The Surgical Management of The Inferior Turbinates
Steven M. Houser
INTRODUCTION
The inferior turbinates are structures with a bony frame work enveloped in both submucosa and mucosa that play a vital role in nasal physiology. The submucosal layer contains the lamina propria, which includes key histologic elements, such as parasympathetic nerve fibers, mucous glands, goblet cells, and abundant vasculature. The vasculature includes special vessels that can become engorged by pooling blood and enlarge the entire structure. The mucosal cover of the inferior turbinates consists of ciliated pseudostratified columnar epithelium, which allows for capturing larger inhaled particles (>4 µm) that can be trapped in mucus, thereby sparing the lungs from a potential insult. The inferior turbinates provide a broad surface area to allow moisture exchange during the inhalation and exhalation of air. The turbinates also appear to play a role in the sensation of nasal airflow through the nose. Despite the importance of inferior turbinates, there are times when these structures are problematic. When the inferior turbinates become too large, either intermittently or permanently, they may obstruct the nasal airway and negatively impact quality of life.
Many methods for turbinate reduction have been described; these include thermal or chemical coagulation, lateralization, submucosal reduction, submucous bone resection, and partial or total turbinate excision. Total inferior turbinectomy was advocated in the late 19th century but was abandoned due to sequelae only to resurge again in the 1970s when previous complications were doubted. As is common in surgery, a judicious and tailored approach typically provides optimal outcomes.
HISTORY
The most common complaint from patients with enlargement of the inferior turbinates is nasal obstruction. As the nose has a “limited vocabulary” (e.g., obstruction, pain, bleeding/drainage, and poor smell), many disease entities may present with nasal obstruction. The clinician’s responsibility is to parse out the findings during evaluation to best plan a tailored treatment for each individual patient. Some of the competing or comorbid diagnoses with hypertrophy of the turbinates include allergic rhinitis, chronic rhinosinusitis with or without polyposis, deviated nasal septum, foreign body, nasal valve collapse, and tumor. Ipsilateral inferior turbinate swelling and pain have been demonstrated to occur experimentally when a balloon is inflated in the maxillary sinus, or if the maxillary sinus ostium is stimulated. Both acute and chronic maxillary sinusitis can have a similar effect on the turbinates. Other chapters in this text will expound on these areas, so I will assume going forward that the clinician has determined that the turbinates are playing a direct role in the patient’s symptom complex and surgical reduction is under consideration.
The patient may state that his or her nose is blocked intermittently or even all the time. By definition, an intermittent obstruction involves the dynamic swelling and shrinking of the turbinate. This type of obstruction may also be postural in nature. For example, rhinitis of recumbency tends to occur at night and develops from unopposed engorgement when the turbinates are on a more even plane with the heart in contrast to the day (i.e., the opposite effect from swollen feet while upright during the day).
A more fixed obstruction may involve bony enlargement or submucosal expansion, which fails to shrink back sufficiently. Rhinitis medicamentosa occurs when submucosal tissue becomes hyperplastic and may become permanently engorged from an overuse of topical decongestants.
PHYSICAL EXAMINATION
A headlight and a nasal speculum often suffice for assessment of the inferior turbinate, though an endoscope may be needed to examine the extent of obstruction, and as part of the evaluation to excludes underlying rhinosinusitis. The turbinates can be examined before and after a topical decongestant is applied to gauge the degree of submucosal thickness. The clinician may also use a Freer elevator or cerumen loop to palpate the thickness of the submucosa.
Radiograph imaging such as CT or MRI scans are not routinely ordered to assess the turbinates, but when obtained to investigate sinus issues, they complement our visual inspection of the nasal cavity. On physical examination, the patient will usually demonstrate turbinate enlargement. Radiographs will document this same finding. The use of the word “usually” may appear odd, but this refers to the fact that patients with rhinitis of recumbency may have normal-appearing turbinates during a clinic appointment, but within several hours of reclining, their turbinates appear much larger. Additional diagnostic tests that supplement the nasal examination include acoustic rhinometry and nasal manometry, although these measures do not focus precisely on the turbinates.
A note should be made at this point regarding empty nose syndrome (ENS). This rare condition results from damage to the mucosal or loss of turbinate tissue and the consequent inability to sense airflow through the nose. An ENS patient will present with nasal obstructive complaints and a history of prior nasal surgery, yet their nasal airway may look quite patent (at times impressively patent after turbinate resection). This is termed paradoxical nasal obstruction. A cotton test can be performed during the office examination: Saline-moistened cotton (approximately half of a standard cotton ball) is placed adjacent to the potentially damaged or absent inferior turbinate tissue. The patient’s subjective response is assessed immediately and again after approximately 10 minutes. The cotton must again be placed without any topical anesthesia as this medication precludes accurate diagnosis of ENS (due to a lack of nasal sensitivity). If the patient suffers from ENS, he or she will report improved breathing with the cotton in place and a diminution of suffocation. A cotton test is invalid in patients with active nasal disease or chronic rhinosinusitis (CRS).
INDICATIONS
The indication for turbinate reduction is a subjective complaint of nasal obstruction with supportive objective findings following failure of medical/conservative management. As hypertrophy of the turbinates is so often an overlapping condition with other diagnoses, treatment for comorbid conditions may negate the need for turbinate reduction. A common example is allergic rhinitis: the turbinates are engorged, but proper allergy management through a three-tier approach (i.e., I: avoidance/environmental control, II: medications, and III: immunotherapy) may obviate the need for surgical intervention on the turbinates.
