Abstract
Symptomatic deviated nasal septum is a commonly encountered clinical condition by otorhinolaryngologist. Non-contrast Computed tomography (NCCT) of nose and Paranasal sinuses is a good tool in the preoperative evaluation of symptomatic deviated nasal septum so as to find hidden sinonasal pathologies in addition to deviated nasal septum. The aim of this article is to find the role and scope of preoperative Computed tomography in the management of symptomatic deviated nasal septum. This cross-sectional observational study was conducted on 120 patients with symptomatic deviated nasal septum, out of which 27 had concomitant hypertrophy of inferior turbinate. All were planned for septoplasty with or without turbinoplasty. Non contrast computed tomography (NCCT) scan was done in all cases. Different findings on NCCT were noted. After NCCT was done, 33 (27.5%) out of 120 patients underwent additional surgical procedures. In conclusion, NCCT of Nose and Paranasal sinus surgery should be given due consideration in the evaluation of symptomatic deviated nasal septum so as to avoid second surgery.
Keywords: DNS, NCCT, Additional, OMC, Sinonasal pathology
Introduction
Nasal obstruction is a highly prevalent problem that can negatively affect quality of life. One of the common causes of nasal obstruction is a deviated nasal septum. The normal nasal septum is straight, symmetrical and meets evenly arched palate in midline [1, 2]. Varying degree of nasal septal deformity occur at a considerable rate at birth and in the adults with a suggestion that the nasal septal deformity of adults cases has commenced at birth, and increasing with growth and age [3, 4]. Nasal septal deformities may cause nasal obstruction, postnasal discharge and aggravate sinusitis, upper airway infection,various middle ear infections
It is associated with varying degree of concomitant inferior turbinate hypertrophy on the side contralateral to the direction of septal convexity. In presence of inflammation, both deviated nasal septum and inferior turbinate hypertrophy could cause decrease in airflow resulting in total obstruction of the nasal airways with consequent sinus blockage leading to chronic nasal congestion and recurrent episodes of acute rhinosinusitis. In the presence of such nasal obstruction, septoplasty can improve the nasal airway.
Diagnostic nasal endoscopy is also used for the diagnosis and grading of nasal septal deviation and turbinate hypertrophies. The limitation with nasal endoscopy is that, it becomes very challenging in the patients with impacted nasal septum and those patients with massive turbinate hypertrophy and some patients who are apprehensive are not comfortable with nasal endoscopy. However, the gold standard method for the evaluation of paranasal anatomy and inflammatory paranasal sinus pathologies is paranasal sinus computed tomography (PNS CT) [5] Preoperative non-contrast computed tomography (NCCT) nose and paranasal sinus (PNS) is often performed in patients undergoing septoplasty for the pre-operative evaluation of the nasal anatomy and concomitant sinonasal pathologies, and to reduce surgical failure [6, 7]. A high incidence of sinusitis in severe DNS when compared with the mild and moderate groups has been reported. Additional surgical interventions owing to computed tomography (CT) performed in addition to septoplasty are much more helpful to relieve the patient’s nasal air passage obstruction [8].
Hence this study is done to document our experience of role of CT scan in predicting concomitant sinonasal pathologies and whether such CT scans add any other surgical procedure to planned septoplasty.
Material and Methods
This cross-sectional, observational study was conducted in the Postgraduate Department of Otorhinolaryngology and Head &Neck Surgery, Government Medical College Srinagar, over a period of 18 months from November 2017 to April 2019.
A Proper Institutional Ethical Clearance was Obtained from Institutional Ethical Committee in 2017
All patients attending the department fulfilling the following inclusion and exclusion criteria were enrolled in the study.
Inclusion Criteria
Patient with chief/predominant complaint of nasal obstruction diagnosed with Deviated Nasal Septum with or without inferior turbinate hypertrophy on anterior rhinoscopy.
Patient 17 years of age and above.
Exclusion Criteria
All patients with nasal polyps on anterior rhinoscopy or nasal endoscopy.
