Central Annals of Otolaryngology and Rhinology
Case Report
Inferior Concha Bullosa
Communicating into the Maxillary
Sinus: Case Report
Murat Şereflican1*, Sıddıka Halıcıoğlu2, Sinan Seyhan1, Veysel
Yurttaş1, Yasemin Ongun Funda3 and Muharrem Dağlı1
1
Department of Otorhinolaryngology, AbantIzzet Baysal University School of Medicine,
Turkey
2
Department of Radiology, AbantIzzet Baysal University School of Medicine, Turkey
3
Department of Otorhinolaryngology, Fatma Hatun Private Hospital, Turkey
Abstract
Concha bullosa or conchal pneumatization refers to the presence of an air cell
within a nasal turbinate. Pneumatization is most commonly seen in the middle turbinate
followed by the superior turbinate. Pneumatized inferior turbinate is rare, and most
of the papers in the literature appear as case reports. In this study, a 33-year-old
female patient complaining from unilateral nasal stuffiness and intermittent headache
is presented. Symptomatology, diagnostic and therapeutic methods for inferior concha
bullosa is discussed. In clinical practice, the pneumatization status should well be studied
on the scans before sinus and turbinate surgery and inferior concha bullosa should be
kept in mind.
ABBREVIATIONS
CT: Computerized Tomography
INTRODUCTION
Inferior turbinates are important anatomical structures
located along the lateral nasal wall. The middle and superior
concha, and occasionally the supreme concha, are parts of the
ethmoid bone, whereas the inferior nasal concha is an independent
bone [1]. The inferior concha is bounded anteriorly by the
internal nasal valve and posteriorly by the choana. Moreover,
it is responsible for filtration, heating, and humidification of the
air inhaled through the nose. It is also responsible for 2/3 of the
airway resistance and thus even small changes in the size of the
inferior concha may lead to major alterations [1,2]. With the
growing use of computed tomography (CT) in the diagnosis of
the inferior concha, the frequency of anatomical variations of the
concha has increased [3]. In terms of frequency, concha bullosa
is the most common anatomic variant of the middle turbinate.
As an alternative, concha bullosa is relatively infrequent in the
superior turbinates and even more uncommon in the inferior
turbinates [4]. Inferior concha bullosa incidence detected in
paranasal CT images is between 0.03 to 4.88 %, incidentally. Even
though, the sex ratio (male to female) is close to one another the
rate is slightly more common in women. The average age is seen
with 36 to 42.1, besides this the disease can occur at every age
[3,5]. Although the inferior concha and the maxillary sinus are of
different embryological provenance, our patient presented with
Cite this article: Şereflican M, Halıcıoğlu S, Seyhan S, Yurttaş V, Funda YO, et al. (2016) Inferior Concha Bullosa Communicating into the Maxillary Sinus: Case
Report. Ann Otolaryngol Rhinol 3(3): 1096.
*Corresponding author
Murat Sereflican, Department of Otorhinolaryngology,
AbantIzzet Baysal University, Faculty of Medicine,
Golkoy, Turkey, Tel: 90-3742534656–3347; Fax: 90-
3742534559; Email:
Submitted: 08 February 2016
Accepted: 07 March 2016
Published: 08 March 2016
ISSN: 2379-948X
Copyright
© 2016 Şereflican et al.
OPEN ACCESS
Keywords
• Nasal concha
• Maxillary sinus
• Nasal obstruction
inferior concha pneumatization associated with the maxillary
sinus. Here, we present this rare case with the review of the
literature.
CASE PRESENTATION
A 33-year-old female patient presented to our clinic with a
2-year history of nasal obstruction, headache and intermittent
postnasal drip. Anterior rhinoscopy and nasal endoscopy
revealed that the right inferior concha was hypertrophic and the
nasal septum was deviated to the left.
A coronal section computerized tomography (CT) scans
showed pneumatized right inferior concha and an air-filled
sac in the pneumatized inferior concha associated with the
right maxillary sinus (Figure 1-3). Septoplasty and submucous
resection (SMR) of the inferior concha were recommended but
the patient objected to the proposed surgeries and thus was
followed up.
DISCUSSION
Concha bullosa, also known as pneumatized concha, is
an anatomical variation of the middle concha, consisting of
pneumatization. It is mostly seen in the middle concha and rarely
seen in the inferior concha [4]. Inferior concha bullosa was first
described by Zinreich [6]. There are three hypotheses regarding
the development of an inferior concha bullosa. The first suggests
that the inferior concha is ossified from two separate centers
and two cartilaginous lamellae during the fetal life. Two ossified

