There is controversy regarding optimum treatment of the hypertrophied inferior turbinate. Patients undergoing rhinoplasty will likely need treatment of bony hypertrophy as well as possibly soft tissue hypertrophy. Although inferior turbinate hypertrophy is a heterogeneous entity, future studies should standardize outcome measures and compare treatment methods with rigorous clinical trials.
Key points
- •
There is controversy regarding optimum treatment of the hypertrophied inferior turbinate.
- •
Patients undergoing rhinoplasty will likely need treatment of bony hypertrophy as well as possibly soft tissue hypertrophy.
- •
Although inferior turbinate hypertrophy is a heterogeneous entity, future studies should standardize outcome measures and compare treatment methods with rigorous clinical trials.
Introduction
Initially, surgery for the nose addressed only the external component. The efforts of surgeons in India to reconstruct nasal defects thousands of years ago are well documented, and Tagliacozzi illustrated dramatic methods of nasal flap reconstruction. The syphilis epidemic of the 1600s and later the First World War provided numerous patients who needed nasal reconstruction as a result of infection and trauma, respectively. Purely aesthetic rhinoplasty was pioneered by Jacques Joseph, who performed surgery on his first patient in 1898. Concurrently, interest in the internal nose also developed. For example, there are reports of inserting a hot poker in the nose to treat nasal obstruction. Then, in the latter part of the nineteenth century, Jones is reported to have had the first description of turbinate surgery (1895). Several years later, Holmes outlined his experience with more than 1500 cases of turbinate resection.
In the early-mid 1900s, inferior turbinate surgery was marked by a period of controversy. Many surgeons thought that turbinate resection resulted in atrophic rhinitis and ozena. As a result, total inferior turbinate resection fell out of favor. A more conservative procedure emerged featuring preservation of anatomy, suggested first by Spielberg, who advocated for submucous resection in 1924.
Flashing forward to today, we have realized the importance of treating both the internal and the external nose at the same time. In a recent survey from the American Society of Plastic Surgeons, 87% of respondents indicated that they would like to see additional instructional courses on the nasal airway. For the nose, function follows form. Inferior turbinate hypertrophy continues to be a clinical focus when evaluating nasal obstruction, and nasal function should be considered for any patient undergoing rhinoplasty surgery. To the extent that septal abnormality is often present in rhinoplasty patients (functional or cosmetic), the author herein also considers articles that discuss the inferior turbinate and septoplasty—often using septoplasty as a proxy for rhinoplasty—as one considers the role of the inferior turbinate in rhinoplasty surgery. Given that the vast majority of rhinoplasty surgeries are performed on adults, studies areconsidered that look at the inferior turbinate in adults only—even though large pediatric studies have been published.
Introduction
Initially, surgery for the nose addressed only the external component. The efforts of surgeons in India to reconstruct nasal defects thousands of years ago are well documented, and Tagliacozzi illustrated dramatic methods of nasal flap reconstruction. The syphilis epidemic of the 1600s and later the First World War provided numerous patients who needed nasal reconstruction as a result of infection and trauma, respectively. Purely aesthetic rhinoplasty was pioneered by Jacques Joseph, who performed surgery on his first patient in 1898. Concurrently, interest in the internal nose also developed. For example, there are reports of inserting a hot poker in the nose to treat nasal obstruction. Then, in the latter part of the nineteenth century, Jones is reported to have had the first description of turbinate surgery (1895). Several years later, Holmes outlined his experience with more than 1500 cases of turbinate resection.
In the early-mid 1900s, inferior turbinate surgery was marked by a period of controversy. Many surgeons thought that turbinate resection resulted in atrophic rhinitis and ozena. As a result, total inferior turbinate resection fell out of favor. A more conservative procedure emerged featuring preservation of anatomy, suggested first by Spielberg, who advocated for submucous resection in 1924.
Flashing forward to today, we have realized the importance of treating both the internal and the external nose at the same time. In a recent survey from the American Society of Plastic Surgeons, 87% of respondents indicated that they would like to see additional instructional courses on the nasal airway. For the nose, function follows form. Inferior turbinate hypertrophy continues to be a clinical focus when evaluating nasal obstruction, and nasal function should be considered for any patient undergoing rhinoplasty surgery. To the extent that septal abnormality is often present in rhinoplasty patients (functional or cosmetic), the author herein also considers articles that discuss the inferior turbinate and septoplasty—often using septoplasty as a proxy for rhinoplasty—as one considers the role of the inferior turbinate in rhinoplasty surgery. Given that the vast majority of rhinoplasty surgeries are performed on adults, studies areconsidered that look at the inferior turbinate in adults only—even though large pediatric studies have been published.