Previous nasal surgery.
Patients with sinonasal tumors.
Acute rhinosinusitis
Written informed consent was taken from all the patients. Detailed history was taken included history about the symptoms, their duration, age, gender and history of previous nasal surgery. A complete nasal examination by inspection and palpation of external nose and assessment of nasal cavity of every patient was done by anterior rhinoscopy.
These patients underwent nasal endoscopic examination by a 0° 4 mm/2.7 mm rigid endoscope. Patients having nasal polyps or sinonasal tumours on endoscopy were excluded. Rest of the patients was advised septoplasty with or without inferior turbinate surgery based on the clinical examination after taking proper consent.
Different endoscopic findings were noted. Deviated Nasal Septum (DNS) was graded by Mladina Classification (1987) [25].
On DNE, Inferior Turbinate Classification system was used preoperatively for grading the amount of airway space that the anterior aspect of the inferior turbinate occupies relative to the total available airway space and were categorized as follows:
Grade 1: 0–25% of total airway space.
Grade 2: 26–50% of total airway space.
Grade 3: 51–75% of total airway space.
Grade 4: 76–100% of total airway space.
Grade 1 was considered normal while grade 2–4 turbinate’s were considered hypertrophied. Turbinate surgery was not done in patients with Grade I turbinate hypertrophy. All patients planned for septoplasty with/without inferior turbinate surgery were subjected to non-contrast computed tomography nose and paranasal sinus coronal and axial sections with slice thickness 3mm, with the aim of providing valuable information about hidden inflammatory pathologies, concha bullosa, turbinate hypertrophy, uncinate process abnormalities, OMC pathologies and anatomical variation contributing to nasal obstruction.
Different NCCT findings were noted. CT scan inflammatory pathologies were graded by Lund and Mackay Radiological Score. Based on CT scan findings, the surgical plan of each patient was modified accordingly.
Statistical Analysis
Data was entered in a Microsoft Excel spreadsheet. Categorical variables were summarized as frequency and percentage. CT findings and intra-operative findings were compared using McNemar chi-square test for each parameter of interest. Two-tailed p-values were reported and a p-value < 0.05 was considered statistically significant. Statistical analysis was done using STATA version 15.
Result and Observation
Total number of patients enrolled were 120. The Mean ± SD (Range) of age was 24.7±7.32 (17–52) years. Maximum number 71 (59.2%) of patients were males and 49 (40.8%) patients were females.
The most common type of DNS (Mladina classification) was type 2 in 52 (43.3%) patients, followed by type 3 in 35 (29.2%) patients, type 4 in 18 (15.0%) patients, type 5 in 6 (5.0%) patients, type 1 in 5 (4.2%) patients and type 6 in 4 (3.3%) patients.
DNE was done in all cases. Hypertrophied inferior turbinate (grade2–4) was seen in 27 patients on DNE. Additional findings seen on DNE were bullous middle turbinate in 10patients (8.3%), Middle meatus discharge seen in 10 (8.3%) patients {2 (1.7%) patients on right, 6 (5.0%) patients on left and 2 (1.7%) patients on bilateral}. Sphenoethmoidal discharge was seen in 1(0.8%) patient on the right side. Paradoxical middle turbinate and accessory ostia were seen in 12 (10%) patients and 2 (1.7%) patients respectively (Table 1).
Table 1.
Abnormal Diagnostic nasal endoscopy findings
| No. of patients | Percentage* | |
|---|---|---|
| Bulbous middle turbinate (n=10) | ||
| Right | 5 | 4.2 |
| Left | 4 | 3.3 |
| Bilateral | 1 | 0.8 |
| Middle meatus discharge/edematous (n=10) | ||
| Right | 2 | 1.7 |
| Left | 6 | 5.0 |
| Bilateral | 2 | 1.7 |
| Sphenoethmoidal recess discharge | ||
| Right | 1 | 0.8 |
| Paradoxical middle turbinate | 12 | 10 |
| Accessory ostia | 2 | 1.7 |
| Inferior turbinate hypertrophy (Grade2–4) | 27 | 22.5 |
*Percentage calculated out of total 120 patients
NCCT nose and PNS which was done in all cases showed many additional findings. Osteomeatal complex block was seen in 17 patients.
