|Ahead of print publication
Decision-making in septal deviations: Septoplasty for anterior septal deviations and submucosal resection for posterior deviations: Is it a practical method?
Rathod Sunil Kumar, Harish Swamy Dharmagadda, Kathyayani Burugula
Department of ENT, Government Medical College, and General Hospital, Nizamabad, Telangana, India
|Date of Submission||20-Dec-2021|
|Date of Acceptance||12-Mar-2022|
|Date of Web Publication||23-Sep-2022|
Department of ENT, Government Medical College, and General Hospital, Nizamabad, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: Classification of septal deviations is varied, but their application in selecting the type of septal surgery is not decisive. Classifying the septal deviations and using it to decide the choice of surgery was reviewed. The aim of the study is to review the use of classification of septal deviations into anterior and posterior to select septoplasty and submucosal resection (SMR), respectively. Materials and Methods: Thirty-four patients with anterior deviated nasal septum were grouped as Group A. Another 34 patients with posterior septal deviation were grouped as Group B. In Group A, patients were aged between 18 years and 47 years with a mean age of 34.28 ± 2.30 years. In Group B, they were aged between 19 and 48 years, with a mean age of 35.25 ± 3.05 years. The male-to-female ratio of the total 68 patients was 1.4:1. Nasal obstruction symptom evaluation (NOSE) score Grade 4 and 5 was noted in 31 (45.48%) patients in Group A and 33 (48.52%) patients in Group B. Right side deviation was noted in 15 (22.05%) of the Group A patients and 20 (29.41%) of the Group B patients. Results: All patients with anterior deviation were subjected to septoplasty, and patients with posterior deviation were subjected to classical SMR surgery. The results were assessed and analysed using the response of recovery in the nasal obstruction NOSE score and the two groups were correlated using Pearson's Correlation coefficient calculator. The R score was 0.9942, and the P value was 0.0001 (P taken as significant at < 0.05). Conclusion: It was observed by the results that deciding the type of surgery as per the direct nasal endoscopy findings whether it was anterior or posterior deviation was easy, practical, and definite final outcome results could be expected at the end.
Keywords: Cartilaginous septum, nasal septum, osseous septum, septoplasty and submucosal resection
|How to cite this URL:|
Kumar RS, Dharmagadda HS, Burugula K. Decision-making in septal deviations: Septoplasty for anterior septal deviations and submucosal resection for posterior deviations: Is it a practical method?. Adv Hum Biol [Epub ahead of print] [cited 2022 Sep 27]. Available from: https://www.aihbonline.com/preprintarticle.asp?id=356796
| Introduction|| |
Deviated nasal septum (DNS) is a common clinical entity presented by nearly 27% of the patients attending the Outpatient department of ENT in India. Amongst the many theories explaining its cause, the most acceptable is direct trauma to the nose,, birth injury and congenital. The prevalence of DNS is as high as 18% to 31% amongst the general population in India. Epidemiological studies point out nasal obstruction as the most common presenting symptom followed by anosmia., Vainio-Mattila in 1974 observed that the prevalence of nasal airway obstruction amongst randomly chosen adults was 33%., The mid-line structure nasal septum divides the nasal cavity; is formed by both cartilage and bony parts,, with an anatomical function to provide support to the aesthetic nose and physiological function to control It has laminar nasal airflow and comfortable respiration., In turn, it helps in heating and humidifying the influenced air for the exchange of gases. Deviations of the nasal septum are anatomical malpositioning of the different constituents of it either cartilaginous or bony parts., Hence, they occur at various levels low, mid or high of the septum and in both anterior or posterior dispositions or in their combination. The deviations are the most common at the bone-to-bone junctions or bone-to-cartilage junctions. The deviations can be smooth or sharp-angled (Spur) type. Based on anatomical malformations, various authors have classified the DNS. A few to mention such classifications are Negus (1955), classifyed deviations as Spur, Deviations and a ccombination of both. He stated that a spur was a sharp angulation of septum at the bone and cartilage junction, but bone enters its formation invariably. Mladina Classification (1987) Midline septum: Type 1, Mild deviation: Type 2, Anterior vertical, C-Shaped, Posterior vertical and C-Shaped: Type 3: S-shaped deviation: Type 4: Horizontal spur Type 5, Horizontal spur with deep groove on the concave side: Type 6: Combination of above types: Type 7: Classification of DNS based on its shape ais (1) C shaped, (2). S shaped, (3) caudal dislocation, (4) Spur and (5) thick Septum (Reduplication). Ballenger (1959) classified DNS as deviation with or without crusts, spur and without external deformity, Deviation with external nasal deformities and Isolated deformities of septum; classified DNS into (1) developmental type and (2) traumatic. DNS results in few permanent changes in the mucosa of the nasal cavity and paranasal sinuses causing mucociliary dysfunction, lymphocytic penetration, retention of secretions and squamous metaplasia and secondary infection are other modifications, resulting in frequent attacks of rhinorrhea, coughing and snoring, apart from external nasal deformities. These changes are due to change in the airflow dynamics of inspired and expired air during respiration. The above classifications do not specify the type of septal surgery that should be undertaken based on their types. Cottle's line was described as a line between anterior nasal spine and nasal spine of the frontal bone. Nasal septum anterior to the line is mostly constituted by the quadrilateral cartilage of the septum, and septum posterior to the line is constituted mostly by bony plates of vomer, perpendicular plate of ethmoid and palatine bone. The present study aims to assess the practicality of using the classification of anterior and posterior deviations and choosing septoplasty and SMR, respectively, as the choice of surgeries.
