.

Enlarged turbinates and nasal congestion can also contribute to headaches and

sleep disorders such as snoring and obstructive sleep apnea, as the nasal airway

is the normal breathing route during sleep. Chronic turbinate hypertrophy is

often unresponsive to medical treatment such as nasal sprays, thus surgical

treatment is required.

Chronic turbinate hypertrophy and nasal obstruction are commonly associated with

rhinitis, the inflammation of the mucous membranes of the nose. When the mucosa

becomes inflamed, the blood vessels inside the membrane swell and expand,

causing the turbinates to become enlarged and obstruct the flow of air through

the nose.

According to several large population surveys, approximately 20% of the

population, or more than 50 million Americans, suffers from some type of chronic

rhinitis.

The Current Treatment Regimen Current treatments for the chronic stuffy nose

range from behavioral changes (i.e., avoiding exposure to the triggers that

cause rhinitis) to invasive surgery. While avoidance of irritants in the

environment is a key factor in managing chronic rhinitis, patient compliance is

difficult. Medical therapy offers only temporary relief of chronic nasal

obstruction due to enlarged turbinates, but it can also be associated with

significant side effects. Surgical treatments can be associated with lengthy

recovery periods and significant patient discomfort.

Medical Therapy Medications designed to treat the stuffy nose, sinus complaints

and the common cold make up the largest segment of the over-the-counter drug

market for the U.S. pharmaceutical industry, accounting for nearly $3.5 billion

in sales. First-line medical treatment for the chronic stuffy nose and

chronically enlarged turbinates associated with rhinitis mainly consists of a

variety of antihistamines, decongestants, and topical and systemic

corticosteroids. These drugs provide only symptomatic improvement; they cannot

cure the condition.

Antihistamine drugs, such as Benadryl?, Claritin? and Chlor-Trimeton?, block the

action of histamine, the agent responsible for symptoms of sneezing and a runny

nose. While antihistamines reduce these symptoms, they do little to alleviate

nasal obstruction.

Antihistamines can cause drowsiness and they are not recommended for daytime use

by people who must drive or operate equipment; newer antihistamines have fewer

sedative effects, but are more expensive.

Decongestants cause constriction of the blood vessels in swollen mucous

membranes, forcing blood out so that the membranes shrink and air passages open.

Typical decongestants include nasal sprays such as Neo-Synephrine? and pills

such as Sudafed? and Actifed?. Decongestants are chemically related to

adrenaline, a natural decongestant that is also a stimulant. One side effect of

this type of drug is a jittery or nervous feeling that can cause insomnia.

Decongestants can also increase a patient's blood pressure and pulse rate.

Decongestants should not be used by patients who have an irregular pulse, high

blood pressure, heart disease or glaucoma. Also, certain decongestant drugs such

as pseudo-ephredine should not be used by patients who suffer from benign

prostate hyperplasia (approximately 13 million men in the United States) because

the drug can aggravate prostate enlargement.

There are a variety of decongestant nasal sprays available over the counter.

These medicines can produce significant, temporary symptomatic relief of nasal

obstruction, however, they can also become addictive as rebound nasal congestion

occurs with overuse.

Several corticosteroid therapies, most in the form of a nasal spray or inhaler,

have been developed to treat chronic nasal obstruction. Intranasal

corticosteroids are available only by prescription and they can be very

effective, however, they are associated with side effects such as bleeding,

drying and crusting.

Patients must take care not to overuse corticosteroid preparations. Although the

drugs are applied topically, some systemic absorption of the agent occurs, which

can disrupt the body's steroid balance. Steroids can also be injected directly

into the turbinates, however, their effectiveness lasts only three to six weeks.

Intranasal cromolyn is another type of drug therapy; it is a preventive

medication and can be very effective in preventing a hypersensitivity allergic

reaction in the turbinates (but only if used before exposure to irritants.

Although side effects are unusual, cromolyn can produce nasal burning, headaches

and sneezing.

In severe cases of allergic rhinitis, immunotherapy (allergy shots) may be

recommended. With immunotherapy, a patient is injected with increasingly larger

amounts of an allergen to encourage the body to build up resistance. While

modestly effective in selected patients, immunotherapy can be a lengthy and

expensive process, which limits patient and physician acceptance of the

approach.

Surgical Therapy Surgical treatment of enlarged turbinates that cause chronic

nasal obstruction is indicated only after patients fail to respond to medical

therapy. turbinate surgery can be performed as an office procedure under local

anesthesia or in the operating room under general anesthesia.

Cautery (burning) of enlarged turbinates can be done with an electrosurgical

probe or a laser and is usually performed as an office procedure. Both

electrocautery and laser surgery are performed on either the surface of the

turbinate tissue or sub-mucosally.