Mucosal thickening or disease of maxillary sinus was seen in 16 (13.3%) patients, anterior ethmoid sinus in 8 (6.7%), posterior ethmoid sinus in 4 (3.3%), sphenoid sinus in 2 (1.7%) and frontal sinus in 1 (0.8%) patient. Osteomeatal complex block (OMC) along with Isolated frontal sinus/recess mucosal thickening was seen in 1 (0.8%) patient, OMC block along with Isolated maxillary sinus mucosal thickening was the CT finding in 8 (6.6%) patients, OMC block along with maxillary sinus and anterior ethmoid sinus mucosal thickening was seen in 4 (3.3%) patients, OMC block along with maxillary sinus, anterior and posterior ethmoid sinus mucosal thickening was seen in 4 (3.3%) patients, isolated sphenoid sinus mucosal thickening was seen in 2 (1.7%) patients.
Hypertrophied inferior turbinate was seen in 27 (22.5%) patients, concha bullosa in 14 (11.6%) patients and DNS was seen in all 120 (100%) patients.
Other anatomical variations seen were pneumatized crista gilla in 17 (14.2%) patients, agger nasi cell in 17 (14.2%) patients, concha bullosa in 14 (11.7%) patients, paradoxical middle turbinate in 12 (10%) patients, haller cells in 10 (8.3%) patients, onodi cells in 9 (7.5%) patients, pneumatized uncinate in 4 (3.3%) patients and accessory ostia in 2 (1.7%) patients (Table 2).
Table 2.
NCCT scan findings in study patients (n=120)
| Finding | No. of patients | Percentage (%) |
|---|---|---|
| OMC block+frontal sinus/recess mucosal thickening (isolated) | 1 | 0.8 |
| OMC block+maxillary sinus mucosal thickening (isolated) | 8 | 6.6 |
| OMC block + Maxillary sinus + anterior ethmoid sinus mucosal thickening | 4 | 3.3 |
| OMC block + Maxillary + anterior ethmoid + posterior ethmoid sinus mucosal thickening | 4 | 3.3 |
| Isolated sphenoid sinus mucosal thickening | 2 | 1.6 |
| Hypertrophied inferior turbinate | 27 | 22.5 |
| Concha bullosa | 14 | 11.6 |
| DNS | 120 | 100 |
| Pneumatized crista gilla | 17 | 14.2 |
| Agger nasi cell | 17 | 14.2 |
| Paradoxical middle turbinate | 12 | 10 |
| Haller cells | 10 | 8.3 |
| Onodi cells | 9 | 7.5 |
| Pneumatized Uncinate | 4 | 3.3 |
| Accessory Ostia | 2 | 1.7 |
Lund Mackay CT Score for sinuses was in the range of 0–3 in 101 (84.2 %) patients, 4–10 in 11 (9.1 %) patients, 11–16 in 8 (6.6%) patients while as none of the patients were seen with Lund Mackay score of 17–24 (Table 3).
Table 3.
Lund Mackay CT scoring for sinuses
| Lund Mackay CT scoring | Frequency | Percentage |
|---|---|---|
| 0–3 | 101 | 84.2 |
| 4–10 | 11 | 9.1 |
| 11–16 | 8 | 6.6 |
| 17–24 | 0 | 0.0 |
| Total | 120 | 100 |
In this study additional findings on CT Scan not seen on DNE were pneumatized uncinate in 4 (3.3%) patients, OMC blocked in 7 (5.8%) patients, haller cells in 10 (8.3%) patients, onodi cells in 9 (7.5%) patients, maxillary sinus mucosal thickening in 16 (13.3%) patients, anterior ethmoid sinus mucosal thickening in 8 (6.7%) patients, posterior ethmoid sinus mucosal thickening in 4 (3.3%) patients, sphenoid sinus mucosal thickening in 2 (1.7%) patients and frontal sinus mucosal thickening in 1 (0.8%) patient (Table 4).
