Functional Turbinoplasty

The Problem

Turbinate hypertrophy is a common cause of functional problems in patients undergoing aesthetic rhinoplasty. Failure to diagnose and treat the problem may cause the persistence of the obstructive symptoms in a large group of patients and even cause a flare up of symptoms in others. Even minor modifications in nasal airflow during different steps of rhinoplasty such as hump removal, tip surgery, lateral osteotomy, or alar base reduction, could uncover inferior and middle turbinate problems resulting in a considerable nasal obstruction that was not diagnosed preoperatively. The nasal valve is responsible for more than half of the total upper airway resistance. The inferior turbinate is an important structure in the nasal valve region, and its enlargement can cause exponential increases in airway resistance. In a published survey from the American Society of Plastic Surgeons, about half of respondents indicated that they treat inferior turbinate hypertrophy with outfracture alone ¹ ; however, there is no evidence of the long-term efficacy of this technique since the lateralized turbinate either returns to the medial position or becomes hypertrophied. Partial turbinectomy, which was the second most common technique in that study, does not preserve normal nasal function and has high complication rates. Therefore, an exact preoperative diagnosis and the proper intraoperative treatment is important to restore normal function of the nose in patients undergoing rhinoplasty.

The Background

The lateral nasal wall has complex anatomy with three main turbinates, multiple clefts, and various openings. The inferior turbinate is an isolated bone. Middle, superior, and occasionally the fourth supreme bone are parts of the ethmoid bone. The clefts below each turbinate are known as their meatus. The inferior turbinate is the largest turbinate and the most dynamic structure of the nose. The inferior meatus contains the opening of the nasolacrimal duct. The middle turbinate is the second largest turbinate of the nose. The complicated structures of the middle meatus are known as the ostiomeatal complex. This is a transitional zone for drainage of the anterior sinuses, which include the anterior ethmoid, maxillary, and frontal sinuses. Therefore, pathologic conditions of the middle turbinate that affect the ostiomeatal complex can influence paranasal sinuses and cause chronic sinusitis ² .

Hypertrophy of the inferior turbinate is the most common cause of turbinate surgery, whereas enlargement of the middle turbinate is the second most common cause.

There are two types of inferior turbinate enlargements: bony and mucosal. Bony enlargement may be classified as vertical, horizontal, or a combination of both ( Fig. 11.1 ). There are many causes of mucosal hypertrophy of the inferior turbinate. Turbinate hypertrophy frequently occurs in the entire length of the turbinate, but sometimes may be confined to the turbinate head or the turbinate tail ( Fig. 11.2 ). Hypertrophy of the turbinate tail is usually overlooked by missing more diagnostic rhinologic investigations, which will be discussed. In patients with severe septal deviation undergoing septorhinoplasty, turbinate hypertrophy can occur on the nondeviated side ( Fig. 11.3 ). Untreated inferior turbinate hypertrophy can lead to the postoperative obstruction of the contralateral side of the deviated septum. An allergic reaction is the other cause of inferior turbinate hypertrophy, where the inferior turbinate appears as a pink−purple color. It is not uncommon in patients with coexistent septal deviation. The condition of the nasal obstruction could be complicated by excessive use of topical decongestants causing rebound phenomena as rhinitis medicamentosa ( Fig. 11.4 ). The most common cause of middle turbinate enlargement is concha bullosa. It arises by extended pneumatization of the ethmoid sinuses into the middle turbinate. Although this anatomic variation is common and mostly asymptomatic, in some patients it could induce symptoms related to the sinuses. Extensive pneumatization of the concha bullosa could also affect the nasal airway ( Fig. 11.5 ). Concha bullosa could also obstruct the ostiomeatal complex and trigger a pathogenic cascade of chronic rhinosinusitis ( Fig. 11.6 ). It is not uncommon to have a combination of different turbinate variations including inferior turbinate bony and soft tissue enlargement in combination with concha bullosa ( Fig. 11.7 ).