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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 269-275

Histopathological study of compensated inferior turbinate hypertrophy and its hypertrophy in allergic rhinitis


1 Department of Otorhinolaryngology, Faculty of Medicine, Al Azhar University, Cairo, Egypt
2 Department of Pathology, Faculty of Medicine, Al Azhar University, Cairo, Egypt

Date of Submission14-Mar-2020
Date of Decision26-Mar-2020
Date of Acceptance29-Mar-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Mohamed A El-Morsy
Lecturer of Otorhinolaryngology, Faculty of Medicine, Al Azahar University, Naser City, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_35_20

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  Abstract 


Background Nasal obstruction resulting from inferior turbinate hypertrophy (ITH) is a common complaint in otorhinolaryngology.
Objective Differentiation between compensatory ITH due to deviated nasal septum (DNS) and ITH due to allergic rhinitis in order for the surgeon to choose the proper surgical techniques.
Patients and methods This study included 60 patients aged between 18 and 50 years (18 men and 12 women). They suffered from ITH as proven by history and endoscopic examination. Patients were subdivided into two groups. Group A: included 30 patients who were presented by compensated ITH due to DNS. Skin prick test was done for all patients of this group to exclude allergic patients. Group B: included 30 patients who were presented by bilateral ITH due to allergic rhinitis. All patients underwent endoscopic partial inferior turbinectomy under general anesthesia with or without septoplasty, taking care to include all three layers of the turbinate. The turbinate specimens were processed in a standard manner in the Department of Pathology, and slides were prepared, and examined histopathologically and micrometrically.
Results The mean thickness of the bony layer of ITH patients in group A was 6.50±1.75 mm, whereas its thickness in group B was 2.25±±1.25 mm with a statistically significant P value=0.001, while the mean thickness of the medial mucosal layer of ITH patients of group A was 2.25±0.5 mm, whereas its thickness (group B) was 4.25±0.75 mm with statistically nonsignificant P value (0.06).
Conclusion The bony layer contributes to the main thickness of compensatory ITH due to DNS because of the significant bony expansion; so, it should be a target of surgery, while surgical techniques that aim to remove the mucosa, leaving the bony part of the turbinate in allergic rhinitis are suitable for such patients.

Keywords: allergic rhinitis, deviated nasal septum, histopathology, inferior turbinate hypertrophy


How to cite this article:
El-Morsy MA, Al Awady MK, Mostafa OM. Histopathological study of compensated inferior turbinate hypertrophy and its hypertrophy in allergic rhinitis. Sci J Al-Azhar Med Fac Girls 2020;4:269-75

How to cite this URL:
El-Morsy MA, Al Awady MK, Mostafa OM. Histopathological study of compensated inferior turbinate hypertrophy and its hypertrophy in allergic rhinitis. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Jul 12];4:269-75. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/269/288278




  Introduction Top


The inferior turbinate (IT) has an important role in the physiology of the nose through temperature regulation and humidification of inspired air, as well as filtration of foreign particles by the mucociliary clearance system [1]. Several causes including allergic rhinitis, nonallergic (vasomotor) rhinitis, and rhinitis medicamentosa can result in significant hypertrophic changes of the IT [2].

When the nasal septum deviates to one side, the increased space of the contralateral nasal cavity is filled with the IT [3]. It is assumed that this counterbalanced mechanism characterized by compensatory hypertrophy originates to protect the more patent nasal side from excess airflow with its drying and crusting effects [4].

Advocates of concomitant turbinate surgery during septoplasty claimed that hypertrophy involves both mucosal elements and the conchal bone, so changes are not spontaneously reversible during septal surgery and should be corrected to avoid obstruction on the opposite side of septal deviation after septal correction [5],[6].

When the medical treatment is inadequate in achieving a significant resolution of nasal obstruction, surgical reduction of the hypertrophic IT has been advocated after failure of medical therapy [7],[8].

Over the years, a variety of reduction techniques have been introduced with the goal of increasing nasal airway passages, preserving the function of the organ, and minimizing peroperative hemorrhage and long-term complications [9].

The decision of inferior turbinectomy should be based not only on the clinical presentation but also on the morphometric features of the organ [10].

