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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00902-6
10.1016/j.radcr.2024.08.117
Case Report
Bilateral nasopharyngeal middle turbinate: A rare anatomical variant
Sherfad Mohamed m_sherfad@med.misuratau.edu.ly
a⁎
Alogbi Osama b
Ayad Bashir M. c
a Department of Radiology, Faculty of Medicine, Misurata University, Misurata, Libya
b Department of ENT, Misurata Medical Center, Misurata, Libya
c Department of Physiology, Faculty of Medicine, Misurata University, Misurata, Libya
⁎ Corresponding author. m_sherfad@med.misuratau.edu.ly
10 9 2024
12 2024
10 9 2024
19 12 57345737
10 8 2024
21 8 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Nasopharyngeal middle turbinate is an extremely rare anatomical variant which has been suggested to correlate with chronic rhinosinusitis. However, due the rarity of this variant, its clinical implications remain inadequately defined. Here, we present a case of a 37-year-old male patient with bilateral nasopharyngeal middle turbinates, one of which had a large cystic lesion causing nasal obstruction. The patient's presentation, radiological and endoscopic findings, as well as the management approach are discussed in the context of the limited literature on this topic.

Keywords

Anatomical variant
Middle turbinate
Nasopharynx
Rhinosinusitis
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pmcIntroduction

The embryological development of nasal turbinates is a complex process that may be associated with various anatomical variations. The nasal turbinates are bony structures projecting along the lateral nasal wall and extending into the nasal cavity. Middle and superior turbinates are processes of the ethmoid bone, whereas the inferior turbinates are independent bones. The turbinates contain extensive vascular capillaries and venous sinusoids essential for warming and humidifying the inhaled air, as well as modifying nasal airflow resistance. They persistently swell and shrink in response to endogenous stimuli and environmental factors, in a process controlled by the sympathetic nervous system and referred to as the nasal cycle [1].

Currently, the escalated application of paranasal computed tomography (CT) scan alongside endoscopic sinus surgery has enabled the identification of numerous anatomical variations of nasal turbinate. The concha bullosa (pneumatized middle turbinate) is the most commonly described variant, other less common variants include secondary and accessory middle turbinates, which can resemble true middle turbinates, whereas the paradoxical middle turbinate is infrequently encountered anomalies [2,3].

Several studies have attempted to elucidate the relationship between anatomic variations of the middle turbinate and chronic sinusitis, however, results have often been found inconsistent [[4], [5], [6]]. The nasopharyngeal middle turbinate is a rare anatomic variant where the middle turbinate extends posteriorly into the nasopharyngeal cavity rather than the nasal cavity [8], and the clinical significance of this anatomical variant remains unclear. Here, we present an uncommon case of bilateral nasopharyngeal middle turbinates with a unilateral large cystic lesion on the left side and discuss the implications of the findings.

Case report

A 37-year-old male presented to the ear, nose, and throat clinic with several months' history of nasal obstruction, frequent headache, nasal itching, snoring, and loss of smell. The patient had experienced a mandibular fracture due to facial trauma, which was successfully treated with surgery. He denied any previous history of asthma or allergic reactions. Physical examination revealed missing middle turbinate on both sides along with a mass-like lesion protruding posteriorly to the nasopharynx on both sides, which appeared larger on the left side obliterating the left choanae (Fig. 1), otherwise clinical examination was essentially unremarkable. The CT imaging of the patient's paranasal sinus cavities demonstrated mild mucosal wall thickening involving the maxillary, ethmoid and left frontal sinuses (Fig. 2). Bilaterally missing middle turbinate was furthermore confirmed. In addition, abnormal bony projection with mucosal covering was detected arising from the medial wall of the nasal cavity and extending posteriorly to the nasopharynx, along with a 3 cm fluid-filled cystic lesion on the left side, which appeared to contribute significantly to narrowing the nasal passages (Fig. 3). Based on these observations, the diagnosis of nasopharyngeal middle turbinate was suspected.Fig. 1 Endoscopic view illustrating an abnormal nasopharyngeal mass protruding posteriorly, obliterating the nasopharynx particularly on left side. (A: right side, B: left side).

Fig 1:

Fig. 2 Rhinosinusitis of ethmoid (A) and left frontal (B) sinuses.

Fig 2:

Fig. 3 CT scan of paranasal sinus showing a bilateral absence of the middle turbinate (arrow) and the presence of bilateral nasopharyngeal middle turbinates (doted arrow). The left-sided turbinate contains a 3 cm fluid-filled cystic lesion (asterisk) causing significant narrowing of the nasal passage. (A: coronal image, B: left sagittal image, C: right sagittal image, D: axial image, E: axial image).

Fig 3:

Medical treatments including, oral antibiotics (doxycycline 100 mg), oral corticosteroid (prednisolone 20 mg) intranasal corticosteroids (fluticasone propionate 0.05%), and saline irrigations were prescribed. After a period of 2 months devoted for conservative treatment, the patient's symptoms improved noticeably primarily the itching and snoring, despite his continual complaining of nasal obstruction mainly on the left side. The patient was subsequently scheduled for surgical management of the left middle turbinate cystic lesion.

Discussion

The architecture of the middle turbinate plays an essential role in the maintenance of normal physiological functions of the nose. Consequently, anatomical variations could conceivably be related to a wide range of functional impairments, thereby influencing different aspects of clinical practice [7]. Nasopharyngeal middle turbinate is a rare anatomical variant arising potentially from an error in the embryological development of the nasal turbinates, where the middle turbinate extends posteriorly into the nasopharyngeal cavity rather than the nasal cavity. Only 2 cases of unilateral nasopharyngeal middle turbinate have been reported in medical literature. In the first case, Kim et al. showed that the existence of this anomalous middle turbinate could be a contributory risk factor for recurrent chronic rhinosinusitis (CRS). The patient in that case required treatment with functional endoscopic sinus surgery and resection of the abnormal turbinate [8]. In contrast, the second case by Lechien and colleagues displayed substantial improvements in the patient's' complains, endoscopic and radiological findings, together with an unremarkable follow-up, which consequently did not support the association between nasopharyngeal middle turbinate and recurrent CRS [9].

Here we presented an extremely rare case of bilateral nasopharyngeal middle turbinate, with one side large cystic lesion obliterating the left choanae. Findings of mild sinus disease was observed, and patient symptoms improved noticeably after medical treatment. A recommendation was made to the patient to pursue surgical intervention for the excision of the cystic lesion occluding the left choana. This case adds to the limited literature on nasopharyngeal middle turbinate variants by documenting a rare bilateral occurrence, thereby contributing to a more comprehensive understanding of its potential clinical impact. Furthermore, our case findings align more closely with those reported by Kim et al. [8], particularly with regards to the association between nasopharyngeal middle turbinate and CRS.

Conclusion

To the best of our knowledge, this particular case represents the third investigation documenting the nasopharyngeal middle turbinate, and signifies for the first time ever, the occurrence of bilateral manifestation. The prevalence of this anatomical variant needs to be determined, and its association with CRS remains to be elucidated. While further work is needed, this study highlights the necessity to raise awareness among otolaryngologists regarding the necessity for thorough examination and imaging of the sinonasal cavities to enable proper diagnosis and management of this unusual anomaly at an early stage.

Patient consent

Verbal and written informed consent were obtained from the patient for publication of this report and accompanying images.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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