Abstract
Deviated nasal septum is one of the most commonly encountered nasal anatomical abnormalities. Various studies showed that deviated nasal septum results in the osteo-meatal complex disease and compensatory turbinate hypertrophy. But only a few studies described the association between type and degree of angle of deviated nasal septum and measured the angle of septal deviation and explore its effect in causation of nasal symptomatology. Hence, this study was undertaken with the aim to study the relation between type and degree of septal deviation with nasal symptomatology and to measure the degree of septal deviation. This was an observational study and data collection was done from August 2017 to August 2019. A total 52 patients with symptomatic deviated nasal septum were studied. Higher septal deviation caused symptoms in 73% of cases and severe degree of angle of septal deviation caused symptoms in 63% of cases. High and severe deviated nasal are more associated with nasal symptoms. Therefore, we could derive a correlation between the cases with higher septal deviation and incidence of nasal symptoms.
Keywords: Septal deviation, Osteo-meatal complex, CT PNS
Introduction
Deviated nasal septum is one of most common nasal anatomical abnormalities encountered by an otorhinolaryngologist. Septal deviation refers to convexities of the septum to one side with accompanying deformities of the midline structures. A marked deviation of portion or of entire nasal septum may cause not only obstructed nasal breathing but also disease within the lateral nasal wall and consecutively in paranasal sinuses.[1] Septal deviation disturbs nasal physiology, not always, but together with conchal hypertrophy and other anatomical variations. Various studies show that it is a deviated septum, which results in the osteo-meatal complex disease and compensatory turbinate hypertrophy and enlarged ethmoid bulla.[2] But in very few studies, angle of septal deviation has been measured and the effect of type and increasing angle of septal deviation in causation of nasal symptomatology has been evaluated. Our study is intended to estimate the degree of nasal septal deviation and to study the correlation between degree and type of septal deviation with nasal symptomatology.
Materials and Methods
This was an observational study and data collection was done from August 2017 to August 2019.Patients above 17 years of age who presented with symptomatic deviated nasal septum were included in the study.
Exclusion criteria.
Patients with all other nasal pathologies and abnormalities, like benign & malignant nasal masses, inferior turbinate hypertrophy, concha bullosa, uncinate process diseases.
Patient who have previously undergone nasal or sinus surgery, or maxillofacial trauma cases.
Pre-existing extensive sinusitis were excluded from the study.
Included patients were subjected to nasal endoscopy and CT scan paranasal sinus (CT PNS) coronal cuts. The coronal CT image that best defined the osteo-meatal (OMC) was utilized for the calculation of the direction and degree of septal deviation. The superior insertion of the nasal septum at the crista galli, its inferior insertion at the level of the anterior nasal spine, and the most prominent point of nasal septal deviation was identified and clearly marked on the respective film. The resultant angle was noted. (Fig. 1) The angle of deviated nasal septum as noted in CT PNS was correlated with the symptoms of the patients and the severity of it was noted. The CT angle of septal deviation was then divided into three categories mild (0–4 degree), moderate (4–8 degrees) and severe (> 8 degrees septal deviation).
Fig. 1.
CT scan PNS (coronal cuts) showing measurement of septal angle deviation in another case which is 14.63 degree
Observation
A total of 52 patients with symptomatic deviated nasal septum were assessed. The demographic data showed that deviated nasal septum is more common in the males (62.14%) between the age group of 23–30 years with the most common site being left side (53%). Association between nasal symptomatology and deviated nasal septum was studied using the Chi square test and logistic regression.
In present study on nasal endoscopy, 67.31% cases had DNS to the left and 32.69% cases had DNS to right. 10% cases had spur, of which 7 cases had spur towards the opposite site of septum deviation. 73.08% cases had high deviated nasal septum and 26.92% cases had caudal deviated nasal septum. (Table 1) Large majority of patients had severe degree of septal deviation (63.46% cases).
Table 1.
Showing association between deviated nasal septum (High/Low) with that of nasal symptom. N = 52
| Nasal symptoms | Deviated nasal septum | |
|---|---|---|
| High | Low | |
| Nasal obstruction | 30 (73.17%) | 11 (26.83%) |
| Headache | 08 (72.73%) | 03 (27.27%) |
| Total | 38 (73.08%) | 14 (26.92%) |
Out of 11 cases with headache as symptom, 8 cases had high DNS and 3 had low DNS and out of 41 cases with nasal obstruction as symptom, 30 cases had high DNS and 11 cases had caudal DNS. 73% cases with nasal obstruction and 72% cases with headache had high deviated nasal septum. (Table 1).
