10.14639/0392-100X-N1896
This meta-analysis was conducted to evaluate the effects of microdebrider-assisted inferior turbinoplasty (MAIT) versus other techniques in treating inferior turbinate hypertrophy.&nbsp; The protocol was registered in PROSPERO (CRD 42019126157). Cochrane Register of Controlled Trials CENTRAL, which includes MEDLINE was searched from inception until September 2021. One hundred twenty-four records were retrieved from the search of the electronic database and other sources. Ten articles were selected and analyzed quantitatively. There was significant reduction of nasal obstruction in microdebrider compared to radiofrequency by visual analogue scale but not by objective evaluations. Microdebrider has similar effect in reducing nasal obstruction to submucosal resection and laser. There was a higher incidence of postoperative bleeding in microdebrider compared to radiofrequency but shorter operative time and lesser intraoperative blood loss compared to submucosal resection.&nbsp; In conclusion, the effect of MAIT is comparable to submucosal resection, laser and radiofrequency in reducing nasal obstruction. Whilst microdebrider has a shorter operative time and less intraoperative blood loss than submucosal resection, postoperative bleeding is greater than radiofrequency.
&nbsp;
text/xml
1827-675X
1896
en
Baharudin Abdullah
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
laser
Microdebrider-assisted inferior turbinoplasty versus other surgical techniques
Text.Serial.Journal
https://www.actaitalica.it/
42
Reviews
2022-11-23
2021-11-05
2022-12-13
2022-12-13
415-426
1
Baharudin Abdullah
2022/11/23
10.14639/0392-100X-N1896
415
Department of Otorhinolaryngology, Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
1827-675X
laser
en
426
Microdebrider-assisted inferior turbinoplasty versus other surgical techniques
https://www.actaitalica.it/article/download/1896/867
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:415-426; doi: 10.14639/0392-100X-N1896




Review


Microdebrider-assisted inferior turbinoplasty versus
other surgical techniques
Turbinoplastica inferiore assistita da microdebrider rispetto ad altre tecniche
chirurgiche
Nithya Kanesan1, Mohd Noor Norhayati2, Suzina Sheikh Abdul Hamid1, Baharudin Abdullah1
1
 Department of Otorhinolaryngology, Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia,
Kubang Kerian, Kelantan, Malaysia; 2 Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia,
Kubang Kerian, Kelantan, Malaysia


SUMMARY
This meta-analysis was conducted to evaluate the effects of microdebrider-assisted inferior
turbinoplasty (MAIT) versus other techniques in treating inferior turbinate hypertrophy.
The protocol was registered in PROSPERO (CRD 42019126157). Cochrane Register of
Controlled Trials CENTRAL, which includes MEDLINE, was searched from inception un-
til December 2021. One hundred twenty-four records were retrieved from the search of the
electronic database and other sources. Thirteen articles were selected and analysed quanti-
tatively. There was a significant reduction of nasal obstruction in microdebrider compared
to radiofrequency by visual analogue scale, but not by objective evaluations. Microdebrider
has similar effect in reducing nasal obstruction to submucosal resection and laser. There
was a higher incidence of postoperative bleeding with a microdebrider compared to radiof-
requency, but shorter operative time and less intraoperative blood loss compared to submu-
cosal resection. In conclusion, the effect of MAIT is comparable to submucosal resection,
laser and radiofrequency in reducing nasal obstruction. While microdebrider has a shorter
operative time and less intraoperative blood loss than submucosal resection, postoperative
bleeding is greater than with radiofrequency.
                                                                                              Received: November 5, 2021
KEY WORDS: turbinoplasty, microdebrider, radiofrequency, submucosal resection, laser
                                                                                              Accepted: July 26, 2022

