Surgical Treatment of Concha Bullosa: A Comparison of the Short-term Results of Crushing and Lateral Laminectomy with and without Mucosal Preservation.

Pneumatized middle turbinate (Concha bullosa) is one of the commonest intranasal anatomical variants. Surgery is the effective method to control symptomatic concha bullosa, however, still no clear definition for the best surgical technique. The aim of our study to assess and compare the short-term outcomes of crushing and lateral laminectomy with and without mucosal preservation in the surgical treatment of symptomatic concha bullosa. Thirty patients who underwent concha bullosa surgery (a total of 42 conchae surgeries) were included in this prospective randomized study. Patients were allocated consecutively and equally into 3 groups: Group A (lateral laminectomy without mucosal preservation, n = 10), Group B (lateral laminectomy with mucosal preservation, n = 10) and Group C (Crushing, n = 10). Patients underwent the preoperative and postoperative visual analogue score (VAS) for nasal obstruction and headache, sinonasal outcome test-22 (SNOT-22) and olfactory detection test. All patients were arranged to postoperative reevaluation for 3 months. All groups showed strong significant improvement in VAS results, SNOT-22 and smell test between preoperative and postoperative scores (P < 0.001). There was a significant difference between the three groups only upon comparing lateral laminectomy groups with crushing group. No significant differences were detected between group A and B regarding all the evaluated variables. According to our results, lateral laminectomy was more advantageous than crushing in surgical management of concha bullosa. Moreover, lateral laminectomy without mucosal preservation was as effective as lateral laminectomy with mucosal preservation and there is no detectable difference between both techniques.

Endoscopic and Radiologic Central Compartment Disease as Predictors of Perennial Inhalant Allergen Sensitization in Chronic Rhinosinusitis.

BACKGROUND: Central compartment atopic disease (CCAD) is a recently described variant of chronic rhinosinusitis (CRS) strongly associated with atopy. The association between central compartment disease (CCD) and inhalant allergy is not well established in South-East Asia, where perennial allergic rhinitis is common. OBJECTIVES: The primary objective was to evaluate endoscopic and radiologic CCD as predictors of perennial allergen sensitization in primary CRS. The secondary objective was to compare clinical characteristics of CCAD with other CRS subtypes (CRSwNP and CRSsNP). METHODS: A retrospective study of consecutive patients with primary CRS who underwent endoscopic sinus surgery at our institution was performed. Allergen sensitization was confirmed by skin or serum testing. Endoscopy records and computed tomography scans of paranasal sinuses were reviewed for CCD. The diagnostic accuracy of endoscopic and radiologic CCD in predicting atopy was calculated. RESULTS: There were 104 patients (43 CCAD, 30 CRSwNP and 31 CRSsNP). Endoscopic CCD was significantly associated with aeroallergen sensitization (odds ratio (OR) 3.99, 95% confidence interval (CI) 1.65-9.67, P = 0.002). Endoscopic CCD predicted atopy with 57% sensitivity, 72% specificity, 69% positive predictive value and positive likelihood ratio of 2.05. Radiologic CCD was not associated with aeroallergen sensitization (OR 0.728, 95%CI 0.292-1.82, P = 0.496). There were more CCAD patients who reported hyposmia (86% vs 42%, P < 0.001) and had anosmia on olfactory testing than CRSsNP (65% vs 14%, P = 0.015). The prevalence of atopy was significantly higher in CCAD than CRSwNP and CRSsNP (70% vs 37% and 42%, P = 0.015 and P = 0.05, respectively). Median serum total immunoglobulin E was higher in CCAD (283 IU/ml) and CRSwNP (127 IU/ml) than CRSsNP (27 IU/ml, P = 0.006 and P = 0.042, respectively). CONCLUSIONS: Endoscopic CCD was a better predictor of inhalant allergy than radiologic CCD in primary CRS, in a locale of perennial allergic rhinitis.

Modified technique improves efficacy for in-office posterior nasal nerve ablation.