Anatomy and physiology of the inferior turbinate
The inferior turbinate is situated as a composite protrusion extending from the internal aspect of the lateral nasal sidewall. Its anterior aspect forms the inferior border of the nasal valve, which is the flow-limiting segment of the nasal airway. The inferior turbinate (conchal) bone is situated superiorly and angled to some degree both medially and inferiorly toward the airway. It has a rough texture to which soft tissue is tightly adherent. The soft tissue of the turbinate is composed of arterial and venous vascular channels as well as smooth muscle. In this way, the turbinate acts as a dynamic erectile organ. Structurally, the inferior turbinate is often seen “curling” around an ipsilateral septal deviation, adopting a lateralized position at the apex of the spur and then becoming more medial anterior and posterior to it ( Fig. 1 A ). A curled configuration may suggest some adaptation in shape to the space allotted or to the airflow pattern in the pathologic airway. Conversely, the inferior turbinate contralateral to a septal deviation often becomes hypertrophied, again suggesting an ultrastructural adaptation to available space ( Fig. 1 B). Indeed, Jun and colleagues found that the hypertrophied turbinate on the concave side of a septal deviation features a change in orientation of the conchal bone relative to the lateral nasal sidewall. Specifically, they found that the angle at which the turbinate protrudes from the lateral nasal sidewall demonstrated a statistically significant increase relative to the other side. In other words, the angle of attachment of the turbinate to the nasal is more obtuse on the more open side. It stands to reason that a space-occupying inferior turbinate that juts out in the airway more could impair subjective airflow.
The blood supply to the inferior turbinate is composed of anterior and posterior contributions. The anterior ethmoid artery and lateral nasal artery provide anterior blood supply, whereas the sphenopalatine artery provides posterior blood supply. One anatomic study emphasized the position of the posterior blood supply and its intimate association with the turbinate bone, finding that 2 primary branches supply blood to the turbinate, and that both remain in bony canals or lie in close approximation to the bone for a significant distance. The anterior and posterior blood supply anastamose along the midportion of the turbinate, forming the inferior turbinate artery. The caliber of the blood vessels along this middle aspect of the turbinate has been noted to increase. Larger vessels in this area may represent an anastomosis phenomenon related to the anterior blood supply or could include contribution from the facial artery. This robust inferior turbinate blood supply allows for use of the inferior turbinate flap in various reconstructive procedures.
The function of the inferior turbinate is to warm and humidify the air that is breathed. As air passes through the nasal valve, it is directed toward the surface of the inferior turbinate, underscoring the importance of both structures for nasal breathing. Laminar airflow passing over the turbinate creates resistance, which causes nasal mucus production, thereby providing humidification. The normal nose can increase humidity of respired air from zero externally to near 100% at the level of the nasopharynx. Increased humidity in the nasopharynx would explain significant upper airway dryness symptoms typically associated with total turbinectomy.
Causes of inferior turbinate hypertrophy
The cause of inferior turbinate enlargement is controversial; many possibilities exist. Indeed, there is even controversy regarding the terminology that should be used when describing this phenomenon. Farmer and Eccles argue that the term “inferior turbinate enlargement” is preferable because there is no true histologic evidence of enlargement of the cells—either bony or soft tissue—which characterizes the definition of hypertrophy. The mucosa is thought by most to play at least a partial role in inferior turbinate hypertrophy. A dynamically enlarged inferior turbinate can result from the engorgement of the vascular soft tissues of the nose as part of the generally accepted nasal congestion-decongestion cycle. A boggy appearance to the inferior turbinate often is a classic finding in patients who have allergic rhinitis. Indeed, Mabry and Marple emphasized the role of allergy and suggested that failure to shrink after decongestant treatment suggested “irreversible hypertrophy.” The use of continuous positive airway pressure has also been anecdotally implicated in turbinate hypertrophy.
Bony enlargement has been implicated in at least some cases of inferior turbinate enlargement. Subsequent retrospective reviews of coronal computed tomographic (CT) scans in patients with compensatory hypertrophy of one inferior turbinate contralateral to a septal deviation showed an increase in cross-sectional area of both bony and mucosal elements as compared with controls, suggesting that treatment of the bone is needed for compensatory hypertrophy. Persistent inflammation in the nose can also create collagen deposition and glandular hypertrophy, resulting in permanent thickening in the nasal mucoperiosteum. These studies, combined with Jun’s work looking at the angle of protrusion of the turbinate, suggest that, in many cases, modifying the turbinate bone in addition to the vascular soft tissues could help relieve nasal obstruction.
