Anatomy of the Nose and Turbinate

The structural anatomy of the nose includes the septum which is the midline structure that separates the left and right breathing passages.  It begins just behind the columella which is the division seen on the external nose.  The front part of the septum is cartilage, whereas it consists of bone posteriorally.  Along both sides, it is covered by mucosa, a type of skin that lines the entire nasal cavity.  The mucosa does have the ability to produce mucous and become inflamed and swollen when it is irritated or infected. Posteriorly, the septum ends, allowing both sides of the nasal cavity to join into one passageway before entering the back of the throat.

Turbinates

On the lateral side of the interior nose are the turbinates.  There are typically three on each side- the inferior, middle, and superior.  In some individuals, there is a fourth- the supreme turbinate.  These structures are like “shelves” that protrude from the side walls.  They are composed of a thin piece of bone surrounded by tissue that is very vascular-it contains a large number of small blood vessels.  Finally, the layer of mucosa covers this tissue.  This large number of blood vessels very close to the surface results in the surface being warmed.  This warmth, along with the moisture on the mucosa, provides the turbinates with their function- to warm and humidify the air as it passes through the nose.

The superior and supreme turbinates are rarely crucial in causing nasal or sinus problems.  The middle turbinate can play a role in sinus infections- not truly impacting the ability to breathe, but instead potentially blocking the normal drainage from the sinus.

Turbinate Hypertrophy

The inferior turbinates can cause significant issues, especially congestion and the actual ability to breath through one’s nose.  The numerous small blood vessels inside the turbinate can dilate, therefore becoming more significant and causing the entire turbinate to enlarge or “hypertrophy.”  This can be temporary or more chronic.

Causes of Turbinate Hypertrophy

Temporary Causes of Turbinate Hypertrophy

For example, the nasal cycle is a typical event in which every 4-6 hours the majority of the blood flow to the nose shifts from one side to the other, causing the turbinates, and actually the lining of that entire side of the nose , to swell and reduce the size of the nasal airway.  This typically does not cause symptoms unless the nasal passage is otherwise narrowed, for example, by a deviated septum.  Similarly, when we are lying down there is an increase in blood that pools in the small vessels leading to enlargement or hypertrophy of the turbinates.

Inflammatory Causes of Turbinate Hypertrophy

Other causes of temporary or intermittent turbinate hypertrophy include allergies, nasal irritation, non-allergic rhinitis, abnormalities of the septum, or chronic sinusitis.When a patient is allergic to items in the environment, an abnormal response occurs, releasing a chemical called histamine.  Two side effects in the nasal cavity are dilation of the small blood vessels in the lining of the nose and a change in mucous production.  Alternatively, many times a patient will have these symptoms, but allergy testing is negative. This results in a diagnosis of non-allergic rhinitis, also known as vasomotor rhinitis.  It is crucial for the patient and physician to understand that this is an accurate diagnosis and does have treatment options that can be different than allergic rhinitis, but also very effective.  Allergic and non-allergic rhinitis can cause either acute or chronic turbinate hypertrophy depending on the severity and frequency.

Nasal Septum Contributing to Turbinate Hypertrophy

Abnormalities of the nasal septum can also lead to turbinate hypertrophy.  A deviated septum, where the bone or cartilage of the septum is crooked or “deviated,”  will produce turbulent airflow through the nose.  This constant irritation of air hitting the turbinates, instead of passing straight by, can cause the turbinate to hypertrophy-similar to forming a callous. In this case, the hypertrophy tends to be permanent and less likely to fluctuate.  Many times the patient may assume or even be told by a health professional that they have allergies.  A specialist such as an otolaryngologist (ENT doctor) can examine the nose to determine the exact cause of these symptoms.  A septal perforation can result from trauma, overuse of legal or illegal drugs placed in the nasal cavity, or after surgery.  In this situation, a hole forms in the septum.  Although commonly asymptomatic, occasionally, this can cause abnormalities of the flow of air or mucous, which through irritation can lead to chronic hypertrophy of the turbinates.  Rarely tumors of the head and neck region can involve the septum or other areas of the nasal cavity and sinuses.  Once again, this can lead to the obstruction of air and mucous causing chronic inflammation.

