If you’re reading this, chances are you, or someone you know, is dealing with Turbinate hypertrophy and are looking for answers. Also known as enlarged turbinates, it is a common condition affecting nasal passages. It occurs when the turbinates (small, finger-like structures inside the nose) become swollen and enlarged, obstructing airflow and causing various symptoms such as nasal congestion, difficulty breathing, and difficulty sleeping. In this post, we’ll delve into the causes of turbinate hypertrophy and discuss the various treatment options available.
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.
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.
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 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.