Inferior Turbinate Outfracture Alone for Nasal Obstruction Has Not Been Studied in Randomized Trials

We selected Camacho et al's1 meta-analysis of randomized trials comparing inferior turbinoplasty techniques for nasal obstruction for review in our residency program's journal club. Level 1a evidence (systematic reviews of randomized trials)2 may transcend various teaching faculty's operative technique preferences and inform trainees on which turbinate reduction method(s) to espouse postgraduation. Only 4 trials met the authors' inclusion criteria. We were surprised to learn that inferior turbinate outfracture alone (82.8% and 82.8% improvement in visual analog score at 1 and 3 years, respectively) achieved similar outcomes as microdebrider-assisted turbinoplasty (81.7% and 80.5%, respectively) and submucosal resection (82.4% and 82.4%, respectively) techniques. Camacho et al1 base the results of inferior turbinate outfracture alone on a single trial by Chen et al3 in which 160 patients were randomized 1:1 to submucosal resection of the inferior turbinate versus microdebrider-assisted turbinoplasty with lateralization. Notably, no patients received inferior turbinate outfracture alone. All surgical procedures were performed by the same surgeon. Importantly, the group that received inferior turbinate outfracture, had submucosal tissue from the inferior turbinates removed with both 3.5-mm diameter serrated and 2.9-mm diameter inferior turbinate blades (Medtronic Xomed) prior to outfracture. Thus, Camacho et al's1 results regarding inferior turbinate outfracture alone are deeply flawed—based on data of patients who received inferior turbinate outfracture with microdebrider submucosal volumetric reduction. Interestingly, the 2 randomized studies with 3-year data included in the systematic review were authored by the same senior author, Dr Hung-Meng Huang (Department of Otorhinolaryngology, Taipei City Hospital, Taipei Medical University). Liu et al4 randomized 120 patients 1:1 to radiofrequency ablation versus microdebrider-assisted turbinoplasty without outfracture, with all procedures performed by the same surgeon. Liu et al enrolled patients between January 2001 and December 2006, while Chen et al3 enrolled patients between January 2002 and December 2006. Dr Huang was therefore simultaneously enrolling patients into 4 treatment arms in 2 separate randomized trials with similar entry criteria, suggesting that patients may not have been fully randomized. Certainly, Dr Huang's coauthors on each study were associated with different Taipei institutions, leading to the possibility that enrollment into the 2 trials may have been site-specific. In summary, we assert that Camacho et al misrepresents the efficacy of inferior turbinate outfracture alone based on their data. Ultimately, this meta-analysis serves as a cautionary exercise for our residents to critically appraise results and referenced studies rather than an informative publication on surgical techniques to emulate. Li-Xing Man, drafted original manuscript, acquired, analyzed, and interpreted data, reviewed and edited final manuscript; Isaac L. Schmale, acquired, analyzed, and interpreted data, reviewed and edited final manuscript. Li-Xing Man has served as site principal investigator and received research funding with fees paid to the institution from AstraZeneca, GlaxoSmithKline, Optinose, and Sanofi/Regeneron, and has received software and hardware support for surgical education research from Stryker. Isaac L. Schmale has served as site principal investigator and received research funding with fees paid to the institution from Aerin Medical and Lyra Therapeutics, and has received software and hardware support for surgical education research from Stryker. None.