Concha bullosa of an inferior turbinate.

Abstract

Pneumatization of the inferior turbinate is a rare intranasal anatomic variant. In the English-language world literature, only 10 cases of inferior turbinate concha bullosa have been reported. We present the 11th such case, which we discovered during an evaluation of a patient who had chronic rhinosinusitis with allergic manifestations.

Introduction

The inferior turbinate is a scroll of bone that extends from the nares anteriorly to the choanae posteriorly. It over-hangs and delineates the inferior meatus, which is anatomically significant only for the nasolacrimal duct orifice that opens at the anterior end of the meatus. (1) Functionally, the inferior turbinate primarily serves to contribute to the humidification and warming of inspired air. The anterior portion of the inferior turbinate also forms part of the nasal valve area, the narrowest region of the nasal passage. (2)

Concha bullosa refers to pneumatization of the intranasal turbinates. It can occur at any level (superior, middle, or inferior), but the term is usually used to describe the aeration of the middle turbinate. In terms of frequency, concha bullosa is the most common anatomic variant of the middle turbinate. Alternatively, concha bullosa is relatively infrequent in the superior turbinates and even more uncommon in the inferior turbinates. (3-12)

In the English-language world literature, only 10 cases of inferior turbinate concha bullosa (ICB) have been reported. (3-9) Three of the 10 patients had bilateral ICB. (6,7,9) In addition, one case report of unilateral inferior turbinate mucocele has been published. (13) In this article, we report a new case of unilateral ICB.

Case report

A 38-year-old woman came to us with concerns consistent with perennial allergic rhinitis and intermittent sinusitis. Her primary symptoms were nasal obstruction, left-sided facial pressure, chronic cough, and nasal and postnasal discharge. She reported a predictable escalation of symptoms during the months of August and September. Her symptoms were of longstanding duration (>10 yr) and were being treated with a combination of prescription antihistamines and a steroid nasal spray. She also reported occasional headache and difficulty with bouts of sinusitis. She denied any history of epiphora, trauma, or sinus surgery.

Physical examination, including anterior rhinoscopy, revealed a normal external nasal appearance. Intranasal examination revealed a boggy nasal mucosa with pale, hypertrophied inferior turbinates and an absence of any mass or discharge. The patient was otherwise healthy.

Coronal noncontrast computed tomography (CT) performed with 3-mm collimation and interval revealed a left ICB, minimal and scattered mucosal thickening, and partial bilateral ostiomeatal unit obstruction (figure). The ICB featured aeration of the lamellar portion of the turbinate. Additionally, the left nasolacrimal duct appeared to be undisturbed, and no communications were identified with the left maxillary sinus or nasal passageway.

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The patient opted to undergo allergy testing by skin endpoint titration (SET), also known as intradermal dilutional testing. She had a markedly positive reaction to ragweed antigen and less strong reactions to various molds, penicillin, and pet dander. She elected to forego any surgical treatment in lieu of more conservative therapy, including immunotherapy injections. At last follow-up, the patient had progressed to the maintenance level of immunotherapy injections and was satisfied with her symptom reduction thus far.

Discussion

With only 11 reported cases in the world English-language literature, there is a relative dearth of information about ICB. Two proposed mechanisms for ICB formation have been presented. Dogru et al proposed that the mechanism involves the ossification of the chondral framework of the inferior turbinate to a double lamella in fetal life and the misinvagination of the epithelium into the double lamella. (4) Namon proposed that air cell formation most likely results from maxillary sinus disease and is associated intimately with the site of inferior turbinate attachment. (13)

Delineating concha bullosa from turbinate hypertrophy and describing both its location within the turbinate and its local anatomic relationships are easily achieved with CT imaging. ICB location within the turbinate may be described in a manner similar to that proposed by Bolger et al for middle turbinate concha bullosa (4):

* Lamellar-type concha bullosa: Pneumatization is localized to the vertical lamella of the turbinate.

* Bulbous-type concha bullosa: Pneumatization is localized to the inferior (or bulbous) pair of the turbinate.

* Extensive-type concha bullosa: Pneumatization is localized to both the vertical lamella and the inferior part of the turbinate.

One CT finding that is central to the evaluation of sinusitis symptoms is visualization of unobstructed ostiomeatal complexes, which are intimately related to the site of inferior turbinate attachment. Other notable findings in the radiologic evaluation of ICB that may contribute to recurrent or persistent sinus disease include the determination of any communications with the nasal passageway or maxillary sinus as described in previous case reports. (3,7,8) Epiphora may also occur as a complaint related to nasolacrimal duct disruption or obstruction of the inferior meatus associated with ICB, and it is easily identified on CT.

