Bleeding post radiofrequency ablation of inferior turbinate: A case study

Fatemah S AlTheyab; Ebraheem A AlNofal

doi:10.4103/sjoh.sjoh_57_22

CASE REPORT

Year : 2023 | Volume : 25 | Issue : 1 | Page : 47-49

Bleeding post radiofrequency ablation of inferior turbinate: A case study

Fatemah S AlTheyab, Ebraheem A AlNofal
Cochlear Implant Centre, King Saud Medical City, Riyadh, Saudi Arabia

Date of Submission	03-Dec-2022
Date of Decision	02-Jan-2023
Date of Acceptance	06-Jan-2023
Date of Web Publication	20-Mar-2023

Correspondence Address:
Dr. Fatemah S AlTheyab
Cochlear Implant Center, King Saud Medical City, P. O. Box: 167, Riyadh 13217
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_57_22

Abstract

Nasal obstruction is a troublesome condition and negatively impacts the quality of life. One of the most important causes is inferior turbinate hypertrophy. Radiofrequency submucosal tissue ablation is an effective technique used to reduce inferior turbinate volume. It is considered a safe, minimally invasive procedure with a low risk of complications. Most of the complications reported were minor such as pain, edema, sneezing, crustation, and bleeding. This study demonstrates a case of major bleeding as a complication of radiofrequency ablation of inferior turbinate aiming to reduce the incidence of such complication. The patient had major bleeding resulting in a drop in hemoglobin level, however, no surgical intervention was required, and he was managed conservatively.

Keywords: Bleeding, radiofrequency ablation, turbinate hypertrophy, turbinoplasty

How to cite this article:
AlTheyab FS, AlNofal EA. Bleeding post radiofrequency ablation of inferior turbinate: A case study. Saudi J Otorhinolaryngol Head Neck Surg 2023;25:47-9

How to cite this URL:
AlTheyab FS, AlNofal EA. Bleeding post radiofrequency ablation of inferior turbinate: A case study. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2023 [cited 2023 Jun 4];25:47-9. Available from: https://www.sjohns.org/text.asp?2023/25/1/47/372142

Introduction

Nasal obstruction is a troublesome condition and negatively impacts the quality of life.^[1] It can result from various anatomical variations and pathological conditions.^[1] One of the most important causes is inferior turbinate hypertrophy.^[1] The inferior nasal turbinate is a normal anatomical structure located in the inferior part of the lateral nasal wall, extending from the anterior nostril to the posterior choana.^[2] It consists of turbinate bone, mucoperiosteum, soft erectile tissue, and mucosa.^[2] The inferior turbinate is supplied by the inferior turbinate artery, one of the terminal branches of the posterior lateral nasal artery.^[3] Furthermore, it receives blood supply from the facial artery through its angular branch.^[3] The main blood supply enters the turbinate 1–1.5 cm from its posterosuperior end, and it runs in a bony canal wrapped by fascia which prevents the artery from contraction causing postsurgery bleeding.^[3] There are multiple techniques used for inferior turbinate volume reduction and one of them is radiofrequency ablation.^[4] It uses radiofrequency to reduce tissue volume with minimal impact on surrounding tissues.^[2] This technique has proven to improve nasal obstruction with minimal complications reported including crusting, adhesions, dryness, and minor nasal bleeding.^[2] In this study, we present a case of major bleeding post radiofrequency ablation of the inferior turbinate, and as far as we know this is the first case reported a radiofrequency turbinoplasty complicated by major bleeding.

Case Report

Our patient is a 39-year-old male, medically free, history of septoplasty, still complaining of bilateral nasal obstruction. On examination, he had inferior turbinate hypertrophy bilaterally with no major septal deviation [Figure 1]. After discussion with the patient, the decision of management was taken to do radiofrequency ablation of the turbinate under local anesthesia.

Figure 1: Coronal view of CT PNS. CT PNS: Computed tomography paranasal sinus

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The procedure was performed in the office under local anesthesia using Olympus Celon Elite ESG-200. The nasal cavities were packed with pledgets soaked in 5% lidocaine for 5 min followed by an injection of 5 ml of 1:100,000 lidocaine with epinephrine. Using a 4 mm 0° scope, the CelonProBreath applicator was inserted in a single point at the most anterior part of the inferior turbinate, and the energy delivered was on default sitting, which was 10 for adults for a duration automated by the device using audible and visible feedback for impedance-controlled tissue ablation when impedance threshold of the tissue is reached [Figure 2].

Figure 2: Endoscopic view of right nasal cavity post radiofrequency ablation

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There were no complications postablation, and the patient was given xylometazoline nasal drops for 3 days only.

On day 14^th postablation, the patient developed major nasal bleeding; he went to the nearest hospital, and he was admitted and packed for 2 days; he also received a blood transfusion as his laboratory results showed a low hemoglobin level. After stabilization, the patient referred to our hospital and he was admitted for observation; he was managed conservatively. No other episode of bleeding was observed during his hospital stay [Figure 3].

