Concha Bullosa Surgery Recommendations
Concha bullosa surgery is recommended when the pneumatized middle turbinate causes significant nasal obstruction, recurrent sinusitis, or interferes with sinus drainage pathways, particularly when the concha bullosa is large (bulbous or extensive type) and medical management has failed to provide symptom relief.
Understanding Concha Bullosa
Concha bullosa is defined as pneumatization (presence of an air cell) within the nasal turbinate, most commonly affecting the middle turbinate 1. While not considered a disease but rather an anatomical variant, concha bullosa can become clinically significant when:
- It causes nasal obstruction
- It contributes to sinus drainage blockage
- It leads to headaches or facial pain
- It becomes infected or develops a mucocele/mucopyocele
Indications for Surgical Intervention
Primary Indications:
- Nasal obstruction: When the enlarged concha bullosa significantly blocks nasal airflow 2
- Recurrent sinusitis: When the concha bullosa obstructs the ostiomeatal complex (OMC) 3
- Headaches and facial pain: When directly attributable to the concha bullosa 2
- Complications: Mucocele or mucopyocele formation within the concha bullosa 4
Type and Size Considerations:
Research shows that surgical outcomes vary based on the type of concha bullosa 2:
- Extensive type: 88.24% complete improvement after surgery
- Bulbous type: 72.72% complete improvement after surgery
- Lamellar type: Only 25% complete improvement after surgery
Preoperative Assessment
Before proceeding with surgery, the following should be evaluated:
- CT imaging: To confirm the presence, size, and type of concha bullosa and assess for other sinonasal pathology 5
- Nasal endoscopy: To visualize the concha bullosa and evaluate for other intranasal abnormalities 6
- Patency of ostiomeatal complex: Determine if the concha bullosa is causing obstruction of sinus drainage pathways 3
- Trial of medical therapy: A minimum 4-week trial of appropriate medical therapy should be attempted before considering surgical intervention 6
Surgical Techniques
The preferred surgical approach depends on the size and type of concha bullosa:
Partial resection (lateral lamellectomy): Removal of the lateral portion of the concha bullosa while preserving the medial portion and its mucosal lining 6
Crushing technique: Compression of the concha bullosa to reduce its size, though this has a higher rate of reformation (as seen in patients who required revision surgery 2-15 years later) 7
Total resection: Complete removal of the concha bullosa, typically reserved for very large conchae or those with complications 2
Endoscopic approach: Preferred method for all concha bullosa surgeries due to improved visualization and precision 2
Expected Outcomes
Surgical management of concha bullosa has demonstrated significant benefits:
Improved nasal airflow: Objective measurements show reduced nasal resistance after surgery (from 0.67-0.71 Pa/cm³ per second to 0.27-0.28 Pa/cm³ per second in bulbous and extensive types) 2
Symptom relief: Complete or partial improvement in 100% of patients with bulbous or extensive concha bullosa 2
Quality of life improvement: Patients report better breathing, reduced headaches, and improved sleep quality 1
Potential Complications
Surgical risks include:
- Bleeding
- Infection
- Synechiae (adhesions) between the turbinate and lateral nasal wall or septum
- Atrophic rhinitis (if excessive tissue is removed)
- Recurrence or reformation of the concha bullosa (particularly with crushing technique) 7
Special Considerations
Concomitant septal deviation: Often present with concha bullosa and may require simultaneous correction 6
Bilateral concha bullosa: May require bilateral surgery, especially when causing complete or partial obstruction of both nasal cavities 5
Pediatric patients: Special consideration needed, particularly with large concha bullosa that may affect sinus development 4
By following these guidelines, appropriate patient selection for concha bullosa surgery can lead to significant improvement in nasal breathing and quality of life, particularly for patients with bulbous or extensive types of concha bullosa.