Published March 3, 2016 as 10.3174/ajnr.

A4705

ORIGINAL RESEARCH
HEAD & NECK

The Impact of Middle Turbinate Concha Bullosa on the

Severity of Inferior Turbinate Hypertrophy in Patients with a
Deviated Nasal Septum
X C.M. Tomblinson, X M.-R. Cheng, X D. Lal, and X J.M. Hoxworth

ABSTRACT
BACKGROUND AND PURPOSE: Inferior turbinate hypertrophy and concha bullosa often occur opposite the direction of nasal septal
deviation. The objective of this retrospective study was to determine whether a concha bullosa impacts inferior turbinate hypertrophy in
patients who have nasal septal deviation.

MATERIALS AND METHODS: The electronic medical record was used to identify sinus CT scans exhibiting nasal septal deviation for 100
adult subjects without and 100 subjects with unilateral middle turbinate concha bullosa. Exclusion criteria included previous sinonasal
surgery, tumor, sinusitis, septal perforation, and craniofacial trauma. Nasal septal deviation was characterized in the coronal plane by
distance from the midline (severity) and height from the nasal floor. Measurement differences between sides for inferior turbinate width
(overall and bone), medial mucosa, and distance to the lateral nasal wall were calculated as inferior turbinate hypertrophy indicators.

RESULTS: The cohorts with and without concha bullosa were similarly matched for age, sex, and nasal septal deviation severity, though
nasal septal deviation height was greater in the cohort with concha bullosa than in the cohort without concha bullosa (19.1 ⫾ 4.3 mm versus
13.5 ⫾ 4.1 mm, P ⬍ .001). Compensatory inferior turbinate hypertrophy was significantly greater in the cohort without concha bullosa than
in the cohort with it as measured by side-to-side differences in turbinate overall width, bone width, and distance to the lateral nasal wall
(P ⬍ .01), but not the medial mucosa. Multiple linear regression analyses found nasal septal deviation severity and height to be significant
predictors of inferior turbinate hypertrophy with positive and negative relationships, respectively (P ⬍ .001).

CONCLUSIONS: Inferior turbinate hypertrophy is directly proportional to nasal septal deviation severity and inversely proportional to
nasal septal deviation height. The effect of a concha bullosa on inferior turbinate hypertrophy is primarily mediated through influence on
septal morphology, because the nasal septal deviation apex tends to be positioned more superior from the nasal floor in these patients.

ABBREVIATIONS: CB⫹ ⫽ cohort with concha bullosa; CB⫺ ⫽ cohort without concha bullosa; ITH ⫽ inferior turbinate hypertrophy; NSD ⫽ nasal septal deviation;
⌬ ⫽ side-to-side difference in inferior turbinate measurements

ness of soft-tissue and/or bone components.2-5 Although limited

N asal airway obstruction is a challenging problem that can
arise from multiple etiologies, which include structural ab-
normalities such as nasal septal deformity and turbinate hyper-
normative data has been published on inferior turbinate size by
using CT, ITH remains a clinical diagnosis.6
trophy. Inferior turbinate hypertrophy (ITH) has received much ITH has been commonly described as occurring contralateral to
attention in the literature in the debate over optimal surgical the direction of nasal septal deviation (NSD) or, alternatively
management of nasal obstruction.1 Although the term “hypertro- phrased, along the concave side of the septum.2,3,7-14 Because of this
phy” is most accurately reserved for the overall enlargement of an association, it has been speculated that ITH is compensatory, to cre-
organ because of increasing cell size, its use is widely accepted in ate physiologically favorable nasal airflow turbulence and to protect
the setting of turbinate enlargement secondary to greater thick- the mucosa from excessive drying and crusting with increased air
flow. In other words, the inferior turbinate may have progressively
Received September 25, 2015; accepted after revision December 21.
enlarged to fill the void in the nasal cavity created by the shifted
From the Departments of Radiology (C.M.T., J.M.H.), Biostatistics (M.-R.C.), and midline with the undesirable result of a smaller-than-expected cross-
Otolaryngology (D.L.), Mayo Clinic, Phoenix, Arizona. sectional area for air passage.2 Using septoplasty to correct NSD
Paper presented in preliminary form at: Annual Meeting of the American Society without addressing the ITH may have the unintended consequence
Head and Neck Radiology, September 10 –14, 2014; Seattle, Washington.
Please address correspondence to Joseph M. Hoxworth, MD, 5777 E Mayo Blvd,
of worsening symptomatic nasal obstruction.7
Phoenix, AZ 85054; e-mail: hoxworth.joseph@mayo.edu Concha bullosa is an anatomic variant of ethmoid air cell de-
http://dx.doi.org/10.3174/ajnr.A4705 velopment in which pneumatization most commonly extends
AJNR Am J Neuroradiol ●:● ● 2016 www.ajnr.org 1

