Abstract
The presence of septal spur may cause various pathologies by affecting the development of the inferior turbinate, osteomeatal unit and uncinate process. We aimed to compare the changes of the angle with inferior turbinate and the maxillary medial wall of the uncinate process in patients with septal spur by normal population. In the study, 138 patients with septal spur and unilateral septum deviation and 83 patients without septum deviation were evaluated retrospectively. The angles of the inferior turbinate and the uncinate process with the medial wall of the maxilla were measured at the ostemaetal unit level. The changes of the inferior turbinate and the uncinate process with the maxilla medial wall compared to the opposite side of the deviated side and the normal population were compared. Angle of the inferior turbinate with the medial wall of the maxilla is significantly smaller in the side with septum deviation to the side without septum deviation and normal population and significantly large in the side without septum deviation to normal population. Angle of the uncinate process with the medial wall of the maxilla is significantly large in the side with septum deviation to the side without septum deviation and normal population and significantly smaller in the side without septum deviation to normal population. Presence of septum base crest are thought to cause structural changes at the inferior turbinate and the uncinate process. We recommend to break the inferior turbinate at the concave side in patients with basal crest.
Keywords: Nasal turbinate, Septal spur, Uncinate process, Computed tomography
Introduction
Nasal septum deviation is a common anatomical variation that affects 80% of adults on average [1]. Septum deviation may cause changes in the airway pattern, which may lead to difficult breathing, sinusitis, bleeding, sleep apnea, infection [2–4]. In patients with unilateral septum deviation, simultaneous inferior turbinate hypertrophy may develop on the opposite side of the deviation [5]. These changes result in mechanical double-sided nasal obstruction [6]. Radiological and histopathological studies have shown that conchal bone hypertrophy may be more important than mucosal hypertrophy [6, 7].
Uncinate process is the most important anatomical landmark in the lateral nasal wall in endoscopic endonasal surgery [8]. Nasal septum deviation leads to narrowing of the osteomeatal unit and associated complications [9].
In our study, it was aimed to compare the angular medial wall of the inferior turbinate and the uncinate process with the side with non-deviation and normal population from the anatomical structures of the lateral nasal wall in unilateral nasal septum deviation and septal spur.
Method
The study has been made by the retrospectively examination of the data obtained from total of 221 patients, 74 male and 64 female 138 patients between 2009–2014 applied to our otorhinolaryngology clinic with the complaint of nasal obstruction, septum deviation has been detected in otorhinolaryngology examination and septal spur determined as a result of evaluation with para-nasal sinus computed tomography and 42 male and 41 female 83 patients having para-nasal sinus computed tomography for various reasons such as headache, odor disorders, endoscopic pituitary surgery, with septum deviation not monitored.
The age, sex, complaints, previous history of surgery, endoscopic examination findings were evaluated retrospectively from patient anamnesis form of Otolaryngology outpatient clinic. A total of 138 patients with unilateral nasal septal deviation and septal spur on paranasal sinus tomography were included in the study. 83 patients who had no septal deviation as a control group and underwent para-nasal sinus tomography for various reasons such as odor disorders and headache were included in the study. None of the patients had a previous history of nasal surgery and no history of acute otolaryngologic inflammation.
The high-resolution BT had the characteristics of 120 kV and 180 mA. The serial images had a thickness of 2.5 mm and a cross-sectional time of 1 s. The angle of the lateral wall of the uncinat process on the para-nasal CT and the angle of the inferior turbinate with the lateral wall were measured in 3 consecutive sections from the anterior osteomeatal unit level and the average of the obtained values was taken. All measurements were made by the same person to ensure consistency. The left side of the septum was convex side and the opposite side of the deviation was evaluated as concave side. In the control group, right and left nasal passages were measured and noted in this way.
Statistical Evaluation
Data analysis was made in IBM SPSS Windows 20.0 package program. Whether the distribution was normal was evaluated by Kolmogorov–Smirnov test. For values with normal distribution, the average was given as ± , for standard deviation and non-normal, it was given as median (minimum–maximum) value. While independent sample T test and ANOVA were used for the values with normal distribution, Mann–Whitney U and Kruskal–Wallis test were used in the analysis of abnormal values. The paired sample T test or Wilcoxon test was used for the conjugate sample between the variables. Pearson correlation coefficient was found to determine correlation between variables.
