Introduction
Nasal decongestants are pharmaceuticals used for nasal congestion due to turbinate hypertrophy. They produce topical vasoconstriction through their sympathomimetic effects, thereby reducing turbinate blood flow and reducing their size.Reference Zucker, Barton and McCoul1, Reference Knipping, Holzhausen, Goetze, Riederer and Bloching2 However, because long-term use can cause some complications, short-term use is recommended. One of these complications is rhinitis medicamentosa.Reference De Corso, Mastrapasqua, Tricarico, Settimi, Di Cesare and Mele3, Reference Rao4
Rhinitis medicamentosa, a condition characterised by secondary nasal obstruction and dependence on topical decongestants, is the persistence of turbinate hypertrophy due to the rebound effect seen following prolonged and excessive use of nasal decongestants. Chronic exposure to sympathomimetic agents leads to mucosal oedema, ciliary dysfunction and structural changes in the nasal mucosa.Reference Cam, Sari, Midi and Gergin5, Reference Ferguson, Paramaesvaran and Rubinstein6 After drug overuse, a decrease in drug effect and duration of effect develops, and a vicious cycle occurs with increasing dose as nasal congestion continues.
Rhinitis medicamentosa is frequently seen in young and middle-aged adults, and is equally common in men and women.Reference Cam, Sari, Midi and Gergin5–Reference Doshi7 The most common symptoms in rhinitis medicamentosa patients are psychological addiction and nasal congestion. It has been observed that patients experience restlessness, anxiety and headache when they stop taking the drug and this has been associated with psychological addiction. In addition, symptoms such as epistaxis, sleep disturbance and sore throat may be observed as a result of nasal congestion.Reference Rao4, Reference Margulis, Jrbashyan, Fisher, Feibish, Stein and Cohen-Kerem8
The first step in rhinitis medicamentosa treatment is to stop nasal decongestant use. Intranasal steroids and nasal saline may be helpful in achieving this.Reference Cam, Sari, Midi and Gergin5, Reference Tulaci, Yayman, Arslan, Canakci, Tulaci and Turan9 However, because patients suffering from nasal congestion usually want to get rid of the symptoms permanently, conservative measures fail and nasal decongestant use continues. In this case, turbinate reduction surgical interventions are considered.Reference Margulis, Jrbashyan, Fisher, Feibish, Stein and Cohen-Kerem8, Reference Fowler, Chin and Massoud10
Two commonly used surgical techniques are holmium laser turbinate reduction and partial turbinoplasty, both of which aim to reduce turbinate size and improve airflow. In holmium laser surgery, the turbinate volume is reduced by submucosal tissue ablation. In turbinoplasty, turbinate volume is mechanically reduced while preserving mucosal integrity by excision of soft tissue or bone.Reference Jourdy11 This study aimed to compare the clinical efficacy, complication rates and post-operative long-term outcomes of these two surgical approaches in the treatment of rhinitis medicamentosa based on patient symptoms.
Materials and methods
A retrospective cohort study was conducted between 2017 and 2024, including 65 patients diagnosed with rhinitis medicamentosa who underwent surgical treatment and had at least 1 year of post-operative follow up in our clinic. Rhinitis medicamentosa diagnosis was made by the authors based on medical history and physical examination. The requirement for diagnosis was the use of nasal decongestants at least once a day for at least four weeks.
Following diagnosis, all patients were treated with a conservative medical approach. After a three-month follow up, surgical treatment was recommended for patients in whom conservative treatment was unsuccessful, and the study was conducted with these patients. All surgical procedures were performed bilaterally under general anaesthesia and with a zero-degree rigid endoscope by the authors.
