The Laryngoscope

C 2014 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Inferior Turbinate Classification System, Grades 1 to 4: Development

and Validation Study

Macario Camacho, MD; Soroush Zaghi, MD; Victor Certal, MD; Jose Abdullatif, MD; Casey Means, MD;
Jason Acevedo, MD; Stanley Liu, MD, DDS; Scott E. Brietzke, MD, MPH; Clete A. Kushida, MD, PhD;
Robson Capasso, MD

Objectives/Hypothesis: To develop a validated inferior turbinate grading scale.

Study Design: Development and validation study.
Methods: Phase 1 development (alpha test) consisted of a proposal of 10 different inferior turbinate grading scales
(>1,000 clinic patients). Phase 2 validation (beta test) utilized 10 providers grading 27 standardized endoscopic photos of
inferior turbinates using two different classification systems. Phase 3 validation (pilot study) consisted of 100 live consecutive
clinic patients (n 5 200 inferior turbinates) who were each prospectively graded by 18 different combinations of two inde-
pendent raters, and grading was repeated by each of the same two raters, two separate times for each patient.
Results: In the development phase, 25% (grades 1–4) and 33% (grades 1–4) were the most useful systems. In the vali-
dation phase, the 25% classification system was found to be the best balance between potential clinical utility and ability to
grade; the photo grading demonstrated a Cohen’s kappa (j) 5 0.4671 6 0.0082 (moderate inter-rater agreement). Live-patient
grading with the 25% classification system demonstrated an overall inter-rater reliability of 71.5% (95% confidence interval
[CI]: 64.8–77.3), with overall substantial agreement (j 5 0.704 6 0.028). Intrarater reliability was 91.5% (95% CI: 88.7–94.3).
Distribution for the 200 inferior turbinates was as follows: 25% quartile 5 grade 1, 50% quartile (median) 5 grade 2, 75%
quartile 5 grade 3, and 90% quartile 5 grade 4. Mean turbinate size was 2.22 (95% CI: 2.07-2.34; standard deviation 1.02).
Categorical j was as follows: grade 1, 0.8541 6 0.0289; grade 2, 0.7310 6 0.0289; grade 3, 0.6997 6 0.0289, and grade 4,
0.7760 6 0.0289.
Conclusions: The 25% (grades 1–4) inferior turbinate classification system is a validated grading scale with high intra-
rater and inter-rater reliability. This system can facilitate future research by tracking the effect of interventions on inferior
turbinates.
Key Words: Turbinates, classification, nose, validation, hypertrophy.
Level of Evidence: 2c
Laryngoscope, 125:296–302, 2015

INTRODUCTION tion, grade 3 was complete occlusion of the nasal cavity,

An objective, validated classification system for cat-
egorizing inferior turbinate sizes is lacking. Two studies
have previously categorized inferior turbinate size in
live patients,1,2 and one study categorized inferior turbi-
nate size based on computed tomography (CT) imaging.3
Friedman et al. reported on submucous resection results
and categorized inferior turbinates as grades 1 to 3
(grade 1 was mild enlargement with no obvious obstruc-
and grade 2 was in between).1 Leitzen et al. graded sev-
eral nasal anatomical variables to correlate them to
obstructive sleep apnea (OSA) and rated inferior turbi-
nate hypertrophy as normal, mild, moderate, or severe
(0, 1, 2, and 3, respectively).2 The CT scan study by
Uzun et al. categorized inferior turbinates as being
lamellar (type 1), bone with compact (type 2), combined
(type 3), and bullous (type 4).3 To our knowledge,