Copyright 2016 by American Society of Neuroradiology.

into the middle turbinate. This can be limited to the vertical la-
mella, extend into the bulbous portion, or extensively involve the
vertical lamella and bulbous segment of the middle turbinate.15 If
one allowed some outlier data, the prevalence is likely in the range
of 21%–53%.15-27 Some of the reported variability can be attrib-
uted to differences in the populations being evaluated, the type of
evaluation (ie, CT versus surgery), and the definition of concha
bullosa (ie, whether to include small lamellar types). Similar to
ITH, a preponderance of published reports support a strong as-
sociation between the presence of concha bullosa and NSD, in
which the nasal septum typically bows toward the contralateral
side and may increasingly do so when middle turbinate pneuma-
tization is greatest.23,24,27-30 Moreover, in bilateral cases, the nasal
septum is usually near midline when the conchae bullosa are bal-
anced in size but usually deviates away from an asymmetrically
enlarged dominant concha bullosa.
When one controls for the shape and severity of a deviated
nasal septum, it has yet to be determined whether a concha bul- FIG 1. Coronal reformatted image from noncontrast sinus CT dem-
losa significantly influences the presence of ipsilateral ITH. Logi- onstrates the measurements of NSD. The midline is defined by a
dashed line extending from the crista galli to the nasal crest. NSD
cally, an interaction may exist between the structures because the severity (solid line) is measured to the point of maximal NSD orthog-
concha bullosa and ITH both commonly develop along the con- onal to the midline. NSD height is determined by measuring the dis-
cave side of a deviated nasal septum within a secondarily widened tance from the point of maximal NSD to the floor of the nasal cavity
parallel to the midline (dotted line).
nasal cavity. The objective of this study was to assess patients with
NSD on CT in an attempt to identify whether the presence or
absence of a concha bullosa influences ipsilateral ITH. Image assessment was performed by a board-certified neuro-
radiologist by using a PACS. The following measurements were
performed on 1.25-mm coronal reformations that were rendered
MATERIALS AND METHODS
This retrospective study, which is compliant with the Health In- in a bone algorithm and viewed at window level and width of 450
surance Portability and Accountability Act, was approved by the HU and 2500 HU, respectively:
institutional review board at the authors’ institution, and the need Concha Bullosa. The maximum transverse width and craniocau-
for informed consent was waived. The radiology information dal length of the middle turbinate concha bullosa (CB⫹ group
management system was used to identify patients who underwent only).
noncontrast sinus CT between January 1, 2011, and July 1, 2014.
NSD. Using the image on which the NSD was most severe, we
All sinus CT scans were acquired with a 64-detector scanner
drew a line from the crista galli to the nasal crest to define the
(LightSpeed VCT or Discovery CT750 HD; GE Healthcare, Mil-
midline. An orthogonal measurement was taken from the mid-
waukee, Wisconsin), and the same CT protocol was used for all
line to the apex of maximal nasal septal deviation (NSD severity). The
studies (120 kV[peak], 180 mA, 0.5-second rotation time, 0.531
vertical distance from the apex to the floor of the nasal cavity was
pitch, and 0.625-mm section collimation). No topical intranasal
measured parallel to midline (NSD height), and the direction of
vasoconstrictors were administered at the time of imaging.
septal deviation was recorded (Fig 1).
The sinus CT scans and corresponding electronic medical re-
cords were evaluated in consecutive reverse-chronologic fashion Inferior Turbinate. Because no standard definition exists for ITH
to determine study eligibility. We specifically excluded patients on CT, 4 measurements were acquired to document the width of
with a Lund-Mackay score greater than zero, prior sinonasal sur- the inferior turbinate and the degree to which it projected into the
gery, CT or clinical findings of sinonasal polyposis, a history of nasal cavity.
head and neck tumor or irradiation, nasal septal perforation, and 1) Lateral offset (Fig 2A) represents the maximum transverse
a documented history of craniofacial trauma. Inclusion required distance from the most medial aspect of the inferior turbinate
that patients were at least 18 years of age at the time of imaging bone to the lateral nasal wall.
and that the sinus CT was of diagnostic quality. Additionally, all 2) Width (Fig 2A) was determined by the maximum transverse
patients were required to have unilateral NSD without a mini- width of the pendulous portion of the inferior turbinate inclusive
mum threshold for severity. Subjects with S-shaped or other com- of soft tissue and bone.
plex bidirectional nasal septal deformities were excluded. In total, 3) Bone width (Fig 2B) represents the maximum transverse
we enrolled 200 patients with NSD: 100 with a unilateral middle width of the inferior turbinate bone.
turbinate concha bullosa (CB⫹) and 100 without a concha bul- 4) Medial mucosa width (Fig 2B) was a transverse measure-
losa (CB⫺). As previously published, concha bullosa was defined ment at the point of maximal soft-tissue thickness along the me-
as ⬎50% pneumatization of the vertical height of the middle tur- dial aspect of the inferior turbinate.
binate, thereby excluding very small conchae bullosa or pneuma- For consistency, these measurements were all performed by
tization of the vertical lamella only.24 the same neuroradiologist at the level of the ostiomeatal complex
2 Tomblinson ● 2016 www.ajnr.org
 compare the middle turbinate mucosa
thickness on the concave side of the de-
viated nasal septum with that on the
convex side. Potential correlations be-
tween the concha bullosa width, concha
bullosa length, NSD severity, and NSD
height were examined by using Pearson
correlation coefficients, and simple lin-
ear regressions were used for modeling
the relationships. All analyses were per-
formed with SAS 9.4 (SAS Institute,
