MANAGEMENT OF CONCHA BULLOSA AND CHRONIC

RHINOSINUSITIS WITH FUNCTIONAL ENDOSCOPIC SINUS

SURGERY : A CASE REPORT
Frenky S. Manullang, Ferryan Sofyan

INTRODUCTION
A concha bullosa (CB) represents the presence of air cell in the turbinates,
and the middle turbinate (MT) concha bullosa is a common nasal cavity
anatomical variation. Pneumatization of the MT happens due to variation in the
ethmoidal air cell system development. (Kalaiarasi et al, 2018). Chronic
rhinosinusitis (CRS) has been defined in European Position Paper on
Rhinosinusitis and Nasal Polyps (EPOS) 2020 as an inflammation of the nose and
paranasal sinus that lasts for >12 weeks, characterized by specific nasal symptoms
(two or more symptoms one of which should be either nasal blockage/
obstruction/ congestion or nasal discharge (anterior/posterior nasal drip),  facial
pain/ pressure,  reduction or loss of smell), and endoscopic signs (either nasal
polyps, and/or mucopurulent discharge primarily from middle meatus, and/or
oedema/ mucosal obstruction primarily in middle meatus), and/or computed
tomography (CT) changes (mucosal changes within osteomeatal complex and/or
sinuses) (Veloso-Teles R and Cerejeira R, 2017; EPOS, 2020; Pittore 2011).
CRS is also one of the most commonly diagnosed diseases of the upper
airways not only in western countries but also increasingly in Asia, it affects about
11% of adults in Europe and about 12% of adults in the United States (Zhang, et
al, 2017). It is a troublesome, chronic inflammatory disease that affects over 10%
of the adult population, causing decreased quality of life, lost productivity, and
lost time at work and leading to more than a million surgical interventions
annually worldwide (Schleimer, 2016). Heath Surveys from Korea, China, and
Brazil revealed prevalences for CRS from 5.5% to 8%, with regions in China
reaching 10% of the population (Bachert, Luo and Phillippe, 2015).
Functional endoscopic sinus surgery (FESS) is a minimally invasive
technique that was introduced in the 1960s by Professors Messerklinger and
Wigand. It was popularised in Europe by Stammberger and in North America by

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Kennedy. FESS is a minimally invasive technique that is used to management of
sinus disease. FESS claims advantages over conventional surgery: permitting a
better view of the surgical field, a more precise and thorough clearance of the
inflammatory change, fewer complications and lower recurrence (Carter, 2019).
CASE REPORT
A 17-year-old female was admitted to Universitas Sumatera Utara
Hospital, Medan in December 2021 with headache complaints. The headache
throbbing and located at the vertex of the head and in the left middle canthus area.
The patient also had complaints of progressive nasal obstruction for 1 months,
more severe on the left side, post nasal drip, intermittent hyposmia and purulent
rhinorrhea out of the nose. She did not have history of any other medical problems
and did not undergo any surgical procedures in the past.
During ENT routine examination we found ears were normal, anterior
rhinoscopy showed left nasal cavity was narrow, the nasal mucosa was appearing
congested, concha bullosa on the left side. Posterior rhinoscopy showed post nasal
drip in the nasopharynx and the oropharynx was normal.
Computed Tomographic (CT) Scan of nose and paranasal sinuses was
done. The scans revealed thickening of the maxillary sinus mucosa, anterior
posterior ethmoid sinus, and bilateral frontal and left sphenoid sinuses. Left
medial concha bullosa (figure 1).

Figure 1. CT scan of the paranasal sinus

Chest x-ray, ECG examination and laboratory result were normal. The
patient underwent FESS under general anastesia on 12th January 10th 2022.

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 After desinfection with povidone iodine and alcohol 70%, epinephrine
1:100.000 tamponade applied to the nasal cavities, inserted through the left middle
meatus and nasal cavity with a 0⁰ telescope guidance and were left there for 15
minutes.
Removed the tamponade from the nasal cavities then the nasal cavities
were evaluated with the telescope. Turbinectomy was performed with the
technique of fracture of the inferior turbinate bone laterally and diathermy was
performed on the hypertrophied inferior turbinate mucosa. The concha bullosa
constricts the middle meatus, so that the concha bullosa was resectioned by
removing the lateral part of the middle concha (figure 2 and 3). After the middle
meatus was more spacious, an unsinectomy was performed to find the maxillary
sinus ostium. Unsinectomy was performed with back biting forceps, the maxillary
sinus ostium was seen, then the maxillary sinus ostium was widened by removing
the inferior and anterior part of the ostium.

