Personalized Selection of Inferior Turbinate Surgery Based on Structural Phenotyping: A Structured Narrative Review and Proposed Decision-Making Framework

Background: Inferior turbinate hypertrophy is a major cause of chronic nasal obstruction and can be treated with several surgical techniques. However, current surgical decision-making is often not personalized to the dominant anatomical and functional substrate of obstruction. No widely adopted structural classification of the inferior turbinate exists, and no standardized algorithm links individual anatomical phenotypes to targeted surgical strategies. Methods: A structured narrative review of PubMed and Scopus was performed from database inception to 1 February 2026, using predefined search terms and eligibility criteria. Studies were selected if they addressed inferior turbinate anatomy, histopathology, imaging morphology, endoscopic grading, nasal valve or septal anatomy, surgical techniques, postoperative outcomes, complications, or patient-reported outcomes. Randomized and prospective trials, histopathological studies, CT morphometric analyses, and validated endoscopic grading systems were considered. Four phenotypes of inferior turbinate hypertrophy were identified and linked to preferred surgical options within a clinically oriented decision algorithm integrating endoscopy, functional testing, and selective CT imaging. This framework was developed to support individualized treatment planning and shared decision-making. Results: Four structural phenotypes were defined: (i) predominantly cavernous/mucosal hypertrophy; (ii) predominantly bony hypertrophy; (iii) anterior nasal valve-turbinate conflict; and (iv) mixed hypertrophy. For mucosal-dominant disease, radiofrequency ablation and laser turbinoplasty are preferred first-line, mucosa-preserving options. For bony hypertrophy, mucosa-preserving powered inferior turbinoplasty is favored for the mid/posterior turbinate, whereas endoscopic pyriform aperture turbinoplasty is preferred for anterior valve-level conflict. Mixed phenotypes are best managed with combined skeletal and mucosal procedures. The algorithm aims to avoid mismatched treatments, such as mucosal-only techniques for rigid bony hypertrophy or extensive skeletal reduction in purely mucosal disease. Perioperative variables relevant to shared decision-making, including type of anesthesia, postoperative morbidity, recovery profile, and expected limitations, were summarized for each technique. Conclusions: This phenotype-guided algorithm provides a structured, evidence-informed framework for the personalized selection of inferior turbinate surgery, emphasizing mucosal preservation, anatomical specificity, patient-centered decision-making, and avoidance of mismatched procedures. It is intended to support, not replace, clinical judgment and to guide future prospective validation studies in personalized rhinologic surgery.