\r\n\tIn this book, the authors will present the highlights of basic research of biomechanical and biochemical pathways of bone homeostasis and the developing clinical methods for treatment of bone loss, either following trauma or systemic disease.
",isbn:null,printIsbn:"979-953-307-X-X",pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"a67783226e0c4e1343d82c3a811ba1b3",bookSignature:"Dr. Nahum Rosenberg",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8442.jpg",keywords:"Bone Homeostasis, Osteoblast, Bone Matrix, Inorganic Component, Organic Componet, Bone Resorption, Cellular Mechanotransduction, Hormonal Regulation, Autografts, Allografts, Distraction Osteogenesis",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 11th 2019",dateEndSecondStepPublish:"September 20th 2019",dateEndThirdStepPublish:"November 19th 2019",dateEndFourthStepPublish:"February 7th 2020",dateEndFifthStepPublish:"April 7th 2020",remainingDaysToSecondStep:"a year",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"68911",title:"Dr.",name:"Nahum",middleName:null,surname:"Rosenberg",slug:"nahum-rosenberg",fullName:"Nahum Rosenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/68911/images/system/68911.png",biography:"Nahum Rosenberg MD, MOrthop (magna cum laude), FRCS\n(England), MBA is an orthopedic surgeon with an MD degree\nfrom Technion – ITT in 1990. He completed his residency in Orthopedic Surgery at the Rambam Medical Center, Haifa between\n1990-97. He received his MOrthop with honors from the Tel Aviv\nUniversity in 1996 and was a Nuffield Fellow (Orthopedic Surgery) in Oxford University in 1998-9. Dr. Nahum was a Fellow\nin Orthopedic Surgery at the University of Nottingham in 2002. He completed his\nMBA from the College of Management Academic Studies, Israel in 2018. Dr. Nahum\nis a senior orthopedic surgeon at the Rambam Health Care Campus since 2003. He\nhas been an Assistant Clinical Professor in the Faculty of Medicine, Technion -ITT,\nHaifa since 2007. He is also a Professor in the Department of Traumatology, Orthopedic Surgery and Disaster Medicine in IM Sechenov First Moscow State Medical\nUniversity 2018-19. Dr. Nahum is a member of the editorial boards in 8 scientific\njournals, as well as a member of the Shoulder Committee of ISAKOS (International Society of Arthroscopy, Knee Surgery and Orthopedic Sports Medicine). He is\nthe author of 80 peer review scientific publications, and the editor of 7 books. His\nresearch interests include: shoulder surgery, the outcome of orthopedic procedures,\nbone biology, bone regeneration, human biomechanics.",institutionString:"Israel Institute of Technology",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Tel Aviv Sourasky Medical Center",institutionURL:null,country:{name:"Israel"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"194667",firstName:"Marijana",lastName:"Francetic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/194667/images/4752_n.jpg",email:"marijana@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"8676",title:"Hip Surgeries",subtitle:null,isOpenForSubmission:!1,hash:"35280afd3082f1a6b3c10bdc0ae447f6",slug:"hip-surgeries",bookSignature:"Nahum Rosenberg",coverURL:"https://cdn.intechopen.com/books/images_new/8676.jpg",editedByType:"Edited by",editors:[{id:"68911",title:"Dr.",name:"Nahum",surname:"Rosenberg",slug:"nahum-rosenberg",fullName:"Nahum Rosenberg"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"65767",title:"Turbinate Surgery in Chronic Rhinosinusitis: Techniques and Ultrastructural Outcomes",doi:"10.5772/intechopen.84506",slug:"turbinate-surgery-in-chronic-rhinosinusitis-techniques-and-ultrastructural-outcomes",body:'\nChronic nasal obstruction is a very frequent condition in rhinological practice that severely interferes with the quality of life [1]. The most common cause of this complaint is chronic hypertrophic rhinitis. It consists of a chronical swelling of the inferior turbinate [2].
\nTurbinate hypertrophy, commonly associated with perennial allergic and nonallergic rhinitis [1], is not a simple enlargement of mucosal and submucosal tissues, but it is characterized by deep histological modifications such as severe damage of the epithelial barrier, disappearance of ciliated and goblet cells, inflammatory infiltration of the lamina propria, fibrosis, prominent venous congestion, and basement membrane interruption [2].
\nPatients generally complain about sneezing, rhinorrhea, postnasal drip, frontal headache, blocked nasal passages, sleep disturbance, and snoring [3].
\nWhen medical treatment with topical corticosteroids, antihistamines, and decongestants fails, surgical reduction of inferior turbinates could be attempted.
\nThe goal of turbinate surgery is to improve nasal patency by minimizing complications such us postoperative hemorrhage, crusting, foul odor, and the “empty nose syndrome” [4].
\nThere is a variety of turbinate procedures, but there is a lack of consensus about which technique is the best [5].
\nTurbinate hypertrophy can be divided into primary and secondary. The primary hypertrophy is related to the submucosal component, while the secondary hypertrophy is due to contralateral septal deviation and is related to the bony component of the turbinate. It is important to distinguish these two types of hypertrophy in order to decide the proper procedure to perform. The anatomic radiologic study (Figure 1) and the rhinomanometric evaluation (Figure 2) are mandatory for surgical indication [6].
\nThe radiologic study with head-CT shows a normal anatomy of the turbinates and the nasosinusal system.
Rhinomanometric evaluation before (A) and after (B) application of nasal topical decongestant shows the improvement of respiratory nasal flux.
Turbinate reduction techniques can be divided into four categories [7]:
Extramucosal debulking procedures
Superficial extramucosal procedures
Dislocation procedures
Submucosal procedures
These procedures include:
Total turbinectomy
Partial turbinectomy
Microdebrider-assisted turbinoplasty (extramucosal technique)
It is a technique that was described for the first time in the last 10 years of the nineteenth century. Jones in 1895 and Holmes in 1900 introduced the concept of total turbinectomy [8].
\nThis technique is considered the most radical surgical technique on the inferior turbinate. After having fractured, the bone plate of the inferior turbinate (Figure 3), levering from the inferior meatus, with an angled scissors, the inferior turbinate is dissected for its entire length remaining adherent to the lateral wall of the nasal cavity.
\nTotal turbinectomy.
For the immediate benefit that the patient obtains, it is often considered as safe and effective though its major complication is the possible bleeding, avoidable, however, both using adequate nasal swabs and avoiding to treat patients who take anticoagulants [9].
\nUnfortunately, this type of surgery, extremely aggressive, can later lead to dry nose syndrome or even the syndrome of the empty nose with a paradoxical obstruction. The obstructive event is due to the loss of normal nasal resistance and the formation of a laminar air column. This situation causes a poor contact between the air and the nasal walls, the mucosa, due to the absence of the sensory fibers of the inferior turbinate, shows a reduction or even a loss of the respiratory flow [6].
\nThe altered aerodynamics pattern, due to total turbinectomy, generates many complications such as copious postoperative bleeding, quantitative reduction of the ciliary movement, mucosal dryness, and deficit of mucus clearance. All this creates stagnation of secretions, crusts formations (sometimes foul-smelling), and frequent infections with gradual development of dry inflammatory forms affecting the pharynx and larynx. Precisely because of its complications, this technique has now fallen into disuse [9].
