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Nasal Septal

The nasal turbinates are large important structures in the nasal airway. Attention to the turbinates and correctly dealing with them can be the difference between success and failure in nasal surgery. There are two pairs of important turbinates, the inferior turbinates and the middle turbinates.

The Inferior Turbinate - purpose and problems

The inferior turbinate is a large structure that runs the length of the nasal airway. It is a highly vascular structure, about the size of your finger. You can almost touch the front part of it with your finger and it extends to the area where your adenoids are. Its purpose is to provide surface area of mucous membrane to humidify the air as it passes and to collect dust and dirt on its surface. The inferior turbinate can change size dramatically. When you have a cold or other problem that causes congestion, it is the inferior turbinate that changes size the most. If you spray a decongestant nasal spray or take a decongestant, the inferior turbinate shrinks up. It can change size slowly over time too. If, for example, someone has a nasal fracture that causes a curved nasal septum, the inferior turbinate will grow to fill in any concavity or deviation of the septum that may result. The inferior turbinate shapes itself to try and prevent an overly open nasal air passage.

In some patients, the nasal turbinate remains persistently enlarged and obstructs the airway and causes a congested feeling. In many people when the underlying problem is treated, such as allergy or infection, then turbinate will return to a normal size. In some people, even if the underlying problem is corrected, the inferior turbinate will remain enlarged.

In patients with a nasal septal deviation, it is not uncommon for both sides to be obstructed. A common scenario would be that one side is obstructed from that actual septal bone being displaced to that side, and on the other, the inferior turbinate becomes enlarged. For some reason the inferior turbinate seems to enlarge more than is needed to accommodate the deviation. When moving someone's deviated septum surgically back towards the middle, it is important to consider the relationship of the inferior turbinate on the more open side.

The Inferior Turbinate - surgical treatment of enlargement

Basically the only surgery that is done to the inferior turbinates, is surgery designed to reduce the size. Some of the procedures also reduce the inferior turbinate's ability to enlarge by coagulating the vascular tissue under the surface.

The inferior turbinate can be reduced in several ways
  • Directly cutting a portion off of the bottom, resection.
  • Removing bone from below the mucous membrane, submucous resection.
  • Using various electric devices to remove tissue from below the surface
  • Fracturing the turbinate outward
  • Combinations of the above
Partial turbinate resection- When the turbinate is very large it is often helpful to remove a portion. In general, a strip of tissue off of the bottom is removed. This is done with special scissors and micro-debriders. It is very important to remove the correct amount of the turbinate. If not enough is removed, then there is little improvement. If too much is removed, there can be problems with drying, crusting, and paradoxical airway obstruction. The biggest negative that comes with this technique is that there is often a good bit of bleeding. The inferior turbinate is a very vascular structure and it can bleed easily. When a portion of the inferior turbinate is removed, it is usually necessary to place nasal packing for 2 or 3 nights. This makes the first nights more miserable. Occasionally there will not be much bleeding during the procedure. When this is the case, it may be elected to skip packing. This usually works out fine if patients are chosen carefully.
    Submucous resection-

    At times, the bony support of the turbinate is the enlarged part. When this is the case, it can be helpful to make an incision through the mucous membrane just to access this enlarged bone and remove portions of it. In my experience this is most helpful when done in conjunction with removal of a very small strip of mucous membrane along the bottom.

    Plasma generator turbinate reduction-

    This is my preferred method of minimally invasive turbinate reduction.This method does not provide enough reduction for some situations but most patients with turbinate enlargement will get satisfactory relief. The procedure is done by passing a small probe, like a wire, under the surface of the turbinate. On the tip of the wire is an electrode that in conjunction with a very special frequency and voltage of electricity, forms a sodium ion plasma from the electrolytes in your tissues. This plasma cloud acts to vaporize tissues and coagulate vessels. It accomplishes this with less heat than standard cauterization techniques that have been used for decades. Less heat mean less post operative discomfort and less healing time. When patients have this done at the office as an isolated procedure, they can drive themselves home and go to work that day or the next. There is very little discomfort and the results may be seen in just a week or two.

    This technique, in my mind, is most helpful for decreasing the wideness of the inferior turbinate. The direct removal alluded to above more specifically treats the height of the turbinate.

    Fracturing the turbinate outward-

    The inferior turbinate will often have some spare room under itself, in the place called the inferior meatus. By fracturing the base of the turbinate it can be displaced laterally and moved out of the airway and into a location that is less critical for breathing.

    Combinations of methods-

    It is often helpful to combine these techniques. In years past, some doctors ended up having to remove most of the turbinate to create an airway. That is rarely the case now. The goal now is to leave behind a normal sized and shaped turbinate where there once was an enlarged or overactive turbinate. Now this end can best achieved by removing smaller portions of the turbinate, and including the submucosal electrical techniques and out fractures.

The Middle Turbinate - purpose and problems

The middle turbinate has a different purpose. It sort of acts as an "awning" that protects the sinus openings from direct airflow. It is located higher up in the nasal cavity. It does not have the highly vascular tissue covering that the middle turbinate has, it's composition is more bone with a thinner mucous membrane covering.

The middle turbinate can cause problems when it is enlarged or shaped abnormally. It can either block the sinus openings and/or it can put pressure on surrounding structures and cause congestion or sinus pain. The middle turbinate can be large enough to obstruct airflow to some degree,

The most common abnormalities of the middle turbinate are the concha bullosa, the club shaped middle turbinate, and a paradoxically curved middle turbinate. All of these variants can cause problems by being too large for the space that they are allotted. It's like putting 10 pounds in a 5 pound sack.

The Middle Turbinate - surgical treatment of enlargement

Surgery on the middle turbinate involves removing a portion of the enlarged bottom so that the remaining portions are shaped like turbinated that don't cause obstruction or problems. It is almost never appropriate to remove all or most of the middle turbinate.

One specific abnormality is called a concha bullosa. This is when an air bubble, or small sinus forms in the middle turbinate. This air bubble causes the middle turbinate to be thicker than it would normally be. The widened structure can cause sinus obstruction or sinus pain. With a concha bullosa, the surgeon will usually remove the outer layer of the structure, leaving behind a structure that is similar to a "healthy" middle turbinate.

The middle turbinate can also be angled laterally more than is desired. This can be its natural orientation, or it can be a problem that arises after sinus surgery. It is often helpful to sew the middle turbinate to the septum in the midline. This is usually done with a dissolvable suture. In some cases this part of the procedure is done in a way that encourages the middle turbinate to heal to the septum in one small spot. This is termed "Bolgerization".

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