| Materials and Methods|| |
Sample size calculation
The sample size was calculated using the formula
SS = Sample Size
Z = Z-Value
P = Percentage of Population
C = Confidence interval
The sample size was calculated as 68.
This study was a prospective observational study which was carried out between February 2019 and February 2020 at government hospital at Nizamabad, Telangana. Sixty-eight patients were included in this study with a clinical diagnosis of DNS. All the patients were attending the ENT Out Patient Department of a Government Medical College and General hospital of Nizamabad. They were divided into two groups. Group A consisted of 34 patients with anterior DNS and Group B consisted of 34 patients with posterior DNS. Patients aged between 18 and 48 years and DNS Patients with anterior and posterior deviations were included. Patients with no complications due to DNS, patients with unilateral and bilateral nasal obstruction, patients willing to join the study and patients with compensatory hypertrophy of the inferior turbinate on the opposite side of concavity were included in the study. Patients with diabetes mellitus and hypertension and patients with debilitating illnesses were excluded. Clinical history of the complaints was elicited from all the patients followed by ENT examination. A nasal obstruction symptom evaluation score (NOSE) was used to assess the severity of nasal obstruction. It included Grade 0: not a problem, Grade 1: mild obstruction, Grade 2: moderate obstruction, Grade 3: severe obstruction, Grade 4: fairly bad and Grade 5: severe obstruction. Direct nasal endoscopy (DNE) was performed, and the level of deviation of the septum and its anterior or posterior disposition were noted. An X-ray of paranasal sinuses (Water's view) was taken in all the patients, and wherever necessary computed tomography (CT) paranasal sinuses were taken, and all the data were analysed using standard statistical methods. The decision of anterior deviation and posterior deviation was based mainly on the complaints of nasal obstruction and DNE. After taking consent, investigations of surgical profile were undertaken.
All the surgeries were performed by the three authors equally distributed amongst themselves. The surgeries were performed both under local infiltration anaesthesia and general anaesthesia depending on the patient's choice and fitness. Positioning of the patient for septoplasty was done followed by draping and decongesting the nasal mucosa with 4% xylometazoline and adrenaline by Moffatting followed by infiltration of the submucosal space of the entire septum with a solution prepared by adding 10 ml of xylocaine 10 ml of distilled water and added with ten drops of adrenaline. Anaesthetic infiltration bilaterally in the submucoperichondrial plane until mucosa is well blanched. This also assisted in hydrodissection of the planes in addition to analgesia and haemostasis.
Raising mucoperichondrial flaps
Using a Killian's nasal speculum to expose the caudal edge of the septum, a hemitransfixion (vertical incision at the very caudal edge) or Killian's incision was made using 15-blade. Freer or Cottle's elevators were used to create a submucoperichondrial plane which was extended posteriorly revealing the quadrangular cartilage, perpendicular plate of ethmoid and vomer bones. Care was taken not to perforate the mucosa, especially if dissection over bony spurs or deviations was needed. The bony and cartilage junction was broken, and the mucoperiosteal flap on the opposite side was then raised through the same incision. Care was taken to avoid perforations of the mucoperiosteal flaps at the same site. As the dissection reaches more posterior aspect, longer nasal speculum was used to obtain better view. The junction between the lower border of the quadrilateral cartilage and the nasal crest of the maxilla was separated and through this gap mucoperichondrium of the opposite side Mucoperichondrium was elevated for few millimeters along the inferior border. The excess inferior strip of the quadrilateral cartilage was excised using a 15 number surgical blade. Now, the quadrilateral cartilage is free on all sides except on its caudal border (Swing door technique). Spurs when present were carefully dissected and excised.
