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In-Office Turbinate Reduction to Improve Nasal Breathing
Yvonne Ogrodzinski • Jan 25, 2023 • 40 hits
Turbinate reduction is a procedural method for improving nasal breathing in patients with turbinate hypertrophy. Though these procedures are typically performed in an operating room, offering in-office procedures allows patients to avoid the OR and return to their daily activities sooner. Dr. Madan Kandula, founder of ADVENT, an ENT private practice, discusses his approach for offering in-office procedures and why turbinate reductions are often his first choice of management nasal breathing challenges.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Turbinate reduction may be offered as an in-office procedure to improve nasal breathing in patients with turbinate hypertrophy.
• Allergy patients with inflammation of the nasal lining may benefit from a combination of turbinate reduction and lining treatment to avoid repeated obstruction.
• Other in-office procedures offered by an otolaryngologist can include nasal swell body reduction, balloon sinuplasty, VivAer, and LATERA.
Table of Contents
(1) Indications for Turbinate Reduction
(2) Turbinate Reduction in Allergic Patients
(3) Exploring Other In-Office Procedures
Indications for Turbinate Reduction
While treating the lining of the nasal cavity may improve nasal breathing for patients, turbinate reduction effectively impacts the anatomy of a patient with turbinate hypertrophy. If indicated, turbinate reduction can be offered with swell body reduction or balloon sinuplasty to give a patient patent anatomy. Dr. Kandula finds that offering effective turbinate reductions through a variety of techniques allows his patients to avoid the operating room. This approach can provide relief to patients who have tried alternative lining treatments, but still experience difficulty with nasal breathing due to turbinate hypertrophy.
[Gopi Shah MD]
Just going back to the nose and the sinus. In terms of breathing treatment through the nose options, other than saline rinses, nasal steroid sprays, what are our options?
[Madan Kandula MD]
Going back to what I was saying before, that simple basic of: you have a nose issue, you have a nose and sinus issue, you've got an anatomy issue or a lining issue. What you're describing is treating the lining. Any medication, whether it's a nasal spray, Flonase, Budesonide, you name it, those are lining treatments. It depends on the patient. Many of our patients have already, they've come to us, they've tried rinses, they've tried Flonase, they've been on antibiotics for sinus conditions. They've been there, done that. At the end of the day, it's up to us to process that, look at them, and say, "Let's come after this, and let's see."
Typically at that new patient visit, it’s evaluating what somebody's done, evaluating what the health of the lining is, and determining, should we try Dymista and whatever the right different angle may be. Let's try that. Let's maximize the lining treatment. Do we need to do allergies testing? If so, let's think about that. Most of the time, the biggest change we can make for our patients is impacting the anatomy. If somebody can be treated with lining treatments, that's fine, but most folks have a combined issue.
Our philosophy is really an anatomy first, office first mindset as it relates to getting that anatomy open. Keep it simple. Let's go for the low-hanging fruit. The lowest-hanging fruit in our specialty is turbinate hypertrophy. Medications can take the edge off of that lining. If we effectively diagnosed, and effectively offered and treated folks with turbinate reductions in office, just because it's so much easier from an access standpoint, we would change the state of health in this country in a profound way.
That one simple thing, and it's something we all learned how to do in our first year of ENT residency, and yet the thing that frustrates me is there are millions of people out there who are suffering needlessly, noses that are blocked up. It's something that takes us five minutes to do and we're unwilling to do as a specialty, not because we don't. I'm sure there are people out there who don't believe it like, "No, that's not true," and I understand that. And then there's the whole empty nose ghosts that haunt our psyches, and I understand that too. At the end of the day, I'd say, I'd rather give somebody patent anatomy versus having them suffer with a challenged anatomy.
[Ashley Agan MD]
On the topic of turbinates, how do you decide if turbinate hypertrophy is the key to unlocking better nasal breathing for the patient? As a follow-up, what is your turbinate reduction method of choice?
[Madan Kandula MD]
Here's what I'd say. I am humble, meager, weak. It's impossible for me to know for sure. Some of these turbinates, is it their septum? Is it their nasal swell body? Is it the valve? Is it that they've got sinus outflow tracks that are tight or that they've got inflammation in the sinuses, or the allergy part of things? There's a lot of things where it's like, "Ah, you know" but it's hard to give you a straight answer without seeing an individual patient.
The assumption for somebody who's coming to us with, "Gosh, I've got congestion. I have a hard time breathing my nose." Maybe it's just happening at night for them. When you lay down and your left side stuffs up. When I lay on my left side and I flip over, and we look in there and things look tight, turbinate reduction is something that's going to come to us. That is the most likely intervention that we're going to think towards for a patient, and that might be a combination. Oftentimes, it is with swell body reduction, many times with balloon sinuplasty if that's indicated, so forth and so on. That is the key to unlocking the nasal airway. It's the simplest thing we can do. It's a very reproducible result.
