Describe the turbinates, turbinate hypertrophy and atrophic rhinitis.

The Turbinates in Health and Disease

• The turbinates (conchae) are scroll-shaped projections from the lateral nasal wall, each covered by respiratory mucosa over a core of venous sinusoids (cavernous erectile tissue).
• They exist to increase the surface area and to direct airflow, and are the organ of nasal air-conditioning.
• The inferior turbinate is by far the largest and is a separate bone; the middle, superior and supreme turbinates are parts of the ethmoid
• The venous sinusoids are the key TO everything: their filling and emptying under autonomic control changes turbinate volume rapidly.
• Sympathetic stimulation empties the sinusoids and decongests; parasympathetic stimulation and vasodilatation congest — which is why exercise opens the nose and lying down blocks it
• Turbinate hypertrophy may be mucosal or bony, and the distinction determines the treatment: mucosal hypertrophy shrinks with a topical decongestant and responds to medical treatment; bony hypertrophy does not shrink and requires surgery. This is exactly what examining the nose again after decongestion demonstrates
• Causes of hypertrophy — allergic and vasomotor rhinitis; chronic rhinosinusitis; compensatory hypertrophy on the concave side of a deviated septum.
• Management is medical first — topical intranasal steroid.
• Surgical reduction where medical treatment fails — submucous diathermy, radiofrequency ablation, submucosal resection of the turbinate bone, microdebrider-assisted reduction, and outfracture
• The governing surgical principle IS TO preserve mucosa and reduce volume.
• Total turbinectomy must BE avoided.
• Its mechanism is loss of the airflow sensors and of the resistance and turbulence needed for the sensation of breathing, together with loss of the air-conditioning surface — and it is largely irreversible and very difficult to treat
• Atrophic rhinitis (ozaena) is the related condition, in which the mucosa and turbinates atrophy, giving an abnormally roomy nose with foul-smelling crusts, merosmia (the patient cannot smell the odour that others find offensive), epistaxis and obstruction
• It is primary — commoner in young women, in India and other warm dry climates, associated with poor nutrition, iron deficiency and klebsiella ozaenae; or secondary to excessive turbinate surgery, radiotherapy, granulomatous disease and trauma
• Treatment — alkaline nasal douching and crust removal, which is the mainstay; 25% glucose in glycerine drops to inhibit proteolytic organisms; topical and systemic antibiotics; correction of iron and vitamin deficiency; and surgical narrowing of the nasal cavity (young’S operation, submucosal implants) in severe cases
• Venous sinusoids under autonomic control explain the nasal cycle, postural blockage and the action of decongestants