RIASSUNTO                                                                                     Correspondence
La presente meta-analisi è finalizzata alla valutazione dell’efficacia della turbinopla-      Baharudin Abdullah
stica inferiore mediante microdebrider (MAIT) rispetto ad altre tecniche di trattamen-        Department of Otorhinolaryngology, Head and
to dell’ipertrofia dei turbinati inferiori. Il protocollo è stato registrato in PROSPERO      Neck Surgery, School of Medical Sciences,
(CRD 42019126157).                                                                            Universiti Sains Malaysia, 16150 Kubang Kerian,
                                                                                              Kelantan, Malaysia
La ricerca bibliografica è stata condotta nel registro “Cochrane Register of Control-
                                                                                              Tel. +60 97676416. Fax +60 97676424
led Trials CENTRAL”, che comprende MEDLINE, includendo articoli fino a dicembre
                                                                                              E-mail: baharudin@usm.my
2021, e ha prodotto 124 pubblicazioni. Tredici articoli sono stati selezionati e analizzati
da un punto di vista quantitativo. Il microdebrider si è dimostrato più efficace nel ridur-
re l’ostruzione nasale rispetto alla radiofrequenza in valutazioni soggettive mediante          How to cite this article: Kanesan N, Norhayati
scala visuale analogica, dato non confermato da test oggettivi. La turbinoplastica con          MN, Hamid SSA, et al. Microdebrider-assisted
microdebrider ha effetti simili nella riduzione dell’ostruzione nasale rispetto alla re-        inferior turbinoplasty versus other surgical tech-
sezione sottomucosa o alla tecnica laser. È stata rilevata un’incidenza maggiore del            niques. Acta Otorhinolaryngol Ital 2022;42:415-
                                                                                                426. https://doi.org/10.14639/0392-100X-N1896
sanguinamento post-operatorio col microdebrider rispetto alla radiofrequenza, ma nel
contempo una minor durata dell’intervento e minor perdite intraoperatorie rispetto alla
                                                                                              © Società Italiana di Otorinolaringoiatria
resezione sottomucosa. In conclusione, l’efficacia di MAIT nel migliorare l’ostruzione        e Chirurgia Cervico-Facciale
nasale è simile alla resezione sottomucosa, radiofrequenza o laserterapia. Mentre l’uti-
lizzo del microdebrider si correla ad una minor durata dell’intervento chirurgico rispet-                    OPEN ACCESS
to alla resezione submucosale, il rischio di sanguinamento post-operatorio è maggiore
rispetto alla radiofrequenza.                                                                 This is an open access article distributed in accordance with
                                                                                              the CC-BY-NC-ND (Creative Commons Attribution-Non-
PAROLE CHIAVE: turbinoplastica, microdebrider, resezione sottomucosa, laser                   Commercial-NoDerivatives 4.0 International) license. The
                                                                                              article can be used by giving appropriate credit and mentio-
                                                                                              ning the license, but only for non-commercial purposes and
                                                                                              only in the original version. For further information: https://
                                                                                              creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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N. Kanesan et al.




Introduction                                                    Eligibility criteria
                                                                We included all randomised controlled trials (RCTs)
Chronic and refractory nasal obstruction is one of the
                                                                comparing MAIT with other surgical techniques for in-
most challenging conditions to treat 1. Although nasal
                                                                ferior turbinoplasty. We included only articles published
obstruction is not life-threatening, it may significantly
                                                                in English. The inclusion criteria were patients of all age
impact the quality of life of patients 2. The anterior end
                                                                groups who presented with obstructive nasal symptom
of the inferior turbinate is the narrowest part of the nasal
airway where hypertrophied inferior turbinate may cause         due to inferior turbinate hypertrophy. Exclusion crite-
significant nasal obstruction 3. Turbinate hypertrophy may      ria were nasal obstruction unrelated to inferior turbinate
lead to nasal obstruction, mouth breathing, snoring and         hypertrophy and patients who underwent other nasal or
retention of secretion 4. First-line treatment of this disor-   sinus surgery. Studies must have extractable data and a
der is pharmacological. When standard pharmacological           follow-up period of at least postoperative one-month to
treatment using steroids, topical decongestants and anti-       be included.
histamines are inadequate, surgical treatment to address
the inferior turbinate hypertrophy is necessary 1. Several      Search strategy
surgical interventions are available, which include using       We searched the Cochrane Register of Controlled Trials
microdebrider, laser argon, carbon dioxide laser, radi-         CENTRAL, which includes MEDLINE from inception
ofrequency, cryocoagulation and submucosal ablation by          until December 2021. Search words used were ‘turbino-
electrocautery 3.                                               plasty’, ‘turbinate reduction’, ‘microdebrider’ in combi-
The goal of turbinate surgery is to reduce the erectile         nation with ‘AND’ and ‘OR’. We applied the Cochrane
submucosal tissue volume and the bony turbinate 5. With         Highly Sensitive Search. We checked the reference list of
volume reduction, surgery on submucosal tissue also cre-        identified RCTs and reviewed articles to find unpublished
ates scarring, which helps prevent the engorgement of the       trials or trials not identified by electronic searches. Ongo-
inferior turbinate 5. It is imperative not to cause excessive   ing trials were searched by using other databases when
damage to the turbinate mucosa, which is associated with        necessary.
a higher risk of throat dryness, nasal crusting, nasal bleed-
ing, synechia formation, osteitis, atrophic rhinitis and in-    Study selection
adequate volume reduction 6. Preservation of the mucosa         Two review authors (NK, NMN) screened the titles and
avoids disruption of normal nasal physiology, including         abstracts from the searches and obtained full-text articles
maintaining the equilibrium of temperature, humidity and        when they appeared to meet the eligibility criteria or insuf-
filtration of inhaled air. Turbinoplasty has emerged as a       ficient information to assess the eligibility. We assessed the
preferred choice to achieve volume reduction while mini-        eligibility of the trials independently and documented the
mising complications associated with such intervention.         reasons for exclusion. We resolved any disagreement be-
Microdebrider-assisted inferior turbinoplasty (MAIT) is         tween the review authors by discussion.
one of the surgical techniques to address the hypertrophic
turbinates 1. We aimed to evaluate the outcomes of MAIT         Data extraction
versus other turbinoplasty procedures in treating patients      Data were extracted using data collection forms. The re-
with inferior turbinate hypertrophy. The primary outcome
                                                                viewers independently extracted study settings, participant
of this meta-analysis was the reduction of nasal obstruc-
                                                                characteristics, methodology and duration of the follow-
tion, while the secondary outcome was complications of
                                                                up. The method of assessment of nasal obstruction together
the procedure.
                                                                with the reported complications of these procedures were
                                                                also extracted.
Materials and methods
The systematic review was conducted according to a pro-         Risk of bias assessment
tocol published in PROSPERO with identification serial          We assessed the risk of bias 7. All trials were classified as
number as CRD 42019126157. The methods and report-              low risk, unclear risk, or high risk depending on random
ing were based on the Cochrane Collaboration and the            sequence generation, allocation concealment, blinding of
preferred reporting items for systematic reviews and meta-      participants and personnel, blinding of outcome assessors,
analyses statement 7. The evaluation was done according         completeness of outcome data, the selectivity of outcome
to the Grading of Recommendations Assessment, Develop-          reporting and other bias. We resolved any disagreements
ment and Evaluation (GRADE) guidelines 8.                       by discussion.



