You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > RECONSTRUCTIVE SURGERY Turbinate DysfunctionArticle Last Updated: Apr 28, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Sanford M Archer, MD, FACS, Associate Professor, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center Sanford M Archer is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Rhinologic Society, American Society for Head and Neck Surgery, Kentucky Medical Association, and North American Skull Base Society Editors: Gregory Branham, MD, Vice-Chair, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Saint Louis University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: turbinate dysfunction, rhinitis, allergic rhinitis, nonallergic rhinitis, vasomotor rhinitis, nasal congestion, rhinitis medicamentosum, turbinoplasty, turbinectomy, nasal headache INTRODUCTIONSection 2 of 12
  All individuals have turbinate dysfunction at some point. Symptoms of turbinate dysfunction range from total nasal obstruction to mild congestion and/or rhinorrhea. Causes of turbinate dysfunction include upper respiratory infection (URI), allergic rhinitis, and vasomotor rhinitis. Drugs or hormones may also induce turbinate dysfunction. This article discusses the common and less common causes of this problem and its focused management. ProblemNasal congestion is the most common symptom associated with turbinate dysfunction. Symptoms may be mild, or the congestion may be so great that the only relief is to overuse (abuse) topical decongestants such as oxymetazoline or phenylephrine. Many patients have tried over-the-counter (OTC) oral decongestants with limited success. The key to successful management is to identify the underlying cause of the turbinate hypertrophy and either correct or treat the cause. Infectious and inflammatory causes are the most common etiologies. FrequencyTurbinate dysfunction is universal. Every person experiences some degree of turbinate dysfunction at some point in his/her lifetime. Persistent dysfunction is less common and involves approximately 50% of the population. EtiologyThe etiology of turbinate dysfunction is multifactorial. Because the turbinates have a very rich blood supply and are governed by the parasympathetic nervous system, anything that affects either of these 2 systems affects the turbinates and, hence, the nose. Allergic rhinitis is the most common cause of turbinate dysfunction. Allergic rhinitis is due to environmental allergens that come in contact with the nasal membranes, causing an inflammatory reaction and resultant congestion and increased drainage. This category is so large that any nonallergic cause of turbinate dysfunction is known as vasomotor rhinitis. Vasomotor is a term that indicates the neurovascular control of the nasal membranes. Causes of vasomotor rhinitis include, but are not limited to, the use of cardiovascular and antihypertensive drugs, female hormones, changes in temperature, and rhinitis of disuse. Any medication a patient takes that stimulates the parasympathetic nervous system can also affect the turbinate mucosa and cause congestion. Female hormones, specifically progesterone, may have a similar effect; therefore, congestion can frequently be experienced during the premenstrual phase of the menstrual cycle and the third trimester of pregnancy. Some female hormone replacement therapy and oral contraceptives that have a higher concentration of progesterone may have similar effects. Condensation rhinitis is well known to snow skiers and is due to the reaction of the nasal membranes to the colder outside environment. An equivalent example is that of taking a cold beverage can outside on a hot day and finding condensation developing on the outside of the can. Rhinitis of disuse occurs in patients who no longer use their noses for airflow (eg, patients who have undergone laryngectomy) or those who abuse topical nasal decongestants (rhinitis medicamentosum). In the first case, the underlying pathophysiology is rebound inflammation due to a lack of feedback from the normal nasal airflow. In the second case, a rebound vasodilation of the turbinates occurs as a response to the topical sympathomimetics. PathophysiologySimilar to the rest of the upper respiratory tract (URT), the membranes of the turbinates are composed of ciliated, pseudostratified, glandular, columnar epithelium. The cilia beat in unison to propel the mucus from the nasal cavity towards the nasopharynx where the mucus can then be swallowed. Mucociliary transport relies on mucus production and ciliary function. Normally, the nose and paranasal sinuses produce approximately 1 quart of mucus in a 24-hour period. When inflamed, that amount can more than double. Mucus contains immunoglobulin A (IgA), immunoglobulin E (IgE), and muramidase. Both the blood supply and the autonomic nervous system control the secretions and level of congestion of the turbinates. The autonomic nervous system provides the general innervation to the nose, with the parasympathetic nerves supplying the resting tone and controlling secretions. The nerve supply originates from the facial nerve at the inferior salivatory nucleus and follows along the distribution of the facial nerve through the sphenopalatine ganglion. The blood supply to the nose comes