turbinate outfracturing only 3 year old

[lee300]

My 3 year old had a T and A done about four months ago for sleep apnea.  He also has pollen allergies with pretty bad nasal congestion as his main symptom.  During the T and A, the ped ENT outfractured his inferior turbinates , as he said he does this routinely in children with predominant nasal obstruction symptoms even if turbinates are normal in size during the procedure.  He told me there were absolutely no risks or complications to this procedure, that it could only help him with his allergies.  Now, four months later, he still mouth breathes and gets nosebleeds from time to time in his left nostril.  Also, He has a lot of nasal crusting in both of his nostrils.  Can this be from minor outfracturing or would it be more likely to be from allergies?  We do nasal irrigation at night, but there is still a lot of nasal crusting in the am.  We live in a fairly humid environment with no heater running.  I asked our ped ENT and was told that it was all related to a habit of mouth breathing drying out his nasal airways, but in reading stuff online I am worried that the turbinate outfracture was unnecessary and may be the culprit and wanted another opinion.  Thanks.

[lee300]

Sorry to bother you again, but still wondering what would cause the excessive inflow of air into the nasal cavity to cause nasal crusting if not from simple outfracturing?  thanks for your help.  

[lee300]

Thank you so much for all of your help.  In addition to my last question, Your second cause of crusting was excessive inflow of air into the nasal cavity, what would cause this excessive inflow of air? I also wanted to ask if the above reasons could be why he has been having some mild nosebleeds especially when he blows the nose.  Wanted to make sure that mild nosebleeds would not be caused from the simple outfracturing either.  Thank you.

[lee300]

Thank you so much for all of your help.  One last question, Your second cause of crusting was excessive inflow of air into the nasal cavity, what would cause this excessive inflow of air?

[Naveen Kumar, MD]

Dear lee300,

Many a times, fracturing of the turbinates also includes resection of the nasal mucosa. If only fracturing of the turbinates is done without resection of mucosa over the nasal turbinates, then crusting is less likely as the mucosa over the turbinates is intact. But then there are various other causes which can cause dryness of the nasal mucosa such as:

1. Allergic rhinitis leading to excessive loss of water from the nasal mucosa leaving it dry and susceptible to crusting.

2. Excessive inflow of air into the nasal cavities leading to crusting and nasal block, which causes mouth breathing further worsening the nasal crusting

To sum it up, mere fracturing of the nasal turbinates cannot cause crusting and lead to atrophic rhinitis. Either of the above two causes could be the prime reason for the crusting.

Regular nasal douching with saline nasal spray can reduce the nasal crusting and dryness of the nose. Consuming plenty of water would also help.

Wishing him good health.

Best Regards
Dr. Naveen Kumar N.

[lee300]

I did read some of those articles in that journal and it talked more about volume reduction of the turbinates.  I thought with outfracturing volume was not lost and they functioned the same.  So with all this said, can nasal crusting be simply from allergies or can a simple lateral outfracture cause crusting and atrophic rhinitis without resection of the turbinate.  Thanks again.

[lee300]

Would there likely be continued problems with crusting and nasal dryness from simple outfracturing rather than a partial turbinectomy.  None of his turbinate was removed, it was just pushed slightly lateral.  I can still see both turbinates when I look in his nose.  I just thought maybe the nasal crusting could be from allergies.

[Naveen Kumar, MD]

Dear lee300,

Thanks for the query

In my opinion, turbinoplasty – or the reduction of turbinates should be performed in cases where the turbinates are enlarged enough to cause narrowing of the nostrils and difficulty in breathing. Turbinoplasty is generally performed in adults and less often in children suffering from either allergic rhinitis or vasomotor rhinitis. It is also usually avoided in children as it can lead to atrophic rhinitis (repeated drying of the nasal mucosa with crusting). Here is a reference that further supports this view (Int J Pediatr Otorhinolaryngol. 2007 Jun;71(6):921-7. Epub 2007 Apr 5.).

Once an adeno-tonsillectomy is performed most children get relieved of the nasal obstruction, but a few of them do continue with mouth breathing as they are habituated to the previous situation and do not make an active effort to breathe through the nose. Following turbinoplasty, there is some amount of bleeding as well as nasal crusting until the mucosa heals completely. Because of the crusting the child continues to have nasal block and reverts back to mouth breathing.

In a case similar to your child’s, I would have preferred to perform the turbinoplasty in a second sitting if needed after assessing the nasal block, rather than combining it with the adeno-tonsillectomy. Following adeno-tonsillectomy there is usually enough space created for the child to breathe. If turbinoplasty is also done in the same sitting there may be drying of the mucosa because of excessive flow of air.

Now since the surgery has already been performed, I would recommend using saline nasal spray 3 to 4 times a day to clear the crusts and keep the nasal mucosa moist. Also, encourage your child to drink plenty of water to stay hydrated. Discuss the use of steroid nasal spray during allergic episodes with your doctor.

Hope that this information helps and hope that you will get better soon.

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Best Regards,
Dr. Naveen Kumar