This morphometric study is the first to include dimensions, composition, and possible pathological changes of inferior turbinate hypertrophy (ITH). Data such as these can help the otolaryngologist to choose the type of turbinate reduction surgery (submucous diathermy or partial turbinectomy) that is suitable [11],[12].


  Aim Top


This study was undertaken to provide quantitative and qualitative information on various soft tissue and bony constituents of ITH, in order for the surgeon to choose the proper surgical techniques.


  Patients and methods Top


This was a prospective study conducted between August 2018 and March 2019 in the Department of Otolaryngology, Al Azhar University Hospitals. This study was approved by medical ethical committee. All patients were informed and a written consent was obtained from all patients. The study included 60 patients aged between 18 and 50 years (18 men and 12 women). They suffered from nasal obstruction as the main symptom as proven by history and examination.

Patients were subdivided into two groups.

Group A: 30 patients were presented by compensated ITH due to septal deviation.

Group B: 30 patients were presented by bilateral ITH due to allergic rhinitis.

Inclusion criteria

  1. Presence of turbinate hypertrophy due to either allergic rhinitis or deviated nasal septum (DNS).
  2. No response to medical therapy.


Exclusion criteria

  1. Patients with other causes of nasal obstruction such as sino-nasal polyposis, nasal granuloma, or neoplasm of the nose and paranasal sinuses.
  2. Patients with vasomotor or nonallergic rhinitis.
  3. Patients less than 18 years old.
  4. Patient who refuse or who are unfit for surgery.


All patients were subjected to the following:
  1. Questionnaire concerning the side, type, and duration of nasal obstruction and associated symptoms such as headache, nasal discharge, epistaxis, sneezing, and degree of response to medical treatment.
  2. Rigid nasal endoscopy was preoperatively performed to detect turbinate hypertrophy either unilateral (compensated due to septal deviation) or bilateral pale bluish hypertrophied turbinate (due to allergic rhinitis).
  3. Computed tomographic scan of paranasal sinuses were done to all the patients preoperatively to exclude any sinus opacity and other causes of nasal obstruction.
  4. Skin prick test (SPT) was done for all patients of group A (compensated ITH due to septal deviation) to exclude allergic patients. SPT was done by introducing specific allergens like house dust, house dust mite, cotton dust, mixed pollens, mixed molds, housefly particles, and grass pollens into the volar part of the forearm of the patient’s skin. The largest diameter of the wheel of each particular test is measured. A positive result being a wheel of more than or equal to 3 mm. Then the patients who had a positive SPT were excluded from this study.
  5. Preoperative routine investigations, complete blood count, coagulation profile, and liver and kidney functions.
  6. Before surgery all patients gave their informed consent.
  7. All patients were submitted to an endoscopic partial inferior turbinectomy under general anesthesia with or without septoplasty. Turbinectomy included all layers that were excised during the procedure; the turbinate architecture was preserved by gentle handling, and care was taken not to damage the mucosal layer.
  8. Postoperatively, all patients were assessed for complications such as hemorrhage, crusting, synechia, and infection and for subjective improvement of their symptoms.
  9. Follow-up visits were scheduled 1, 3, and 6 months after surgery. During each visit nasal examination by rigid nasal endoscopy was performed.


Tissue preparation and measurements

The turbinate specimens were immediately fixed in 10% buffered formalin, decalcified with 14% neutral ethylenediamine tetraacetic acid, and thereafter dehydrated with increasing concentrations of ethanol. The specimens were embedded in paraffin blocks and 4-μm-thick sections were cut from paraffin blocks at a plane perpendicular to the mucosal surfaces. Sections were stained with hematoxylin and eosin and were histologically evaluated. The dimensions of the middle and posterior portions of the IT were recorded with a calibrated eyepiece attached to the microscope at ×40 magnification and included the overall thickness of the IT, the thickness of medial mucosal layer (MML), bone layer, and lateral mucosal layer (LML).

The condition of venous sinusoids, submucosal glands, and inflammatory cells infiltrate as lymphocytes, plasma cells, and eosinophils in each group was also studied.


  Results Top


The present study included 60 patients (18 men and 12 women) aged between 18 and 50 years. Patients were subdivided into to two groups:

Group A included 30 (50%) patients who were diagnosed to have ITH secondary to deviated septum (compensatory hypertrophy).

