Diagnosis and treatment

Turbinate hypertrophy: why do the turbinates swell, and what can be done?

The article on what the nasal turbinates are explains the anatomy calmly. This page answers the next question, the one that usually brings the patient here: mine is swollen, now what?

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“Doctor, I was told I have extra tissue growing inside my nose. Does it need to come out?” This is one of the most frequent questions from people who arrive at the office after years with a blocked nose. Almost always, what the person describes as extra tissue inside the nose is an enlarged inferior turbinate, and the technical name for that is turbinate hypertrophy.

The article on what the nasal turbinates are explains the anatomy calmly. This page answers the next question, the one that usually brings the patient here: mine is swollen, now what?

What turbinate hypertrophy is

Inside each side of the nose there are three elongated structures, the turbinates (inferior, middle and superior), formed by a bony core covered by mucosa and by tissue rich in blood vessels. This lining is soft, reddish and spongy to the touch, which is where the popular description comes from. It is not a tumor, nor something that “grew there by mistake”: it is a normal part of the nose, and it has a function. It is the turbinate that warms, humidifies and filters the air before it reaches the lungs.

Turbinate tissue works like a sponge with its own tap: it swells and subsides several times a day, alternating between one side of the nose and the other. That is physiological. The problem appears when it starts to stay swollen, stops subsiding and permanently occupies the space through which air should pass. This persistent enlargement is turbinate hypertrophy, and the inferior turbinate is the one most often involved.

Let us separate two things that confuse many people. A nasal turbinate swollen by inflammation is reversible and usually responds to medication. A turbinate that has enlarged chronically, with thickening of the tissue, responds less and sometimes does not respond at all. Much of the management is decided on that difference.

Why do the turbinates swell?

There is rarely a single cause. In the office, we actively look for each of these possibilities, because they can occur together:

Rhinitis, mainly allergic rhinitis. It is the most common cause. In poorly controlled allergic rhinitis, the mucosa stays inflamed and the turbinates stay swollen. Dust, dust mites, animal dander, mold and weather changes keep the cycle going.
Chronic use of decongestant spray (vasoconstrictor, such as Naridrin, Afrin, Neosoro or any other brand). This one deserves special attention. The spray unblocks the nose immediately, but daily and prolonged use leads to a rebound effect: the nose blocks up faster and faster, the person increases the dose and the turbinates stay permanently swollen. The condition has a name, rhinitis medicamentosa, and it is one of the causes of hypertrophy we see most. Coming off that cycle is part of the treatment and requires follow-up.
Deviated septum. When the wall that divides the nose is crooked, the wider side tends to compensate with a larger turbinate. This is known as compensatory hypertrophy. It explains why, at times, the side that blocks is not the side of the deviation.
Irritants in the environment and at work. Smoke, pollution, strong smells, air conditioning drying the air all day long.
Anatomical and hormonal factors. Naturally bulky turbinates, changes in the bony structure, as well as situations such as pregnancy and some medications taken continuously, which can keep the mucosa congested.
Persistent inflammation of the sinuses. In chronic sinusitis (chronic rhinosinusitis), inflammation of the mucosa is not restricted to the sinuses and also involves the turbinates.

Symptoms: what it is like to live with swollen turbinates

The main complaint is always the same: difficulty breathing through the nose. But it comes with a set of other issues that people do not always associate with the nose:

These symptoms are not exclusive to turbinate hypertrophy. A deviated septum, polyps and adenoids produce similar complaints. That is precisely why the investigation comes before any treatment decision. The overview of all the causes is on the page on nasal obstruction.

A constantly blocked nose, or one that alternates sides, typically worse at night and when lying down
A feeling that one side never opens completely
Mouth breathing, mainly during sleep, with a dry mouth and throat on waking
Snoring, fragmented sleep and tiredness through the day
A nasal-sounding voice, reduced sense of smell and taste
Runny nose, sneezing and itching in the nose, when rhinitis is present
Headache or facial pressure in some cases
Dependence on decongestant spray in order to sleep

How we assess: the consultation and flexible nasolaryngoscopy

The assessment starts with the conversation: how long the nose has been blocked, on which side, what makes it better and what makes it worse, which medications have already been used (and for how long), whether decongestant spray is in daily use, how sleep is going.

Then comes the examination. Flexible nasolaryngoscopy (nasal endoscopy) is performed in the office itself, with a thin microcamera that goes into the nose and shows, in real time and on the screen, the actual size of the turbinates, the septum, the mucosa, the adenoid region and the sinus openings. It is quick and generally well tolerated. We usually show the image to the patient during the examination, because seeing the inside of your own nose changes the conversation about treatment.

When necessary, we add a sinus CT scan or allergy testing. If there is snoring or suspected apnea, a sleep assessment is included as well.

