Nasal turbinate hypertrophy

Nasal turbinate hypertrophy is the enlargement of the nasal turbinates, most commonly the inferior nasal turbinate, and can result in difficulty breathing through the nose. Turbinate hypertrophy is most commonly caused by edema of the nasal mucosa (often due to allergic or vasomotor rhinitis) and/or structural nasal abnormalities. Diagnosis is based on direct visualization of the enlarged turbinates on anterior rhinoscopy or nasal endoscopy. Initial treatment includes intranasal corticosteroids and saline, and treatment of underlying etiologies. Surgery is reserved for refractory cases.

• Most common ^[1][2]
  • Allergic rhinitis
  • Vasomotor rhinitis
• Other etiologies include:
  • Infection (e.g., nasopharyngitis) ^[2][3]
  • Chronic rhinosinusitis ^[4]
  • Rhinitis medicamentosa ^[5]
  • Anatomical variant or acquired deformity
    • Deviated nasal septum ^[4]
    • Concha bullosa

• Nasal obstruction, leading to: ^[5]
  • Difficulty breathing through the nose
  • Snoring
  • Obstructive sleep apnea
• Symptoms of sinusitis and rhinitis, e.g.: ^[4][5]
  • Nasal congestion
  • Rhinorrhea
  • Headache and facial pain

Approach ^[6][7][8]

• Perform rhinoscopy and/or nasal endoscopy to visualize the turbinates.
• Consider topical nasal decongestant application to assess for symptomatic relief.
• Perform further diagnostic studies as needed for:
  • Diagnostic uncertainty
  • Abnormalities on nasal examination
  • Evaluation of the suspected underlying etiology (see also “Diagnostics for allergic rhinitis” and “Diagnostics for deviated nasal septum.”)

Direct visualization of the turbinates ^[7]

• Modalities ^[6][9]
  • Anterior rhinoscopy
  • Nasal endoscopy
• Findings
  • Enlarged turbinates, usually the inferior turbinates
  • Findings suggestive of an underlying etiology of nasal turbinate hypertrophy, e.g.:
    • Allergic rhinitis: pale, boggy nasal mucosa ^[10]
    • Deviated nasal septum

Narrowing or collapse of nasal structures when the patient breathes suggests additional obstructive etiologies. ^[6][7]

Imaging ^[7][11]

• Indications
  • Other causes of nasal obstruction suspected
  • Bony cause suspected (e.g., concha bullosa) ^[12]
  • If needed for surgical planning
• Modalities: CT or MRI of the sinuses ^[10]

Imaging is rarely recommended in children because it has limited utility. ^[9]

Initial treatment includes pharmacotherapy to relieve nasal obstruction and management of the underlying etiology of hypertrophy. Refer patients with refractory symptoms to ENT for surgical evaluation.

Conservative treatment of nasal turbinate hypertrophy ^[2][7]

Treatment of nasal inflammation and hypertrophy

Duration of treatment depends on underlying etiology and response to therapy.

• Intranasal corticosteroids
  • Budesonide (off-label)
  • Mometasone (off-label)
  • Fluticasone (off-label)
  • Beclomethasone dipropionate, monohydrate (off-label)
• Intranasal saline ^[2][9]
  • Saline spray
  • Irrigation with hypertonic (2.7%) saline

Treatment of underlying etiology

• Allergic rhinitis: See “Management of allergic rhinitis.”
• Vasomotor rhinitis: See “Treatment of vasomotor rhinitis.”
• Rhinitis medicamentosa: Discontinue alpha-1 sympathomimetic decongestants.

Intranasal sympathomimetic decongestants should not be used for more than 3–5 days because of the risk of rhinitis medicamentosa. ^[10][13]

Surgery ^[1][5][11]

• Indication: persistence of symptoms after 3 months of conservative treatment ^[9]
• Options: involve reducing the size of the mucosa, submucosa, and/or bone
  • Turbinoplasty ^[1]
  • Turbinectomy ^[7]
• Complications ^[11]
  • Bleeding or crusting
  • Intranasal synechia formation
  • Empty nose syndrome: a feeling of nasal obstruction despite patent airways; may be seen after complete turbinectomy ^[14]