A Middle Turbinate Variant: Paradoxical Rotation of The Middle Turbinate
One of the variations in the shape of the middle turbinate is the "paradoxical middle turbinate". The paradoxical middle turbinate may predispose to impaired drainage of the sinuses from the normal ostiomeatal unit and nasal obstruction. The word "paradoxical" used here means that the middle turbinate edge is inferomedially curved while the concave surface of the turbinate faces the nasal septum (the turbinate shape shown in the left image and the red line in the image above). In the image above, the normal middle turbinate shape is shown on the right side with the green dotted line. It is usually bilateral but can also be seen unilaterally. The concavity of the normal morphology of the middle turbinate faces laterally. In contrast, the concavity of the paradoxical middle turbinate faces the nasal septum. As an easy morphological explanation, the normal middle turbinate configuration is usually the same as the inferior turbinate (i.e., medially convex). As an anatomical variant, when the convexity is reversed (laterally convex) and lateral, it is called Paradoxical middle turbinate.
Clinical significance of paradoxical middle turbinate
Paradoxical middle turbinate can make the procedure difficult when an endoscopic procedure is planned for the sinuses. There is no current definitive scientific treatment protocol or scientific articles on how to surgically treat paradoxical middle turbinate. During endoscopic sinus surgery, if it makes access to the middle meatus and sinuses difficult, the paradoxical middle turbinate can be conservatively removed or reshaped with endoscopic technique.
Diagnosis
Paradoxical middle turbinate is an anomaly frequently encountered in people with no complaints and can be easily recognized on CT paranasal sinuses; however, it can be overlooked during endoscopic nasal examination.
Paradoxical middle turbinate may only involve a portion of the turbinate and the rest may be normal. The prevalence rates reported in different studies may vary, by definition, because some consider any involved part of the turbinate as paradoxical curvature, while others may consider this variation only in cases where the entire turbinate is unusually curved towards the opposite side (source >> https://radiopaedia.org/cases/paradoxical-right-middle-turbinate). Paradoxical middle turbinate tightness varies between 9% and 34%. It is usually present bilaterally in 40% to 80% of cases.
Paradoxical middle turbinate - clinical manifestations
Usually, patients do not experience any symptoms. However, due to the significant narrowing of the middle nasal meatus and ostiomeatal complex obstruction due to paradoxical middle turbinate, normal drainage of the paranasal sinuses may be prevented, leading to facilitating sinusitis. Sometimes, when there is also a concha bullosa, nasal obstruction may be observed.
Paradoxical middle turbinate - Radiographic features
Middle turbinate morphology and size are best evaluated on CT scans of the paranasal sinuses in coronal sections. Paradoxical middle turbinates, which are usually not detected on endoscopic examination, are detected on CT.
Treatment
If asymptomatic, paradoxical middle turbinate does not require any treatment. If it causes recurrent sinusitis attacks or complicates endoscopic sinus operations, it can be partially resected endoscopically.
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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