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Steven Y Park, MD  
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Specialties: Sleep-breathing disorders

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The Turbinates: What You Should Know

Jul 07, 2010 - 11 comments
Tags:

Nasal congestion

,

stuffy nose

,

turbinate enlargement

,

Nasal polyps

,

nasal allergies



Most people know about the septum and sinuses when it comes to breathing, but not many people (even most doctors) know about the nasal turbinates. Turbinates are like wings along the sidewalls of your nasal cavity, opposite your midline nasal septum. There are three paired structures: the inferior, middle and superior turbinates. Your sinus passageways drain from underneath the middle turbinates. Swollen turbinates are probably responsible for most cases of nasal congestion.

The turbinates are bony on the inside and surrounded by a mucous membrane covering, with a very rich vascular tissue in between. The vascular tissue can engorge significantly, like what occurs with the penis. Any degree of inflammation, irritation or infection can aggravate turbinate swelling. Allergies are a common cause. Even weather changes such as temperature, pressure or humidity fluctuations can aggravate turbinate swelling. In many instances patients are told by their medical doctors that they have nasal polyps, when in fact, it's a very enlarged turbinate that's seen.

Sometimes it's difficult to tell whether a swollen structure is a turbinate or a polyp. A polyp is a protuberance of mucous membrane that grows beyond the normal tissue boundaries. Most nasal polyps originate from underneath the middle turbinates where the sinuses drain, but polyps can also occur anywhere in the nose, including on the turbinates.

Turbinate Trivia

One important feature of the turbinates that not too many people know about is what's called the nasal cycle. The turbinates alternate in size from side to side every few hours. One side shrinks and the other side swells. Normally you won't notice this, unless both your turbinates are somewhat congested. If you have a deviated septum, then you'll notice this more.

Gravity also affects the size of your nasal turbinates. When you lay down, blood pools in the vessels, leading to slight engorgement. 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 your breathing passageways.

Sometimes, the balance between the two halves of the involuntary nervous system(the sympathetic and parasympathetic parts) is out of alignment, and this automatic mechanism doesn't work properly. So when you lay down or exercise, the vessels don't constrict fully. Other times, the turbinates become extra sensitive to allergies, weather changes, chemicals, scents or odors. Once it's irritated, an inflammatory reaction occurs which leads to engorgement and production of mucous. This is called vasomotor or nonallergic rhinitis. Throat acid reflux 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, your septal geometry, and the how flimsy your nostrils are. (See the other sections on the septum and flimsy nostrils.) Your nose is not just a passive tube that acts a channel for air to pass into the lungs—it's a very dynamic structure, able to change minute by minute.

What You Must Know About Turbinate Surgery

If you've tried all the conservative options for treating your allergies or nasal congestion, and surgery is the only option left, there are a few very important facts that you must know before undergoing any type of turbinate surgery. Decades ago, surgeons use to remove significant amounts or completely the lower nasal turbinates. Initially, patients would breathe much better, but years later would complain of either a dry nose or a constantly runny nose and even a return of nasal congestion. Paradoxically, when you look into these patient's noses, the nasal cavity would be wide open. The is called the empty nose syndrome (ENS).

We now know that turbinates are a vital part of your nasal anatomy and functioning, and you need a certain amount of nasal resistance to perceive and benefit from proper breathing.

There are a variety of options for shrinking nasal turbinates, from more conservative to more aggressive. The simplest procedure that can be performed in the office is an intramural cautery procedure. This is where a needle or a probe is placed underneath the mucous membranes and the blood vessels are either cauterized or vaporized. With time, the scar tissue that's created shrinks and tightens the turbinate soft tissues. You'll see various names such as radio-frequency or Somnoplasty. One recent variation called Coblation uses radiofrequency energy to vaporize tissues at relatively low temperatures. All these procedures have the advantage that they can be performed in the office, and no cutting or excising of the mucous membrane is involved.

The remaining procedures are usually performed in the operating room, under local or general anesthesia. There are many ways that surgeons modify, shrink, de-bulk, or excise parts of the turbinate. The previously mentioned in-office procedures can be performed along with any other procedures, such as a septoplasty or sinus surgery. The simplest way is to physically cut the front-lower portion of the turbinate off using scissors or electrocautery. Sometimes the deep bony parts are removed as well. Complete inferior turbinate resections are rarely performed anymore due to the possible risk of the "empty nose syndrome."

