Turbinate Dysfunction Treatment & Management

Medical therapy is the first-line approach to the treatment of turbinate dysfunction; however, the appropriate choice of therapy relies on the appropriate diagnosis. Several categories of medications are available that have an effect on the turbinate mucosa and affect patients' symptoms. Nasal decongestants, in both topical and oral forms, are some of the most effective drugs available for reducing congestion of the turbinate mucosa. Topical sprays, oxymetazoline and phenylephrine, are extremely powerful alpha-agonists, and prolonged use can cause a rebound effect. Rebound develops within 4-5 days and if prolonged is known as rhinitis medicamentosum.

Oral decongestants are also very effective for reducing congestion and do not cause rebound swelling of the mucosa with prolonged use. Pseudoephedrine and phenylephrine are 2 common forms of oral decongestants. Main concerns regarding their use include elevation of blood pressure in hypertensive patients and urinary retention in patients with benign prostatic hypertrophy. Prolonged use of oral decongestants may lead to tolerance and ineffectiveness. Phenylpropanolamine was voluntarily withdrawn by the Food and Drug Administration (FDA) because of cases of hemorrhagic stroke occurring in women. This drug is presently unavailable for use as an oral decongestant.

Antihistamines are agents that affect the turbinates by blocking the effects of histamine at H1 receptor sites. Many antihistamines are available OTC and by prescription. These medications are only indicated in patients with allergic rhinitis. Used in conjunction with oral decongestants, antihistamines can relieve congestion and drainage symptoms. Adverse effects are drug specific and range from sedation and memory effects (with the earlier generation antihistamines that cross the blood-brain barrier) to excessive dryness. Antihistamines are contraindicated in patients with glaucoma.

Intranasal steroid sprays are useful for turbinate dysfunction. These medications are labeled for the management of allergic rhinitis but, like all steroids, also have nonspecific anti-inflammatory effects. The newest sprays in this class are extremely safe and have no significant suppression of the hypothalamus-pituitary axis (HPA).

Intranasal steroids are administered every day and require continued daily use for any significant benefits. Proper direction of the spray nozzle to the lateral nasal wall prevents the most common adverse effects of nasal dryness, which include epistaxis and septal perforation (rare). Tolerance should not occur with prolonged use. The latest controversy concerning the use of nasal steroids in children is growth suppression. The latest studies investigating the use of oral steroid inhalers, which have a higher level of absorption, do not support this concern in at least 2 of the available steroid sprays.

The leukotriene receptor antagonist montelukast is also approved for use in cases of seasonal and perennial allergic rhinitis. Improvement in daytime symptom scores of nasal congestion, rhinorrhea, and sneezing were evident in clinical studies. Adverse effects are similar to those of a placebo.

Intraturbinate injections of steroids are also used to treat inflammatory mucosal hypertrophy. Care must be taken because cases of blindness have been reported with this technique. A preliminary report of intraturbinate injection of botulinum toxin A for vasomotor rhinitis showed symptom improvement compared with placebo in a small cohort study. ^[7]

Surgical therapy is reserved for symptomatic patients with persistent hypertrophy of the turbinates who are not responding to medical management or in whom medical management is contraindicated. Because the function of the turbinates is important, care must be taken to avoid excessive resection and the resultant dry nose syndrome (ozena).

The most important decision-making factor in the surgical management of the symptomatic patient with enlarged turbinates is whether the hypertrophy is bony, mucosal, or a combination of both. If bony hypertrophy is present, then some form of resection is necessary, either by way of an actual trimming of the bone and mucosa or through submucosal resection of the turbinate bone. ^[1] Submucosal resection of the inferior turbinate preserves most of the mucosa and allows for preservation of function. This technique is less likely to cause atrophic rhinitis when performed properly. Turbinate trim allows for resection of the turbinate through both the bone and mucosa. If excessive mucosa is resected, prolonged healing and mild-to-moderate nasal dryness may occur postoperatively.