Cary, North Carolina). All hypothesis
tests were 2-sided, and statistical signifi-
cance was defined as P ⬍ .05.
FIG 2. Coronal reformatted image from noncontrast sinus CT demonstrates the measurements
of inferior turbinate size. A, The maximum transverse distance from the most medial aspect of RESULTS
the inferior turbinate conchal bone to the lateral nasal wall (lateral offset) is defined by the dotted The CB⫹ and CB⫺ cohorts were simi-
line. The maximum transverse width of the pendulous portion of the inferior turbinate inclusive
of soft tissue and bone (width) is depicted by the solid line. B, The greatest width of the inferior larly matched in age, sex, and NSD se-
turbinate bone (bone width) is demarcated with a solid line, while the thickest transverse dimen- verity (Table 1). The mean (SD) trans-
sion of the soft tissue along the medial aspect of the inferior turbinate (medial mucosa width) is verse width and craniocaudal length of
identified with a dotted line.
the middle turbinate conchae bullosa
Table 1: Comparison between CB groups for patient characteristics and measurementsa were 7.5 mm (2.2 mm) and 15.5 mm
CB− CB+ Entire Cohort (3.8 mm), respectively, in the CB⫹
Variable (n = 100) (n = 100) (N = 200) P Value group, and the NSD height was signifi-
Age (yr) 52.6 (16.6) 54.2 (17.4) 53.4 (17.0) .50b cantly greater in the presence of a con-
Sex (female) 54 (54.0%) 59 (59.0%) 113 (56.5%) .48c tralateral middle turbinate concha bul-
NSD severity (mm) 7.1 (1.6) 7.3 (2.0) 7.2 (1.8) .25b
losa (mean, 19.1 ⫾ 4.3 mm versus
NSD height (mm) 13.5 (4.1) 19.1 (4.3) 16.3 (5.1) ⬍.001b
⌬Lateral offset (mm) 2.7 (1.8) 1.9 (2.0) 2.3 (1.9) ⬍.01 b 13.5 ⫾ 4.1 mm; P ⬍ .001). Concha bul-
⌬Width (mm) 3.4 (2.0) 2.5 (2.3) 2.9 (2.2) ⬍.01b losa width showed statistically signifi-
⌬Bone width (mm) 1.3 (0.7) 0.9 (0.8) 1.1 (0.8) ⬍.01b cant moderate correlations for NSD
⌬Medial mucosa width (mm) 1.0 (1.5) 0.7 (1.5) 0.8 (1.5) .13b height (Pearson r ⫽ 0.30, P ⬍ .01) and
NSD severity (Pearson r ⫽ 0.20, P ⫽
a
All values are displayed as mean (SD) except for sex, which is presented as count (%).
b
Two-sample t test was used to compare the CB⫹ and CB⫺ groups.
␹ tests were used to compare the CB⫹ and CB⫺ groups.
c 2 .04). However, concha bullosa height
was not significantly correlated with NSD
on the posterior-most coronal image on which the primary max- height or NSD severity. Because concha bullosa height and width
illary sinus ostium was visible. As an indicator of ITH for each were highly correlated (Pearson r ⫽ 0.53, P ⬍ .001), simple linear
patient, side-to-side differences (⌬) in inferior turbinate mea- regression was performed by using only concha bullosa width as
surements were calculated by subtracting the side ipsilateral to the the predictor. There were statistically significant positive relation-
apex of the NSD from the contralateral side. In other words, a ships between NSD height and concha bullosa width (␤ coeffi-
positive value for this difference would support the hypothesis cient ⫽ 0.61, standard error ⫽ 0.20, P ⬍ .01) and NSD severity
that the inferior turbinate on the concave side of the nasal septum and concha bullosa width (␤ coefficient ⫽ 0.19, standard error ⫽
was larger than the one on the opposite side. 0.09, P ⬍ .04).
To assess the potentially confounding influence of vasoconges- Bivariate analysis was initially undertaken to evaluate the in-
tion related to the normal nasal cycle, we recorded the maximal mu- dicators of ITH related to concha bullosa status. No significant
cosal thickness along the inferior aspect of the middle turbinate for relationships were identified on the basis of age or sex. As seen in
the concave and convex sides of the deviated nasal septum. Table 1, the values for ⌬lateral offset, ⌬width, and ⌬bone width
Patient characteristics and side-to-side differences for the in- were greater in the CB⫺ group compared with CB⫹, but the
ferior turbinate measurements were compared between the pres- results for ⌬medial mucosa width did not reach significance.
ence and absence of the concha bullosa by using the 2-sample t However, this comparison does not correct for the potentially
test for continuous variables and the ␹2 test for categoric variables. confounding influence of NSD severity and NSD height. Pearson
Pearson correlation coefficients were also used to assess the correlation coefficients were examined to determine the strength
strength and direction of linear relationships for the inferior tur- and direction of potential relationships between the side-to-side dif-
binate measurement differences relative to NSD severity and NSD ferences in inferior turbinate measurements and NSD severity and
height for all 200 subjects, in addition to being stratified by CB⫹ NSD height (Table 2). When we evaluated the data in aggregate
and CB⫺ groups. Multiple linear regression models were con- and divided into CB⫹ and CB⫺ groups, ⌬lateral offset, ⌬width, and
ducted for predicting the side-to-side differences in inferior tur- ⌬bone width showed strong potential as indicators of ITH as corre-
binate measurements, controlling for CB⫹, NSD severity, NSD lated to NSD severity and NSD height, while the level of strength for
height, and potential interaction terms. A paired t test was used to ⌬medial mucosa width was again not as strong.
AJNR Am J Neuroradiol ●:● ● 2016 www.ajnr.org 3
Table 2: Pearson correlation coefficients (P value) between side-to-side differences in inferior turbinate measurements and risk factors
by concha bullosa group
CB− (n = 100) CB+ (n = 100) Entire Cohort (N = 200)
Septal Septal Septal Septal Septal Septal
Deviation Deviation Deviation Deviation Deviation Deviation
Variable Severity Height Severity Height Severity Height
⌬Lateral offset 0.31a (⬍.01) ⫺0.13 (.20) 0.36a (⬍.001) ⫺0.17 (.10) 0.31a (⬍.001) ⫺0.24a (⬍.001)
⌬Width 0.23a (.02) ⫺0.22a (.03) 0.23a (.02) ⫺0.13 (.21) 0.20a (⬍.01) ⫺0.26a (⬍.001)
⌬Bone width 0.43a (⬍.001) ⫺0.24a (.02) 0.56a (⬍.001) ⫺0.31a (⬍.01) 0.47a (⬍.001) ⫺0.35a (⬍.001)
⌬Medial mucosa width ⫺0.03 (.76) ⫺0.21a (.04) ⫺0.08 (.43) ⫺0.03 (.79) ⫺0.07 (.35) ⫺0.16a (.03)
a
Pearson correlation coefficients that were significant at the P ⬍ .05 level.