We have a variety of techniques. It is the reality. Basically, a volumetric reduction by whatever means necessary is effective. Whether that's coblation, whether that's microdebrider. I've reduced turbinates probably every single way that's possible. The only common theme is if you do it effectively, you get good results. Again, the things I'm saying, there's controversy in the nuance. To me, what is an effective turbinate reduction? An effective turbinate reduction is reducing inferior turbinates front to back.
I don't know how. I don't understand the physics of those in our specialty who profess that it's only the anterior head of the inferior turbinate that matters. I took physics, and that doesn't make any sense at all. How is that possible, that that's where it's at? Somebody's going to have to educate me on that one. Again, to me, we, and I'd say it started with me, like to impact turbinates in a meaningful way. We're not shy about it. It's just saying, "This is an issue, let's get it out of the way."
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Turbinate Reduction in Allergic Patients
Patients with allergies often need special consideration due to inflammation of the nasal mucosa that could lead to turbinate hypertrophy over time. Allergy patients who receive a turbinate reduction can be counseled on lining treatments to reduce inflammation. Patients who choose not to treat their lining could need additional turbinate reduction in the future. Dr. Kandula believes that allergy patients with nasal obstruction will benefit most from a thorough turbinate reduction combined with medications or immunotherapy.
[Gopi Shah MD]
Before we go to 95% in the office, because that is super interesting, and I think that's also a big part of this conversation. Just in terms of inferior turbinates, do you think differently for your patients that are really bad allergy patients? Do you ever worry about taking too much, or how often do you have to revise? Those are the kinds of things that tend to always make me, I guess, be a little bit more conservative because I'm like, "They tend to grow back," but how often do you actually see it?
[Madan Kandula MD]
There's what we've been taught, and there's what you see. What I see is that a thorough turbinate reduction, it's hard to describe. "What is he saying when he says thorough?" Not a bashful turbinate reduction. An adequate reduction where there's adequate patency through the nose front to back for everybody who could benefit from that, who's got anatomy that's tight, especially allergy patients. The times where allergy patients fail, this is what I see and this is what I strongly believe is, an allergy patient who is coming to you with nasal obstruction, they've got an anatomy issue, likely. Number one, they've got a lining issue. If they're an allergy patient, they're telling you, or their body's saying, "I've got a lining issue." That's one thing. That lining issue over time is going to create an anatomy issue. If you have inflammation in the lining of the nose, over time, that's going to create turbinate hypertrophy. That's what happens.
Why does that happen? Because the body perceives the world as an enemy and is shutting it off, and is trying to shut it down. If you try to just treat the lining issue when the anatomy is already compromised, you can't adequately treat the lining issue. Even Flonase isn't necessarily going to get where it needs to go. It is making sure that the patient's aware about what's going on, making sure you're aware about what's going on. In that scenario, it would be doing a thorough turbinate reduction, making sure that the patient is aware upfront that we are addressing the anatomy component of this. There is a lining component that is important to treat as well. Whether we're going to treat that with medications or immunotherapy or whatever the case may be, the optimal situation for you is your anatomy’s patent and your lining’s calm. If we get you to that point, the likelihood for having to go back and touch the turbinates is minimal. It's not nothing, but it's as low as we can make it be. That's good enough for me, and it's generally good enough for most patients. If you just tell it like it is to them.
Now on the flip side, say we do a turbinate reduction on somebody who's got massive allergy issues or inflammation issues, just generally. They've got a much higher, and we're not able or they're not willing to treat that lining situation, they have a much higher likelihood of a recurrence of the turbinate hypertrophy. When it is a choice that they're making, they need to understand that that's the choice that they're making. Some people just have inflammation and there's nothing that, you can do everything you want, and we're all helpless sometimes and they're helpless. Those patients, you do a turbinate reduction, they've got massive inflammation, nothing that you're trying is helping the inflammation. They're going to be more likely to have to have that turbinate reduction done again.
People are people, and people absorb things differently. But if you're putting it just out there in front of somebody, I think we fear, I think I was born or bred to fear. Like "God, what if I do something and it doesn't work, and now I'm the worst person in the history of the world and the patient is going to hate me and they're going to tell everybody that I'm the worst person?" It's like, "No, I don't think that's actually a healthy mindset." I think you can control what you can control, and it's your duty to control that. Then there's the stuff that you can't control and you let that go. I've been meaning that, you don’t just go like, "Whatever." But I think you can recognize that and you could say, for that patient, like I just said, if you've got this inflammation issue and say we do a turbinate reduction, you're feeling great, you're breathing through your nose, like, "I'm doing great. This Flonase, I don't like the taste. I don't like the smell, I don't want to use it. Then you say, "Yes, I hear you. When we're looking in there and we see inflammation in the lining over time, that might steal away the gains we just made. I want you to be aware of that," and they say, "Understood. I don't care. I'll be back here in 10 years," or whatever the case may be. That's their choice. I don't know what else we would do about it. Sometimes I feel like we are fearful of having just honest and frank conversations with our patients, and they're dying for that conversation oftentimes. They want that. They can handle the truth if you can just deliver the truth, but we far too often bury the truth. I don't know why we bury it. It doesn't make sense to me, but yeah.
