Interventional procedure consultation document

Powered microdebrider turbinoplasty for inferior turbinate hypertrophy

 

The inferior turbinates are ridges along the inside of the nose.  If the tissue covering them becomes inflamed and swollen it can obstruct the flow of air, leading to congestion or a completely blocked nose. Powered microdebrider turbinoplasty aims to shrink the swollen inferior turbinates by inserting a small electrically-powered rotating shaver through the nostril, into the turbinate and removing excess tissue from its interior.   

The National Institute for Health and Care Excellence (NICE) is examining powered microdebrider turbinoplasty for inferior turbinate hypertrophy and will publish guidance on its safety and efficacy to the NHS. NICE’s Interventional Procedures Advisory Committee has considered the available evidence and the views of specialist advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about powered microdebrider turbinoplasty for inferior turbinate hypertrophy.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the provisional recommendations
• the identification of factual inaccuracies
• additional relevant evidence, with bibliographic references where possible.

Note that this document is not NICE’s formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that NICE will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare draft guidance which will be the basis for NICE’s guidance on the use of the procedure in the NHS.

For further details, see the Interventional Procedures Programme manual, which is available from the NICE website.

Through its guidance NICE is committed to promoting race and disability equality, equality between men and women, and to eliminating all forms of discrimination. One of the ways we do this is by trying to involve as wide a range of people and interest groups as possible in the development of our interventional procedures guidance. In particular, we aim to encourage people and organisations from groups who might not normally comment on our guidance to do so.

In order to help us promote equality through our guidance, we should be grateful if you would consider the following question:

Are there any issues that require special attention in light of NICE’s duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations between people with a characteristic protected by the equalities legislation and others?

Please note that NICE reserves the right to summarise and edit comments received during consultations or not to publish them at all where in the reasonable opinion of NICE, the comments are voluminous, publication would be unlawful or publication would otherwise be inappropriate.

Closing date for comments: 18 April 2014

Target date for publication of guidance: July 2014

 

 

 

 

1                      Provisional recommendations

1.1                  Current evidence on the efficacy and safety of powered microdebrider turbinoplasty for inferior turbinate hypertrophy is adequate to support the use of this procedure with normal arrangements for clinical governance, consent and audit or research.

 

 

 

 

 

2                      Indications and current treatments

2.1                  Inferior turbinates are ridges inside the nose, covered by mucous membrane, which increase the surface area within the nose and help to filter and humidify inspired air. Inflammation of the mucous membrane (rhinitis) can cause inferior turbinates to swell (turbinate hypertrophy). This narrows the nasal passage, and may cause complete nasal obstruction. Symptoms include breathing difficulties, excessive mucous secretion (rhinorrhoea), postnasal drip, facial discomfort or pain and mid-facial headaches.

2.2                  Treatment options depend on the duration and severity of turbinate hypertrophy. Medical treatments include corticosteroid injections, nasal corticosteroid sprays and decongestants. Surgical treatments include radiofrequency-assisted turbinoplasty and laser-assisted turbinoplasty. These procedures are reserved for symptomatic patients with persistent hypertrophy of the turbinates who have had no response to medical management, or for whom medical management is contraindicated.

 

 

 

 

3                      The procedure

3.1                  Powered microdebrider turbinoplasty aims to reduce the size of inferior turbinates that are swollen due to vasomotor or allergic rhinitis. It removes submucosal vascular stromal tissue, while preserving overlying respiratory mucosa, using a cutting tool with irrigation and suction functions (microdebrider).

3.2                  Powered microdebrider turbinoplasty is usually preformed using local anaesthesia. Under direct vision, a microdebrider is inserted through the nostril and into the anterior face of the inferior turbinate, just medial to the mucocutaneous junction. The microdebrider is advanced until it pierces the mucosa. A submucosal pocket is then made by sweeping the microdebrider in anterior-to-posterior and superior-to-inferior directions. Stromal tissue is then removed using irrigation and suction.

 

 

 

 

 

4                      Efficacy

This section describes efficacy outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.

