What is the concha (turbinate)?  What are the functions of the Conchae? 

Turbinates are three structures on the lateral walls of both nasal cavities (lower, middle, upper concha) located from the bottom upwards. The inside of these structures consists of the outside part of the bone, mucous membrane, and soft tissue in between. The largest turbinate is the lowest in front.
The turbinates have three main functions. They warm the air we breathe, humidify the air and assist in filtering the air. In addition, the turbinate mucosa provides the immune function of the nose by producing various enzymes such as immunoglobulin, lysozyme, lactoferrin, and protective proteins together with the nasal mucosa. The air reaches a temperature of 25 degrees and 90% humidity until it reaches the nasal area. When performing this function, the inferior turbinate grows or shrinks from time to time. Growth and shrinkage occur when the blood circulation of the turbinate increases and decreases. 80% of healthy adults have a cycle called the nasal cycle. In this cycle, the lower turbinate on one side of the nose grows and the other side gets smaller. This cycle is repeated every 3-6 hours. This cycle is often not noticed as the total air flowing through the nose is unchanged.

 

Causes of Turbinate Hypertrophy 

• Allergic Rhinitis The most important cause of turbinate hypertrophy is allergy (allergic rhinitis).

• Hormonal reasons Hypothyroidism, Diabetes, Acromegaly (excessive secretion of growth hormone)

• Medicines Some medications for blood pressure and heart (Alpha antagonists, Beta blockers, Angiotensin Converting Enzyme (ACE) inhibitors), Methyl Dopa, Oral Contraceptives (birth control pills), Psychotropic drugs, Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), Rhinitis medicamentosa

• Compensatory hypertrophy is the swelling of the turbinate on the opposite side of the deviation in those with septum deviation.

• Structural growth The bone part of the lower turbinate may be structurally large. During the development of the middle turbinate may occur concha bullosa. A concha bullosa is a pneumatized (air-filled) cavity within a nasal concha. 

• Infections Nasal conchae swell in infections such as colds, flu, and sinusitis.

• Environmental factors Dirty air, Cigarette smoke, Paint, Bleach, some perfume scents, Chemical gases

• Vasomotor rhinitis  Especially after the age of 35-40, there is a sudden change in the neural stimulation of the nasal concha with cold and dry air, high humidity, smoking, chemical irritant smells, fatigue, stress, sudden temperature or humidity change. As a result, the nasal conchae swell, and excessive secretion is produced from the nasal mucosa that cause nasal congestion and a runny nose. Symptoms start suddenly and last for a short time.

• Causes of physiological and temporary growth Nasal cycle, Exercise, Pregnancy (increases especially in the last weeks of pregnancy, occurs in 15-20% of pregnant women and passes 2 weeks after birth), Adolescence (turbinates swell due to hormonal changes), Positional (side-lying position causes blood pooling and swelling in the underlying concha, the pooled blood is discharged again in the upright position, and nasal congestion decreases), Sexual Arousal and Orgasm (turbinates swell with a mechanism called nasogenital reflex)

What are the symptoms of turbinate hypertrophy?

• Nasal congestion, sleeping with mouth open, snoring; Nasal congestion usually increases in the lying position. The reason is that the turbinates get more blood in the lying position. Due to sleeping with the mouth open, there is a feeling of dryness and stickiness in the throat, especially in the morning. Sleep quality is negatively affected and often causes feeling of fatigue upon waking. Besides, the inability to comfortably breathing through the nose reduces the effort capacity.

• Smell disorder. Concha hypertrophy, like other causes of nasal congestion may cause smell difficulties because the breathing passages are blocked, preventing scent molecules to reach the olfactory  (scent region) in the upper part.

• Pain in the face area may cause contact headache by forming mucosal contact areas. This type of pain is generally located in the anterior region of the face and has a dull character. It is not very severe but uncomfortable.

• Postnasal drip

How Is Turbinate Hypertrophy Diagnosed?