Objectives: Posterior nasal nerve (PNN) ablation is a minimally invasive treatment option for patients with chronic rhinitis. Recent evidence shows that parasympathetic innervation of the nasal cavity is more extensive and there are many fibers posterior to the lateral attachment of the middle turbinate. We describe a modified ablative technique that targets the extensive innervation of the posterior nasal nerves. Methods: Description of the technique and retrospective cohort analysis. In addition to the traditional radiofrequency and cryoablation targets, three additional treatment sites posterior to the middle turbinate were targeted using radiofrequency ablation, as well as one focused treatment posteroinferior to the middle turbinate attachment using cryotherapy ablation. The primary outcome collected was a 30% improvement in overall rhinitis symptoms. Results: Forty-five patients received treatment and completed 3-month follow-up using the modified technique for radiofrequency and cryotherapy PNN ablation. Previously, our institution documented a 64.5% responder rate at 3 months. After introducing the modified technique, the response rate at 3 months significantly improved (64.5% vs. 91.1%, p = .004). Conclusions: This report suggests improved efficacy with implementation of the modified technique for in-office PNN ablation. Given the extensive nature of the post-ganglionic parasympathetic fibers of the nasal cavity which often emerge posterior to the middle turbinate attachment, a modified technique to target these branches should be considered. Prospective randomized studies comparing this modified technique to the traditional technique are needed. Level of Evidence: III.

[Intraosseous cavernous hemangioma of the middle turbinate. Clinical cases]. / Vnutrikostnaya kavernoznaya gemangioma srednei nosovoi rakoviny. Klinicheskie sluchai.

Intraosseous vascular pathology of the turbinates is extremely rare in the practice of an otorhinolaryngologist and can be presented in various histopathological variants. The article presents two clinical cases in which an intraosseous cavernous hemangioma was hidden under the mask of a hypertrophied middle turbinate. The final diagnosis was established by the results of histological examination. The analysis of these clinical cases indicates that, despite the low prevalence, atypical clinical and CT picture, intraosseous formations of the nasal cavity can be of a vascular nature and certainly require a comprehensive examination, including CT, CT with contrast and/or MRI of the nose and paranasal sinuses. These clinical observations indicate that preliminary embolization of feeding vessels before surgical treatment is not required.

Multiple coexisting variations of skull and cervical spine anatomy in a symptomatic patient - uncommon or uncommonly noticed? A CT-based case study.

INTRODUCTION: Among many anatomical variations of the skull and cervical spine, some may be an underlying cause of a disease, while others remain clinically silent. The estimated individual prevalences of them differ, but given the available data it is impossible to clarify how frequently they coexist with each other. The following study presents an example of seven anomalies, amongst which at least few have manifested clinically in the examined patient. CASE REPORT: A 35 y.o. Polish woman who suffered from chronic sinusitis was subjected to a computed tomography scan. Mild thickening of the anterior ethmoidal cells' mucosa, bilateral concha bullosa, paradoxical right middle turbinate, bilateral uncinate process pneumatization and arrested pneumatization of sphenoid sinus were found and addressed in context of the reported symptoms. Simultaneously other, clinically silent anatomical anomalies, were found - namely ossification of the anterior petroclinoid ligament, incomplete medial basal canal and bilateral arcuate foramen. CONCLUSION: To the best knowledge of the authors, this case report is the first to present such a coexistence of this many various anatomical anomalies, among which some played a crucial part in the chronic sinusitis experienced by the patient. Concurrence of multiple variations in the same anatomical area or functional unit may exacerbate clinical presentation of a patient. Identifying a single anomaly ought to warrant a thorough investigation into any other potentially existing variants.

Anatomic Relationship Between the Head of the Middle Turbinate and First Olfactory Filum: A Radiographic Assessment.

BACKGROUND: The endoscopic modified Lothrop procedure (EMLP) has become a frequently utilized procedure in rhinologic surgery. One of the most serious complications of the procedure is cerebrospinal fluid leak, which may occur due to lack of recognition of the anterior skull base in the region of the first olfactory filum (FOF), or direct injury to the FOF itself. OBJECTIVES: To evaluate the position of the head of the middle turbinate (MT) relative to the FOF, which is an important landmark in the EMLP. METHODS: A series of previously obtained patient computed tomography scans of the sinus were reviewed. A reproducible process was implemented to obtain the measurements. First, the FOF was identified on an axial series. Using a localization feature of the radiographic software, this anteroposterior (AP) position could be visualized in a coronal plane. Subsequently, the MT was viewed in a sagittal plane, where a measurement between the head of the MT and the AP position of the FOF could be performed. RESULTS: The AP distance between the head of the MT and the FOF was measured in 92 patients. The head of the MT was either at or anterior to the FOF in all measured subjects. The mean anterior distance of the head of the MT to FOF was 3.6 mm (±2.4 mm) on the right, and 3.8 mm (±2.2 mm) on the left. The range in AP distance was 0 to 12 mm. There was no significant difference in AP distance between the head of the MT and FOF based on gender (P = .413) or diagnosis (P = .254). CONCLUSIONS: In our study, the head of the MT was reliably at or anterior to the FOF in all subjects, suggesting its utility as a fixed landmark in endoscopic sinus surgery, particularly in the EMLP. LEVEL OF EVIDENCE: N/A.