416
                                                                                        Microdebrider versus other surgical techniques




Grading quality of evidence                                   domised trials, three articles did not report the outcomes of
We assessed the quality of evidence for primary and sec-      interes, and one article was not available in English. Thir-
ondary outcomes according to the GRADE methodology            teen articles were included in this review, all of which were
for risk of bias, inconsistency, indirectness, imprecision    analysed quantitatively.
and publication bias that was classified as very low, low,
moderate and high 8.                                          Participants
                                                              Table I shows the characteristics of the included trials.
Statistical analysis                                          Eleven of the 13 trials were single-centre trials 3,9-18 and two
We undertook a meta-analysis using Review Manager 5.3.5       were multicentre trials 19,20. All the trials were in adults ex-
software (RevMan 2014) and used the random-effects            cept for one 20, which was in children with a mean age of
model to pool data. The heterogeneity was interpreted as      11.6 years.
follows: 0 to 40% might not be important; 30 to 60% may
represent moderate heterogeneity; 50 to 90% may repre-        Intervention
sent substantial heterogeneity, and 75 to 100% would be       Nine trials 3,9,12-18 compared MAIT with radiofrequency,
considerable heterogeneity 7. We measured the treatment       and three trials 10,11,20 compared it with submucosal re-
effect for dichotomous outcomes using risk ratio (RR), and    section. Three trials 17-19 compared MAIT to diode la-
for continuous outcomes, we used mean difference (MD)         ser. MAIT was performed under local anaesthesia in 9
and standardised mean difference (SMD) with 95% confi-        trials 3,9,10,12-15,17,18 and under general anaesthesia in 3 tri-
                                                              als 16,19,20. One trial11 did not state the type of anaesthesia
dence interval (CI).
                                                              used. All procedures were done as an endoscopic tech-
                                                              nique. The procedure of MAIT was performed by insert-
Results                                                       ing a microdebrider submucosally, medial to the conchal
Study selection                                               bone from the anterior head of the inferior turbinate along
We retrieved 126 records from search of the electronic da-    its entire length until the posterior end 3,9-12,14-20. In addition
tabases and one record from other sources (Fig. 1). Follow-   to MAIT, one trial 10 out-fractured the inferior turbinate
ing removal of the duplicates, 126 records were left. Af-     and lateralised it. Another trial 13 performed MAIT by us-
ter screening, 98 records were excluded. We identified 28     ing a microdebrider to trim the redundant and hypertro-
articles as possibly meeting the review inclusion criteria.   phied mucosa of the anterior head and the inferomedial
Fifteen articles were excluded, of which 11 were non-ran-     side of the inferior turbinate.
                                                              Similarly, radiofrequency was performed by applying a
                                                              radiofrequency probe submucously at the anterior, medial
                                                              and inferior portions of the inferior turbinate in an anterior
                                                              to posterior direction 3,9,12-18. A submucosal resection was
                                                              performed by making an initial mucosal incision on the
                                                              head of the inferior turbinate 10,11,20. The submucosal tissue
                                                              was dissected using an elevator from the medial surface
                                                              and inferior edge of the concha bone along the length of
                                                              inferior turbinate and subsequently removed. A laser tur-
                                                              binoplasty technique was performed by creating an inci-
                                                              sion at the anterior aspect of the inferior turbinate 17-19.
                                                              A bare optical fibre was inserted submucosally, and laser
                                                              pulses were delivered to the turbinate via the optical fibre
                                                              along its entire length.