Table 3: Multiple linear regression models predicting side-to-side DISCUSSION

inferior turbinate measurement differences Concordant with previous reports, the current study supports the
Dependent ␤ Coefficient association between NSD and contralateral ITH.2,3,7-14 NSD se-
Variable/Predictor (Standard Error) P Value
verity and NSD height best predicted the severity of ITH without
⌬Lateral offset ⬍.001a
NSD height ⫺0.10 (0.02) ⬍.001 significant contribution from the presence or absence of the con-
NSD severity 0.36 (0.07) ⬍.001 cha bullosa. Although some of the prior reports did not objec-
⌬Width ⬍.001a tively measure the severity of NSD, 1 study found that inferior
NSD height ⫺0.12 (0.03) ⬍.001 turbinate bone thickness on the side opposite the NSD positively
NSD severity 0.28 (0.08) ⬍.001 correlated with NSD severity as measured by septal angle and
⌬Bone width ⬍.001a
NSD height ⫺0.06 (0.01) ⬍.001 volume.13 In contrast, Akoğlu et al9 attempted to associate the
NSD severity 0.22 (0.02) ⬍.001 angle of the deviated septum with the cross-sectional areas for
⌬Medial mucosa width .06a hypertrophied inferior turbinate bone, mucosa, and overall size,
NSD height ⫺0.05 (0.02) .03 but no significant correlation was found. This may be because a
NSD severity ⫺0.04 (0.06) .45 septal angle eliminates some useful information. When one mea-
a
Overall model P value. sures the angle from the region of the crista galli, severe NSD
centered closer to the floor of the nasal cavity and a milder NSD
Regression models were constructed with ⌬lateral offset, positioned more superiorly can yield the same septal angle but
⌬width, ⌬bone width, and ⌬medial mucosa width as the depen- have a different impact on septal morphology and surrounding
dent variables, respectively, while NSD severity, NSD height, structures. Therefore, NSD in the current study was characterized
CB⫹, and appropriate statistical interaction terms were the inde- by 2 variables, NSD severity and NSD height.
pendent variables. No statistically significant interactions were The elimination of the concha bullosa from the regression
identified, so these terms were removed. Because CB⫹ was highly model does not mean that it is irrelevant, because the bivariate
associated with NSD height (P ⬍ .001), these variables essentially analysis clearly showed significant associations between the
concha bullosa and the indicators of ITH (ie, side-to-side mea-
conveyed the same information so that both could not achieve
surement differences in inferior turbinate bone width, overall
significance within the same model. Because the models contain-
width, and the degree of intranasal projection). Instead, it
ing NSD height and NSD severity had the best overall statistical
merely indicates that the presence of a concha bullosa did not
significance, CB⫹ was removed from the regression models. The
provide additional statistical significance in a multiple regres-
regression models for ⌬lateral offset, ⌬width, and ⌬bone width
sion model because it presumably conveys much of the same
reached significance (P ⬍ .001), with all of these variables show-
information as the parameters of NSD. On the basis of the
ing an inverse relationship with NSD height and a positive rela-
current results, the severity of ITH correlates directly with
tionship with NSD severity (Table 3). The model for ⌬medial
NSD severity and inversely with NSD height. This correlation
mucosa width approached, but did not reach, statistical signifi-
effectively accounts for the observation that the apex of maxi-
cance (P ⫽ .06). In other words, as the nasal septum further de- mal NSD tends to be located more superiorly in the presence of
viates, the inferior turbinate on the concave side of the septum a unilateral concha bullosa.
becomes asymmetrically enlarged, but the degree of enlargement Prior studies have documented the presence of ITH in NSD
is abated as the apex of the NSD moves farther away from the floor in a variety of different ways. Some of the earliest work on ITH
of the nasal cavity. This relative increase in inferior turbinate size used acoustic rhinometry to indirectly evaluate the extent of
can be explained with this model as greater projection of the tur- ITH by estimating the cross-sectional area of the nasal cavity as
binate bone more medially into the nasal cavity (⌬lateral offset) a function of the distance from the nostrils.2,7 Because of an
and an increase in the width of the pendulous portion of the incomplete response following topical nasal decongestant ap-
inferior turbinate (⌬width), with the latter driven by thickening plication, it was concluded that ITH must result from com-
of bone more than mucosa. bined mucosal and skeletal hypertrophy. CT has been used as
Middle turbinate mucosal thickness did not differ significantly an alternative form of in vivo assessment for ITH associated