from branches of both the internal and external carotid artery systems. The terminal branches of the internal maxillary artery supply most of the mucosal surfaces of the nasal cavity. ClinicalPatients with turbinate dysfunction report nasal congestion, postnasal drainage, and occasionally, midfacial headaches or facial pain and discomfort. Anterior rhinorrhea is less common but may be noted. These symptoms can occur irrespective of etiology. If marked swelling of the turbinates results in contact with the septum or lateral nasal wall, then nasal headaches may occur. Patients report pressure and headaches in the central forehead and medial canthal regions. Symptoms of congestion in some cases may be so bad that the patient develops an addiction to OTC nasal sprays containing either oxymetazoline or phenylephrine. This condition is known as rhinitis medicamentosum. Intermittent blockage of 1 nasal passage followed by switching of the congestion to the other nasal passage is a common report and is known as the nasal cycle. Patients may describe positional congestion, such as when lying on 1 side while sleeping. The nose is thought to shut down 1 nasal passage every 2-4 hours in order to prevent desiccation and irritation from inhaled air. The extent of this shutdown can range from complete obstruction to a slight degree of congestion that is hardly noticed. Treatment is not required unless the symptoms are exaggerated because this shutdown is part of normal nasal physiology. If a middle turbinate is paradoxically bent (curved or angled laterally) or if it contains a sinus (concha bullosa), the ostiomeatal complex may be compromised more easily and lead to acute or recurrent acute rhinosinusitis. This anatomic deformity may require surgical correction after failure of medical management. Concha bullosa occurs in approximately 30% of the population and usually is an incidental finding on imaging modalities. INDICATIONSSection 3 of 12
Indications for the management of turbinate dysfunction include a clinical history of bothersome nasal congestion and postnasal drainage with or without paranasal sinus disease or a significant septal deformity. Because the ability to breath out of one's nose is a quality of life issue, many patients take it for granted, and when the nasal airway is diminished, people often tolerate it. Many treatments are available for this disorder, and isolating the etiology is hallmark for successful therapy. Identifying whether symptoms are due to allergies or other causes is the first step. A careful history and allergy testing, if indicated, are most useful. Offending medications may be substituted or at least identified. If the patient continues to have symptomatic turbinate dysfunction, then initiate medical therapy. Surgical therapy is reserved for those patients that do not respond to appropriate medical therapy and clinically remain symptomatic. RELEVANT ANATOMYSection 4 of 12
The 3 paired turbinates are located on the lateral nasal wall. The superior and middle turbinates are part of the ethmoid bone, whereas the inferior turbinates form a separate and unique bone. Covered by both respiratory and olfactory epithelium, the superior turbinate is located high in the nasal vault and usually arises from the cribriform plate of the ethmoid bone. The middle turbinate has a wide variation in origination. This bony extension of the ethmoid can be observed arising from the cribriform plate, the lamina papyracea, or the uncinate process in some cases. See Nose Anatomy; CT Scan, Nasal Cavity; CT Scan, Sinuses. The inferior turbinate bone arises on the inferior portion of the lateral nasal walls. The bone itself is penetrated heavily by vascular channels, which supply the overlying respiratory epithelium. The lacrimal duct exits into the nose below the inferior-anterior portion of this structure. CONTRAINDICATIONSSection 5 of 12
Surgical therapy is reserved for symptomatic patients with persistent hypertrophy of the turbinates who are not responding to medical management or in whom medical management is contraindicated. See Surgical therapy. WORKUPSection 6 of 12
Imaging Studies
Other Tests
Histologic FindingsEosinophilic infiltration of the mucosal membranes leads to suspicion of allergic causes for turbinate inflammation. Infiltration by other inflammatory cells is also observed but is less diagnostic. TREATMENTSection 7 of 12
Medical therapyMedical therapy is the first-line approach to the treatment of turbinate dysfunction; however, the appropriate choice of therapy relies on the appropriate diagnosis. Several categories of medications are available that have an effect on the turbinate mucosa and affect patients' symptoms. Nasal decongestants, in both topical and oral forms, are some of the most effective drugs available for reducing congestion of the turbinate mucosa. Topical sprays, oxymetazoline and phenylephrine, are extremely powerful alpha-agonists, and prolonged use can cause a rebound effect. Rebound develops within 4-5 days and if prolonged is known as rhinitis medicamentosum. Oral decongestants are also very effective for reducing congestion and do not cause rebound swelling of the mucosa with prolonged use. Pseudoephedrine and phenylephrine are 2 common forms of oral decongestants. Main concerns