Effectiveness of Volumetric Reduction of Middle Concha Bullosa by Crushing Technique in Chronic Nasal Obstruction

Abstract

To study the effectiveness of volumetric reduction of middle concha bullosa by crushing technique in chronic nasal obstruction cases on selection basis of 3Dimensional computed tomography measurements. Patients with complains of nasal obstruction underwent an Observational study. They were subjected to nasal endoscopy and computed tomography of paranasal sinuses with 3D size estimation of middle turbinate to confirm concha bullosa. 37 patients with unilateral/bilateral lesions were divided into 4 groups on the basis of ranged sizes. These were subjected to volume reduction by crushing technique with marsulizer under local/general anesthesia with necessary post-operative medications and the final outcomes were judged on basis for nasal endoscopy and computed tomography of paranasal sinus at 1 year. Out of 37 patients with total 42 concha bullosa, 5 had bilateral lesion. After crushing techniques, following results were obtained. In group A with pre-operative volume of concha between 0.60 and 0.80 ccm, 11 succeeded to achieve post-operative value of < 0.60 ccm. In group B, C, D with preoperative concha volume > 0.80 ccm all succeeded in achieving the post-operative value of < 0.60 ccm. 50% reduction in volume of concha occurred in 88% cases of group A and 100% in cases of other groups post-operatively at 1 year. Encouraging results with negligible consequences are ensued upon in case of chronic nasal obstruction due to concha bullosa by doing its volumetric reduction by crushing technique with marsulizer instrument.

Introduction

Pneumatization of middle turbinate is known as concha bullosa is fairly a common occurrence. On reviewing the literature the incidence between 14 and 40% is found. C.B. is a radiological diagnosis [1] and is often an incidental finding on computed tomography. It is usually an asymptomatic one requiring no treatment. Yet some situations, may warrant surgical correction of it.

Conventional radiology does not permit a detailed study of the nasal cavity and paranasal sinuses, and has now largely been replaced by computerised tomographic (CT) imaging [2]. This gives an applied anatomical view of the region and the anatomical variants that are very often found. C.B. is best diagnosed on computed tomography. Not only the anatomy but also the patho-physiology of C.B. has been studied in detail. Middle turbinate regulates nasal airflow in parabolic fashion, while limiting medially it protects middle meatus. It also helps in thermal and humidity adjustment of inspiratory air and facilitates blowing of nose. C.B. may grow to such an extent that it fills the space between septum and lateral nasal wall. This may cause blockage of osteomeatal complex completely, thus creating areas of mucosal contact thus inviting the process of sino-nasal inflammation. Its ostium may drain into frontal recess, lateral sinus or hiatus. So, obstruction of drainage of concha itself can lead to mucocele formation [3].

Based on location of pneumatisation, Bolger has divided C.B. into 3 types:

1. Lamellar (vertical lamella of middle turbinate).

2. Bulbous (bulbous portion of middle turbinate).

3. Extensive (both vertical and bulbous portions of middle turbinate). This is rather extensive form of concha and is commonly associated with septal deviation to the opposite side [1, 4].

C.B. correction many times becomes essential surgical step during various endoscopic sinus surgeries in managing sinus disease. Different techniques like lateral or medial marsupialization, crushing and stripping, resection has been described in literature for the management of concha bullosa 3.7,10.

Methodology

37 patients participating in this study (Table 1) had one or more complaints of- effortive nasal inspiration, considerable nasal obstruction, difficult snotting/blowing to clear mucus, disturbed smelling sensation, headache (sequelae to constricted middle meatus like acute/chronic sinusitis, mucocele/pyocele).

Table 1.