From the Department of Psychiatry, Sleep Medicine Division
(M.C.), Stanford Outpatient Medical Center, Redwood City, California,
U.S.A; Department of Head and Neck Surgery (S.Z.), University of Cali-
fornia, Los Angeles, California; Department of Otorhinolaryngology
(V.C.), Hospital Lusıadas, Porto, Portugal; CINTESIS–Center for
Research in Health Technologies and Information Systems (V.C.), Univer-
sity of Porto, Porto, Portugal; Department of Otorhinolaryngology (J.A.),
Hospital Bernardino Rivadavia, Buenos Aires, Argentina; Stanford
School of Medicine (C.M.), Stanford, California; Reynolds Army Commu-
nity Hospital (J.A.), Fort Sill, Oklahoma, U.S.A; Department of Otolaryn-
gology–Head and Neck Surgery, Sleep Surgery Division (S.L.), Stanford
University Medical Center, Stanford, California, U.S.A; Department of
Otolaryngology–Head and Neck Surgery (S.E.B.), Walter Reed National
Military Medical Center, Bethesda, Maryland, U.S.A; Department of
Psychiatry, Division of Sleep Medicine (C.A.K.), Stanford Hospital and
Clinics, Redwood City, California, U.S.A; and the Department of Otolar-
yngology–Head and Neck Surgery, Sleep Surgery Division (R.C.), Stan-
ford University Medical Center, Stanford, California, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
August 18, 2014.
This work was performed at Stanford Hospitals and Clinics, Stan-
ford, California, U.S.A.
The views herein are the private views of the authors and do not
reflect the official views of the Department of the Army or the Depart-
ment of Defense.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Macario Camacho, MD, US Army Major,
MC, Department of Psychiatry, Sleep Medicine Division, Stanford Outpa-
tient Medical Center, 2nd Floor, Stanford Hospital and Clinics, 450
Broadway St., Redwood City, CA 94063.
E-mail: drcamachoent@yahoo.com
DOI: 10.1002/lary.24923

Laryngoscope 125: February 2015 Camacho et al.: Inferior Turbinate Classification System
296
Fig. 1. (A) Horizontal percentage of airway space was determined by estimating the percentage of distance the anterior aspect of the infe-
rior turbinate occupied in the lateral to medial dimension. (B) Total percentage of airway space was estimated by the space occupied by
the anterior aspect of the inferior turbinate relative to the total space available at the same anteroposterior location in the nasal cavity.
(C) An example of a nasal septal deviation, in which the inferior turbinate grading would be a grade 4 with the horizontal airway space and
a grade 2 based on total percentage of airway space. A 5 airway, T 5 turbinate.
however, a standardized classification system for grading
inferior turbinates with validation testing has not been
published.
Enlargement of the inferior turbinates (inferior tur-
binate hypertrophy) can contribute to or cause symp-
toms of nasal airway obstruction. Several studies have
demonstrated that inferior turbinate reduction (in symp-
tomatic patients with hypertrophy) significantly
decreases nasal obstruction.4–10 The purpose of this
study was to develop and validate an objective and reli-
able classification system for grading inferior turbinate
sizes for use in clinical practice or research purposes.
Other classification systems in the head and neck use 1
to 4 (tongue position)11,12 and 0 to 4 (tonsils and
adenoids)11,13,14 grading scales. Therefore, during the
development we explored several possible classification
systems to determine which system provides the best
balance between the ability for providers to grade reli-
ably and the potential for use in both clinical and
research settings.
MATERIALS AND METHODS
The study was conducted over a 10-month period as a
prospective clinical assessment of potential inferior turbinate
classification systems. We reviewed several previously pub-
lished studies reporting grading scales,13,15,16 classification
systems,11,14,17 and the study by Stewart et al., in which the
Nasal Obstruction Symptom Evaluation (NOSE) Scale was
developed and validated18; relevant components from these
studies were used to plan and develop our study. This inferior
turbinate study was divided into three phases: 1) development:
alpha-testing in a live clinical setting, 2) validation: beta-
testing using standardized photographs, and 3) validation:
pilot testing in a live clinical setting. This study was approved
by the institutional review board at Stanford Hospital and
Clinics prior to initiation (protocols: 26191, 28623, and 29938).
Laryngoscope 125: February 2015
Written permission was obtained on June 25, 2013 to proceed
with this study.
Phase 1
During the development phase, the inferior turbinates of
patients from the Stanford Sleep Medicine Division clinic and
the Stanford Sleep Surgery Division clinic from July 1, 2013 to
February 27, 2014 were evaluated with either anterior rhinos-
copy or nasal endoscopy. Multiple providers participated in the
alpha testing of 10 different inferior turbinate classification sys-
tems. Classification systems tested included two major types of
grading scales, the first being the horizontal percentage of air-
way space and the second being total percentage of airway
space. When evaluating the inferior turbinates, the potential
grading systems were developed based on the views obtained
from either nasal endoscopy or anterior rhinoscopy (with a
nasal speculum or a handheld otoscope). The horizontal per-
centage of airway space was graded by estimating the percent-
age of space that the anterior aspect of the inferior turbinate
occupies relative to the horizontal space available (lateral
border 5 lateral-most aspect of the turbinate that can be seen
from anteriorly and medial border 5 nasal septum) (Fig. 1A).
The total percentage of airway space was graded by estimating
the space occupied by the anterior aspect of the inferior turbi-
nate relative to the total space available at the same anteropos-
terior location in the nasal cavity (superior border 5 the most
superior aspect of the anterior end of the inferior turbinate that
can be seen from anterior view, inferior border 5 nasal cavity
floor, lateral border 5 the most lateral portion of the inferior
turbinate that can be seen from anterior view and medial bor-
der 5 nasal septum) (Fig. 1B). An example demonstrating the
difference between the two systems for grading in the presence
of a nasal septal deviation is demonstrated in Figure 1C.
For both major types of classification systems, five sub-
types of classification systems were tested to include: a 10%
scale (1 5 0%–10%, 2 5 11%–20%, an so on), a 20% scale
(1 5 0%–20%, 2 5 21%–40%, and so on), a 25% scale (1 5 0%–
25%, 2 5 26%–50%, 3 5 51%–75%, 4 5 76%–100%), a 33% scale
(1 5 0%–33%, 2 5 34%–66%, 3 5 67%–99, 4 5 100%), and a 50%
Camacho et al.: Inferior Turbinate Classification System
297
Fig. 2. (A) Grade 1 (0%–25% of total airway space). (B) Grade 2 (26%–50% of total airway space). (C) Grade 3 (51%–75% of total airway
space). (D) Grade 4 (76%–100% of total airway space).

