Inferior turbinate hypertrophy (swollen turbinates) – What you need to know

What is an inferior turbinate?

The inferior turbinate is a sausage-like bony structure that lies along the side wall of your nose (one on each side of the nasal cavity) (Fig 1a &b). Your nose has three pairs of turbinates (superior, middle and inferior turbinates). The functions of the turbinates are to humidify, warm and direct the air as it passes through the nasal cavity. They also produce mucous that traps dirt and bacteria as it passes through the nose. The inferior turbinates are the largest and most prominent of the turbinates and can cause significant nasal blockage when they are enlarged.

Why do I have a swollen or enlarged inferior turbinate?

Enlarged inferior turbinates (inferior turbinate hypertrophy) are the most common cause of nasal blockage (Fig 2). The size of the turbinate varies with many factors. Many people notice that one side of the nose is more congested at certain times of the day and then at a different time in the day the opposite side is congested. This alternating congestion is normal and is known as the nasal cycle. On the other hand, when there is infection  or inflammation in the nose, the turbinates on both sides become swollen and you may feel blocked on both sides at the same time. This also happens very commonly in allergic rhinitis, a condition caused by hypersensitivity of the nose to environmental allergens.

Figure 2 – A comparison between a normal (patient’s right side) versus an enlarged (patient’s left side) inferior turbinate. The inferior turbinate has a bone with surrounding erectile soft tissue. The erectile soft tissue of the inferior turbinate can swell up when exposed to an allergen

How is a swollen inferior turbinate treated?

Majority of the time, enlarged inferior turbinates are due to Rhinitis (sensitive nose). Treatment of Rhinitis with allergen or trigger avoidance, nasal steroid sprays and oral antihistamines with decongestants do help relieve nasal blockage in majority of patients with enlarged inferior turbinates. Nasal steroid sprays work by reducing the amount of inflammation on the inferior turbinates. However, in some people, this may not be enough to provide adequate relief or may not be a long-term solution. Hence, in such patients, inferior turbinate reduction procedures may be considered.

When do I need inferior turbinate reduction procedures (or surgeries)?

These procedures will be recommended by your ENT surgeon if you have persistent blocked nose from inferior turbinate hypertrophy (enlarged inferior turbinates) and have not responded adequately to nasal steroid sprays and medications.

What are inferior turbinate reduction procedures (or surgeries)?

There are many different methods to reduce the size of the inferior turbinates. They range from the least invasive procedures such as radiofrequency ablation of the turbinate to the most aggressive procedure such as total turbinectomy (complete removal of the inferior turbinate). Quite often, an inferior turbinate reduction procedure is performed with a Septoplasty to correct any concurrent deviated (bent or crooked) nasal septum. Based on the surgeon’s judgement and your preference, the following types of inferior turbinate reduction surgery can be considered. Your consultant ENT Specialist in Singapore will discuss the pros and cons of each procedure.

The two most commonly performed procedure to reduce the size of the inferior turbinates are:

• 1) Radiofrequency (RF) or Coblation of the inferior turbinates

This method is performed under local anaesthesia (i.e you will be awake during the procedure). It involves applying local anaesthetic (L.A.) medications in the nasal cavity to make it numb. This is done by spraying, direct application with nasal patties (small gauze strips soaked with anaesthetic medications) and injection. Once the nose is well-anaesthetised, the instrument “probe”, (either radiofrequency or coblation®) is inserted into the inferior turbinate and energy is applied through the probe (Fig 3).  Each application takes less than a minute and is repeated 2-3 times on each side, depending on the size of your turbinates.

Figure 3 – A probe (with coblation or radiofrequency energy) is inserted into the soft tissue of the inferior turbinate to induce shrinkage of the turbinate (done under local anaesthesia).

After radiofrequency or coblation application is completed, patties are placed directly at points where the probe had been inserted to help minimise bleeding. Your wellbeing will be monitored in the clinic or day surgery ward for up to an hour or two after the procedure. Once you have been assessed to be well, the patties will be removed by a member of the surgical team. Patients go home on the same day but are advised that there may be a small amount of blood staining at the front of the nose.

