- Letter to the Editor
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- Mosaad Abdel-Aziz ORCID: orcid.org/0000-0002-7250-53881,
- Ahmed Nassar1,
- Ahmed Ibrahim Yousef1 &
- …
- Omar Aly Sabry1
The Egyptian Journal of Otolaryngology volume40, Articlenumber:150 (2024) Cite this article
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Key points
1.The inferior turbinate is a static structure with a dynamic function as it plays a major role in the formation of nasal valve and laminar airflow.
2.The inferior turbinate resembles an eggplant: it has head, body, and tail; and it is formed of 3 layers which are an outer covering mucosa, an intermediate submucosal connective tissue, and an inner bony concha.
3.Eggplant turbinoplasty technique involves removal of the infero-lateral part of the inferior turbinate longitudinally.
4.The excised part consists of soft tissue and bone, and the raw area is covered with a medial soft tissue flap.
5.The medial turbinate mucosa is preserved which is very important for warming and humidification of the inspired air.
6.The procedure decreases the size of the turbinate without major changes in the shape to maintain the laminar airflow.
7.Intraoperative bleeding is usually minimal as the inferior turbinate artery enters the turbinate through its upper surface.
8.Postoperative crustations is avoided as the raw area is completely covered with a medial soft tissue flap.
9.The procedure does notneed special equipments.
10.This turbinate reduction technique respects both the anatomical shape to maintain normal laminar airflow, and the physiologic concepts with preserving the medial mucosa for airway protection.
To the Editor
The lateral nasal wall is formed of 3 spiral-shaped turbinates on each side. The turbinate is formed of 3 layers: an inner bony skeleton called concha; intermediate connective tissue contains arterioles, venous sinusoids, and autonomic nerve plexus; and an outer mucosal layer formed of respiratory epithelium. The inferior concha is an isolated laminar structure, while the middle and superior conchae are parts of the ethmoid bone. These turbinates have respiratory and immune functions [1]. The inferior turbinate (IT) is the largest one, and it resembles an eggplant which is formed of a head, body, and posterior end (Fig.1). The head of the IT forms the lateral boundary of the internal nasal valve; hence, it plays a major role in airflow resistance. The IT is considered a static anatomical structure with a dynamic function as it maintains the nasal airflow as a laminar flow instead of turbulent flow which may cause mucosal irritation with loss of normal sense of breathing [2].
Demonstration of the inferior turbinate and eggplant: transverse section of the inferior turbinate (At); transverse section of an eggplant (Ae); longitudinal section of the inferior turbinate (Bt); longitudinal section of an eggplant (Be)
Hypertrophy of IT may be caused by allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa, frequently recurring common cold, exposure to certain chemicals, smoking, emotional stress, change in temperature or humidity, taking certain medications or hormone therapy, and anatomical deformity may lead to compensatory hypertrophy. It leads to nasal obstruction with its consequences on other nasal functions [2, 3]. There are many techniques used for the treatment of hypertrophied IT extending from cauterization (surface or submucosal) to total turbinectomy. Monopolar and bipolar diathermy, cold instruments, coblation, radiofrequency, ultrasound, laser, and microdebrider have been used for the reduction of the IT [2, 4]. Whatever the turbinate reduction technique, we should respect both the anatomical shape and the physiologic concept; this is to maintain the laminar airflow and the protective immune function, especially of the medial IT mucosa.
Our procedure is done under general anesthesia with oral endotracheal intubation; the patient’s head is positioned up at 30°, and both nasal cavities are inspected with the nasal endoscope of 4 mm diameter and 0 angle. The IT is injected with adrenaline in saline (1;100.000) for hemostasis and hydro-dissection. A scalpel No. 15 is used to incise the soft tissue of the IT with deepening the incision to the bone starting from the posterior end to the head, the incision is curved laterally at the head (Fig.2). A freer dissector is used to dissect the soft tissue from the bony concha on its medial side; this is done from anterior to posterior along the whole length of the IT (Fig.3). If the submucosal tissue is found to be bulky, it can be trimmed with scissors. Heymann scissors are used to excise the lateral part of the IT including soft tissue and part of the bone along the whole length of the IT (Fig.4). Finally, we turn the medial mucosal flap laterally with the freer dissector to cover the raw on the lateral side of the IT (Fig.5). The same procedure is done on the opposite nasal cavity. A merocele nasal pack impregnated with tobramycin eye ointment is used to pack each nasal cavity; this could make firm contact between the soft tissue flap and the raw area. The pack is removed after 72 h, to give enough time for adherence between the flap and the raw area.