scale (1 5 0%–50%, 2 5 51%–100%). Each scale was also tested
with a grade 0, with this category being reserved for completely
absent inferior turbinates.
Phase 2
After determining that the total percentage of airway
space classification system was more applicable for clinical and
research purposes because it allowed for classification despite
septal spurs and septal deviations, the consensus was that the
two subtypes of classification systems that provided the best
balance between potential clinical utility and ability to grade
were the 25% scale and 33% scale. The 10% and 20% scales
were found to be too difficult to estimate, and therefore would
be less practical for clinical or research purposes. The 50%
grading scale was too broad and provided insufficient data for
general use. One of the authors (M.C.) reviewed over 100 videos
and over 1,500 endoscopic photos of inferior turbinates. The
best 27 photos were selected based on clarity and demonstration
of superior, medial, inferior, and lateral boundaries and were
used for grading purposes.
Each of the 10 authors (one medical student, one oral sur-
geon, one adult neurologist, three otolaryngology residents, and
four otolaryngologists) independently graded the inferior turbi-
nates. The two subtypes of classification systems used were
based on the total percentage of airway space system. The 25%
grading scale included: grade 1, 0%–25%; grade 2, 26%–50%;
grade 3, 51%–75%; and grade 4, 76%–100%. The 33% grading
scale included: grade 1, 0%–33%; grade 2, 34%–66%; grade 3,
67%–99%; and grade 4, 100%. To ensure an unbiased rating,
each author rated the photos independently of one another and
also rated them on different days. The photos were viewed and
the grades were handwritten with the date and the name of the
system (either 25% or 33%) and were labeled as being the first
or second rating. Once the authors had graded all of the photos
twice, and the ratings were then entered onto an Excel (Micro-
soft Corp., Redmond, WA) spreadsheet and submitted for statis-
tical analysis by one of the authors (S.Z.). The raters were also
asked to comment on their impression of clinical and research
utility for each scale.
Phase 3
One hundred consecutive clinic patients were prospec-
tively rated from March 1 2014 to April 21, 2014 and had spe-
cific inclusion criteria: 1) adult sleep medicine clinic or sleep

Laryngoscope 125: February 2015 Camacho et al.: Inferior Turbinate Classification System
298