regarding their use include elevation of blood pressure in hypertensive patients and urinary retention in patients with benign prostatic hypertrophy. Prolonged use of oral decongestants may lead to tolerance and ineffectiveness. Phenylpropanolamine was voluntarily withdrawn by the Food and Drug Administration (FDA) because of cases of hemorrhagic stroke occurring in women. This drug is presently unavailable for use as an oral decongestant. Antihistamines are agents that affect the turbinates by blocking the effects of histamine at H1 receptor sites. Many antihistamines are available OTC and by prescription. These medications are only indicated in patients with allergic rhinitis. Used in conjunction with oral decongestants, antihistamines can relieve congestion and drainage symptoms. Adverse effects are drug specific and range from sedation and memory effects (with the earlier generation antihistamines that cross the blood-brain barrier) to excessive dryness. Antihistamines are contraindicated in patients with glaucoma. Intranasal steroid sprays are useful for turbinate dysfunction. These medications are labeled for the management of allergic rhinitis but, like all steroids, also have nonspecific anti-inflammatory effects. The newest sprays in this class are extremely safe and have no significant suppression of the hypothalamus-pituitary axis (HPA). Intranasal steroids are administered every day and require continued daily use for any significant benefits. Proper direction of the spray nozzle to the lateral nasal wall prevents the most common adverse effects of nasal dryness, which include epistaxis and septal perforation (rare). Tolerance does not occur with prolonged use. The latest controversy concerning the use of nasal steroids in children is growth suppression. The latest studies investigating the use of oral steroid inhalers, which have a higher level of absorption, do not support this concern in at least 2 of the available steroid sprays. The leukotriene receptor antagonist montelukast is also approved for use in cases of seasonal and perennial allergic rhinitis. Improvement in daytime symptom scores of nasal congestion, rhinorrhea, and sneezing were evident in clinical studies. Adverse effects are similar to those of a placebo. Intraturbinate injections of steroids are also used to treat inflammatory mucosal hypertrophy. Care must be taken because cases of blindness have been reported with this technique. Surgical therapySurgical therapy is reserved for symptomatic patients with persistent hypertrophy of the turbinates who are not responding to medical management or in whom medical management is contraindicated. Because the function of the turbinates is important, care must be taken to avoid excessive resection and the resultant dry nose syndrome. The most important decision-making factor in the surgical management of the symptomatic patient with enlarged turbinates is whether the hypertrophy is bony, mucosal, or a combination of both. If bony hypertrophy is present, then some form of resection is necessary, either by way of an actual trimming of the bone and mucosa or submucosal resection of the turbinate bone. Submucosal resection of the inferior turbinate preserves most of the mucosa and allows for preservation of function. This technique is less likely to cause atrophic rhinitis when performed properly. Turbinate trim allows for resection of the turbinate through both the bone and mucosa. If excessive mucosa is resected, prolonged healing and mild-to-moderate nasal dryness may occur postoperatively. More options are available for the management of the patient with turbinate dysfunction that is due entirely to mucosal hypertrophy. Every physical treatment imaginable has been tried on the turbinate mucosa at one time or another. Because no single superior technique is clearly available, the experience of the surgeon and the intraoperative findings play the greatest role in the choice of techniques. Physical injury to the mucosa consists of cryosurgery (cold), thermal ablation (heat), or radiofrequency ablation. Both cryosurgery and radiofrequency ablation require special and costly equipment. Superficial thermal ablation can be performed with a laser or cautery unit. Intramural ablation can be preformed with a cautery unit or with a radiofrequency device. Phenol application to the turbinate mucosa has been used in the past but is no longer used because of toxicity issues. Trimming the excessive mucosa also is very effective for the management of turbinate hypertrophy. Care must be taken to not be overly aggressive in the amount of mucosa removed for the previously stated reasons. Preoperative detailsPreoperative evaluation is important in determining whether the turbinate hypertrophy is bony, mucosal, or a combination of both. Determining whether or not a significant septal deformity is contributing to the patient's symptoms is critical. If septal deformity is present, correction of the septum at the time of the turbinate surgery provides the appropriate management and ensures a successful outcome. Maximally decongesting the nose with any of the topical decongestants in the office affords a relatively easy way to determine the extent of bony and mucosal hypertrophy. This allows the surgeon to plan the