A novel technique with butterfly splint for middle turbinate stabilization in sinus surgery.

OBJECTIVE: To assess the efficacy of newly designed butterfly splint with special technique for middle turbinate stabilization in preventing adhesion following bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP). STUDY DESIGN: Prospective, double-blind, randomized controlled. SETTING: University hospitals. METHODS: Following ESS, in cases of traumatized and/or unstable middle turbinates, newly designed butterfly plastic splint was randomly inserted in the middle meatus of one nasal side, while no splint was inserted in the other (control). Patients were followed up on after 1 week, 1 month, and 6 months. Endoscopic examination and a visual analog scale were used to evaluate each side of the nasal cavity for adhesion, crusting, pus, pain, nasal obstruction, and nasal discharge. RESULTS: Thirty patients (60 nasal sides) were included. For all investigated parameters, there was no significant difference between the splinted and non-splinted sides at the first week visit. Adhesion was found significantly less in the splinted sides (3%) than the non-splinted sides (27%) after 1 month (P = 0.038). The adhesion rate in the splinted sides remained 3% at the 3 month follow-up visit, however, in the non-splinted sides, the rate increased up to 30% (P = 0.007). Throughout the follow-up visits, all other investigated parameters remained statistically insignificant between both sides. CONCLUSIONS: The newly designed butterfly plastic splints to avoid middle turbinate adhesion is safe and effective in both reducing middle meatal adhesion with low complication rate in CRSwNP patients undergoing ESS and middle turbinate stabilization in its intermediate position.

Nasal obstruction in a 14 year old girl caused by a huge middle turbinate mucocele appearing radiologically as an inverted papilloma.

Introduction: We present a case of a fourteen year old girl who presented with a large intra-nasal mass to the ENT team at a district general hospital in the UK. Presentation of case: The girl presented predominantly with nasal obstruction and some symptoms of allergic rhinitis. Imaging revealed a large lesion abutting the skull base and causing bony remodelling with marked septal deviation. Based both on CT and MRI imaging, the reporting (non-head and neck) radiologist suggested inverted papilloma as a differential diagnosis. Intra-operative exploration in fact revealed a very large left middle turbinate mucocele extending to the left frontal sinus. The mass was excised endoscopically without complications. Discussion: Although concha bullosa of the middle turbinate of the nose are common, development of a mucocele within them is far less common and for such a mucocele to develop to this size in a child is extremely rare. The egg shell lining of the lesion can be a tell-tale sign of their aetiology when taken alongside other radiological factors. This case highlights challenges in radiological diagnosis of intra-nasal masses in children, which can lead to delays and increased anxiety. Conclusion: When assessing nasal masses in children it is important to keep a wide differential due to the challenges of diagnosis. A close conversation should be had with local head and neck radiologists and, of course, where there is a unilateral nasal mass tissue sampling is essential and may be taken as part of a full excision where clinically indicated.

Cultured Mesenchymal Cells from Nasal Turbinate as a Cellular Model of the Neurodevelopmental Component of Schizophrenia Etiology.

The study of neurodevelopmental molecular mechanisms in schizophrenia requires the development of adequate biological models such as patient-derived cells and their derivatives. We previously utilized cell lines with neural progenitor properties (CNON) derived from the superior or middle turbinates of patients with schizophrenia and control groups to study schizophrenia-specific gene expression. In this study, we analyzed single-cell RNA seq data from two CNON cell lines (one derived from an individual with schizophrenia (SCZ) and the other from a control group) and two biopsy samples from the middle turbinate (MT) (also from an individual with SCZ and a control). We compared our data with previously published data regarding the olfactory neuroepithelium and demonstrated that CNON originated from a single cell type present both in middle turbinate and the olfactory neuroepithelium and expressed in multiple markers of mesenchymal cells. To define the relatedness of CNON to the developing human brain, we also compared CNON datasets with scRNA-seq data derived from an embryonic brain and found that the expression profile of the CNON closely matched the expression profile one of the cell types in the embryonic brain. Finally, we evaluated the differences between SCZ and control samples to assess the utility and potential benefits of using CNON single-cell RNA seq to study the etiology of schizophrenia.

Giant concha bullosa presented as left nasal mass: a case report and literature review.