A Incision of the mucoperiosteum along the posterior aspect of the inferior turbinate. B The procedure is demonstrated on eggplant
A Elevation of the soft tissue flap from the medial aspect of the inferior turbinate. B The procedure is demonstrated on eggplant
A Excision of the inferolateral part of the inferior turbinate longitudinally. B The procedure is demonstrated on eggplant
A Turning the soft tissue flap laterally to cover the raw on the inferolateral aspect of the inferior turbinate. B The procedure is demonstrated on eggplant
Eggplant turbinoplasty is the most preferable technique for us; we gave our technique this name as the medial part of the IT is excised (bone and soft tissue) longitudinally from anterior to posterior like an eggplant. It can be done for the reduction of hypertrophied turbinate refractory to medical treatment; either this hypertrophy includes soft tissue, bone, or both. It decreases the size of the turbinate without major changes in the shape, so it does not disturb the laminar airflow. Also, it has a major advantage in which the lateral raw area is completely covered with the medial soft tissue flap, this could decrease the postoperative crustations and it may fasten the healing process.
Intraoperative bleeding is a major complication of turbinate reduction surgery; the inferior turbinate artery—which is a branch of sphenopalatine artery—enters the inferior turbinate through its upper surface 0.5–1.0 cm from its posterior end [5]. As our technique involved excision of the infero-lateral part of IT, the bleeding may be lesser than in other types of conventional turbinectomy. Furthermore, covering the raw area with the medial soft tissue flap not only decreases the postoperative crustations but also could decrease the postoperative bleeding.
Although eggplant turbinoplasty does not need special equipments, it may have the disadvantage of leaving the nasal pack for about 72 h; nasal packing may be annoying for the patient. After removal of the pack, the patient should be instructed to do nasal saline irrigation at least 2 times daily for about 2–3 weeks.
Data availability
The datasets used during the current study are available from the corresponding author on reasonable request.
Abbreviations
- IT:
-
Inferior turbinate
References
Smith DH, Brook CD, Virani S, Platt MP (2018) The inferior turbinate: an autonomic organ. Am J Otolaryngol 39(6):771–775. https://doi.org/10.1016/j.amjoto.2018.08.009
Ye T, Zhou B (2015) Update on surgical management of adult inferior turbinate hypertrophy. Curr Opin Otolaryngol Head Neck Surg 23(1):29–33. https://doi.org/10.1097/moo.0000000000000130
Larrabee YC, Kacker A (2014) Which inferior turbinate reduction technique best decreases nasal obstruction? Laryngoscope 124(4):814–815. https://doi.org/10.1002/lary.24182
Bergmark RW, Gray ST (2018) Surgical management of turbinate hypertrophy. Otolaryngol Clin North Am 51(5):919–928. https://doi.org/10.1016/j.otc.2018.05.008
Scott JR, Psaltis AJ, Wormald P (2020) Vascular anatomy of the inferior turbinate and its clinical implications. Am J Rhinol Allergy 34(5):604–609. https://doi.org/10.1177/1945892420914185
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Authors and Affiliations
Department of Otolaryngology, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
Mosaad Abdel-Aziz,Ahmed Nassar,Ahmed Ibrahim Yousef&Omar Aly Sabry
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- Mosaad Abdel-Aziz
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- Ahmed Nassar
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- Ahmed Ibrahim Yousef
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- Omar Aly Sabry
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Contributions
MA wrote the commonly used techniques and conclusion sections. AN wrote the used technique. AIY collected and revised the references. OAS handled the figures. All authors read and approved the final manuscript.
Corresponding author
Correspondence to Mosaad Abdel-Aziz.
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Mosaad Abdel-Aziz is a corresponding author of this study and an editorial board member of the journal. He declares competing interests for this submission. He has not handled this manuscript. The rest of the authors have no conflict of interest to declare.
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Abdel-Aziz, M., Nassar, A., Yousef, A.I. et al. Eggplant turbinoplasty: how I do it. Egypt J Otolaryngol 40, 150 (2024). https://doi.org/10.1186/s43163-024-00723-0
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DOI: https://doi.org/10.1186/s43163-024-00723-0