\nTASCA states that it is wrong to transform the nasal cavities into rigid and inanimate tubes, unable to perform the functions of congestion and decongestion, depriving them of their natural function [10]; and for Huizing and de Groot, total turbinectomy is a nasal crime, and they do not consider it useful to perform the resection of more than a third or half of the inferior turbinate unless it is a tumor [11].
\nThe partial turbinectomy (Figure 4) is used to limit the large surgical resections that are performed with total turbinectomy, and consists in the removal of the mucosa and bones of the anterior third of the inferior turbinate. The degree of resection is directly proportional to the degree of hypertrophy. Initially, the mucosal and the submucosal tissue are removed, and if there is bone hypertrophy, a small bone resection is also performed. There are several partial turbinectomy techniques.
\nPartial turbinectomy.
The oldest technique is the crushing and trimming introduced by Kressner in 1930. Other technique is selective mucosotomy, which consists of the removal of the anterior or/and the posterior region of the turbinate following defined section lines. The diagonal resection consists in a sagittal exeresis with the purpose of preserving the head of the turbinate and eluting the posterior region of the turbinate. The horizontal resection of the inferior edge of the turbinate avoids the risk of bleeding from the sphenopalatine artery [12], which instead occurs in the diagonal resection [7].
\nThe degloving technique was proposed by Chevretton et al. It consists of the resection of a large part of the turbinate, leaving the bone and the periosteum intact [7, 13].
\nTASCA et al. reported that the only appropriate techniques are “Crushing with remodeling” and “Resection of the tail.” It is preferable to perform a resection of the posterior region of the inferior turbinate, because the elimination of the head of turbinate causes a great functional damage. It creates a deficit of the mucociliary clearance and the inferior turbinate loses its function of directing the inspiring currents [10].
\nCrushing with remodeling is indicated if the hypertrophy is both anterior and posterior and allows to respect the functional capacity of the remaining portion of the turbinate. The turbinate is compressed using specific pliers and then reduced by cutting parallel or slightly diagonal strips starting from the lower edge. After the medial fracture of the turbinate performed with a smooth and chamfered instrument (the handle of a Cottle chisel can be used), it is squeezed with modified-Kressner tongs both anteriorly and posteriorly. The size of the turbinate is reduced by removing a strip from its rather flaccid bottom edge with Heymann-type scissors. If necessary, a part of bone is removed. Finally, the turbinate remaining laterally is repositioned. It is advised to perform a second surgical time if the hypertrophic tissue is excessive, avoiding to remove it in a single time [14].
\nResection of degenerated tissue: if a part of the turbinate is damaged irreversibly, it is removed using long angled scissors or a loop [14].
\nEven if partial inferior turbinectomy is a simple and effective surgical procedure, it is equally troublesome if not performed correctly. Excessive resection of the inferior turbinate can lead to peri- or postoperative bleeding, from medial and inferior surface of the inferior turbinate, synechiae with the nasal septum and floor of nasal cavity, frequent post nasal blood drip, nasal crusting, and atrophic rhinitis. By using appropriate tools and limiting demolition, these complications can be avoided [15].
\nA study by Passali et al. demonstrated how the partial turbinectomy technique performed at the level of the inferior turbinate resolves most of the nasal obstruction. This technique however, even if minimally, causes damage to the nasal mucosa and therefore it is necessary that the surgeon is experienced to avoid complications [1, 16].
\nSapci et al. reported that the use of radiofrequency to reduce hypertrophy of turbinates leads to an improvement of nasal obstruction and does not alter the ciliary mucus clearance. With the partial turbinectomy technique, the results obtained were similar to those of results with the radiofrequency tissue ablation technique [1, 17].
\nSalzano et al. enrolled four groups of patients each treated with radiofrequency, high-frequency electrocautery treatments, and lower partial turbinotomy to reduce the hypertrophied lower turbinates. They show that the partial inferior nasal turbinectomy is the best method of treatment, because it does not cause damage to the nasal mucosa or underlying sensibility nerves [18].
\nIn the 1996, the microdebrider was first used by Davis and Nishioka to remove both medial and inferior redundant mucosal tissue and hypertrophied cavernous sinusoid of the inferior turbinate and the anterior head region of the inferior turbinate, up the superficial layer to the periosteum [19].
\nGenerally, if the microdebrider-assisted turbinoplasty is limited to the decongestion of the turbinates only, the patient undergoes local anesthesia with vasoconstrictive drugs to create a large ischemia avoiding intraoperative bleeding. General anesthesia is necessary in the event that a septal or paranasal sinus surgery is also associated. In our experience, the local anesthesia is performed using soaked gauzes with Xylocain hydrochloride 5% and naphazoline 0.02% set on the nasal floor and on the medial wall of the inferior turbinate. We have left the infiltration of the turbinate and given the possible neurovegetative complications described by Ravikumar et al. [20].
\nThis procedure is performed under the endoscopic guidance using an 0° endoscope 4-mm diameter. The microdebrider is a device that consist of a handpiece on which is positioned a rotating blade protected by a blunt end that sucks and removes the hypertrophic tissue. The surgeon moves the blade of the microdebrider, with 2300–3000 rev/s speed of oscillation, along the inferior turbinate from posterior to anterior region and with continuous suction. It is suggested to proceed in posteroanterior direction to obtain a clean field, free of blood. The timing of surgery necessary to accomplish the procedure is about 1–2 min long for each nasal cavity [3, 20]. At the end of the surgery, nasal packing of variable length between 8 and 10 cm are placed.
\nNasal packing are used to prevent postoperative bleeding and to fill the dead space inside the nasal cavity [21], where it remains only for 48 h and does not change the functional recovery of the mucosa [3]. The patient is advised to instill nasal drops containing vitamin A and Vaseline oil for about a month after surgery [3].
\nMicrodebrider technique is mainly discussed because of its supposed interference on mucociliary clearance.
\nAccording to Lee and Lee [21], the microdebrider causes minimal mucosal damage that does not significantly modify the ciliary mucus transport time. In fact, the entire respiratory epithelium of the nasal cavities, and not only the mucosa of the inferior turbinate, is responsible for this physiological mechanism.
\nAccording to a study conducted by our University Clinic in the 2012, the microdebrider does not damage the respiratory epithelium, but rather stimulated its regeneration. Studies conducted on animal models have shown that basal cells move the bare mucosa forward after a mechanical injury. The cells undergo transient squamous metaplasia, and then they differentiate both goblet and ciliated cells. This mechanism has also been demonstrated in human nasal cavities. The debridement of the mucosa leads to an improvement in nasal obstruction, rhinorrhea, hyposmia, headaches, snoring, and postnasal drip. It is never associated with consequences such as dryness, crusts, or nasal irritation or with alteration of mucosal function [3].
\nAccording to a study conducted by Van et al. [22], the use of the microdebrider technique allowed a success of 93% and only 17 patients presented temporary complications such as bleeding, crusting, and synechia [21]. Lee and Lee have demonstrated, through a 2006 study, that the use of the microdebrider is more effective than the group of patients who have been treated with coblation in obstructive symptomatology and in reducing the volume of the mucosa of the head of the inferior turbinate 12 months after the intervention [21]. It has been defined as the best technique for the treatment of inferior turbinates hypertrophy [3].
\nSuperficial extramucosal procedures include
Laser-assisted ablation
Electrocautery
Chemosurgery
Cryoturbinectomy
Argon plasma coagulation
Infrared coagulation
Argon laser has been the first application of laser surgery for inferior turbinate, and has been performed by Lenz et al. in 1977 [23], even if was popularized only in the 1990s [24].