4.1                  In a randomised controlled trial of 120 patients treated by powered microdebrider or radiofrequency-assisted turbinoplasty, mean visual analogue scale scores (ranging from 1 to 10, with lower scores indicating better outcomes) for nasal obstruction, sneezing, rhinorrhoea and snoring improved from 8.7 to 1.4, 6.2 to 1.7, 7.0 to 1.6 and from 6.6 to 1.6 respectively in the microdebrider group at 6‑month follow-up (p values<0.05). In the radiofrequency group, mean visual analogue scale scores for nasal obstruction, sneezing, rhinorrhoea and snoring improved from 8.5 to 1.5, 6.0 to 1.8, 6.6 to 1.7 and from 6.7 to 1.6 respectively at 6‑month follow-up (p values <0.05). No statistically significant differences in visual analogue scale scores were observed between the 2 treatments at 6-month follow-up. At 3‑year follow-up, mean visual analogue scale scores for nasal obstruction, sneezing, rhinorrhoea and snoring were better in the microdebrider group (1.6, 1.9, 1.7 and 1.8 respectively) than in the radiofrequency group (8.3, 5.6, 6.5, and 6.2 respectively). All inter-group comparison p values were <0.05.

4.2                  In a randomised controlled trial of 160 patients treated by powered microdebrider turbinoplasty or submucosal resection of the inferior turbinate, mean visual analogue scale scores (ranging from 1 to 10, with lower scores indicating better outcomes) for nasal obstruction, sneezing, rhinorrhoea and snoring improved from 8.7 to 1.5, 6.2 to 1.8, 7.0 to 1.6 and from 6.7 to 1.5 respectively in the microdebrider group at 2‑year follow-up (p values <0.0001). In the submucosal resection group, mean visual analogue scale scores for nasal obstruction, sneezing, rhinorrhoea and snoring improved from 8.5 to 1.5, 6.0 to 1.8, 6.7 to 1.7 and from 6.6 to 1.6 respectively at 2‑year follow-up (p values <0.05); no statistically significant differences were observed between groups at 2-year follow-up. At 3‑year follow-up, mean visual analogue scale scores for nasal obstruction, sneezing, rhinorrhoea and snoring were 1.5, 1.8, 1.6 and 1.6 respectively in the microdebrider group and 1.5, 1.8, 1.7, and 1.6 respectively in the submucosal resection group (there were no statistically significant differences between groups).

4.3                  In the randomised controlled trial of 120 patients treated by powered microdebrider or radiofrequency-assisted turbinoplasty, mean total nasal resistance (using 75 Pa as the reference point) improved from 0.32 to 0.15 Pa/ml/s (p<0.05) and from 0.31 to 0.15 Pa/ml/s (p<0.05) respectively at 6‑month follow-up (there was no statistically significant difference between groups). At 3‑year follow-up, mean total nasal resistance in the microdebrider and radiofrequency-assisted turbinoplasty groups were 0.16 and 0.31 Pa/ml/s respectively (p<0.05).

4.4                  In a randomised controlled trial of 40 patients treated by powered microdebrider or laser-assisted turbinoplasty, nasal cavity volumes increased from 8.5 to 13.3 cm³ (p<0.05) and from 8.3 to 13.2 cm³ (p<0.05) respectively at 6‑month follow-up (there was no statistically significant difference between groups).

4.5                  Specialist advisers listed subjective and objective improvements in the nasal airway as key efficacy outcomes.

 

 

 

 

 

5                      Safety

This section describes safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.

5.1                  Postoperative bleeding was reported in 27% (8/30) of patients after powered microdebrider turbinoplasty in a randomised controlled trial of 60 patients treated by powered microdebrider or radiofrequency-assisted turbinoplasty.

5.2                  Postnasal drip was reported in 10% (3/30) of patients after powered microdebrider turbinoplasty in the randomised controlled trial of 60 patients treated by powered microdebrider or radiofrequency-assisted turbinoplasty.

5.3                  Nasal crusting was reported in 12% (7/60) of patients after powered microdebrider turbinoplasty in a randomised controlled trial of 120 patients treated by powered microdebrider or radiofrequency-assisted turbinoplasty.

5.4                  Nasal dryness was reported in 3% (2/80) of patients after powered microdebrider turbinoplasty in a randomised controlled trial of 160 patients treated by powered microdebrider turbinoplasty or submucosal resection of the inferior turbinates.

5.5                  Specialist advisers did not highlight any additional adverse events that were not identified in the available literature.

 

 

 

 

Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
March, 2014

 

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It is the responsibility of consultees to accurately cite academic work in order that they can be validated.