Infectious Causes of Turbinate Hypertrophy

Finally, infection of the nose and or sinuses can cause turbinate hypertrophy.  The sinuses, which are bony cavities not in the nose, but rather drain their mucous into the nose through small passages, can be infected acutely- commonly for 5-7 days, chronically in which case the infection never truly resolved.  Having infection adjoining the nasal cavity can result in the nose becoming inflamed and enlarging the turbinates.  Primary infections of the nose are less common but include bacteria such as Staphylococcus. These are often evident by small pimples or “furuncles” at the entrance of the nose.  The inflammation caused by this can result in turbinate hypertrophy.

Treatment of Turbinate Hypertrophy

Conservative Management of Turbinate Hypertrophy

In some instances, then use of turbinate hypertrophy, especially if it is an environmental allergy, can be identified and eliminated, resulting in the relief of symptoms.  This may require formal allergy testing or simply observation by the patient to isolate the offending substance.  If the allergen is ubiquitous or just something the patient cannot or will not avoid, then treatment with immunotherapy (allergy shots) or medication such as antihistamines or nasal steroid sprays can be used.  It may not be desirable to take a chronic medication without pursuing other treatments such as those offered after a thorough examination by an ENT physician.

Nasal irrigations can also be used to improve turbinate hypertrophy.  This treatment involves using a mechanism to irrigate the nasal cavity and rinse away irritants therefore cleaning the nose.  It is necessary to use some force behind the rise, either with a squeeze bottle or bulb or one of the several mechanized versions available.  Many different solutions are available, but usually a saline based liquid is mild and effective.

Procedural Treatment of Turbinate Hypertrophy

if these relatively conservative treatments are not satisfactory in relieving the patient’s symptoms, or if the patient desires a more permanent solution, then a procedural option should be considered.  At this point, evaluation should be performed by an ENT physician to correctly identify the diagnosis of turbinate hypertrophy and attempt to identify contributing factors as mentioned previously, which may also need to be treated to achieve success.

Surgery of Turbinate Hypertrophy

In the past, surgery of the turbinates was the only procedural option.  This was typically done under general anesthesia and involved surgically “trimming” the turbinates to remove a portion of the turbinate physically, reducing its size and therefore giving the patient more room to breathe.  Postoperatively there was packing consisting of. Gauze-like material is placed in the nasal cavities for 3-5 days.  This is very uncomfortable for the patient.  Additionally, the patient experiences bleeding and crusting for a few weeks as the area heals.  This surgery typically produces an excellent result but overall is an unpleasant recovery.  Also, very infrequently, the patient can experience a permanently dry nose, also known as empty nose syndrome, if the resection is overly aggressive.

Non-Surgical Procedural Options for Turbinate Hypertrophy

There are now several options to reduce the size of the turbinates that can be performed under local anesthesia in the physician’s office.  Most involve the use of heat energy, such as radiofrequency, which is delivered into the turbinate.  This results in turbinate reduction.  This is well tolerated by the patient, does not result in bleeding or scabbing, and  does not require packing, allowing a patient to return to normal activities almost immediately.  Success rates rival traditional surgery, and the risk of a permanently dry nose is essentially eliminated.

