Retention of expansion nasal surgery treatment of OSAHS inferior turbinate cavernous tissueYu Feng, Gong Huicheng, Zhang Qunhui, Zhang Haoli
Retention of expansion nasal surgery treatment of OSAHS inferior turbinate cavernous tissue
Yu Feng, Gong Huicheng, Zhang Qunhui, Zhang Haoliang
Department of Otolaryngology Head and neck surgery hospital, Guangzhou 510620, China
Objective to investigate the improved surgical treatment of OSAHS by nasal cavity expansion. Methods 55 cases of obstructive plane type I OSAHS patients, treatment group was treated with retention of inferior turbinate spongiform expansion nasal surgery, the preoperative and postoperative PSG results were compared to the control group of 26 cases of inferior turbinate resection, two group PSG after operation were compared. Results all patients were followed up for 6~12 months. There were significant differences in AHI, AI, LSaO2 and MSaO2 in the preoperative and postoperative PSG parameters of the treatment group (P < 0.01). Compared with the control group, the therapeutic effect of the treatment group was better than that of the control group (PSG). Conclusion: preservation of inferior turbinate cavernous tissue expansion nasal surgery can not only preserve the physiological function of the nasal cavity, but also on the curative effect of treatment of OSAHS type I do, than the commonly used inferior turbinate resection effect is good.
[Key words] inferior turbinate; spongy tissue; expansion surgery; OSAHS
AbstractObjectiveToinvestigatetheimprovedsurgicalapproachofnasalcavitysurgeryexpansionforOSAHS.Methods55OSAHSpatientswithchokingplanebelocatedinthenasalcavitybecamethetreatmentgroup, cavemosumsofinferiorturbinatehadbeenretainedinnasalcavitysurgeryexpansion, thepreoperativedataandpostoperativedataresultswerecompared, thedataofAHI, AI, LSaO2andMSaO2existsignificantdifference.26casesinferiorturbinatewerepartialremovedsubmucosal.thePSGoftwogroupswerecompared.Patientswerefollowedupfor6to12months, thelatterhadpoorresults.ConclusionTheoperationofcavemosumsofinferiorturbinatehadbeenretainedinnasalcavityreservedrhinalfunction, clinicaleffectforOSAHStype I wasassured, thismodeofoperationisbetterthanportioninferiorturbinatesubmucosaexcision.
[Keyword] inferiorturbinate; Cavemosum; cavitysurgeryexpansion; OSAHS
Obstructive sleep apnea hypopnea syndrome (OSAHS) blocking plane mainly concentrated in the nasal cavity (type I), oropharynx (type II), tongue (type III) three levels, this paper mainly studies the simple type of patients with nasal obstruction plane, is the upper respiratory tract of the portal, with the breath, heating and humidifying, cleaning and filtering, immune defense, resonance, olfactory function, inferior turbinate with spongy tissue, composed of blood vessels and sinus capacity, plays a key role in the physiological function of the nasal cavity, nearly 3 years in our hospital diagnosed as OSAHS (obstructive plane type I) with retention of expansion nasal surgery the intervention of inferior turbinate cavernous tissue, report as follows:
1 materials and methods
1.1 clinical data
From August 2009 ~2012 August by polysomnography (PSG), nasal endoscopy, electronic laryngoscope, sinus CT, tongue level CT related oropharyngeal examination confirmed the diagnosis of OSAHS (moderate and severe)  patients with obstructive plane type I, a total of 55 cases, male 47 cases, female 8 cases the average age of 41.2 years, 10.5 years, polysomnography monitoring results of 39 moderate cases, 16 severe cases (AHI:5~15) (AHI > 30); nocturnal hypoxemia in 41 moderate cases and 14 severe cases.
