Turbinate Dysfunction

1
Turbinate Dysfunction

• Shashidhar S. Reddy, MD, MPH
• Matthew Ryan, MD
• March 2003

2
Overview

• Focus on Nasal Obstruction
• Anatomy
• Histology and Physiology
• Evaluation of Nasal Obstruction
• Turbinate Disorders
• Medical Management
• Surgical Management

3
Anatomy

• Inferior Turbinate
• An inferior infolding of the lateral nasal wall.
• 60 mm in anterior to posterior direction.
• Forms an important component of the nasal valve.
• Derived from the maxilloturbinal ridge.

4
Anatomy

• Middle Turbinate
• Lies medial to the anterior ethmoid air cells,
  the maxillary sinus ostium, the nasofrontal duct,
  and the uncinate process.
• Length of 40 mm and mean height of 14.5 mm
  anteriorly and 7 mm posteriorly.
• Develops from the second ethmoturbinal.

5
Anatomy

• Superior Turbinate
• Meatus drains the posterior ethmoid air cells.

6
Anatomy

• Nasal Valve
• External Nasal Valve
• Boundaries include
• lower lateral cartilages
• Soft tissue alae
• Membranous septum
• Sill of the nostril
• Can be site of obstruction (e.g. s/p rhinoplasty)

7
Anatomy

• Internal Nasal Valve
• Boundaries include
• Septum
• Upper lateral cartilages
• Anterior end of inf. Turbinate
• 1.3cm from nares
• Accounts for 50 of airway resistance
• Inferior turbinate can affect this area greatly

8
Histology

• Three layers of Turbinates
• Medial thin mucosa
• Bone
• Lateral thick mucosa

From   Berger Laryngoscope, Volume
111(12).December 2000.2100-2105
9
Histology

• Mucosa
• Pseudostratified columnar ciliated respiratory
  epithelium
• Goblet cells produce salts, glycoproteins,
  polysaccharides, lysozymes.
• Complex array of arteries, veins, and venous
  sinusoids.
• Lamina Propria contains the above tissue.

10
Physiology

• Functions of the Nose Related to Turbinates
• Airway
• Filtration most particles gt 30?m
• Heating to 31-37 degrees
• Humidification to 95

11
Physiology

• Chemical or microbial irritation leads to rapid
  inflammatory response.
• Nasal cycle lasts 2-6 hrs, occurs in 20-80 of
  people.
• Sympathetic nervous system increases vascular
  resistance
• Parasympathetic nervous system (vidian nerve)
  relaxes capacitance vessels.
• Sensory receptors temperature receptors

12
Evaluation of Patients

• History nasal obstruction symptoms
• Physical exam
• Look for dynamic and structural cause of nasal
  obstruction.
• Check before and after decongestion.

13
Evaluation of Patients

• Rhinomanometry
• Anterior pressure sensor in one nostril, flow
  meter in a mask.
• Posterior pressure sensor in the mouth, flow
  meter in a mask.
• Ohms Law RP/V
• Normal is .15 to .3 Pa/cm3
• gt.3 is usually associated with symptoms.

14
Evaluating Patients

• Acoustic Rhinometry
• Measures cross-sectional area (CSA)
• Minimal CSA before consistent reporting of nasal
  obstruction is .3cm2 or less.
• Above .3cm2, reliability to predict gradation of
  symptoms is controversial.

15
Evaluating Patients

• Other tests
• Olfaction tests
• Nasal smear
• Tests of humidity and heating

16
Turbinate Disorders

• Allergic rhinitis
• Histologic turbinate findings mast cell
  abundance, seromucous gland hyperplasia,
  interstitial fibrosis, eosinophils on smear.
• Probably the most frequent cause of
  turbinate-related nasal obstruction.
• Acute rhinosinusitis Exam similar to AR
• Leukocytes on nasal smear.