The advantages and disadvantages of both surgical methods were explained to the patients, and the surgical method to be performed was determined according to the patients’ preference. Demographic information of the patients, the duration and frequency of nasal decongestant use, previous nasal surgical procedures, pre-operative computed tomography findings and post-operative symptoms were recorded. Symptom assessment was performed before surgery and at 12 months post-operative using the Sino-Nasal Outcome Test 22 (SNOT-22) questionnaire total score, the SNOT-22 obstruction subscore and a visual analogue scale (VAS).Reference Cakir Cetin, Kumus, Keskinoglu, Sutay and Ecevit12, Reference Ottaviano, Pendolino, Nardello, Maculan, Martini and Russo13 Patients under 18 years of age and those with nasal pathology causing nasal obstruction, such as nasal septum deviation, allergic rhinitis and nasal polyps other than turbinate hypertrophy, were excluded from the study. In addition, patients who could not be followed up after surgery were excluded.
The SNOT-22 is a validated, patient-reported outcome measure widely used to assess the severity of sinonasal symptoms and their impact on quality of life. It consists of 22 items covering physical, functional and emotional domains, including nasal obstruction, rhinorrhoea, facial pain, sleep disturbance and psychological discomfort. Each item is scored ranging from 0 (‘no problem’) to 5 (‘problem as bad as it can be’), yielding a total score between 0 and 110, with higher scores indicating greater symptom burden. The SNOT-22 has been extensively applied in clinical research and surgical outcome evaluation for sinonasal disorders.
VAS is a simple, reliable and widely used instrument for quantifying subjective symptoms such as pain, nasal obstruction or overall discomfort. It typically consists of a 10-cm horizontal line anchored by two descriptors at each end, representing the extremes of symptom intensity (e.g. ‘no symptom’ to ‘worst imaginable symptom’). Patients are asked to mark a point on the line that best corresponds to their perceived symptom severity. In our study, participants were asked to indicate the severity of their nasal obstruction complaint.
The study was conducted in accordance with the Declaration of Helsinki and with approval from the ethics committee. The retrospective analysis of medical records of patients was performed in accordance with the ethical standards and with the Declaration of Helsinki. The study was approved by the Ethics Committee of the KTO Karatay University (Ref. Number 2024/002). We worked in accordance with the Declaration of Helsinki and subsequent amendments. Written informed consent forms were received from all participants.
Holmium laser turbinate reduction
Patients underwent surgery under general anaesthesia with zero-degree rigid endoscopic vision. Laser safety precautions were taken. All patients underwent bilateral inferior turbinate reduction using holmium laser (Ho: YAG) pulse energy: 1 J/pulse, repetition rate 10 Hz. A small hole was opened in the aspirator connection hose and the laser fibre cable was passed through. Then, the cable was passed through the nasal aspirator and placed submucosally starting from the posterior part of the inferior turbinate and laser shots were made from a total of five points towards the front. To prevent mucosal damage, shots were not made to the mucosa and all shots were made submucosally. No nasal packing was placed on the patients after the procedure. Paracetamol, nasal irrigation and antibiotic pomade were prescribed to the patients.
Partial turbinoplasty
Under general anaesthesia, lidocaine with adrenaline injection was performed into the inferior turbinate mucosa with a zero-degree endoscope. An incision was made at the base of the turbinate from the anterior end of the inferior turbinate to the posterior end with a number 15 scalpel. The medial mucosa of the turbinate was protected with blunt dissection and the soft tissue was separated from the turbinate bone to create a medial flap. After the turbinate bone was resected together with the lateral mucosa, the medial flap was placed laterally on the resected part. Bleeding control was achieved with bipolar cautery. Surgicel (Surgicel®; Ethicon, Somerville, USA) was laid on the inferior turbinate incision line. No nasal packing was used. Antibiotics, paracetamol, nasal irrigation and antibiotic pomade were prescribed to the patients.
Results
Sixty-five patients, 32 females and 33 males, with a mean age of 32.5 years (minimum 18 years, maximum 74 years), were included in the study. Holmium laser turbinate reduction was performed in 25 patients and partial turbinoplasty in 40 patients. There was no statistically significant difference between the two groups in terms of sex and age distribution (p > 0.05). Twenty-one patients had previously undergone septoplasty or rhinoplasty (6 in the holmium laser turbinate reduction group and 15 in the partial turbinoplasty group).