between the concave (mean, 2.2 ⫾ 0.7 mm) and convex (mean, with NSD by acquiring different measurements of bone and
2.2 ⫾ 0.6 mm) sides of the deviated nasal septum (P ⫽ .99, paired soft-tissue components of the inferior turbinate and compar-
t test). ing these results internally with the contralateral side or exter-
4 Tomblinson ● 2016 www.ajnr.org
nally with a control population.8,9,11-13 In general, these CT preted as ITH being an acquired compensatory process in NSD
data support the findings of acoustic rhinometry that compen- rather than a congenital abnormality.
satory ITH arises from increased bone and mucosal thickness. A separate study compared patients with NSD and stratified
Additionally, as measured by distance or angle, the inferior them as to whether the NSD was thought posttraumatic or con-
turbinate on the concave side of a deviated septum projects genital.14 Inferior turbinate measurements were compared be-
farther medially into the nasal cavity.11,14 Histopathologically, tween the convex and concave sides of the septum to delineate
Berger et al3 compared resected inferior turbinate specimens in ITH. In the congenital group, the bone of the inferior turbinates
patients undergoing surgery for NSD with ITH and compared on the concave side of the septum projected more medially into
them with freshly harvested postmortem specimens. The con- the nasal cavity on the basis of the distance and angle relative to
chal bone in the ITH group showed a 2-fold increase in thick- the lateral nasal wall. The authors concluded that the conchal
ness, which accounted for approximately 75% of the difference bone plays a much greater role in ITH in congenital NSD, under-
in overall turbinate thickness compared with the cadaveric scoring the much longer time needed to acquire osseous-versus-
controls, with no significant difference in bone type (lamellar soft-tissue changes. The notion that the mucosal component of
versus compact). The mucosal contribution to ITH was much compensatory ITH is more dynamic is also supported by a study
less, though the appropriateness of comparing surgically re- that evaluated patients who underwent septoplasty without a tur-
sected turbinates with postmortem specimens has been ques- binate operation and then underwent repeat CT at least 1 year
tioned.5 When viewed in aggregate, this previously published postoperatively.10 On average, the medial mucosa of the hyper-
work supports compensatory ITH arising from both bone and trophied inferior turbinate on the concave side of the septum
mucosal thickening. The tendency of the bone findings to be preoperatively became thinner by approximately 1 mm after the
slightly more reproducible across studies may relate to the in- septal deformity was corrected. This finding was presumed to
herent variability in mucosal thickening introduced by normal represent the mucosal response to narrowing of the adjacent air
mucosal cycling. In the current study, the lack of a difference in channel caused by moving the septum back to midline. In con-
middle turbinate mucosal thickness along the concave and trast, the turbinate skeletal structure was unchanged.
convex sides of the deviated nasal septum argues against the While long-standing NSD appears to lead to the develop-
presence of a systematic bias from the nasal cycle. However, the ment of ITH, the precise relationship between NSD and con-
multivariable model for ⌬medial mucosal width showed that cha bullosa continues to be debated. A significant body of ev-
there was no statistically significant difference (P ⫽ .06), and idence not only associates NSD and concha bullosa but also
this might be attributable to the added variability introduced indicates that the NSD is typically directed away from the con-
by the nasal cycle. In contrast, the 3 ITH variables that included cha bullosa when unilateral or the dominant concha bullosa
osseous structures were all highly significant. when bilateral.16,23,24,28,29 The severity of NSD tends to be greater
The choice of representative measurements in the current in larger or more extensively pneumatized conchae bullosa; con-
study was grounded in the previously published body of versely, the prevalence of a concha bullosa correlates positively
literature.2,3,7-9,11-14 Inferior turbinate width (total and bone with the severity of NSD.23,24,28,29 The current results further
only) and the distance that the inferior turbinate projects into the strengthen the intimate relationship between concha bullosa and
nasal cavity were selected as appropriate representations of ITH. NSD by demonstrating that the apex of maximum NSD is posi-
Because the medial mucosal layer of the inferior turbinate tends to tioned more superiorly when a unilateral concha bullosa is pres-