Diagnosis of inferior turbinate hypertrophy
Diagnosis of inferior turbinate hypertrophy is done primarily by physical examination. Anterior rhinoscopy can help determine the angle at which the turbinate attaches to the lateral nasal sidewall. It will also provide information regarding the soft tissue bulk of the turbinate. A wax curette can be used to gently palpate the anterior head of the inferior turbinate to assess soft tissue bulk. If this is poorly tolerated, a topical anesthetic can be placed. With anterior rhinoscopy, simultaneous evaluation can be done in quick succession of the septum as well as the nasal valve. Patients who have prior CT imaging of the sinonasal cavity can undergo radiographic assessment of the inferior turbinates, but ordering new imaging would ordinarily not be indicated. For the inferior turbinate partially obscured by a deviated septum or otherwise difficult to assess, especially posteriorly, nasal endoscopy may be warranted.
Treatment for inferior turbinate hypertrophy
Nonsurgical Treatment
Both surgical and nonsurgical treatments exist for inferior turbinate hypertrophy. Assuming that inferior turbinate hypertrophy can involve not only a soft tissue but also a bony component, it would stand to reason that nonsurgical therapy would be limited to possible improvements in the soft tissue component only—the mucosa and submucosal vascularized spaces—because a spray or pill would not be expected to effectively modify or reposition “hard” tissue such as cartilage or bone. Studies outlining nonsurgical therapy for inferior turbinate hypertrophy use “nasal obstruction” as a proxy given that isolating the effects of systemic treatment on a single intranasal structure is impossible. Patients enrolled in such studies often carry a diagnosis of allergic rhinitis. Knowledge of nonsurgical therapy for nasal obstruction is important for the rhinoplasty surgeon because optimizing the nasal airway by reducing systemic or diffuse inflammation allows for better evaluation of the fixed structure of the nose. Comprehensive treatment of the nose includes controlling for allergy and other inflammatory causes. In addition, the surgeon may be asked to treat nasal obstruction medically before insurance approval for rhinoplasty. Finally, postoperative nasal obstruction after rhinoplasty may call for adjuvant medical therapy.
Even though second-generation oral antihistamines (OAH) remain popular for nonsurgical treatment of nasal obstruction and are easily accessible over the counter, first-line therapy should include intranasal steroid (INS) spray. Steroids have represented a time-tested anchor of nonsurgical therapy for nasal obstruction. Steroid injections into the inferior turbinate were described more than 30 years ago. More recently, INSs were developed, and Benninger and colleagues demonstrated in 2010 that treatment of allergic rhinitis symptoms with INS was superior to OAH, intranasal antihistamine spray (IAH), leukotriene receptor antagonists, and cromolyn. Subsequent studies have suggested that IAH may be equivalent, such as a randomized controlled trial comparing INS and IAH. Even though INSs do not seem to represent the higher level risk that systemic steroids do, the true risk of these topical sprays is not known. As with other proposed interventions, proper informed consent is important. When prescribing INS, an effort should be made to discuss possible side effects, such as adrenal suppression, depressed immune function, glaucoma, epistaxis, septal perforation, nasal irritation, and nasal dryness.
Surgical Treatment
A helpful concept to keep in mind when evaluating surgical treatment of the inferior turbinate is whether that treatment is addressing soft tissue, bone, or both. A slender turbinate with an obtuse angle of attachment or thicker bone may require bony work, whereas a boggy turbinate with thickened mucosa and an acute angle of attachment may call primarily for treatment of soft tissue. Certainly, there are combinations of both in which bony and soft tissue abnormality co-exist.
Treating the bone: inferior turbinate lateralization
Modern-day modification of the inferior turbinate bone can include repositioning only (lateralization) or partial removal. Lateralization has been examined in several studies that were summarized nicely by Moss and colleagues in a letter to Plastic and Reconstructive Surgery in 2015. The appeal of lateralization is that it is conservative and anatomy sparing. The perceived downside is that it is not durable. Perhaps the best pure study of turbinate lateralization was done by Aksoy and colleagues. In this study, 40 patients underwent inferior turbinate lateralization only without other turbinate procedures. Thirty-two of these patients also had septoplasty. Preoperative, 1-month, and 6-month radiographic studies were done by CT scan. Findings were remarkable for a statistically significant decrease in the angle of turbinate relative to the lateral nasal sidewall, the distance of the turbinate from the lateral nasal sidewall, and the cross-sectional area lateral to the turbinate. The authors of this study also placed Doyle splints for a week, which could possibly minimize early turbinate remedialization. Admittedly, their follow-up period was short.
