Effect of Deviated Nasal Septum on Maxillary Sinus Volume and Occurrence of Sinusitis

Abstract

Nose is the central part of mid-face and has an important functional, aesthetic and psychological role. The first modern and accurate descriptions of the paranasal sinuses can be traced to the works of the late 19th century Austrian anatomist Emil Zuckerkandl. In our study we tried to relate deviated nasal septum (DNS) with occurrence of sinusitis and its effect on volume of the maxillary sinus. It is a pioneer study in the field of otolaryngology and not many studies have been conducted on this topic. This is a cross sectional study involving patients with deviated nasal septum and having symptoms of sinusitis like fever, general malaise, body ache, headache, pain, tenderness, nasal discharge and post nasal discharge. The study was conducted at the department of otolaryngology at a tertiary care center on 84 subjects out of which 71 patients got CT scan done, which were included in the study. All subjects having Grade 5 and 6 DNS showed blocked osteomeatal complex (OMC) on CT scan while in Grade 2 the occurrence was only 50%. This finding was suggestive of increase in incidence of OMC block with increasing grade of DNS. The maxillary sinus volume for the cases was seen maximum in range of 9.1–10 cu mm by software and in the range of 8.1–9 cu mm for geometric analysis. Cases with Grade 2 DNS showed maximum cases in volume range of 11.1–12 followed by 9.1–10. On the other hand volume by geometric analysis showed equal cases in range 8.1–9 and 10.1–11. The study showed strong association of blocked OMC with high grade DNS. It also showed reduced sinus volume in higher grades of DNS. Further studies are needed in this field with a higher number of subjects to establish the relation between decreased volume of maxillary sinus and grade of DNS.

Introduction

Nose is the central part of mid-face and has an important functional, aesthetic and psychological role. Respiration, olfaction, humidification and phonation are among its most important functional roles. In addition, the aesthetic importance and its impact on the individual psyche have been the subjects of many previous studies. For example, when looking at a face, observers spend the largest amount of gaze time on the nose and eyes, underscoring its prominent position in the central face.

Many historical references to the paranasal sinuses exist. The earliest such reference can be dated back to the works of Galen, who described the presence of the ethmoid air cells. Later descriptions of the maxillary sinuses by Leonardo da Vinci (1489), the sphenoid sinuses by Giacomo Berengario da Carpi (1521), and the frontal sinuses by Coiter (16th century) introduced early anatomists and scholars to the presence of these craniofacial air cells [1].

The first modern and accurate descriptions of the paranasal sinuses can be traced to the works of the late 19th century Austrian anatomist Emil Zuckerkandl. His detailed study and illustrations of the paranasal sinuses set the standard for generations of anatomists and physicians. Countless 19th and 20th century anatomists, radiologists, and surgeons have further contributed to advancing the knowledge of sinus anatomy. The introduction of computed tomography (CT) and the wider use of it in the last 20 years have further contributed to the physician’s ability to appreciate nuances of paranasal sinus anatomy and accurate disease correlation [1].

CT has become a useful diagnostic modality in the evaluation of the paranasal sinuses and an integral part of surgical planning. It is also used to create intra operative road maps. Today, CT is the radiologic examination of choice in evaluating the paranasal sinuses of a patient with sinusitis. Familiarization with the radiologic landmarks and cross sectional anatomy on patient CT scans, along with clinical correlation, can further enhance ability to understand sinus CT findings.

In our study we tried to relate deviated nasal septum (DNS) with occurrence of sinusitis and its effect on volume of the maxillary sinus. It is a pioneer study in the field of otolaryngology and not many studies have been conducted on this topic. So we have tried to compare each possible variable in our study with other previous studies.

Materials and Methods

This is a cross sectional study involving patients with deviated nasal septum and having symptoms of sinusitis like fever, general malaise, body ache, headache, pain, tenderness, nasal discharge and post nasal discharge.

The study was conducted at the department of a tertiary care center on 84 subjects out of which 71 patients got CT scan done which were included in the study.