appropriate procedure and discuss the risks and benefits of those procedures with the patient preoperatively. Decongesting the nose also provides a better view of the septum posteriorly. In cases where middle turbinate surgery is considered in the management of nasal headaches, a trial of maximum decongestion preoperatively may relieve the headache symptoms temporarily and help confirm the presumptive diagnosis. The author uses a strict regimen of a topical decongestant bid or tid for 4 days in combination with an oral decongestant. The patient is instructed to record whether this improves or resolves the headache while on this regimen. The patient is told that this is only a diagnostic test and cannot be used indefinitely because of rebound effects. Bony hypertrophy impacting the septum or lateral nasal wall is not expected to respond to this medication trial. Steroids are not used because effects are nonspecific and may be misleading. Preoperative airflow studies are not routinely performed but can be useful in comparison of the preoperative and postoperative states. Intraoperative detailsCareful examination of the state of the turbinate mucosa is made before and after vasoconstriction to allow for the right treatment plan. The turbinates are decongested and, if surgical therapy is anticipated, injected with a vasoconstrictive agent usually in a vehicle of lidocaine. This helps minimize bleeding during the procedure. If excessive bleeding is noted, elevated blood pressure may be the culprit; ask the anesthesiologist to assist in this matter. Topical decongestants and/or packs may be applied for further control of bleeding. Following completion of the procedure, nasal packs are placed. Septal splints are applied as appropriate. If general anesthesia is used, the patient is gently extubated to avoid undue elevations of blood pressure and increased risk of bleeding. Postoperative detailsBecause nasal packs are present in the immediate postoperative period, humidified air is provided for patient comfort. Pain control is used, but care is taken to avoid respiratory depressants. Antiemetics and other routine medications are also available as necessary. Packs are removed when appropriate, usually on the first postoperative day. The patient is instructed to keep the nose well moisturized postoperatively to aid in healing and comfort levels. The patient is provided or instructed to obtain a lubricating spray of the physician's preference, usually saline. Nose blowing is discouraged for several weeks, and sneezing is aided by an opened-mouth technique. Avoidance of heavy lifting and straining is recommended for the first few weeks following surgery. Follow-upThe patient usually returns to the surgeon's office for a postoperative visit within the first week. Packs are removed, if present, and the postoperative instructions are again reviewed. Follow-up appointments are scheduled based on the procedure performed and patient healing. COMPLICATIONSSection 8 of 12
Depending on the procedure performed, the most common complications of turbinate surgery are bleeding and prolonged nasal dryness with crusting. Bleeding is minimized by careful surgical techniques and the use of packing. Antihypertensive medications are started immediately following surgery. Postoperative trauma can lead to bleeding and so the patient is instructed to keep the nose well moisturized with the use of a nonmedicated nasal spray. Avoidance of nose blowing and opening of the mouth with sneezing are very helpful. No heavy lifting or straining is permitted for the first 2-3 weeks. Doing all of the above and staying well hydrated can minimize crusting. Vaseline can be applied to the anterior nares for symptomatic relief at bedtime and throughout the day as needed. Atrophic rhinitis (ozena) can develop in a patient with over-resected inferior turbinates. Increased nasal hygiene is necessary in those circumstances. OUTCOME AND PROGNOSISSection 9 of 12
When performed for the appropriate reasons, turbinate reduction surgery is very successful in reducing symptoms of congestion. Because no surgical procedure cures the underlying condition, further medical therapy may be necessary, especially in patients with allergic rhinitis; however, even these patients experience a significant improvement in both nasal airway and drainage symptoms. FUTURE AND CONTROVERSIESSection 10 of 12
As with any medical condition, advances in the understanding of both allergic and vasomotor rhinitis will lead to better medical therapies. Surgical therapy will continue to be reserved for patients whose conditions are refractory to medical therapy. The relationship between turbinate hypertrophy and sleep-disordered breathing problems is also currently under investigation. The major controversies surrounding turbinate surgery continue to be centered on the best techniques for management. Avoidance of overly aggressive therapies and control of the underlying disease states are paramount to disease management. The toughest issue to reconcile is that turbinate dysfunction is a quality of life issue. Management of this problem is not mandatory but very helpful for patients' quality of life. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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