be the widest because it contains the thickest lamina propria, it ent and that the severity of NSD increases in direct proportion to
was also chosen for measurement.3 We chose the coronal image concha bullosa width. However, causation remains uncertain. Be-
used for assessment through the level of the maxillary sinus os- cause a number of studies have documented a preserved air chan-
tium to include the concha bullosa, while noting that the contri- nel between the medial aspect of the concha bullosa and the nasal
butions of bone and mucosa to ITH have been validated for the septum, it is unlikely that an enlarging concha bullosa directly
middle third of the inferior turbinate.8,9,12 pushes the septum.16,23,24
The precise mechanism underlying the development of com- It has been previously suggested that concha bullosa and
pensatory ITH in NSD remains unclear, but there is evidence to NSD represent 2 incidental and potentially unrelated develop-
suggest a long-standing acquired process. Aslan et al12 stratified mental anomalies that tend to appear concomitantly or that a
adult (mean age, 40.2 ⫾ 12.4 years) and pediatric (mean age, concha bullosa develops to fill in vacant space created by a
10.9 ⫾ 3.8 years) cohorts into those who had NSD versus those preexisting NSD, termed the “e vacuo” hypothesis.31 However,
with a straight or nearly straight septum and calculated intertur- a study comparing dizygotic and monozygotic twins found
binate ratios to determine relative size differences in bone and that the intrapair similarities were virtually identical for the
soft-tissue components of the inferior turbinates (ie, an increased presence of a deviated nasal septum (23% versus 25%), but
ratio suggested ITH). For bone more than soft-tissue structures, monozygotic twins had an intrapair similarity for concha bul-
the adults with NSD had significantly higher interturbinate ratios losa of 70% compared with 25% for dizygotic twins, suggesting
compared with the adults with a straight septum, thereby indicat- a genetic influence in the presence of a concha bullosa.32 Thus,
ing ITH. In contrast, the interturbinate ratios did not significantly a high probability of congenital coexistence of NSD and con-
differ between the pediatric groups on the basis of the presence of cha bullosa seems questionable. In addition, the concha bul-
NSD, and the adults with NSD had significantly higher intertur- losa would be more apt to precede NSD because of a stronger
binate ratios than the children with NSD. The results were inter- genetic link, thereby contradicting the e vacuo hypothesis.
AJNR Am J Neuroradiol ●:● ● 2016 www.ajnr.org 5
 Additional observations have further disputed these prevailing inferior turbinate. Arch Otolaryngol Head Neck Surg 2006;132:
hypotheses.23 Not all individuals with septal deviation have con- 588 –94 CrossRef Medline
5. Eccles R. Query, concerning mechanism of inferior turbinate en-
cha bullosa, while most cases with a large or dominant concha
largement. Arch Otolaryngol Head Neck Surg 2007;133:624; author
bullosa have septal deviation. Moreover, there are instances of reply 624 –25 Medline
medium-to-large bilateral conchae bullosa in the setting of a 6. Balbach L, Trinkel V, Guldner C, et al. Radiological examinations of
straight nasal septum. Consequently, it is difficult to establish a the anatomy of the inferior turbinate using digital volume tomog-
purely congenital association between the 2 anatomic variants, raphy (DVT). Rhinology 2011;49:248 –52 CrossRef Medline
and the compensatory growth of a concha bullosa to fill in the 7. Grymer LF, Illum P, Hilberg O. Septoplasty and compensatory infe-
rior turbinate hypertrophy: a randomized study evaluated by
space vacated by a deviated nasal septum also seems implausible.
acoustic rhinometry. J Laryngol Otol 1993;107:413–17 CrossRef
In fact, Sazgar et al23 recently hypothesized that it is the NSD that Medline
is more likely to be compensatory for a concha bullosa by synthe- 8. Egeli E, Demirci L, Yazýcý B, et al. Evaluation of the inferior
sizing this idea with the prevailing literature and substantiating it turbinate in patients with deviated nasal septum by using
with a discussion of fluid dynamics. computed tomography. Laryngoscope 2004;114:113–17 CrossRef
Medline
The limitations of the current study are primarily related to the
9. Akoğlu E, Karazincir S, Balci A, et al. Evaluation of the turbinate
generalizability of the results regarding the relationship of NSD, hypertrophy by computed tomography in patients with deviated
concha bullosa, and ITH. In an attempt to eliminate confounding nasal septum. Otolaryngol Head Neck Surg 2007;136:380 – 84
variables, the strict inclusion criteria eliminated patients with ac- CrossRef Medline