Concha bullosa (CB) is not considered to be a disease, but rather a variation of the paranasal sinus. A CB is defined as the presence of an air cell within the turbinate (pneumatization). The main function of CB is to maintain upper respiratory humidity, regulate thermoregulation, and regulate airflow and filtration. It is common for CB to occur in the middle turbinate, while superior and inferior locations appear to be rare. The patient in this case report was presented mainly with nasal obstruction. During examination, a large mass was found in the left nasal cavity, causing a deviated nasal septum to the right. For this patient, surgery was the last resort. Either perioperative or postoperative complications were observed, and the quality of life of patients improved after surgery.

Superiorly Based Middle Turbinate Flap for Repair of Cerebrospinal Fluid Rhinorrhea: A Cadaveric Feasibility Study and Case Series.

Objectives Cerebrospinal fluid (CSF) leaks of the anterior cranial base are frequently repaired with endonasal, multilayered reconstructions. Vascularized tissue flaps are superior to free mucosal grafts and biomaterials in many cases. Limitations of previously described flaps include reach, rotation, pedicle availability, and postoperative sinonasal morbidity. The objective of this study is to describe the superiorly based middle turbinate flap, a novel vascularized mucosal reconstruction option, and to present a case series demonstrating flap utility. Design Cadaveric feasibility study with technical description and illustrative case series. Setting Tertiary medical center. Participants Three silicone-injected cadaveric specimens (6 sides); 7 patients with CSF rhinorrhea from bony dehiscence of the anterior cranial fossa repaired with a superiorly based middle turbinate flap. Outcome Measures Cadaveric feasibility, in vivo repair outcomes, sinonasal symptoms, and postoperative healing. Results Cadaveric dissection demonstrated a consistent vascular plexus arising from the anterior and posterior ethmoid arteries, originating at the superior attachment of the middle turbinate and traveling inferiorly to supply the mucosa of the middle turbinate. Mean surface area of the flap was 776.67 ± 114.60 mm 2 . The clinical series of 7 patients involved leaks around the cribriform plate and fovea ethmoidalis. There were no instances of repair failure. All cases showed rapid and complete remucosalization without significant sinonasal morbidity. Conclusion The superiorly based middle turbinate flap is a reliable, versatile, and effective option for a vascularized mucosal flap onlay that can be used in anterior skull base reconstruction. This flap is particularly useful in the repair of defects involving the cribriform plate and fovea ethmoidalis.

Bilateral enlarged concha bullosa: a case report and literature review.

Concha Bullosa (CB) is a common sinonasal anatomical variant, which commonly extends into the middle turbinate. Generally, patients presenting with CB are asymptomatic and often incidentally diagnosed with a non-contrast computed tomography scan of the paranasal sinuses. In cases of extensive pneumatization, large CB may cause significant signs and symptoms-commonly, headaches, nasal obstruction, and hyposmia. With only a few reported cases of large CB in the literature; we herein, report a rare case of an unusually massive bilateral CB that resulted in complete obstruction of the left nasal cavity and partial obstruction of the right nasal cavity, in addition to a review of relevant literature.

Current practices regarding middle turbinate resection among otolaryngologists.

Objectives: Resection of the middle turbinate (MT) during endoscopic sinus surgery (ESS) has been a controversial topic among otolaryngologists for many years. Some studies advocate resection and have shown improved outcomes postoperatively, while studies favoring preservation show a decreased incidence of postoperative complications. The current practice pattern regarding this subject is unknown. The goal of this study was to learn the current practice of MT resection during ESS among otolaryngologists. Method: We performed an electronic anonymous survey of practicing otolaryngologists. Results: We found that the majority of the 252 responders stated that they will perform an MT resection in certain clinical situations, while there is a small subset that advocates never resecting the MT for inflammatory sinus disease (n = 6, 2.4%). Participants were significantly more likely to perform MT resection in patients undergoing revision compared to primary ESS for all conditions included. The complication of greatest concern among participants was iatrogenic frontal sinus obstruction, while empty nose was of the least concern. The majority of participants responded that MT resection was of extreme or moderate benefit for improved visualization and drug delivery postoperatively. When compared to general otolaryngologists, fellowship-trained rhinologists were less concerned about potential complications following MT resection and were more likely to perceive an extreme or moderate benefit from turbinate resection postoperatively. Conclusion: There remains debate over MT resection among otolaryngologists, but the results of this study show that the majority of participating otolaryngologists will perform a resection in certain clinical situations.

The Transverse Turbinate Line: A Reliable Landmark for the Maxillary Sinus Natural Ostium.