1.2 nasal obstruction factors
Endoscopic examination showed 48 cases of various types of nasal septum, inferior turbinate hypertrophy mulberry like changes in 12 cases, CT showed abnormal thickening of inferior turbinate bone in 41 cases, simple inferior turbinate mucosal thickening in 10 cases, 7 cases of concha 10 side, uncinate process hypertrophy 6 cases 8 sides, 8 sides of 4 cases of middle turbinate hypertrophy the middle turbinate, 2 cases of reverse bending in 2 sides, 1 cases of middle turbinate long side 2, 9 cases of chronic sinusitis and nasal polyps, 1 cases of adenoid hypertrophy.
1.3 surgical methods
The treatment group of 55 cases of middle turbinate cavernous tissue preserved under the first expansion nasal surgery, endoscopic nasal cavity surface anesthesia and local anesthesia of inferior turbinate, inferior turbinate and nasal vestibule incision is located at the junction of the inferior turbinate mucosa and skin, from the top to the bottom of the nasal region vertical curved incision about 1cm, turbinate bone surface depth. With the nasal septum raspatory attract isolated inferior turbinate mucosa of inferior turbinate bone exposure, surface roughness, the endoscopic into the mucosa of inferior turbinate, continue to back, until the formation of a bag, the inferior turbinate bone to the medial open (thick and hard can cut through the same method), the inferior turbinate mucosa of lateral separation, until completely separated from the inferior turbinate mucosa and mucosa inside and outside the bottom, from the front to the back section for straight forceps under lower turbinate swelling, about inferior turbinate bone 1/2~1/3, inferior turbinate reduction Check the total nasal mucosa, patency after satisfactory front incision suture needle 1, for example is the nasal septum replica of the inferior turbinate bone as cartilage of nasal septum, inferior turbinate mucosa as the medial and lateral nasal septum mucosa. Other obstruction of the nasal cavity and paranasal sinuses according to need treatment, nasal septum deviation with submucous resection of part, has reached completely straight and volume reduction to the corresponding cutting age should be reduced in 16~21 years, as far as possible to retain most of the septal cartilage. All anatomic abnormalities may be in the bottom of the incision in the inferior turbinate mucosa, to divest from both sides, exposed middle turbinate bone, with straight forceps, reset reserved mucosa. Hypertrophy of the uncinate process should also be retained mucosa. Nasal polyps, adenoids and chronic sinusitis are important factors for obstruction.
The control group of 26 cases of inferior turbinate resection, no inferior turbinate following incision, cutting aspirator and knife head into the thorn from mucosa of inferior turbinate directly under nasal endoscopic surveillance knife head in the submucosal inferior turbinate to sneak back, the starting power system, the knife head cutting edge back under observation turbinate volume reduction, until the return under a front end. The other structures of nasal cavity and adenoid were treated with the same treatment group.
2.1 comparison of sleep monitoring parameters in the treatment group before and after operation
Turbinate cavernous tissue retained in 55 cases of expansion nasal surgery, preoperative underwent PSG monitoring, 6~12 months after operation 40 cases were followed up successfully parallel PSG monitoring, statistical data see table 1.
