Turbinate Dysfunction

Shashidhar S. Reddy, MD, MPH

Faculty Advisor: Matthew Ryan, MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

March 12, 2003

Overview

Focus on Nasal Obstruction

Anatomy

Histology and Physiology

Evaluation of Nasal Obstruction

Turbinate Disorders

Medical Management

Surgical Management

Anatomy

Inferior Turbinate:

An inferior infolding of the lateral nasal wall.

60 mm in anterior to posterior direction.

Forms an important component of the nasal valve.

Derived from the maxilloturbinal ridge.

Anatomy

Middle Turbinate

Lies medial to the anterior ethmoid air cells, the maxillary sinus ostium, the nasofrontal duct, and the uncinate process.

Length of 40 mm and mean height of 14.5 mm anteriorly and 7 mm posteriorly.

Develops from the second ethmoturbinal.

Anatomy

Superior Turbinate

Meatus drains the posterior ethmoid air cells.

Anatomy

Nasal Valve

External Nasal Valve

Boundaries include:

lower lateral cartilages

Soft tissue alae

Membranous septum

Sill of the nostril

Can be site of obstruction (e.g. s/p rhinoplasty)

Anatomy

Internal Nasal Valve Boundaries include:

Septum

Upper lateral cartilages

Anterior end of inf. Turbinate

1.3cm from nares

Accounts for 50% of airway resistance

Inferior turbinate can affect this area greatly

Histology

Three layers of Turbinates

Medial thin mucosa

Bone

Lateral thick mucosa

From: Berger: Laryngoscope, Volume 111(12).December 2000.2100-2105

Histology

Mucosa

Pseudostratified columnar ciliated respiratory epithelium

Goblet cells produce salts, glycoproteins, polysaccharides, lysozymes.

Complex array of arteries, veins, and venous sinusoids.

Lamina Propria contains the above tissue.

Physiology

Functions of the Nose Related to Turbinates:

Airway

Filtration – most particles > 30m

Heating – to 31-37 degrees

Humidification – to 95%

Physiology

Chemical or microbial irritation leads to rapid inflammatory response.

Nasal cycle lasts 2-6 hrs, occurs in 20-80% of people.

Sympathetic nervous system increases vascular resistance

Parasympathetic nervous system (vidian nerve) relaxes capacitance vessels.

Sensory receptors = temperature receptors

Evaluation of Patients

History – nasal obstruction symptoms

Physical exam

Look for dynamic and structural cause of nasal obstruction.

Check before and after decongestion.

Evaluation of Patients

Rhinomanometry

Anterior – pressure sensor in one nostril, flow meter in a mask.

Posterior – pressure sensor in the mouth, flow meter in a mask.

Ohm’s Law: R=P/V

Normal is .15 to .3 Pa/cm3

>.3 is usually associated with symptoms.

Evaluating Patients

Acoustic Rhinometry Measures cross-

sectional area (CSA)

Minimal CSA before consistent reporting of nasal obstruction is .3cm2 or less.

Above .3cm2, reliability to predict gradation of symptoms is controversial.

Evaluating Patients

Other tests:

Olfaction tests

Nasal smear

Tests of humidity and heating

Turbinate Disorders

Allergic rhinitis

Histologic turbinate findings: mast cell abundance, seromucous gland hyperplasia, interstitial fibrosis, eosinophils on smear.

Probably the most frequent cause of turbinate-related nasal obstruction.

Acute rhinosinusitis – Exam similar to AR

Leukocytes on nasal smear.

Turbinate Disorders

Chronic Rhinosinusitis

Leads to longstanding changes in mucosa.

Fibrosis, polyposis.

Vasomotor Rhinitis

Nasal congestion, rhinorrhea only

Drug Induced Rhinitis

Turbinate Disorders

Nasal Polyposis

Etiology unclear - ?denervated mucosa

Samter’s Triad

Atrophic Rhinitis

Progressive slow atrophy of nasal mucosa

Questionable association with aggressive turbinate resection

Turbinate Disorders

Anatomic

Septal Deviation

Concha Bullosa

From: Baylor Grand Rounds Archive

Turbinate Disorders

Anatomic

Paradoxical middle turbinate curvature in 10-29%

Synechiae, polypoid changes

Medical Management

Allergic Rhinitis – Nasal steroids with oral and/or topical antihistamines, systemic decongestants.

Drug induced rhinitis – cessation of topical medicine and switch to steroids.

Nasal Polyposis – systemic steroids, topical steroids.

Rhinosinusitis: Antibiotics

Surgical Management

Total inferior Turbinectomy

Benefits:

Most effective in terms of LONG TERM improvement of airway

Ophir et al followed 186 patients for 10 years and showed that 82% showed subjective improvement, 95% had widely patent airways

Surgical Management

Total Inferior Turbinectomy

Disadvantages –

Postoperative hemorrhage rate of 5-8%

Nasal crusting, sometimes lasting for months, up to 15% at one year, in a study by Mabry et al (40pts. followed for one year)

Synechiae 6-12% of the time

Atrophic rhinitis? Classic study by Moore shows rate of 66% in group of 18 pts at 3-5 years. Six ENTs in Australia reported none in 17,000 cases. (Fry et al 1992)

Surgical Management

Partial Turbinectomy

Anterior portion, at nasal valve, is resected.