tive inflammatory sinus disease, posttraumatic sinonasal defor- 10. Kim DH, Park HY, Kim HS, et al. Effect of septoplasty on inferior
mity, bilateral conchae bullosa, and small lamellar conchae bul- turbinate hypertrophy. Arch Otolaryngol Head Neck Surg 2008;134:
419 –23 CrossRef Medline
losa. Moreover, the study population consisted of patients with a
11. Jun BC, Kim SW, Cho JH, et al. Is turbinate surgery necessary when
clear unilateral pattern of septal deflection, and it has been recog- performing a septoplasty? Eur Arch Otorhinolaryngol 2009;266:
nized that different patterns of concomitant turbinal hyperplasia 975– 80 CrossRef Medline
and concha bullosa vary on the basis of NSD morphology.33 Last, 12. Aslan G, Uzun L, Ugur MB, et al. Unilateral inferior turbinate bone
ITH and NSD were exclusively defined by CT appearance with no hypertrophy: is it compensatory or congenital? Am J Rhinol Allergy
2013;27:255–59 CrossRef Medline
correlate as to the presence of clinically significant nasal obstruc-
13. Orhan I, Aydin S, Ormeci T, et al. A radiological analysis of inferior
tion. Because the study population was limited to subjects with turbinate in patients with deviated nasal septum by using com-
clear sinuses on CT, the overwhelming majority never underwent puted tomography. Am J Rhinol Allergy 2014;28:e68 –72 CrossRef
a thorough rhinologic evaluation, thereby limiting the ability to Medline
make meaningful imaging-clinical correlations. In reality, symp- 14. Korkut AY, Islim F, Gulseven Ciftci S, et al. Evaluation of inferior
turbinate hypertrophy in patients with congenital and traumatic
tomatic nasal obstruction from ITH and NSD is best determined
nasal septum deviation. J Laryngol Otol 2012;126:784 – 88 CrossRef
clinically. The CT-based measurements performed in this study Medline
were a tool to identify anatomic features that contribute to the 15. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic
development of ITH, not a recommended form of clinical variations and mucosal abnormalities: CT analysis for endoscopic
assessment. sinus surgery. Laryngoscope 1991;101:56 – 64 Medline
16. Bhandary SK, Kamath PS. Study of relationship of concha bullosa to
nasal septal deviation and sinusitis. Indian J Otolaryngol Head Neck
CONCLUSIONS Surg 2009;61:227–29 CrossRef Medline
The degree of compensatory ITH increases in proportion to 17. Javadrashid R, Naderpour M, Asghari S, et al. Concha bullosa, nasal
the severity of NSD and decreases as the NSD apex moves septal deviation and paranasal sinusitis; a computed tomographic
farther superiorly from the nasal floor. Although the presence evaluation. B-ENT 2014;10:291–98 Medline
18. Kayalioglu G, Oyar O, Govsa F. Nasal cavity and paranasal sinus
of a unilateral middle turbinate concha bullosa is associated
bony variations: a computed tomographic study. Rhinology 2000;38:
with less severe ITH, this effect is primarily attributed to the 108 –13 Medline
higher apex of the NSD seen with concha bullosa, as opposed to 19. Lam WW, Liang EY, Woo JK, et al. The etiological role of concha
an independent relationship between concha bullosa and ITH, bullosa in chronic sinusitis. Eur Radiol 1996;6:550 –52 CrossRef
both of which are commonly found along the concave side of a Medline
deviated septum. 20. Nadas S, Duvoisin B, Landry M, et al. Concha bullosa: frequency
and appearances on CT and correlations with sinus disease in
308 patients with chronic sinusitis. Neuroradiology 1995;37:234 –37
CrossRef Medline
REFERENCES 21. Nouraei SA, Elisay AR, Dimarco A, et al. Variations in paranasal
1. Jackson LE, Koch RJ. Controversies in the management of inferior sinus anatomy: implications for the pathophysiology of chronic
turbinate hypertrophy: a comprehensive review. Plast Reconstr Surg rhinosinusitis and safety of endoscopic sinus surgery. J Otolaryngol
1999;103:300 –12 CrossRef Medline Head Neck Surg 2009;38:32–37 Medline
2. Hilberg O, Grymer LF, Pedersen OF, et al. Turbinate hypertrophy: 22. Ozcan KM, Selcuk A, Ozcan I, et al. Anatomical variations of nasal
evaluation of the nasal cavity by acoustic rhinometry. Arch Otolar- turbinates. J Craniofac Surg 2008;19:1678 – 82 CrossRef Medline
yngol Head Neck Surg 1990;116:283– 89 CrossRef Medline 23. Sazgar AA, Massah J, Sadeghi M, et al. The incidence of concha bul-
3. Berger G, Hammel I, Berger R, et al. Histopathology of the inferior losa and the correlation with nasal septal deviation. B-ENT 2008;4:
turbinate with compensatory hypertrophy in patients with devi- 87–91 Medline
ated nasal septum. Laryngoscope 2000;110:2100 – 05 CrossRef 24. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and
Medline its relationship to nasal septal deviation and paranasal sinus dis-
4. Berger G, Gass S, Ophir D. The histopathology of the hypertrophic ease. AJNR Am J Neuroradiol 2004;25:1613–18 Medline

