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Nasal Obstruction Treatment: The Impact of Turbinates & Swell Bodies
Melissa Malena • Aug 7, 2023 • 79 hits
Nasal obstruction can cause a wide variety of symptoms, posing a unique challenge to clinicians. Nasal swell bodies and nasal turbinates can swell at different times throughout the day, resulting in noticeable breathing changes. In order to diagnose and treat nasal obstruction patients, a careful history must be taken along with tests to determine the cause of discomfort. According to expert ENT Dr. Jayakar Nayak, tissue enlargement or tissue atrophy can be the source of similar symptoms, but must have different treatments in order to be successful. A key part of a successful nasal obstruction treatment protocol is a consistent nasal regimen.
This article features excerpts from the BackTable ENT podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Nasal turbinates, torpedo-like structures suspended within the nose, are found in all mammals and play a crucial role in breathing. They filter pollutants, bacteria, and viruses from the air we breathe, preventing these particles from reaching our lungs. They also warm the air due to their rich blood supply and close proximity to the air that enters our noses.
• Nasal turbinates and nasal swell bodies, including the nasal vestibular body, can swell and unswell, causing diurnal variation in nasal airflow. This fluctuation in airflow can make one nostril feel more blocked than the other at different times of the day.
• A comprehensive history taking is crucial, noting patient symptoms, nasal regimens, past procedures, and their goals from the nasal obstruction treatment. Determining what helps the patient, such as Afrin or a nasal decongestant, can indicate whether tissue enlargement is causing their problem.
• Regular nasal regimens using saline rinses can significantly benefit patients with turbinate hypertrophy by clearing mucus, drawing fluid away from tissues, and potentially reducing swelling.
Table of Contents
(1) Anatomy & Impact of The Nasal Turbinates on Airflow
(2) The Role of Nasal Swell Bodies in Nasal Obstruction
(3) Treatment Algorithm for Nasal Turbinate Hypertrophy
(4) The Importance of Nasal Regimens
Anatomy & Impact of The Nasal Turbinates on Airflow
There are various anatomical structures within the nose, including the septum, turbinates, and the recently identified nasal vestibular swell bodies. Nasal turbinates are torpedo shaped structures which appear pink due to well innervated blood flow and are present in all mammals. Swollen nasal turbinates lead to nasal obstruction. Patients most commonly present with complaints of nasal congestion and obstruction making it difficult for them to breathe. The nasal turbinates and swell bodies also play a role in warming and filtering the air we breathe. According to Dr. Nayak, the turbinates attract and direct airflow through the nasal passages via their tubular shape.
[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?
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The Role of Nasal Swell Bodies in Nasal Obstruction
Nasal vestibular bodies, akin to septal bodies, are swollen sections found along the septum that can obstruct airflow and cause persistent nasal obstruction. Airflow within the nose primarily occurs in the lower one-third of the nasal cavity and can be compromised due to enlarged turbinates or a deviated septum. There is a diurnal variation of the turbinates, where one side swells while the other shrinks, leading to alternating congestion. This phenomenon is subjective and not everyone experiences it in the same way.
[Dr. Jayakar Nayak]
We coined the term nasal vestibular body based on that previously coined term called the septal body. The nasal septum there, you can have multiple swell bodies in the nose, I should say that, throughout the length of the septum. I have such a variety of patients out there now who see me for persistent nasal obstruction, and complex nasal obstruction issues. I have seen swell bodies throughout the length of the posterior septum, which isn't something we learn about, the central septum, but the septal body is this anterior or front of the nose, superior, top of the nose swelling that can happen 2 centimeters in, and 2 centimeters superiorly to the nostril.
Yes, it can. I've seen some patients that have such a large septal swell body that it seems to obstruct and almost descend towards the nostril and contribute to nasal obstruction. When I decongest that structure with some topical decongestants we have in the office, and only that structure, some patients will say, "Wow, that's so much better. I can breathe so much better." Again, people can have multiple components to this, but the fact is that airflow typically happens in the lowest one-third in the nose. The majority of airflow happens in the lowest one-third of the nose, which is basically, if you think of the nose in thirds, the lower part of the nostril to the top of the nostril, they'll call that one-third.
That part, to the bottom of your eyes, another third, and there's a top third above that. Most of the airflow happens in the lowest one-third of the nose. If you looked at the vectors of airflow that are modeled in computer modeling, it's in the lowest one-third of the nose, and maybe the lowest part of the second third. That means right around the nostril area, right around the inferior turbinates, and just the base of the middle turbinates, that's where most of the airflow goes. The septal body, therefore, is usually above that. It's not really always involved in airflow, but it can be when it's enlarged enough.