Fig. 3. Anterior rhinoscopy with a handheld otoscope. This
method was used for prospective clinical grading of the inferior
turbinates.
surgery clinic patients, 2) patients could provide informed con-
sent themselves, 3) there was sufficient time during the
appointment to be able to educate the patients regarding the
study and to obtain informed consent, and 4) there were at least
two medical providers available to rate the inferior turbinates
two separate times. Exclusion criteria: children (<18 years old).
Two hundred inferior turbinates were classified by using the
25%, grades 1 to 4 grading scale (Fig. 2). Every patient’s right
and left turbinates were rated four times (twice by each of two
raters). Fifteen different medical providers participated in the
clinic patient ratings. The providers’ specialties included: inter-
nal medicine, pediatric neurology, adult neurology, pediatric
pulmonology, adult pulmonology, family medicine, internal med-
icine, radiation oncology, oral surgery, otolaryngology, and a
medical student. The patients’ inferior turbinates were rated
during the clinic visit (with a common handheld otoscope, Fig.
3), with the ratings written on blank paper each time and then
placed into an opaque envelope. After both medical providers
had rated the turbinates twice (once at the beginning and once
at the end of the physical exam), the ratings were taken out of
the envelope and were documented onto the grading sheet and
the results were shown to the patients, and the figures demon-
strating the sizes were explained to them.
Statistics
Data were entered into an Excel 2013 worksheet and anal-
ysis performed using JMP 10 Pro (SAS Institute Inc., Cary,
NC). Pairwise comparisons of inter-rater reliability were deter-
mined for each pair of raters by calculating the percent overall
agreement and Cohen’s kappa (j) statistic using the JMP 10
Pro software.19 A weighted average was determined by combin-
ing all pairwise comparisons into two categories—rater 1 and
rater 2—and then calculating the Cohen j.20 Overall percent
agreement as well as the overall intrarater reliability values
were reported. Weighted j values for each category (i.e., cate-
gorical j) as well as the overall weighted j were also reported.21
Results of the j statistics were reported using the following
strength of agreement categories: poor (<0.00), slight (0.00–
0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–
0.80), and almost perfect (0.81–1.00) agreement.22
RESULTS
Phase 1
After testing the classification systems for 3
months, grade 0 was eliminated because no patient
examined to that point had complete absence of the infe-
Laryngoscope 125: February 2015
rior turbinates. After using each of the systems an addi-
tional 6 months, the major type found to be most useful,
because it allowed for grading despite septal spurs or
septal deviations, was the total percentage of airway
space classification system grades 1 to 4, with either
25% or 33% interval scales as described previously.
Phase 2
The 25% grades 1 to 4 classification system demon-
strated the best balance between potential clinical utility
and the ability of the authors to grade standardized photos
(moderate inter-rater reliability: Cohen’s
j 5 0.4671 6 0.0082). Categorical j (measurement of inter-
rater agreement for any given grade) are as follows: grade
1 5 0.5132 6 0.0140, grade 2 5 0.2274 6 0.0140, grade
3 5 0.3361 6 0.0140, and grade 4 5 0.7542 6 0.0140. For
the 33% grade 1 to 4 system, overall Cohen’s j5
0.4233 6 0.0086, and the consensus was that this classifica-
tion system had less potential for use in clinical or research
settings.
Post hoc analysis was performed by creating a
third grading scale retrospectively, by converting the
33% grade 1 to 4 scale to a 1 to 3 system by adding the
grade 4 ratings to the grade 3, thus converting the
results to a 1 to 3 system, which combined grade 3
(67%–99%) and grade 4 (100%) so that the new 33%
grade 3 was 67% to 100% (j 5 0.5405 6 0.0100). A fourth
grading scale was created by converting the 25% grades
1 to 4 system to a 50% grades 1 to 2 system by combin-
ing grades 1 to 2 and combining grades 3 to 4; there-
fore, the new 50% grade 1 is 0% to 50%, and the new
50% grade 2 is 51% to 100% (j 5 0.6207 6 0.0140. These
latter two grading systems were associated with the
lowest clinical or research utility impression among the
raters. There was consensus among the raters that the
25% grades 1 to 4 system offered the best balance
between potential clinical/research utility and inter-
rater reliability.
Phase 3
The 100 patients’ mean 6 standard deviation
(M 6 SD) for age was 50.1 6 17.2 years (range, 18–87
years), for body mass index was 30.0 6 7.4 kg/m2 (range,
18–62 kg/m2), and for the NOSE scale score was
33.3 6 24.0 (range, 0–90). Live-patient grading with the
25% (grades 1–4) classification system demonstrated an
overall inter-rater reliability of 71.5% (95% confidence
interval [CI]: 64.8–77.3), with overall substantial agree-
ment (j 5 0.704 6 0.028). Intra-rater reliability was
91.5% (95% CI: 88.7–94.3) (Fig. 4). Characteristics of the
25% classification system among the 200 inferior turbi-
nates shows the following distribution: 25% quartile 5
grade 1, 50% quartile (median) 5 grade 2, 75% quarti-
le 5 grade 3, 90% quartile 5 grade 4. Mean turbinate
size 5 2.22 (95% CI: 2.07-2.34, SD 5 1.02). For the cate-
gorical j: grade 1 5 0.8541 6 0.0289, grade
2 5 0.7310 6 0.0289, grade 3 5 0.6997 6 0.0289, and
grade 4 5 0.7760 6 0.0289 (Fig. 5). Inferior Turbinate
M 6 SD for grades based on race/ethnicity were: African
Camacho et al.: Inferior Turbinate Classification System
299