Pre- and post-operative SNOT-22 and VAS scores are given in Table 1. Within-group analysis demonstrated that significant improvement was observed in all post-operative scores in both groups (p < 0.05). While no difference was observed in pre-operative scores between the groups, post-operative SNOT-22 total and obstruction scores were lower in favour of partial turbinoplasty (p < 0.05). No significant difference was found in post-operative VAS scores (p > 0.05).
Pre- and post-operative SNOT-22 and VAS scores
Table 1 Long description
The table compares symptom outcomes before and after surgery for two groups: holmium laser turbinate reduction (25 people) and partial turbinoplasty (40 people), using SNOT-22 total, SNOT-22 obstruction, and a VAS symptom score. Before surgery, groups were similar: SNOT-22 total 35.7 versus 38.7, obstruction 4.2 versus 4.3, and VAS 8.0 versus 8.3, with no statistically significant differences. After surgery, both groups improved markedly: SNOT-22 total fell to 10.3 in the holmium group and 8.4 in the partial turbinoplasty group, and obstruction fell to 1.0 versus 0.6. The post-operative differences between groups were statistically significant for SNOT-22 total and obstruction, favoring partial turbinoplasty. VAS also improved in both groups to 2.2 versus 1.7, but the between-group difference was not statistically significant. P values indicate statistical significance only and do not convey effect size or clinical importance.
SNOT-22 = Sino-Nasal Outcome Test 22; VAS = visual analogue scale.
In the first month after surgery, complications requiring hospital admission were observed in the partial turbinoplasty group in 6 patients as a result of bleeding and in 10 patients as a result of foul odour and nasal congestion caused by crusting. In the holmium laser turbinate reduction group, hospital admission was observed in two patients as a result of bleeding and in one patient as a result of foul odour and nasal congestion caused by crusting (Table 2).
Post-operative complications
Table 2 Long description
The table reports counts of specific post-operative complications in two treatment groups: holmium laser turbinate reduction with 25 patients and partial turbinoplasty with 40 patients. Minor bleeding occurred in 2 patients in each group. Major bleeding was reported only after partial turbinoplasty, affecting 4 patients, and none in the holmium laser group. Foul odour with nasal congestion was much more common after partial turbinoplasty, with 10 cases versus 1 case after holmium laser reduction. Empty-nose syndrome occurred once in the partial turbinoplasty group and not in the holmium laser group. Continued nasal decongestant use was reported in 5 holmium laser patients and 3 partial turbinoplasty patients. Atrophic rhinitis was not reported in either group. Because the group sizes differ, these counts do not directly indicate risk without considering the number of patients in each group.
Four of the six patients in the partial turbinoplasty group who presented with bleeding underwent surgery under general anaesthesia to control bleeding. These patients were found to have exposed bone particles. It was thought that the infected bone specimen could have triggered the bleeding. The other two patients in the partial turbinoplasty group and two patients in the holmium laser turbinate reduction group who presented with bleeding were treated symptomatically. Ten patients in the partial turbinoplasty group presented with a foul odour due to undissolved surgicel and crusting. Endoscopic cleaning was performed, followed by nasal irrigation, and their complaints resolved. The complaints of the patient in the holmium laser turbinate reduction group who presented with a foul odour were resolved with nasal irrigation. Atrophic rhinitis was not detected in any patient. One patient in the partial turbinoplasty group was thought to have developed empty-nose syndrome. Five patients in the holmium laser turbinate reduction group and three patients in the partial turbinoplasty group continued topical decongestant use occasionally (Table 2).