Group B included 30 (50%) patients who had allergic rhinitis and associated ITH. No patient had nonallergic rhinitis.

In this study, all the patients in both groups (100%) presented with nasal obstruction. In group A: 30 (100%) patients presented with nasal obstruction; headache was present in 20 (66.6%) patients; recurrent epistaxis was present in 14 (46.2%) patients, nasal discharge was present in six (19.9%) patients, and sneezing and itching were not present in any patient, while in group B: 30 (100%) patients presented with nasal obstruction, headache was present in 14 (46.6%) patients, recurrent epistaxis was present in six (19.9%) patients, nasal discharge was present in 26 (86.8%) patients, and sneezing and itching were present in 30 (100%) patients ([Table 1] and Chart 1).
Table 1 Clinical manifestations in both groups

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In this study, results of the micrometric study showed that the mean total thickness of ITH in group A was 10.25±2.50 mm and in group B it was 7.25±2.75 mm with statistically significant P value=0.001 ([Table 2] and [Figure 1] and [Figure 2]).
Table 2 Total thickness of the inferior turbinate hypertrophy in both groups

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Figure 1 Micrometric image of compensated ITH shows thickening of BL is more than MML. BL, bony layer; ITH, inferior turbinate hypertrophy; MML, medial mucosal layer.

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Figure 2 Micrometric image of ITH of allergic rhinitis shows thickening of BL is less than MML. BL, bony layer; ITH, inferior turbinate hypertrophy; MML, medial mucosal layer.

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Also, the mean thickness of the bony layer (BL) in ITH patients with a DNS (group A) was 6.50±1.75 mm, whereas its thickness in the allergic rhinitis group (group B) was 2.25±1.25 mm with statistically significant P value=0.001 ([Table 3] and Charts 2 and 3).
Table 3 Thickness of the bony layer (mm) of inferior turbinate hypertrophy in both groups

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The mean thickness of the MML in ITH patients with a DNS (group A) was 3.25±0.5 mm, whereas its thickness in the allergic rhinitis group (group B) was 4.25±0.75 mm with statistically nonsignificant P value (0.06) ([Table 4] and Chart 2).
Table 4 Thickness of medial and lateral mucosal layer in mm of inferior turbinate hypertrophy in both groups

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The mean thickness of the LML in ITH patients with a DNS (group A) was 1.25 ±0.25 mm, whereas its thickness in the allergic rhinitis group (group B) was 1.75±0.75 mm with statistically nonsignificant P value=0.17 ([Table 4] and Chart 2) ([Figure 1] and [Figure 2]).

In this study, the thickness of the ITH and the condition of venous sinusoids in each group was also studied. Both groups showed congested venous sinusoids. Lymphocytes and plasma cells and eosinophils were the prominent inflammatory cells in the allergic rhinitis group ([Figure 3]), whereas in the ITH group with a DNS lymphocytes and plasma cells were inflammatory cells and mast cells were less prominent ([Figure 4]). None of the specimens examined in this study showed dysplasia, malignant changes, or chronic granulomatous changes ([Figure 5] and [Figure 6]).
Figure 3 Histopathological pictures of ITH of allergic rhinitis shows marked eosinophilic inflammatory infiltrate. ITH, inferior turbinate hypertrophy.

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Figure 4 Histopathological pictures of compensated ITH of DNS show edematous stromal with little inflammatory infiltrate (hematoxylin and eosin, ×100). DNS, deviated nasal septum; ITH, inferior turbinate hypertrophy.

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Figure 5 Histopathological pictures of ITH of allergic rhinitis shows proliferating mucous secreting glands. ITH, inferior turbinate hypertrophy.

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Figure 6 Histopathological pictures of compensated ITH shows dilated, congested blood vessels (hematoxylin and eosin, ×100). ITH, inferior turbinate hypertrophy.

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Postoperative complications were assessed. Crusting was seen in two (13.3%) patients in group A. Patients were advised to use nasal alkaline douching. Two (10%) patients developed synechia at the site of turbinectomy and septoplasty. Synechia was released under local anesthesia.

This study showed that the BL contributes the main thickness of compensatory ITH due to DNS and it should be a target of surgery with proper choice of surgical technique, that is a method like submucous diathermy would not be able to relief this patient from nasal obstruction.

