Tutorial - Turbinate Surgery and Atrophic Rhinitis
This tutorial explains the role of the turbinate and why surgery is sometimes performed to reduce their size. It also looks at the complications of the surgery and the management of atrophic rhinitis.
Staff at AEC see patients who have undergone nasal surgery and who may need such surgery in the future. This short tutorial introduces knowledge that will help them understand why surgery is sometimes needed and what complications surgery can cause.
Air-conditioning and functional anatomy of the nose
As you know the function of the nose is to condition the breathed air so that it is fit to enter the lungs. This function is broken into three parts:
To do its job well it needs a large surface area, lots of mucus glands and a rich blood supply. The nose has turbinates and these increase the surface area greatly. They are filled with blood vessels and they are covered in mucus secreting glands.
The sensation of nasal blockage
The sensation of nasal obstruction can arise due to swellings in the lining of the nose. These narrow the airway and require greater effort to breath air in. The following diagram shows some causes of nasal obstruction: a deviated nasal septum, thickening of the linings of the nose as in rhinitis, and nasal polyps.
Another cause of a sensation of nasal obstruction is a decrease in the sensation within the nose. The brain detects air flow through the nose because air cools the lining of the nose. Cool receptors are triggered and the degree of cooling is related to the amount of air flowing through the nose. The lining of the nose needs to be wet for this to work. If the nose becomes dry inside this cooling sensation is lost and the brain interprets this as obstruction.
Rhinitis and its treatment
Patients with rhinitis develop thickening of the mucosa on the turbinates and this leads to nasal obstruction. This is treated with nasal steroid spray (and sometimes with nasal douching and long term antibiotics as well).
If nasal steroids do not help the patient, an operation can be performed to reduce the size of the inferior turbinate. This is sometimes done by itself and sometimes with an operation to straighten the nasal septum. Turbinate surgery may reduce the size or remove the turbinate completely.
Reducing turbinate size and its complications
There are a number of ways to reduce the size of a nasal turbinate:
1. Cautery – reduces the size of the turbinate for a year or two
2. Injection with steroid – as above
3. Surgery – longer term improvement
Soft tissue reduction anteriorly or along whole length of turbinate
Removal of soft tissue and bone
Unfortunately, reducing turbinate size may have complications. Bleeding from the nose is quite common as is temporary infection and crusting inside the nose. More importantly, surgery may cause secondary atrophic rhinitis if too much turbinate is removed.
This occurs in two forms: primary and secondary.
The primary form is commoner in developing countries (eg China, Africa, India, Philippines). It is a progressive disorder of thinning of the mucosa, wide nasal passages, thick secretions and later crusts, dry blood, and a foul smell from the nose. Klebsiella species are thought to be causative but Pseudomonas and E. coli are found along with Aspergillus fungus.
The secondary form usually follows nasal surgery especially turbinate reduction.
The pictures show atrophic mucosa, abundant crusts and associated inflammation.
Management of Atrophic Rhinitis
Management is often very long term and patients require a lot of support and understanding, especially if they have the primary form of the disease. This is because the smell that arises from the infection in their nose is so intense that they are often shunned by their communities.
1. Nasal irrigation. This should be performed twice daily with warmed saline. Steroids and antibiotics can be added to the irrigation fluid but this is this best left to the ENT Department. Budesonide respules (0.25mg/2ml) and bactroban, levofloxacin, or ceftazidime are appropriate choices
2. Antibiotics. These can be put in the lavage as above or used to treat acute infections
3. Nasal moisturization if possible. This can be acheived with petroleum jelly, and with personal lubricants eg KY Liquid
4. Surgery. Can be performed to close the nostrils and this is quite successful although not popular with the patient