Statistical analysis was done using Statistical Package of Social Science (SPSS Version 15; Chicago Inc., USA). Data comparison was done by applying specific statistical tests to find out the statistical significance of the comparisons. Quantitative variables were compared using mean values and qualitative variables using proportions.

Grading of DNS by Mladina ‘Classification for Deviated Nasal Septum [2]

In our study grade of DNS was classified according to Mladina’s classification and volume of maxillary was calculated.

Type 1

Unilateral vertical ridge in the area of nasal valve does not disturb the function of nasal valve.

Type 2

Similar to type 1 but more severe obstruction and disturbance of nasal valve.

Type 3

Unilateral vertical ridge at the level of the head of the middle turbinate.

Type 4

Defines two crest one at the level of the head of the middle turbinate other on the opposite side in the valve area disturbing the functions.

Type 5

Unilateral ridge on the base of the septum other side of the septum is straight.

Type 6

Unilateral sulcus running through the caudal ventral part of the septum other side there is a ridge accompanying asymmetry of the nasal cavity.

Type 7

Mix of types from 1 to 6.

Calculation of Sinus Volume by Software

CT scanning was performed from the alveolar process to the infraorbital margin using a Siemans CT scanner. CT slices 1 mm were obtained parallel to the Frankfurt plane.

The unit was set for equal magnification (1.25) of the anterior and posterior maxillary regions. All patients were also carefully positioned with the Frankfurt plane parallel to the floor. The maxillae, maxillary sinuses, and scales on CT images were used to create a 3-dimensional image of the maxillary sinus, to display a solid model of each maxillary sinus, and to measure maxillary sinus volumes using the 3-dimensional reconstruction system. Serial section was successively entered from the alveolar process to the infraorbital margin at the same pitch [3]. Successive area of sections were taken and volume was calculated from a software taking multiple sections.

Calculation of Volume by Geometric Formula

For the calculation of the volume, maximum AP [breadth], maximum vertical [length] and maximum horizontal diameter [height] was taken. The following formula was used [4].

$$1/3\times \text{maximum length}\times \text{maximum breadth}\times \text{maximum height}$$

Observation and Results

The study included a total of 71 cases which included 48 (68%) males and 23 (32%) females with male: female ratio being 2.08:1. The maximum number of patients 42 (59.2%) were in the age group 21–30 years followed by 18 (25.4%) in age group 31–40 years, by this we can assume that sinusitis affects young adults mostly.

The most common symptom in the study was nasal obstruction seen in 54 (76%) cases followed by URTI and headache in 32 (45.1%) cases each. Fever was the least reported symptom affecting 9 (12.7%) cases, while most common sign was PNS tenderness in 23 (32.4%) patients. Grade 3 DNS was seen in 21 (29%) cases followed by Grade 4 and 5 having equal proportion of 20%. Thus showing that unilateral vertical ridge at level of middle turbinate is most common.

The highest number of cases 14 (100%) with nasal obstruction was seen with Grade 5 DNS followed by Grade 3, 4 each having 71% cases with similar complain (Table 1). Grade 4 and Grade 5 had the maximum number of cases with the complaint of headache.

Table 1.

Showing association of DNS and signs and symptom

Grade of DNS	Total number	Nasal obstruction	Headache	URTI	PNS tenderness
Grade 2	10	6	5	7	7
Grade 3	21	15	7	8	9
Grade 4	14	10	8	9	2
Grade 5	14	14	8	6	3
Grade 6	12	8	4	2	2

Grade 5 and 6 DNS showed 100% cases having blocked osteomeatal complex (OMC) on CT scan while Grade 2 the occurrence was only 50%. This finding suggests increase in incidence of OMC block with increasing grade of DNS (Table 2).

Table 2.