Table 4.
Findings on CT Scan (not found on DNE) (n = 120)
| No. of patients | Percentage | |
|---|---|---|
| Pneumatized Uncinate | 4 | 3.3 |
| OMC blocked | 7 | 5.8 |
| Haller cells | 10 | 8.3 |
| Onodi cells | 9 | 7.5 |
| Maxillary sinus mucosal thickening | 16 | 13.3 |
| Anterior ethmoid sinus mucosal thickening | 8 | 6.7 |
| Posterior ethmoid sinus mucosal thickening | 4 | 3.3 |
| Sphenoid sinus mucosal thickening | 2 | 1.7 |
| Frontal sinus mucosal thickening | 1 | 0.8 |
In this study, out of 120 patients, 93 (77.5%) patients were planned for septoplasty and 27 (22.5%) patients were planned for Septoplasty and Inferior turbinoplasty before CT scan (Table 5).
Table 5.
Treatment plan before CT scan
| Treatment plan | No of patients | Percentage |
|---|---|---|
| Septoplasty | 93 | 77.5 |
| Septoplasty + inferior turbinoplasty | 27 | 22.5 |
| Total | 120 | 100 |
After CT scan was done, preoperative surgical plan changed. Out of 93 cases planned for only Septoplasty in pre-CT group, 72 underwent septoplasty only as planned, while 21 patients underwent septoplasty with additional procedures after CT scan and out of 27 patients that were planned for septoplasty with inferior turbinoplasty after getting CT Scan done, only 15 patients underwent septoplasty and inferior turbinoplasty only and additional procedures were done in 12 patients. In this study, 33 (27.5%) out of 120 patients underwent additional surgical procedures after CT scan (Table 6).
Table 6.
Treatment plan before and after CT scan
| Treatment plan before CT scan | Treatment plan after CT scan | Total | |
|---|---|---|---|
| No change in treatment plan | Additional procedure (change in treatment plan) | ||
| Septoplasty | 72 | 21 | 93 |
| Septoplasty + Inferior turbinoplasty | 15 | 12 | 27 |
| Total | 87 | 33 | 120 |
Additional procedures in 21 patients out of 93 patients planned for septoplasty before CT were conchoplasty in 8 patients, middle meatal antrostomy (MMA) in 6 patients, middle meatal antrostomy and anterior ethmoidectomy (MMA + AE) in 2 patients, middle meatal antrostomy and anterior and posterior ethmoidectomy in 2 patients, sphenoidotomy in 2 patients and frontal sinusotomy in 1 patient (Table 7).
Table 7.
Additional procedures after CT scan in study patients (n = 33)
| Additional procedure after CT scan | Plan before CT scan | Total | |
|---|---|---|---|
| Septoplasty | Septoplasty + Inferior Turbinoplasty | ||
| Conchoplasty | 8 | 6 | 14 |
| MMA | 6 | 2 | 8 |
| MMA+AE | 2 | 2 | 4 |
| MMA+AE+PE | 2 | 2 | 4 |
| Frontal Sinusotomy | 1 | 0 | 1 |
| Sphenoidotomy | 2 | 0 | 2 |
| Total | 21 | 12 | 33 |
Additional procedures done in 12 cases out of 27 patients who were planned for septoplasty and inferior turbinoplasty before CT scan were conchoplasty in 6 patients, middle meatal antrostomy in 2 patients, middle meatal antrostomy and anterior ethmoidectomy in 2 patients, middle meatal antrostomy with anterior and posterior ethmoidectomy in 2 patients (Table 7).
Discussion
Nasal obstruction is a highly prevalent problem that can negatively affect the quality of life. One of the common causes of nasal obstruction is a deviated nasal septum. In the presence of such nasal obstruction, septoplasty can improve the nasal airway. The mean age of patients in our study was 24.7 ± 7.32 years with a range of 17–52 years. A similar study by Adeel et al. [9] found a mean age of 31.0 ± 13.15 while in a study by Kanwar et al. [10 majority of patients (33%) were in the age group of 21–30 years.