                                                              Outcomes
                                                              Relief of nasal obstruction was measured subjectively via
                                                              a visual analogue score (VAS) and subjective nasal ob-
                                                              struction scale (SNOS), and objectively via acoustic rhi-
                                                              nometry and mucociliary transport time. Visual analogue
                                                              score evaluated the subjective feeling of nasal obstruction
Figure 1. Flow diagram of study selection.                    based on a scale ranging from 0 (no obstruction) to 10



                                                                                                                                417
N. Kanesan et al.




Table I. Characteristics of included studies.
 First        Country        Number       Inclusion period                     Comparison         Study period   Outcome measures           Patient selection
 author,                      of pts/
 year                       trial sites*
 Akagun,             Turkey           40/ 1            Sept 2007 -            Radiofrequency        3 months      Nasal obstruction;     Allergic and non-allergic
 2016 9                                                June 2008                                                    Complication                   rhinitis
 Kizilkaya,          Turkey           30/1            August 2004 -           Radiofrequency        6 months      Nasal obstruction;        Non-allergic rhinitis
 2008 12                                             September 2005                                                 Complication
 Lee,                 South           60/1            March 2003 -            Radiofrequency       12 months      Nasal obstruction;       Non-allergic rhinitis
 2006 13              Korea                          September 2004                                                Operative time

 Liu,                Taiwan           120/1           January 2001 -          Radiofrequency         3 years       Nasal obstruction         Allergic rhinitis
 2009 14                                             December 2006
 Pelen,              Turkey           40/1            January 2009 -          Radiofrequency        2 months      Nasal obstruction;     Allergic and non-allergic
 2016 15                                               March 2010                                                   Complication                   rhinitis
 Chen,               Taiwan           120/2           January 2002 -           Submucosal           3 months      Nasal obstruction;     Allergic and non-allergic
 2007 20                                             December 2005              resection                           Complication                   rhinitis
 Kumar,               India           30/1           November 2009 -          Radiofrequency        6 months      Nasal obstruction;        Non-allergic rhinitis
 2014 3                                                 April 2011                                                  Complication;
                                                                                                                   Operative time
 Chen,               Taiwan           160/1           January 2002 -           Submucosal            3 years      Nasal obstruction;         Allergic rhinitis
 2008 10                                              December 2006             resection                           Complication
 El Henawi,           Egypt           46/1                 N/A                 Submucosal           6 months      Nasal obstruction;     Allergic and non-allergic
 2011 11                                                                        resection                           Complication;                  rhinitis
                                                                                                                   Operative time
 Kassab,              Egypt           40/2                    N/A               Diode laser         6 months      Nasal obstruction;     Allergic and non-allergic
 2012 19                                                                                                            Complication;                  rhinitis
                                                                                                                   Operative time
 Harju,              Finland          98/1           February 2014 -          Radiofrequency,       3 months      Nasal obstruction;     Allergic and non-allergic
 2018 17                                             September 2017             Diode laser                         Complication;                  rhinitis
                                                                                                                   Operative time
 Hegazy,              Saudi           70/1           December 2010 -          Radiofrequency        6 months      Nasal obstruction;         Chronic rhinitis
 2014 16             Arabia                             May 2012                                                    Complication
 Harju,              Finland          77/1           February 2014 -          Radiofrequency,      12 months      Nasal obstruction      Allergic and non-allergic
 2021 18                                             September 2017             Diode laser                                                        rhinitis
N/A: Not available; * /1 indicates 1 trial site,/2 indicates 2 trial sites.


(complete obstruction). Subjective nasal obstruction scale                                      cedures. Three trials 3,13,16,17 stated the operative time differ-
quantified the severity of nasal obstruction by a 4-scale meas-                                 ence, and 2 trials 3,12 reported the incidence of recurrent nasal
urement where 0 is no obstruction, 1 is mild obstruction, 2 is                                  obstruction between microdebrider and radiofrequency. All
moderate obstruction, 3 is severe obstruction and 4 is com-                                     trials 10,11,20 comparing microdebrider with submucosal resec-
plete obstruction. All 9 trials comparing microdebrider and                                     tion reported on complications related to the procedures. One
radiofrequency reported relief of nasal obstruction. Six tri-                                   trial 11 stated the operative time difference between microde-
als 9,13,14,16-18 measured nasal obstruction using VAS; one trial15                             brider and submucosal resection. Two trials 17,18 comparing
measured using SNOS and one trial 12 did not report it. Four                                    microdebrider with diode laser reported crusting post-opera-
trials 9,12,14,18 evaluated mucociliary transport time and 4 tri-                               tion. One trial 19 evaluated the operative time difference and
als 13,15,17,18 evaluated via acoustic rhinometry. All trials 10,11,20                          amount of blood loss, but did not report the values.
comparing microdebrider with submucosal resection used
VAS to measure the relief of nasal obstruction. Additionally,                                   Risk of bias in included studies and quality of evidence
2 trials 11,20 evaluated it by mean total nasal resistance. Three                               Four trials 9,17-19 described the randomisation method that was
trials 17-19 comparing microdebrider with laser, measured re-                                   assessed as low risk of bias. Three trials 10,12,17 did not elabo-
lief in nasal obstruction by VAS and acoustic rhinometry.                                       rate on the randomisation method, which was assessed as high
Seven of the 9 trials 3,9,12,13,16-18 comparing microdebrider with                              risk, and it was not reported in the other five trials 3,11,13-16,
radiofrequency reported the complications related to the pro-                                   which was assessed as unclear risk. Allocation concealment