if allergic or non allergic rhinitis is determined to be a contributing factor in causing turbinate hypertrophy, there are now procedures that are performed in the office that provide longstanding relief.  The posterior nasal nerve provides the stimulus that guides nasal congestion and drainage.  In both types of rhinitis, this nerve can produce abnormal impulses causing an increase in these symptoms.  Recently, two treatments one using cryotherapy, the other radiofrequency have been shown to be effective and safe in treating this disorder.  Both techniques require only local anesthesia and involve the ENT doctor to use a small endoscope to locate the area overlying the nerve precisely.  A small device is then placed on the area under direct vision.  Cryotherapy applies very cold temperatures to the area, while radiofrequency uses heat energy.  Both techniques take less than a minute to treat each site, and 2-3 sites are usually treated on each side of the nose.  The treatment and recovery are not painful, although some patients undergoing cryotherapy will experience a headache for up to 24 hours.  The patient may resume normal activity immediately.  Many times the elimination of the rhinitis symptoms will allow the turbinates to return to average size, or the turbinates can be reduced directly at the same time by one of the minimally invasive techniques mentioned previously.

Turbinate Hypertrophy-Summary

Turbinate hypertrophy can cause nasal obstruction and difficulty breathing.  If symptoms are bothersome to the patient, a thorough examination by an ENT doctor can help confirm the diagnosis and identify any contributing factors.  Medical management and in-office procedures are now available and can provide relief from these symptoms safely and effectively.

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Sinus infections can be incredibly painful, and they can become debilitating if when they are not diagnosed and treated properly. The relief of a “cured” sinus infection quickly evaporates when the telltale symptoms of an infection return and patients are left wondering why sinusitis won’t stay away. In addition to causing discomfort and/or missed days of work, untreated and recurrent sinus infections can lead to more permanent damage in the sinus cavities and nasal passages. 

While the very occasional, acute sinus infection (sinusitis) is relatively normal, recurrent or chronic sinus infections are not. If a sinus infection returns again after you’ve finished a round of antibiotics and/or have followed your physician’s at-home treatment instructions to the letter, please schedule another appointment ASAP.  

You may need a referral to an ENT (ear-nose-throat) specialist to determine why the sinus infection continues to come back, and whether anatomical corrections may be necessary to fix the problem once and for all.  

Acute Versus Chronic Sinus Infection 

The American Academy of Otolaryngology defines sinus infections in one of two ways: 

Acute sinusitis 

This is the normal manifestation of a sinus infection. Acute sinusitis clears up in four weeks or less and is often the unfortunate effect of a respiratory infection (cold or flu) or from chronic allergies. It occurs once, it lasts for a short time, the infection is treated with or without medication (yes, some sinus infections clear on their own!), and the patient should remain sinus infection free for a year or more.  

Chronic sinusitis 

If your sinus infection lasts for longer than 12-weeks, or it continues to come back again and again within a matter of weeks or months, you’re diagnosed with chronic sinusitis. There are multiple causes of untreatable or frequently occurring sinus infections. Chronic infections are most frequently connected to some type of obstruction that prevents sinus cavities from draining properly, trapping bacteria and/or viruses inside the sinus cavities. 

Visit our video about the Cause of Chronic Sinusitis to learn more. 

Reasons Your Sinusitis Keeps Coming Back 

Here are some of the reasons your chronic sinusitis continues to come back: 

Excessive inflammation of the nasal passages 

Contrary to what most people think, the sinuses consist of far more space than just the nasal passages and behind the cheekbones. There are four sets of sinuses located in the head, and all of these drain mucus through the nasal passages, which act as one of the body’s sinus exit points. Your throat also acts as a drain for the sinuses. This is why people with sinusitis often experience discomfort in the throat, resulting from post-nasal drip. 

If the nasal passages become inflamed, they get stopped up and the body has a hard time draining all of that backed up, infected, and often thickened mucus. This exacerbates the sinus infection, causing it to settle in even more.  