We found male preponderance and the same is well reported in literature [9, 10] but its significance isn’t clear.
On Diagnostic nasal endoscopy (DNE), the distribution of DNS (by Mladina classification) was type 2 in 52 (43.33%) patients, followed by type 3 in 35 (29.16%) patients, type 4 in 18 (15.0%) patients, type 5 in 6 (5%) patients and type 1 in 5 (4.2%) patients and type 6 in 4 (3.3%) patients. None of the patients had type 7 in our study.
These findings are in accordance with the study done by Gupta et al. [11] who found type 2 DNS in 45% of patients followed by type 3 DNS in 20.50% of patients. In contrast Etigada et al. [12] found type 3 DNS in 8 (26.66%) patients followed by type 2 in 7 (23.33%) patients.
In our study, 27 (22.5%) patients had hypertrophied inferior turbinate on DNE. Similarly a study done by Kishore et al. [13] found hypertrophied inferior turbinate in 20% of patients while in contrast Venkatchalam et al. [14] found inferior turbinate hypertrophy in 10% patients.
Diagnostic nasal endoscopy showed that 10 (8.3%) patients had bullous middle turbinate. In a similar study done by Sayani et al. [15] bullous middle turbinate was found in 7.6% of patients which is comparable to the findings of the present study. In another study conducted by Kishore et al. [13] bullous middle turbinate was seen in 5.35% of patients.
Middle meatus discharge on DNE was seen in 10 (8.3%) patients, sphenoethmoidal recess secretions in 1 (0.8%) patient, paradoxical middle turbinate in 10 (8.3%) patients and accessory ostia were seen in 2 (1.7%) patients. Kishore et al. [13] found middle meatus discharge and paradoxical middle turbinate in 10.7% of patients while a study done by Sood et al. [16] found middle meatus discharge in 4% of patients. In a similar study done by Shelkar et al. [17] paradoxical middle turbinate was seen in 7% of patients and accessory ostia in 1% patient.
In our study, no major pathology was visible on DNE other than DNS (deviated nasal septum), inferior turbinate hypertrophy and bullous middle turbinate.
NCCT nose and PNS which was done in all cases showed many additional findings.
Mucosal thickening in maxillary sinus was seen in 16 (13.3%) patients, anterior ethmoid sinus in 8 (6.7%), posterior ethmoid sinus in 4 (3.3%), sphenoid sinus in 2 (1.7%) patients and frontal sinus in 1 (0.8%) patient and blocked osteomeatal complex was seen in 17 (14.2%) patients. A similar study done by Gupta et al. [11] found incidence of involvement of different sinuses as maxillary sinus (27.2%) followed by frontal sinus (17%) and sphenoid sinus (3%). Another study by Berenholz et al. [18] found isolated maxillary sinus disease in 15% patients, isolated ethmoid sinus disease in 3% and frontal sinus disease in 3% patients.
Concha bullosa was seen in 14 (11.7%) patients in our study. Concha bullosa was seen in14%, 15% and 16% of patients in studies by Llyod et al. [19], Mamatha et al. [20] and Dua et al. [21] respectively. In contrast it is reported as 32% and 35% in studies by Rajneesh et al. [22] and Karatas et al. [23] respectively.
Hypertrophied inferior turbinate on CT scan was seen in 27 (22.5%) patients. Eylgor et al. [24] found inferior turbinate hypertrophy in 25.1% patients which is comparable to our study while in contrast a high percentage (57.3%) was seen in a study done by Chakraborty et al. [25].
NCCT of nose and PNS showed right sided C-shaped DNS in 44 (36.7%) patients, left sided C-shaped DNS in 49 (40.8%) patients, S shaped DNS in 17 (14.1%) patients and C/S shaped DNS with spur in 10 (8.3%) patients. A study done by Kanwar et al. [10]—found DNS towards right side in 43.9% patients and towards left side in 28.5% patients. Another study done by Rehman et al. [26] found right sided DNS in 59.4% patients and left sided DNS in 40.5% patients.