Results for p < 0.05 were considered statistically significant.
Results
Among the 268 patients included in the study, 155 were female (57.8%) and 113 (42.2%) were male. Among the 138 patients in the study group, 74 (53.6%) were male and 64 (46.4%) were female; among the 83 patients in the control group, 42 (50.6%) were male and 41 (49.4%) were female. There was no statistically significant difference between the groups in terms of gender.
The patients ranged between 17–69 years old and the mean age was 35.9 years. The patient group was between 17–69 years old and the mean was 35.1. The control group was between 18–68 years old and the mean age was 37.3 years. There was no statistically significant difference between the groups in terms of age.
The angle of the inferior turbinate with the medial wall of maxilla was determined as 65.28° (in the range of 40.7°–96.2°) on average in convex side and 87.15° (60.2°–109.8°) in concave side. Comparison of angles at the convex and concave side was statistically significant. The angle of the uncinate process with the medial wall of maxilla was measured as 160.81 (116.7–187) in convex side and 152.37 (121.4–179.4) in concave side. The comparison between these values was statistically significant (Table 1).
Table 1.
Comparison of the angular medial wall of the inferior turbinate and the uncinate process between the concave side and the convex side in the septum deviation group
| Angle value averages | p value | |
|---|---|---|
| Angle between the inferior turbinate and the medial wall of the maxilla on the convex side | 65.28 ± 10.08 | 0.000a |
| Angle between the inferior turbinate and the medial wall of the maxilla on the concave side | 87.15 ± 9.79 | |
| Angle between the uncinate process and the medial wall of the maxilla on the convex side | 160.81 ± 12.87 | 0.000b |
| Angle between the uncinate process and the medial wall of the maxilla on the concave side | 152.37 ± 13.35 |
p < 0.05 statistically significant
aPaired sample T test
bWilcoxon test
The angles of inferior turbinate in control group was measured as 82.94° (65°–99.4°) right nasal passage and 83.79° (64°–106.9°) left nasal passage. The comparison of right and left nasal passages in the control group was not found statistically significant. The angle of uncinate process with the medial of maxilla was measured as 158.28° (138.7°–177°) in right nasal process and 158.99° (142.1°–180.6°) in left nasal process. Comparison of these two values was not found statistically significant (Table 2).
Table 2.
Comparison of the angle of the inferior turbinate and the uncinate process with the maxilla medial wall between the right and left nasal passages in the control group
| Angle value averages | p value | |
|---|---|---|
| Angle between right nasal passage inferior turbinate and medial wall of maxilla | 82.94 ± 8.08 | 0.093a |
| Angle between left nasal passage inferior turbinate and medial wall of maxilla | 83.79 ± 8.25 | |
| Angle between right nasal passage uncinate process and medial wall of maxilla | 158.28 ± 8.98 | 0.434b |
| Angle between right nasal passage uncinate process and medial wall of maxilla | 158.99 ± 9.63 |
p < 0.05 statistically significant
aPaired sample T test
In the comparison of the patients with septum deviation with the control group, since there was no difference between right and left nasal passages, convex side was compared with right nasal passage angle values and left nasal passage angle values on concave side in control group. The angle of the inferior turbinate and the uncinate process with the medial wall of the maxilla was found statistically and significantly different in both convex and concave side of the control group. Similar evaluations were made in terms of the uncinate process. When the uncinate process angles were evaluated, the control group was found to be statistically significant on both convex and concave side (Table 3).
Table 3.
Evaluation of measurements between patients with septum deviation and control group
| Angle value averages | p value | |
|---|---|---|
| Angle between the inferior turbinate and the medial wall of the maxilla | ||
| Convex side | 65.28 ± 10.8 | 0.000a |
| Control group (right) | 82.94 ± 8.08 | |
| Concave side | 97.14 ± 9.79 | 0.010a |
| Control group (left) | 83.79 ± 8.25 | |
| Angle between the uncinate process and the medial wall of the maxilla | ||
| Convex side | 160.81 ± 12.87 | 0.020b |
| Control group (right) | 158.28 ± 8.98 | |
| Concave side | 152.37 ± 13.36 | 0.000a |
| Control group (left) | 158.99 ± 9.63 | |
p < 0.05 statistically significant
aIndependent samples T test
bMan Whitney U test
Discussion
Coronal imaging of para-nasal sinuses is an important method in the evaluation of the septum and lateral nasal wall [2]. The inferior turbinate is an independent bone in the lateral nasal wall, with a central bone structure and a mucosal cover on it and makes joints with surrounding bone structures. There is a rich venous blood supply of the inferior turbinate, which plays an important role in adjusting and humidifying the temperature of the inhaled air [10].