A study of CT variation in nasal and paranasal anatomy in patients with symptoms of sinus disease was published by Zinreich et al. (3) They evaluated patients who had sinus disease symptoms, with and without middle turbinate concha bullosa, with CT to determine the incidence of coexisting ostiomeatal disease. They found no overall increase in ostiomeatal disease in patients with middle turbinate concha bullosa compared with those without concha bullosa.

Symptoms often associated with various levels of turbinate hypertrophy or concha bullosa include nasal obstruction or congestion, facial pain, and headache. Nasal obstruction or congestion is known to be caused by inferior turbinate hypertrophy, and in many cases it is responsive to therapy directed at such. Middle turbinate hypertrophy and concha bullosa, via contact points with the nasal septum, are known to be associated with headache and facial pain. (15) However, conflicting views on the role of inferior turbinate hypertrophy in headache and facial pain have been presented. Dogru et al reported improvement in headache following an inferior turbinate resection in a case of pneumatized inferior turbinate. (4) Conversely, Cankaya et al reported no improvement in headache symptoms following partial resection of an ICB. (5) It is interesting that in the same report, Cankaya et al noted subsequent improvement of headache following ipsilateral middle turbinate resection.

ICB does not necessarily require surgical treatment, especially when there is no overall enlargement of the turbinate and other modalities are available to treat underlying causes of symptoms. Unlu et al presented a case of ICB without inferior turbinate enlargement that did not require surgical resection for symptom relief. (8) In our case, the patient opted for medical therapy and is satisfied with her therapeutic results to date. Her symptoms of left-sided facial pressure were probably secondary to mucosal edema that caused intermittent obstruction of her left ostiomeatal complex. Her ICB was an incidental finding noted on CT.

This is not to say that surgical treatment is inappropriate for symptomatic ICB. Techniques for ICB resection have been adapted from procedures that were originally designed for middle turbinate surgery. Dogru et al described the excision of the lateral aspect of the inferior turbinate in an anterior-to-posterior direction. (4) This procedure is appropriate only for those cases in which ICB does not extend into the maxillary sinus. ICB with extension into the maxillary sinus that is resected in this manner might result in an iatrogenic inferior meatal antrostomy. Another method was reported by Unlu et al, (8) who modified the middle turbinoplasty technique first described by Har-el and Slavit (16) for resecting the inferior turbinate. A procedure specific to ICB alone has not been reported in the literature.

In preparation for surgical intervention, it is important to consider other underlying causes of turbinate hypertrophy or enlargement. Two factors known to contribute to turbinate hypertrophy or enlargement include compensatory hypertrophy (opposite a deviated septum) and chronic rhinitis of vasomotor, medicamentous, or allergic origin. Surgical correction is likely to be followed by a recurrence if the underlying cause or causes of turbinate hypertrophy or enlargement are not addressed, especially in cases of allergic rhinitis.

Nasal congestion is often reported to be the most common complaint among patients with allergic rhinitis. (17) Additionally, the interrelationship between allergy and sinusitis has long been recognized in the literature. (18) At the otolaryngology clinic at the University of Nebraska Medical Center, patients with allergy symptoms are evaluated in a standardized fashion by SET. In a recent study of 3,329 otolaryngology clinic allergy patients, Lane et al reported that 30% of those who noted improvement in symptoms following immunotherapy eventually required additional nasal or sinus surgery for alleviation of symptoms. (19) These findings suggest that sinonasal disease in allergy patients often requires both medical and surgical approaches. Moreover, these findings also emphasize the importance of the otolaryngologist in the comprehensive management of rhinosinusitis with allergic manifestations.

References

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(18.) Van Dishoeck HA. Franssen MG. The incidence and correlation of allergy and chronic maxillary sinusitis. Pract Otolaryngol 1957;19:502-8.

(19.) Lane AP, Pine HS, Pillsbury HC III. Allergy testing and immunotherapy in an academic otolaryngology practice: A 20-year review. Otolaryngol Head Neck Surg 2001;124:9-15.

From the Department of Otolaryngology Head and Neck Surgery, University of Nebraska Medical Center, Omaha.

Reprint requests: Wm. Alan Ingram, MD, University of Nebraska Medical Center. 981225 Nebraska Medical Center, Omaha, NE 68198-1225. Phone: [phone]; fax: [phone]; e-mail: [e-mail]