418
                                                                                                                                                  Microdebrider versus other surgical techniques




was mentioned in one of the trials 19, assessed as low risk, but                                           als 9,13-18 measured reduction of nasal obstruction subjec-
was unclear in 12 trials 3,9-18,20 and assessed as unclear risk. All                                       tively using continuous data. A significant reduction of
13 trials measured the primary outcome and were included in                                                nasal obstruction was achieved with microdebrider com-
the meta-analysis. Eleven trials 3,9,11-13,15-20 measured the pri-                                         pared to radiofrequency (Fig. 2, Tab. II). Four trials 9,12,14,18
mary outcome at 2 to 12 months with no patient lost during                                                 evaluated the mucociliary transport time. There was no sig-
follow-up. Two other trials 10,14 measured outcomes for up to                                              nificant difference in mucociliary transport time between
3 years with less than 20% of patients lost to follow-up. All                                              microdebrider and radiofrequency (Supplementary Fig. 1,
the trial protocols were not provided, but all trials reported                                             Tab. II). Four trials 13,15,17,18 reported evaluation by acoustic
the outcomes specified in their respective methodology. We
                                                                                                           rhinometry. There was no significant difference between
detected no other potential sources of bias.
                                                                                                           microdebrider and radiofrequency by acoustic rhinometry
                                                                                                           (Fig. 3, Tab. II).
Comparisons and effects of interventions
                                                                                                           Microdebrider versus submucosal resection
Primary outcomes                                                                                           All trials 10,11,20 comparing microdebrider with submucosal
Microdebrider versus radiofrequency                                                                        resection reported relief of nasal obstruction using VAS.
All trials 3,9,12-18 comparing microdebrider with radiofre-                                                Two of the trials 10,20 were continuous data. There was no
quency reported the relief of nasal obstruction. Seven tri-                                                significant difference between microdebrider with submu-

Table II. Summary of findings for microdebrider versus radiofrequency.
                                        Microdebrider compared to radiofrequency for turbinate hypertrophy
                                                                         Patient or population: Turbinate hypertrophy
                                                                                  Intervention: Microdebrider
                                                                                 Comparison: Radiofrequency
 Outcomes                                                                         No. of                 Certainty of            Relative                   Anticipated absolute effects
                                                                               participants             the evidence               effect               Risk with                   Risk difference
                                                                                (studies)                 (GRADE)                (95% CI)             Radiofrequency               with Microdebrider
 Reduction of nasal obstruction by subjective                                       436                    ⨁⨁⨁◯                       -                         -         SMD 1.22 lower
 assessments (VAS and SNOS)                                                       (7 RCTs)                 Moderatea                                                     (2.12 lower to 0.33
                                                                                                                                                                                lower)
 Mucociliary transport time                                                         270                    ⨁⨁⨁◯                       -           The mean mucociliary     MD 0.42 lower
                                                                                  (4 RCTs)                 Moderateb                               transport time was 0  (1.21 lower to 0.37
                                                                                                                                                                               higher)
 Incidence of post-operative bleeding                                               296                    ⨁⨁⨁◯                  RR 4.58               14 per 1,000      50 more per 1,000
                                                                                  (3 RCTs)                 Moderateb             (1.35 to                               (5 more to 200 more)
                                                                                                                                  15.57)
 Incidence of crusting                                                              176                    ⨁⨁⨁◯                      -            The mean incidence of               MD 0.03 higher
                                                                                  (3 RCTs)                 Moderatea                                 crusting was 0                 (0.31 lower to 0.36
                                                                                                                                                                                          higher)
 Recurrent nasal obstruction                                                        120                    ⨁⨁⨁◯                  RR 0.37               117 per 1,000               74 fewer per 1,000
                                                                                  (2 RCTs)                 Moderateb             (0.09 to                                            (106 fewer to 63
                                                                                                                                  1.54)                                                    more)
 Operative time                                                                     246                    ⨁⨁◯◯                      -              The mean operative                MD 5.37 higher
                                                                                  (4 RCTs)                   Lowa,b                                     time was 0                 (3.91 lower to 14.65
                                                                                                                                                                                          higher)
 Reduction of nasal obstruction (acoustic rhinometry)                               206                    ⨁⨁◯◯                       -             The mean reduction                MD 0.37 lower
                                                                                  (4 RCTs)                   Lowa,b                                 of nasal congestion             (1.35 lower to 0.61
                                                                                                                                                   (acoustic rhinometry)                  higher)
                                                                                                                                                          was 0
* The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RR: risk ratio; SMD: standardised mean difference; RCT: Randomised controlled trial; VAS: Visual analogue score; SNOS: subjective nasal obstruction scale. a: High
heterogeneity: b: Small sample size.
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect




