Greg Smith: And a lot of patients with turbinate hypertrophy have hypertrophy turbinates because of allergies. So one of the things that most of the time we’ll do as well are allergy workups, allergy medications, and potentially even immunotherapy to try to shrink the turbinates prior to doing surgery.
Nishant Reddy: Hello, everyone. Welcome to the We Knows Noses podcast. This is N.J.-
Samir Undavia: Incredible hand gesture.
Nishant Reddy: Yes, we do.
Samir Undavia: And jazz hands.
Nishant Reddy: This is NJ ENT. We have Dr. Smith. We have Dr. Undavia, myself, Dr. Reddy, we have another riveting episode for you. Today we’ll be talking about turbinate hypertrophy. So first let’s just go over what is turbinate hypertrophy, maybe Dr. Smith.
Greg Smith: So, the turbinate are these heating humidifying structures along the side wall of the nose. They exist on both sides of the nose and their purpose is for heating humidification and filtering out all dirt, dust, pollen, debris. Hypertrophy occurs when you get enlargement of those turbinates, which can lead to nasal obstruction and blockage of the airways.
Nishant Reddy: And when the turbinates get large, they can cause all sorts of issues. What kind of symptoms would you expect patients to have? If you have enlarged turbinates?
Samir Undavia: The two main things you’d have are that you’d be obstructed. Do they take up too much room inside your nose and you feel like you have a clogged nose. Some patients say that it’s always clogged on one side. Some patients say it’s clogged on both sides. Some patients say it alternates from side to side. That is a key sign of enlarged turbinates. Some patients also will say that they’re very leaky. You have a runny nose constantly with a lot of mucus either coming out front or they have a post nasal drip in the back.
Nishant Reddy: And sometimes it’s all very common. Complaint is if when you’re laying down when your heart is similar to the level of your nose, your nose is more likely to get engorged. And typically your turbinates are what’s what gets more swollen. So you’re much more likely to have trouble breathing when you’re sleeping, when you have turbinate hypertrophy. So let’s say you have enlarged turbinate as you’ve been told by your doctor that your nose is swollen. What are some non-surgical ways, medical ways of treating?
Greg Smith: Sure. So one of the most simple ways of doing it, more of a homeopathic way is doing like a saline irrigation, flushing out the dirt, dust, pollen that’s settling in the nose and that can decrease your reactivity to a lot of those allergens that we talk about that can create swelling, venous, and engorgement and enlargement of those turbinates. So the salt water rinses are very good for keeping and maintaining kind of a natural cleansing mechanism within the nose too. Thins out the mucus and allows the transport of the mucus with these little Celia that sweeps the mucus kind of up and out of the sinuses and down the back of the throat, helps thin that mucus out and allow for a faster transport of these dust and particles and things like that that can create inflammation. So saline sprays, saline irrigation, nasal steroids are a category of medication that can be used both over the counter and prescription.
And then nasal steroids come in a variety of different flavors, if you will, and a bunch of different, even delivery methods as well. And ENT or a practitioner can talk to you about those and which one might be the best for your level of obstruction. So, these nasal steroids work by kind of slowly shrinking the turbinates. There are other over the counter sprays, which we see a lot of patients coming in already on, which aren’t always good, which are the nasal decongestant sprays. These work by shrinking up the blood vessels within the turbines.
These are decongestants like Oxymetazoline or Afrin and Neosynephrine, which quickly shrink the turbinates. However, long term the turbinates are kind of intelligent and slowly get used to these and they get bigger and bigger and bigger and bigger and bigger. So, a patient may spray it, feel an improvement from when they sprayed it to a couple minutes later. But in reality from several weeks and months back, they’re actually way larger than they used to be, which was down here. And that’s called Rhinitis Medicamentosa or addiction to Afrin. So, we see that frequently and hopefully none of you have that problem, but it can be resolved and fixed.
Nishant Reddy: Yeah, so speaking of Rhinitis Medicamentosa that’s something that we see very commonly. If you’re addicted to Afrin or addicted to Sudafed. And if you look under a microscope – interestingly – what happens in that case is the way that these decongestants work is they constrict blood vessels. And when you constrict blood vessels, the turbinates shrink up. But eventually what happens is if you use it chronically, your body starts growing new blood vessels into that turbinate space. And it’s a term called neovascularization. And what that results in is eventually turbinates that are very, very congested with blood resulting in trouble breathing. And that makes it much more difficult later on if you’re ever to do a procedure to try to shrink them and it increases the likelihood of potential bleeding. So, we talked about the medical nonsurgical ways of dealing with turbinate hypertrophy. Do you want to, Dr. Undavia talk about the surgical ways-
Samir Undavia: Sure, sure.
Nishant Reddy: – That we can treat it?
Samir Undavia: Well, the turbinate is made out of lining, which is the mucosa and then bone underneath. So, most surgical ways to treat the turbinate are really about reducing one or both of those things. You just want to make a little bit more room and get both of those components a little bit smaller. So you can either reduce the amount of mucosa and soft tissue over the bone. You can either take some of the bone out or you could do a combination of the two. And there are many different ways to take care of the turbinate surgically. And that’ll tell you a couple things. First, there is a tailored approach for each patient. Each patient might have a slightly different reason for having large turbinates, but the second unfortunate reason is that if there’s many different ways, there’s not just one right way to do it. So, each way will have its benefits and risks.
So, one of the things that we could do is you could just take out a little bit of the bone and allow the mucosa to just shrink down onto the empty space that we created. Or you can take out a little bit of mucosa underneath the surface. You can take out a part of the surface plus a mucosa underneath that, or you can take out basically what’s called a lateral edge just underneath the turbinate, a little bit of the lining there. And the three of us probably will have some combination of that, that we do, but that might not be identical. Right?