OBJECTIVES: Approximating the maxillary sinus natural ostium's (MSNO) natural position during anterograde surgery is challenging, as only a single visual "landmark," the maxillary line, is routinely offered to guide the identification of the MSNO in three-dimensional space. Despite almost 40 years of endoscopic sinus surgery (ESS) experience in North America, maxillary recirculation and discontinuity between the natural and surgical ostia are commonly encountered during revision ESS. Consequently, we feel an additional visual landmark would assist in localizing the MSNO with or without image guidance. In this study, we aim to provide a second reliable landmark in the sinonasal cavity. METHODS: We present a cadaveric anatomical landmark series that provides a second visual landmark for the MSNO, which we have labeled the transverse turbinate line (TTL): a 2-millimeter zone of confidence for the craniocaudal positioning of the MSNO that can be combined with the anteroposterior (AP) landmark of the maxillary line. RESULTS: In our study, 40 cadaveric sinuses were dissected, and the TTL was found to correspond consistently with the zone between the superior and inferior aspects of the MSNO. CONCLUSION: We anticipate that this second relational landmark may decrease the time required for anterograde access to the MSNO in trainees, increase the accuracy of identification, and translate to lower long-term recirculation and maxillary surgery failure rates. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3285-3291, 2023.

Cultured Mesenchymal Cells from Nasal Turbinate as a Cellular Model of the Neurodevelopmental Component of Schizophrenia Etiology.

Study of the neurodevelopmental molecular mechanisms of schizophrenia requires the development of adequate biological models such as patient-derived cells and their derivatives. We previously used cell lines with neural progenitor properties (CNON) derived from superior or middle turbinates of patients with schizophrenia and control groups to study gene expression specific to schizophrenia. In this study, we compared single cell-RNA seq data from two CNON cell lines, one derived from an individual with schizophrenia (SCZ) and the other from a control group, with two biopsy samples from the middle turbinate (MT), also from an individual with SCZ and a control. In addition, we compared our data with previously published data from olfactory neuroepithelium (1). Our data demonstrated that CNON originated from a single cell type which is present both in middle turbinate and olfactory neuroepithelium. CNON express multiple markers of mesenchymal cells. In order to define relatedness of CNON to the developing human brain, we also compared CNON datasets with scRNA-seq data of embryonic brain (2) and found that the expression profile of CNON very closely matched one of the cell types in the embryonic brain. Finally, we evaluated differences between SCZ and control samples to assess usability and potential benefits of using single cell RNA-seq of CNON to study etiology of schizophrenia.

[Atypical presentation of a polyp of Killian]. / Cas clinique. Présentation atypique d'un polype de Killian.

The antrochoanal polyp or polyp of Killian is a benign nasal tumour that arises from the maxillary sinus. The polyp originating from the middle turbinate is an entity rarely described in the literature. We report here a rare case of Killian polyp originating from the middle turbinate which was explored by computed tomography and magnetic resonance imaging of the facial bone. The polyp was removed by an endoscopic surgical technique. The extraction was made from the oropharynx. Preoperative recognition of these anatomical variations is particularly important to avoid intraoperative surprises.

Le polype antro-choanal ou polype de Killian est une tumeur bénigne naso-sinusienne qui prend naissance au niveau du sinus maxillaire. Le polype provenant du cornet moyen est une entité rarement décrite dans la littérature. Nous rapportons ici un cas rare de polype choanal provenant du cornet moyen qui a été exploré par tomodensitométrie et par résonance magnétique du massif facial. Le polype été retiré par une technique de chirurgie endoscopique. L'extraction a été réalisée à partir de l'oropharynx. La reconnaissance préopératoire de ces variations anatomiques est particulièrement importante pour éviter les surprises peropératoires.

Anatomical landmarks for localisation of the anterior ethmoidal artery: a combined radiological and cadaveric (endoscopic) study.

