Chronic enlargement (hypertrophy) of the turbinates and the accompanying symptom of nasal obstruction affect people throughout the day, as well as during sleep. A chronic stuffy nose can impair normal breathing, force patients to breathe through the mouth and turn the simple acts of eating, drinking and speaking into an annoying and sometimes painful experience.

Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and obstructive sleep apnea, as the nasal airway is the normal breathing route during sleep. Once turbinate enlargement becomes chronic, it is irreversible except with surgical intervention.

Chronic turbinate hypertrophy and nasal obstruction are commonly associated with rhinitis, the inflammation of the mucous membranes of the nose. When the mucosa becomes inflamed, the blood vessels inside the membrane swell and expand, causing the turbinates to become enlarged and obstruct the flow of air through the nose.

According to several large population surveys, approximately 20% of the population, or more than 50 million Americans, suffers from some type of chronic rhinitis. Common forms of rhinitis that can cause enlarged turbinates and nasal congestion include allergic, vasomotor, irritative and drug-induced.

Nasal obstruction is a frequent symptom of seasonal allergic rhinitis (hay fever) and perennial (year-round) allergic rhinitis, which occurs when an individual is exposed to allergens such as molds, pollens or animal dander. For some people, allergic rhinitis is nothing more than a nuisance, but for others it can be a debilitating condition that significantly detracts from the quality of their work and recreational lives.

Estimates of the number of Americans who suffer from allergic rhinitis vary from 14 million to 26 million people to 30% of the population. However, many people mislabel their allergy symptoms as persistent colds or sinus problems and allergic rhinitis is probably underdiagnosed.

Individuals suffering from allergic rhinitis account for more than $4 billion in healthcare costs in the United States each year.

Vasomotor rhinitis results from dysfunction of the nerves that control the nasal mucosa. The turbinates of a patient who suffers from vasomotor rhinitis can overreact to changes in external temperature and humidity, becoming enlarged and causing congestion when, for example, the person moves from a warm area into an air-conditioned room.

Irritative rhinitis occurs when the nose becomes hyperreactive to irritants such as cigarette smoke, chemicals, dust or strong odors, and the turbinates become red and enlarged. Irritative rhinitis can leave sufferers tired, irritable and with impaired concentration.

Drug-induced rhinitis is usually due to excessive use of nasal sprays or nose drops administered in response to nasal obstruction. These decongestant medications are intended for short-term treatment only and overuse can cause "rebound" congestion, which in turn leads to increased use of the medication and can lead to addiction. Patients who experience drug-induced rhinitis become unresponsive to the drugs they have been using and typically suffer from swollen, red turbinates and persistent nasal obstruction.

The Current Treatment Regimen

Current treatments for chronic nasal congestion range from behavioral changes (i.e., avoiding exposure to the triggers that cause rhinitis) to invasive surgery. While avoidance of irritants in the environment is a key factor in managing chronic rhinitis, patient compliance is difficult. Medical therapy offers only temporary relief of chronic nasal obstruction due to enlarged turbinates, but it can also be associated with significant side effects. Surgical treatments can be associated with lengthy recovery periods and significant patient discomfort.

Medical Therapy

Medications designed to treat congestion, sinus complaints and the common cold make up the largest segment of the over-the-counter drug market for the U.S. pharmaceutical industry, accounting for nearly $3.5 billion in sales. First-line medical treatment for the chronic stuffy nose and chronically enlarged turbinates associated with rhinitis mainly consists of a variety of antihistamines, decongestants, and topical and systemic corticosteroids. These drugs provide only symptomatic improvement; they cannot cure the condition.

Antihistamine drugs, such as Benadryl®, Claritin® and Chlor-Trimeton®, block the action of histamine, the agent responsible for symptoms of sneezing and a runny nose. While antihistamines reduce these symptoms, they do little to alleviate nasal obstruction.

Antihistamines can cause drowsiness and they are not recommended for daytime use by people who must drive or operate equipment; newer antihistamines have fewer sedative effects, but are more expensive.