Similarly, the middle turbinates aren't extremely involved in airflow. Maybe 10% to 20% of the airflow versus 80% in the lower 1/3 of the nose. Some people have enlarged middle turbinates, now that descend and can really compress or restrict the airflow so that even a middle turbinate can be part of that. I'd say the majority of patients, it's mostly inferior turbinates. If there's a septal deviation or crookedness that's there or a polyp that descends all the way into the lower one-third of your nose, those are the things that'll contribute to true nasal obstruction.
[Dr. Ashley Agan]
For these swell bodies that develop, is there a hypothesis or a known reason why some people are developing these, it's almost like extra turbinate tissue in the nose, is it? What's the thought?
[Dr. Jayakar Nayak]
Yes, no, it's a great question. I don't think we know. We actually are looking at the histology of that nasal vestibular body, and towards the floor of the nose, and these front corners of the nose. The histology seems to be similar to turbinate tissue and to especially the septal swell body tissue, just an area of a buildup of some piloerector tissue, some just excessive soft tissue. It's dynamic because there's definitely some vessels in that, that swell and unswell. All of these structures that I was mentioning before are not static structures.
The turbinates can swell and unswell, and there's something called diurnal variation of the nose that you learn also when you do our specialty, where the left side turbinate might swell every 8 to 12 to 16 hours. If that's happening, then the opposite turbinate, the right turbinate, is shrinking. Similarly, if you take a CAT scan of that patient, then one day later it might be the opposite, where now the right turbinate has hypertrophied and the left turbinate has shrunk down. There's clearly some sympathetic or parasympathetic innervation to those turbinates that are providing this alternating variation, left side, and right side.
Some patients can even notice this. I've never noticed nasal obstruction on either side at any time except for standard viral cold or rhinovirus, URI. Other than that, my turbinates are swelling and unswelling on the left and right sides, and yours might be too, but I don't notice it. Some patients they'll say, "I notice right away I'm always blocked on my left side and tomorrow, it's going to be the right side." If they sleep on a certain side, the side that's down towards the pillow, congests more. "I've switched to the side that I'm sleeping on, and that side congests."
Sometimes that means they're extremely aware of this. One thing about the nose that will always be the case I think, is the nose is a very subjective place. You might have the most severe 100% blockage of your nose on the left side from a severe cartilage and bone septal deviation. Some patients will say, "I can't breathe through my left side. I hate my left side of breathing." Then you survey another 50 patients, and they'll say, "I love my breathing. I have no breathing problems whatsoever," even though they had the same degree of obstruction. That's because they're breathing so well through the right side, they never noticed their left side.
That happens frequently. Some people have severe turbinate hypertrophy, and they'll swear that they've never had a breathing problem, they don't snore. They've never had complaints about any aspect of their breathing, and they're completely fine.
[Dr. Ashley Agan]
You'd mentioned the diurnal system, the subjective sensation when patients come in and they say they sleep on one side. I don't really know how to explain, I don't think I really understand when they come to me with that kind of complaint. How do you respond to patients with some of those observations that they have? You know they have those symptoms, but I don't always know how to say why they have those symptoms.
[Dr. Jayakar Nayak]
Yes. First, the nose has so many differences between every individual compared to other structures. Let's just say just compared to the heart. The heart is such a tightly regulated and tightly defined structure. It's a structure that's within our chest, behind skin, muscle, bone, ribs. It's always roughly the same size and roughly the same angle and position. It has chambers and the valves are even the same size in virtually everybody, virtually all adults, and so when you have a valve problem, everyone has the same physiology.
Everyone is going to have some kind of heart issue. They're going to have weakness, fatigue. You'll need to see a doctor, you might need a procedure done. Also, surgery for the heart is very well-defined. There's so much more research and thousands of doctors who do research every year compared to ENT specialties, or there aren't many labs, and that much research going on. Again, the idea being that that's a tightly regulated system by size, by physiology, by even constants, numerics. We know about all the blood flow and chambers and strength, and so many aspects of cardiac physiology and flow.