Discussion
Rhinitis medicamentosa is a condition characterised by treatment-resistant nasal obstruction that develops as a result of long-term topical decongestant use. Underlying mucosal oedema and turbinate hypertrophy are the primary mechanisms that complicate treatment.Reference Doshi7, Reference Yang, Eremeeva, Svistushkin, Lisenkova, Smolyarchuk and Nedorubov14 While first-line treatment involves discontinuing decongestant use and applying topical steroids, these approaches are insufficient in many cases, leading to surgical intervention.Reference Zucker, Barton and McCoul1, Reference Ferguson, Paramaesvaran and Rubinstein6, Reference Fowler, Chin and Massoud10
The present study provides a comparative evaluation of holmium laser turbinate reduction and partial turbinoplasty in the surgical management of rhinitis medicamentosa. The findings demonstrate that both surgical modalities offer significant improvement in sinonasal symptoms and patient-reported quality of life measures. However, partial turbinoplasty showed a greater therapeutic efficacy on the SNOT-22 obstruction subscore and total score, albeit at the expense of a higher complication rate. These results contribute meaningful insights to the ongoing discussion surrounding optimal surgical intervention for rhinitis medicamentosa, particularly in patients with substantial turbinate hypertrophy unresponsive to conservative therapy.
Holmium laser turbinate reduction resulted in significant reductions in both SNOT-22 and VAS scores, and resulted in significant post-operative symptom relief. These outcomes are consistent with the physiological effects of Ho: YAG laser ablation, which allows controlled tissue vaporisation, minimal penetration depth and effective haemostasis. The relative preservation of mucosal structures observed in our cohort aligns with the known advantages of laser-based techniques in maintaining mucociliary function.Reference Jourdy11, Reference Yang, Eremeeva, Svistushkin, Lisenkova, Smolyarchuk and Nedorubov14, Reference Doreyawar, Gadag, Manjunath, Javali, Maradi and Shetty15 Despite less extensive tissue removal, the holmium laser turbinate reduction demonstrated effective results, suggesting that targeted mucosal remodelling is sufficient to restore nasal airflow in many rhinitis medicamentosa patients.
In contrast, partial turbinoplasty provided greater improvement in several areas, including subjective obstruction, nasal resistance and other nasal symptoms, at one-year post-operative follow up. This enhanced efficacy likely reflects the more substantial volume reduction achievable with mechanical resection. By directly addressing both soft tissue and bony hypertrophy, partial turbinoplasty offers a more definitive anatomical correction in cases of advanced rhinitis medicamentosa, where mucosal oedema and structural remodelling are prominent.Reference Jourdy11, Reference Doreyawar, Gadag, Manjunath, Javali, Maradi and Shetty15 These findings support the notion that traditional surgical approaches may be particularly beneficial for individuals with severe or long-standing disease.
However, the increased success associated with partial turbinoplasty must be interpreted in light of its higher complication rate. In our study, patients undergoing partial turbinoplasty experienced greater incidences of post-operative bleeding, crusting, mucosal dryness and transient sensory disturbances. Although most complications were self-limiting and manageable with standard post-operative care, some patients underwent reoperation to control bleeding. Importantly, the integrity of the turbinate plays a crucial role in humidifying and conditioning inspired air, and excessive tissue loss has been implicated in long-term complications such as atrophic rhinitis or empty-nose syndrome.Reference Barham, Thornton, Knisely, Marcells, Harvey and Sacks16 Atrophic rhinitis was not encountered in our study, but empty-nose syndrome was noted in one patient. The increased incidence of post-operative complications in this regard underscores the need for careful patient selection when choosing a more invasive procedure.