There are several things you can do to relieve and reverse swollen and sensitive sinus passages: 

• Inhale steam (a hot shower is great for this) and use a nasal-specific saline solution to flush the nasal passages once, twice, or three times per day. Your doctor can show you how to do this safely. 
• Avoid smoking cigarettes or inhaling second-hand smoke 
• Use an air purifier and humidifier, especially while you sleep, to keep the passages moist 
• Take a shower at night to flush allergens from the day down and out of your sinuses, and then splash your face with warm water in the morning to flush allergens and irritants that settled on your face or in your nose while you slept 
• Drink lots of fluids (hot teas, especially herbal teas designed to support breathing, sinus pressure and/or allergies are highly recommended) 
• Avoid outdoor activities that over-expose you to pollen such as mowing the grass, laying in a field, hiking through high grasses/weed, etc. 
• Take care of your immune system by eating well (try an anti-inflammatory diet), getting plenty of rest, and managing stress. This is your body’s best chance of fighting infections on its own. 

Dr. Hester may prescribe a corticosteroid nasal spray or even an oral steroid to provide more immediate and dramatic inflammation relief. These meds should be used as directed. NEVER use corticosteroid nasal sprays or oral steroids for longer than advised. You can wind up doing more harm than good. If the sinus symptoms persist, contact your doctor to schedule a follow-up appointment. 

Your sinusitis keeps coming back because you don’t have an accurate diagnosis 

If the infection lasts longer than a couple of weeks or the pain is becoming unbearable, seek medical treatment immediately. Accurate diagnosis is key to treating sinusitis, especially when the infections return over and over again. You can treat allergies all you want, but a polyp, deviated septum, or other anatomical abnormalities in the nasal passages won’t disappear without more expert treatment. 

A comprehensive examination of the nose and sinus passages by a specialist is necessary to evaluate the correct diagnosis and cause of your symptoms. In some cases, what has been previously diagnosed as a ”sinus” issue has, in fact, been caused by another issue. Identifying the correct diagnosis is the first step to feeling better.

You may have an anatomical issue blocking sinus drainage 

There are several anatomical issues that prevent sinus cavities and/or the nasal passages from draining properly. Examples of these include: 

A previous nasal fracture (you broke your nose) 

Nasal bones are the most commonly broken bones in the body. Sometimes they heal well on their own, or they seem as if they did. Over time, you may experience signs or symptoms that the nose didn’t heal as well as you’d hoped. In fact, your previously fractured nose may have set in a crooked position. Or, the break may have been worse than you knew, leading to fractures deeper in the sinus cavities that didn’t heal well.  

Anyone who has broken their nose in the past is at higher risk for chronic sinus infections, so make sure to mention your nasal fracture history when you make an appointment with our office. 

Nasal polyps or other soft tissue obstructions 

Sometimes, for reasons that are unclear, the thin tissue lining the nasal passages develop small, benign (non-cancerous) tumors. We call these nasal polyps. As you know, it does not take much to obstruct the airway, so even a single polyp can lead to significant airway and breathing issues – including chronic snoring – as well as recurring sinus infections. Most often though, people with polyp-related sinusitis have multiple polyps obstructing the nasal passages.  

Fortunately, we can remove nasal polyps or other soft tissue obstructions using minimally-invasive procedures such as nasal airway remodeling. 

Deviated septum 

Some people are born with deviated septums, others develop them after a traumatic accident or injury – even when the injury seemed relatively mild. The nasal septum is that thin wall that divides the right and left sides of your nasal passages. If the wall is offset or deviated to a severe enough degree, it compromises both breathing and sinus drainage.  

If the septum has deviated to the point that it causes health problems, Dr. Hester will work with you to determine which treatment method or surgical procedure is best for correcting the deviation.  

Scar tissue in the sinus cavities 

Previous injuries, anatomic defects from birth, or previous sinus injections can all cause scar tissue to build up in the sinuses. This blocks the cavities from functioning and draining properly, which can trap irritants in the cavity. Recurrent sinus infections can continue causing more scar tissue, further compounding the problem. 

If Dr. Hester notices that scar tissue is impacting sinus function, he may recommend endoscopic sinus surgery to clear the tissue away.  

Turbinate hypertrophy 

The turbinates are long, narrow passageways that occur along the main nasal passageways. Their job is to warm and moisten the air that you breathe. Most people have three turbinates – inferior, middle, and superior turbinates. Once in a while, people are born with four. If the turbinates become inflamed or enlarged (called turbinate hypertrophy), they fill up the nasal cavity and it won’t drain properly. 