Exploring Other In-Office Procedures
Depending on the patient, other nasal components or treatments may be considered. A thorough evaluation of the patient based on scans, history, and symptoms can determine whether or not a patient has an internal issue that can be fixed in-office. Dr. Kandula prefers turbinate reductions as a first step treatment to improve nasal breathing. However, for his patients with sinus issues, Dr. Kandula commonly offers balloon sinuplasty for the maxillary and frontal sinuses. Performing these procedures often offers the patient adequate airflow to improve their nasal breathing. The VivAer procedure or LATERA implants may be considered for patients with a valve blockage.
[Ashley Agan MD]
Very well said. Transitioning to talking about office procedures and what can be done in the office, do you have almost like a menu of options that you sit down and talk to patients about and be like, "Look, this is the technology we have. This is what can be done in the office, and then out of all of these things we do, these five things might be something that could help you in particular." How does that look like, and what is on your menu?
[Madan Kandula MD]
Sure, that's a good way to look at it. From an anatomy standpoint in the nose, the components or the areas that we consider: septum, turbinates, swell body. I always felt like turbinates and swell body, they're the same thing, it's just a different location of a turbinate. It's a septal turbinate. Still, I feel like it’s especially still learning about what do you do with that one? Basically, you've got the septum, you've got the turbinate, whether it's inferior or septal turbinate, you've got the valve, for the majority. Some people might have polyps and some people might have adenoid hypertrophy, but if you took the large majority, those are the components. It depends on the patient, it depends on the situation. Out of those components, that our preference as far as intervening is the turbinates first. So inferior and septal, and then it depends. Septum versus valve tend to be backburner kind of things. The septum is very easy conceptually. You see it, you can address it. We tend to do our septums in the OR, which there's a whole conversation around, "Why do you do that?"
There's a reason we do that, but regardless, I'd say we tend to do our septums in the OR which then says, "What can we do in the office to help you?" Then you start saying from a pure nose standpoint, we can reduce the turbinates, typically the inferior and the septal turbinate. The valve, basically, we assess, we evaluate and we say, "Boy, that's a backburner issue." We talk to our patients who have those issues, meaning that it's more of an uphill battle. In my hands with all sorts of techniques and technology through the decades that I've been doing this, I cannot achieve consistent results with nasal valve issues, whether internal or external. I can't.
It's very nuanced. It's a real thing. I'm definitely on the side of the fight on the valve that it is an issue, but if you address the internal issues first, the likelihood of you needing to address that valve is minimal. There are valve maximalists who say every patient who has a nose problem has a valve problem. I've seen it too many times with our patients where you see somebody with a valve issue, you see somebody with obstruction internally, you correct the internal obstruction, and they're fine. They don't need anything else, and if they do need something else, focusing on the nose, that's our algorithm. If somebody has valve collapse or narrowing there, then it's something we identify, we talk about, we say, "We're going to get these internal issues corrected in the office and we're going to see how you're feeling." If you're feeling like you're where you need to be, wonderful. If you're not, it depends on the situation, but we might consider VivAer or LATERA rarely. We don't do a ton of rhinoplasty at this point, so if somebody really needs that functional rhinoplasty, we've got folks we can tuck them in with. That's the nose component.
From a sinus component as it relates to anatomy, it's evaluating their scan, evaluating their symptoms, evaluating their history, and putting that all together. The most common treatment that we'll offer for our patients who have sinus issues is balloon sinuplasty for the maxillary and frontal sinuses. The thought there is that common sinus outflow of tracks, of frontals coming into anterior ethmoids, maxillary is coming into anterior ethmoids.
That area, if it is tight, if it is even slightly compromised, that's a domino that once it starts tipping, is going to start clipping off downstream. If we can get those areas open, it's helpful. What I said out of the gate, nose and sinus anatomy patent, that's the most key area. If you have basically adequate outflow, adequate airflow into those areas, that impacts actual nasal breathing, which is a very controversial thing for me to say, but it's true. I see it all the time. It also just impacts the health of the nose and the sinuses.
Our most common treatment is balloon sinuplasty for the maxillary frontal sinuses, turbinate reduction, nasal swell body reduction combined together. We're coming to that conclusion after evaluating all of these specific possibilities for a patient for whom they've got a deviated septum. That is something that, if you didn't correct that, you're not going to help this person, we'll do that right out of the gate kind of thing. There's a mindset and a likelihood about how we practice, but every patient's unique and every clinician needs to make sure that they know that they're in control, and they can do it if necessary.
Dr. Madan Kandula
Dr. Madan Kandula is a practicing ENT and the founder and CEO at ADVENT in Milwaukee, WIsconsin.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, October 4). Ep. 72 – The Future of Otolaryngology is in the Office [Audio podcast]. Retrieved from https://www.backtable.com
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