Nasal Obstruction Treatment: The Impact of Turbinates & Swell Bodies

[Dr. Ashley Agan]
Let's just set the stage. When we're talking about the nose, and nasal obstruction, and the anatomy we're talking about, talk to us about the nasal turbinates, the nasal cycle, the nasal vestibular swell body, or swell bodies, or nasal turbinates, what's going on in the nose? What's all that stuff in there for, and how does it relate to how we're breathing?

[Dr. Jayakar Nayak]
Right. Thanks for the very broad and open-ended question. That's very sweet of you. No, it's really early morning on Saturday for this. In terms of just nasal breathing, one of the things that rhinologists, and general otolaryngologists, and pediatric otolaryngologists see is one of the major complaints that patients come in for is, "I can't breathe through my nose. My nose is congested. My nose is stuffy." We have a job of trying to figure out why that might be. There are so many reasons patients can have nasal obstruction, we'll just call it that for ease.

Nasal obstruction can be from something like a deviated septum. The septum is the midline central wall of our nose, ideally would be central and divide our nose into left and right sides evenly, but many times that structure is crooked. That wall is bent to the left, to the right, actually to both sides. Sometimes that wall is fractured from trauma, or from a sports injury, things like that. That's one major and very common reason for nasal obstruction. Two are nasal polyps. Growths in the nose, inflammatory growths in the nose that can block either left or both nasal cavities.

In kids, adenoids. Adenoids are in the very back of the nose, and that can lead to blockage of air passage from the nose into the throat and lungs. Another major component of nasal breathing are these other dynamic structures in the nose called turbinates, and what we termed the nasal vestibular bodies, back in 2016. We actually coined that term. The turbinates are these shelf-like structures, torpedo-shaped structures that hang, in many cases, from the side walls of the nose, which are the inferior turbinates, and are pendant-like chandeliers into the airway, and the lower part of the nose.

Those are the inferior turbinates. There are two sets of turbinates in the central part of the nose called the middle turbinates, and two others that are even higher in the nose, and they are called the superior turbinates. Those two turbinates are more attached to the skull base centrally and superiorly. Again, all three, though, hang and are suspended within the nose. They are directly involved in our airflow and in the sensation of airflow. I think one of the remarkable facts about turbinates is that all mammals have turbinates. All mammals have at least six turbinates.

The inferior ones are the ones that are just behind our nostrils. Again, there's these finger-like or torpedo-like structures that are about 5 centimeters long from front to back. The middle turbinates, again, are higher, and then superior turbinates are higher than that, but the six sets of turbinates are on all species, and they must be there for a reason. Through evolution and development, all mammal species have evolved this mechanism for breathing through the nose through this tubular torpedo-like structure. Now, the lower mammals have more turbinates.

They're called ethmoturbinals, they're in the back of the nose because other lower vertebrates are more dependent on sense of smell, so those more turbinates are thought to be more involved in smell. We've lost those other turbinates because we are thought to have more dependence on sight and sound. At least those six turbinates are preserved throughout so many species, so, again, their importance must be there. With that said, the lower turbinates, those inferior turbinates in humans, I think more than any other species, I don't know about the other species too well, the inferior turbinates somehow tend to swell or hypertrophy in humans.

Because they're right behind the nostrils, they can completely congest or obstruct the nose, and they tend to take a life on their own. This is a major and very common cause of nasal obstruction in patients. Understanding what are the actual cause of that nasal obstruction, again, it could be multifactorial, or sometimes just one cause, but turbinate hypertrophy is extremely common as a cause for nasal obstruction. Then finally, we identified one because I see so many patients with nasal obstruction, and now empty nose syndrome, which we're going to talk about.

These are little swell bodies that I started to see so commonly in some patients with persistent and recalcitrant nasal obstruction. Then these swell bodies are more towards the nasal floor, if you look at the nose from the front, if you think of the nostril like a clock, the six o'clock position of the nostril, or the four o'clock, and the eight o'clock positions of the nostril in a way. Just in the corner, just behind the nostril, there's these swell bodies that tend to form. A good number of patients, about 25% to 30% of patients have these little swell bodies too.

That can naturally also take up some of the room of your nostril, just like a turbinate can, and just like a deviated septum can. Any of those things can contribute to your sense of poor airflow or a lack of airflow. In the end, you've asked me what these structures are, so I think I try to define what the general makeup is from the nasal obstruction, and what can contribute to it. Then, what the turbinates actually do, we learn in residency that the turbinates are there to filter airflow. They filter pollutants, bacteria, and viruses. They're our first screen for air from our nose to get trapped into the mucus so that those particles don't end up in your lungs and trachea.

That's one. Two, because the turbinates have such a good blood supply, and all of the tissue in our nose is pink compared to the skin, the skin is a different texture to it, and different color to it because the vessels are a little lower. In the nose, the tissue is pink because the vessels are so close to the surface. It's a very thin epithelium compared to the skin on our hands and feet. Because of that, therefore, the blood supply and the air that enters our nose can be warmed more easily because it comes in closer contact to the mucosa of the nose, the pink tissue of the nose.