                                                                                                                                                                                                         419
N. Kanesan et al.




A




B




C




Figure 2. Relief of nasal obstruction based on the visual analogue scale: (A) microdebrider versus radiofrequency; (B) microdebrider versus submucosal resec-
tion; (C) microdebrider versus diode laser.



420
                                                                                                           Microdebrider versus other surgical techniques




A




B




Figure 3. The acoustic rhinometry assessment between: (A) microdebrider and radiofrequency; (B) between microdebrider and diode laser.


cosal resection (Fig. 2, Tab. III). Another trial 11 using di-                of crusting between microdebrider and submucosal resec-
chotomous data showed no significant difference between                       tion 10,11 (Fig. 5, Tab. III). Postoperative pain was identical be-
microdebrider and the submucosal resection (Tab. III).                        tween microdebrider and submucosal resection 11 (Tab. III).
Microdebrider versus diode laser                                              The incidence of recurrent nasal obstruction was equiva-
Two trials 17,18 reported that the relief of nasal obstruction                lent between microdebrider and radiofrequency 3,12 (Sup-
using VAS as continuous outcomes demonstrated no sig-                         plementary Fig. 2, Tab. II). Likewise, there was no dif-
nificant difference between groups (Fig. 2, Tab. IV). One                     ference in the operative time between microdebrider and
trial 19 reported using dichotomous data showed no signifi-                   radiofrequency 3,13,16,17 (Fig. 6, Tab. II). A shorter operative
cant difference between groups by VAS (Tab. IV). There                        time was observed in microdebrider compared to submu-
was no significant difference between microdebrider and                       cosal resection 11 in addition to less intraoperative blood
diode laser by acoustic rhinometry (Fig. 3, Tab. IV).                         loss 11 (Tab. III). No significant difference was seen in the
                                                                              incidence of crusting between microdebrider and diode la-
Secondary outcomes                                                            ser 17,18 (Fig. 5, Tab. IV).
Microdebrider had a higher incidence of postoperative
bleeding compared to radiofrequency 12,13,17 (Fig. 4, Tab. II).
                                                                              Discussion
Three trials 16-18 comparing microdebrider with radiofrequen-
cy reported no difference in the incidence of crusting (Fig. 5,               Summary of main results
Tab. II). Similarly, no different was found in the incidence                  This meta-analysis concluded that MAIT is a promising



                                                                                                                                                   421
N. Kanesan et al.




Table III. Summary of findings for microdebrider versus submucosal resection.
                                     Microdebrider compared to submucosal resection for turbinate hypertrophy
                                                                         Patient or population: Turbinate hypertrophy
                                                                                  Intervention: Microdebrider
                                                                             Comparison: Submucosal resection
 Outcomes                                                  No. of              Certainty of         Relative effect                              Anticipated absolute effects
                                                        participants          the evidence             (95% CI)                     Risk with                             Risk difference with
                                                         (studies)              (GRADE)                                           Radiofrequency                             Microdebrider
 Reduction of nasal obstruction by VAS                        280                ⨁⨁◯◯                         -                    The mean nasal                            MD 0.1 lower
                                                           (2 RCTs)                LOW a,b                                        obstruction was 0                   (0.36 lower to 0.15 higher)
 Reduction of nasal obstruction by VAS                         46                ⨁⨁◯◯                   RR 1.00                    913 per 1,000                          43 fewer per 1,000
                                                            (1 RCT)                LOW a,b           (0.84 to 1.20)                                                     (146 fewer to 183 more)
 Incidence of crusting                                        206                ⨁⨁◯◯                   RR 0.25                    146 per 1,000                          109 fewer per 1,000
                                                           (2 RCTs)                LOW a,b           (0.02 to 2.78)                                                     (143 fewer to 259 more)
 Incidence of pain                                             46                ⨁⨁◯◯                       -                 The mean pain score                            MD 0.9 lower
                                                            (1 RCT)                LOW a,b                                           was 0                            (2.17 lower to 0.37 higher)
 Operative time                                                46                ⨁⨁◯◯                         -               The mean duration of                          MD 18.29 lower
                                                            (1 RCT)                LOW a,b                                       operation was 0                     (20.33 lower to 16.25 lower)
 Intraoperative blood loss                                     46                ⨁⨁◯◯                         -              The mean intraoperative                        MD 10.7 lower
                                                            (1 RCT)                LOW a,b                                      blood loss was 0                      (15.62 lower to 5.78 lower)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RR: risk ratio; SMD: standardised mean difference; RCT: Randomised controlled trial; VAS: Visual analogue score; SNOS: subjective nasal obstruction scale. a: High
heterogeneity; b: Small sample size.
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect




