Concha bullosa of a superior turbinate.

Patient 1. A 50-year-old woman complained of right facial pain and headache. She had a history of recurrent sinus infections and allergies, for which she had been treated with numerous medications. She denied previous sinus surgery or trauma. Computed tomography (CT) of the sinuses showed a concha bullosa of the right superior turbinate and chronic mucosal thickening in the ethmoid and maxillary sinuses bilaterally, as well as in the right sphenoid sinus (figure 1, A and B). Findings on nasal endoscopy were unremarkable with the exception of the concha bullosa (figure 1, C). The patient underwent bilateral endoscopic sinus surgery, including a right sphenoidotomy and a partial removal of a pneumatized right superior turbinate (figure 1, D). Her facial pain and headache resolved during the postoperative period.

Patient 2. A 92-year-old hypertensive woman complained of persistent headache. CT of the sinus showed a hyperpneumatization of the right superior turbinate (figure 2, A) and a possible mucocele on the right side of the sphenoid sinus (figure 2, B). Because of her age and precarious cardiac condition, the patient declined surgical treatment.

Anatomically and technically, the superior turbinate has been the least accessible and most neglected of the turbinates. Furthermore, only a few clinical conditions have been reported to be associated with superior turbinates.[1] However, recent advances in CT and nasal endoscopy have allowed for closer examination of this hidden turbinate. Specifically, pneumatization of the superior turbinate has been better identified by these advances.

Diagnosis of a concha bullosa of the superior turbinate usually requires evaluation by CT.[2,3] The standard coronal view of the sinus will show pneumatized cells just below the skull base and adjacent to the septum in the area of the superior turbinate.[2,3] Nasal endoscopy in the office, unfortunately, does not allow for ready access to this area. The pneumatization of the superior turbinate frequently leads to a reduction in the amount of room available for instrumentation in an already narrow area. The expanded superior turbinate will often occupy the space between the septum and the middle turbinate.[3]

Stammberger has reported that a symptomatic concha bullosa of the superior turbinate is extremely rare.[1] The condition usually becomes clinically apparent when the pneumatized turbinate protrudes anteriorly and inferiorly into the region between the middle turbinate and the nasal septum. Even without evidence of mucosal disease in the pneumatized superior turbinate, this protrusion can lead to headaches, as has been reported by Clerico.[3] This blockage might theoretically lead to hyposmia. Extension into this area by the expanded superior turbinate will lead to obstruction of the ostium of the sphenoid sinus.

The treatment of symptomatic superior turbinate concha bullosa almost always entails surgical intervention. In cases of associated headache, a partial superior turbinectomy to eliminate mucosal contact between the superior turbinate and the septum will achieve a significant reduction in symptoms.[3] In cases of hyposmia, a partial superior turbinectomy is performed to allow sufficient aeration to the superior meatus. Symptomatic concha bullosa of the superior turbinate with sphenoid sinusitis will respond to a partial superior turbinectomy combined with sphenoid sinusotomy.

References

(1.) Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C. Decker, 1991:160-9.

(2.) Ariyurek OM, Balkanci F, Aydingoz U, Onerci M. Pneumatized superior turbinate: A common anatomic variation? Surg Radial Anat 1996;18:137-9.

(3.) Clerico DM. Pneumatized superior turbinate as a cause of referred migraine headache. Laryngoscope 1996;106:874-9.