The uncinate process is a thin sickle-shaped structure between the inferior turbinate and the middle turbinate in the anterior lateral nasal wall. The localization of the uncinate process plays an important role in the development of pathological events in the anterior sinuses. The uncinate process articulates with inferior turbinate bone component at the inferior [11].
Nasal airflow is mainly regulated by turbinate and the most important role in nasal resistance is the inferior turbinate [12]. Compensatory contra-lateral inferior turbinate hypertrophy is frequently observed in unilateral septum deviation [5]. Asymmetry in the nasal passage due to septum deviation is one of the most common causes of upper airway obstruction [10].
Recent studies have shown that the concha bone has more effect on the lower turbinate hypertrophy than the medial and lateral mucosa [7, 13]. In this study, concha bone thickness and mucosal thickness were evaluated, and it was stated that the concha bone was more than the concave side on the convex side [14]. In another study, the angle of the inferior turbinate with the lateral nasal wall was measured and the inferior turbinate angle on the convex side was significantly lower than the normal population and the concave side [15, 16]. In our study, the angle of the inferior turbinate with lateral nasal wall was statistically significant when compared with concave and normal population in the convex group. This situation showed that the inferior turbinate angle in the septum deviations of the basal crest decreased on the convex side secondary to deviation and on the concave side it increased significantly compared to both the normal population and the convex side. This suggests that septum deviation may be important in lateral nasal wall development.
Uncinate process is an important anatomical structure in the development of sinusitis in osteometal unit. The development of sinusitis on the deviated side was significantly higher in patients with septum deviation [8, 9]. To evaluate the effects of septum deviation on lateral nasal wall development, although our retrospective study did not evaluate the development of sinusitis, the angle of the uncinate process with the lateral nasal wall was significantly different from the concave side and normal population on the convex side. This suggests that septum deviation may cause sinusitis by affecting the lateral nasal wall. However, prospective studies are needed about.
Various studies have shown a significant relationship between septum deviation and asymmetric facial development [17, 18]. In the study made by Kim et al., it was found that deviation affected the development of lateral nasal wall development [17].
After the septoplasty operation, the nasal airway is opened on the convex side and there are very different opinions about the interventions on the concave side. In patients with septal spur, since the inferior turbinate hypertrophy is observed on the concave side, the idea of interfering with this side has been present for a long time [14, 15]. In our study, the lower turbinate angle on the opposite side of the deviation was significantly higher than the normal population in the patients with septal spur. The wide angle of the inferior turbinate towards the medial may cause narrowing of the air passage on the concave side by taking the septum in the middle line after septoplasty. This results in an increase in the postoperative period of nasal congestion in the concave side.
Conclusions
It was thought that septal spur would be effective in asymmetric development by evaluating the angles of the inferior turbinate and uncinate process with lateral nasal wall in the development of lateral nasal wall. Septoplasty allows the convex side of the nasal cavity to expand. However, correction of the nasal septum results in a decrease in the nasal passage and nasal congestion on the concave side. At the same time, the angle of the uncinate process with the lateral nasal wall may be effective in narrowing of the uncinate and development of sinusitis. It is thought that there is a need for larger prospective studies. Considering the results of our study, it is recommended to break the inferior turbinate in the concave side after septoplasty in patients with basal crest.
Acknowledgements
All authors have confirm that the paper is not under consideration for review in any other journal.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors’ Contribution
All authors have made contributions to the paper, and have reviewed it before submission.
Compliance with Ethical Standards
Conflict of interest
The authors declare that there is no conflict of interests regarding the publication of this paper.
Consent
The authors obtained the written informed consents from the patients for publication of the report.
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.
Footnotes
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