\nLaser surgery has been described with many different procedures such as interstitial, contact, or noncontact. This technique has been performed in topical anesthesia, with slow risk of bleeding, with high compliance of patient.
\nMany types of lasers have been used for turbinate reduction. They differ in wavelength: CO2 (λ: 10,600 nm), diode (λ: 940 nm), Ho:YAG laser (λ: 2080 nm), Nd:YAG laser (λ: 1064 nm), argon-ion (λ: 488–514 nm), and potassium-titanyl-phosphate (KTP) with a wavelength similar to Argon laser [25].
\nThe CO2 laser, Nd:YAG laser, and diode laser has been the light source most used [10] in surgery. Pulsed light mode has been safer than continuous light mode with lesser local damage.
\nThe application of light can be straight as longitudinal strip (laser-strip carbonization) with cross-light beams (cross hatched) and in “single-spots” at a range of 1–2 mm. The most used is the laser strip carbonization. Many studies showed that the best use of this kind of laser for the turbinate is “single-spots,” because to be able to preserve healthy portions of mucous for the rapid epithelization [26].
\nThe CO2 laser has a high cutting precision and superficial vaporization, but is not more maneuverable; above all, for the posterior section of the inferior turbinate, indeed it does not have a flexible optical fiber. CO2 laser has worse capacity of coagulation, higher price, and worse handling than Ho:YAG, argon-ion, Nd:YAG, and KTP lasers.
\nDiode laser has been used for the turbinate surgery because it has a good capacity of coagulation of soft tissue with minimal risk to damage the periosteum [27].
\nYAG laser has a good capacity of penetration of deep tissue respecting the superficial epithelium with a good intraoperative hemostasis but in literature has been reported the presence of post operatory edema with an initial respiratory obstruction, for this reason its use has greatly reduced over time [28].
\nPotassium titanyl phosphate (KTP) laser is an efficient method to treat a tissue with a high vascularity, as the inferior turbinate had a wavelength that is selectively absorbed by endogenous chromophore as melanin and hemoglobin [29]. In this way, it has a selective action toward submucosal tissue, sparing surface mucosa. Tissue sample treated with KTP surgery is evaluated macroscopically and histologically: necrotizing sialometaplasia, cartilage destruction, and dilated glands with excess mucus occurred, whereas cilia were present [30].
\nMany authors agree that laser surgery produces permanent histologic changes in turbinate soft tissue [31]: reduction of gland serum mucous and damage of the superficial epithelium with reduction of mucociliary transport [32]. All these change have implications for the postoperative period with presence of scabs and dry mucous. Despite its first listed disadvantages, CO2 laser is the least damaging of all lasers [33].
\nThis method uses the heat to clot the soft tissue, causing necrosis and fibrosis with volume reduction of the turbinate. The risk of intra- and postoperative bleeding is uncommon, but the presence of scab and scarring is frequent. Due to the high temperature achieved, this technique is destructive on the mucous and can reduce the efficiency of mucociliary transport [34]. The electrocautery exist in two modalities: monopolar and bipolar. The use of bipolar mode is safer and more effective for significant nasal obstruction reduction [35].
\nIn 1926, Denker and Kahler described the use of trichloroacetic acid [36] (TCA) solution to the inferior turbinate in the hypertrophic rhinitis. The effect of TCA consists in protein degeneration [37]. This action on turbinate mucosa is aggressive and damages the mucociliary function. We can study the mucociliary function with the “saccharine time” (ST) [36]: when a saccharine granule is adhered to the nasal mucosa it is dissolved within 1 min, the molecules are then transported to the nasopharynx where the patient recognizes the sweet taste, if the ST is short there is an efficient mucociliary function. In 2008, many authors showed that the “saccharine time” (ST) has been reduced in the early and late period after the TCA application. TCA treatment can induce inhibition of Th2 cell infiltration, a condition typical of allergic rhinitis [38].
\nThis method is characterized by an application on the surface of inferior turbinate of nitrous oxide for a period of 90–120 s at the −40/−80°C. The cryotherapy causes the formation intracellular of ice crystals and the demolition of cell membrane [39]. A recent paper suggests that regeneration of healthy ciliated nasal epithelium is a constant feature without evidence of scarring [40]. The efficacy on vasomotor rhinitis has been showed [39], but is not sustainable overtime [41].
\nArgon plasma coagulation (APC) originally has been used on gastrointestinal lesions under endoscopy then it has been introduced into otolaryngological field [42]. In this method, the current flow is conducted through ionized argon gas (so-called plasma)[43]. The equipment consists of a deliverer of argon gas connected to a high-frequency current generator; the argon, ionized by the monopolar current, covers the surface of the area to be coagulated, without touching it, with a penetration inside the tissue of not more than 2–3 mm [44]. The short tissue vaporization, the rapid application, and the very short propagation of postcoagulation smoke bring further advantages in the performance of small operations in restricted areas as into nasal region [45].
\nInfrared coagulation (IC) has been performed for the first time in 1975 by Nath and Kiefhaber [45]. The light reflects from a 15-V tungsten-halogen lamp from a gold surface. The reflected light has been a spectral maximum in the infrared range: 10,000 A. The tip causes a thermal necrosis on the tissue at 100°C without surface adhesion or carbonization [46]. IC of inferior turbinate seems to be easy to use and safe. It has low cost and patient acceptance. These features make it an attractive alternative to other methods currently used for turbinate reduction [46]. However, the efficacy of this method is especially on the head of inferior turbinate, because the tip is bulky and has an angle of 30° with their column and is hard to perform on the posterior portion of the turbinate [46].
\nTurbinate dislocation techniques include:
Inferior turbinate lateralization (or outfracture)
Conchopexy
The inferior turbinate lateralization is a routinely performed procedure. It is a simple technique introduced by Killian in 1904 in order to avoid turbinectomy complications [34, 47]. It is usually performed by using a Goldman or a Freer elevator or a long nosed nasal speculum. The procedure usually begins with an infracture of the inferior turbinate bone (the inferior aspect of the turbinate is pulled medially). An external force is then applied to the turbinate leading to a bone fracture and a dislocation of the turbinate to the lateral nasal wall (Figure 5) [48]. This procedure does not modify the anatomy of the surrounding structures, dislocate the uncinate process [49], and close the Hassner valve; hence, there is no blockage of lacrimal duct.
\nInferior turbinate outfracture.
However, the outfracture provides only a temporary improvement of nasal respiration, because the dislocated turbinate often resumes its original position [50]. Generally, this procedure is associated with septoplasty or rhinoplasty. It is also associated with other turbinate reduction techniques because it does not treat the hypertrophy of the turbinate. It is particularly indicated in cases of bony hypertrophy. In order to perform this procedure, it is necessary that the inferior meatus is sufficiently large to contain the dislocated turbinate [51].
\nIn 1990, O’Flynn et al. invented the “multiple submucosal outfracture” (Figure 6) in order to improve the efficacy of the outfracture procedure: a little incision is practiced at the cephalic portion of the turbinate near the turbinate bone; the mucosa and the submucosa are elevated with a periosteal elevator and the turbinal bone is fractured into six to eight portions and the bony fragments are dislocated laterally [52].