The distribution of 3D measurements of Middle Concha on CT Scan

Sr	R MT Vol [CCM]		L MT Vol [CCM]		Absolute ratio %		Remark
	Pre VR	Post VR	Pre VR	Post VR	Pre VR	Post VR
1. ABD	0.403		0.680	0.410	68	01.73	L-CNO
2. PRM	0.567		0.858	0.562	51	00.88	L-CNO
3. DMR	0.678	0.323	0.800	0.423a	18	30.95	B-CNO
4. MCV	0.824	0.412	0.357		130	15.40	R-CNO
5. TR	0.722	0.350	0.490		47	40.00	R-CNO
6. YYP	1.055	0.496	0.512		106	03.22	R-CNO
7. MNJ	0.967	0.440	0.850	0.410	14	07.31	B-CNO
8. TKT	0.760	0.356a	0.412		85	15.73	R-CNO
9. BMR	0.756	0.444	0.845	0.405	11	09.62	B-CNO
10. KKL	0.280		0.694	0.342	147	22.14	L-CNO
11. MNB	0.450		0.812	0.380	80	18.42	L-CNO
12. DLM	0.268		0.658	0.319	145	19.02	L-CNO
13. KCP	1.110	0.526	1.045	0.490	6	07.34	B-CNO
14. JJP	1.203	0.587	0.590		103	00.51	R-CNO
15. GHT	0.297		0.712	0.330	139	11.11	L-CNO
16. HTR	1.256	0.556	0.624		100	12.23	R-CNO
17. BMD	0.678	0.334	0.410		65	22.75	R-CNO
18. KKP	0.938	0.445	0.567		66	27.41	R-CNO
19. OPW	0.265		0.660	0.326	145	23.01	L-CNO
20. PPP	0.446		1.105	0.506	147	13.45	L-CNO
21. ERP	0.624	0.304	0.387		61	27.30	R-CNO
22. RTP	0.453		0.772	0.350	70	29.42	L-CNO
23. GHY	0.386		0.844	0.410	118	06.21	L-CNO
24. HHR	0.445		0.852	0.410	91	08.53	L-CNO
25. NVB	1.230	0.564	0.834	0.405	47	39.25	B-CNO
26. BMD	0.370		0.804	0.390	117	05.40	L-CNO
27. HJP	0.346		0.922	0.442	166	27.74	L-CNO
28. PKK	0.885	0.440	0.480		84	09.09	R-CNO
29. LKP	0.497		0.875	0.422	76	17.77	L-CNO
30. PLG	1.164	0.555	0.433		140	28.17	R-CNO
31. BBD	1.223	0.596	0.605		99	01.51	R-CNO
32. PLR	0.354		0.810	0.402	128	15.53	L-CNO
33. SSB	0.972	0.456	0.390		149	16.92	R-CNO
34. MDS	0.893	0.415	0.433		106	04.33	R-CNO
35. SSR	1.231	0.588	0.565		117	04.07	R-CNO
36. OLT	0.581		1.069	0.488	84	19.05	L-CNO
37. USN	0.554		1.026	0.489	85	13.29	L-CNO

N = 37 with CNO Unilateral = 32 Bilateral = 5

R right, L left, B bilateral, CNO chronic nasal obstruction, VR volume reduction

^aNumber indicates failure to achieve ≥ 50% reduction in volume

On anterior rhinoscopy, middle concha is usually seen in absence of gross deviated nasal septum, anteriorly dislocated nasal septum, sinus pathology, space occupying lesion, Inferior conchal enlargement. It appears pinkish in color with smooth lateral curve and usually uncovered with secretions/crusts.

Diagnostic nasal endoscopy with topical nasal decongestant with a 0° Hopkins nasal endoscope of 4 mm (in adults)/2.4 mm (in adolescents) was performed.

Further plain computed tomography of paranasal sinus coronal and sagittal sections were done, after self cleaning (snotting) and 30 min after instilling topical nasal decongestant. Presence of Sinus turbinate, ossification in turbinate, sinus pathology, gross morphological comparison between turbini of both sides and 3Dimensional measurements of bilateral C.B were done.

The subject group was divided into unilateral and bilateral presence of concha bullosa and further sub-divided into 4 groups based on the individual volume size of bulbous type of C.B.on computerized tomography as; A, B, C and D (0.6–0.8 cm³), (0.81–1.0 cm³), (1.01–1.2 cm³) and (> 1.21 cm³) respectively, for pre-operative and post-operative measurements.

Inclusion & Exclusion criteria for patients are mentioned in Table 2.

Table 2.

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
No DNS or corrected DNS	Presence of active/chronic sinusitis, DNS and Hypertrophic turbinate
Normo-serative for allergy	Sero-positive for allergy (Ig E, Ig M)
Age > 14yrs	Age < 14yrs and congenital nasal anomalies
Uni/bilateral nasal obstruction > 3 months	Presence of polyp or inflammed mucosa of concha bullosa.
Presence of sinus turbinate on CT image	Nasal valvular dysfunction
On CT image Unilateral obstruction- 3D volume of turbinate > 0.6 cm3 and/or ratio between volume of 2 turbini > 65% Bilateral obstruction- 3D volume of turbinate > 0.6 cm3	General absolute contraindication

Surgical Preparation and Technique

After taking well informed written consent of patient, nose was prepared with tamponades impregnated with 4% Lignocaine + 1:1,00,000 Adrenaline for 20 min. Sedation or General Anesthesia was used in adolescent or if septal correction was required. Cold equipments for septal surgery, nasal endoscopes 0° & 30°, Marsulizer for crushing, pieces of gel films, suction apparatus were used. When indicated, Septoplasty was first performed. Volumetric reduction of C.B. was preceded by local infiltration with 2% Lignocaine + Adrenaline 1:80,000 at medial aspect, apex, axilla and lateral curvature of middle turbinate (0.5–0.8 cc each). Gel film pieces were applied on lateral and medial surface of concha for 2 min. Marsulizer was used to grip the concha (short of apex or axilla) firmly and close to crush medial and lateral walls together. Twisting of C.B. was avoided. The crushing force was maintained for 2–3 min and the instrument was withdrawn with sucking out gel film of lateral aspect of treated concha. No nasal packing was required.