All the steps of surgery remained the dame, but mucoperichondrial and mucoperiosteal flaps were elevated on both sides.
| Septal Deviation Correction|| |
A “L”-shaped strip of cartilage was left to maintain dorsum of the nose and tip of the nose stability (dorsal and caudal edges); A twisting movement is often employed to remove sections of cartilage or perpendicular plate of ethmoid and vomer bone. Removed cartilage was saved, reshaped and replaced in between the two mucosal flaps. Interrupted sutures were placed using absorbable suture material (e.g., Vicryl). Nasal cavity was packed with glove finger and ribbon gauge soaked in neosporin ointment.
Nasal packing was removed after 48 h and discharged with a prescription of antibiotics and analgesics and oral decongestants. They were followed up after 1 week and 4 weeks. Nasal cavity douching was advised during this period. Nasal obstruction score was measured at the end of 4 weeks.
Standard statistical methods such as percentage, P value and mean standard deviation were used.
| Results|| |
Sixty-eight patients diagnosed with DNS were grouped as those having anterior nasal septal deviation: Group A and those with posterior septal deviation as Group B (34 patients in each group). The youngest patient was aged 18 years, and the eldest patient was 47 years in Group A and 19 years and 48 years, respectively, in Group B. The mean age was 34.28 ± 2.30 years in Group A and 35.25 ± 3.05 years in Group B. The age distribution in both the groups was tabulated in [Table 1]. Amongst 68 patients, there were 40 males (58.82%) (19 in Group A [27.94%] and 21 in Group B [30.88%]) and 28 (41.17%) female patients (15 in Group A [22.05%] and 13 in Group B [19.11%]). The male-to-female ratio was 1.4:1. The age distribution of patients belonging to both the groups was tabulated in [Table 1]. Using NOSE score, the nasal obstruction was graded in both the groups and found that Grade 4 and 5 together constituted to 31 (45.48%) patients in Group A and 33 (48.52%) patients in Group B [Table 1]. Right side deviation was noted in 15 (22.05%) of the Group A patients and 20 (29.41%) of the Group B patients [Table 1].
|Table 1: The gender, age distribution and variables of the septal deviation (n=69)|
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Postoperatively, both the groups were assessed by DNE and NOSE score at the end of 4 weeks. It was observed that the NOSE score grading had improved to Grade 1 and 2 in both the groups. Similarly, the DNE showed septum in the mid-line with minimum scarring and crusting. The number of patients in Group A and B were 24 (70.58%) and 26 (76.47%), respectively, with Grade 1 NOSE score. Ten (29.41%) and 08 (20.59%) patients in Group A and Group B, respectively, with NOSE score 2 [Table 2]. The incidence of complications in both the groups was listed with their incidences in [Table 2]. There was a significant improvement in both the groups in terms of NOSE score grading being reduced from Grade 3 to 5 to 1 to 2.
|Table 2: The postoperative nasal obstruction symptom evaluation score and complications during follow up in both groups (n-69; Group A-34 and Group B-34)|
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A correlation was made between the results of surgeries in both the groups using the NOSE scores data. The statistical method used was Pearson's correlation coefficient calculator. The R score was 0.9942, and the P value was 0.0001(P taken as significant at < 0.05), [Table 3].
