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

A 42-year-old woman came to the office with right facial pressure and right nasal stuffiness of several months' duration. Coronal computed tomography (CT) of the sinuses detected right chronic ethmoid and maxillary sinusitis (figure, A), despite appropriate long-term antibiotic treatment. The enlarged middle turbinate caused a narrowing of the right middle meatus and subsequently blocked the outflow of right ethmoid and maxillary sinus drainage.

Nasal endoscopy at surgery detected concha bullosa bilaterally. Further examination revealed the presence of an unusual "punched-out" opening in the midportion of the thickened medial wall of the right middle turbinate (figure, B). It appeared to be a drainage opening to the concha bullosa. A microdebrider was used to open the anterior end of the right concha bullosa, and the inside lumen of the concha bullosa was visualized (figure, C). The mucosa was edematous. Inspection of the lumen with a 30[degrees] telescope clearly showed the interior aspect of the ostium of the medial wall of the concha bullosa, which opened into the right nasal cavity (figure, D). The patient underwent a resection of the lateral wall of the right concha bullosa together with a right anterior ethmoidectomy and a middle meatal antrostomy. Polypoid tissue and thick mucus were found. A similar opening was found in the middle turbinate on the left side. No surgery was performed on the left because the patient had no symptoms on that side. Postoperatively, she had a markedly patent right middle meatus and did well. One year later she was still asymptomatic.

The middle turbinate--the center of the three processes that are suspended from the lateral wall of the nasal cavity--projects over the ethmoid bulla and the uncinate process. It is attached superiorly to the cribriform plate, and its free border slopes inferiorly and posteriorly. The base of the middle turbinate can be invaded by ethmoid air cells, which can enlarge the turbinate; an enlarged turbinate is known as a concha bullosa. (1) This anatomic variant is relatively common; Zinreich et al reported that its incidence was 34% in their study of 320 patients with sinus disease. (2)

Clinically, a concha bullosa has relevance as a potential source of ethmoid sinusitis. The enlarged turbinate can also cause obstruction of the middle meatus. Generally, the posterior ethmoid cells have been reported to give rise to a concha bullosa. (1) Subsequently, drainage from a concha bullosa is generally directed posteriorly into the ethmoid system. The drainage from the ethmoid bulla (the largest and most constant anterior ethmoid air cell) opens into the middle meatus and then into the nasal cavity. The ostium of the ethmoid bulla is often found in the hiatus semilunaris superior, but it can also be found in the anterior or lateral bulla wall, the ethmoid infundibulum, the hiatus semilunaris inferior, and the retrobullar recesses. (3)

The expected drainage of the aerated middle turbinate would be directed posteriorly into the ethmoid and from there into the middle meatus. In the case described here, a rare opening in the medial wall of the middle turbinate was found bilaterally.

References

(1.) Hollinshead WH. Anatomy for Surgeons. 2nd ed. Vol. 1, The Head and Neck. New York: Harper & Row, 1968.

(2.) Zinreich SJ, Mattox DE, Kennedy DW, et al. Concha bullosa: CT evaluation. J Comput Assist Tomogr 1988;12:778-84.

(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 Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group. New Haven, Conn., and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa).