Anatomical Variations of the Middle Turbinate Concha Bullosa and its Relationship with Chronic Sinusitis: A Prospective Radiologic Study

Abstract

Introduction A pneumatized turbinate, also called concha bullosa, is a normal anatomical variant of the paranasal sinus region. Depending on the site of pneumatization, the concha is classified into extensive, bulbous or lamellar type. The middle turbinate concha bullosa has been implicated as a possible etiological factor in chronic sinusitis. Objectives The aim of this study was to investigate the anatomical variations of the concha bullosa, based on paranasal sinus imaging, and its possible association with sinusitis. Methods This prospective descriptive study was performed at the Department of ENT and Head Neck Surgery over a period of one year, from 2016 to 2017. We studied the computed tomography scans of the nose and paranasal sinuses- in axial, coronal and sagittal planes-of patients who had symptoms of nasal obstruction, or headache and features of chronic sinusitis. Results Out of the 202 scans studied, the prevalence of concha bullosa was 31.7%. The concha was bilateral in 35 (54.7%) patients and unilateral in 29 (45.3%) patients. Out of 99 conchae, 54 were on the right side and 45 were on left side. Ipsilateral sinusitis was found in 40.4% of the sides in the scans of subjects with concha. There was no statistically significant association between any type of middle turbinate concha with sinusitis, but sinusitis was more predominant with the extensive type of concha ( p > 0.05). Conclusion Multiple air cells, mucocele, pyocele and inflammatory mucosal thickenings in the concha are relatively rare. Detailed knowledge of anatomic variations of the concha bullosa is imperative for the radiologists and the operating surgeons.

Keywords: mucocele; sinusitis; turbinates.

Fig. 1

(a and b) Axial sections of computed tomography of the paranasal sinuses showing mucosal thickening within the right concha bullosa, and thickening of the surrounding bony walls. Also noted are areas of mild mucosal thickening in both maxillary sinuses and a mucosal polyp in the anterior wall of left maxillary sinus.

Fig. 2

(a) Coronal and (b) axial sections of non-contrast computed tomography of paranasal sinuses show expansile soft tissue density within the concha bullosa causing extreme thinning of the bony walls and mass effect on and thinning of the medial wall of right orbit and the nasal septum, suggestive of a mucopyocele of the concha bullosa. Fig 2a also shows obstruction of the right maxillary sinus drainage pathway with resultant chronic sinusitis.

Fig. 3

(a) Coronal and (b) axial sections of computed tomography of the paranasal sinuses show the presence of multiple air cells within the bilateral concha bullosae. Deviation of the nasal septum to the left side is noted. Also seen is a small mucosal polyp in the inferior wall of the left maxillary sinus.

Fig. 4

(a and b) Coronal sections of non-contrast computed tomography scan of the paranasal sinuses showing pneumatized vertical lamella of left middle turbinate (lamellar type of concha shown with arrow). Incidental deviation of the nasal septum to the right side is noted.

Fig. 5

Coronal section of computed tomography of the paranasal sinuses shows extensive pneumatisation of the inferior portion and vertical lamella of the bilateral middle turbinates, more on the right side, suggestive of extensive/large type of concha bullosa.