It's thought that the nasal tissues, and the turbinates, and the general nasal mucosa warms the air that we breathe. That's another function of the nose, and the nasal physiology, and turbinates. We've also found that, from our research, it seems to be that another role of the turbinate is actually almost serving as a magnet for airflow so that the air is actually attracted to these. Especially in the lowest four structures, the two inferior turbinates left and right, the two middle turbinates left and right. Absence of one of those turbinates actually leads to very aberrant airflow because the magnet is gone, and then airflow is distributed in an abnormal way.

Whereas when the turbinate is present, it almost attracts air to it. It must be because of its tubular structure and tubular appearance. That must be part of the nasal physiology again because its absence in some patients, not all patients, can lead to very aberrant and uncomfortable airflow.

[Dr. Ashley Agan]
You mentioned nasal vestibular swell bodies on the floor and anteriorly. What about the swell bodies that we talk about sometimes on the septum? Is that a thing, if you will, as well? Is that recent, or does that contribute to nasal airflow or obstruction?

[Dr. Ashley Agan]
Moving on towards clinical presentation, when patients come to you, what are some of the main complaints, or how do they present that? More importantly, what are you always asking in the history? What are some of the things that you always remember to ask your patients?

[Dr. Jayakar Nayak]
When patients come to see me, there are, again, I have a wide range of patients. I do have some primary patients who may have heard about me, or they want to see a Dr. Stanford, and they've never had surgery in their nose. Just yesterday, I saw someone who had a surgery she was very unhappy with, from another state, and I've had other patients who come in after nine surgeries in their nose. Either way, you try to assess everyone in the same general capacity. What specifically are your symptoms? Are they left-sided primarily, right-sided primarily, or you just can't tell? You want to see what their nasal regimen is. Are they doing anything that makes them feel better?

Saline rinses, nasal steroid sprays, a combination of sprays. Some patients are using moisturizer in their nose, ointments, or certain gels, things like that. Naturally, you want to know about any past surgeries, past procedures, trauma to the nose. Then, what generally is their goal? Maybe they came in because they had a recent diagnosis of sleep apnea, and they actually have no nasal obstruction, but they were told that their nose is a problem because they can't tolerate the CPAP mask for positive pressure. You may have to find out maybe what you can do to help them just tolerate their CPAP mask more. Sometimes that's not a nasal obstruction complaint, that's, "I came here because my doctor told me to come here." Those are a range of things I think that are important to suss out when you're meeting a patient.

[Dr. Ashley Agan]
On your exam, are you scoping every patient that comes in? Do you always decongest?

[Dr. Jayakar Nayak]
Actually, to go back to the last question, the one thing I also try to figure out is what helps them, and again, what their nasal regimen is. Does Afrin help them or not? Does a nasal decongestant like Afrin or something called major decongestant? There are multiple decongestants out there. Does that help them, or do they feel worse on that? That really helps to put them into a category of that tissue enlargement is causing their problem. Therefore, tissue shrinking from Afrin or a decongestant, really impacts their quality of life, impacts their sleep.

That's a big aspect of what you can learn from someone just from interviewing them without even looking in their nose. Now, in the Stanford rhinology practice, because the patients have both sinus and nasal problems, I rarely use a nasal speculum anymore. Virtually everybody in my practice gets an endoscopy. Everyone gets an endoscopy of the anterior nasal cavity, left side and right side, prior to any decongestant. I see every new patient negative, no spray of any kind. Just want to see that vestibular bodies are present or absent. The presence of hypertrophy even to the anterior head of the turbinate, presence of caudal or anterior septal deviation on the left side or right side.

Then once that's documented and everything is archived, we have photo documentation of everything, and it's saved on our servers. Then after that, if they, for example, have empty nose syndrome or something like that that I have to test, then I'll do a cotton test, which we can get into. If they don't, and it's just standard nasal obstruction or sleep apnea, or something like that, then I will put in a topical decongestant. I try to do it on a cotton swab or a pledget because I don't want the spray going globally. I just want to address that lower one-third nasal obstruction.

I try to put cotton pledgets and decongestant on the turbinates and on the swell bodies, and then leave them in for only a minute and a half or so, and then take them out. Then I ask if patients are feeling better. They usually don't know what I'm doing. I ask them to just trust me because I want them to just not be biased by everything I'm doing. Just, "I did something to your nose. Do you like it or not?" Many times they're just amazed. They've never tried Afrin, and they're like, "Yes, I love this. I love this breathing. This is exactly how I want to breathe.

This is amazing." That kind of thing. That's great because they're not really know what's coming. They just heard that I'm the doctor to see or I'm one of the doctors to see. They have an experience that they know is very beneficial for them, which is great. Then from there, we can decide what the best pathway is for them. Now, some patients, that's why you do it, they will say to you, "No, I feel exactly the same with Afrin." "Okay, so great. I just needed to know that. Then let's figure out what else might be the problem." They do find other pathology that might be there. It might be, again, a completely different issue than you were expecting at the time. Then, of course, some patients come in with imaging, so, yes, we're going to analyze that imaging. In those cases, CAT scans or MRIs. That will help you determine where the issue might be.

