Clinical Medicine Insights: Ear, Nose and

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Role of Surgery in Isolated Concha Bullosa

Hatem Soliman Badran
Department of Otorhinolaryngology-Head and Neck Surgery, Kasr Al-Aini School of Medicine, Cairo University,
Cairo, Egypt. Corresponding author email: [email protected]

Abstract
Objective: To study the benefit of surgery in different types of isolated concha bullosa.
Design: Prospective case series.
Setting: Academic Medical Center.
Patients: Forty seven symptomatic patients complaining of nasal congestion and block, headache and facial pain having concha bullosa
without any other sinonasal finding. Their conchae bullosa were classified as lamellar, bulbous and extensive concha bullosa. They were
subjected to endoscopic operation.
Main outcome measures: Subjective evaluation of postoperative improvement of sinonasal symptoms and objective pre- and postoperative measurement of total nasal resistance by rhinomanometry.
Results: Two patients (25%) of lamellar type showed complete improvement, 5 patients (62.5%) showed partial improvement and
1 patient (12.5%) showed no improvement. Regarding bulbous type, 16 patients (72.72%) showed complete improvement, 6 patients
(27.28%) showed partial improvement and no patient (0%) showed no improvement. Regarding extensive type, 15 (88.24%) patients
showed complete improvement, 2 patients (11.76%) showed partial improvement and no patient (0%) showed no improvement. The
total nasal resistance was 0.25Pa/cm3 per second postoperatively compared with 0.37Pa/cm3 per second preoperatively in patients
having lamellar type; 0.28Pa/cm3 per second postoperatively compared with 0.71Pa/cm3 per second preoperatively in patients having
bulbous type; and 0.27Pa/cm3 per second postoperatively compared with 0.67Pa/cm3 per second preoperatively in patients having
extensive type.
Conclusions: With proper patient selection, the operative management is of great value in relieving the sinonasal symptoms in patients
having isolated Concha bullosa. This will be more obvious in certain types as bulbous and extensive types especially of large sizes.
Keywords: concha, bullosa, rhinomanometry, lamellar, bulbous and extensive

Clinical Medicine Insights: Ear, Nose and Throat 2011:4 1319

doi: 10.4137/CMENT.S6769
This article is available from http://www.la-press.com.
the author(s), publisher and licensee Libertas Academica Ltd.
This is an open access article. Unrestricted non-commercial use is permitted provided the original work is properly cited.
Clinical Medicine Insights: Ear, Nose and Throat 2011:4

13

Badran

Introduction

Anatomic variations in paranasal sinus region have

been shown to be of clinical importance.1 Concha
bullosa (CB) is a hypertrophy and pneumatization
of the nasal turbinate, occurring most often in the
middle, and less commonly, in the inferior or superior
turbinates. Its association with high incidence of sinus
infection is not sure.2,3
CB is one of the most common variations of the
sinonasal anatomy. A 14%53.6% frequency of concha bullosa was reported by various studies.4 Bolger
et al have classified pneumatization of the concha
based on the location as lamellar concha bullosa
(LCB), bulbous concha bullosa (BCB) and extensive
concha bullosa (ECB).1
The aim of this study is to demonstrate the relation
between CB and symptomatology of the nose and
the benefits of doing surgery in different types of
isolated CB.

Patients and Methods

Prospective study obtained between August 1, 2008

and September 30, 2010 in Saudi German Hospital
in Jeddah; Saudi Arabia. A total of 47 patients of
different age groups, who were admitted to our clinic
complaining of symptoms related to sinonasal region
and their paranasal CT studies showed pneumatization
of the middle concha, were included in this study.
The most common symptoms encountered in
these patients were nasal obstruction, headache and
intermittent pain in the periorbital area, between the
eyes, or in the cheeks and frontal bone. The occurrence
of such pain is accompanied by the congestion and
feeling of the pressure deep inside the nasal cavity.
Mostly, the pain is unilateral lasting between few
hours up to several days. The intensity of pain varies
from an individual to the other but it is more of
dull, boring character and typically unresponsive to
common pain relieving medications. We tried medical
treatment for all patients as systemic antibiotics,
systemic analgesics, systemic antihistaminics, local
corticosteroids and nasal decongestants for 15 days
with no or mild improvement.
Any patient who had a sinus problem, sinonasal
polyposis or previous sinus surgery was excluded
from the study.
All examinations were performed for evaluation
of symptoms referable to the sinonasal region.
14