\nMultiple submucosal outfracture.
It was described for the first time by Fateen in 1967. It consisted in a dislocation of the inferior turbinate into the maxillary sinus after antrostomy or demolition of part of the lateral nasal wall [53]. Although the efficacy of this technique had no success, it is now considered obsolete.
\nSubmucosal procedures include:
Submucous resection (or turbinectomy)
Cold technique turbinoplasty
With manual instrumentation
With electronic tools
Thermal turbinoplasty
Diatermocoagulation
Laser surgery
Radiofrequency (RFAIT)
Radiofrequency coblation technique (RFCT)
Ultrasound
Quantic molecular resonance
Submucosal corticosteroids injection
Submucous resection was first described by Spielberg in 1924 [54] and then elaborated by Howard House in 1951 [32]. It consists of removing the inferior turbinal bone and the submucosal erectile tissue with preservation of the overlying mucosa [55]. A premedication with vasoconstrictors and local anesthetics is used for both the medial and lateral surfaces of the turbinal mucosa. The Freer knife is used to perform incision over the head of turbinate and is inserted to the previously exposed anterior edge of the conchal bone. The mucosa is separated from the bone by repeated small cutting strokes. The mucoperiosteum is separated from the medial and the lateral surfaces of the bone for a distance of 1.5 cm. The thick anterior portion of the turbinal bone is grasped with the Takahashi forceps, rotated and then removed. The remaining 2/3 of the bones are very thin, so there is no need to remove it. Sutures are not necessary [32]. By maintaining the mucosal flaps, the normal nasal function is preserved. There is a minimum risk for crusts formation, except for the incision site. There is a low risk for postoperative bleeding, but postoperatively nasal packing is necessary. This technique is particularly effective in cases of prominent bony hypertrophy. A mucosal shredding in inexperienced hands may occur [55]. The submucosal resection leads to fibrosis of the submucosal tissue from the deep layers of the turbinate with the reduction of the immunocompetent cells and IgE. The resection also provokes a damage of the postnasal nerve fibers resulting in the reduction of sneezing and rhinorrhea in allergic patients [56, 57].
\nTurbinoplasty was first described by Mabry in 1982 (Figure 7). According to Mabry’s technique, a No. 15 blade is used to make an incision from the inferior tip of the turbinate, down to the level of conchal bone, until the posterior edge of the turbinate. A mucosal flap is prepared and elevated from the medial surface. The inferior and lateral part of the turbinate (including bone, soft tissue and lateral mucosa) are then removed with forceps. The residual mucosal-covered soft tissue flap is then curled upon itself to form a “neoturbinate” [58].
\nCold turbinoplasty with manual instrumentation (Mabry’s technique) (A) incision from the inferior tip of the turbinate, (B) mucosal flap, (C and D) the bone and soft tissue of the inferior and lateral part of the turbinate lateral mucosa removal. (E) Residual mucosal curled upon itself to form a “neoturbinate.”
Powered microdebrider-assisted turbinoplasty is an effective technique with fewer complications of crusting and similar favorable outcomes to manual submucosal resection [55]. It is performed under endoscopic guidance. Local infiltration is given in the inferior turbinate. A vertical incision is made in the anterior tip of the inferior turbinate. The microdebrider is then introduced through the incision and by rotating continuously in a circular fashion it removes all stromal tissue [59]. Finally, anterior nasal packing is kept in nasal passages for 48 h [1]. Microdebrider offers preservation of both the mucosa and the anatomy/physiology of the turbinate. However, this technique is associated with a major risk of postoperative bleeding [55].
\nThis technique was first introduced by Beck in 1930. It is performed using an Abbey needle at 20 W of power. Under endoscopic guidance, the needle is introduced in the anterior tip of the inferior turbinate until the posterior edge. A second pass is performed along the inferior medial edge and a third pass midway between the previous passes. This technique is associated with more complications, such as postoperative bleeding, crusts formation, mucosal dryness, edema, and avascular necrosis [60, 61].
\nLaser treatment of the inferior turbinates is generally used as extra mucosal technique. Potassium-titanyl-phosphate (KTP) laser has been applied directly inside the turbinate to reduce the vascular tissue. KPT laser energy is well absorbed by hemoglobin and pigmented tissue. Thus, the engorged vessels strongly absorb the laser energy resulting in shrinkage of the vessels and submucosal tissue. The procedure is conducted as described: an 18-gauge needle is inserted into the submucosa of the inferior turbinate from its anterior edge to about 2 cm. KTP laser is delivered by inserting the fiber through lumen of the needle previously applied, the needle is removed and a retrograde photocoagulation is performed. Results seem to be good with the respect of the mucosa. Patients complain about the long period they have to wait for healing [62, 63].
\nAmong the thermal techniques, radiofrequency ablation of the inferior turbinate is one the most performed because of its simple utilization, the possibility to be performed even only under local anesthesia, and its rare complications [64, 65].
\nThis method works generating a high frequency, but low intensity energy. The instrument consists of a monopolar or bipolar generator and a handpiece (probe) that contains electrodes [66]. The electrodes do not get heated themselves [67]. They induce an ionic stirring, and collision between ions and tissue molecules gives out heat over the surrounding submucosal layer of the turbinates (2–4 mm around the active portion of the electrode), preserving overlying mucosal integrity within its mucociliary function. The temperature achieved is always controlled (60–90°C) and carbonization phenomena are excluded [68].
\nThe tip of the electrodes can be introduced in front part (or “head”) of the inferior turbinate in one time and pushed across all its length (single insertion site technique) or in three steps (head, body, tail of turbinate), ideally under endoscopic guide. Some authors usually manage just the anterior hypertrophy of the turbinate, as responsible of most nasal resistances [69].
\nThe reduction of the volume of the turbinate is visible just during the surgery, but long term results cannot be estimated during the procedure.
\nIn the first 24–48 h, nasal obstruction can get worse because of the edematous reaction [69], to improve in the following 2–3 weeks, in which the original tissue is replaced by scar tissue, which has a lower thickness. The shrinkage of turbinates enhances with the partial subsequent reabsorption of the scar tissue and the submucosal fibrosis [68] that join the mucosa to the periosteum of the inferior nasal concha. Blood flow is reduced too. Intraoperative and postoperative complications (such as hemorrhage) are rare, and usually there is no need in nasal cavity packing [68].
\nThis surgical option is repeatable and its repetition can stabilize results over time [68].
\nA different type of radiofrequency bipolar technique is the so-called coblation (term that derives from the union of the words “Cold” and “Ablation”) that consists of a bipolar wand and a standard electrosurgical unit. The thermal lesion of the submucosal tissue is caused by the ionic agitation of an electrically conductive fluid (normal saline) added in the space between the electrode and the tissue. This ionic agitation determines a molecular disintegration that is minimal because of the minimum distance between the active and passive electrodes. For the turbinate surgery, two probes are available: the “Reflex Ultra 45 wand” and the “Hummingbird wand” [70, 71].
\nThe surgeon, using the wand, under optical guidance, can create a tissue channel or more, depending on the size of the inferior turbinate to be reduced. In this technique, which can be conducted even under local anesthesia, the infiltration of the turbinate with saline solution is important. Radiofrequency energy promotes a submucosal fibrosis process, which leads to the dimensional reduction of the turbinate, in the absence of involvement of the mucosal lining and/or of the mucociliary transport system. Nasal packing is not required [70].
