Endoscopic Excision of Concha Bullosa (CB)

Aerated (or Pneumatized) Middle Turbinate

The anomaly in which the middle turbinate is filled with air different from normal is called "concha bullosa" or "pneumatized middle turbinate". It is mostly detected by chance. Occasionally, the sinus can block sinus orifices and cause recurrent inverse episodes or nasal congestion. Rarely, during upper respiratory tract infections, the inside may become infected with secretory secretion (Mucopyocele of Concha Bullosa).

Concha bullosa was first described by Santorinus in 1739 and is seen in 14-53% of population. Three types of cone bullosa, lamellar, bulbous and extensive, are defined (source >> Is pneumatization of middle turbinates compensatory or congenital? - PMC (nih.gov)). Concha bullosa is quite common in the community. It can be seen unilaterally or bilaterally in the nose. The incidence for at least one concha bullosa has been reported as 44%; 23% of the general population have unilateral turbinate and 21% have bilateral concha bullosa. Nasal septal deviation has a close relationship with concha bullosa. It is common for large compensatory bullous concha bullosa to occur as the middle part of the middle turbinate pneumatizes, in order to narrow the unilateral abnormally widened air passage and prevent an abnormal amount of outside air from entering the sinuses, especially in patients with severe septal deviation. However, sinusitis occurs equally in people with or without concha bullosa (source >> Concha bullosa - an overview | ScienceDirect Topics). Konka Bulloza insidansı, nazal septum deviasyonu olan bölgede daha yüksekti ve deviye olmayan taraf daha sıktır. Bu durum kompansatuar bir mekanizma nedeniyle olabilir (source >> Volumetric Computed Tomography Analysis of Middle Turbinate Aeration (Concha Bullosa) in Nasal Septal Deviation (eurjrhinol.org)).

About The Middle Turbinates

Middle turbinate (MT) is one of the most important anatomical and physiological structures located in the middle of 3 separate tubinates in the nasal cavity. Middle turbinates have roles in regulating and heating the air flow entering the nose, the flow pattern, preventing the rapid and dirty air entry into the sinuses, and regulating the sense of smell. Various variations and changes in middle turbinates have been documented with the prevalence of computed tomography examinations and the evaluation of endoscopic nasal examination images. Many middle turbinate variations have been described, some of which are paradoxical middle turbinate, pneumatic middle turbinate, secondary middle turbinate, and accessory and furcation middle turbinate. Some of them can be seen together more than one at the same time. The middle turbinate is located both at the base of the skull and in the center of the opening areas of the sinuses into the nose. In case the middle turbinates grow in volume, change in structure, become infected or expand towards the sinus openings, conditions such as sinusitis, nasal congestion, problems with smelling, and headache may occur. Concha bullosa with middle turbinates pneumatization is one of the most common sinonasal variations (source >> Radiological middle turbinate variations and their relation to nasal septum deviation in asymptomatic adult). The hollow part of the pneumatized middle turbinate may be infected by microorganisms that cause upper respiratory tract infection, causing it to fill with an abscess (Infected Concha Bullosa), a cystic structure may appear in the middle (Mucocele of Concha Bullosa), and the cystic structure itself may be infected (Infected Concha Bullosa Mucocele or Mucopyocel of Concha Bullosa).

How is The Diagnosis of Concha Bullosa Made?

During the endoscopic nasal examination, your ENT doctor may see that the middle turbinate is larger than normal and may suspect concha bullosa. An imaging examination with computed tomography is required for definitive diagnosis. Concha bullosa is diagnosed with the appearance of an air-filled, bubble-shaped middle turbinate on computed tomography.

Concha Bullosa Treatment

The aim of the treatment of concha bullosa is to reduce the volume of the concha bullosa, to normalize the sinus drainage, and to eliminate the symptoms associated with mucosal contact. The following techniques can be used for concha bullosa resection or resection:

- partial resection with microdebrider
- endoscopic concha bullosa resection
- reduction with radiofrequency
- concha bullosa crushing
- modified techniques using the above in combination
- endoscopic turbinoplasty

Endoscopic resection or crushing method may be preferred when there is usually bulbous type turbinate bullosa.