Paradoxical middle turbinate was found in 12 (10%) patients, haller cell in 10 (8.3%) patients, Onodi cell in 9 (7.5%) patients, pneumatized uncinate in 4 (3.3%) patients, Agger nasi cell and pneumatized Crista galli in 17 (14.2%) patients each and accessory ostia were found in 2 (1.7%) patients. A similar study done by Eylgor et al. [24] found Agger nasi cell in 16.1% patients, paradoxical middle turbinate in 10.8% patients and haller cell in 9.3% patients. Chakraborty et al. [25] found Agger nasi cell in 26.8% patients, paradoxical middle turbinate in 14.63% patients, Onodi cell in 10.9% patients and pneumatized crista galli in 8.3% patients. Adeel et al. [9] found haller cell in 9.1% patients, onodi cell in 7.8% patients and pneumatized uncinate in 5.2% patients while study done by Sachdeva et al. [27] found accessory ostia in 2% patients.
Lund Mackay scoring of C T for sinuses was in the range of 4–10 in 11 (9.1 %) patients, 11–16 in 8 (6.6%) patients while as none of the patients were seen with Lund Mackay score of 17–24. Joseph et al. [28] in their study found Lund Mackay CT score in the range of 4–10 in 4 (14.8%) patients, followed by 11–16 in 11 (40.7%) patients and 16–24 in 12 (44.4%) patients.
In this study out of 120 patients, 93 (77.5%) patients were planned for septoplasty only and 27 (22.5%) patients were planned for septoplasty with inferior turbinoplasty before CT scan. Out of 93 patients planned for septoplasty before CT scan, 21 patients underwent additional procedures after CT scan and among 27 patients planned for septoplasty with inferior turbinoplasty before CT scan, surgical plan changed in 12 patients after CT scan. In this study, 33 (27.5%) out of 120 patients underwent additional surgical procedures after CT scan.
Additional surgical procedures done were conchoplasty in 14 (11.6%) patients, middle meatal antrostomy in 8 (6.7%) patients, middle meatal antrostomy and anterior ethmoidectomy in 4 (3.3%) patients, middle meatal antrostomy, anterior and posterior ethmoidectomy in 4 (3.3%) patients, frontal sinusotomy in 1 (0.8%) patient, and sphenoidotomy in 2 (1.7%) patients.
In a similar study done by Eylgor et al. [24] the rate of additional surgical procedures was 34.7% and the additional procedures were inferior turbinate reduction in 14.3% patients, concha bullosa resection in 11.6% patients, ESS in 8.7% patients. Karatas et al. [23] found additional findings on CT as concha bullosa in 14 (35%) patients, retention cyst of the maxillary sinus in 2 (5%) patients, paradox middle nasal concha in 2 (5%) patients, inferior concha hypertrophy in 18 (45%) patients, frontal osteoma in 1 (2.5%) patient, antrochoanal polyp in 1 (2.5%) patient, and chronic sinusitis (maxillary, ethmoidal, frontal) in 7 (17.5%) patients. In another study by Berenholz et al. [18] 16 patients (14%) patients had their surgical treatment altered and the procedures were conchoplasty in 7% patients, FESS in 7% patients. In a study done by Gunbey et al. [29] computed tomography had changed their surgical procedure in 8.3% patients. Our results of change in the surgical treatment plan after CT scan nose and PNS are in concurrence with the studies of Eylgor et al. and Karatas et al. but slightly different from the results of Berenholz et al. and Gunbey et al.
Conclusion
Nasal obstruction in otherwise healthy person is usually caused by Deviated nasal septum. Computed tomography is able to identify some additional pathological findings that cannot be found on physical examination thereby guiding in removal of these pathologies simultaneously with Septoplasty so as to avoid possible second surgery to be performed later. The incorporation of preoperative CT scan in patients undergoing septoplasty with or without turbinoplasty deserves a special consideration.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Nisar Hussain Dar, Email: darnisar@yahoo.com.