Fig. 4. Statistical attributes of the 25% (grades 1–4) inferior turbinate
classification system from the pilot study of live clinical grading
among 100 patients (n 5 200 inferior turbinates). (A) Overall inter-rater
agreement of 71.5% (95% confidence interval [CI]: 64.8–77.3). (B)
Inter-rater j testing demonstrates substantial agreement
(j 5 0.7039 6 0.028). (C) Intrarater reliability is 91.5% [95% CI: 88.7–
94.3]. (D) Categorical j scores include: grade 1, 0.8541 6 0.0289;
grade 2, 0.7310 6 0.0289; grade 3, 0.6997 6 0.0289; grade 4,
0.7760 6 0.0289; and overall 0.7661 6 0.0171.
Americans (four patients) 5 3.25 6 0.64, Asians (11
patients) 5 2.93 6 0.79, Caucasians (73 patients) 5
2.13 6 0.89, Indians (five patients) 5 2.09 6 0.73, and
Latinos (seven patients) 5 1.92 6 0.87. The inferior turbi-
nate grades 1 to 4 correlation coefficients with apnea-
hypopnea indices were 20.037, and NOSE scale scores
were 0.184.
Fig. 5. Distribution of turbinate size: 25% (grades 1–4) inferior turbinate classification system. In a pilot study among 100 sleep-medicine
and sleep-surgery patients (n 5 200 inferior turbinates), a score of grade of 1 corresponds to the 25% quartile, a score of grade 2 corre-
sponds to the 50% quartile, a score of grade 3 corresponds to the 75% quartile, and a score of grade 4 corresponds to the 90% quartile.
Std Dev 5 standard deviation; Std Err 5 standard error.
Laryngoscope 125: February 2015
300
DISCUSSION
There were four main findings from this study.
First, our study demonstrates that the 25% (grades 1–4)
inferior turbinate classification system is a validated
grading scale and can be used for rating live patients as
well as for rating endoscopic videos or photos. There was
moderate agreement for endoscopic photo grading and
substantial agreement for live patients; it is unclear
exactly why there was a difference, but we hypothesize
that it is easier to assess depth perception using a three-
dimensional view (live patients) compared to a two-
dimensional view (photos). Additionally, during the
photo grading, the raters used two different systems
(25% and 33% systems), whereas in live-patient grading
only one was used. Overall, the 25% grading scale is
easy to learn, takes only a few seconds per side, and can
be documented in the electronic medical record sepa-
rately (right and left). The fact that it is also a 25%
scale, which is similar to other head and neck classifica-
tion systems, such as the grades 1 to 4 Friedman and
Mallampati tongue positions11,12 and grades 0 to 4 for
tonsils and adenoids,11,13,14 makes it easier to remember
than using a different percentage such as 10%, 20%,
33%, or 50%. Despite the overall j scores being higher
for the post hoc-created categories of 33% (grades 1–3)
and 50% (grades 1–2), the consensus among every pro-
vider (n 5 17) using the grading scales during the devel-
opment phase was that the 25% scale was the best
balance between practicality, usefulness, and inter-rater
reliability j scores. As an extreme example, if a grades 0
to 1 scale (turbinate absent or present, respectively)
were used, then it would be expected that the j score
would be near perfect, but the classification system
would not be very clinically useful.
Second, this classification system can be used in
patients with other nasal abnormalities. During the
development phase, the consensus was that to make the
grading scale the most generalizable, the total percent-
age of airway space classification was a better choice. A
major problem with the horizontal percentage of airway
space classification system is that if there is a significant
Camacho et al.: Inferior Turbinate Classification System
spur or nasal septal deviation, in which the septum
touches the turbinate, the system would classify the tur-
binate as a grade 4 on that side (as demonstrated in Fig.
1C), even if the inferior turbinate on that side of the
nasal cavity was small and there was plenty of space
above and below the contact point. In the same scenario,