\nIn the short-term postoperative period, often it is usual to observe a “rebound swelling” of the turbinate, due to the tissue edema, that can last even 10 days, to resolve its self in about 6 weeks. As the common radiofrequency technique or even more frequently, additional therapeutic sessions can be necessary, because of a gradual recurrence of symptoms after some time. Patients with the lowest preoperative nasal conductance of airflow gain greatest objective benefit from turbinate coblation. This means that patient selection with objective measurements is very important [72].
\nThe mechanism of action of this technique consists of the transformation of low frequency ultrasounds (44 + 4.4 KHz) into mechanical oscillations, induced by an acoustic transducer, through a piezoelectric phenomenon. The probe, introduced into the turbinate submucosa through the creation of two parallel intraparenchymal tunnels, ultimately produces a process of ultrasonic disintegration, particularly evident at the level of the cavernous and connective tissue, with reduction of the volume of the turbinate due to the formation of abundant intramural fibrotic tissue. A histopathological analysis with an electronic microscope showed regeneration of respiratory epithelium (ciliary regeneration), after 3 months reduction of hyperplasia; decrease in the number of goblet cells and glandular elements; and restoration of a normal pseudo-layered ciliated epithelium, after 6 months [73, 74].
\nUnlike the other existing technologies, which base their operating principle on a transfer of thermal energy (heat generated by the passage of current), the molecular quantum resonance scalpel suitably modulated to produce tissue separation not by thermal vaporization, but as a consequence of the “resonance” effect at the cellular level. The energetic quanta, opportunely calibrated for the tissue to be treated, are able to break the molecular bonds inside the cell, without increasing the kinetic energy and, therefore, without increasing the temperature. The result is an extremely precise and delicate biological result, in the absence of damage necrosis. The temperature reached does not exceed 45°C. For the coagulation process, the frequencies are slightly modified, so as to make the molecules vibrate inside the cell and induce a modest rise in temperature (up to about 63°C), which in turn allows to obtain the coagulation of the tissue affected by fibrinogen protein decline. Submucosal decongestion of the turbinate is performed by means of insertion with a headpiece, activated by a QMR machine, so-called Quantum (Telea, Sandrigo-Vicenza, Italy), for a total of 20–30 s, at an intensity force of 3.5, with immediate causes a shrinkage of the mucosa. Since this is a substantially new technique, even if a special dedicated bipolar electrode exists and it is already operating regularly, there are only a few references in the current literature [6, 75].
\nThe injection of a “long acting” steroid solution is a minimally invasive method, which still guarantees a rather limited benefit over time (it is maximum after 1 week and generally lasts for no longer than a month). It is performed by a slow submucosal injection of triamcinolone acetonide at the level of the turbinate head. A possible complication, even if extremely rare, consists of a transient or permanent loss of sight, which is thought to derive from a retinal vasospasm or a retrograde embolization affecting the retinal circulation (devastating retinal thromboses can also occur) [6, 76, 77].
\nThe great interest in turbinate surgery is documented by the large number of surgical techniques proposed over the years and by the production of specific surgical devices by the healthcare industry. However, this diversity of opinions and the quantity of proposed techniques, all valid and scientifically documented, underlines the continuous research to balance the need to solve the obstruction and to maintain the function of the nasal mucosa that unfortunately, in chronic pathologies, like vasomotor rhinitis, is still severely damaged. In literature, in fact, a reduction in epithelial thickness and disappearance of ciliated and goblet cells, the absence of tight junctions, nasal mucus overproduction, inflammatory infiltration in lamina propria [73], marked disruption of the intercellular spaces, and frequent basement membrane interruption [78] can be observed. The lack of mucociliary clearance, absence of tight junctions, widening of intercellular spaces, and discontinuity of the basement membrane induce a reduction in epithelial defense functions, so that environmental factors may directly act on subepithelial structures. As a result, in the nasal respiratory mucosa, an increased responsiveness of trigeminal afferent fibers and secretory and vascular reflexes might occur representing the basis of symptoms [79].
\nThe presence of these profound alterations makes us understand that a preservation of histologically altered mucosa translates inevitably into maintaining an impaired nasal function. On the other hand, it was to demonstrate [2] that the total removal of the nasal mucosa with “cold technique,” without high temperatures, that burned and damaged the edges of the removed mucosa, results in a subsequent complete ultrastructural restoration of the healthy tissue.
\nFor this reason, any technique, among those described, the surgeon want to adopt, in any case will have to follow any simple rules: do not use high temperatures, do not remove bone tissue and remove all the hypertrophic and damaged mucosa.
\nI have to thank Dr. Fiorella Cazzato who, with skill and ability, illustrated the present work by enriching it with the original explanatory drawings of various techniques.
\nThe authors declare that there is no conflict of interest regarding the publication of this article. All authors have seen and approved the manuscript being submitted. We warrant that this chapter is the authors’ original work. We warrant that the chapter has not received prior publication and is not under consideration for publication elsewhere. This research has not been submitted for publication nor has it been published in whole or in part elsewhere. We attest to the fact that all authors listed on the title page have contributed significantly to the work, have read the manuscript, attested to the validity and legitimacy of the data and its interpretation, and agreed to its submission.
\nFor more than a decade, a group of auto manufacturers (OEMs, or Original Equipment Manufacturers) and technology companies have been working on the development of autonomous vehicles. There had, in fact, been work on the concept stretching back to the 1930s but it was only towards the end of the first decade of the 21st century that there was widespread interest in the concept. This seems to have been stimulated by the need for the tech companies, which had generated huge surpluses, to find projects in which to invest their money combined with the desperate fear of motor manufacturers that autonomy would be an essential part of the offer within a few years.
\nThroughout this period, the claims for this new technology have been ambitious. One of the earliest presentations by a senior motor industry figure was at the Shanghai Expo held in 2010. With a backdrop of a film showing a blind girl being raced through canyons of Shanghai’s tower blocks in her driverless pod and a pregnant mother being rushed to hospital in an autonomous ambulance, Kevin Wale, the then boss of General Motors set out his prediction for 2030: ‘Our vision for the future is free from petroleum, free form emissions, free from accidents, free from congestion and at the same time fun and fashionable’ [1]. The key was for cars to be autonomous. This would ensure, he said, that there would be no traffic jams, no accidents and no emissions since all the vehicles would be electric.
\nThis optimistic view set the tone for much of the subsequent coverage. The presentation of the concept of autonomy has been relentlessly positive emphasising a series of potential advantages. The aspect that is stressed most often is safety. Protagonists of the new technology point to the fact that about 1.25 million people are killed on roads annually, including around 40,000 in the US. Since more than 90 per cent of these are the result of human error, the claim is that this number could be dramatically reduced. Take out the drivers, and the errors will go with them. Autonomous cars do not get drunk or fall asleep at the wheel, so the argument goes, and therefore they are will undoubtedly be safer. The National Highway Traffic Safety Administration suggested that ‘automated vehicles’ potential to save lives and reduce injuries is rooted in one critical and tragic fact: 94 per cent of serious crashes are due to human error. Automated vehicles have the potential to remove human error from the crash equation, which will help protect drivers and passengers, as well as bicyclists and pedestrians’ [2].