Showing grade of DNS and OMC blockage relation

Grade of DNS	Total number	OMC blocked
Grade 2	10	5 (50%)
Grade 3	21	17 (81%)
Grade 4	14	13 (93%)
Grade 5	14	14 (100%)
Grade 6	12	12 (100%)

The maxillary sinus volume for the cases was seen maximum in range of 9.1–10 cu mm by software and in the range of 8.1–9 cu mm for geometric analysis.(Table 3). Cases with Grade 2 DNS showed maximum cases in volume range of 11.1–12 followed by 9.1–10. On the other hand volume by geometric analysis showed equal cases in range 8.1–9 and 10.1–11. Maximum cases with Grade 3 DNS showed maxillary sinus volume in range 9.1–10 cu mm for both geometric and software based analysis (Table 4). Grade 4 DNS maxillary sinus volume by both geometric and software analysis fell in the range of 9.1–10 cu mm for maximum number of cases. Geometric and software analysis of maxillary sinus volume for cases with Grade 5 DNS well in range of 8.1–9 for maximum number of cases. 8.1–9 cu mm is the range of maxillary sinus volume for maximum number of cases with Grade 6 DNS for both software and geometric analysis, whereas for higher range of volume no cases were seen (Tables 5, 6).

Table 3.

Showing volume of maxillary sinus and number of cases

Volume (cu mm)	Software		Geometric
	Right	Left	Right	Left
7.1–8	1	3	9	6
8.1–9	20	28	25	44
9.1–10	27	25	31	17
10.1–11	17	10	6	4
11.1–12	6	5	0	0

Table 4.

Showing relation between Grade 3 DNS and maxillary sinus volume

Volume (cu mm)	Software		Geometric
	Right	Left	Right	Left
7.1–8	0	0	0	0
8.1–9	2	4	2	13
9.1–10	6	14	19	8
10.1–11	13	2	0	0
11.1–12	0	1	0	0

Table 5.

Showing relation between Grade 5 DNS and maxillary sinus volume

Volume (cu mm)	Software		Geometric
	Right	Left	Right	Left
7–8	0	0	8	1
8.1–9	9	8	6	13
9.1–10	5	6	0	0
10.1–11	0	0	0	0
11.1–12	0	0	0	0

Table 6.

Showing relation between Grade 6 DNS and maxillary sinus volume

Volume (cu mm)	Software		Geometric
	Right	Left	Right	Left
7–8	1	3	1	3
8.1–9	9	9	9	9
9.1–10	2	0	2	0
10.1–11	0	0	0	0
11.1–12	0	0	0	0

Discussion

Gender Distribution

In a study done by Shoib et al. [5] “Association between Symptomatic Deviated Nasal Septum and Sinusitis” in which there were 112 males and 88 females showing a male predominance in accordance to our study. The predominance can be attributed to a male predominant Indian society and lacking health awareness among Indian females. Contrast to our findings a study by Sumaily et al. [6]. The DNS was found to be 120 cases in males and 118 cases in females, total number of cases being 238 with almost equal incidence in male and female 50.4 and 49.6% respectively.

Age Distribution

Maximum number of patients in our study was in the age group 21–30 years and sinusitis was seen in 59.15% of the cases in this age group that were included. This can be compared to a study done by Poore and Gupta [7]. Chronic sinusitis was found common in the age group between 21 and 40 years (50.74%) which is in corroboration to our findings. The findings may be because of the age group being exposed more to environmental pollutants, allergens and infections leading to sinusitis.

Signs and Symptom

In our study the most common symptom was nasal obstruction, followed by URTI and headache (Table 7). Similarly in a study done by Shoib et al. [5] headache was seen in 186 patients (93%), nasal obstruction in 178 patients (89%), nasal discharge in 126 patients (63%), facial pain in 95 patients (47.5%), fever in 55 patients (27.5%), halitosis in 20 patients (10%), cough in 17 patients (8.5%), fatigue in 6 patients (3%). In the study conducted by Singh [3] headache was the predominant symptom seen in 80% of patients, nasal blockage was seen in 76.66%, nasal discharge in 43.33%, facial pain in 40% patients.