In present study, degree of angle of nasal septal deviation as detected on CT scan paranasal sinus (coronal cuts) was differentiated into three groups mild, moderate and severe degree of septal deviation. One patient was included in mild group, 18 in moderate group and 33 patients in severe degree of septal deviation group according to this categorization. This implies that most patients had septal angulation in severe range (63.46%), followed by moderate (34.62%), then mild (1.92%).
We found that statistically significant correlation was present between degree of deviation of nasal septum and duration of symptoms. Patients with severe degree of deviation of nasal septum are associated with longer duration of nasal symptoms (p < 0.05). This signifies that as the degree of deviated nasal septum increases it blocks the adjacent osteo meatal unit (OMC) and this blocks the air passage and hence causing the symptoms.
In present study, among the duration of symptoms, maximum that is 59.62% cases were having symptoms for more than three years followed by 25% cases with symptoms for 1–3 years duration and 15.38% cases had symptoms for less than one-year duration. This was correlated statistically with degree of deviation of nasal septum and significant association was found. (p = 0.001) This signifies that severe degree of septal deviation causes persistent and prolonged symptoms.
Discussion
Nasal septal deviation disturbs nasal physiology, not always, but together with conchal hypertrophy or other anatomical variations. Besides nasal obstruction, nasal septum deviation exerts pressure on neighbouring structures. This, in turn, disturbs drainage pathways, affecting mucosal ciliary function through contact, leading to obstruction and secondary nasal infection in all sinuses by disturbing normal mucus drainage.
In present study, among symptomatic DNS cases,73.08% cases had high deviated nasal septum and 26.92% cases had caudal deviated nasal septum. This signifies that high septal deviation has more effect in blocking the airflow as well as osteo-meatal complex and hence causing nasal symptoms such as nasal obstruction and headache.
Literature lacks data on the effects of types and degree of septal deviation on nasal symptomatology. Poorey VK et al. [3], has concluded that DNS leads to sinusitis because of osteo-meatal blockage that we cannot compare in our study as we have excluded sinusitis.
In present study, the degree of septal deviation was categorised into mild, moderate and severe group. 72% patients with high deviation of nasal septum were found to be symptomatic. This implies that it is not the severity but the site of deviation of nasal septum is significant in causation of nasal symptoms.
Mundra RK et al. [4] in their study showed that on CT evaluation of 61 patients with mean septal angulation was found to be 15.06° (range 5–35°). Depending on degree of septal angle patients were divided into 3 categories. Group I (0°–9°), Group II (10°–15°), Group III (> 15°) In, both group I and II equal number (24) of patients were there. His study also showed that there was a significantly increased incidence of hypertrophy of the contra lateral middle turbinate, contra lateral concha bullosa in group III patients. However, these groups were not compared in causation of nasal symptoms but they have studied the compensatory changes caused by DNS.
In present study, among the clinical symptoms, the most common presenting symptoms was nasal obstruction (78.84% cases) followed by headache (21.16% cases) in high DNS. And 59.62% cases having duration of symptoms for more than three years. On nasal endoscopy, left sided DNS was found to be more common (63% cases). On CT scan, maximum cases were found having severe (> 8) degree of angle of septal deviation (63.46% cases). Similarly, in study by V K Poorey et al. [3], the most common presenting symptoms were nasal obstruction (86.56% cases) and headache (73.13% cases) followed by nasal discharge (52.23%). However, symptoms their duration were not correlated with degree of septal deviation, which was the case in our study.
Authors have observed in the present study that with increasing angle of deviation of septum there is statistically significant increase in duration of nasal symptoms (p < 0.05) and patients with higher deviation of nasal septum were associated with longer duration of nasal symptoms (p = 0.001).
Calhoun et al. [5] examined the paranasal sinus CT images of both asymptomatic and symptomatic patients. This study showed a strong correlation between septal deviation and sinus disease, although the degree of septal deviation was not measured and association of DNS with that of nasal symptoms was not studied.
Conclusion
Deviated nasal septum, is one of the most common anatomic variation encountered in clinical practice with large amount of dilemma about its management lingering around. Since mere presence of DNS is not an indication of surgery, we the authors of this article recommend surgical intervention if the patient has a high and severe degree of deviation on CT PNS.
Funding
None.
Declarations
Conflict of interest
Authors declare no conflict of interest.
Footnotes
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References
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