Surface cautery results in edema and crusting in the nose which can last three

weeks or longer, while sub-mucosal cautery can cause swelling for up to 10 days.

Another method for improving nasal obstruction is outward fracture of the

turbinate bone(s), which moves the turbinate away from its obstructive position

in the airway. This approach, however, does not address the usual source of

obstruction---enlarged sub-mucosal tissue, and the fractured turbinate often

returns to its previous position.

turbinate resection (removal of the bone and/or soft tissue) and excision

(removal of the soft tissue only) can be performed with surgical scissors or a

laser. After the surgery the nose must be packed for several days with gauze

containing antibiotic ointment.

Bleeding, which can usually be managed by packing the nose, is the greatest risk

for patients undergoing standard turbinate resection. Over-resection of the

turbinates has been reported as the cause of excessive, irreversible drying of

the turbinates. Resection, excision and surface cautery can all be associated

with prolonged crusting and healing, which occurs over a four- to six-week

period.

NEW TECHNOLOGY for PATIENTS with PERSISTENT NASAL OBSTRUCTION A non-surgical

minimally invasive technique using the application of temperature controlled

radiofrequency (TCRF) to the nasal region has been developed at our center and

has been found to give significant relief for those that suffer from nasal

obstruction due to allergic rhinitis (swelling of the soft tissues of the inner

nose). A summary of this problem and a discussion of this radiofrequency

technology are presented below.

Overview: The Problem The symptoms of nasal obstruction: inability to breathe,

congestion, runny nose, post nasal drip and even headache are well known to most

patients as signs of an acute upper respiratory infection or a reaction to

environmental irritation such as allergies. However, for many individuals this

obstruction is chronic and markedly affects their quality of life on a daily

basis.

Causes and Conventional Treatment

Medical Allergies can lead to symptoms by stimulating the nasal tissue to

release chemicals that cause swelling and drainage. If these stimulants can be

identified, avoidance may be attempted. Medications such as antihistamines,

decongestants, and nasals steroids are often used and can be successful.

However, some patients experience side effects and variable success rates.

Finally, immunotherapy (allergy shots) is excellent for many allergy symptoms,

but less effective for pure nasal obstruction. In addition, it may take a

prolonged period of treatment to see benefits.

Individuals without true allergies may also suffer from nasal obstruction. In

these cases environmental stimuli such as a change in humidity or temperature,

or even a reaction to some foods cause swelling through a slightly different

mechanism. Unfortunately for the patient, the symptoms are the same and the

treatments are generally similar but less effective.

Although some patients may have anatomic abnormalities such as a deviated

septum, the main cause of the majority of nasal obstruction is enlargement of

structures known as turbinates. The turbinates are on the lateral walls on each

side of the nose. They are made up of tiny layers of bone much like a sponge and

are covered with a very vascular layer of soft tissue. These essential

structures provide a necessary function in the warming and humidification of the

air entering the airway. However, when chronically stimulated the soft vascular

tissues surrounding the spongy bone of the turbinates enlarge and actually block

nasal airflow. Any one that has ever suffered a stuffy nose from a common cold

has experienced nasal obstruction and a runny nose as a result of turbinate

swelling.

Surgical As mentioned above, conservative treatments such as medications can be

attempted, however if unsuccessful, direct reduction of the turbinates may be

required to relieve the symptoms. Surgical turbinate reduction where the leading

one- third to one- half of the turbinate is actually removed is effective but

invariably results in crusting and bleeding from the nose during the recovery

period. It is also commonly performed in an operating room. Other treatments

such as laser reduction still have similar side effects.

New Non-Surgical Technology

The Solution: Temperature Controlled Radiofrequency is a recently developed non

surgical approach researched and developed by our group which uses a tiny

electrode to heat the turbinate tissue from within, eventually causing reduction

of the size of the turbinate as the body reabsorbs the treated tissue. Since no

" cutting " of the tissue is done, there is little or no bleeding, crusting, or

pain. The use of radiofrequency is not new to medicine as it has been used for

decades in the fields of neurology, cardiology, urology and surgery. However, it

was not previously used for the shrinkage of soft tissue in the upper airway

until our group scientifically investigated this technology and added special

thermocouples to the electrodes to monitor temperature delivery. These

temperature control applications allowed for a safe delivery of energy and the

ability to precisely select and treat the delicate tissues of the nose.

Temperature controlled radiofrequency is minimally invasive and can be done in

the office with only local anesthesia (much like your dentist would use) and the

patient can resume normal activity almost immediately. This method also

preserves the normal function of the turbinate, but usually results in excellent

airflow to the patient.