Another popular method is called a sub-mucous resection (meaning the any deep bone, cartilage or tissue is removed, leaving behind the overlying mucous membrane). For the turbinates, an incision is made lengthwise along the lower portion of the inferior turbinate, and the bone is exposed and a portion removed.

The mucous membrane layers are replaced and pressed down onto the raw bony bed with soft nasal packing. A more recent way of doing this without making an incision is to use what's 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 which oscillates back and forth, while simultaneously applying a vacuum to suction out whatever tissues is removed (either soft tissue or bone).

What To Expect After Surgery

Most surgeons still use nasal packing, especially with the more aggressive procedures, to keep the mucous membrane layer pressed against the raw surfaces. Since turbinate procedures are usually performed alongside septal procedures, nasal packing with or without splints are more common than not. Depending on surgeon preference, packing may or may not be used for some of the minimally invasive procedures.

Turbinate procedures by themselves are not considered painful. Most patients don't take any pain medications, unless other procedures are performed simultaneously.
It may take anywhere from days to weeks before your breathing improves significantly, since there will be swelling, blood and mucous immediately after the procedure. Many surgeons clean out this debris a few days to a week after the procedure in the office during follow-up.

Nasal saline can be applied every few hours just after the surgery to loosen the secretions. Blowing your nose is discouraged until you get the go ahead from your surgeon during the first post-op visit.

Turbinate surgery is a very useful procedure that can be done alone or in combination with other procedures. Bleeding and infection, although rare, can occur, just like any other surgical procedure. There can be anesthesia risks as well. In the rare chance that the procedure fails, reasons for failure include too conservative of a procedure, persistent nasal septal deviation, or nasal valve collapse.


The above article is an excerpt from my E-Book, Un-Stuffing Your Stuffy Nose. Download for FREE by clicking here: http://tinyurl.com/23dgf38. Steven Y. Park, MD is a surgeon and author of the book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired. Endorsed by New York Times best-selling authors Christiane Northrup, M.D., Dean Ornish, M.D., Mark Liponis, M.D., Mary Shomon, and many others. http://doctorstevenpark.com.



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by nuclearpowerpants, Jul 08, 2010
In my humble opinion turbinate surgery, ablation, resection or destruction of the tissue in any way should be avoided like the plague. Why? Because the turbinates contain vital autonomic nerve receptors which regulate the breathing cycle and can seriously through your sympathetic / parasympathetic tone out of balance. This can (and often does) lead to serious conditions like insomnia and raised stress levels.
Just ask any Empty Nose Syndrome sufferer.

The fact is, I have rarely, if ever, seen a patient that has truly "eliminated all options" before resorting to surgery. In fact, I was told that I would need turbinate surgery by three different ENTs without any of them mentioning allergy immunotherapy as a viable alternative. This year I have completed a full course of allergy injections and, lo and behold, my turbinates have shrunk and I can breathe freely. All without having to chop out important parts of my anatomy in order to fill the wallets of my ENT surgeons who were simply too lazy, greedy or ignorant to mention the multiple alternatives available.

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by Tammy2009, Jul 08, 2010
I am very happy and grateful for turnibate surgery plus septoplasy.  I can breathe better than ever after only a week and a half.  

Although I have tried many things, 3 different nasal sprays, already on allergy shots (1 1/2 years into it), antihistamines don't work and already top dose of symbicort and my asthma still isn't controlled.  Probably not controlled because I could barely breathe through my nose.

Although at the moment the asthma is worse because of all the stupid drainage from after surgery.  oh well.

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by specialmom, Jul 08, 2010
Interesting.  I had never heard of turbinates until my 4 year old was having horrible bloody noses several times a day.  His pediatrician perscribed an allergy medication------------ no, I take that back.  Over the counter allergy medication was recommended and given.  No more bloody noses, no more issue with turbinates.  

By the way, I believe whole heartedly that most physicians are good people and genuinely try to help their patients.  