If your nose is always blocked and you have never been through this investigation, that is the first step. Book an evaluation

Grades of turbinate hypertrophy: what they mean

Anyone who leaves a consultation or an imaging report with the word “grade” in it almost always arrives with the same question: is grade 3 serious? There are different classifications in medical practice, and one of the most widely used grades the inferior turbinate from 1 to 4 according to the proportion of the airway it occupies (Camacho and colleagues, 2015; see References):

Two caveats about these numbers. First, the grade describes how much the turbinate occupies, not how much you suffer: there are patients with grade 2 who are very symptomatic and patients with grade 3 who breathe reasonably well. Second, the grade on its own does not indicate surgery. It is one piece of data within the whole, alongside the symptoms, the response to medical treatment and whatever else is present in the nose.

When it is genuinely concerning: obstruction that persists despite well-conducted medical treatment, obstruction always on the same side, recurrent bleeding, loss of smell, persistent facial pain, or any different-looking change seen at examination. In these cases, the investigation needs to go beyond the label of the grade.

Grade 1: the turbinate occupies up to about a quarter of the nasal airway
Grade 2: it occupies between a quarter and a half
Grade 3: it occupies between a half and three quarters
Grade 4: it occupies more than three quarters, practically closing the passage

Medical treatment first

In turbinate hypertrophy, treatment almost always starts with the medical step, because the most common cause is inflammatory and responds to medication. In practice, this usually involves:

Besides treating, this step has a diagnostic role: it separates what is inflammation, which responds to medication, from what is structure, which does not. Without this stage, it is hard to know what surgery would actually solve.

Nasal corticosteroid spray, used correctly and continuously for the period indicated. It is the mainstay of treatment. It reduces swelling of the mucosa and gives space back to the nose, but it takes some weeks to reach full effect, and that is where many people give up too soon.
Saline nasal rinsing, in adequate volume, which removes secretions and allergens and improves the action of the corticosteroid spray.
Environmental and allergy control, including, in selected cases, discussion of immunotherapy (allergy shots) with a specific assessment.
Planned withdrawal of the vasoconstrictor, when there is dependence on decongestant spray.

When turbinate surgery comes in

Turbinate surgery is considered when nasal obstruction persists and affects quality of life despite medical treatment carried out correctly and for long enough, and when flexible nasolaryngoscopy shows that the enlarged turbinate is in fact what is closing the passage of air.

There is no indication based on the grade alone, on a CT report alone, or on how long the complaint has lasted. The indication comes from the examination and the conversation, not from a catalog. Results vary from case to case, and the decision is built together with the patient.

“Does the surgery take out the extra tissue?”

In most cases, no. The current goal is not to remove the tissue inside the nose, it is to reduce the volume of the turbinate while preserving its mucosa and its function. The turbinate is not a useless appendage: it warms, humidifies and filters the air. A nose without a turbinate breathes poorly in a different way, with dryness, crusting and a paradoxical feeling of blockage.

That is why everyday language (“taking the tissue out”, “scraping the inside of the nose”) describes poorly what is done today. What is done, in most indications, is to reduce.

Turbinoplasty

Nasal turbinoplasty reduces the volume of the turbinate while preserving the mucosa that covers it. It can be performed with different technologies, among them the laser, radiofrequency and the microdebrider technique, with removal of excess internal tissue and of the bony component when necessary. The choice of technique depends on what the nasolaryngoscopy showed, on the type of hypertrophy (more mucosa, more bone) and on the overall picture.

Laser turbinoplasty is the technique detailed on the page on laser turbinoplasty.

Turbinectomy

Turbinectomy is the term used for resection of the turbinate, partial or total. It is worth explaining that difference, because the two names circulate as if they were synonyms and they are not.

Partial turbinectomy removes a portion of the turbinate and is still used in selected situations. Total turbinectomy, which removes the whole turbinate, now tends to be avoided as routine management: removing the entire structure eliminates the function of warming and humidifying the air and can lead to a dry nose, crust formation and persistent breathing discomfort, a condition that is hard to reverse. Current practice tends to preserve mucosa and function whenever reduction solves the problem.

None of this means that one technique is good and the other bad in the abstract. It means the choice is individual and needs to be explained beforehand, with the indication, the alternative and the limit of each option.

And the septum?

When there is a significant deviated septum together with the hypertrophy, correcting only one of the two usually leaves the complaint half solved. In these cases, septoplasty and turbinate reduction are frequently scheduled in the same surgical session. It is one of the most common explanations for the sentence we hear often: “I had septum surgery and my nose is still blocked.”

Do the turbinates grow back after surgery?

This question comes up a lot, and the answer has two parts, because “growing back” and “swelling again” are different things.

Swelling again is common and is not always recurrence. The reduced turbinate is still living tissue, with mucosa that responds to allergens, infection and irritants. If the rhinitis that caused everything is not controlled after surgery, the remaining turbinate becomes congested again and the sensation of a blocked nose may partly return. That is why we insist that surgery does not replace treatment of the rhinitis: it opens space, medical control keeps that space open.

Actually growing back, in the sense of new structural hypertrophy, can happen over the years in some patients, especially when the causal factor persists (uncontrolled allergy, return to decongestant spray, continued exposure to irritants). It is not the rule, and it is not possible to promise that it will not occur in an individual case.

In practice, what increases the chance of a lasting result is the combination of a well-made indication, a technique that preserves mucosa and continued treatment of the cause after surgery.