Sanam Altaf, Email: drsanams0009@gmail.com.
Suhail Amin Patigaroo, Email: Dr_suhail_jnmc@yahoo.co.in.
Shabir Ahmad, Email: drshabir@yahoo.com.
Rashid Rafiq, Email: Rashid@yahoo.com.
References
- 1.Gray LP (1972) Early treatment of septal deformity and associated abnormalities. Mod Nose Throat, pp 219–236.
- 2.Gray LP (1978) Deviated nasal septum. Incidence and etiology. Ann Otol Rhinol Laryngol 87(50):3–20. [DOI] [PubMed]
- 3.Brain D. The etiology of neonatal septal deviation. Fac Plast Surg. 1992;8(4):191–193. doi: 10.1055/s-2008-1064650. [DOI] [PubMed] [Google Scholar]
- 4.Kent SE, Reid AP, Nairnand ER, Brain DJ. Neonatal septal deviations. J R Soc Med. 1988;81(3):123–135. doi: 10.1177/014107688808100305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Wuister AM, Goto NA, Oostveen EJ, et al. Nasal endoscopy is recommended for diagnosing adults with chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014;150:359–364. doi: 10.1177/0194599813514510. [DOI] [PubMed] [Google Scholar]
- 6.Akoglu E, Karazincir S, Balci A, Okuyucu S, Sumbas H, Dagli AS. Evaluation of the turbinate hypertrophy by computed tomography in patients with deviated nasal septum. Otolaryngol Head Neck Surg. 2007;136(3):380–384. doi: 10.1016/j.otohns.2006.09.006. [DOI] [PubMed] [Google Scholar]
- 7.Kahveci OK, Miman MC, Yucel A, et al. The efficiency of nose obstruction symptom evaluation (NOSE) scale on patients with nasal septal deviation. Auris Nasus Larynx. 2012;39:275–279. doi: 10.1016/j.anl.2011.08.006. [DOI] [PubMed] [Google Scholar]
- 8.Hatipoglu HG, Cetin MA, Yuksel E. Nasal septal deviation and concha bullosa coexistence: CT evaluation. B-ENT. 2008;4:227–232. [PubMed] [Google Scholar]
- 9.Adeel M, Rajput MSA, Akhter S, Ikram M, Arain A, Khattak YJ. Anatomical variations of nose and para-nasal sinuses: CT scan review. J Pak Med Assoc. 2013;63(3):317–319. [PubMed] [Google Scholar]
- 10.Kanwar SS, Mital M, Gupta PK, Saran S, Parashar N, Singh A. Evaluation of paranasal sinus disease by computed tomography and its histopathological correlation. J Oral Mxillofac Radiol. 2017;5:46–52. [Google Scholar]
- 11.Gupta S, Gurjar N, Mishra HK. Computed tomographic evaluation of anatomical variations of paranasal sinus region. Int J Res Med Sci. 2016;4(7):2909–2913. doi: 10.18203/2320-6012.ijrms20161975. [DOI] [Google Scholar]
- 12.Etigada Y, Majeed J. Clinical and radiological evaluation of deviated nasal septum in classifying and surgical management of the deviated septums. IOSR-JDMS. 2017;16(2):13–20. doi: 10.9790/0853-1602031320. [DOI] [Google Scholar]
- 13.Kishore K, Badial V, Luthra D, Jamwal PS. Pattern of abnormal findings in adult with nasal obstruction on rhinoscopy and nasal endoscopy. JK Sci. 2012;14(3):125–128. [Google Scholar]
- 14.Venkatachalam VP, Bhat A. Functional endoscopic sinus surgery—a newer surgical concept in the management of chronic sinusitis. Indian J Otolaryngol Head Neck Surg. 1999;52:13–16. doi: 10.1007/BF02996424. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Sayani RK, Vishwakarma R. Nasal endoscopy in ENT: should it be included as a part of routine examination in ENT OPD. Int J Res Med. 2016;5(3):101–105. [Google Scholar]