Holmium laser turbinate reduction offers advantages in terms of preserving mucosal integrity, less intra- and post-operative bleeding, and faster recovery. These features are particularly important for out-patients and those prioritising minimally invasive procedures.Reference Janda, Sroka, Baumgartner, Grevers and Leunig17 Furthermore, holmium laser turbinate reduction may be the first choice for patients who cannot attend follow-up appointments, such as those from out-of-town or rural areas, because of the increased risk of complications. Conversely, although partial turbinoplasty is technically more challenging, it offers a robust and reliable method for effective symptom relief in anatomically complex cases. The superior symptom relief observed with partial turbinoplasty may justify its use in select patients, particularly those with significant turbinate enlargement or those who have failed less invasive procedures.Reference Doreyawar, Gadag, Manjunath, Javali, Maradi and Shetty15, Reference Barham, Thornton, Knisely, Marcells, Harvey and Sacks16
Our findings also highlight the importance of post-operative care in optimising outcomes for both procedures. Effective management of oedema, crusting and mucosal healing is critical for ensuring successful long-term results and minimising early post-operative symptoms. In particular, the higher complication rate associated with partial turbinoplasty highlights the need for structured follow up and patient compliance with saline irrigation, topical treatments and endoscopic cleaning when necessary.Reference Jourdy11, Reference Janda, Sroka, Baumgartner, Grevers and Leunig17, Reference Bhandarkar and Smith18
In a study conducted by Margulis et al.,Reference Margulis, Jrbashyan, Fisher, Feibish, Stein and Cohen-Kerem8 patients with rhinitis medicamentosa were divided into conservative and surgical treatment groups, and the treatment success of these two approaches was compared. The conservative treatment group received intranasal steroids, intranasal or oral antihistamines and nasal irrigation, while the surgical group underwent turbinoplasty. They noted that decongestant use decreased in both groups after treatment and the SNOT-22 score decreased in the surgical group, but there was no significant decrease in SNOT-22 in those receiving conservative treatment.
Caffier et al.,Reference Caffier, Frieler, Scherer, Sedlmaier and Göktas19 in their study using diode laser inferior turbinate reduction in treatment-resistant rhinitis medicamentosa, demonstrated that laser treatment is a safe, well-tolerated and long-term effective method. No significant post-operative bleeding, infection or other major complications were reported; oedema resolved completely within the first week and crusting within six weeks. Six months post-operatively, nasal airflow significantly increased by both subjective (VAS) and objective (rhinomanometry) measurements. In this study, it was observed that decongestant dependence was completely terminated in 88 per cent of patients 6 months after surgery and in 74 per cent 1 year later. The authors emphasised that diode laser inferior turbinate reduction preserves mucosal tissue, significantly improves patients’ quality of life and is an effective, safe and minimally invasive option for the treatment of rhinitis medicamentosa.
In another retrospective study investigating the effects of adding posterior nasal nerve neurolysis to radiofrequency ablation surgery in the treatment of refractory rhinitis medicamentosa, 9 patients underwent radiofrequency ablation alone and 28 patients underwent radiofrequency ablation and posterior nasal nerve neurolysis. Both methods were reported to be successful in eliminating nasal decongestant dependence and improving nasal symptom scores. The study reported a 94 per cent success rate in eliminating nasal decongestant dependence after 12 months of post-operative follow up for all patients. Furthermore, adding posterior nasal nerve neurolysis to radiofrequency ablation in resistant rhinitis medicamentosa patients has been demonstrated to have a significant benefit in improving nasal symptoms. The study reported that no major complications were encountered during a 1-year follow up of 37 patients, with only 1 patient experiencing anterior epistaxis on the post-operative 24th day, which was controlled with tamponade. The authors argued that these two procedures, which can be performed quickly under local anaesthesia, are effective, readily available, inexpensive and safe for the treatment of rhinitis medicamentosa.Reference Liao, Hwang, Shih, Teng and Huang20
In a similar study, Neiderman et al.Reference Neiderman, Caspi, Eisenberg, Halevy, Wengier and Shpigel21 reported significant improvements in quality of life scores in rhinitis medicamentosa patients who underwent radiofrequency ablation and that nasal decongestant use was discontinued in all rhinitis medicamentosa patients. In the study by Li et al.,Reference Li, Misra, Harvey and Kalish22 with an average follow-up period of 3.4 years, it was reported that in the surgical treatment of rhinitis medicamentosa resistant to conservative treatment, decongestant use was discontinued in 91.1 per cent of cases and significant improvement in nasal symptom scores was achieved. Therefore, it has been argued that surgical options are effective methods in the treatment of resistant rhinitis medicamentosa. In another study of 36 rhinitis medicamentosa patients who underwent inferior turbinate reduction, the discontinuation rate for nasal decongestant use was reported as 86.1 per cent.Reference Di Ponio, Samad, Pellizzari, Mackie, Deeb and Craig23 In our study, this rate was found to be 80 per cent in the holmium laser turbinate reduction group, 92.5 per cent in the partial turbinoplasty group and 87.7 per cent in all patients, yielding a result parallel to the literature.