\nA second key argument is convenience. Regular daily commutes of an hour or more in each direction are commonplace and that time will become available again to the drivers who can use it to answer emails, make calls or even just read a book. There is too, the potential for the technology to enable many more people to use cars, such as blind people or dementia sufferers. This idea was a key part of the presentation by Google’s then head of its autonomous car project at to a congressional committee, Chris Urmson who cited the example of ‘Justin Harford, a man who is legally blind’ who had told him ‘what this is really about is who gets to access transportation and commerce and who doesn’t’ [3]. These comments were met with great enthusiasm by campaigners for people with disabilities such as, for example, Parnell Diggs, the Director of Government Affairs for the National Federation of the Blind, who told the committee ‘we anxiously anticipate the day that all blind people will have the opportunity to driver independently, and we believe that autonomous vehicles will make this day possible’.
\nA third major advantage claimed for the technology is that people will no longer need to own their own cars. The idea is that vehicles will be shared use, ready to be called up at a moment’s notice through an app. This, in turn, will enable vast swathes of parking areas to be repurposed since once at their destination people will be able to despatch their vehicle to its next user or to distant car parks.
\nWith reduced car ownership, there will be more road space available as cars will no longer be parked on kerbs. Moreover, because autonomous cars will be driven in a controlled way, without the vagaries of human control, there will be a much more efficient use of highways as the well-known wave effect will be eliminated. Zenzic, the organisation which coordinates the UK’s research programme claimed in a press release that connected autonomous vehicles could reduce transport emissions by between 5 to 20 per cent by reducing congestion and was ‘the key to becoming climate neutral’ [4].
\nThere have been numerous attempts to quantify all the gains from the introduction of autonomous vehicles. A study [5] by KPMG, for example, suggested that British drivers would save £5bn per year in reduced insurance, car parking and running costs. A report by Rand [6] argued that the increase in lane capacity on highways might amount to 500 per cent and that autonomous cars would lead to an improvement in fuel use of between 4 to 10 per cent. Ohio University’s Future of Driving report [7] stated that harmful emissions would be reduced by 60 per cent by the introduction of autonomous vehicles. Zenzic claims that the industry will be worth £52 billion in the UK and £907 billion worldwide by 2035 [8].
\nAll this, however, is rather mundane and to make it more exciting the promoters of the technology is that they wrap up these ideas with language that represents a radical and exciting vision for the future such as in the speech by Kevin Wale of GM. There is talk of ‘life-changing’ experience, of ‘freeing up large amounts of time’, of clean air and ‘emptier roads’.
\nWhile the various manufacturers and tech companies have different conceptions of what this new driverless world may look like, the long term vision converges around a triple revolution: in the future vehicles will be driverless, electric and shared used. This is the Holy Grail for the industry as in this scenario driverless vehicles would dominated the transport landscape, taking over not just the existing privately driven car market but also making deep inroads into public transit and expanding the use of cars by enabling, as mentioned above, many people with disabilities or without a licence to ‘drive’.
\nThis is based on a variety of assumptions around very profound and radical societal changes. Yet, neither the breadth of these changes nor the huge number of obstacles that need to be overcome before this vision can become a reality are examined by those putting out this vision. Quite apart from the depiction of a transport world completely different from the one in which we live today, the very long period during which there would be a mix of driverless and conventionally-driven vehicles is given little attention.
\nIndeed, the idea that a totally driverless world is possible stretches credulity. The very example given at the Shanghai Expo of an ambulance carrying a pregnant woman is an unlikely scenario for a driverless vehicle as emergency vehicles are allowed to break the rules precisely because they must have priority. Even in a near driverless world, emergency vehicles, VIP limos, other urgent transport and various other types of vehicle are likely to remain conventionally driven.
\nThe scenario presented by the concept’s enthusiasts is, in fact, three separate revolutions bundled into one. The least innovatory and radical of these assumptions is that vehicles will increasingly be electric. That is highly likely but upscaling the production and sale of electric cars beyond the current minority market has proved difficult because of the high initial cost, the short range (or more pertinently fears about the range) and the slow rate of development of new models. Currently sales represent around 2.6 per cent of the global market [9]. This is growing but only slowly and there are concerns that the biggest constraint will be the production of sufficient batteries to support a rapid expansion in the electric and hybrid share of the market. The availability of charging points, the difficulties many flat dwellers would have in charging their vehicles overnight and the various issues around the sustainability of batteries all point to a relatively slow take-up of electric vehicles.
\nSetting these difficulties aside, the second assumption is an even bigger obstacle, The notion that drivers will happily dispense with their own cars once driverless models become widely available and rely on Uber type services to call up vehicles when they are needed has very little evidence to support it. There are indeed a minority of Millenials living in urban areas who are happy to dispense with car ownership. For people who at the moment live in a city served by good private hire and taxi services including Uber, the option of not owning a car is perfectly feasible. However, once they move to the suburbs, or have children, they tend to purchase their own vehicles. For the past century or so, people have bought their own cars, despite the high cost, for a whole host of reasons: convenience, choice of type of vehicle, accessibility, enjoyment and, for many, keeping up or bettering the Joneses. In fact, driving is still considered by many to be a pleasure. The idea that suddenly this will all be abandoned because vehicles will no longer be driven but will be autonomous has little logic and no research to back it up. Indeed, on the contrary, the providers of shared use vehicles accept that ‘car clubs are not for everyone and there are many who still aspire to car ownership, even Millenials. I don’t see a time when all vehicles will be shared.’ [10] People like the convenience of having, say, baby seats, golf clubs or tools in the car and moreover, the guarantee that the car is outside the home for immediate use. Relying on a shared use vehicle accessed through an app when they have to get to work at a particular time or take the kids to school will never be able to replace that flexibility.
\nThere is another practical objection to the model here. At the moment services such as Uber and Lyft are available principally in large urban conurbations. If the world were genuinely to become dominated by share use vehicles, they would have to serve small towns and even villages. There is simply no feasible business model in which such areas would have access to a pool of shared use vehicles at short notice. Even if the shared use model might be widely accepted in central urban areas, it is difficult to envisage it taking off in more sparsely populated suburbs let alone small towns, villages or rural areas. The provision of sufficient cars would simply not be cost effective as no supplier would take the financial risk.
\nThe recent pandemic leads to other difficulties. Who would guarantee that these cars were clean and not full of the previous occupants’ litter or, worse, germs? There are a myriad other reasons why this scenario is implausible such as the lack of any business model: the costs of maintaining a service as these vehicles would need supervision and a back-up service; the initial investment required to set up such a business given the cost of the technology; and the reluctance of the public to part with their own vehicles and effectively replace them with an app. This model is, on the face of it, a very strange basis for the massive investment programmes by the tech and auto manufacturers given the lack of evidence that people are prepared to buy into this model. So why has this shared use concept become so important for the autonomous car protagonists?