Decongestants cause constriction of the blood vessels in swollen mucous membranes, forcing blood out so that the membranes shrink and air passages open. Typical decongestants include nasal sprays such as Neo-Synephrine® and pills such as Sudafed® and Actifed®. Decongestants are chemically related to adrenaline, a natural decongestant that is also a stimulant. One side effect of this type of drug is a jittery or nervous feeling that can cause insomnia. Decongestants can also increase a patient’s blood pressure and pulse rate.

Decongestants should not be used by patients who have an irregular pulse, high blood pressure, heart disease or glaucoma. Also, certain decongestant drugs such as pseudo-ephredine should not be used by patients who suffer from benign prostate hyperplasia (approximately 13 million men in the United States) because the drug can aggravate prostate enlargement.

There are a variety of decongestant nasal sprays available over the counter. These medicines can produce significant, temporary symptomatic relief of nasal obstruction, however, they can also become addictive as rebound nasal congestion occurs with overuse.

Several corticosteroid therapies, most in the form of a nasal spray or inhaler, have been developed to treat chronic nasal obstruction. Intranasal corticosteroids are available only by prescription and they can be very effective, however, they are associated with side effects such as bleeding, drying and crusting.

Patients must take care not to overuse corticosteroid preparations. Although the drugs are applied topically, some systemic absorption of the agent occurs, which can disrupt the body’s steroid balance. Steroids can also be injected directly into the turbinates, however, their effectiveness lasts only three to six weeks.

Intranasal cromolyn is another type of drug therapy; it is a preventive medication and can be very effective in preventing a hypersensitivity allergic reaction in the turbinates(but only if used before exposure to irritants. Although side effects are unusual, cromolyn can produce nasal burning, headaches and sneezing.

In severe cases of allergic rhinitis, immunotherapy (allergy shots) may be recommended. With immunotherapy, a patient is injected with increasingly larger amounts of an allergen to encourage the body to build up resistance. While modestly effective in selected patients, immunotherapy can be a lengthy and expensive process, which limits patient and physician acceptance of the approach.

Surgical Therapy

Surgical treatment of enlarged turbinates that cause chronic nasal obstruction is indicated only after patients fail to respond to medical therapy. Turbinate surgery can be performed as an office procedure under local anesthesia or in the operating room under general anesthesia.

Cautery (burning) of enlarged turbinates can be done with an electrosurgical probe or a laser and is usually performed as an office procedure. Both electrocautery and laser surgery are performed on either the surface of the turbinate tissue or sub-mucosally.

Surface cautery results in edema and crusting in the nose which can last three weeks or longer, while sub-mucosal cautery can cause swelling for up to 10 days. Another method for improving nasal obstruction is outward fracture of the turbinate bone(s), which moves the turbinate away from its obstructive position in the airway. This approach, however, does not address the usual source of obstruction---enlarged sub-mucosal tissue, and the fractured turbinate often returns to its previous position.

Turbinate resection (removal of the bone and/or soft tissue) and excision (removal of the soft tissue only) can be performed with surgical scissors or a laser. Physicians can reduce nasal obstruction by cutting away excess tissue from the surface of the turbinate with angled scissors. Following treatment, the nose must be packed for several days with gauze containing an antibiotic ointment.

Bleeding, which can usually be managed by packing the nose, is the greatest risk for patients undergoing standard turbinate resection. Over-resection of the turbinates has been reported as the cause of excessive, irreversible drying of the turbinates. Resection, excision and surface cautery can all be associated with prolonged crusting and healing, which occurs over a four- to six-week period.

Laser resection of the turbinates uses light energy that reaches temperatures of 750°C to 900°C (1,400°F to 1,700°F) to vaporize the turbinate mucosa. Safety issues related to the use of the laser require special precautions and physicians must take special care to avoid burning the nasal septum and face. The crusting and bleeding rates with laser surgery are similar to cautery procedures.

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