Techniques For Reduicng The Concha Bullosa 

Endoscopic concha bullosa resection / reduction is an effective method for the treatment of concha bullosa. Apart from this, there are techniques such as concha bullosa reduction with radiofrequency and partial excision of the concha bullosa with microdebrider. Another technique is to narrow the concha bullosa by squeezing with the help of a clamps. It is a technique that is mostly applied especially in bulbous type concha bullosa. In the video above, the medial half of the concha bullosa is excised endoscopically after local anesthetic injection.

Can concha bullosa come back after surgery?

After resection of concha bullosa with endoscopic technique or reduction with microdebrider, since tissue loss is permanent, concha bullosa cannot grow back to its former size. In addition, when simple radiofrequency techniques or partial crushing method are applied, concha bullosa may reach the dimensions as a result of long-term allergic rhinitis or edema due to inflammation.

How much does concha bullosa surgery cost?

Although the average price varies according to the method applied, the hospital used and the tools; The total cost of concha bullosa surgery is between 1500-2500 US Dollars.

Patient care after concha bullosa resection

After the operation, the patient can be discharged on the same day, internal silicone splints are placed in the nose when septoplasty and inferior turbinate reduction are also performed during the procedure. It is kept in the nose for 5-7 days. When the operation is performed under general anesthesia, patients should not eat or drink water for 4 hours after the operation. In order to prevent the increase in bleeding, it should be avoided for 10 days without blowing the nose and from sports activities that may cause trauma. Products such as garlic, fish oil and ginklo biloba, which may have a blood thinning effect that may cause increased nosebleeds after the operation, and spicy foods should be avoided.

Mucosal contact headaches due to middle turbinate pathologies

In recent years, headaches have been defined due to mucosal contact areas in the nose, as defined in bone spur formation. Headaches, which are not easily defined and can be confused with tension headaches, arising from mucosal contact and compression areas in the nose have been described in patients with large concha bullosa. The reduction of the concha bullosa volume and the disappearance of these headaches confirm the diagnosis. In addition, reduction or disappearance of headaches after local anesthetic injection into mucosal contact areas may be diagnostic.

Concha bullosa is not a disease, it is an anatomical variation!

Normally, there are 3 pairs of turbinates inside our nose. Sometimes there should be a single bone wall in the middle turbinate; There may be two walls and air can fill between them. This way it can take the form of a bubble. This condition is a variation of concha bullosa, not a disease. Bullous turbinate, which is a congenital structural difference (anatomical variation), is mostly seen in the middle turbinate and rarely in the lower inferior turbinate. It does not cause any symptoms in most patients. It is found in the wide nasal cavity, especially in patients with nasal septum deviation.

Concha Bullosa is available from birth!

Since concha bullosa is a congenital anatomic variant, this is present when patients are already born. That is, it does not appear after birth. In the developmental stage, the volume of the nose increases with the increase in volume. Concha bullosa is a condition different from a nasal polyp. Nasal polyps are lesions that appear later in the nose, occupying space and appearing in the form of a bunch of grapes. Although nasal polyps can occur anywhere in the nose; origin of nasal polyp from within the concha bullosa is a rare condition.

Can concha bullosa cause deviated septum?

The important information I would like to say to clear up the confusion here is that the concha bullosa is usually located in the nose on the side of the contralateral deviation of the nasal septum. Concha bullosa is not the cause of nasal septum deviation, however; Due to nasal septum deviation, while one side narrows in the nose, the other side expands and in the wide nasal cavity, the concha bullosa can narrow the cavity by increasing its volume. Concha bullosa is not among the causes of nasal septum deviation.

Giant concha bullosa can cause nasal congestion and smell problems!

Concha bullosa rarely enlarges to a great extent, causing closure of the nasal cavity and sinus openings, causing both nasal congestion and olfactory problems at the same time. Sometimes, a mucosal or abscess may develop in the concha bullosa, causing it to enlarge even more. Sample article link >> [A giant bilateral concha bullosa causing nasal obstruction]

Link group where you can read articles about Concha Bullosa published on this website >> https://www.ent-istanbul.com/search?q=Concha+Bullosa+

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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