Most people know about the septum and sinuses when it comes to breathing, but not many people (including most doctors) know about the turbinates. The turbinates are wing-like along the lateral walls of the nasal cavity, opposite the midline nasal septum. There are three paired structures: the lower, middle, and upper turbines. Its sinus ducts drain below the intermediate turbinates. Inflamed turbinates are probably responsible for most cases of nasal congestion.
The turbinates are bony inside and are surrounded by a mucosa that covers them, with a very rich vascular tissue between them. The vascular tissue can swell significantly, as occurs with the penis. Any degree of inflammation, irritation, or infection can aggravate turbinate swelling. Allergies are a common cause. Even climatic changes, such as fluctuations in temperature, pressure, or humidity, can aggravate turbinate swelling. In many cases, doctors tell patients that they have nasal polyps, when in reality, what is seen is a greatly enlarged turbinate.
Sometimes it is difficult to tell if a swollen structure is a turbinate or a polyp. A polyp is a growth of the mucous membrane that grows beyond the limits of normal tissue. Most nasal polyps originate below the middle turbinates, where they drain the sinuses, but polyps can also occur anywhere in the nose, including the turbinates.
turbinate curiosities
An important feature of the turbinates that not many people are aware of is what is called the nasal cycle. The turbines alternate in size from side to side every few hours. One side shrinks and the other side swells. You won’t normally notice this unless both of your turbines are somewhat congested. If you have a deviated septum, you will notice it more.
Gravity also affects the size of the nasal turbinates. When you lie down, blood accumulates in the vessels, which causes a slight congestion. However, your involuntary nervous system detects this relative change and automatically constricts your blood vessels to improve breathing. The same process occurs when you exercise: due to activation of the sympathetic nervous system, the turbinates shrink, opening up the airways.
Sometimes the balance between the two halves of the involuntary nervous system (the sympathetic and parasympathetic parts) is not aligned and this automatic mechanism does not work correctly. So when you lie down or exercise, the vessels do not fully contract. Other times, the turbinates become more sensitive to allergies, weather changes, chemicals, odors, or scents. Once irritated, an inflammatory reaction occurs, leading to congestion and mucus production. This is called vasomotor or non-allergic rhinitis. Acid reflux from the throat has been shown to be associated with this condition.
Ultimately, how well you breathe through your nose is determined by a combination of the size of your turbinates, the geometry of your septum, and the weakness of your nostrils. (See the other sections on the septum and weak nostrils.) Your nose is not just a passive tube that acts as a channel for air to pass into your lungs, it is a highly dynamic structure, capable of changing by the minute.
What you should know about turbinate surgery
If you have tried all the conservative options to treat your allergies or nasal congestion, and surgery is the only option left, there are some very important facts to know before undergoing any type of turbinate surgery. Decades ago, surgeons used to remove significant amounts or completely of the lower nasal turbinates. Initially, the patients breathed much better, but years later they complained of a dry or constant runny nose and even a recurrence of nasal congestion. Paradoxically, when you look at the noses of these patients, the nasal cavity would be wide open. It’s called empty nose syndrome (ENS).
We now know that the turbinates are a vital part of the anatomy and function of your nose, and you need a certain amount of nasal resistance to sense and benefit from proper breathing.
There are a variety of options for reducing turbinates, from the most conservative to the most aggressive. The simplest procedure that can be performed in the office is an intramural cautery procedure. This is where a needle or probe is placed under the mucous membranes and the blood vessels are cauterized or vaporized. Over time, the scar tissue that is created shrinks and tightens the soft tissues of the turbinates. You will see several names, such as radiofrequency or somnoplasty. A recent variation called Coblation uses radio frequency energy to vaporize tissue at relatively low temperatures. All of these procedures have the advantage that they can be performed in the office and do not involve cutting or excision of the mucous membrane.
The rest of the procedures are usually performed in the operating room, under local or general anesthesia. There are many ways that surgeons reshape, shrink, debulk, or remove parts of the turbinate. The in-office procedures listed above can be performed in conjunction with any other procedure, such as septoplasty or sinus surgery. The easiest way is to physically cut the lower front part of the turbinate with scissors or electrocautery. Sometimes the deep bony parts are also removed. Complete resections of the inferior turbinates are rarely performed because of the possible risk of “empty nose syndrome.”
Another popular method is called a submucosal resection (meaning any deep bone, cartilage, or tissue is removed, leaving the overlying mucous membrane behind). For turbinates, an incision is made along the bottom of the inferior turbinate, the bone is exposed, and a portion is removed.
The mucous membrane layers are replaced and pressed onto the raw bone bed with a light nasal packing. A newer way to do this without making an incision is to use what is called a suction microdebrider. This device has been used for years in sinus surgery. The tip of a long, thin rod with an open end has a rotating blade that oscillates back and forth, while at the same time applying a vacuum to suck out any tissue that is removed (either soft tissue or bone).
What to expect after surgery
Most surgeons still use nasal packing, especially with more aggressive procedures, to keep the mucous membrane layer pressed against raw surfaces. Since turbinate procedures are usually performed in conjunction with septal procedures, nasal packing with or without splints is more common than not. Depending on the surgeon’s preference, the packing may or may not be used for some of the minimally invasive procedures.
The goring procedures themselves are not considered painful. Most patients do not take pain medication unless other procedures are being performed simultaneously.
It may take days to weeks before your breathing improves significantly, as there will be swelling, blood, and mucus immediately after the procedure. Many surgeons clean this debris a few days to a week after the procedure in the office during follow-up.
Nasal saline may be applied every few hours right after surgery to loosen secretions. Blowing your nose is discouraged until cleared by your surgeon during the first post-operative visit.
Turbinate surgery is a very useful procedure that can be performed alone or in combination with other procedures. Bleeding and infection, although rare, can occur, just like any other surgical procedure. There may also be anesthesia risks. In the rare possibility that the procedure fails, reasons for failure include an overly conservative procedure, persistent deviation of the nasal septum, or nasal valve collapse.