The turbinates are structures inside the nose that are attached to the right and left walls of the nasal cavity. There are three turbinates on each side: the upper (superior), middle, and lower (inferior) turbinates. The most important ones are the inferior turbinates (the largest) and the middle turbinates (the second largest). They are made out of thin bone covered by nasal membranes. The turbinates have three primary functions: they warm, humidify, and filter air as it passes through the nose on its way to the lungs. These are the structures which cause the nose to be blocked and for the nose to “run” when we have a cold. They are also the structures which swell and cause blockage and a drippy nose in an allergic patient exposed to an allergen. Abnormalities of the turbinates can be variations in their position, size, and how much they swell. Occasionally, the turbinates may have a shell of bone surrounded by the membrane rather than a single thin piece of bone surrounded by membrane. This may result in a predisposition to sinus infections, nasal obstruction, and/or be a migraine trigger (see below).
People may not be aware of it, but it is normal for the turbinates to swell and shrink throughout the day. The turbinates are larger on one side and smaller on the other, but then reverse (on the average) every 4 hours. When there are other causes of blockage such as a deviated (crooked) septum or when someone has a cold, one may become aware of alternating stuffiness. The turbinates may also swell when the head is in a dependant position (when a person is lying down). If a person is lying on their side, the turbinate in the lowest position may be more swollen and that nostril will be more blocked. If a patient turns over, the swelling and blockage will slowly reverse.
There are various medications which can reduce the swelling of the turbinates including pills and sprays. In allergic individuals, treatment of allergies can result in decreased turbinate swelling. Interesting and importantly, use of certain over-the-counter sprays such as neosynephrine or Afrin® decongestant can shrink the turbinates temporarily but, when used regularly, actually result in swelling of the turbinates so that they take up more room than they did before being sprayed. This is called “rebound” and can be a very debilitating problem causing very severe, difficult-to-treat nasal obstruction.
More and more articles are being published linking nasal “contact points” with certain types of headaches, in particular, migraines. Contact points occur when the turbinates come into contact with the wall that divides the nose into two chambers (the septum). Particularly when there is a sharp spur of the septum that contacts one or more turbinates, swelling of the turbinate(s) can cause increased pressure against the spur and may cause a cascade of events that results, in certain patients, in migraine headache.
The turbinates are sometimes dealt with surgically as part of rhinoplasty surgery.
Diagnosis
Diagnosis of turbinate problems is made when symptoms are suggestive of such problems and when a physician examines the inside of the nose and sees enlarged or malpositioned turbinates. The turbinates are well visualized and their relationship to the sinuses can readily be seen on CT scan.
Your First Visit
Potential turbinate surgery patients will be asked questions related to nasal congestion/obstruction, drainage, allergies, trauma, previous nasal surgery, sinus problems, and headache. The inside of the nose will be examined with a bright light and an instrument called a speculum which gently opens the nostrils so the doctor can see inside. Sometimes, a flexible telescope is used to look deeper into the nasal cavity and better see the turbinates.
Ideal Candidates
The best candidates for turbinate surgery are symptomatic men and women with functional or anatomically abnormal turbinates who are physically healthy and who have realistic expectations.
The Surgery
Turbinate surgery is performed entirely through the nostrils and, except when a rhinoplasty is done in combination with turbinate surgery, no bruising or external changes in the shape of the nose should occur. When combined with a rhinoplasty, the external appearance of the nose will be altered and swelling and bruising of the nose and face may be evident. Turbinate surgery may also be combined with sinus surgery and/or septoplasty.
The surgery is almost always done as an outpatient unless a patient has other medical problems, and is usually done under general anesthesia. There are various ways the turbinates can be addressed. Turbinates may be repositioned (therapeutic outfracture) or cauterized. They may be treated with the laser or with cryotherapy: both techniques cause controlled damage either with a laser or by freezing. The bone inside the turbinates can be removed (submucous resection), or a portion of the bone and membrane may be removed. For turbinates that have a shell of bone (concha bullosa), half of the abnormal turbinate can be removed leaving a “normal” turbinate behind. The time required for the operation varies depending on exactly what is done and with what the procedure is combined.
Following turbinate surgery, and depending on exactly what was done and how much bleeding occurred, packing may or may not be used. Traditional packing is with a long, narrow gauze. More surgeons are now using either a sponge-like material or dissolvable packing.
Recovery and results
Patients are usually very stuffy after the surgery because of swelling of the membranes. Most patients experience discomfort rather than severe pain. There is usually some minor oozing of blood out the nostrils which slows as the days pass. Postoperative care usually includes frequent use of saline (salt water) mist and/or rinse.