Passali and colleagues showed the benefits of lateralization with a fairly large prospective randomized trial. In their study, comparison was made between submucosal resection with and without lateralization, turbinectomy, laser cautery, electrocautery, and cryotherapy. Submucosal resection provided the best results and was statistically significantly better as measured by patient’s symptom scores. Adding lateralization to submucosal resection improved symptom scores but did not reach statistical significance. Preservation of nasal physiology, as measured by secretory immunoglobulin A and mucociliary clearance time, was maintained. Notably, 92 of the original 382 patients were included in the 6-year follow-up, providing a relatively robust study group. Similarly, microdebrider-assisted turbinate reduction has been found to deliver favorable outcomes when combined with turbinate outfracture.
Treating the bone: submucosal resection of conchal bone
One of the largest reported series of true submucosal resection of the turbinates has been reported by Rohrich and colleagues. They described fracturing the turbinate laterally, excising a small amount of mucosa inferolaterally, and removing bone along the inferior half of the conchal bone. Their technique seems to be an effective way to reduce the vertical length of the turbinate and open up the inferior nasal airway. Of 281 patients in their study who underwent this procedure, only one had mucosal crusting and none had bleeding, recurrent obstruction, or symptoms of atrophic rhinitis. Even though this procedure reduces the total surface area of inferior turbinate available for warming and humidifying air, the nose generally seems to be able to compensate for a smaller inferior turbinate with minimal symptoms. Durable improvement over a 4-year follow-up has also been reported after submucous resection of conchal bone in allergic rhinitis patients in which all mucosa was preserved and the “mucoperiosteal sack” was cauterized.
Inferior turbinate reduction with concurrent septoplasty
Inferior turbinate hypertrophy frequently coexists with other sinonasal abnormality, including deviated septum, chronic rhinosinusitis, and nasal valve collapse. Performing septoplasty with inferior turbinate reduction is especially common and, based on the aforementioned evidence of enlargement of the contralateral inferior turbinate, it would seem that turbinate reduction would be indicated. Specifically, in a large retrospective review spanning 12 years, there was a statistically significant decrease in the need for revision surgery in patients who underwent simultaneous turbinate reduction at time of primary septoplasty. In contrast, Becker and colleagues showed no benefit of concurrent turbinate reduction at time of primary septoplasty. A recent clinical consensus statement from the American Academy of Otolaryngology–Head and Neck Surgery noted that inferior turbinoplasty is an effective adjunctive procedure to septoplasty, although the tone of the recommendation was guarded.
Inferior turbinectomy
In computer models, total resection of the inferior turbinate increases area within the nose but simultaneously decreases nasal resistance and impairs the ability of the nose to warm and humidify inspired air. Concerns also exist for postoperative bleeding after turbinectomy given the close proximity of arterial blood supply to the bone. Postoperative pain can also occur. Extended follow-up via use of a questionnaire prompted Moore and colleagues to conclude that total turbinectomy should not be performed. However, large retrospective studies suggest relative safety of inferior turbinectomy. Talmon and colleagues reported 357 total inferior turbinectomies performed in a dry climate (Israel) with 6-year follow-up. In this study, there were no cases of atrophic rhinitis, and 348 of 357 reported being “satisfied” with the operation at 6 months. The perioperative bleeding rate was 1.7%, and the 18-month rate of nasal crusting was 3.7%. Moreover, many patients undergoing Le Fort osteotomy have turbinectomy as part of their maxillary repositioning. For example, Movahed and colleagues reported on 603 patients who underwent partial inferior turbinectomy involving two-thirds (presumably anteriorly) of each turbinate. No details are provided, but they emphasized that “chart review showed no significant long-term complications.”
Electrosurgery for inferior turbinate enlargement
There is a myriad of studies that examine electrosurgery for inferior turbinate enlargement, and much of this literature is outside the scope of this review. Electrosurgical techniques include cautery (diathermy) of the inferior turbinate, coblation of the inferior turbinate, and radiofrequency ablation of the inferior turbinate. Many of these studies examine inferior turbinate enlargement in isolation, often addressed in a clinic setting under local anesthesia, making this body of literature somewhat less relevant for rhinoplasty surgeons who are more likely to proceed to surgery under general anesthesia. Many studies are also weakened by short follow-up periods and lack of standardized outcomes measures.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