- 16.Sood VP. Nasal and sinus endoscopy. Indian J Otolaryngol. 1990;42(4):143–146. doi: 10.1007/BF02994919. [DOI] [Google Scholar]
- 17.Shelkar R, Vedi J, Ekhar V, Dasgupta KS, Lanjewar K. Role of nasal endoscopy in sinonasal diseases. Int J Sci Study. 2014;2(1):6–10. [Google Scholar]
- 18.Berenholz L, Kessler A, Lapinsky J, Segal S, Shlamkovitch N. Nasal obstruction in the adult: is CT scan of the sinuses necessary? Rhinology. 2000;38(4):181–184. [PubMed] [Google Scholar]
- 19.Lloyd GA. CT of the paranasal sinuses: study of a coronal series in relation to endoscopic sinus surgery. J Laryngol Otol. 1990;104(6):477–481. doi: 10.1017/S0022215100112927. [DOI] [PubMed] [Google Scholar]
- 20.Mamatha H, Shamasunder NM, Bharathi M, Prasanna L. Variations of ostiomeatal complex and its applied anatomy: a CT scan study. Indian J Sci Technol. 2010;3:904–907. doi: 10.17485/ijst/2010/v3i8.17. [DOI] [Google Scholar]
- 21.Dua K, Chopra H, Khurana AS, Munjal M. CT Scan Variations in Chronic Sinusitis. Ind J Radiol Imag. 2005;15(3):315–320. doi: 10.4103/0971-3026.29144. [DOI] [Google Scholar]
- 22.Rajneesh RSA. radiological study of anatomical variations in ostiomeatal complex in patients with chronic rhinosinusitis. Int J Otorhinolaryngol Head Neck Surg. 2017;3(3):529. [Google Scholar]
- 23.Karatas¸ D, Yuksel F, Senturk M, Dogan M, The contribution of computed tomography to nasal septoplasty. J Craniofac Surg. 2013;24:1549–1551. doi: 10.1097/SCS.0b013e3182902729. [DOI] [PubMed] [Google Scholar]
- 24.Eylgor H, Kucuktepe U, Yilmaz MD, Osma U, Durmus E, Erol B, et al. Is performing the paranasal sinus CT before the septal operation change the indication of surgery? Eur J Rhinol Allergy. 2018;1:43–46. [Google Scholar]
- 25.Chakraborty P. Jain RK (2016) Radiologic variations of nose and paranasal sinuses: a CT based study. JMSCR. 2016;4(5):10536–10541. [Google Scholar]
- 26.Rehman A, Hamid S, Ahmad M, Rashid A. A prospective study of nasal septal deformities in Kashmiri population attending tertiary care hospital. Int J Otolaryngol Head Neck Surg. 2012;1:77–84. doi: 10.4236/ijohns.2012.13016. [DOI] [Google Scholar]
- 27.Sachdeva P, Sachdeva KS, Singh B, Singh M, Kaur M, Goyal I, Kataria G. A CT and DNE of osteomeatal complex variants and their correlation in chronic rhinosinusitis patients. Int J Otorhinolaryngol Head Neck Surg. 2017;3(3):606–610. doi: 10.18203/issn.2454-5929.ijohns20173032. [DOI] [Google Scholar]
- 28.Joseph M, David C, Vincente GM, Chua AH. Pediatric endoscopic sinus surgery in a tertiary government hospital: patient profile and surgical indications. Phil J Otolaryngol Head Neck Surg. 2009;24(1):13–17. doi: 10.32412/pjohns.v24i1.705. [DOI] [Google Scholar]
- 29.Gunbey E, Karabulut H, Gunbey HP, Cingi C. Is preoperative paranasal sinus computed tomography necessary for every patient undergoing septoplasty. Int Forum Allergy Rhinol. 2015;9:839–845. doi: 10.1002/alr.21545. [DOI] [PubMed] [Google Scholar]