Figure 3: Endoscopic view of right nasal cavity showing crustations post radiofrequency ablatio

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Discussion

Radiofrequency submucosal tissue ablation is an effective technique used to reduce inferior turbinate volume.^[5] It can be used as an in-office procedure for patients who are poor candidates for surgery.^[5] Radiofrequency energy delivered will create thermal injury (80°C), leading to submucosal necrosis which will be replaced by fibroblasts.^[5] Later, the wound will contract as a part of the healing process, leading to turbinate volumetric reduction and relief of nasal obstruction.^[5] It is considered a safe, minimally invasive procedure with a low risk of complications.^[6] Most of the complications reported were minor such as pain, edema, sneezing, crustation, and bleeding.^[7]

Bleeding has been reported as a complication of radiofrequency ablation.^[6],[7],[8] Bäck et al. reported 2 out of 283 patients had bleeding, one perioperatively, and the other 14 days postablation, and it was managed conservatively,^[8] which was the same for our patient; the bleeding occurred on day 14 postablation, and it was managed conservatively by nasal packing without major surgical intervention. Local vasoconstriction and the location of needle insertion might play a role in postoperative bleeding as suggested by Evcimik.^[7] He proposed that it can occur due to lack of vasoconstrictive with local anesthesia in immediate bleeding, whereas in late bleeding, excessive use of energy or application of ablation in the posterior part of the turbinate which might injure the posterior lateral nasal branch of the sphenopalatine artery can result in bleeding.^[7] The Olympus company recommended the use of 2% adrenalin-free lidocaine solution as a local anesthetic agent; however, our observation showed that the use of adrenaline in combination with lidocaine was associated with less bleeding and pain for the patient. It is recommended to avoid excessive energy delivery, especially at the posterior end of the inferior turbinate.^[7] Moreover, that could be one of the contributing factors of the bleeding in our patient as the location of the insertion was in the most anterior part of the inferior turbinate, but submucosal thermal lesions are created along the entire length of the turbinate reaching posteriorly which might cause a direct injury to the posterior lateral nasal artery. However, the energy delivered to submucosal tissue was automated within a safe range by the device.

Crustation is one of the reported complications in the first few days following the procedure, especially at the site of needle insertion.^[9] Our patient developed bleeding after recurrent sneezing so we hypothesized that the crusts dislodged by the force of sneezing and resulted in bleeding. Recurrent sneezing could be due to allergic rhinitis symptoms caused by the dry dusty climate which is well known in our area. A study showed that the prevalence of AR symptoms was 82.4% in the Middle East area with the most common trigger of symptoms being dust.^[10] Crust formation can be avoided by proper insertion of the device tip.^[7] In addition, it is recommended to use saline irrigation postturbinoplasty to remove crustation as it is an easy procedure and proven to be a safe and effective adjunctive without serious side effects.^[11] A prospective clinical trial conducted by Nuseir AF et al. suggested that the use of 5-fluorouracil at the end of the surgery reduced postoperative crustation without any significant side effects.^[12] We propose that prevention of crustation formation will reduce the bleeding postradiofrequency turbinoplasty.

Conclusion

Radiofrequency ablation is a safe, minimally invasive procedure, although minor complications can occur as bleeding and crustations which can be avoided by proper needle insertion and the use of irrigation and lubricant postablation.

We recommend to investigate the effect of needle insertion location and use of saline irrigation on the rate of crustation and bleeding postradiofrequency ablation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Passali D, Loglisci M, Politi L, Passali GC, Kern E. Managing turbinate hypertrophy: Coblation versus radiofrequency treatment. Eur Arch Otorhinolaryngol 2016;273:1449-53.
2.	Abdullah B, Singh S. Surgical interventions for inferior turbinate hypertrophy: A comprehensive review of current techniques and technologies. Int J Environ Res Public Health 2021;18:3441.
3.	Al-Shouk AA, Tatar İ. The blood supply of the inferior nasal concha (turbinate): A cadaveric anatomical study. Anat Sci Int 2021;96:13-9.
4.	Vijay Kumar K, Kumar S, Garg S. A comparative study of radiofrequency assisted versus microdebrider assisted turbinoplasty in cases of inferior turbinate hypertrophy. Indian J Otolaryngol Head Neck Surg 2014;66:35-9.
5.	Utley DS, Goode RL, Hakim I. Radiofrequency energy tissue ablation for the treatment of nasal obstruction secondary to turbinate hypertrophy. Laryngoscope 1999;109:683-6.
6.	De Corso E, Bastanza G, Di Donfrancesco V, Guidi ML, Morelli Sbarra G, Passali GC, et al. Radiofrequency volumetric inferior turbinate reduction: Long-term clinical results. Acta Otorhinolaryngol Ital 2016;36:199-205.
7.	Sapçı T, Güvenç MG, Evcimik MF. Radiofrequency treatment for inferior turbinate hypertrophy. Kulak Burun Bogaz Ihtis Derg 2011;21:56-60.
8.	Bäck LJ, Liukko T, Sinkkonen ST, Ylikoski J, Mäkitie AA. Complication rates of radiofrequency surgery in the upper airways: A single institution experience. Acta Otolaryngol 2009;129:1469-73.
9.	Deenadayal DS, Kumar MN, Sudhakshin P, Hameed S. Radiofrequency reduction of inferior turbinates in allergic and Non allergic rhinitis. Indian J Otolaryngol Head Neck Surg 2014;66:231-6.
10.	Almehizia AA, AlEssa RK, Alwusaidi KM, Alzamil KA, AlJumah M, Aljohani S, et al. Allergic rhinitis: Disease characteristics and coping measures in Saudi Arabia. PLoS One 2019;14:e0217182.
11.	Papsin B, McTavish A. Saline nasal irrigation: Its role as an adjunct treatment. Can Fam Physician 2003;49:168-73.
12.	Nuseir AF, Alsalem M, Alzahr M, Ababneh M, Alomari AI, Alzoubi F. The effect of topical 5-flurouracil application post endoscopic inferior turbinoplasty. Am J Otolaryngol 2017;38:135-8.