The truth about turbinates

“…rhinological adenoids was a disappearing condition and that the
operation for it was seldom needed at the present day and would ultimately follow the amputation of the uvula or the removal of the inferior turbinal into the limbo of forgotten industries.”

-Somerville and Hastings, Royal Proceedings in Medicine, 1932

Much is discussed by experts on the topic about the ideal treatment of the (inferior) turbinates – cautery, radiofrequency, ultrasound sharp removal, direct steroid injections and even cryotherapy. Treating the turbinates with nasal steroids and subsequently surgery is a big business for small innocent structures inside the nose. Most are convinced that because turbinates are there, they must be the CAUSE of nasal blockage. As they debate which way to “shrink” the turbinates is best, of course they completely miss the point of why they are there in the first place. This is a symptom of both two-dimensional thinking and fixed business models. Of course, as with anything that for 100 years that needs to be repeatedly re-branded as the next big thing, almost the entire concept is questionable…

In reality, the turbinate is not a mystery organ that undergoes inflammation, and then needs to be shrunken by well-meaning experts. Instead, it a critical part of the nasal airflow system that maintains air-pressure in the throat to prevent collapse during sleep, by PREVENTING turbulent airflow within the nose and maintaining smooth jets of inspired air from the nostrils. I know…you were told the exact opposite was true, and that shrinking the turbinates would help your sleep symptoms. The turbinate is not the cause of nasal obstruction in most cases (except in its most extreme form when the turbiate has become so swollen to become polypoid or extremely stretched out (see video below). Unfortunately, most doctors and patients confuse two entirely distinct conditions as one, and this creates a massive inefficiency in our healthcare. The two distinct conditions are: 1). True nasal obstruction, which manifests as a deformity of narrow nostrils, or a very deviated septum – (this is less common) and 2). Nasal Disuse (or underuse) – (which is extremely common and coined by Stanford’s late Christian Guilleminault), and simply means that the nose FEELS obstructed but is simply not used or is underused. Obviously, #1 (True obstruction) can be fixed if the obstruction is relieved, and that is another topic for another day. But, #2 (Nasal Disuse) can be confusing to all because it consists of invisible forces! Particularly as we age, or have diminishing tone from poor diet and sedantarism, during sleep, our mouths reflexively open due to relaxation, just as our arms and legs go limp, so do our mouths. This causes us to breathe through our mouths instead of our nose! So, the air flowing through the mouth now means that during the night, the nose has less air flowing through it. This an unused railroad track that develops weeds and damage to the rails, this under-used passage that is inadvertently neglected, lacks the flow of air pressure against its walls which prune and clean excess mucosa like the wind prunes dune plants at the beach. This failure of mucosal pruning in the nose can stretch the tissue itself inwardly, and cause “growth” of the lining of the turbinates, the shock structure that protects us from the vacuum forces. The turbinate’s job is also to temporarily stretch its skin and grow this mismatch in flow to maintain laminar or straight flow on inspiration from the nasal inlet or nostril if these openings are narrow. For example if the turbinate is too small and thus the cavity is too large relative to the nostril, airflow is not increased but becomes turbulent like a lake in the middle of the stream, and this reduces airflow and pressure to the pharynx.But, when the the lack of airflow forces become too great from too much severe nasal underuse and mouth-breathing, the turbinates become damaged, and inflammatory cells rush to the rescue. Of course, because clinicians do not directly see the night time pressure-mediated trauma but instead do their examination in the office during waking hours, they only see the resultant inflammation, the only therapeutic target remains anti-inflammatories, (nasal steroids), or mechanical (usually heat) shrinkage. Only the rarest of physicians mentions night-time barotrauma, (lack of airflow related damage) to the tissues as the cause of the problem. Most, instead will call the disease allergic rhinitis in mild cases, and when more severe, and the vacuum damage extends to the chambers known as sinuses, will call it “sinusitis”. Then, the patient, suffering from never-ending night-time barotraumas, can after steroid treatment, have sinuses or turbinates “cleaned out” which means removing the damaged tissue, but of course in all cases, the problem shortly returns, because the root cause is almost never addressed. It is worsened in the cold winter up north where dry humid air further worsen the damage from the vacuum, and it is worsened in parts of the south where too much moisture and humidity in the summer cause buildup of fungus in the vacuum damaged tissues. But, of course the majority only focus treatment on the downstream problems of inflammation, stretched tissues or colonizing organisms like bacteria or fungus that are not the root cause, but gives the illusion of improvement because symptoms temporarily improve, and the medical industrial complex (described by Elisabeth Rosenthal in American Sickness) is satisfied, because a condition that is always treated but never cured is a boon to industry. The practical but not easy solution is the restoration of nasal breathing at night, NOT by treating the nose, but by keeping the jaws SHUT! This can be achieved with improved body tone, or even using a jaw-closure garment or intra-oral device. Not lying on the back is helpful, as in the supine position, the jaw feels the exertion of more gravity encouraging opening versue prone (stomach down- *best), or side-sleeping. I spend a lot of energy explaining this, because people who have nasal disuse like I just described have limited results from surgery, so if we can not distinguish obstruction from disuse, we will have many poor results, as presented in most of the medical literature that has failed to distinguish between the two conditions, so uses survey type outcome measures that only focus on temporary symptoms rather than more concrete variables to justify the continued limited techniques that were known to be marginal in 1932 (see quote). Of course, you can have both obstruction and underuse, and in these challenging cases, the physician still must distinguish which treatments treat which of the two problems, and combined therapy is required for resolution: like a functional rhinoplasty combined with a post-op use of a nighttime jaw closure device. In children, mouth-breathing commonly occurs before the jaws and tone mature during adolescence, and this mouth-breathing causes growth of the tonsils and adenoids the same way that the turbinates grow, from negative pressure and usually dryness, and again, these structures are seen as the cause of the difficulty, but are actually the result. Almost a parallel pediatric version of the turbinates! If you have more questions, let us know, whether you want to help yourself or improve efficient delivery of healthcare.