The nasal wings are opened with a little a device called a nasal speculum and the intranasal examination is made. With this examination, the anterior and middle parts of the lower turbinates  and the anterior part of the middle turbinate can be observed easily. Endoscopic examination is performed to see the posterior part of the nasal concha. In the endoscopic examination, an intranasal examination is performed with a 2.7 or 4 mm thick instrument called nasal endoscope, with a tiny camera and light at the tip. Both examination methods are painless and short. Diagnostic of concha hypertrophy often does not require further examination. However, a detailed evaluation can be made by taking sinus tomography in order to see the growths on the bony part of the concha and concha bullosa.

How Is Turbinate Hypertrophy Treated?

• Medication Cortisone nasal sprays, Decongestants, Antihistamines

• Radiofrequency Application The procedure can be easily done with local anesthesia. A needle is inserted into the inferior turbinate from 3 different points. Heat is generated in a limited area at the tip of the needle. Since heat generation is in a limited area, it does not damage the turbinate mucosa. The procedure takes an average of 5-10 minutes for each turbinate. First, the turbinate swells and after the 3rd week starts to shrink in the procedure performed areas. This process is completed after 1.5 months. There is not much bleeding. The procedure does not require hospitalization and you can return to work the next day. According to the literature data, efficiency of the procedure is up to 80-90%. However, based on my observations, the effectiveness of radiofrequency application is less than reported and requires several procedures. In the long term it does not replace surgical reduction. If the turbinates swell again, radiofrequency application can be repeated 2-3 times with an interval of 2 months. Lateralisation of the turbinates right after the radiofrequency, increases the effectiveness of the procedure. Personally, I prefer radiofrequency in children,  patients using blood thinners, patients I think the cause of nasal congestion is only turbinate hypertrophy, patients whose turbinate bone is not large and who are at risk of receiving general anesthesia and also in patients who do not want surgical treatment or who need to return to work in a short time.

Concha Reduction, Surgical Treatment Concha surgery can be performed under general anesthesia, local anesthesia or sedation.Nowadays techniques in which the nasal concha is reduced from the inside while preserving the turbinate mucosa are the techniques with the least side effects, shorter recovery time, less postoperative bleeding and crusting, and more successful results. In the endoscopic submucous concha reduction surgery the excess soft tissue underneath the turbinate is shaved without damaging the mucosa that covers it with a tool called a microdebrider and  removed from by vacuuming. In cases where the turbinate bone is large, some of the bone is removed. The operation takes an average of 10-15 minutes for each turbinate. After the surgery, a tampon is placed in the nose for 1-2 days. The patient can go home on the same day. After the tampons are removed, there may be slight bleeding for 2-3 days. During the recovery period, crusting may occur in the nose for a few weeks. These crusts can be cleaned by softening them with physiological saline. Rest is recommended for 7-10 days after surgery. If there are no side effects after the surgery, the patient can start office work and travel after the 5th postoperative day. 10 days after the operation, you can inhale normal water into your nose and blow your nose lightly. Laser has been used frequently for a reduction in the past years. However, it is no longer preferred because of post-operative crusting, pain, additional cost, and because it is not superior to the techniques used today. Conchae are indispensable structures of nasal functions. For this reason, it is very risky to reduce it excessively or to take it completely. In such a case, “empty nose syndrome” occurs and even if air passes through the nose, the person does not feel that the air has passed, the nose is constantly dry, crusted and a bad smell occurs. In children, reduction with radiofrequency is preferred instead of surgical treatment. Surgical treatment is more effective and more permanent, but recovery time is longer compared to radiofrequency.

Precautions in Concha Hypertrophy cases

Raising the head of the bed, Humidifying the room, and Washing the nose with ocean water can reduce turbinate hypertrophy.

Complications After Concha Surgery?

Complications are rare in turbinate surgery. Possible complications:

• Bleeding; The rate of bleeding requiring intervention is less than 1%. 

• Infection 

• Adhesion in the nose 

• Empty nose Syndrome

Does Concha Hypertrophy Recur After Surgery?

Since the turbinate mucosa is preserved in the surgery, the turbinates may re-grow, albeit slightly, especially in patients with allergic rhinitis. The re-growth rate is higher in the radiofrequency method.