Table 7.

Comparision of various symptoms in DNS among different studies

Symptoms	Singh [1] (%)	Venkatachalam [2]	Shoib et al. [3] (%)	Present study (%)
Headache	80		93	45.07
Nasal obstruction	76.6	87.1%	89	76.05
Nasal discharge	43.3	70%	63	33.8
Facial pain	40		47.5	32.39

Grade of DNS

According to Mladina’s classification maximum number of cases in our study had Grade 3 DNS followed by Grade 4 and 5 having equal proportion of each. This can be compared to a study done by Shoib et al. [5]. Caudal dislocation was seen in 23 patients (11.5%), C-shaped deviation was seen in 141 patients (70.5%), S-shaped deviation was seen in 59 patients (29.5%) and spur impinging on lateral wall in 76 patients (38%).

OMC Blockage and DNS

This can be compared to the study done by Sumaily et al. [6] where Grade 3 and 4 DNS showed 40.5% of the cases with OMC blockade. Whereas in our study it was found to be 35.1% in accordance to the above study (Table 2). The p value in our study came out to be 0.1673 which denotes the relation between DNS and OMC blockade is non significant.

Maxillary Sinus Volume

In a study done by Uchida et al. [8] the sinus volume was calculated as an aid in determining the volume of graft bone needed before grafting autogenous bone to the maxillary sinus floor and it came out 7.69 ± 1.54 cu cm. Whereas in a study done by Ariji et al. [9] to conclude that the transverse and anteroposterior widths of the maxillary sinus on axial CT are convenient indices for its size found the average volume to be 9.61 cu mm. These findings are in accordance to our study where the maxillary sinus volume for the cases was seen maximum in range of 9.1–10 cu mm by software and in the range of 8.1–9.0 cu mm by geometric formula.

Grade 2 DNS the p value for relation of DNS and volume of maxillary sinus by software analysis came out to be 0.017 for the right and 0.061 for left maxillary sinus which was significant. Whereas by geometric formula it was 0.017 for both right and left maxillary sinus turning out to be significant. On the other hand p value for Grade 3 DNS and maxillary sinus volume by software was found to be 8.73 and 3.58 for right and left respectively both being non-significant. Similarly geometric analysis turned out to be non significant for both right and left maxillary sinuses with p value of 1.65 and 5.95 respectively (Table 8).

Table 8.

p value for maxillary sinus volume and grade of DNS

Grade of DNS	p value of maxillary sinus by software analysis		p value of maxillary sinus by geometric formula
	Right	Left	Right	Left
Grade 2	0.017	0.061	0.017	0.017
Grade 3	8.73	3.58	1.65	5.95
Grade 4	7.45	0.007	0.0002	0.048
Grade 5	8.53	0.0002	0.0002	1.75
Grade 6	8.62	3.99	8.63	3.99

The p value for relation between Grade 4 DNS and maxillary sinus volume by software was 7.45 for right and 0.007 for left maxillary sinus. On the contrary p value for above relation using geometric formula turned out to be significant for both right and left with p values of 0.0002 and 0.048.

The findings for p value for sinus volume by geometric analysis and Grade 5 DNS for right sinus was significant being 0.0002 and that for left was non-significant with a value of 1.75.

For Grade 6 the p value for relation between DNS and volume of maxillary sinus by software came out to be 8.62 for the right and 3.99 for left maxillary sinus both being non-significant. Similarly p value for relation between DNS and volume of maxillary sinus by geometric was found to be 8.63 and 3.99 for right and left sinuses and both values turning out to be non significant.

Conclusion

In the study we found definite association of grade of DNS and decreased volume of maxillary sinus although not statistically significant. Osteomeatal complex was found to be blocked in all cases with high grades of DNS. Our studies shows there is effect of deviated nasal septum on maxillary sinus ventilation and development, but further studies are needed in this field with a higher number of subjects to positively establish the relation between decreased volume of maxillary sinus and grade of DNS.

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.