More options are available for the care of the patient with turbinate dysfunction that is due entirely to mucosal hypertrophy. Every physical treatment imaginable has been tried on the turbinate mucosa at one time or another. Because no single superior technique is clearly available, the experience of the surgeon and the intraoperative findings play the greatest role in the choice of techniques.

Physical injury to the mucosa consists of cryosurgery (cold), thermal ablation (heat), or radiofrequency ablation. Both cryosurgery and radiofrequency ablation require special and costly equipment. Superficial thermal ablation can be performed with a laser or cautery unit. Intramural ablation can be preformed with a cautery unit or with a radiofrequency device. ^[8] Phenol application to the turbinate mucosa has been used in the past but is no longer used because of toxicity issues. Trimming the excessive mucosa is also very effective for the management of turbinate hypertrophy. Care must be taken to not be overly aggressive in the amount of mucosa removed for the previously stated reasons.

A newer technique using a very small (2 mm) microdebrider blade through a small stab incision shows great promise in reducing the size of the inferior turbinates without requiring external physical injury to the mucosal membranes. This technique also shows excellent long-term results compared with diathermy and radiofrequency ablation. ^[9] See the video below.

A randomized, double-blind study by Barham et al found that medial flap turbinoplasty had better outcomes in inferior turbinate reduction than did submucosal electrocautery and submucosal powered turbinate reduction. At 5-year follow-up, decongestants were being used only occasionally or not at all in 90.2% of the turbinoplasty nasal cavities, compared with 15.8% and 37.8% of the cavities that underwent electrocautery and submucosal powered turbinate procedures, respectively. Moreover, just 12% of the turbinoplasty cavities required a revision procedure, versus 54% and 40% of the electrocautery and submucosal powered turbinate procedure cavities, respectively. ^[10]

In a study of pediatric patients with chronic nasal congestion, Whelan et al found that inferior turbinate reduction resulted in symptom improvement. The investigators reported that the median sum score from the Nasal Obstruction Symptom Evaluation (NOSE) survey dropped from 65 points out of 100 preoperatively to 20 points at the end of the first postoperative year. While a median of one medication was taken preoperatively, postoperatively that fell to zero. However, patients with allergic rhinitis had a significantly higher 12-month postoperative NOSE score than did those without the condition. ^[11]

Preoperative evaluation is important in determining whether the turbinate hypertrophy is bony, mucosal, or a combination of both. Determining whether or not a significant septal deformity is contributing to the patient's symptoms is critical. If septal deformity is present, correction of the septum at the time of the turbinate surgery provides the appropriate management and ensures a successful outcome.

Maximally decongesting the nose with any of the topical decongestants in the office affords a relatively easy way to determine the extent of bony and mucosal hypertrophy. This allows the surgeon to plan the appropriate procedure and discuss the risks and benefits of those procedures with the patient preoperatively. Decongesting the nose also provides a better view of the septum posteriorly.

In cases in which middle turbinate surgery is considered in the management of nasal headaches, a trial of maximum decongestion preoperatively may relieve the headache symptoms temporarily and help confirm the presumptive diagnosis. The author uses a strict regimen of a topical decongestant bid or tid for 4 days in combination with an oral decongestant. The patient is instructed to record whether this improves or resolves the headache while on this regimen. The patient is told that this is only a diagnostic test and cannot be used indefinitely because of rebound effects. Bony hypertrophy impacting the septum or lateral nasal wall is not expected to respond to this medication trial. Steroids are not used because effects are nonspecific and may be misleading. Preoperative airflow studies are not routinely performed but can be useful in comparison of the preoperative and postoperative states.

Careful examination of the state of the turbinate mucosa is made before and after vasoconstriction to allow for the right treatment plan. The turbinates are decongested and, if surgical therapy is anticipated, injected with a vasoconstrictive agent usually in a vehicle of lidocaine. This helps minimize bleeding during the procedure. If excessive bleeding is noted, elevated blood pressure may be the culprit; ask the anesthesiologist to assist in this matter. Topical decongestants and/or packs may be applied for further control of bleeding.