PURPOSE: The anterior ethmoidal artery is a major surgical landmark that is susceptible to iatrogenic injury during surgery of the anterior ethmoidal sinus, frontal sinus, and skull base. The present study aimed to define the location of the anterior ethmoidal artery in relation to specific anatomical landmarks using radiological imaging and endoscopic dissection. METHODS: Eighty-six anterior ethmoidal arteries were assessed using computed tomography scans (bilateral analyses) and forty anterior ethmoidal arteries were assessed using cadaveric specimens (bilateral analyses). The skull base, anterior nasal spine, anterior axilla of the middle turbinate, and nasal axilla were morphometrically analysed to determine their reliability as anterior ethmoidal artery landmarks. RESULTS: Distances to the skull base, anterior nasal spine, and nasal axilla displayed statistically significant differences between sexes and sides (p < 0.05). All landmarks demonstrated excellent reliability as anatomical landmarks for the localisation of the anterior ethmoidal artery, radiologically and endoscopically (ICC values ranged from 0.94 to 0.99). CONCLUSION: The middle turbinate axilla was the most reliable landmark, due to the lack of statistically significant differences according to sex and laterality, and the high inter-rater agreement between measurements. Anatomical knowledge of variations and relationships observed in the present study can be applied to surgeries of the anterior ethmoidal sinus, frontal sinus, and skull base to improve localisation of the anterior ethmoidal artery, preoperatively and intraoperatively, and avoid iatrogenic injury of the vessel.

Bacterial colonization differences between central compartment atopic disease and eosinophilic chronic rhinosinusitis.

KEY POINTS: Culturable bacterial colonization is similar between type 2 CRS phenotypes Staphylococcus aureus coinfection is similar between eosinophilic CRS and CCAD Patients with CCAD were younger, consistent with current knowledge of the disease.

Preservation versus resection of middle turbinate in endoscopic transnasal transsphenoidal pituitary surgery.

BACKGROUND: The strategic position of the middle turbinate (MT) within the nasal cavity makes it the first kick start to resect pituitary pathology through Endoscopic Transnasal Transsphenoidal Surgery (ETTS). This research aimed to determine if the type of endonasal endoscopic approach, MT resection (MTres) versus MT preservation (MTpre), for pituitary surgery affects olfaction and sinonasal function within a subjective as well as objective manner. PATIENTS & METHODS: A prospective cohort comparative study was conducted to compare the sinonasal and olfaction outcomes pre and post operatively for both groups. Sinonasal symptoms were evaluated subjectively by Sino-Nasal Outcome Test (SNOT-22), while objectively by Peri-Operative Sinus Endoscope Score (POSE) along with Lund-Mackay radiological scoring system (LMS), and a Sniffin Sticks Identification test (SIT) (Burghart, Germany) was used to measure the olfaction intensity. In both groups were used on a pre-operative period and after one, three, and six months post operatively. RESULTS: 96 patients were recruited within predetermined criteria. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively. The average change in score (delta) was an increase of 0.3, with changes ranging from -3 to +4. There was no significant difference in sinonasal symptoms score among both groups, with ρ 0.07 posts operatively. There was a minor upsurge in POSE score and LMS in the preservation group but without remarkable differences with ρ value 0.1 and 0.2 subsequently. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively. CONCLUSION: Despite these amendments to the nasal cavity, we approved that these changes do not affect the sinonasal functions.

Endoscopic appearance of duplicated middle turbinate, case series and literature review.

INTRODUCTION AND IMPORTANCE: Duplication of the middle turbinate is an extremely rare condition encountered in rhinology clinic. Knowledge and awareness of the nasal turbinates' variations are important to perform a safe endoscopic surgery and evaluate patients with inflammatory sinus diseases. CASE PRESENTATION: Case series of two patients who visited rhinology clinic in academic university hospital. Case 1: presented with 6-month history of nasal blockage. Nasal endoscopy revealed bilateral duplication of the middle nasal turbinates. Computed tomography scans showed bilateral medially curved and anteriorly folded uncinate process, and right middle turbinate concha bullosa and its superior end of the middle turbinate was turned medially. Case 2: A 29-year-old gentleman presented with nasal obstruction mainly to the left side for several years. Nasal endoscopy showed bifid right middle turbinate and severe deviated nasal septum to the left. Upon imaging, a sinus computed tomography scan demonstrated a duplication of the right middle turbinates in the form of two middle nasal concha. CLINICAL DISCUSSION: Different rare anatomical variations can occur at different points during the embryological development. These rare variations include double middle turbinate, accessory middle turbinate, secondary middle turbinate, and bifid inferior turbinate. The appearance of double middle turbinate can be encountered in rhinology clinic only 2 % of the time. Upon reviewing the literature, only few case reports were found regarding the double middle turbinate. CONCLUSION: A double middle turbinate has important clinical implications. Anatomical variation may lead to narrowing in the middle meatus which makes the patient vulnerable to sinusitis or maybe associated with secondary symptoms. We report rare cases of middle turbinate duplication. Awareness of the nasal turbinates' variations is important for detection and management of inflammatory sinus diseases. Further studies are needed to identify the association of other pathology.