[Dr. Ashley Agan]

Can we go back to how you decongest the nose? You're not spraying the Afrin. Are you using the sinus surgery pledgets, the long, 1 by 3 pledgets, dip it in the Afrin, and then, with a bayonet, packing the nose? Is that what you mean?

[Dr. Jayakar Nayak]
The truth be told, I actually even like cotton balls that I unroll. They come in like a little rolled confirmation. In any case, I just separate them out, and I make my own pledgets that are 2 centimeters by 1 centimeter. I just like them a lot better because they're just softer and not the woven cotton that you get in these surgical pledgets that we use in the operating room. They have a string on them. I just don't do it that way. I just make these pledgets beforehand. Then having these little containers, so each patient gets a container that has just decongestant in it, like Afrin, for example, or phenylephrine.

That'll just place with a bayonet, right onto the turbinates, and then I'll just ask them if they're breathing better. Then separately, I'll decongest separately with a smaller pledget, the nasal vesicular body on the left side and right side. Then ask them, "Okay, are you better by 50% with a turbinate, or now, are you better or not with the second thing we did?" Sometimes they'll say no. Sometimes they'll say, "Absolutely." Things like that. I just try to even ferret out and try to investigate, is it just your turbinate hypertrophy that's causing your obstruction on your left side or right side? Is it just your nasal swell body on the left side or right side that's contributing to, again, your sense of nasal obstruction?

Then again, do you enjoy this or not? They'll be decongested for about two or three hours after you place that in. Then they get to experience that for a few hours at least on their drive home, or hotel, or wherever. Yes, that's how I like to do it. The reason is that sometimes our sprays, especially if the spray has lidocaine in it, patients just don't like it. So much of the visit is sometimes spent like, "I don't know, my throat is really uncomfortable." They're coughing and hacking, and they need water. [chuckles] All this extra spray goes down the throat, and it just turns into this slightly traumatic experience and visit.

I'd rather just keep it at nasal as much as possible and just talk about the nasal problem and not deal with this little dripping of the posterior throat and swelling to the throat that they feel. Anyway, I'm just trying to make it as clean as possible, but it does take time to do it.

[Dr. Ashley Agan]
How long do you leave them in there for?

[Dr. Jayakar Nayak]
I leave them in there for about a minute, maybe a minute each side. Then I'm always alternating sides, so then I'll take it out. I'll put it in the left side, then I'll put it in the right side. Then we'll talk for 30 seconds, we'll get into a little part of history. Then I'll take it out of the left side and right side. Then I'll take pictures again, by the way. I'll do another photo documentation of them after decongestion. You'll see that some patients even need two rounds of decongestion. Their turbinates are so huge or their nasal swell body is so huge, they have to do a second round.

Then they're like, "Yes, oh, I didn't even feel that. Whenever any doctor did this, it was only 10% better. Now you did this twice, and you took the time to do that, now I see." That's because many patients have central and posterior turbinate hypertrophy that the first pledget couldn't even get to. The first pledget was placed in the first 2 centimeters. Now that you can see that first 2 centimeters, and you should take a photo of that, oh, I see, I still can't see the choanae. I can't see the back of the nose. All right, let's try again, so then I put a second pledget deeper in.

Now I decongest the entire length of the 5-centimeter turbinate on both sides. They're like, "Oh, that is some of the best breathing I've had in years or so." Then you can really say, okay, they have nasal obstruction from, just anterior head hypertrophy of the turbinate, which is that front part of the turbinate, or the central or the posterior. I'd say actually, with some of the redo and recalcitrant patients that I have seen over the years, many of whom thought they have empty nose syndrome, for example, it turns out that just looking in their nose as a new observer and analyzer of what's happening to them, many of these patients who don't like their breathing, and they, again, subjectively think they have this empty nose syndrome problem, a good fraction of them just have posterior turbinate hypertrophy.

That's it. They came for miles and sometimes other states and everything for that. All I do is decongest their nose, but before, because surgery helped give them this conundrum, then, in that case, I'll ask them to use Afrin at home once a week. Just once a week because your nose can get addicted to Afrin. I just have them spray in this decongestant spray on their own. Just continue your nasal regimen six days of the week, but every Sunday, I want you to document for me, with a spreadsheet, what your symptoms were 0 to 10 during the 6 days.

Then on the seventh day, when you used the Afrin, how was your nasal obstruction symptom on the left side or right side? If it every time improves to a lower number, lower for me is better on a number scale, then great. Then I think we've proven that even in your home environment in Nevada, in Southern California, in the Bay Area, in New York, wherever they're coming from, okay, that where you live, you have the same experience that you had in my office. Okay, then it is posterior turbinate hypertrophy. I think we were right about that. Then we can talk about what to do about that. I do think that just that little test is just underutilized. I think we're sometimes under-analyzing the patients' nasal cavities.