Figure 2. Incision of the left middle turbinate

Figure 3. After removing the lateral side of the middle turbinate, opened concha
bullosa was seen with 0° telescope revealing the anterior compartment.

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 Figure 4. Evaluate bleeding using adrenaline gauze tampons

Anterior etmodectomy was performed by removing the ethmoid bulla to

the lamina basalis. Lamina basalis penetrated to see the posterior ethmoid and
posterior ethmoid looks clean (figure 5). The sphenoid ostium was identified
towards the media inferior and the ostium was open. Bleeding was treated with
anterior packing.

Figure 5. Ethmoid sinus was clean.

Post-operative the patient was given antibiotic, analgetic, steroid

medication orally, and analgetic drip in ringer lactate infusion. The anterior
tamponade was removed 2 days after surgery and next day we did a nasal
irrigation. During the postoperative period, the patient's complaints subsided and
she had a marked improvement.

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DISCUSSION
CRS will have months or year of progressively worsening sinonasal
symptoms before they are diagnosed. In some cases, patients without a history of
significant sinonasal symptomatology will present with continuous symptoms that
can be traced back to an initial inciting event-usually a severe upper respiratory
infection or flu-like illness. Nasal obstruction, hyposmia and rhinorrhea are
common symptomatic complaints, but facial pressure or headache, and post-nasal
drainage are also common. Symptoms alone are unreliable for the diagnosis of
polypoid CRS, but smell dysfunction seems to be one feature that is more
commonly encountered in CRSwNP. This smell dysfunction may be a result of
obstruction of airflow into theolfactory cleft or direct inflammation of the mucosa
of the olfactory cleft. This was consistent with our patient which shown nasal
complaint consisted of progressive nasal obstruction for 1 months, more severe on
the left side, post nasal drip, intermittent hyposmia and purulent rhinorrhea out of
the nose. (Fokkens et al, 2020; Ryan, 2014).
Concha bullosa on the other hand usually presented with headache, nasal
obstruction, post-nasal drip, purulent nasal discharge. A research by Alnatheer et
al shown that all sample (100%) presented with nasal obstruction, followed by
headache in 77% (10/13) of the patients and septal deviation in 61% (8/13) of the
cases (Table 3). The site of CB in the inferior turbinate was bilateral in six cases,
followed by left-sided in five cases and right-sided in two cases. This was
consistent with our patient which shown headache as her main complaint.
(Alnatheer et al, 2021)
EPOS 2020 has divided CRS in terms of primary and secondary and to
divide each into localized and diffuse disease based on anatomic distribution. In
primary CRS, the disease is considered by endotype dominance, either type 2 or
non-type 2. Clinically localized primary CRS is then subdivided into two
phenotypes – allergic fungal rhinosinusitis (AFRS) or an isolated sinusitis. For
diffuse CRS, the clinical phenotypes are predominantly eCRS and non-eCRS,
determined by the histologic quantification of the numbers of eosinophilic. For
secondary CRS, again, the division is into localized or diffuse and then considered
by four categories dependant on local pathology, mechanical, inflammatory and

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immunological factors. Thence a range of clinical phenotypes are included as
show. CRS without nasal polyps (CRSsNP) is most common compare with CRS
with nasal polyps (CRSwNP), CRSsNP was more prevalent in subjects younger
than 40 years (EPOS, 2020). Regarding the patien CRS diagnosis, in accordance
to the theory it is most likely that the patient diagnosis fell into primary CRS
category or CRSwNP.
Anatomic variants have been studied because the obstructionof the
ostiomeatal complex has been suggested as a risk factor for developing CRS. A
systematic review analyzing the role of septal deviations in CRS demonstrated a
significant association of septal deviation and rhinosinusitis (EPOS, 2020).
Anatomic variations in the region of the osteomeatal complex have been
hypothesized to play a role in the cause of isolated chronic maxillary sinusitis.
Bolger et al. classified pneumatization of concha bullosa into three groups.
They referred to pneumatization localized to the vertical lamella of the middle
concha as “lamellar concha bullosa,” pneumatization localized to the inferior (or
bulbous) pair of the concha as “bulbous concha bullosa,” and extensive
pneumatization to both the vertical lamella and the bulbous part of the of the
concha as “extensive concha bullosa.” The degree of pneumatization is directly
proportional to the severity of symptoms. Whereas the lamellar and bulbous types
are usually asymptomatic, extensive bullous concha manifests symptoms (Al
Riyami 2020).

