The nasal turbinates and turbinate reduction

 Left inferior (lower) turbinate of the nose (courtesy Hawke Library, Michael Hawke MD), looking from the front of the nose. The nasal septum is seen on the left and the turbinate is seen on the right of the picture.

Left inferior (lower) turbinate of the nose (courtesy Hawke Library, Michael Hawke MD), looking from the front of the nose. The nasal septum is seen on the left and the turbinate is seen on the right of the picture.

What are the inferior turbinates?

The nose acts like a radiator and air conditioner for the airways. It warms and moisturises air which we breathe in and also removes dust particles. This means that cold, dry air which comes in at the nostrils reaches the same temperature and humidity as a rainforest by the time it reaches the back of the nose, so that the windpipe and lungs receive clean, warm and moist air.

To allow the nose to work in this way, it needs a large surface area inside, like the piping in an air conditioning unit or at the back of a fridge, or a radiator’s bars: the larger the area, the better. The nose has three large “radiator bars” on each side, upper/middle/lower, which consist of a bony bar with soft tissue coverings. The are called the turbinates of the nose.

The largest of these are the lowest ones on each side: the inferior turbinates. Unlike the other ones, which are hard to see when we look in the nose with a light, the inferior turbinates are big and obvious pink fleshy lumps, which are easily seen. If you open up your nostril with your thumb in front of a mirror, this is what you will see. They can be very big in people with colds or allergies and are often mistaken for polyps in the nose: but the turbinates will be tender if poked with a probe, while polyps (which are much less common) are not painful or tender.

What problems can the turbinates cause?

All of us have turbinates in our noses, and they usually don’t cause any problems. They are shaped in such a way to allow smooth air flow, without blocking the nose. They become bigger during colds, causing congestion and a blocked nose, but are normally not a problem.

But in some children and adults, they can be very big and bulky, blocking breathing and sometimes contributing to snoring and even sleep apnoea. Sometimes this is related to allergies, often accompanied by sneezing and itching of the nose and eyes, but in other people they can be enlarged without any allergic cause.

How are enlarged turbinates treated?

If patients have allergic symptoms (irritation- itching of the nose and eyes and sneezing and congestion and mucus production) then medical treatment is often very effective.

It’s important to think about which allergens are involved, and skin prick allergy tests may help to identify these. Reduction of exposure to the allergens can help (eg removal of carpets and cleaning bedding for people with dust mite allergy and wearing sunglasses in summer for hay fever sufferers).

Rinsing of the nose with saline solutions is effective in reducing the load of allergens in the nose. Options include Sterimar spray or the NeilMed sinus rinse system.

Medical options should cover both the irritative symptoms (itch and sneezing) and the obstructive symptoms (congestion and mucus production). A non-drowsy antihistamine (eg cetirizine twice a day or loratidine once a day) should help with the irritative symptoms, while a steroid nose spray (eg fluticasone or mometasone) will help with the congestion and mucus production. The two types of medication work well together, in different ways.

It is really important to use all of these measures correctly and consistently, ideally every day or every other day, but not here and there- they will not be as effective. To use the nose spray most effectively, hold the spray bottle in the left hand when squirting the right nostril and vice versa, so that the spray hits the side wall of the inside of the nose, rather than the septum in the middle. A gentle sniff will be enough. As a rule of thumb, bottles of spray tend to last for about 6 weeks before they run out. If they last much less than this, you may be using too much, or if they last longer then you may not be using it regularly enough.

Decongestant drops and sprays, which are available over the counter, should not be used for more than a few days at a time. They may affect the blood vessels inside the turbinates, so that if used for longer periods, the turbinates may become persistently bulky and inflamed, no longer responding to medications. This is known as rhinitis medicamentosa.

Surgery for the turbinates

If the inferior turbinates remain large and are causing congestion, despite these medical measures, then surgery may help reduce their size and help with the breathing. But it is important to note that medical treatment may still be required in the longer term, in addition to the surgery, to keep the nose lining settled.

Traditionally, reduction of the turbinates was done by trimming the soft tissues to reduce their size. Now, we have much more gentle methods available, where an electric probe is inserted through the nostril into the soft tissue of the turbinate each side and an electric current is applied, which shrivels up the soft tissue from inside, without injuring the nose lining. So healing is typically very fast and risks of heavy bleeding are very low.

I use the Coblation technique, which uses a particular type of electric probe which does not burn or char the nose lining. It is demonstrated here. This is a straightforward procedure. Some colleagues perform this under local anaesthetic in adults, but for children it is done under general anaesthetic and can be combined with other procedures, eg removal of the tonsils and adenoids.

What is the recovery period and what are the risks?

Most patients having this sort of procedure can go home later the same day and resume normal activities within a few days, but I would suggest avoiding swimming, flying and vigorous exercise for up to two weeks. Pain is usually minimal and can be managed with paracetamol and ibuprofen. The nose can be quite congested as it heals, so I offer patients decongestants for a few days afterwards. The nose should then feel much better than before surgery within a week or two.

Bleeding can occur, but this is usually light and will settle with simple pinching of the nose. Heavier bleeding is much less likely and would need admission to hospital in rare cases. First aid measures for nosebleeds are discussed here.

In the long term, some patients will still need to use their steroid and antihistamine medications and some will have recurrence of symptoms, needing the surgery to be repeated. Very occasionally, the procedure may result in a band of scar tissue (an adhesion) across the inside of the nose between the turbinate and nasal septum, which may need to be treated with another small procedure.

Summary

Large nasal turbinates can be seen in the context of allergies, but sometimes this is not the case. If they are causing symptoms, then medical treatment can be very effective. If needed, surgery for the turbinates is very gentle and effective at shrinking their size. But ongoing medical treatment may still be required as well in some patients.