\nThe reason, in fact, points to their Achilles Heel and demonstrates that the extent to which this triple revolution is an impossible dream that more sensible advocates now see as being ‘decades away’ [11]. The supporters of autonomous cars have been forced to put forward this shared use scenario because of their fear of the criticism that the advent of driverless cars will lead to an increase in cars on the road and consequently greater congestion. They argue that since cars are in use for only around 5 per cent of their time, having autonomous cars which are shared will lead to a massive reduction in the number of vehicles on the road. There are obvious logical objections to this. Most people want their cars at peak times in the morning and evening, and very few use them at 3 am in the morning. Therefore the parc of vehicles would have to be far higher than the 5 per cent figure which this scenario implies even if all were shared use and driverless. Moreover, no clear business model has been set out for how such a massive business as providing vehicles for, literally, millions of people in a city would work. The practicalities of essentially making available hundreds of thousands of vehicles that would need to be centrally owned by a single entity (competition would add another layer of complexity) has never been set out. This is not an evolutionary process but a revolutionary one. In reality, the prompt for this scenario is the auto manufacturers’ concern about understandable concerns that mass autonomy would lead to an increase, not a reduction, in congestion. There is much logic in that argument. If autonomy makes it easier for people to access individual cars rather than public transport, then it is highly likely there will be an increase in demand. Moreover, in a world dominated by autonomous vehicles, there would be considerable mileage undertaken by completely empty cars travelling between users. Uber presently has an average passenger occupancy rate of 0.6 (in addition to the driver) which means their vehicles are been driven for nearly half the time without a passenger. This emphasis on shared use is therefore borne of the necessity to argue that the spread of autonomy will lead to a reduction in congestion when the opposite has much more logic. It is a defence to a criticism, not a presentation of a realistic scenario.
\nThe third element of this triple revolution, the widespread use of cars that are entirely capable of driving without human intervention is an even tougher obstacle to overcome. At present, the technology is at what has been called level 3. Cars can perform routine driving tasks such as on highways, even selecting routes and not requiring human input for steering but they still require constant attention from the driver. There have been countless tests and trials, and millions of miles have been driven by vehicles that have many features that allow them to be computer-controlled but despite the investment of an estimated $100bn [12], the technology is nowhere close to delivering a car that can be driven anywhere in any weather conditions with complete safety which is defined at Level 5.
\nWaymo’s ‘robo taxi’ service in Phoenix, Arizona, and Silicon Valley (for employees only) started operating in December 2018 but has been beset with problems. In fact, all the cars still have safety drivers, except for a minority which are ‘geo-fenced’ and all are monitored - and sometimes controlled – remotely. Passengers have complained of being dropped off in the wrong place, experiencing unexplained stops sometimes so sudden that they have caused whiplash and near collisions with cyclists: ‘In about 2.5 per cent of Phoenix rides and 6.5per cent of Silicon Valley rides, Waymo vehicles stood still for a long period of time before either the human driver took over or a Waymo representative monitoring the vehicle from a remote location helped the car figure out how to start moving again. One Waymo rider The Information that during three trips in one week this summer, the Waymo vehicle got stuck each time’ [13].
\nMost of the testing in the US has been carried out by cars monitored by an operator who is supposed to intervene when things are about to go wrong – something that clearly did not happen when the unfortunate woman wheeling a bike which had bags on its handlebars in Arizona was killed because the car failed to recognise her as human. It identified her initially as a plastic bag and then as a cyclist who was not on a collision course and only too late as a human being. This accident, which caused the death of Elaine Herzberg in Tempe Arizona in March 2018 was a key demonstration of the inability of even the most sophisticated computers to recognise ‘outlier’ situations. The fact that Herzberg was pushing a bicycle which had bags on its handlebars clearly was not a situation that the on board computer had been programmed to recognise. This is proving to be the biggest single obstacle to progress in the development of the autonomy aspect of these vehicles. However many millions of miles have been covered on the road, they will never be sufficient for the vehicles to learn about all eventualities and therefore the ability to reach full driverlessness must be in doubt. Indeed, despite the large amount of testing that has already taken place, most of the cars still cannot operate in heavy rain, snow or off road.
\nAll of this has helped increase scepticism about the concept. Almost half of Americans say they would not get in a self-driving taxi, according to a poll by the advocacy group Partners for Automated Vehicle Education. [14] The poll, carried out at the beginning of 2020, found that 48 per cent of the 1200 adults surveyed would ‘never get in a taxi or ride-share vehicle that was being driven autonomously’, while a further 21 per cent said they were unsure about doing so. While a fifth of respondents said that autonomous vehicles would never be safe, another fifth stated, incorrectly, that it is possible ‘to own a completely driverless vehicle today’, highlighting the confusion that still remains over how far the technology has already developed. On the other side of the coin, people want to continue driving. A post-pandemic lockdown survey in Le Monde [15] found that half of all car owners actually missed driving while they were unable to travel.
\nThe fact that so many people believe that the driverless car is already a reality is the product of the tremendous hype that has accompanies the investment. entities. In an article for the online academic magazine Transportation Research Interdisciplinary Perspectives [16], Liza Dixon argues that much of the material put out by the companies developing autonomous vehicles is misleading as it fails to distinguish between autonomy and driving aids. She defines autonowashing as making unverified or misleading claims that misrepresent the appropriate level of human supervision required by a partially or semi-autonomous product, service or technology. This is, in fact, a characteristic of much of the PR output of the industry.
\nShe cites the use of vague language and the failure to prove claims as being characteristics of autonowashing, and she highlights the media’s culpability in relation to its ‘utopian’ reporting and exaggeration of the level of autonomy. Indeed, there are numerous examples of articles whose headlines suggest they are about ‘driverless’ vehicles but that go on to reveal that there is a safety driver at the wheel.
\nDixon points out, the phenomenon is somewhat self-defeating for the industry, which depends on building trust among potential users. By exaggerating claims and failing to consider disadvantages, the industry is weakening its own case. She writes: ‘Autonowashing leads to overtrust, which leads to misuse. If a driver management system is unable to assist the user in error prevention, accident, injury or death may occur. This results in negative media coverage which can then stir public distrust in vehicle automation, threatening the return on investment’.
\nThe extraordinary level of hype is, in fact, a key part of the current business model which appear to more about attracting investment funds than actually developing a fully autonomous vehicle. Given the clear and obvious obstacles facing the industry, the reasons to justify the vast level of investment are surprisingly unclear. Yet it continues unabated. Waymo managed to raise $3bn in the market in the Spring of 2020 while survey of the top thirty companies in the field published in The Information [17] revealed that $16 billion was spent on autonomous vehicle R&D in 2019: ‘Just three companies spent half of that money – Alphabet’s Waymo, GM’s Cruise and Uber… Four other companies, including Apple, Baidu, Ford and Toyota, spent most of the rest.’ According to a Fortune magazine article of 7 January 2020, while Waymo remains the market leader after eleven years of research, the company ‘remains an expensive science project in search of a business’.
\nThe benefits of removing the driver from cars have been heavily promoted by these companies but as we have seen do not stand up to close scrutiny. Since clearly the model of the triple revolution is unlikely ever to be realised, which means that the notion of blind or infirm people being able to regain autonomous mobility is a myth, what of the other purported benefits of a move to driverless vehicles?
\nThe safety benefits are far less marked than suggested by the industry. The Insurance Institution for Highway Safety has calculated [18] that just a third of accidents would be prevented by the use of autonomous vehicles. This is because only accidents that are what the researchers call ‘sensing and perception’ errors, such as driver distraction or failure to spot a hazard, will be prevented. The technology cannot prevent the majority of accidents, which the IIHS believes are caused by ‘prediction errors’, such as misjudging the speed of other vehicles, excessive speed when road conditions are treacherous, and mistaken driver efforts to avoid a crash. One example is when a cyclist swerves into the path of an autonomous car. The vehicle may have seen the cyclist but it cannot manoeuvre quickly enough to avoid hitting them.