Turbinates are responsible for all kinds of sinus and breathing issues, including difficulty breathing, snoring, chronic stuffiness, and sinus infections that never seem to end. Enlargement of the inferior and/or middle turbinates are the most likely to cause issues. If you are diagnosed with turbinate hypertrophy, Dr. Hester can provide a comprehensive outline of treatment options to find the one that is right for you. In some cases, home treatments and/or medications can reduce their enlargement enough to be effective. For others, surgical procedures are the only successful mode of treatment. 

Abnormal growths or other anatomical abnormalities 

The body is a mysterious and complex series of systems. Seemingly out of nowhere, tissues can thicken, cells can excessively multiply causing tumors, or small issues that didn’t cause problems in the past can begin to cause you trouble. If your nasal passages or sinus cavities experience abnormal growths of any kind, they can usually be removed through surgery. If it is a tumor or mass, we will biopsy the tissue to make sure it is not cancerous.  

Most anatomical abnormalities affecting the bony or soft tissues comprising the sinus cavities can be repaired via surgery, greatly eliminating the experience of recurrent sinus issues. 

Accurate Sinus Diagnosis And Treatments Is Essential 

The only way to stop recurring sinus infections once and for all is to have an evaluation by a specialist who has the specialized training and experience to accurately diagnose their cause. Once you have an accurate diagnosis, we can discuss the options. The goal is always to provide the patient with all the available options, discuss the advantages and disadvantages of each, and help you find the best treatment plan for you.

Stop Suffering 

Do you suffer from recurring sinus infections? Contact us here at the office of Dr. Jerome Hester, ENT, or give us a call at (650) 268-5133, to discuss your concerns. Dr. Hester is an expert at treating all of the variations that lead to chronic sinusitis, and he always strives to find the least invasive treatment methods. Everyone deserves to breathe easily, and we look forward to helping you do just that.

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The nasal bones are the most commonly broken bones in the body. It actually does not take a significant amount of force to break these bones, and so routine activities, even including many sports, or even having an unfortunate accident around the home, can lead to a broken bone.

Typically, the symptoms are discomfort, many times the area around the bridge of the nose will turn black and blue, there is sometimes nasal bleeding associated with this, and congestion. Immediate treatment, including ice to the area, keeping the head elevated, and even the use of over-the-counter nasal decongestants sprays for a short period of time, usually no longer than three to five days, can be used to treat these symptoms.

Many times, we do not even perform X-rays of a presumed nasal fracture, since the X-ray itself will not necessarily determine whether any treatment is taken. Certainly, however, if there’s a loss of consciousness associated with the accident, or if there’s any concern that other fractures of the bones of the face could have occurred, medical attention is warranted.

The main reasons to address a nasal fracture are either that the portion of the nasal bones and the septum inside the nasal cavity are crooked or deviated enough to cause obstruction, or that the external bones have cause a cosmetic deformity. If either one of these issues have come about, then the choice can be either to do a closed fracture, where no incision is made, and usually under mild anesthesia. The fracture is simply reset back into position. On the other hand, many times these abnormalities are not noted immediately, or the decision is to not proceed immediately into a surgical procedure to correct them.

Both abnormalities, the nasal obstruction, as well as the cosmetic deformity, can then be treated later on in a more formal way, to either correct the deviation of the septum, or to reset the nasal bones to attain normal cosmetic result.

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The septum is a wall of bone and cartilage that separates the nose into left and right sides. A deviated septum simply means that the septum itself is crooked. Many of us have mildly deviated septums just as part of our normal anatomy. However, the septum itself can be caused to be more crooked by even mild trauma. For example, as a child running around the front room, falling down, bumping one’s nose is enough to crack the septum which will lead it to be crooked and this can get worst over time. Certainly, more major trauma can also be a cause. In some individuals, we believe they are born with a septum that is somewhat crooked or deviated.