Greg Smith: Right.
Samir Undavia: I know Dr. Smith likes to take out just the lateral side and a little bit of the bottom. I like to take out a little bit of the bottom and a little bit of the back. Dr. Reddy?
Nishant Reddy: Yeah, I do a combination. What’s the biggest risk of, you try to balance the risks and the benefits with all these procedures? The biggest – do you want to talk about the biggest risk of taking out too much of the lining or too much of the mucosal lining of the turbinate?
Samir Undavia: Yeah. So, from a risk perspective, the reason that there’s many different risk profiles for all the different types of turbinates, because you could just push them over, then you really still have a big turbinate is the immediate risk and the long term risk. The immediate risk, there’s a bleeding risk. So, for the first three weeks or so, you can have an increased risk of nose bleeds about 2 to 3%. You can have a lot more crusting for the first several weeks. I like to tell patients eight weeks or so. But usually it’s actually around five or six. And those are the short term risks. The crusting will stop all by itself, once the lining totally remucolsalizes, the bleeding risk again goes away within three weeks, once the lining resurfaces. The risk of taking out too much turbinate is something called empty nose syndrome or Ozena.
And it’s a real controversial syndrome and every nose is probably a little bit different. But the theoretical risk here is that you have created more room inside the nose. So, you would assume that your breathing is better, but in truth you have less resistance. Your nose likes to feel a little bit of resistance, and you also have less nerve endings to feel the air going into your nose. So, all of a sudden, even though you’re moving more air, you can’t feel it. And it’s a very troublesome symptom. You feel like you’re stuffy, although you can see the air moving in and out.
Greg Smith: In my mantra, what I always tell my patients is that I can always remove more. I can’t put any back in. So I’d rather be a little more conservative with turbinate reduction than overly aggressive because, sometimes risks and complications like this. But, all of us do our best to make sure that we get the right amount for each individual patient. Yeah,
Samir Undavia: Correct.
Nishant Reddy: Dr. Smith, do you want to talk about the small rare risk of epiphora?
Samir Undavia: Yeah.
Nishant Reddy: With these procedures.
Greg Smith: So, the turbines themselves, underneath of the turbinates are these series of grooves and the sinuses ventilate in between kind of the upper grooves within these turbinates, in the lower groove there is the nasolacrimal duct, which is a tear duct, which drains the tear system. So, tears are made in the upper outer part of the eye and sweep down across the eye and go into the tear duct and collecting system there, and then empty into the nose just underneath the inferior turbinate. And so, damage and scarring can occur of the tear duct, which can lead to chronic tearing within the eyes or inflammation within the tear system.
Nishant Reddy: And that’s very rare. That’s usually, if your surgeon is aware of that, the anatomy, that’s a very unlikely complication to happen.
Samir Undavia: The one complication I did not say, or risk that I did not say talk about was that if patients are not used to getting a whole bunch of allergens into their nose because their turbinates are so big and block the entry of the allergens into the nose, when we make the allergens smaller, when we make the turbinate smaller, more allergens can get into the nose. And then you can have symptoms related to allergies a little bit more like a runny nose or itchy eyes. You still probably will breathe very well, but you can get some allergens and it can make your nose very wet on the inside. And we have things to treat that, but it’s just something to warn patients about.
Greg Smith: And a lot of patients with turbinate hypertrophy have hypertrophy turbines because of allergies. So, one of the things that most of the time we will do as well are allergy workups, allergy medications, and potentially even immunotherapy to try to shrink the turbinates prior to doing surgery.
Nishant Reddy: And there’s a whole host of new in-office procedures we could do even before considering surgery. The in-office procedures, they tend to be more conservative. You’re usually taking a millimeter here, a millimeter there trying to improve the airway. You don’t necessarily get the bigger improvements that you can potentially go with surgery. But there’s, on one end of the spectrum, there’s radiofrequency ablation of the turbinates. So, you basically put a small, tiny little radiofrequency probe into your nose and try to shrink some of the mucosa.
Samir Undavia: Are patients asleep for this? Are they awake?
Nishant Reddy: Oh, so no, they’re awake. It’s done right in the office. We numb up your nose with some cotton balls, with some numbing medication and it’s usually just a few minutes procedure on each side.
Samir Undavia: You drive yourself home?
Nishant Reddy: Yeah, drive yourself home. Very minimal amounts of pain and very minimal amounts of recovery afterwards. So, there’s radiofrequency ablation that we can do in the office. There is this relatively new balloon called the Acclarent tract balloon. And what this does is essentially you just put the balloon in your nose, we inflate it, and it pushes your turbinate over to the side. It might also move over any tiny slight septal deviations over to the other side. Now that balloon is, it’s relatively new, the long term data isn’t out yet. It probably doesn’t have a long term as great of an effect as some of the other procedures. And then finally, you can actually do a lot of the same turbinate reductions that you do in the operating room, you can actually do in the office. So for patients that prefer to have low, shorter downtime and avoid general anesthesia, we can do a lot of the turbinate reductions right in the office if we need to. Anything else to add, guys?
Samir Undavia: I think we’re good.
Nishant Reddy: Yeah, I think that covers it.
Samir Undavia: Yeah.
Nishant Reddy: Great.
Samir Undavia: Thanks for watching. We’re NJ ENT and if you have any questions, please email us firstname.lastname@example.org. Call or text us at (609) 710-6673. And look forward to our other podcast, like us if you can.