Central
Figure 1 The coronal CT image of the right inferior concha bullosa
communicating into the right maxillary sinus.
Figure 2 The coronal CT image of the right inferior concha bullosa.
Figure 3 The axial CT image of the right inferior concha bullosa.
lamellae and an air-filled sac between these two lamellae may
develop as a result of the epithelial invagination among the
lamellae that ossify in the order of development. The second
hypothesis suggests that air cell-formation most likely results
from maxillary sinus disease and is associated confidentially with
the site of inferior turbinate attachment. The above two theories
can be termed as non-communicating type pneumatization.
The third hypothesis suggests that in foetal life, maxillary sinus
Ann Otolaryngol Rhinol 3(3): 1096 (2016)
Şereflican et al. (2016)
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pneumatization extends into the inferior turbinate, and this
finding can be readily seen in axial CT [5]. In our patient, we
considered that the mechanism of the development of inferior
concha was similar to that of the third hypothesis since the
pneumatization in our patient was associated with the maxillary
sinus. Though very rare, inferior concha bullosa associated with
the maxillary sinus has been reported in several studies in the
literature. In a study by Yang et al., 8 out of the 18 cases of inferior
concha bullosa were associated with the maxillary sinus [5].
Another study by Baldea et al., [3] 6 out of the 10 cases of inferior
concha bullosa were associated with the maxillary sinus.
Inferior concha bullosa is usually asymptomatic and
incidentally diagnosed on paranasal CT [7]. Although the
pneumatization of the inferior turbinate generally does not give
any symptoms, nasal obstruction, rhinorrhea and dysosmia may
be seen due to severe pneumatization and enlargement of the
inferior concha. In patients with large pneumatization, inferior
concha bullosa may lead to headache as a result of mucosal
contact and epiphora as a result of nasolacrimal duct blockage
[4,8].
Endoscopic examination reveals no findings that could
indicate inferior concha bullosa except for concha hypertrophy.
Therefore, CT remains the most ideal method in the diagnosis
of inferior concha bullosa. In particular, coronal section CT is a
valuable tool for the diagnosis of inferior concha bullosa. It is
usually identified as incidental in the CT images taken by other
reasons. Yang et al., [5] reported that 16 patients with inferior
concha bullosa were detected in 59238 CT images performed for
another reason. In another study, Baldea et al., [3] determined 10
patients with inferior concha bullosa in 205 paranasal CT images
taken by other reasons.
Cone-beam computed tomography (CBCT) is a technique first
announced in Italy in 1997 [9]. Among its advantages are lower
radiation dose compared to standard computed tomography.
(CT), used in medical tomography, and its high spatial
resolution of bone tissue, which makes it a widely used method
in general dental practice [10,11]. However, we have not a CBCT
scan in our Radiology department so that we couldn’t take an
image with CBCT for our patient.
There is no need for treatment in asymptomatic inferior
concha bullosa. The goals of treatment are to maximize the nasal
airway, to preserve nasal mucosa function, and to minimize
complications. Medical treatment such as steroid nasal sprays
may be attempted, but often are not successful in these cases
and surgery is required. The most common methods used in the
treatment of inferior concha bullosa include injection of steroids
or sclerosing agents into the submucosal area, radiofrequency
ablation, cauterization, cryoturbinectomy, and concha resection
[1,12]. Out fracture of the inferior concha, resection of the lateral
lamella of the concha bullosa of inferior turbinate, or submucous
resection are the surgical treatment options in the management
of the symptomatic concha bullosa [7,8] (Table 1). Unlu et al.,
suggested that partial turbinectomy can be performed in cases of
inferior concha bullosa that have no association with the maxillary
sinus but performing partial resection in the cases extending
to the sinus may cause inferior meatalantrostomy, leading to
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Central

Table 1: The table summarizing age of diagnosis, symptoms of presentation, treatment and outcome.
Reference Age Sex Complaint CT findings Treatment Outcomes
Ural A,UsluS.
Out fracture and
23 M Left nasal obstruction Sol alt konkabülloza Close to full recovery
radyofrequency

The lateral lamella of the

Nasal blockage, nasal pain, Nasal obstruction
Pneumatization of the inferior
Kiroglu AF., et al. 14 F and purulent discharge at was resolved
left inferior turbinate Conchabullosa was
the left side After surgery
resected
The inferior
conchabullosa was
resected removing Nasal obstruction
Rhinorrhoea and nasal Pneumatization of the
Pittore B, Al Safi W, JarvisS. 24 F the free edge of the had improved
obstruction left inferior turbinate
inferior turbinate using significantly
turbinectomy scissors

Patient did not accepted

Right inferior concha Patient did not
Yuca K, et al. 37 F Nasal obstruction any kind of surgery
bullosa return for follow up

Patient did not accepted

BaykaraM, PolatC, UysalIO, Left nasal obstruction and Left inferior concha Patient did not
37 F any kind of surgery
SoyluE. headache bullosa return for follow up

Bilaterally inferior and Nasal obstruction

AkagünF, ErdoğanBA, Bilaterally out fracture
35 F Nasal obstruction middle concha bullosa had improved
BoraF and radyofrequency
significantly
A little complaints
Ingram WA, Richardson Nazal obstruction and post Left inferior concha Patient did not accepted of the patients
38 F
BE. nasal discharge bullosa any kind of surgery were resolved with
medical treatment

persistent sinusitis by impairing the mucous circulation [13].
Total turbinectomy is contraindicated because it can increase the
risk of the patient developing atrophic rhinitis, in particular in
hot and dry climates [1].
In conclusion, inferior concha bullosa should be kept in
mind in the differential diagnosis of commonly encountered
inferior hypertrophy. A suitable treatment should be planned
for symptomatic cases and the association between the concha
bullosa and the maxillary sinus should be investigated prior to
surgical planning.
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Cite this article

Şereflican M, Halıcıoğlu S, Seyhan S, Yurttaş V, Funda YO, et al. (2016) Inferior Concha Bullosa Communicating into the Maxillary Sinus: Case Report. Ann Oto-
laryngol Rhinol 3(3): 1096.

Ann Otolaryngol Rhinol 3(3): 1096 (2016)

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