An unusual lateral ostium of a concha bullosa of the middle turbinate. (Rhinoscopic Clinic).

A 46-year-old woman complained of difficult nasal breathing and recurrent sinusitis. Coronal computed tomography (CT) of the sinuses revealed the presence of a large concha bullosa in the left middle turbinate along with septal deviation and ethmoid sinusitis (figure, A and B). An unusual lateral ostium of the left concha bullosa was also noted (figure, A). The concha bullosa appeared to obstruct the superior portion of the left nasal cavity.

After medical treatment failed, the patient underwent endoscopic sinus surgery, which included resection of the lateral wall of the left concha bullosa, septal reconstruction, and partial anterior ethmoidectomy. At surgery, the left concha bullosa was opened with a microdebrider, and the inside lumen of the concha bullosa was inspected with a 4-mm, 0[degrees] telescope (figure, C). Careful examination revealed the presence of a drainage opening in the posterior portion of the lateral wall of the concha bullosa of the middle turbinate (figure, D). Mucus from the concha bullosa was found to exit from this ostium. The telescope was then removed from the concha bullosa and inserted into the left middle meatus. Examination clearly showed an oval opening in the posterior portion of the lateral wall of the left middle turbinate (figure, E). Blood-tinged mucus was emanating from the inside of the concha bullosa into the left middle meatus. The opening was enlarged anteriorly by removing the lateral wall of the concha bullosa. Post-operatively, the patient's nasal passages were adequate, and she healed very well.

Pneumatization of the middle turbinate (and less commonly of the superior turbinate) can be clinically significant. (1) In an earlier installment of RHINOSCOPIC CLINIC, we described an unusual medial ostium of a concha bullosa of the middle turbinate. (2) In the present installment, we report an uncommoa lateral ostium of the concha bullosa. The concha bullosa usually drains into the frontal recess (1) or the anterior ethmoids; from there, it drains into the middle meatus and then into the nasal cavity. The anterior ethmoid cells drain into the middle meatus--of ten through the hiatus semilunaris superior, but sometimes through the anterior or lateral bulla wall, the ethmoid infundibulum, the hiatus semilunaris inferior, or the retrobullar recess. (3)

The expected drainage of the concha bullosa would be directed posteromedially into the frontal recess and anterior ethmoid sinus and then into the middle meatus. In this article, we have described an unusual opening through the lateral wall of the concha bullosa. Careful endoscopic examination might detect an opening of the concha bullosa in an unexpected location.

References

(1.) Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C. Decker, 1991.

(2.) Christmas DA, Mirante JP, Yanagisawa E. An unusual medial ostium of a concha bullosa of the middle turbinate. Ear Nose Throat J 2002;81:491-2.

(3.) Yanagisawa E, Joe JK. Christmas DA. Where is the ostium of the ethmoid bulla? Ear Nose Throat J 1999;78:886-7.

From the Section of Otolaryngology, Hospital of St. Raphael, New Haven, Conn., and the Yale University School of Medicine, New Haven (Dr. Yanagisawa); and the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Mirante and Dr. Christmas).