Dott. Lino Di Rienzo Businco
Direttore Centro di Otorinolaringoiatria, Clinica Santo Volto – Roma
Presidente SIDERO onlus – www.sidero.it

Surgery for turbinate hypertrophy is very common and represents the eighth most frequent procedure employed in the otolaryngological field [1].
Over years numerous surgery techniques for the treatment of inferior turbinate hypertrophy have been proposed, in which the principle problem was to increase the nasal airflow preserving the functions of the mucosal lining, location of important protective activity and of pharmaceutical drug absorption useful in the long term postoperative treatment of submucosal membrane inflammation (turbinectomy, submucosal membrane extraction with or without debrider, cryocoagulation, receptors determines the perception of the passage of air from the nose) [9,10].

Various world specialists have tried to identify a reconstructive surgical technique capable of improving the symptoms of ENS, with encouraging yet partial results; Rice and Di Rienzo Businco with the use of hyaluronic acid [11,12], Yong with inferolateral endonasal cartilage implants [13], and Papay with his fibromuscular temporalis graft implantation [14], but these techniques reveal problems with the reabsorption of the substance used in reconstruction over time. Those problems have been overcome by Jiang with Medpor's implants which is resolute regarding the volume loss but with scarce effectiveness on the recovery of mucosal functionality [15] and by Modrznski with submucosal mono or bipolar electrocauterization, Laser CO and diode, injections of hydroxyapatite on the turbinate and septum [16].

radiofrequencies, coblator, molecular quantum resonance) [1,2]. Before the diffusion of turbinate shrinkage mini-invasive techniques without thermic damage, many of the former techniques (in particular those using high temperatures with old generation radiofrequencies and those extremely demolitive ones with scissors with partial or complete amputations of the turbinate, though they guaranteed an apparent increase of the nasal airflow and a reduction of air resistance to rhinomanometry) were accompanied by a loss of nasal sensitiveness and by the paradoxical reduction of the perception of the air passage with the damage of the mucosal nervous receptors of intranasal anatomy and of the mucosa itself, and by the production of aerial vortices with secondary atrophic rhinitis leading to real 'Empty nose' syndromes (ENS) with crusting, bleeding and synechiae, with a strong negative impact on the quality of the patient's life [1,3,4] ENS, described for the first time by Kern and Stenkvist in 1994, is a rare and highly debilitating pathology, and fortunately not all patients subjected to demolitive surgical intervention on turbinates (inferior or middle) develop this syndrome [5,6].

However, when ENS occurs (this may happen after months or years from demolitive surgery), its symptoms strongly reduce the quality of life, and they can be summarized in: intranasal mucosal dryness, paradoxical nasal breathing obstruction (notwithstanding the large intranasal airspace), facial pains, cephalea, crusting and altered nasal discharge, with a variability of clinical manifestations which differ according to patient.

In these cases of iatrogenic damage with ENS and secondary atrophic rhinitis, the medical therapy (antihistamines, steroids, specific nasal immunotherapy, nasal wash solutions.) prove themselves invariably insufficient to resolve the symptoms of nasal obstruction and inflammations of the patient, with the quality of life considerably reduced and with few possibilities on the doctor's part to improve the local nasal clinical history casefile [8,9]. Even the usual examination tools employed for the evaluation of nasal patency (rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow) are unable to correlate with the clinical symptoms of patients as they do not investigate the physiological mechanisms of the subjective perception of the intranasal airflow (the activation of TRPM8 Also, the studies of AlloDerm (acellular dermal matrix) was proposed by Saafan as having a greater efficacy with respect to silastic implants, yet with partial results when compared with a relatively invasive surgical technique.

For some years, plasma enriched with platelets, Platelet Rich Plasma (PRP) have been extensively employed in medicine and surgery for their properties to stimulate an efficient regeneration of both soft tissue and bone tissue (better scar healing and with a reduction in postoperative infections, pain and blood loss) leading these blood components to be routinely used in various branches of surgery and medicine.

The widespread use of platelet derivatives has certainly proved favourable in their efficacy, combined with an extreme easiness of use and not least in the absence of adverse reactions. Adipose tissue has likewise been the object of great attention these years, for its regenerative potential (above all Stromal Vascular Fraction SVF, Adipose Stem Cells ASC), developed to return volume and functionality, especially in plastic surgery [20- 23]. Based on these assumptions, our aim was to verify the efficacy and safety of a new and simple endoscopic infiltrative technique for the reconstruction in patients affected with ENS, of atrophic turbinates and partially amputated, in that they had been coagulated or resected by previous nasal surgery, in addition to a topical medical treatment based on thermal water cleansing and a humidifying vitamin unguent. Such a reconstructive endoscopic surgical technique, different from other methodologies as described in previously published literature which entail intranasal cutting and more invasive implants, is based on the simple injective proceedings in locations of resected turbinates, of PRP mixed with autologous fat taken from a periumbilical extraction (PRL).

The fat was purified utilizing Coleman's technique [24,25], and the mixture of PRL thus attained was injected endoscopically into a group of ENS affected patients, comparing the functional results with a group checked with ENS undergoing sole medical therapy. Our aim was to compare the variations of clinical-instrumental parameters and symptoms from the beginning to the end of the treatments - dividing patients into two groups of study, the first (group A), with sole medical pharmaceutical therapy and the second (group B) with the same medical therapy to which was added an endoscopic treatment with PRL on inferior turbinate regions previously amputated.

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