17
Turbinate Disorders

• Chronic Rhinosinusitis
• Leads to longstanding changes in mucosa.
• Fibrosis, polyposis.
• Vasomotor Rhinitis
• Nasal congestion, rhinorrhea only
• Drug Induced Rhinitis

18
Turbinate Disorders

• Nasal Polyposis
• Etiology unclear - ?denervated mucosa
• Samters Triad
• Atrophic Rhinitis
• Progressive slow atrophy of nasal mucosa
• Questionable association with aggressive
  turbinate resection

19
Turbinate Disorders

• Anatomic
• Septal Deviation
• Concha Bullosa

From Baylor Grand Rounds Archive
20
Turbinate Disorders

• Anatomic
• Paradoxical middle turbinate curvature in 10-29
• Synechiae, polypoid changes

21
Medical Management

• Allergic Rhinitis Nasal steroids with oral
  and/or topical antihistamines, systemic
  decongestants.
• Drug induced rhinitis cessation of topical
  medicine and switch to steroids.
• Nasal Polyposis systemic steroids, topical
  steroids.
• Rhinosinusitis Antibiotics

22
Surgical Management

• Total inferior Turbinectomy
• Benefits
• Most effective in terms of LONG TERM improvement
  of airway
• Ophir et al followed 186 patients for 10 years
  and showed that 82 showed subjective
  improvement, 95 had widely patent airways

23
Surgical Management

• Total Inferior Turbinectomy
• Disadvantages
• Postoperative hemorrhage rate of 5-8
• Nasal crusting, sometimes lasting for months, up
  to 15 at one year, in a study by Mabry et al
  (40pts. followed for one year)
• Synechiae 6-12 of the time
• Atrophic rhinitis? Classic study by Moore shows
  rate of 66 in group of 18 pts at 3-5 years. Six
  ENTs in Australia reported none in 17,000 cases.
  (Fry et al 1992)

24
Surgical Management

• Partial Turbinectomy
• Anterior portion, at nasal valve, is resected.
• Advantages
• Addresses nasal valve
• Courtis showed 92 satisfaction at gt2 years
• Disadvantages
• Similar to total, but less severe

25
Surgical Management

• Submucous Resection
• Advantages
• Decreased risk of hemorrhage
• Preserves mucociliary clearance and air
  conditioning
• Disadvantages
• Technical difficulty
• Tendency to relapse 25 in a 1988 study by
  Mabry et al

26
Surgical Management

• Mucosal Lesion-Producing techniques
• Electrocautery, Cryosurgery, Laser Surgery
• Advantages
• Local Anesthesia, Easy, low hemorrhage risk
• Disadvantages
• Extensive post-op crusting, probable regrowth of
  lesions

27
Surgical Management

• Laser Illustrations

28
Surgical Management

• Submucous Lesions
• Radiofrequency unipolar or bipolar
• Study by by Back et al on twenty patients showed
  improvement in nasal cross-sectional area by
  acoustic rhinometry at one year
• KTP, Argon, and CO2 have all been shown to be
  effective.

29
Surgical Management

• Corticosteroid Injection
• Advantages minimally invasive, low cost, cost
  effective
• Disadvantages - Effects wear off by 6 weeks
• Microdebrider

30
Surgical Management

• Vidian Neurectomy
• Ligate vidian nerve, thus cutting parasympathetic
  supply.
• Transantral, Transseptal, Transpalatal.
• Good immediate relief (Fernandes et al) reports
  88 of 139 patients reported improvement in
  rhinorrhea.
• Can have high complication rate including bleeding

31
Surgical Management

• Middle Turbinate
• Concha Bullosa
• Indications
• Complications

32
Surgical Management

• Middle Turbinate
• Medialization after sinus surgery
• Prevents synechiae formation?

33
Surgical Management

• Resection of the normal middle turbinate?
• Havas, et al. show clear benefit in reducing
  synechiae requiring revision at osteomeatal
  complex after partial resection of middle
  turbinate (15 without resection vs. 7.1 with)
  in a randomized trial of gt1000 patients.

34
Conclusion

• Anatomy
• Histology/Physiology
• Evaluation of Nasal Obstruction
• Turbinate Disorders
• Medical Management
• Surgical Management
• Controversial

35
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