Table IV. Summary of findings for microdebrider versus diode laser.
                                          Microdebrider compared to diode laser for turbinate hypertrophy
                                                                         Patient or population: Turbinate hypertrophy
                                                                                  Intervention: Microdebrider
                                                                                   Comparison: Diode Laser
 Outcomes                                                  No. of              Certainty of         Relative effect                              Anticipated absolute effects
                                                        participants          the evidence             (95% CI)                     Risk with                             Risk difference with
                                                         (studies)              (GRADE)                                           Radiofrequency                             Microdebrider
 Reduction of nasal obstruction                              148                 ⨁⨁⨁◯                         -               The mean reduction of                         MD 0.06 higher
 (acoustic rhinometry)                                     (3 RCTs)              Moderatea                                  nasal obstruction (acoustic                (0.3 lower to 0.42 higher)
                                                                                                                                rhinometry) was 0
 Reduction of nasal obstruction (VAS)                         108                ⨁⨁⨁◯                         -                          -                                 MD 0.04 lower
                                                           (2 RCTs)              Moderatea                                                                            (0.81 lower to 0.73 higher)
 Reduction of nasal obstruction (VAS)                          40                ⨁⨁◯◯                   RR 1.13                    902 per 1,000                         40 fewer per 1,000
                                                            (1 RCT)                LOW a             (0.83 to 1.55)                                                    (140 fewer to 183 more)
 Incidence of crusting                                        108                ⨁⨁⨁◯                       -                 The mean incidence of                        MD 0.28 higher
                                                           (2 RCTs)              Moderatea                                       crusting was 0                       (1.27 lower to 1.83 higher)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RR: risk ratio; SMD: standardised mean difference; RCT: Randomised controlled trial; VAS: Visual analogue score; SNOS: subjective nasal obstruction scale. a: High
heterogeneity; b: Small sample size.
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect




422
                                                                                                      Microdebrider versus other surgical techniques




Figure 4. The incidence of post-operative bleeding between microdebrider and radiofrequency.


surgical intervention for inferior turbinate hypertrophy with                 with a microdebrider, such as submucosal tunnelling and
a favourable effect. There was a significant reduction of na-                 extraturbinal resection coupled with lateralisation of the
sal obstruction with a microdebrider compared to radiofre-                    inferior turbinate.
quency by VAS and SNOS measurements. However, there                           In general, all studies had low to unclear risk of bias in
was no difference in the two techniques based on objective                    all domains except in blinding of participants and person-
evaluations using rhinometry and mucociliary transit time.                    nel. There was no evidence of selective reporting bias in all
In addition, the effect of microdebrider on the reduction of                  reported trials. Loss during follow-up was less than 20%
nasal obstruction commensurate with those of submucosal                       in all included trials, and all the trials performed intention-
resection and diode laser. In terms of complications, micro-                  to-treat analysis. Due to the low to moderate quality of
debrider has a higher incidence of postoperative bleeding                     evidence, the results should be interpreted cautiously. Fur-
compared to radiofrequency but a smaller amount of intra-                     ther randomised controlled trials with a greater number of
operative blood loss and shorter operative time compared                      participants and robust objective evaluation might provide
to submucosal resection. The microdebrider demonstrated                       a better quality of evidence. Additionally, trials with ex-
no difference in recurrent nasal obstruction, operative time,                 tended follow-up period could evaluate the long-standing
or crusting compared to radiofrequency and a similar effect                   outcomes of the technique.
to submucosal resection in the incidence of crusting and
postoperative pain.                                                           Potential biases in the review process
                                                                              We eliminated publication bias by checking the reference
Quality of evidence                                                           lists of all related trials for further references and searching
Using GRADE, the level of evidence that contributed to                        multiple databases without language restriction. We could not
this review was assessed as low to moderate quality. The                      construct a funnel plot to detect bias or heterogeneity due to
quality of evidence for the primary outcome was low to                        an insufficient number of trials contributing to each outcome.
moderate in the comparison of microdebrider versus ra-
diofrequency, low for microdebrider versus submucosal                         Agreements and disagreements with other reviews
resection and low to moderate for microdebrider versus                        A review by Acevedo et al. 21 comparing microdebrider and
diode laser. For the secondary outcomes, comparisons of                       radiofrequency showed that the two methods are equally
microdebrider with radiofrequency, submucosal resection                       effective in reducing nasal obstruction. In contrast, a more
and diode laser ranged from low to moderate quality of evi-                   recent meta-analysis by Mirza et al. 22 reported that a micro-
dence. Overall, most of the trials have a small number of                     debrider has better outcomes compared to to radiofrequency
patients and high heterogeneity, which could be attributed                    in reducing nasal obstruction, but has a higher rate of postop-
to surgeons with varying levels of expertise performing the                   erative bleeding. Although the present meta-analysis found a
surgical procedure. The high heterogeneity could also be                      microdebrider is superior to radiofrequency in reducing nasal
contributed to the different techniques being performed                       obstruction subjectively, this effect was not supported by ob-