Types of concha bullosa (arrows): (A) lamellar type, (B) bulbous type, and
(C) extensive type (El-Din, et al. 2020)

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 Different types of unilateral concha bullosa (CB) shown by coronal computed
tomography images. (A) Right lamellar type CB (arrow). (B) Right bulbous CB (arrow).
(C) Right extensive CB (arrow) (El-Din, et al. 2020)

These anatomic factors include conchae bullosae, Haller cells,

paradoxical middle turbinates, and substantial septal deviations or spurs that can
be seen to narrow the ipsilateral airway or impinge on the middle meatus on
computed tomographic (CT) scanning and intranasal examination (Kieff, et al,
2014). The other variant anatomy is adenoid hyperthrophy, it can obstruct the
posterior choanae interfering with the natural drainage of the nasal and hence the
sinus secretions resulting in stasis which provide good media for bacterial growth
and consequently infection of the paranasal sinuses (Yaseen, 2011). Our patient is
consistent with Kieff study which shown CRS combined with conchae bullosae.
The diagnosis of CRS requires that inflammation be documented on
physical examination, in addition to persistent symptoms that usually include at
least two of the following: nasal obstruction (81–95%), facial congestion/
pressure/fullness (70– 85%), discolored nasal discharge (51–83%), and hyposmia
(61–69%) (Suh and Kennedy, 2011). The existence of major and minor criteria
including facial pain or pressure, facial congestion, nasal obstruction, halitosis,
headache, and hyposmia are essential for diagnosis. None of the symptoms of the
disease-specific, thus, the sign-based diagnosis alone is not reliable and
endoscopic surveillance and CT-scan procedures are required for the confirmation
of diagnosis (Nikakhlagh, Bakhshi and Noeoozi, 2015). Our patient comes with
symptoms of headache, nasal obstruction, hyposmia, and rhinorrhea. During
ENT examination

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anterior rhinoscopy showed left nasal cavity was narrow, the nasal mucosa was
appearing congested, concha bullosa on the left side. Posterior rhinoscopy showed
post nasal drip in the nasopharynx and the oropharynx was normal.
The different imaging modalities in diagnosing rhinosinusitis
(conventional X-ray, computerized tomography (CT), cone beam CT and
magnetic resonance imaging (MRI) have been evaluated of which overall CT scan
remains the gold standard in the radiologic evaluation of rhinologic disease,
notably CRS. The first guidelines that recommended CT sinus imaging and/or
nasal endoscopy for confirmation of the symptoms-only based diagnosis of
chronic rhinosinusitis were the EPOS guidelines. (EPOS, 2020). A scan is
mandatory prior to surgery, both to confirm the presence and extent of disease,
and to identify any anatomical features that may predispose to the risk of
complications. In this patient, CT-scan revealed revealed thickening of the
maxillary sinus mucosa, anterior posterior ethmoid sinus, and bilateral frontal and
left sphenoid sinuses with left medial concha bullosa
There are several therapeutic options including the application of
antibiotics, corticosteroids, antihistamines, nasal lavage, decongestant,
immunotherapy, and surgery. Based on EPOS 2020, Primary Unilateral CRS was
treated with direct surgery (FESS) (EPOS, 2020). In this case, the patient
underwent FESS under general anastesia on 12th January 10th 2022.
FESS usually aims to enlarge the maxillary sinus ostium or perform
ethmoidectomy with the intention of reducing recurrence rates or removing nasal
polyps, concha bullosae or other anatomic repair. The extent of surgery varies
from widening the maxillary antrum through to radical clearance of the entire
sinuses. It therefore involves not just the removal of a polyp, but opening the thin
bony lamella of the sinuses (e.g. ethmoid). The technique has been used since the
1970s in treating a variety of sinus conditions (Dalziel et al, 2003). In our case,
the patient underwent FESS which remove the patient concha bullosae and
removing the ethmoid bullae thus opening the ethmoid area.
CONCLUSION
We report a 17-year-old female with concha bullosae and chronic
rhinosinusitis. The patient underwent history taking, physical examination, CT-
scan, ECG, chest x-ray and other laboratory procedure in which CT-scan

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confirmed

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our diagnosis. The patient was then treated with a surgical intervention of
Functional Endoscopic Sinus Surgery (FESS) and the outcome was satisfying.

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