Enlarged inferior turbinates and surgery for nasal congestion

What are the inferior turbinates?

The inferior turbinates are long structures attached along the side walls on both sides of the inside of the nose, and they warm and humidify the air you breathe in. They consist of bone covered by a mucous membrane (mucosa), so enlargement is thought of in two ways: cases where the bone is large and cases where soft tissue such as the mucosa is swollen.

A review of rhinoplasty and the inferior turbinates explained that turbinate enlargement is not a single condition but a mix of different forms ^[2]. The same review considered that patients undergoing rhinoplasty are likely to need treatment for enlargement of the bony part and may also need treatment for soft tissue enlargement ^[2].

Nasal congestion has more than one cause

Nasal congestion (nasal airway obstruction) is a common symptom in ear, nose, and throat (ENT) practice, and its causes are often structural or inflammatory ^[1]. Symptoms are usually described as resulting from several factors acting together ^[1].

Common structural causes include enlarged inferior turbinates, a deviated septum, and narrowing or collapse of the internal or external nasal valves ^[1]. Of these, the internal nasal valve is the narrowest point of the nasal airway in cross-section, so it is said to be the most sensitive to anatomical differences and to changes in size caused by surgery ^[1].

For this reason, it is stressed that a good result requires a thorough preoperative evaluation, including nasal endoscopy, to pinpoint the cause of the blockage and tailor treatment to it ^[1].

Treatments to consider before surgery

One common cause of swelling in the mucosa of the inferior turbinates is allergic rhinitis. According to a US clinical practice guideline, allergic rhinitis is one of the most common conditions in adults and is estimated to affect nearly 1 in 6 Americans ^[3].

The guideline made a strong recommendation that clinicians recommend nasal steroid sprays for patients with allergic rhinitis whose symptoms affect their quality of life, and it presented other medications and immunotherapy as options depending on symptoms ^[3]. Inferior turbinate reduction was addressed as an option that may be offered to patients whose medical treatment has failed and who have nasal blockage and enlarged inferior turbinates ^[3]. Which medications to use, and how, should be decided through a medical consultation.

However, this guideline was developed based on patients and healthcare settings in the United States, and it states that it is not intended to set a standard of care for individual patients or to limit treatment ^[3].

Surgical methods and preserving the lining

Inferior turbinate reduction is a commonly used method to improve nasal breathing in patients with enlarged inferior turbinates ^[4]. Most methods are described as aiming to preserve the turbinate mucosa in order to protect sensation and normal mucociliary clearance, the way the lining moves mucus out of the nose ^[4].

Lasers are also among the tools used in turbinate surgery. A review of lasers in nasal (rhinologic) practice concluded that no single laser currently suits every case, so staying aware of the latest clinical results helps in choosing treatment ^[5]. Inferior turbinate reduction is also often performed together with septoplasty ^[6].

How long do the results last?

According to a review, most surgical methods improve subjective nasal breathing in many patients, but the benefit often decreases over time ^[4]. The same review stated that more clinical trials comparing surgical methods, and more research on long-term effects, value, and cost, are needed ^[4].

The best treatment remains debated. Because turbinate enlargement is a mix of different forms, it has been pointed out that future research should standardize how outcomes are measured and compare treatments in rigorous clinical trials ^[2]. There is not yet enough evidence to say with certainty that any one method lasts longer.

If a cause of mucosal swelling, such as allergic rhinitis, persists, symptoms can return, so the underlying cause may still need to be managed after surgery.

Complications and precautions

Inferior turbinate reduction is generally described as having a relatively low complication rate ^[4]. However, one rare complication is empty nose syndrome, which is said to be most typically associated with surgery that removes all or nearly all of the inferior turbinate ^[4]. For this reason, how much to reduce the turbinates is decided carefully.

When it is combined with septoplasty, the complications of septal surgery itself also need to be considered. One review listed the complications of septoplasty as excessive bleeding, leakage of cerebrospinal fluid from the nose (CSF rhinorrhea), injury to the eye muscles, wound infection, septal abscess, toxic shock syndrome, septal perforation, saddle nose deformity, a sunken nasal tip, and sensory changes such as loss of smell or reduced sensation in the teeth ^[6]. The same review stressed that securing a good view during surgery is key to preventing complications ^[6].

What to check during your consultation

Nasal congestion often has several overlapping causes, so it is best to decide on treatment after the cause has been confirmed with an examination and endoscopy ^[1].

• Whether the blockage changes with the season or with your body position
• Whether you have given medical treatment for conditions such as allergic rhinitis a fair try
• Whether you also have problems with the septum or nasal valves besides the turbinates
• What method will be used, how much will be reduced, and whether the mucosa will be preserved
• What can be done if the benefit wears off