                                                                                                                                              423
N. Kanesan et al.




A




B




C




Figure 5. The incidence of crusting between: (A) microdebrider and radiofrequency; (B) microdebrider and submucosal resection; (C) microdebrider and diode laser.


jective evaluations. Though two previous meta-analyses 21,22                        prehensive overview of the overall effects and complications
have evaluated the effects of microdebrider compared to ra-                         of MAIT in comparison with other surgical techniques.
diofrequency, to the best of our knowledge there is no meta-
analysis assessing the effects of microdebrider compared to                         Conclusions
submucosal resection and laser. Thus, the present meta-anal-                        Microdebrider-assisted inferior turbinoplasty is an effec-
ysis contributes to the existing literature by providing a com-                     tive surgical technique with an effect comparable to radiof-



424
                                                                                                        Microdebrider versus other surgical techniques




Figure 6. The operative time between microdebrider and radiofrequency.


requency, submucosal resection and laser in reducing nasal                2
                                                                               Yamasaki A, Levesque PA, Bleier BS, et al. Improvement in nasal
                                                                               obstruction and quality of life after septorhinoplasty and turbinate
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While MAIT provides greater reduction of subjective na-                        lary.27859
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                                                                               Vijay Kumar K, Kumar S, Garg S. A comparative study of radiofre-
evaluation, and has a higher incidence of postoperative                        quency assisted versus microdebrider assisted turbinoplasty in cases
                                                                               of inferior turbinate hypertrophy. Indian J Otolaryngol Head Neck
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Conflict of interest statement                                            5
                                                                               Abdullah B, Singh S. Surgical interventions for inferior turbinate hy-
The authors declare no conflict of interest.                                   pertrophy: a comprehensive review of current techniques and tech-
                                                                               nologies. Int J Environ Res Public Health 2021;18:3441. https://doi.
Funding                                                                        org/10.3390/ijerph18073441
This research did not receive any specific grant from funding
                                                                          6
                                                                               Lee CF, Chen TA. Power microdebrider-assisted modification of en-
                                                                               doscopic inferior turbinoplasty: a preliminary report. Chang Gung
agencies in the public, commercial, or not-for-profit sectors.                 Med J 2004;27:359-365.
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                                                                               Higgins JP, Thomas J, Chandler J, et al. Cochrane handbook for sys-
Author contributions                                                           tematic reviews of interventions. Version 6.0. Cochrane 2019 (http://
NK, NMN and BA made a substantial contribution to the                          handbook.cochrane.org/, Accessed February 22, 2020).
conception and design of the article, to the acquisition,
                                                                          8
                                                                               Guyatt GH, Oxman AD, Kunz R, et al. What is “quality of evidence”
                                                                               and why is it important to clinicians? BMJ 2008;336:995-998. https://
analysis and interpretation of data. SSAH critically revised                   doi.org/10.1136/bmj.39490.551019.BE
the article and gave the final approval of the version to be              9
                                                                               Akagun F, Imamoggu M, Cobanoglu HB, et al. Comparison of radi-
published.                                                                     ofrequency thermal ablation and microdebrider-assisted turbinoplasty
                                                                               in inferior turbinate hypertrophy: a prospective, randomized, and
                                                                               clinical study. Turk Arch Otorhinolaryngol 2016;54:118-123. https://
Ethical consideration                                                          doi.org/10.5152/tao.2016.1747
The systematic review and meta-analysis design of this ar-                10
                                                                               Chen YL, Tan CT, Huang HM. Long-term efficacy of microde-
ticle does not require ethical approval from our institution.                  brider-assisted inferior turbinoplasty with lateralization for hyper-
                                                                               trophic inferior turbinates in patients with perennial allergic rhini-
This article does not involve generation of new data from                      tis. Laryngoscope 2008;118:1270-1274. https://doi.org/10.1097/
human or animal and no consent is necessary.                                   MLG.0b013e31816d728e
                                                                          11
                                                                               El Henawi Del D, Ahmed MR, Madian YT. Comparison between
                                                                               power-assisted turbinoplasty and submucosal resection in the treat-
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Supplementary Figure 1. The mucociliary transport time between microdebrider and radiofrequency.




Supplementary Figure 2. The incidence of recurrent nasal obstruction between microdebrider and radiofrequency.



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