Table 1 Comparison of the parameters of sleep monitoring in the treatment group before and after the operation of nasal dilation in 40 cases
Monitoring time AHIAILSaO2MSaO2BMI
Times (/h) (%) (%) (Kg/m2) (/h)
Preoperative (n=40) 33.6 + 11.129.7 + 9.877.4 + 9.190.5 + 3.626.2 + +
Postoperative (n=40) 16.2 + 5.517.7 + 6.884.7 + 6.393.9 + 2.825.9 + +
T value 8.886.3188.8.131.52
P value 0.01 < 0.01 < 0.01 < 0.01 > > 0.05
2.2 of the 26 patients in the control group of inferior turbinate resection, preoperative underwent PSG monitoring, preoperative data mean AHI was 27.5 + 9 /h, the mean AI was 20.2 + 8.2 /h LSaO2 + 6.6%, the average is 79.2, the mean value of MSaO2 was 91.3 + 2.2%; 6~12 months after operation 17 cases were followed up successfully. Parallel PSG data monitoring, postoperative mean value of AHI was 16.5 + 6 /h, the mean AI was 15.2 + 7 /h, mean LSaO2 was 85.6 + 4.9%, 93.4 + 2% MSaO2 mean
Table 2 curative effect comparison between treatment group and control group
Group AHI drop value AI value of LSaO2 increased by MSaO2 value decreased by SLT90
(/h) (/h) (%) (%) (%)
Group A (n=40) 17.4 + 7.212.0 + 5.57.3 + 3.33.4 + 1.54.5 + +
Group B (n=17) 11 + 3.95.0 + 1.86.4 + 3.52.1 + 1.24.1 + +
T value 4.327.190.902.390.70
P value < < 0.01 > > > 0.05 < 0.05 > > 0.05, 0.01
2.3 turbinate atrophy: 40 cases were successfully in 12 cases followed up for more than 2 years, 2 cases of 4 side nasal dry, smooth action with symptoms, but no scar and smelly nasal disease, 2 cases of this examination showed bilateral inferior turbinate meatus of nose is small, slightly wider; 10 cases were followed up for 1~2 years. There were no symptoms; 18 cases were followed up for 6~ 12 months; 1 cases of 1 side nasal dryness, foreign body sensation v. symptoms, the 1 side specialist examination showed inferior nasal meatus in size as usual, slightly wider.
As a part of expansion nasal surgery in the treatment of OSAHS, when there is obstruction following nasopharyngeal plane, it is necessary to solve the two stage surgery pharyngeal plane problem. Nasal congestion effects on sleep breathing in abroad is inconclusive [2,3], OSAHS in nasopharyngeal nasal obstructive plane for a single case is rare, and sleep apnea generally lighter, method of text selection is based on the case of snoring, sleepiness symptoms of nasal obstruction and three for the screening conditions, and to the neck too thick, soft palate, pharynx droop, himantosis tissue congestion, tongue hypertrophy, micrognathia and other factors in order to exclude the condition, therefore expansion nasal surgery postoperative patients with snoring, nasal congestion and sleepiness these three symptoms may be greatly eased, and through the comparison of PSG data before and after the operation has been verified.
The physiological function of the inferior turbinate plays a very important role in the respiratory system, the main physiological function in the spongy tissue of mucosa and submucosa of the 2 structure to reflect, apart from the front part of squamous epithelium and transitional epithelial, after 2/3 were pseudostratified ciliated columnar epithelium and cilia swing clean excretion, mucus glands and submucosal serous gland secretions, and cilia movement composed of mucus by strengthening the consciousness of protecting the mucosa, in recent years the domestic surface ablation turbinate is gradually eliminated. But the spongy tissue as another important structure of inferior turbinate, has not been widely recognized, the physiological function of the inferior turbinate cavernous tissue has: the air heating and humidifying temperature close to temperature, humidity is more than 95%, in order to adapt to the needs of the respiratory physiology; maintain certain nasal resistance. The lungs open in the inspiratory phase uniform, smooth completion of the exchange O2 and CO2; the bilateral vascular capacity under concha contraction and expansion, the formation of nasal cycle, helps sleep when turning over; the capacity of blood vessels and blood sinus to the inferior turbinate to maintain a certain volume, not the formation of atrophic rhinitis and empty nose syndrome . It retains the inferior turbinate cavernous tissue and inferior turbinate mucosa of inferior turbinate bone is equally important, become the main object of expansion nasal surgery, partial resection of inferior turbinate bone has two advantages: after removal of inferior turbinate bone volume was significantly reduced; the replacement of lateral fracture, avoid fracture bone hyperplasia occurred in long term the recurrence of nasal obstruction. The nasal mucosa was intact and there was no postoperative adhesion. A little more controversial: the skeleton structure of inferior turbinate was removed, the inferior turbinate tissue lost support, whether there will be a decline in the long term? In this case the longest follow-up of only three years, there were 3 cases of 5 cases of inferior turbinate atrophy mild side, there is no evidence to prove that there is no support cavernosal tissue atrophy, male genitalia is an example, so keep turbinals part of the complete resection of cavernous tissue will cause inferior turbinate atrophy, can only be confirmed by the clinical observation and animal experiment.