Post-op Care

Drugs used were

• A.Amoxycillin-Clauvanic acid 312.5–625 mg TID for 5 days
• B.Anti-infammatory for 7 days
• C.Non-sedative Antihitamines for 14 days
• D.Nasal topical decongestant for 7 days

Nasoendoscopic follow-up was done at 1, 3, 6, 12 weeks (Fig. 1).

Fig. 1.

From left to right in order of A, B, C -naso-endoscopic images in pre-op and intra-op period and post-op at 1 year

Computed tomography (Turbinate Volume measurement) follow-ups were done at 6 and 12 months and more if indicated (Figs. 2, 3).

Fig. 2.

On LEFT side image shows preoperative measurements of pneumatised middle turbini of a 16 year old boy. On RIGHT side image is showing lowered measurement of Rt C. B. 1 year postopertively; unopertaed Lt side shows marginal increase in size of middle turbinate

Fig. 3.

showing pre and post-op images of PNS. LEFT image shows highly pneumatized Left middle turbinate. Right image shows post-op impression of reduced left middle turbinate at 1 year

Complications

Only the mild pain lasting for 1-3 days was noticed post-opertaively in 5 patients. No other complication occurred after the surgical intervention.

Results

Cohort: 37 (42 C.B.s) M/F: 29/8

Age Groups 14–18 years: 4 19–60 years: Mean = 33 years.

Unilateral cases: 32 Bilateral cases: 5

On Nasal Endoscopy

• Large uniform mass of concha was seen, touching the bony septum and obliterating the gap.

• Paradoxical curve of middle turbinate was seen in 30% cases.

• Obliteration of middle meatus was found in 40% of the patients.

• On palpation it had firm/bony hard consistency.

• Accessory middle concha was present in 5% of cases.

Difference between volumes of middle turbinates, pre and post volume reduction was significant as per the Interpretation using paired t test in unilateral cases (Table 3).

Table 3.

Table displaying the volume (SEM) in pre and post-op phases of C.B. with statistical significance in unilateral cases

Right MT volume mean SD (N = 20)		P value	Left MT volume mean SD (N = 22)		P value
Pre VR	Post VR		Pre VR	Post VR
0.94 ± 0.21	0.43 ± 0.14	0.001	0.86 ± 0.12	0.39 ± 0.11	0.018

To assess whether 50% reduction occurs in middle turbinate volume after treatment?

In both Right and Left middle turbini volume, there is 2 sided t test p value < 0.05, meaning there was statistically significant difference between pre middle turbinate volume reduction value and post middle turbinate volume reduction value. So, there is 50% reduction in post middle turbinate volume after treatment in unilateral cases with Also Interpretation using paired t test in bilateral cases (Table 4).

Table 4.

The volume (SEM) in pre and post-op phases of C.B. with statistical significance in bilateral cases

Right MT volume mean SD (N = 20)		P value	Left MT volume mean SD (N = 22)		P value
Pre VR	Post VR		Pre VR	Post VR
0.95 ± 0.21	0.67 ± 1.08	0.262	0.84 ± 0.12	0.39 ± 0.108	0.011

Also it indicates 50% reduction in volume of middle turbinate is more effective on Lt side in bilateral cases.

Out of 37 patients with 42 C.B., 5 had bilateral C.B. After crushing techniques, following result was obtained (Table 5).

• Out of 13 C.B. with 0.61–0.8 cm³ as pre-operative volume (group A), post-operatively at 6 and 12 months, none of the C.B. had volume > 0.6 cm³, 2 C.B.s had volume 0.61–0.8 cm³.

• In group B (0.81–1.00 cm³ pre-operative C.B. volume), group C (1.01–1.20 cm³ pre-operative C.B. volume) and group D (> 1.21 cm³ pre-operative C.B. volume), post-operatively at 6 months and 1 year, no C.B. had volume greater than lower limit of the group that it belonged.

• More than 50% reduction in C.B. volume occurred in 88% cases of group A and 100% cases of other groups post-operatively at 1 year.

Table 5.