Compare that to the nose where you just look around any room, the nostril size is different in everybody. The nasal shape is different. Some people have curved and angled noses. Some people have broad nostrils and longer noses, wider noses, smaller noses. Similarly, we have all these variables of deviated septum and turbinate enlargement or not, some people have surgery or not. The point is, I think that the airflow is so different for everybody. Also, what's going to happen and what's going to affect my ability to breathe through my nose is how much lung capacity I have.
If I have, my lungs don't work so well, then I'm not expecting to breathe so well through my nose. You're used to that, and you just get used to those things. Again, I think so many variables go into our nose shape, anatomy structure, and airflow that I think that as a result, everyone's sensation of airflow, and what they get used to is so subjectively different. That's one. Then I think that we don't know too much about this yet, but the innovation that I think people have and the receptors people have for that sense of airflow might be very different in individuals.
That some people seem to be extremely sensitive to little changes in the airflow. It might be some of those patients I mentioned before, that they notice the left side versus right side. Others don't. Some people we know are very hypersensitive to perfumes and changes in the environment and the humidity. "I know right away I'm going to get congested today." I've never felt that. I don't have that kind of barometer that's so tightly tuned. In any case, I think that there might be those kinds of receptor changes and differences between people, that again, make us different and just individual.
Those things will be ferreted out with time, but for now, I think that's, it's just something that we accept. Similarly, we accept other variations. If you have fingers that are different sizes, you just get used to it. It's not like there's anything wrong with you. It is just considered a variation in the size of certain parts of your body. It's okay, it's within the normal range. I think that also it is something that we just learn to get used to. If we get that used to in our hands and our joints, then we probably get used to it with our nose.
Treatment Algorithm for Nasal Turbinate Hypertrophy
Dr. Nayak shares his unique approach to nasal obstruction treatment for patients with turbinate hypertrophy, discussing the range of patients he sees, from those never before treated to those unhappy with prior surgeries. He emphasizes the importance of understanding a patient's symptoms and their history, as well as what helps relieve their symptoms. Afrin and nasal decongestants are common tools used in distinguishing the causes of nasal issues. Dr. Nayak also details his procedure for nasal examination, which includes the use of endoscopy and topical decongestants. He also stresses the significance of patient feedback in determining the success of a nasal obstruction treatment or intervention.
[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.
The Importance of Nasal Regimens
Nasal regimens are an effective nasal obstruction treatment in the management of turbinate hypertrophy, particularly saline rinses and steroid sprays. Patients should be reminded of the importance of maintaining a regular nasal regimen for long-term health, likening it to daily oral hygiene. Saline is quite beneficial, both for its ability to cleanse and reduce swelling in the nasal tissues. While acknowledging the diverse range of available nasal steroids, Dr. Nayak emphasizes the importance of patient preference and tolerance in selecting an optimal regimen. Saline rinses with budesonide steroids can also be combined for enhanced benefit, particularly for patients who have not experienced relief from other methods. However, patients should not use this combination for longer than six months as the long term safety is unknown.
[Dr. Ashley Agan]
Let's go into nasal regimens. I typically think of saline, I think of some Flonase. Do you have an algorithm, or what do you like to have patients try, or what do you think helps, doesn't help if they've done the Flonase or Dymista and that doesn't work? What's your regimen?
[Dr. Jayakar Nayak]
I usually say to patients that being on some kind of nasal regimen is just necessary for us to assess what the best things are that'll help you. At the minimum, they need to be on a nasal regimen because if we do a procedure, saline spray is going to be part of their care and part of their healing process, so they should get used to being on a regimen anyway. What's important in a nasal regimen, is a nasal saline of any type. Frequent use of saline mist, frequent use of Ocean spray, Deep Sea spray. Those are just little spritzer bottles of salt water or a NeilMed or similar type of saline rinse where patients mix it themselves with an 8-ounce bottle of clean water, and they put in a salt packet that's buffed with both sodium bicarbonate and salt.
[Dr. Ashley Agan]
Do you think sinus rinses that we're talking about now is better for the turbinate hypertrophy nasal obstruction patients, or do you think saline mist or drops are the same or enough?
[Dr. Jayakar Nayak]
I don't know. That's a great question. I don't think anyone knows. I personally feel like just anything that they're putting in their nose that's saline is better than not putting it in. I think that as long as you're doing it-- There are some patients who just insist that nasal rinses go up their ear, making them uncomfortable, so I'd rather them do some kind of saline like a mist than not. I do think that larger volume rinses have changed rhinology practice. Every study that's ever looked at nasal saline has shown benefit. I think thousands of surgeries have probably been canceled or postponed because patients have benefitted from the use of nasal saline.