If presenting at the time of headache, a Xylocaine test

was done, provided there is no sign of infection. This
is done by inserting a cotton wool probe soaked in
Xylocaine (2% or 4%), between the CB and the lateral
wall and nasal septum where they touch one another,
to see if this aborts headache. The pain disappeared
within 5 to 10 minutes in 19 out of the 28 patients
presenting at the time of headache.
Pneumatization of the middle concha was classified
depending on the pneumatization of the lamellar and
bullous portions of the middle concha as lamellar and
bulbous, respectively. Pneumatization of both the
lamellar and bullous portions of the middle concha
was classified as the extensive type.
If a CB was present, it was graded in size as small,
moderate or large. If bilateral concha were present,
sizes were compared and when one was larger, it was
identified as dominant.
All patients were subjected to endoscopic partial
lateral middle turbinectomy. Nasal tampons were
removed 2days after surgery and followed clinically
over next 3 months. Endoscopic examination visits
were performed 7, 15, 30, 60 and 90 days after
surgical treatment.
Assessment of the effect of surgery was determined
by subjective patient questionnaire given to the
patients 6 months postoperative. Then the results
were graded either complete improvement if there
is complete disappearance of the nasal obstruction,
headache and facial pain, partial improvement if the
patient reported improvement of nasal obstruction and
headache without complete cure or no improvement
if nasal obstruction, headache and intermittent pain
nasal obstruction, headache and facial pain persist.
All patients were subjected to anterior rhinomanometry preoperatively and 6months postoperatively.
The anterior rhinomanometry procedure included
the placement of a pressure sensor in one nostril and
detected the flow of air in the other nostril. Hence,
the resistance of each nasal cavity and total nasal
resistance could be calculated separately.
We got approval for doing this work from the
Saudi German Hospital ethical committee dated
July 1st 2008.

Statistical method

The data were coded and entered using the statistical

package SPSS version 12. The data were summarized
Clinical Medicine Insights: Ear, Nose and Throat 2011:4

Role of surgery in isolated concha bullosa

using descriptive statistics: mean, standard deviation,

minimal and maximum values for quantitative
variables and number and percentage for qualitative
values. Statistical differences between groups were
tested using Chi Square test for qualitative variables.
The cutoff level for P-value is 0.05. P-values less
than, or equal to 0.05 were considered statistically
significant.

Results

A total of 47 patients were included in this study.

There were 30 females (63.8%) and 17 males
(36.2%). The mean + standard deviation of age of the
patients included in the study was 30+19, ranging
from 18 to 57.
Unilateral conchae bullosa were noted in 25
(53.2%) patients (Fig.1) and bilateral conchae bullosa
were noted in 22 (46.8%) patients (Figs.24).
A total of 69 conchae bullosa were detected. Of the
conchae bullosa, 37 (53.6%) were at the left and 32
(46.4%) at the right side.
Eight (17%) patients had lamellar type (Fig. 2),
22 (46.8%) had bulbous type (Figs.1 and 3) and 17
(36.2%) had extensive type (Figs.2 and 4) (Fig.5).
Regarding the patient questionnaire given to the
patients 6 months postoperative, with the lamellar
type, 2 patients (25%) showed complete improvement,
5 patients (62.5%) showed partial improvement and
1 patient (12.5%) showed no improvement.
Regarding the patients with the bulbous type,
16 patients (72.72%) showed complete improvement,
6 patients (27.28%) showed partial improvement and
no patient (0%) showed no improvement.
Regarding the patients with the extensive type, 15
(88.24%) patients showed complete improvement,
2 patients (11.76%) showed partial improvement and
no patient (0%) showed no improvement. There were
no important complications.
A statistically significant difference was found
between different types and improvement among
them (Table1) (Fig.6).
Regarding the preoperative results of rhinomanometry, the minimum, maximum, and median total
nasal resistance calculated at 150 Pa of pressure in
patients having lamellar conchae bullosa was 0.17,
1.14, and 0.37Pa/cm3 per second, respectively, compared with 0.17, 0.46, and 0.25 Pa/cm3 per second
6months postoperatively.
Clinical Medicine Insights: Ear, Nose and Throat 2011:4

Figure 1. Unilateral bulbous concha bullosa.

Figure 2. Bilateral concha bullosa (Lt. Lamellar, Rt. Extensive).

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Badran

Regarding the patients with the bulbous type, the

minimum, maximum, and median total nasal resistance calculated at 150Pa of pressure was 0.23, 2.38,
and 0.71Pa/cm3 per second, respectively, compared
with 0.16, 0.49, and 0.28Pa/cm3 per second 6months
postoperatively.
Regarding the patients with the extensive type,
the minimum, maximum, and median total nasal
resistance calculated at 150 Pa of pressure was
0.28, 1.92, and 0.67 Pa/cm3 per second, respectively, compared with 0.20, 0.51, and 0.27 Pa/cm3
per second 6 months postoperatively (P = 0.018)
(Table2) (Fig.7).
P-value demonstrates the difference in improvement between various types with the highest percentage of complete improvement among extensive
followed by bulbous types and the least among lamellar type. In this study, P-value is less than 0.05. This
means the presence of statistically significant difference between groups.

