Pneumatized inferior turbinate: report of three cases.

Pneumatization (concha bullosa) of the inferior turbinate is a very rare anatomic anomaly. Since the first description of a pneumatized inferior turbinate in 1988 by Zinreich et al, (1) sporadic cases of this condition have been reported. (2-7) According to Ingram and Richardson, 11 cases of inferior turbinate concha bullosa (ICB) have been reported in the English-language world literature. (6) We report three additional cases.

Case reports

Patient 1. A 38-year-old man presented with long-standing nasal congestion. He had tried several medications prescribed by his primary care physician. He brought with him a computed tomography (CT) scan of his sinuses. Our clinical examination revealed that his inferior turbinates had hypertrophied (figure 1, A). Examination of the previously obtained CT (figure 1, B, C, and D) revealed a well-pneumatized right inferior turbinate, a significant lateral communication between the pneumatized inferior turbinate and the right maxillary sinus, an incomplete pneumatization of the left inferior turbinate, and a left pneumatized middle turbinate. We treated the patient with a decongestant and steroid nasal spray, and his symptoms subsided.

[FIGURE 1 OMITTED]

Patient 2. A 50-year-old woman complained of nasal stuffiness. Examination revealed hypertrophied inferior turbinates and a septal deformity. CTs of the sinuses identified a concha bullosa of the right inferior turbinate, marked hypertrophy of both inferior turbinates, extension of the concha bullosa from the right inferior turbinate into the right maxillary sinus, and an intraseptum of the right maxillary sinus (figure 2). We treated the patient with intermittent decongestant and steroid nasal-spray therapy. Surgical treatment was recommended, but the patient declined.

[FIGURE 2 OMITTED]

Patient 3. A 45-year-old man complained of nasal stuffiness. Examination revealed hypertrophy of the middle and inferior turbinates. CTs of the sinuses revealed a left ICB in the middle third, which was associated with complete opacification of the left maxillary sinus and obstruction of the left ostiomeatal complex (figure 3). The ICB was present on at least three coronal cuts. On an anterior cut, the ICB was open on the lateral aspect. In this case, the ICB did not communicate with the maxillary sinus. Surgical treatment was suggested, but the patient declined because he was already undergoing extensive treatment for cancer of the tongue and pharynx and multiple-stage reconstruction.

[FIGURE 3 OMITTED]

Discussion

The inferior turbinate is an independent bone that originates in the lateral nasal wall. It is covered with a thick mucous membrane that contains a plexus cavernosus. It is so arched that the inferior meatus, lying below and lateral to it, is narrowed both anteriorly and posteriorly; it is both wider and higher at its middle. (8)

Diagnosis of ICB is usually made by coronal CT. The inferior turbinate should be examined from the naris anteriorly to the choana posteriorly. Pneumatization apparently occurs in the midportion of the inferior turbinate. In most cases of ICB, there is communication with the maxillary sinus. (1-3, 5, 6) In the rest, there is no such communication. (2, 4, 7) Dogru et al proposed that the mechanism of ICB formation involves the ossification of the chondral framework of the inferior concha, which results in a double lamella during fetal life and the misinvagination of the epithelium. (3)

Pneumatization can occur in any nasal turbinate. Middle turbinate pneumatization is most common, and it may cause symptoms of nasal obstruction. (1, 7) Pneumatization of the superior turbinate also may cause congestion or sinus obstruction. (9) Pneumatization of the inferior turbinate is rare. (1-7) ICB does not always require surgical treatment, particularly when congestion responds to medical therapy.

Symptomatic ICB might respond to (1) outfracture of the inferior turbinate and squeezing of the ICB with Takahashi's forceps or a concha bullosa crusher, (10) (2) simple excision of varying amounts of the free edge of the inferior turbinate with angled scissors, (3) submucous resection of the inferior turbinate, or (4) bipolar submucosal electrocoagulation. (11) Dogru et al described the resection of the lateral portion of the ICB. (3) However, when there is communication between the ICB and the maxillary sinus, lateral resection may create an inferior meatal antrostomy, thereby causing a recirculation problem. Submucosal inferior turbinate reduction turbinoplasty with a microdebrider may also be a useful procedure.

References

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

(2.) Dawlaty EE. Inferior concha bullosa--A radiological and clinical rarity. Rhinology 1999;37:133-5.

(3.) Dogru H, Doner F, Uygur K, et al. Pneumatized inferior turbinate. Am J Otolaryngol 1999;20:139-41.

(4.) Ozcan C, Gorur K, Duce MN. Massive bilateral inferior concha bullosa. Ann Otol Rhinol Laryngol 2002;111:100-1.

(5.) Unlu HH, Altuntas A, Aslan A, et al. Inferior concha bullosa. J Otolaryngol 2002;31:62-4.

(6.) Ingram WA, Richardson BE. Concha bullosa of an inferior turbinate. Ear Nose Throat J 2003;82:605-7.

(7.) Braun H, Stammberger H. Pneumatization of turbinates. Laryngoscope 2003;113:668-72.

(8.) Hollinshead WH. The head and neck. In: Hollinshead WH. Anatomy for Surgeons. Philadelphia: Harper and Row, 1982.

(9.) Christmas DA, Ho SY, Yanagisawa E. Concha bullosa of a superior turbinate. Ear Nose Throat J 2001 ;80:692-4.

(10.) Woolford TJ, Jones NS. A concha bullosa crusher for use in endoscopic sinus surgery. J Laryngol Otol 2000;114:205-6.

(11.) Goode RL, Pribitkin E. Diagnosis and Treatment of Turbinate Dysfunction. Alexandria, Va.: American Academy of Otolaryngology Head and Neck Surgery Foundation, 1995.

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