the total percentage of airway space classification could
classify the turbinate as a grade 2 on that side, by tak-
ing into account the percentage that the turbinate is
obstructing the airway space, thus making this system
more clinically useful.
Third, our pilot data among 100 patients (n 5 200
inferior turbinates) show an interesting and useful rela-
tionship between the 25% grades 1 to 4 classification
system and the distribution of inferior turbinate size
among the study sample. A grade of 1 corresponds to the
25% quartile, a grade of 2 corresponds to the 50% quar-
tile, a grade of 3 corresponds to the 75% quartile, and
grade of 4 corresponds to the 90% quartile. A major ben-
efit of this classification system is that it not only allows
a provider to objectively document and communicate the
actual size of the inferior turbinate (grade 1 5 0%–25%
of airway space, grade 2 5 26%–50%, grade 3 5 51%–
75%, grade 4 5 76%–100%), but the classification scale
also offers a measure of how any individual patient com-
pares to all others among our sample population of sleep
medicine and sleep surgery patients. A patient with a
turbinate size grade 4 has turbinates that are larger
than 90% of this clinical population, whereas a patient
with grade 2 turbinates, for example, corresponds to tur-
binates of average size.
Last, because the data presented in this study are
the preliminary results based on 100 sleep medicine and
sleep surgery patients, we caution about generalizing at
this time, and encourage other researchers to start
incorporating the system into their practices, track their
data, and publish the short- and long-term results. It
will likely take several studies over several years to
establish normative data (i.e., mean inferior turbinate
grades for patients of different ages, races, surgical can-
didates) and future systematic reviews and meta-
analyses summarizing the literature before more defini-
tive generalizations can be made. There are several
areas for future research in using this classification sys-
tem, such as inferior turbinate grade changes with: 1)
upright versus supine positions, 2) nasal cycle over 1
day versus a series of days, 3) decongestion and its role
in determining bony versus soft tissue hypertrophy, 4)
OSA and treatment with positive pressure therapy, 5)
allergic rhinitis with and without treatment, 6) different
races, ages, general population groups versus surgical
candidates, 7) sleep, and 8) medical or surgical manage-
ment in general, in both short and long term.
Limitations
We acknowledge that despite having multiple pro-
viders from several specialties and locations involved in
development of the inferior turbinate classification sys-
tem and during the rating of endoscopic photos, only the
Stanford Sleep Medicine clinic and Sleep Surgery clinic
Laryngoscope 125: February 2015
participated in the live-patient grading. To make the
system generalizable across specialties, we included both
otolaryngologists and nonotolaryngologist in the develop-
ment and validation testing (photo and live clinic rat-
ings), and only required the widely available handheld
otoscope for examination. Every patient was graded
twice, and in a manner in which raters were blinded
from each other’s ratings. After the validation phase was
completed, the inferior turbinate grading scale has been
incorporated into the nasal examination portion of the
electronic medical record. A follow-up to this article is
the results study, which involves multiple institutions,
and our goal is to publish results with detailed analyses
of preliminary findings once 500 or more patients have
been evaluated.
CONCLUSION
The 25% (grades 1–4) inferior turbinate classifica-
tion system is a validated grading scale with high intra-
rater and inter-rater reliability. This system can
facilitate future research by tracking the effect of both
medical and surgical interventions on inferior
turbinates.
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