And in children? The enlarged tissue is usually something else

Parents come to the office asking about surgery for the enlarged tissue inside a child’s nose, usually after noticing that their child breathes through the mouth, snores and sleeps poorly. Here there is an important difference compared with adults.

In children, the enlarged tissue that most often blocks the nose is not the turbinate, it is the adenoid, which sits behind the nose and is not visible on external examination. A major source of confusion is that, in everyday speech, the adenoid may also be described as extra tissue in the nose, which leads to this mix-up. Turbinate hypertrophy also exists in childhood, almost always linked to allergic rhinitis, but treatment is conservative first, and turbinate surgery in children is far less frequent than in adults and, when performed, we most often opt for a simple cauterization.

For that reason, in a child who breathes through the mouth, the correct sequence is to assess before operating on anything: consultation, examination of the nose and of the adenoid region, and age-specific criteria to decide between watchful waiting, medical treatment and surgery. That decision is individualized and explained to the parents.

Blocked nose, snoring and apnea: the connection that often goes unnoticed

A large share of patients who seek help for snoring or poor sleep have, at the root of the problem, a nose that does not let air through. The reasoning is simple: with a blocked nose, the body resorts to mouth breathing, which is an emergency route, and an open mouth during sleep favors snoring and instability of the airway.

This has two practical implications. The first is that treating turbinate hypertrophy may improve snoring in some patients, although it is not, in itself, a treatment for sleep apnea. The second is that, in people using CPAP (the positive pressure device used in apnea), a blocked nose is one of the most common reasons for difficulty adapting to the device: air does not come in well, the mask is uncomfortable, the patient gives up. Clearing the nose may make that adherence easier.

If, besides the blocked nose, you snore or wake up tired, bring that complaint to the same assessment. The two things speak to each other more than they seem to.

Frequently asked questions

Is turbinate hypertrophy serious?

It is not a serious condition in the sense of being life-threatening, but it can considerably affect quality of life, sleep and day-to-day energy, and it does not tend to resolve on its own while the cause persists. What calls for more careful investigation is obstruction that persists despite treatment, obstruction always on the same side, or obstruction that comes with bleeding, loss of smell or facial pain.

Are “extra tissue in the nose” and turbinate hypertrophy the same thing?

In adults, in practice, yes. What patients describe as extra or spongy tissue is the turbinate, mainly the inferior turbinate, and an enlarged turbinate is what turbinate hypertrophy means. Watch out for two frequent confusions: in children, the same description usually refers to the adenoid, which sits behind the nose; and a nasal polyp is something else, a growth of the mucosa that patients may also call extra tissue. The examination tells the three apart.

Can turbinate hypertrophy be treated without surgery?

In many cases, yes, especially when the main component is inflammatory. Nasal corticosteroid used correctly, saline rinsing and allergy control usually reduce swelling of the turbinates and give space back to the nose. Surgery comes in when that path, carried out correctly and for long enough, has not resolved the obstruction.

Does turbinate surgery hurt? What is recovery like?

The procedure is performed under anesthesia, and pain control during surgery is handled by the anesthesia team. Afterwards, the usual pattern is discomfort and a blocked nose for a few days, requiring nasal rinsing and relative rest. Recovery time and the need for packing vary according to the technique used and according to whether the surgery was isolated or combined with septoplasty. In our service, the use of packing is restricted to very specific cases and is uncommon. These details are explained case by case at the consultation, before any decision.

Does health insurance cover turbinate surgery?

Care at Dr. José Eduardo Marcondes’ office is private, with the possibility of reimbursement by your plan, and guidance on the necessary documentation is part of the process. Coverage of the procedure itself depends on the plan, on the type of contract and on the clinical documentation supporting the indication.

I had septum surgery and my nose is still blocked. Could it be the turbinates?

It could, and it is one of the most common explanations. If the deviated septum was not the only cause, enlarged turbinates, uncontrolled rhinitis or sinusitis can keep the obstruction going even with the septum corrected. It is worth reinvestigating with flexible nasolaryngoscopy before concluding that the surgery did not work.

Where is the assessment carried out in São Paulo?

Care is private, at the Morumbi and Itaim Bibi offices in São Paulo, and Alphaville, in Barueri. Flexible nasolaryngoscopy is performed during the consultation itself, which usually makes it possible to leave the appointment with the nose already assessed and a treatment plan discussed. In some cases, additional tests are needed before the management is settled.

References

1. Camacho M, Zaghi S, Certal V, et al. Inferior turbinate classification system, grades 1 to 4: development and validation study. Laryngoscope. 2015;125(2):296-302. 2. Camacho M, Zaghi S, Tran D, Song SA, Chang ET, Certal V. Inferior turbinate size and CPAP titration based treatment pressures: no association found among patients who have not had nasal surgery. Int J Otolaryngol. 2016;2016:5951273. DOI 10.1155/2016/5951273. PMID 26904126. 3. Agência Nacional de Vigilância Sanitária (Anvisa). Alerta SNVS/Anvisa/NUVIG/GFARM nº 04, de 16 de julho de 2013. Nafazolina: risco de intoxicação e contraindicação de uso em crianças.