I just think of it just as a generic wash for the nose. I think of it like, and I would describe it as brushing your teeth. You feel better after brushing your teeth. You feel a little more sanitary, a little better, a little cleaner, and I think that clearing out mucus from the nose, for a lot of patients, is great with the saline. Also, water is thought to be-- Follow the salt water. A little bit of salt water outside of the tissues will draw fluid away from the tissues, and hopefully, reduce hypertrophy even for a short amount of time, reduce some of the swelling from the tissues and the nose. I think a larger volume is always better, but again, it's in terms of patient tolerance. If you're dealing with children, it's hard to get any kind of spray in the nose, so we'll take anything.
[Dr. Ashley Agan]
I tell them it's like brushing their teeth or flossing. Their rinses are my flossing. If I don't floss, I get cavities. That's just me. If they aren't rinsing, we're going to have boogers. They're going to be everywhere, just what it is.
[Dr. Jayakar Nayak]
Right, no, there you go. Anyway, I think that saline is the main safe care no matter what. Just, it's been around for thousands of years, and there's nothing you have to worry about. There are so many patients who ask about the side effects of every medication and everything. This is not a medication even. This is just a home remedy that's been around for thousands of years. We use it, it's safe. Then I always have a recommended nasal steroid spray of some kind. Similarly, there are spritzer bottles like the three over-the-counter ones of Flonase, Nasacort, and Rhinocort.
There are about seven plus prescription ones. Whatever is best for the patient is fine. They're all just different variants of steroids, just different slight versions, and percentages of steroids, so, the user's choice on if they want to go over-the-counter. If their insurance covers whatever spray, I'll use that.
[Dr. Ashley Agan]
Does your body get used to them? Do you have to change the amount every six months, or do you believe in that?
[Dr. Jayakar Nayak]
Yes. I usually start with some of the generics and the over-the-counter ones. Some patients feel like it wasn't working for them, and then like the Flonase stopped working for them for some reason. Then sure, we can try that. I don't know if it's well documented that there's tolerance to these medications. They're just considered to be standard, tens of thousands of patients have been studied over decades, that is, so we know it's safe. I don't think that there's a tolerance per se to any of these medications. They're such low concentration.
There's 0.25% steroid in these bottles. That's why they're probably so much less harm in general, but it's a rare patient who comes in and says that. It's also a rare patient that comes in, and they do say this, that when they use X nasal steroid spray, "I get palpitations, I get jittery. I can't." I'm like, "1 in 1,000." I'll say that, but they'll say it, and then you have to adjust. It might be true. Initially, I dismissed it, but again, enough patients have said it over the years, I was like, "Okay, maybe it's true."
The other thing is that I try to put patients on topical, actually rinses again. Then I try to get two birds with one stone. I put saline rinses that they've made at home, the NeilMed squeeze bottle is the most commonly known I'm pretty sure. Then you add in a budesonide steroid or mometasone steroid to it. budesonide is easily found. It's FDA-approved for asthma and reactive airway disease, but most rhinologists I know use it very liberally in the nose or in the sinuses for its utility for post-operative healing, things like that. Beauty of that now wash that had the saline benefit, but also has a slight higher dose steroid in it and higher dose in Flonase, now, you're adding this to the tissues and it's permeating the lower node nasal cavity and that central third of the nasal cavity.
Then I think that's a really good benefit for a lot of patients. I have a lot of patients who said that "Saline and Flonase didn't help me, but saline plus budesonide, that combination rinse really benefited me for pain or for some of this facial pressure, for just nasal congestion, for CPAP working better." I definitely try those things first. For some reason then if we have a known allergy component, I'll add in one of the antihistamine sprays, Astelin or Astepro. That's a great nasal regimen in my book. That they can continue safely for years if they never come back, or if they come from a far distance from Stanford, so don't worry about those as much.
Then if they're on budesonide rinses though, really the data has only been published for six months for safety, so I try not to add people on budesonide rinses except for that short period of time, maybe up to six months or so. Then I try to get them off of that and try to get them on one of the standard regimens of saline plus X nasal steroid spray.
Dr. Jayakar Nayak
Dr. Jaykar Nayak is a a professor of otolaryngology head and neck surgery at Stanford in Palo Alto, California.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, February 14). Ep. 89 – Turbinates, Nasal Congestion, and the Dreaded Empty Nose [Audio podcast]. Retrieved from https://www.backtable.com
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