|Table 3: The comparison of preoperative and postoperative nasal obstruction symptom evaluation score in both the groups (n=68; Group A-34 and Group B-34)|
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| Discussion|| |
Nasal septum plays a crucial role in providing the support to the dorsum of the nose and functional breathing. The present study was conducted to assess the practicality of using classification of anterior and posterior deviations and choosing septoplasty and SMR, respectively, as the choice of surgeries. This study was conducted with an objective to assess the grade of nasal obstruction, nature of DNS (anterior or posterior), site and level of septal deformity and finally to assess the final outcome in terms of improvement in nasal obstruction score. Review of literature shows no difference in gender in regards with the incidence of symptomatic septal deviation or their final outcome of surgeries performed. The male-to-female ratio in this study was 1.4:1. Whereas Muhammad and Nabil-ur Rahman from their descriptive study on 200 patients showed a ratio of 4.26:1. Reporting of higher incidence of DNS in males may be due to more susceptibility to trauma in males or random assignment of patients. From the same study as well as another study by Sathyaki et al. the age distribution of the patients was from 15 to 60 years. The mean age was 40.13 ± 11.67. In the present study, the mean age was ranging from 34.28 ± 2.30 years in Group A and 35.25 ± 3.05 in Group B. The most prominent symptom which brought the patient to the ENT outpatient department in this study was Nasal Obstruction which was measured subjectively with NOSE score. Similar findings were reported by LHaltom JR, Cannon CR et al in 1998 Sathyaki DC, Geetha C et al. in 2014. pointed out the necessity of classifying nasal septal deviation from their study. Parrilla et al. Stressed the need for understanding the significance of knowledge of anatomy behind the septal deviation and analysing the pre-operative findings are important to plan and decide the surgery which will help in reducing the post-operative complications and prevents repeat surgery. Bowmann and Baumann cautioned in their study that C-and S-shaped deformities require better planning and require more complex surgeries than simple twists of the septum. However, never mentioned or classified the deviations as anterior and posterior, and no specific surgery was identified. Lee and Baker stated that C- and S-shaped deformities require sometimes surgical scoring on the convex side of septal deviation to mime the tissue memory of the cartilage. Cerkes pointed out that an anteroposterior C-shaped deviation usually is associated with a contralateral septal deviation and in the absence of external deformity appearance of deviation of only septum should caution the surgeon that some other forces are playing a role in its deviation. While a cephalocaudal C-shaped deviation usually presents as a visible C-shaped external deformity. He also emphasised that middle and lower third deformities of the external nose are always associated with septal deviations, and hence the surgery of rhinoplasty and septal corrective surgeries should always be planned together to avoid re-operations. Many methods of septal correction surgeries are described in the literature (Cottle 1958). Due to frequent complications with Classical SMR surgery a more conservative surgery was evolved “Septoplasty” which can also be done in patients below 18 years which eliminates possible poor development of the mid face. In present times endoscopic septal corrections are performed which were previously recommended by Stammberger and Posawetz in 1990, Haltom et al. in 1998 Sathyaki et al. in 2014. Sawhney and Sinha pointed out the necessity of classifying nasal septal deviation by its severity of deviation (marked, moderate and mild); earmarking various sites of septum within the above grades as cartilage and bony deflection, dislocation of septal cartilage and level of deviation. Buyukertan et al. divided the septum into ten segments: anterosuperior, anteromedial and anteroinferior), mediosuperior, mediomedia, medioinferior, posterosuperior, posteromedial, posteroinferior and caudal end of the septum nasi. But they failed to indicate the right choice of surgery for the type of Classification and area of septal deviation. In the present study, 68 patients with DNS presenting with anterior nasal septal deviation: Group A, posterior septal deviation as Group B were analysed. The patients were aged between 18 years and 47 years in Group A. In Group B, the patients aged were between 19 and 48 years. The mean age was 34.28 ± 2.30 years in Group A and 35.25 ± 3.05 years in Group B. The male-to-female ratio was 1.4:1. NOSE score Grade 4 and 5 was noted in 31 (45.48%) patients in Group A and 33 (48.52%) patients in Group B [Table 1]. Right side deviation was noted in 15 (22.05%) of the Group A patients and 20 (29.41%) of the Group B patients [Table 1]. All patients with anterior deviation were subjected to septoplasty and patients with Posterior deviation were subjected to classical SMR surgery. The results were assessed and analysed using the response of recovery kin the nasal obstruction NOSE score, and the two groups were correlated using Pearson's Correlation coefficient calculator. The R score was 0.9942, and the P value was 0.0001(P taken as significant at < 0.05), [Table 3]. It was observed by the results that deciding the type of surgery as per the DNE findings whether it was anterior or posterior deviation was easy, practical and definite final outcome results could be expected at the end.
| Conclusions|| |
Septoplasty for anterior septal deviations and classical SMR surgery for Posterior deviations of the septum is an easy method, more practical and the end results are more predictable.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]