Overall, the alignment between our findings and existing literature reinforces a stratified approach to rhinitis medicamentosa management. Laser-based interventions appear most suitable for patients with moderate mucosal disease, offering symptom relief with fewer complications, whereas partial turbinoplasty may be more appropriate for severe hypertrophy despite its higher morbidity. This underscores the importance of stratifying patients based on anatomical and clinical characteristics rather than adopting a uniform surgical strategy for rhinitis medicamentosa. The observed pattern of greater efficacy but higher morbidity in the partial turbinoplasty group reinforces a tailored and patient-centred approach to surgical planning.
Our study has several limitations that warrant consideration. Firstly, the retrospective design inherently limits our ability to establish causal relationships because it relies on observational data. This design choice may introduce potential biases into the findings. Secondly, patient self-selection within our cohort, particularly the tendency for patients with more significant nasal obstruction to opt for surgical intervention, could introduce a selection bias. Consequently, the generalisability of our surgical outcomes to the broader population might be affected. Thirdly, the absence of objective airflow measurements in our study restricts a comprehensive evaluation of the physiological impact of the surgical interventions. While improvements in subjective symptom scores are significant, their corroboration with objective data would enhance the robustness of our findings. Furthermore, although our sample size was adequate for preliminary analysis, it may limit the broader generalisability of the results. Longer-term follow-up studies would be valuable to assess the durability of clinical benefits and identify any late-onset complications. Future prospective research incorporating larger cohorts, multicentre participation and extended observation periods would further elucidate the optimal role of each surgical modality.
• Rhinitis medicamentosa is a challenging condition resulting from prolonged topical nasal decongestant use for which treatment often requires surgical intervention when conservative management fails
• Holmium laser turbinate reduction and endoscopic partial turbinoplasty are two surgical procedures that can be used in the surgical treatment of rhinitis medicamentosa and both result in significant post-operative improvement in Sino-Nasal Outcome Test 22 (SNOT-22) and visual analogue scale scores
• While pre-operative symptom scores were similar between groups, post-operative SNOT-22 total and obstruction scores were significantly lower in the partial turbinoplasty group compared with the holmium laser turbinate reduction group
• The partial turbinoplasty group demonstrated a higher incidence of early post-operative complications, including bleeding, crusting and foul odour, and holmium laser turbinate reduction was associated with fewer and milder complications
• Occasional post-operative decongestant use persisted in a small proportion of patients in both groups
• Surgical technique selection should be individualised based on disease severity, patient expectations and risk tolerance
Conclusion
Both holmium laser turbinate reduction and partial turbinoplasty are effective surgical options for treating rhinitis medicamentosa, each offering its own advantages and disadvantages. Partial turbinoplasty provides superior symptom relief but carries a higher risk of post-operative complications. Holmium laser turbinate reduction represents a safer and less invasive alternative. Prospective studies that include objective airway measurements and eliminate patient selection biases will be more helpful in guiding rhinitis medicamentosa surgical techniques. The choice between these techniques should be individualised, taking into account patient-specific factors and surgical goals, and carefully considering the balance between efficacy and potential morbidity.
Competing interests
None declared.