Many people are not bothered by this deviation or others will accommodate to it over time. In other words, it has been there since they were very young therefore they don’t notice necessarily that they’re not breathing as well as they could. In other cases, the individual is actually told that they may have allergies and this is the cause for nasal obstruction especially if the nasal cavity itself has not been examined. However, it is a major cause of impeding normal nasal airflow. The human body we now know performs at its best when breathing to the nose is easy and unimpeded. The nasal cavity serves a function of warming and humidifying the air as it comes in and out which allows it to perform better as it is going through daily activities.

A diagnosis of a deviated septum is relatively simple for a trained professional. It is simply a nasal examination. In other words, just looking inside of one’s nose. X-rays are generally not indicated. More significant test such as a CAT scan also generally are not indicated to diagnose a deviated septum. If the septum is deviated, it can cause problems as outlined as far as nasal obstruction. It has also been attributed to certain types of headaches and leading to the increased risks of sinus infections.

The only true treatment for a deviated septum is surgical repair. The surgery itself is performed through the nasal cavity without any outside incisions. There is no need to break the major nasal bones at the top of the nose to perform a septoplasty or repair of the deviated septum and so this is usually a fairly short outpatient surgery. In today’s world, it is uncommon that it is necessary to pack the nose. This was a treatment that was used at the end of septoplasty where gauze packing was packed inside the nasal cavity to stabilize. Unfortunately, this was extremely uncomfortable for the patient in the three to five days it was in place and lead to the significant morbidity of that procedure. We now are in most cases able to avoid the need for packing.

One also does not have any cosmetic change, not immediately after the surgery. In other words, there’s no black and blue after the surgery and the surgery itself does not change the shape of the nose. Finally, when this surgery is done for the right reason, and what I mean by that, when the surgery is done in order to improve nasal breathing in an individual who has a deviated septum, it generally is very successful as it opens the airway and allows the airflow to go through.

When the procedure is done for more obscure reasons such as headaches, many times the successful rate is a little more suspect. It is difficult to predict this success rate ahead of time and the patient should be counseled that the surgery is being done in an attempt to relieve these symptoms but without any promise.

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There are numerous causes for chronic sinusitis. Basically, all of us have four sets of sinuses located in the head. These sinuses are not actually in the nose, but rather drain into the nose through small passages. We’re unclear what the real cause or usefulness of the sinuses truly is.

As this mucus is being produced on a daily basis from the sinuses, it flows out of the sinus, into the nasal cavity, and then is washed down the back of the throat. Material from the environment, whether they could be bacteria, viruses, allergy particles, dust particles, land on top of this mucus, and then is cleared to the back area.

However, in some occasions, this material can sit around for a while, and lead to more formations, causes swelling, which then causes obstruction of flow of mucus. If this obstruction continues, and perhaps even leads to a cause of obstruction of the sinus opening itself, the mucus then is trapped within the sinus, and an infection can develop, because trapped mucus is a perfect growth medium for both bacteria and viruses.

Therefore, the treatment options in order to break this cycle are either to prevent it from occurring in the first place, or once it occurs, trying to open up the sinus drainage pathways, so that it can drain unobstructed. As far as trying to prevent the occasion from happening, the use of nasal rinses, the use of decongestants and antihistamines, and even nasal steroid sprays, can assist in this.

Once the obstruction has occurred, however, these mechanisms are usually inadequate. Although nasal irrigations can help clear the mucus that is in the nasal cavity, and perhaps lessen the inflammation, usually the use of either topical decongestant nasal sprays, such as Afrin, which unfortunately can only be used for three to five days at a time, or even the use of antibiotics in order to clear the infection is necessary.

In some cases, if this occurrence continues, either in its duration or in its frequency, surgical mechanisms to open the sinus are necessary, to allow the re-introduction of normal mucus flow through the nasal cavity.

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