Advantages

Addresses nasal valve

Courtis showed 92% satisfaction at >2 years

Disadvantages

Similar to total, but less severe

Surgical Management

Submucous Resection

Advantages

Decreased risk of hemorrhage

Preserves mucociliary clearance and air conditioning

Disadvantages

Technical difficulty

Tendency to relapse – 25% in a 1988 study by Mabry et al

Surgical Management

Mucosal Lesion-Producing techniques: Electrocautery,

Cryosurgery, Laser Surgery

Advantages Local Anesthesia, Easy,

low hemorrhage risk

Disadvantages Extensive post-op

crusting, probable regrowth of lesions

Surgical Management

Laser Illustrations

Surgical Management

Submucous Lesions Radiofrequency –

unipolar or bipolar Study by by Back et al

on twenty patients showed improvement in nasal cross-sectional area by acoustic rhinometry at one year

KTP, Argon, and CO2 have all been shown to be effective.

Surgical Management

Corticosteroid Injection

Advantages – minimally invasive, low cost, cost effective

Disadvantages - Effects wear off by 6 weeks

Microdebrider

Surgical Management

Vidian Neurectomy Ligate vidian nerve, thus cutting

parasympathetic supply.

Transantral, Transseptal, Transpalatal.

Good immediate relief (Fernandes et al) reports 88% of 139 patients reported improvement in rhinorrhea.

Can have high complication rate including bleeding

Surgical Management

Middle Turbinate

Concha Bullosa

Indications

Complications

Surgical Management

Middle Turbinate:

Medialization after sinus surgery

Prevents synechiae formation?

Surgical Management

Resection of the normal middle turbinate?

Havas, et al. show clear benefit in reducing synechiae requiring revision at osteomeatal complex after partial resection of middle turbinate (15% without resection vs. 7.1% with) in a randomized trial of >1000 patients.

Conclusion

Anatomy

Histology/Physiology

Evaluation of Nasal Obstruction

Turbinate Disorders

Medical Management

Surgical Management

Controversial

Bibliography: McCaffrey, Thomas V., “Nasal Function and Evaluation,” Byron J. Bailey’s Head and Neck Surgery – Otolaryngology, Third Edition, pgs 261-271. Lippincott Williams and Wilkins Philadelphia, 2001.

Lindemann, Jorg, MD “Impact of Unilateral Sinus Surgery with Resection of the Turbinates by Means of Midfacial Degloving on Nasal Air Conditioning,” Laryngoscope, 112(11), pgs. 2062-2066.

Jafek, Bruce W. et al “ Nasal Obstruction,” Head and Neck Surgery – Otolaryngology, Third Edition, pgs 293-308. Lippincott Williams and Wilkins Philadelphia, 2001.

Dowley, A.C. et al “The effect of inferior turbinate hypertrophy on nasal spray distribution to the middle meatus,” Clinical Otolaryngology 26(6) pgs 488-490.

Ophir, D. et al, ”Total inferior turbinectomy for nasal airway obstruction,” Archives of Otolaryngology 111:93, 1985. Courtiss, E.H. et al “Resection of obstructing inferior turbinates: a 6 year follow-up,” Plastic Reconstructive Surgery

72: 913, 1983. Jackson, Lance E et al “Controversies in the Management of Inferior Turbinate Hypertrophy: A Comprehensive

Review,” Lippincott Williams and Wilkins, Plastic and Reconstructive Surgery 103(1) pgs 300-312. Leunig, Andread, MD et al “Ho: YAG Laser Treatment of Hyperplastic Inferior Nasal Turbinates,” Laryngoscope

109(10) pgs 1690-1695. Havas, TE; Lowinger, DSG, “Comparison of functional endonasal sinus surgery with and without partial middle

turbinate resection,” Annals of Otolgoy, Rhinology, Laryngology, 109:634-640 pp 113-119. 10. Fisher, E.W. “Acoustic Rhinometry Reproducibility and Reliablity,” Clinical Otolaryngology, 22(4) pp 307-317.

Hanif, J et al, “The nasal cycle in health and disease.” Clinical Otolaryngology and Allied Sciences, 25(6) pp 461-467. Mygin, N. “Nasal Polyposis, Eosinophil dominated inflammation, and Allergy,” Thorax 55(supplement 2) pp s79-s83.

Berger, Gilead et al, “Histopathology of the inferior turbinate with compensatory hypertrophy in patients with deviated nasal septum,” Laryngoscope 111(12) pp 2100-2105.

Saunders, M.W. et al, “Parameters of nasal airway anatomy on magnetic resonance imaging correlate poorly with subjective symptoms of nasal patency” Clinical Otolaryngology & Allied Sciences 24(5) pp 431-434.Howard, et al “Understanding the Nasal Airway: Principles and Practice,” Plastic and Reconstructive Surgery, 109(3) pp 1128-

1146.Thornton, Robert S., “Middle Turbinate Stabilization Technique in Endoscopic Sinus Surgery” Arch Otolaryngol Head Neck Surg.1996;122:869-872Dogru, Harun. Tuz, Mustafa. Uygur, Kemal. Cetin, Meltem, “A New Turbinoplasty

Technique for the Management of Concha Bullosa: Our Short-Term Outcomes,” Laryngoscope. 111(1):172-174, January 2001.Back et al, “Sumucosal Bipolar Radiofrequency thermal ablation of inferior turbinates: A long-term

follow-up with subjective and objective assessment,” Laryngoscope 112(10) pp 1806-1812.