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by Steven Y Park, MDBlank, Jul 08, 2010
Bardcan,

I did qualify in my article that surgery is a consideration only if you've exhausted all other options, which includes, allergy medications, immunotherapy, and avoidance measures. Many patients have severe nasal congestion issues and test negative to all allergies. In this case, it's a neurologic imbalance that's causing the chronically swollen turbinates. Simultaneously, you also have to address all the other dietary, lifestyle, and stress aggravating factors than can cause a general imbalance of your autonomic nervous system. Poor breathing while sleeping is a major undiagnosed problem that most physicians don't address enough.

The empty nose syndrome is a terrible thing to have, but fortunately, it's not seen as often, as total resection of the turbinates are rarely, if ever done anymore. This is why various minimally invasive mucosa sparing surgical options were developed.

I don't think you can make a blanket statement that all turbinate surgery is bad. I routinely see patients that have undergone allergy shots for years with no improvement whatsoever. Different people have different responses, so treatment options have to be customized. If surgery is performed properly for the right reasons after all other options have been tired, it can be a useful addition to the overall care of the patient.

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by FrankFrank33, Jul 13, 2010
I had this surgery done to me. When I went in for the initial consultation, my doctor tried to insert the slim cable with a camera on the end into my nasal passages, and it would not even go in on one side. The other side a little better, but with a little force. ouch. but I had the surgery, and it changed my life. i could not breathe at night before the surgery, everytime I laid down in bed my nose would stop up and i could not breathe AT ALL through my nose.. everyone thought i just had the worst allergies and would just have to live with them. finally, tired of taking the same pills and sprays over and over, i went for a cat scan, then the surgery. it has been three years, and after the surgery i have felt like a new person, like i had been robbed of quality of life for all those years before

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by trwilli24, Aug 27, 2010
Dr. Park,

You mention empty nose syndrome sometimes happened in the past when some dotors removed all the inferior turbinates but you do not mention anything about middle turbinectomies.

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by Steven Y Park, MDBlank, Aug 27, 2010
trwilli24,

ENS doesn't happen as often when middle turbinates are removed because the middle turbinates are much smaller, and they're usually not removed entirely. A portion of it is sometimes removed during sinus surgery to access the sinus passageways. In general, it's best to preserve as much of the turbinates as possible.

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by trwilli24, Aug 28, 2010
that's a fine line you walk there, if you don't remove enough tissue then obstruction still persists, remove too much tissue and empty nose syndrome can happen. I'm glad I chose business as my major instead of opting for med school.

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by home34, Sep 15, 2010
Hi Doctor! My daughter had the surgery back in June of this year.  It was amazing how she could breathe better and her voice even sounded better. She got her first cold and it seems she is back to constantly sniffing & having to blow her nose.  Was the surgery all for nothing?  Or am i being paranoid since she has dealt with it for 12 years.  The cold lasted about a week but the stuffy, runny nose persists.

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by trwilli24, Oct 01, 2010
I just wanted to point out that the whole "empty nose" syndrome thing is probably over rated, but just the mere fact that the ENS site exists should be a real eye opener to the otolarynology community. All it takes is a quick visit to that site to realize that the suffering is immense - and what's worse is this syndrome is iatrogenic and completely avoidable. To top it all off, there is virtually no treatment for it whatsoever and only one or two doctors world wide are even trying to treat it. In my opinion, since this condition is iatrogenic, the otolarynology community owes it to those that have been afflicted adequate treatment and to reeducate surgeons who still perform total or even near total turbinectomies on the importance of turbinate tissue. Quite frankly, I think I'd rather be dead than have ENS.

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by peewee745, Jan 30, 2011
I had nasal turbinates removed in my doctor's office using intramural cautery.  This should not have been done in a dr.'s office as I am a cardiac patient taking Plavix 75mg. daily.  Caused hemorrhaging of the nose after the procedure.  Had to be rushed to the emergency room at Maimonides Medical Center in Bklyn, NY.  Now, presently I seem to have the same symptomology, and after reading some info found out these turbinates can get swollen again due to various factors.  What do I do now?  This difficulty in breathing cause me severe anxiety and panic cause I feel I can't breathe?  What should I do?  my email is ***@****

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