In view of the risk of inferior turbinate may atrophy, surgical resection of the inferior turbinate bone only lower swelling parts, if inferior turbinate bone on diffuse thickening, then backwards sagittal resection of the lower end of the 1/3 to 1/2, such as the operation of excessive expansion of nasal cavity volume of nasal resistance decreased rapidly, a lot of gas through the nasal cavity, easy to direct stimulation of the trigeminal nerve branches in the nasal cavity caused by reflex headache . Another common problem of this type of operation is the mucosal tear, inferior turbinate mucosa both inside and outside of this risk, and is connected with a medial incision tear rare, causes are: incision length insufficient tension; the long-term use of decongestants cause mucosal brittleness. Processing method of tear suture can not find cases of perforation.
Need to deal with the common middle turbinate has five kinds: polypoid, conchabullosa, reverse bending, and long bone hypertrophy, the main principles of surgical two retention, retention of middle turbinate mucosa and nasal and nasal olfactory methyl in the form were not too big change, mainly by Han Demin  the middle turbinate functional operation of resection, polypoid mucosa to be; conchabullosa, reverse bending and bony hypertrophy in three cases with the front end and the bottom end of the long incision, dissection of middle turbinate mucosa in nasal bones exposed at both ends, and as part of the abnormal reduction and resection. Retention of middle turbinate; middle turbinate mucosa of elders to bone resection and truncated.
The nasal and oropharyngeal plane plane exist at the same time blocking OSAHS patients, the general processing order is the first for the two phase of expansion nasal surgery treatment for palatopharyngoplasty, the latter because the risk is too large, the first to reduce the risk of the postoperative asphyxia, but also can improve the curative effect of UPPP surgery . In addition, this method is also suitable for patients with chronic rhinitis without snoring and nasal obstruction.
The Editorial Committee of  Chinese Journal of Otorhinolaryngology Head and neck surgery, Chinese Medical Association of Otolaryngology Head and neck surgery branch of study group. The throat of obstructive sleep apnea hypopnea syndrome diagnosis and treatment guidelines [J]. Chinese Journal of Otorhinolaryngology Head and neck surgery, 2009,44 (2): 95-96.
deVitoA, BerrettiniS, CarabelliA, etal.Theimportanceofnasalresistanceinobstructivesleepapneasyndrome:astudywithpositionalrhinomanometry[J].SleepBreath, 2001,5 (1): 3-11.
PevernagieDA, deMeyerMM, ClaevsS.Sleep, breathingandthenose[J].SleepMedRev, 2005,9 (6): 437-451.
DammM, EckelHE, JungehulsingM, etal.Olfactorychangeatthresholdandsuprathresholdlevelsfollowingseptoplastywithpartialinferiorturbinectomy.AnnOtolrhinollaryngol, 2003112:91-97
 Hao Xiaomin, Liu Shuiming, et al. Analysis of curative effect of 108 cases of nasal endoscopic dilation in nasal endoscopic surgery, 2011,46 () () (586-588.)
 Han Demin. Nasal endoscopic surgery [M]. Beijing: People's Medical Publishing House, 2001:31.
 Peng Yikun, Hu Defeng, Yu Bing generation, etc. expansion nasal plasty effect on pharyngeal effect of modified uvula Chinese. Journal of Ophthalmology, 2011,11 (5): 301-304.
Figure 1 Figure 2 incision of inferior turbinate mucosa under a medial separation
Figure 3. Isolation of a lateral mucosa from the inside and outside of the mucosa, figure 4
Figure 5 bite except inferior turbinate portion of Figure 6 in addition to continue to bite a total of about 1/3 of the inferior turbinate
Figure 7 the front end of the suture figure 8 incision suture needle 1
Figure 9 Figure 10 lower turbinate peel separation mucosa with straight forceps in bone mass