Figure 3. Bilateral bulbous concha bullosa.

Discussion

Figure 4. Bilateral extensive concha bullosa.

Type of conchae bullosa among studied group

17%

36%

47%

Lamellar

Bulbous

Extensive

Figure 5. Type of Conchae bullosa among studied group.

16

Concha bullosa (CB) is the pneumatization of the

concha and is the most frequent variation of the
sinonasal anatomy.4 It is most commonly encountered
in the middle concha. It is rarely found in the
superior and inferior conchae. This pneumatization
results when ethmoid air cells migrate to the middle
concha.5
The CB incidence in the literature ranges from
14%53.6%. Some authors have not included smallsized or lamellar type conchae bullosa in their studies.4
Scribano etal have reported incidences up to 67% and
Perez-Pinas et al up to 73%.6,7 Presence of bilateral
conchae bullosa ranges from 45%61.5%.48 Zinreich
et al used coronal CT to evaluate 320 patients for
sinus disease, and found that 34% exhibited CB on
at least one side.5 CB was bilateral in 46.88% of the
cases in our study.
Bolger et al have divided the pneumatization of
the middle concha into three groups: lamellar type
is the pneumatization of the vertical lamella of
the concha; bulbous type is the pneumatization of the
bulbous segment (inferior portion of the turbinate);
pneumatization of both the lamellar and bulbous
parts is called extensive CB.1 They studied anatomic
variations of the paranasal sinuses in 202 patients

Clinical Medicine Insights: Ear, Nose and Throat 2011:4

Role of surgery in isolated concha bullosa

Table 1. The relation between improvement and type.
Type
Improvement

No improvement

Count
%
Count
%
Count
%
Count
%

Partial improvement
Complete improvement
Total

based on CT images, and observed lamellar-type CB

in 46.2% of the cases, bulbous-type CB in 31.2%,
and extensive CB in 15.7%.1 In this study; eight
(17%) of the conchae bullosa were lamellar type,
22 (46.8%) were bulbous type and 17 (36.2%) were
extensive type.
There is no consensus on the frequency of CB
or frequency of types of CB. The variances may
be due to differences between the study groups,
differences in pneumatization parameters and the
analytical methods used. There are studies pointing
out that the size of CB is important for the presence
of symptoms.5,9
ENT specialists believe that especially bulbous type CB with large dimensions may have a
role in nasal complaints.10 The degree of pneumatization determines the severity of symptoms.
The lamellar type usually does not cause severe
symptoms, whereas the bulbous and extensive
forms typically are symptomatic.8 The most common symptoms are nasal obstruction and facial
pain. Swelling of the nasal turbinates particularly
in the middle part of the nasal cavity may result in
Relation between improvement and type

Number

25
20

Completed

15

Partial

10

No

5
0
Lamellar

Bulbous

Extensive

Type
Figure 6. Relation between subjective improvement and type.

Clinical Medicine Insights: Ear, Nose and Throat 2011:4

P-value

Lamellar

Bulbous

Extensive

1
12.5%
5
62.5%
2
25.0%
8
100.0%

0
0.0%
6
27.3%
16
72.7%
22
100.0%

0
0.0%
2
11.8%
15
88.2%
17
100.0%

0.011

contact with the nasal septum or lateral nasal wall

in especially sensitive area creating a trigger for
development of headache. This type of headache
is called: Middle turbinate headache syndrome and
is characterized by intermittent pain located in the
periorbital area, between the eyes, or in the cheeks
and frontal bone. The occurrence of such pain is
accompanied by the congestion and feeling of the
pressure deep inside the nasal cavity. Mostly the
pain is unilateral lasting between few hours up to
several days. The intensity of pain varies from an
individual to the other but it is more of dull, boring
character and typically unresponsive to common
pain relieving medications.
We studied the importance of surgical intervention
to different types of CB (lamellar, bulbous and
extensive) in relation to nasal symptoms relief and
change in the total nasal resistance as measured by
rhinomanometry. Total nasal resistance is less variable
than unilateral nasal resistance because it incorporates
both nasal airways and, thus, is not affected by the
nasal cycle. Consequently, it is a better predictor
of the presence of nasal obstruction. The patients
included in our study were symptomatic cases suspected of having sinonasal disease. Therefore the
statistical interpretations of the conclusions of our
study are valid only for the symptomatic population.
The results should not be generalized to the whole
population.
Postoperative follow-up of our patients for
6 months revealed complete improvement of the
patient symptoms in 25% of the lamellar type,
compared with 72.72% of the bulbous type and
88.24% of the extensive type. Also, there is partial
improvement in 62.5% of the lamellar type compared

