The “Quadra-Bullosa”: A Novel Case of Quadruple Septated Concha Bullosa

A 69-year-old gentleman presented with chronic nasal congestion and recurrent sinus infections. Physical examination was notable for a leftward septal deviation and moderate inferior turbinate hypertrophy. Nasal endoscopy did not reveal polyps, purulence, or significant middle meatal edema. After a period of conservative treatment with daily nasal steroid spray and sinus rinses, he underwent imaging for persistent symptoms. A computed tomography scan demonstrated ostiomeatal obstruction, septal deviation, and bilateral concha bullosa (CB) of both the middle and superior turbinates. The CB of the left middle turbinate was especially unique given the 4 separate septations (Figure 1A and B).

Figure 1.

A, Coronal computed tomography (CT) demonstrates 4 separate air spaces within a left middle turbinate. B, Sagittal view depicts air spaces (white circles) within both the lamellar and bulbar portions of the middle turbinate.

When the middle turbinate becomes pneumatized, it forms a pocket of air referred to as a CB. Concha bullosa is an anatomical variant with an incidence ranging from 14% to 53%. ¹ Reported implications include nasal septal deviation, obstruction, chronic sinusitis, and headache. ² A classification scheme of CB based on the location of the air spaces includes lamellar (vertical lamellar pneumatization), bulbar (inferior bulbar pneumatization), and extensive (both lamellar and bulbar portions) types. ³ Bulbar and extensive types are more commonly associated with sinonasal pathology. ⁴

Very rarely, septations of the CB occur when the airspace is divided into distinct cavities. Cases of CB with multiple distinct air cells within the turbinate are infrequently seen and only double and triple septations have been reported. ^{4 -7} This is the first case of a quadruple septated CB. Although the etiology, function, and complications of septated CB remain unknown, an awareness of the varying pneumatization patterns can help guide treatment.