For more details, see: source papers here.

and a technical book I wrote on the topic here:

Finally, James Nestor wrote a book designed for the public that touches these topics:
The video below captures the nature of aerodynamics on turbinate stretching…

5 responses to “The truth about turbinates

  1. Thanks so much for posting such an insightful and valuable post. For most of my life, I was a mouth breather, especially under exertion, due to nasal congestion. I bought the Nestor book as soon as it came out and have been working successfully to improve my nose breathing by forcing myself to breathe through my nose. I have a bright field/dark field microscope, various stains, etc., and have seen a lot of fungi in my nasal mucus, verified by KOH test, lots of eosinophils, eosinophilic mucin and Charcot Leyden crystals, so I have been rinsing with various antifungals. Also experimented with a DIY microemulsion rinse using warm normal saline, coconut oil, and a dash of emulsifier, Polysorbate 80, mixed in a smoothie blender. After a nasal rinse with this microemulsion, fungi viewed in my microscope were disintegrating. But no adverse effects noted. This in vivo efficacy was consistent with the in vitro efficacy I’ve read about for microemulsions with fungi. Nose breathing is getting better and better. Thanks again for your great site, insights, and posts.

  2. This is an interesting article, but it raises a couple of questions.

    1. How does breathing through your mouth induce a vacuum in your nose? In that case, your nose is bypassed. Breathing THROUGH your nose induces a vacuum during air intake.

    2. Once your turbinate is damaged by disuse or vacuum, what’s the solution? The article doesn’t say.

    1. You are correct. I came to the same conclusion several months after writing this blog post, and also realized that it is not negative pressure transmitted to the nasal cavity but a simple lack of airflow. I now think that the airflow essentially prunes the nasal cavity mucosa by exerting positive pressure against the sidewalls and limiting the erectile tissue of the nose to expand. Thus, to answer # 2, the answer is to restore nighttime and daytime constant nasal airflow to restore this air pressure against the sidewall that “prunes” the turbinate.

  3. Quick question. If I were to somehow keep my son’s mouth shut at night or during the day, he would literally suffocate. He has such a terrible obstruction from turbinates.

    What I keep trying to understand and maybe this post somewhat explained it….what is the root cause of this inflammation? We’ve seen allergists, ENT’s etc and no one can come to a conclusion as to WHY this is an issue.

    I have a suspicion that is similar to what you are seeming to elude to…the temperature in the home has an effect. I am anecdotally noticing that when the air conditioner comes on in the summer and the heat in the winter is when we run into issues with our kiddo most.

    So am I hearing you say that this is your theory as well?

    1. The nose is kind of “use it or lose it”. When my 12 year old was very small he always had his mouth open, and thus nose sounded congested all the time. At the time, I couldn’t figure out what came first the chicken or the egg, did mouth-breathing cause nasal congestion or did nasal congestion cause mouth-breathing. Obviously a severely crooked nose causes mouth-breathing in itself, but in the majority of small, not developed kids with normal looking noses, it is the mouth-breathing that causes nasal congestion. So, gradually, I experimented gently with myself and learned about the kid too, first when he was sleeping, gently holding my hand under his chin to close the mouth. The snoring always stopped immediately, and the restlessness improved. I extended this to 5 minutes and more, then as he got older I explained it to him, and designed garments from scuba hoods that would gently keep his jaw closed but he could still open his lips if he wanted or needed. Gradually the nose cleared, the snoring disappeared. I did the same thing to myself with jaw tape, and we both still use something to maintain jaw closure at night to get a great night’s sleep and not have dry mouth and congestion. In the winter here, it gets very dry too, so we lowered the heat 5 years ago from 74 to 63 over a few months tracking humidity, and all of the regular winter runny noses, dry eyes, red skin, rashes, dry mouths and sore throats disappeared. So, the two concepts work together.

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