Groups based on CB Vol measures (in cm³) on CT images

Groups based on CB Vol (cm3)	A (0.61–0.8)	B (0.81–1.0)	C (1.01–1.2)	D (> 1.2)
No. of Pre-op CBs	13	17	7	5
No. of CBs in Vol. Post-op (3 months)	0	0	0	0
No. of CB in Vol. Post-op (1 year)	2	0	0	0
% of patients with > 50% Reduction in CB Vol. at 1 year	88	100	100	100

Discussion

C.B. is the most common anatomical variation of the osteomeatal complex region. The mechanism of pneumatization of the nasal turbinates is still unknown. Several theories have been proposed for its occurrence: some of them are expansion of sinus pneumatization into the turbinate during intrauterine period, fusion abnormality during intrauterine development, and conchal bone micro fractures during late puberty causing nasal mucosal invagination expanding to bullosa cavity. Also, two different theories have been suggested on this issue by Stammberger [5]. According to the first theory, after the formation of septum deviation, the air flow pattern of nasal cavity and on the opposite side of the space provokes the development of C.B. According to another theory, the C.B. and septal deviation are two different anomalies. It has been shown that anterior and posterior ethmoidal air cells are liable for pneumatization of C.B. roughly in 55% and 45% of the cases, respectively. Although the majority are asymptomatic, due to its negative effect on paranasal sinus ventilation and mucociliary cleaning of the middle meatus, CB can cause the development of maxillary or ethmoidal sinusitis. The severity of symptoms resulting from C.B. is closely associated with the degree of pneumatization. Intranasal turbinates are required for the maintenance of normal nasal functions such as humidification, hydration, lubrication of the upper respiratory system, olfaction, filtration, and thermoregulation [6].

Middle concha with its insertion is an important landmark in Functional Endoscopic Sinus Surgery and Anterior Skull Base Surgery and is preserved intact in crushing technique. It is one of the key factor in maintaining smooth nasal inspiration and expiration and acts like sniffing, snotting. Hence, it is important to maintain its physical and morphological structure.

Crushing technique was used earlier by Woolford T.J and Jones N.S. [7] just satisfies these requisites without the post-operative consequeces as synechiae,crusts formation and bleeding in contrast to other concurrent invasive techniques: Turbinoplasty/Partial excision [3, 8, 9].

The results presented in this study for improved nasal airway after volumetric reduction are comparable to the technique of crushing with intrinsic stripping [10] when bulbous type C.B.is selected for comparison. We have not observed repneumatisation at the operated site in this study with follow-up of 1 year as been reported in other study [11].

Salient features of this technique are

1. Mainly an OPD procedure.

2. Mostly done under local anesthesia.

3. Complications/sequele such as bleeding, crusting, synechie, mucocoele,smell disturbances, facial pain or headache were not reported.

4. Post-operatively– No evidence to suggest post-op epithelial inclusion cyst formation/flappy turbinate/re-pneumatization.

5. Maintains mucociliary function.

A retrospective blind-fold study using a random data collection of 46 patients from a recognized imaging centre [12] having nasal obstruction with C.B. was done (Fig. 4). It showed the results as mentioned below: Out of 22 patients of bilateral C.B., 15 patients had CB volume > 0.6 cm³. They all had complain of bilateral nose block. 4 patients had CB volume > 0.4 cm³, of which 1 had complain of bilateral nose block. 3 patients had CB volume < 0.4 cm³, of which 1 had complain of bilateral nose block.

Fig. 4.

The graphical data of 46 patients with complaints of nasal obstruction with CT 3D measurements of C.B

Observation of this study shows that maximum number of patients with bilateral nose block have C.B. volume > 0.6 cm³.

Conclusion

• Sinus turbinate is fairly common presentation with symptoms of nasal obstructive breathing.

• Nasoendoscopic findings with topical decongestant along with computed tomographic volumetric measurement is cardinal to ease the diagnosis.

• In the presented series a cut-off volume size of 0.6 cm³ and a ratio of more than 65% volume in bulbous variety of concha bullosa is in close accord with unilateral nasal obstruction. In bilateral cases volume size of concha bullosa above 0.6 cm is directly related to the bilateral nasal obstruction.

• Crushing technique in is easy and quick and safe procedure in when applied on office basis.

• Encouraging results with negligible consequences are ensued upon.

Author’s Contribution

Narendra Suratwala and Jay Suratwala were responsible for following tasks related to manuscript preparation. 1) Collection of data of clinical and radiological investigations. 2) Ensuring the treatment to the subjects. 3) Reviewing the outcomes of treatment during follow-ups with repeat nasal endoscopic and radiological investigations. 4) Recording the side effects of scheduled treatments. 5) Handing over the above data to biostatistician for valuation. 6) All of the above data is further processed for manuscript writing, table and graph making with reference work. H.D. Jadawala contributed to this article by going through extensive statistical data and un-biasly processing it. He also was involved in the making of tables and graphs.

Funding

The study presented as “Effectiveness of volumetric reduction of middle concha bullosa by crushing technique in chronic nasal obstruction” is non-funded project.

Compliance with Ethical Standards

Conflict of interest

There is no conflict of whatsoever interest arising out of the making/submitting this manuscript between the authors and any financial/educational/medical institute.