On the other hand, mucosal layers contribute to the main thickness of the turbinate in patients with allergic rhinitis. So surgical techniques like submucous diathermy (which aim to remove the mucosa with leaving the bony part of the turbinate) are suitable for such patients.


  Discussion Top


In the present study, a total of 30 patients aged between 18 and 50 years with ITH were selected (18 men and 12 women).

Assessment of which type of turbinate hypertrophy were depending on: the history, clinical examination, and endoscopic examination.

In this study, the clinical outcome, histopathological features of ITH, and complications of partial inferior turbinectomy in the DNS as well as in allergic rhinitis were studied.

In this study, the results of micrometric histopathological study showed that the thickness of BL in the compensated ITH group (group A) was 6.50±1.75 mm, whereas its thickness in the allergic rhinitis group (group B) was 2.25±1.25 mm with statistically significant P value (0.001).

This is similar to the study of Hegazya et al., who showed that thickness of the BL was 11.25±2.75 and 5.5±2.5 mm in compensated ITH patients with DNS and in the allergic rhinitis group, respectively. Also, in their study, the mean thickness of MML in compensated ITH patients with DNS was 8.5±3.5 mm, whereas its thickness in the allergic rhinitis group was 9.5±3.5 mm. The mean thickness of LML was 6.25±2.25 mm in the DNS group and 7.5±3.5 mm in the allergic rhinitis group [13].

In a study of Berger et al. [14] who showed that the mean thickness of MML, the BL, and LML was 1.76±0.26, 1.03±0.54, and 1.03±0.36 mm, respectively, in the control group and it was 1.87±0.37, 2.03±0.50, and 1.26±0.38 mm, respectively, in DNS with ITH. Also in their study it has been shown that in the case of ITH with DNS, the hypertrophy of the BL of the turbinate exceeds other layers and accounts for three-fourths of the entire growth of IT.

Berger and colleagues and Hegazya and colleagues concluded that hypertrophy of BL in ITH patients with DNS is more than hypertrophy of the mucosal layer, so the bone layer should be a target of surgery with proper choice of surgical technique, that is a method like submucous diathermy would not be able to relief the patients from nasal obstruction.

Also, this study showed that the mean thickness of MML of the compensated ITH group (group A) was 3.25±0.5 mm, whereas its thickness in the allergic rhinitis group (group B) was 4.25±0.75 mm with statistically nonsignificant P value=0.06 and the mean thickness of LML in the compensated ITH group (group A) was 1.25±0.25 mm, whereas its thickness in the allergic rhinitis group (group B) was 1.75±0.75 mm with statistically nonsignificant P value=0.17.

These results are similar to the results of Hadar et al. [15] who proved that the significant enlargement of the MML plays a major role in the perception of nasal obstruction due to chronic irritation of allergy; thus, relief of the obstruction mainly demands reduction of this layer.

Also, these results are similar to the results of Rohrich et al. [16], who stated that submucous diathermy is a popular practice recommended as a treatment for ITH of allergic rhinitis especially anterior portion when contributes to airway resistance.

Finally, understanding the histopathology of the hypertrophic IT is imperative for the development and management of IT reduction surgery [17].


  Conclusion Top


In this study, clinical outcome, histopathological features of ITH, and complications of partial inferior turbinectomy in the DNS as well as allergic rhinitis were studied.

According to micrometric analysis, we found that the osseous and mucosal portion of the turbinate can be hypertrophic. Patients with allergic rhinitis were associated with a swelling of the mucosa. On the other hand, unilateral enlargement of the bony structure was observed in patients with severe septal deviation. This is very important to find the real cause of nasal obstruction, in order for the surgeon to choose proper surgical techniques.

This study showed that the BL contributes to the main turbinate thickness in cases of compensatory ITH due to DNS and it should be a target of surgery with choice of proper surgical technique, that is a method like submucous diathermy would not be able to relieve this patient from nasal obstruction.

On the other hand, in allergic rhinitis this study showed that the hypertrophy of the mucosa is more than hypertrophy of the conchal bone. So, surgical techniques such as submucous diathermy (which aim to remove the mucosa with leaving the bony part of the turbinate) are suitable for such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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