It is important to know that while the turbinate tissues are reduced in size at the time of surgery, this is soon followed by swelling of the tissues, and it is only after several weeks before the turbinates start to shrink. Therefore, you may actually feel that your nose is blocked for up to a month after the procedure. Radiofrequency or coblation of the inferior turbinates may have to be repeated after 2-3 months in some patients if they still have significant blocked nose.

2) Medial Flap Inferior Turbinoplasty (MFIT)

This method is performed under general anaesthesia (patient completely asleep). Local anaesthesia is also administered to improve patient comfort in the early post-operative period. In this procedure, a portion of the mucosal lining of the turbinate is preserved) while the rest of the turbinate tissue, including most of the bone is removed. At the end of the procedure the flap is positioned so as to create a much smaller version of its original (Fig 4).

The amount of tissue removal is greater in MFIT than for RF/coblation of the inferior turbinates, hence improvement in nasal breathing is more immediate.  A recent study has shown that this procedure has the highest success rate in relieving nasal blockage  in patients with inferior turbinate hypertrophy. However, the chance of post-operative bleeding may also be higher (~5%). The surgeon may insert packing materials that are either absorbable (does not require removal) or non-absorbable (usually removed 1 -2 days after surgery). If non-absorbable material is used, the patient will have to stay in the hospital till the packs are removed (usually overnight to 2 days).

What are the possible risks and complications from inferior turbinate reduction procedures?

Inferior turbinate reduction surgery is common and the risk of complications is low. There is no external cut or wound on the face as the surgery is performed through the nose. The main risks of turbinate reduction procedure are crusting, bleeding, postoperative wound infection and, very rarely, empty nose syndrome. The more aggressive the procedure, the more likely the patient will feel immediate improvement in nasal obstruction and also the less likely that the patient will require a second procedure. However, the risks of complications are also higher with more aggressive procedures. The patient should have a thorough discussion with the surgeon on the benefits and risks of each procedure before deciding.

What do I do to help in my recovery after inferior turbinate reduction surgery?

You will be instructed to perform saline nasal sprays and/or saline nasal irrigations for an average period of 2-4 weeks after surgery. This is required to help you to clear your nose of mucus secretions, old blood and crusts and to help in the healing and recovery of the nasal lining. Patients also feel much more comfortable after saline sprays and irrigations. In addition, your surgeon will also prescribe you with a variable combination of antibiotics, painkillers and anti-inflammatory medications.

Are there any food restrictions after inferior turbinate reduction procedures?

Once the anaesthetic medications have worn off, you should be able to resume a normal healthy diet. There is no evidence that any particular food will worsen your recovery or outcome of your surgery However, it is advisable to avoid very hot and spicy food or excessive alcohol, in the 1^st week after surgery as the increased blood flow associated facial flushing may potentially increase the risk of bleeding from the incompletely-healed tissues of the nose at this time.

When can I resume physical activity?

Return to activity after turbinate reduction surgery varies from person to person and depends on the type of procedure that is performed and have been discussed above. Broadly-speaking, there is minimal bleeding with radiofrequency/coblation procedures and patients who undergo these treatments can quickly return to work and light exercise within 2-3 days after the procedure.

With the more aggressive procedures (medial flap turbinoplasty and various types of turbinectomy), patients are advised to rest at home for 1 week. Normal indoor sedentary activities can often be resumed in the 2^nd week. After 2 weeks, most patients can return to school or office-based work. Light exercise can usually be resumed after 3 weeks when the healing from surgery is almost complete.

Are there alternatives to Inferior Turbinate Reduction Surgery?

The alternative to inferior turbinate reduction surgery would be continuation of medical treatment (nasal steroid sprays and oral antihistamines or decongestants). The patient should understand that once his or her condition reached the stage that surgery is recommended, it is unlikely that the patient’s symptoms will get very much better with medical treatment alone. There is vey little risk of leaving inferior turbinate hypertrophy untreated but the patient will have to accept the symptoms (nasal blockage and congestion) associated with it.

Best wishes,

Dr Gan Eng Cern