Cool, Small, Dry Turbinate: Empty Nose Syndrome

It's Not Just That Turbinate Volumes Are Small; The Fact That The Fibrotic and Mucous Membranes Have Changed Also Cause Their Functions to Be Negatively Affected

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Turbinates in the nose, as I mentioned in previous articles, are unique, round sausage or pressed sausage-shaped tissues with a mucosal membrane covered with mucus layer and ciliated epithelium, abundant capillary vascular network and warm tissue inside, and bone-containing tissues in the innermost part. There are 3 of these structures in each nasal cavity. These structures perform the task of rotating the air taken from the nose by hitting themselves, increasing the intranasal airway resistance, slowing the air taken from the nose, thus gradually cleaning, humidifying, heating, purifying and pressurizing the air that moves by slowing down and rotating. Especially the inferior tubinates, which are at the bottom, are the most responsible for nasal functions.

What should the characteristics of healthy turbinates be?

Normal Turbinate - Big, Moist, Warm, Close to Sausage Shaped

Above is a normal size and healthy inferior turbinate image
- moist mucous membrane
- no signs of infection (red colour) or allergy (pale colour) are present
- adequately sized and large
- hot due to adequate capillary circulation, since no prior intervention has been made

It can be seen that the gap between the nasal septum and the turbinate is narrow. In other words, the air entering the nose cannot easily pass into the lower respiratory tract in a dry, cold, dirty way (it can go by being purified, heated, humidified, pressurized 😊 )

Healthy, functioning turbinates are essential to nasal physiology and should have the following characteristics:

- it should be in a volume that can narrow the airway to a certain extent.

This information is very important. The distance between the inferor turbinate and the nasal septum should not be too large, and the anterior part of the inferior turinate should not be too small, so that the air drawn into the nose does not enter too quickly, rotates and moves in a circus manner. Especially the front part is the area where the air hits first. Airflow pattern becomes linear when turbinate volumes are reduced too much after surgical resection or abnormal reduction of turbinate volumes. That is, the air that is fast, with little contact with the turbinates moves to the cold, dirty, unpressurized air first to the nasopharynx and then to the lower respiratory tract. A condition that causes adverse changes in all respiratory tracts and a decrease in oxygen absorption - nasal hyperventilation and the more advanced empty nose syndrome may occur.

- the surface mucosa should be moist, the mucus layer should be thick, and there should be ciliated epithelium

The air that hits the turbines regularly is humidified, purified and heated to move backwards. Particles, microorganisms, allergens adhering to the warm mucus layer covering the Trubinate surface, together with the dirty mucus layer, are moved towards the nasal cavity by the movement of the cilia. We are usually unaware of it, but we swallow the mucus that flows backwards from our nose! When this used and contaminated mucus layer reaches our stomach, thanks to our gastric juice, which is as acidic as azure, the particles and microbes are eliminated. In other words, the moistness of the mucous membrane next to a constantly moving mucus layer is very important in humidifying the inhaled air. Especially when excessive electrocauterization, turbinate reduction with radiofrequency, changes due to heat damage in the surface mucosa, drying, crusting, epithelial changes occur, the humidification of the air hitting the dry turbinates will inevitably decrease. Sometimes patients with excessively shrunken turbinates are uncomfortable because of the mucus that is too solid and cannot be easily cleared from the nose.

- dense capillary network providing adequate blood circulation!

Turbinates are "warm" tissues because they contain a very dense network of blood vessels. As a result of repetitive radiofrequency, laser or electrocautery application, recurrent fibrosis and decreased blood circulation result in not only a reduced turbidity, but also a drier and cooler structure. In other words, the duties of the turbines to heat the air are not only due to the decrease in air contact due to the shrinkage; it could also be due to them getting colder than normal.

Empty nose syndrome and nasal hyperventilation can be a health problem that manifests itself with abnormal acceleration of the air entering the nose and decrease in nasal functions, which can significantly reduce the quality of life in patients. Interestingly, although the turbinate volume is not very small in some patients; Empty nose syndrome symptoms may occur. This may be due to changes in the turbinate tissue due to excessive radiofrequency, decreased blood circulation and its cooling, or drier mucous membranes and eptiel changes. Diagnostic confusion and differences in treatment among many physicians cause difficulties in patients dealing with this health problem.

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In the tomography image above, turbinate radiofrequecny reduction and turbinate resection procedures were performed twice in different clinics before, the patient's right inferior turbinate was left with very little rest tissue and the expanded air passage (red arrow), left inferior turbinate was almost completely resected, and much more enlarged intranasal air passage (yellow arrow) is seen.

Injection of hyaluronic acid fillers into turbinates can increase volume and moisture content, but not heat and increase too much!

While some of the patients with empty nose syndrome are desperately seeking a solution; considers the injection of filler materials containing hyaluronic acid into turbinates as a treatment tool in order to increase the volume of turbinates by enlarging and to increase the intranasal airway resistance again and bring it closer to normal. Important points to highlight here:

- Augmentation of turbinates with elephant injection is used especially for the injection of the anterior part of the inferior turbinate and some nasal septum. In particular, inflating the most anterior parts of the inferior turbinates in this way can allow the coarse air to enter the nose more slowly. Patients with abnormally reduced or excision turbinates are unlikely to benefit from elephant injection. In these patients, procedures such as intranasal cartilage implantation and Modified Young's Operation may be appropriate.

It should be emphasized that the injected hyaluronic acid is not living tissue and does not have blood circulation. Although it provides both volume increase and volume increase due to its ability to form a water molecule 1000 times its own molecular weight and its natural edema-forming effect; The general disadvantages are that it can be injected in a limited amount and it is not sufficient for every patient.

You can find a lot of information on this subject in this website.

Below are the paranasal sinus tomography photographs and examination photographs of the patient who had previously undergone nasal surgery in different clinics and had symptoms of empty nose syndrome (feeling of cold air in the nose, headache, feeling of insufficient air intake, sticky nasal secretion). There is a cyst completely obliterating a maxillary sinus in tomography images. The entire nasal mucosa is hypertrophied due to rapid, polluted and dry air contact.