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Badran
Table 2. The relation between the result of rhinomanometry and type of concha bullosa.
Type

Rhinomanometry

Minimum

Maximum

Median

P-value

Lamellar

Preoperative
Postoperative
Preoperative
Postoperative
Preoperative
Postoperative

0.17
0.17
0.23
0.16
0.28
0.20

1.14
0.46
2.38
0.49
1.92
0.51

0.37
0.25
0.71
0.28
0.67
0.27

0.018

Bulbous
Extensive

with 27.28% of the bulbous type and 11.76% of

the extensive type. In the whole study group, only
one patient showed no improvement. His CB was
of the lamellar type. In general, the patients showed
marked improvement in symptoms. There were no
important complications.
Our rhinomanometric results revealed that the
median total nasal resistance was 0.25 Pa/cm3 per
second postoperatively compared with 0.37 Pa/cm3
per second preoperatively in patients having lamellar
conchae bullosa. Also, it was 0.28Pa/cm3 per second
postoperatively compared with 0.71 Pa/cm3 per
second preoperatively in patients having bulbous
type. Lastly, it was 0.27 Pa/cm3 per second
postoperatively compared with 0.67Pa/cm3 per second preoperatively in patients having the extensive
type. The rhinomanometric change corresponded

with the patients subjective improvement in the

relief of nasal obstruction.
P-value in this study is less than 0.05 that denotes
the presence of statistically significant difference
in improvement between different groups with the
highest percentage of complete improvement among
extensive followed by bulbous types and the least
among lamellar type.
These results suggest that there is intimate relation
between CB and sinonasal symptoms. Also, there is variation in sinonasal symptoms regarding the size and type
of CB. The symptoms are more severe and prominent
in certain types of CB as bulbous and extensive types
especially in large size conchae. So, those patients
having bulbous and extensive types especially of large
sizes usually express marked improvement in response
to the operative management.

Relation between rhinomanometric results and type

Pressure Pa/cm3 per second

2.5
2

1.5

0.5
0
Preoperative

Postoperative

Preoperative

Lamellar

Postoperative

Preoperative

Bulbous

Minimum

Maximum

Postoperative

Extensive

Medium

Figure 7. Relation between rhinomanometric results and type.

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Clinical Medicine Insights: Ear, Nose and Throat 2011:4

Role of surgery in isolated concha bullosa

Disclosure

This manuscript has been read and approved by

the author. This paper is unique and is not under
consideration by any other publication and has
not been published elsewhere. The author and peer
reviewers of this paper report no conflicts of interest.
The author confirms that they have permission to
reproduce any copyrighted material.

References

1. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic
variations and mucosal abnormalities: CT analysis for endoscopic sinus
surgery. Laryngoscope. 1991;101:5664.
2. Lloyd GA. CT of the paranasal sinuses: study of a control series in relation to
endoscopic sinus surgery. J Laryngol Otol Jun. 1990;104(6):477.

3. Pochon N, Lacroix JS. Incidence and surgery of concha bullosa in chronic

rhinosinusitis. Rhinology Mar. 1994;32(1):11.
4. Zinreich S, Albayram S, Benson M, et al. The ostiomeatal complex and
functional endoscopic surgery. In: Som P, editor. Head and Neck Imaging.
4th ed. St. Louis: Mosby. 2003;14973.
5. Zinreich SJ, Mattox DE, Kennedy DW, etal. Concha bullosa: CT evaluation.
J Comput Assist Tomogr. 1988;12:77884.
6. Scribano E, Ascenti G, Loria G, et al. The role of the ostiomeatal unit
anatomic variations in inflammatory disease of the maxillary sinuses. Eur
J Radiol. 1997;24:1724.
7. Pinas-Perez I, Sabate J, Carmona A, et al. Anatomical variations in the
human paranasal sinus region studied by CT. J Anat. 2000;197:2217.
8. Unlu HH, Akyar S, Caylan R, et al. Concha bullosa. J Otolaryngol.
1994;23:237.
9. Uygur K, Tz M, Dogru H. The correlation between septal deviation and
concha bullosa. Otolaryngol Head Neck Surg. 2003;129:336.
10. Stammemberger H. Functional Endoscopic Sinus Surgery. Philadelphia:
BC Decker. 1991;1619.

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