\nThese doubts make the motivation of those seeking to promote this technology unclear. There seems to be no short or medium term prospect of making a return on this capital. One driver of the high levels of investment is the assumption that the first to develop full autonomy will make super profits by establishing a monopoly. However even Waymo is now suggesting that the full driverless model is not achievable. An article on CNET [19] in November 2018 quoted the CEO of Waymo, John Krafcik, as expressing doubts over whether autonomous cars would ever become ubiquitous:
\n‘It’ll be decades before autonomous cars are widespread on the roads – and even then, they won’t be able to drive themselves in certain conditions. Autonomy always will have some constraints’.
\nWhile this suggests that there is a need for a model that is very different from the ones previously proposed, there is no sign at this stage of what it is.
\nChristian Wolmar, author of 20 books principally on transport matters including Driverless Cars: on a road to nowhere?, London Partnership Publishing, 2020.
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\\n\\nSve odredbe koje se odnose na ponudu, prihvat ili razmatranje plaćanja, a za koja mi pružamo asistenciju klijentu, bilo na ugovoreni ili fiksni način, a s ciljem da se ostvare potrebe i želje klijenta u svezi s našim uslugama, su podložne zakonskim odredbama Ujedinjenog Kraljevstva.
\\n\\nOsim ako nije suprotno navedeno, IntechOpen i/ili svi davatelji licence vlasnici su intelektualnog vlasništva nad svim materijalima na www.intechopen.com. Sva prava intelektualnog vlasništva su pridržana. Stranice sa www.intechopen.com možete gledati, preuzimati, dijeliti, dijeliti poveznice i printati za osobnu uporabu, a temeljem pravila sadržanih u ovim Odredbama i uvjetima.
\\n\\nMi koristimo kolačiće. Korištenjem IntechOpenove stranice slažete se s korištenjem kolačića u skladu s IntechOpenovom Politikom privatnosti. Većina modernih, interaktivnih stranica koristi kolačiće kako bi omogućila ponovno pronalaženje korisničkih detalja kod svakog posjeta. Na našoj stranici kolačići se uglavnom koriste kako bi omogućili funkcionalnost i olakšali posjetiteljima korištenje stranice.
\\n\\nIntechOpen ili njegovi suradnici niti u jednom slučaju neće biti odgovorni za štete (štete uključuju gubitak podataka ili profita, druge poslovne prekide, te sve ostale štete) koje nastanu zbog korištenja materijala na IntechOpenovoj stranici ili nemogućnosti da se iste koriste, čak i ako je IntechOpen ili njegov predstavnik o takvoj šteti obaviješten pismenim ili usmenim putem. Neke jurisdikcije ne dozvoljavaju ograničenja garancija ili ograničenja obveza za posljedične ili slučajne štete pa se u tom slučaju ova ograničenja možda ne odnose na vas.
\\n\\nMaterijali koji se pojavljuju na IntechOpenovoj stranici mogu sadržavati manje greške, tipfelere ili fotografske greške. IntechOpen može napraviti promjene na bilo kojem materijalu koji se nalazi na stranici u bilo koje vrijeme.
\\n\\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
\\n\\nZadržavamo pravo vlasništva nad cjelokupnom stranicom www.intechopen.com i nad svim materijalom na toj stranici. Koristeći se našim uslugama, slažete se da maknete sve poveznice na našu stranicu odmah nakon što to od vas zatražimo. Također, zadržavamo pravo da ove Odredbe i uvjete, i politiku o poveznicama izmjenimo u bilo koje vrijeme. Koristeći se poveznicama na naše stranice slažete se s ovim Odredbama i uvjetima.
\\n\\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\\n\\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\\n\\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\\n\\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
\\n"}]'},components:[{type:"htmlEditorComponent",content:"Pristupom na stranicu www.intechopen.com slažete se s ovim odredbama, sa svim primjenjivim zakonskim odredbama, te se slažete s poštovanjem svih lokalnih zakona. Korištenje i/ili pristup ovoj stranici temelji se na potpunom prihvaćanju ovih odredbi. Svi materijali na ovoj stranici zaštićeni su primjenjivim zakonima o autorskim pravima i žigu.
\n\nSljedeća terminologija odnosi se na Odredbe i uvjete, te na sve naše ugovore:
\n\nKlijent, stranka, vi, vaš odnosi se na vas, osobu koja pristupa ovoj stranici i prihvaća IntechOpenove Odredbe i uvjete;
\n\nKompanija, tvrtka, mi, naše odnosi se na tvrtku IntechOpen;
\n\nStranke, strane odnosi se na klijenta i na nas, ili samo na klijenta ili nas.
\n\nSve odredbe koje se odnose na ponudu, prihvat ili razmatranje plaćanja, a za koja mi pružamo asistenciju klijentu, bilo na ugovoreni ili fiksni način, a s ciljem da se ostvare potrebe i želje klijenta u svezi s našim uslugama, su podložne zakonskim odredbama Ujedinjenog Kraljevstva.
\n\nOsim ako nije suprotno navedeno, IntechOpen i/ili svi davatelji licence vlasnici su intelektualnog vlasništva nad svim materijalima na www.intechopen.com. Sva prava intelektualnog vlasništva su pridržana. Stranice sa www.intechopen.com možete gledati, preuzimati, dijeliti, dijeliti poveznice i printati za osobnu uporabu, a temeljem pravila sadržanih u ovim Odredbama i uvjetima.
\n\nMi koristimo kolačiće. Korištenjem IntechOpenove stranice slažete se s korištenjem kolačića u skladu s IntechOpenovom Politikom privatnosti. Većina modernih, interaktivnih stranica koristi kolačiće kako bi omogućila ponovno pronalaženje korisničkih detalja kod svakog posjeta. Na našoj stranici kolačići se uglavnom koriste kako bi omogućili funkcionalnost i olakšali posjetiteljima korištenje stranice.
\n\nIntechOpen ili njegovi suradnici niti u jednom slučaju neće biti odgovorni za štete (štete uključuju gubitak podataka ili profita, druge poslovne prekide, te sve ostale štete) koje nastanu zbog korištenja materijala na IntechOpenovoj stranici ili nemogućnosti da se iste koriste, čak i ako je IntechOpen ili njegov predstavnik o takvoj šteti obaviješten pismenim ili usmenim putem. Neke jurisdikcije ne dozvoljavaju ograničenja garancija ili ograničenja obveza za posljedične ili slučajne štete pa se u tom slučaju ova ograničenja možda ne odnose na vas.
\n\nMaterijali koji se pojavljuju na IntechOpenovoj stranici mogu sadržavati manje greške, tipfelere ili fotografske greške. IntechOpen može napraviti promjene na bilo kojem materijalu koji se nalazi na stranici u bilo koje vrijeme.
\n\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
\n\nZadržavamo pravo vlasništva nad cjelokupnom stranicom www.intechopen.com i nad svim materijalom na toj stranici. Koristeći se našim uslugama, slažete se da maknete sve poveznice na našu stranicu odmah nakon što to od vas zatražimo. Također, zadržavamo pravo da ove Odredbe i uvjete, i politiku o poveznicama izmjenimo u bilo koje vrijeme. Koristeći se poveznicama na naše stranice slažete se s ovim Odredbama i uvjetima.
\n\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\n\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\n\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\n\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
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