Following completion of the procedure, removable or absorbable nasal packs are placed. Septal splints are applied as appropriate. If general anesthesia is used, the patient is gently extubated to avoid undue elevations of blood pressure and increased risk of bleeding. See the image below.

Bony hypertrophy of the right inferior turbinate following topical vasoconstriction.

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Because nasal packs are present in the immediate postoperative period, humidified air is provided for patient comfort. Pain control is used, but care is taken to avoid respiratory depressants. Antiemetics and other routine medications are also available as necessary. Packs are removed when appropriate, usually on the first or second postoperative day. Absorbable packing materials are becoming more commonplace and reduce the discomfort of packing removal while trading for a longer period of congestion postoperatively. Postoperative antibiotics are usually continued until the packing has been removed.

The patient is instructed to keep the nose well moisturized postoperatively to aid in healing and comfort levels. The patient is provided or instructed to obtain a lubricating spray of the physician's preference, usually saline. Nose blowing is discouraged for several weeks, and sneezing is aided by an opened-mouth technique. Avoidance of heavy lifting and straining is recommended for the first few weeks following surgery.

The patient usually returns to the surgeon's office for a postoperative visit within the first week. Packs are removed, if present, and the postoperative instructions are again reviewed. Follow-up appointments are scheduled based on the procedure performed and patient healing.

Depending on the procedure performed, the most common complications of turbinate surgery are bleeding and prolonged nasal dryness with crusting. Bleeding is minimized by careful surgical techniques and the use of packing. Antihypertensive medications are started immediately following surgery. Postoperative trauma can lead to bleeding and so the patient is instructed to keep the nose well moisturized with the use of a nonmedicated nasal spray. Avoidance of nose blowing and opening of the mouth with sneezing are very helpful. No heavy lifting or straining is permitted for the first 2-3 weeks.

Doing all of the above and staying well hydrated can minimize crusting. Vaseline can be applied to the anterior nares for symptomatic relief at bedtime and throughout the day as needed. Atrophic rhinitis (ozena) can develop in a patient with over-resected inferior turbinates. Increased nasal hygiene is necessary in those circumstances.

When performed for the appropriate reasons, turbinate reduction surgery is very successful in reducing symptoms of congestion. Because no surgical procedure cures the underlying condition, further medical therapy may be necessary, especially in patients with allergic rhinitis; however, even these patients experience a significant improvement in both nasal airway and drainage symptoms. ^[12]

A prospective study by Vijay Kumar et al comparing radiofrequency ablation with the microdebrider technique in the treatment of inferior turbinate hypertrophy found that, while both modalities were effective in relieving nasal obstruction, preoperative symptoms recurred in a small portion of the radiofrequency group. The study included 60 patients with chronic nasal obstruction caused by inferior turbinate hypertrophy that had been unresponsive to medical treatment. The patients were divided evenly between the two treatments and were followed up postoperatively at 1 week and at 1, 3, and 6 months. Although significant improvement occurred in all preoperative symptoms in both groups over the course of the follow-up period, symptoms recurred in three of the patients treated with radiofrequency ablation. No recurrence was seen in the microdebrider group. ^[13]

A study by Nilsen et al suggested that for patients with nasal obstruction, treatment with a combination of septoplasty and radiofrequency therapy of the inferior turbinates (RFIT) may be more effective than RFIT alone. Using the visual analogue scale to assess symptoms, the investigators found that patients who underwent septoplasty/RFIT had a postoperative nasal obstruction score of 27.5, compared with 37.2 for patients treated only with RFIT. ^[14]

As with any medical condition, advances in the understanding of both allergic and vasomotor rhinitis will lead to better medical therapies. Surgical therapy will continue to be reserved for patients whose conditions are refractory to medical therapy. The relationship between turbinate hypertrophy and sleep-disordered breathing problems is also currently under investigation.

The major controversies surrounding turbinate surgery continue to be centered on the best techniques for management. Avoidance of overly aggressive therapies and control of the underlying disease states are paramount to disease management. The toughest issue to reconcile is that turbinate dysfunction is a quality of life issue. Management of this problem is not mandatory but very helpful for patients' quality of life.