6 Tomblinson ● 2016 www.ajnr.org

25. Unlü HH, Akyar S, Caylan R, et al. Concha bullosa. J Otolaryngol concha bullosa, nasal septal deviation and sinusitis. Rhinology 2003;
1994;23:23–27 Medline 41:103– 06 Medline
26. Uygur K, Tüz M, Dogru H. The correlation between septal deviation 30. Hatipoglu HG, Cetin MA, Yuksel E. Nasal septal deviation and concha
and concha bullosa. Otolaryngol Head Neck Surg 2003;129:33–36 bullosa coexistence: CT evaluation. B-ENT 2008;4:227–32 Medline
CrossRef Medline 31. Stammberger H. Functional Endoscopic Sinus Surgery: The
27. Yiğit O, Acioğlu E, Cakir ZA, et al. Concha bullosa and septal deviation. Messerklinger Technique. Philadelphia: B.C. Decker; 1991:156 – 68
Eur Arch Otorhinolaryngol 2010;267:1397– 401 CrossRef Medline 32. Chaiyasate S, Baron I, Clement P. Analysis of paranasal sinus devel-
28. Elahi MM, Frenkiel S, Fageeh N. Paraseptal structural changes and opment and anatomical variations: a CT genetic study in twins. Clin
chronic sinus disease in relation to the deviated septum. J Otolaryn- Otolaryngol 2007;32:93–97 CrossRef Medline
gol 1997;26:236 – 40 Medline 33. Baumann I, Baumann H. A new classification of septal deviations.
29. Aktas D, Kalcioglu MT, Kutlu R, et al. The relationship between the Rhinology 2007;45:220 –23 Medline

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