Abstract
Rhinosinusitis is an extremely prevalent disorder that has a significant impact on the quality of life of affected individuals. Nasal septal deviation may either cause osteomeatal obstruction or may interfere with proper airflow and potentially predispose to sinusitis. This study was aimed to find
The incidence of various types of DNS and
To find co relation between NSD and sinus pathology
This work was done on 100 cases with clinical features of deviated nasal septum and co existing features of rhinosinusitis. Detailed nasal endocopic examination was done. DNS was classified according to Mladina system of classification. CT PNS was done in all cases and rhinosinusitis documented according to Lund–Mackay scoring system. Finally an attempt was made to correlate DNS and Rhinosinusitis.Type II and Type I deviations were the most common types of septal deviations found. 84% of the patients with DNS had rhinosinusitis. There was a statistically significant correlation between nasal septal deviation and rhinosinusitis with p value ≤ 0.05. Our study also significantly correlates the predisposition of rhinosinusitis on the same side as DNS. We hereby conclude that in a case of DNS, co-existent rhinosinusitis should be ruled out, first by detailed history taking and then if warranted by CT-PNS. Such chronic patients treated by septoplasty alone may never be relieved of their symptoms. Thus combined septopasty and FESS is advisable.
Keywords: Deviated nasal septum, Chronic rhinosinusitis, CT-PNS
Introduction
The nasal septum consists of membranous, bony and cartilaginous parts. It anatomically and physiologically separates the nasal cavity into right and left parts.
Septal deviation refers to the convexity into one side of nasal cavity. Extensive deviation causes obstruction in the free flow of air through the nostril and may lead to various symptoms of DNS and disease of paranasal sinuses [1].
Any change in the alignment of septum may lead to obstruction of air flow and hinderance to muco-ciliary clearance [2]. Muco- ciliary clearance is an important functional process that allows mucus to coat the ciliated epithelium. It acts as the first barrier against physical and biological injuries [3]. Further it puts strain on the immunological system and effects the osteomeatal complex causing various symptoms and sinonasal disease [4].
Role of Anatomical Obstruction
Patency of the pathways through which the sinuses drain is crucial of adequate mucocilliary function and subsequent sinus drainage [5]. Osteomeatal obstruction may lead to fluid accumulation and stagnation creating a moist, hypoxemic environment ideal for pathogenic growth [6].
Major anatomic variations leading to OMC obstruction are deviated nasal septum, concha bullosa, paradoxical middle turbinate and Haller cell.
DNS is one of the most common cause of OMC obstruction is discussed here using DNE and CT as tools of imaging and data collection.
Aim of the Study
Is to find the Incidence of types of nasal septal deviation and to find co relation between NSD and sinus pathology. Anatomical variations like concha bullosa, paradoxical middle turbinate and infraorbital cells are not included in the study.
Materials and Methods
Our work was done on cases attending both OPD and IPD in the department of ENT, MMIMSR MULLANA, AMBALA with clinical features of deviated nasal septum and co existing features of rhinosinusitis.
100 subjects were included in the study.
The age, sex, address and occupation of the patient was recorded. A thorough history of nasal obstruction and symptoms of rhinosinusitis was taken. Family history, past history, history of immunological disorders, allergic disorders and addiction was taken. History of nasal trauma was carefully elicited. Detailed clinical examination both local and general was done with special reference to nose and para nasal sinuses.
Anterior and Posterior rhinoscopy with detailed functional assessment of nasal patency was done.
Nasal endoscopy was done with the help of 4 mm 0° and 30° nasal endoscopes. It was done under local anaesthesia after decongesting the nose.
After detailed clinical and endoscopic examination, DNS was classified according to Mladina system of classification (Figs. 1, 2, 3).
Fig. 1.
Incidence of septal deviation according to Mladina classification found in our study
Fig. 2.
Correlation between different grades of NSD as per Mladina’s classification and rhinosinusitis found in our study
Fig. 3.
Correlation between rhinosinusitis and laterality of septal deviation found in our study
He divided septal deformities into seven types.
Types 1 and 2 depict spectrum of septal deviations that involved a unilateral vertical ridge in the nasal valve area.
Type 2 included the deformities that were severe enough to disturb the physiology of nasal valve.
Type 3 deformity refers to a unilateral vertical ridge which was present at the level of head of middle concha.
Type 4 deformity included features of type 3 in combination with type 1 or 2 and resulted in S type shaped deformity.
Type 5 and 6 deformity have horizontal base with horizontal crest that frequently comes in contact with wall of nose.
Type 6 deformity has predominant maxillary crest opposite to the deviation with crest of septum on side of deviation.
Type 7 deformity includes the combinations of any of the other six types.
The major drawback of this classification system is unidentification of cause of septal deviations despite describing the variation anatomically.
Then all the patients were taken for CT Scan of Nose and PNS in coronal, axial and saggital sections using 5 mm thickness slices at Ingenuity CT (Philips, Netherland).
CT scans were evaluated for the involvement of various sinuses and its findings were documented according to Lund Mackay scoring system.
Lund–Mackay Scoring System for Chronic Sinusitis
- 0 points
Normal sinus.
- 1 points
Incomplete/partial cloudiness of sinus.
- 2 points
Complete/total cloudiness of sinus.
Scores were given as 0 points, 1 points or 2 points for left and right side of each of the sinuses and total scores were calculated.
An attempt was made to evaluate the type of DNS, and to make a correlation between type of deviated nasal septum and chronic sinusitis.
Inclusion Criteria
- Patients
-
1. Between age group of 10–60 year.
2. Clinically symptomatic patients of deviated nasal septum.
3. Clinically symptomatic patients of chronic rhinosinusitis.
Results
Age distribution: The cases were divided into 5 groups according to age. Maximum cases were 43% in the age group of 21–30 years. Minimum age was 10 and maximum age was 60 year.
Sex distribution: Out of 100 patients 58 were males and 42 were females. Male to female ratio was 1.38:1 (Tables 1, 2, 3, 4, 5).
Table 1.
Symptomatology
| Symptomatology | Number of patients (100) |
|---|---|
| Anterior nasal discharge | 80 |
| Nasal obstruction | 62 |
| Headache | 37 |
| URTI | 37 |
| Post nasal discharge | 36 |
| Facial pain | 21 |
| Disturbance of smell sensation | 20 |
Table 2.
Clinical findings
| Clinical findings | Percentage of cases (n = 100) |
|---|---|
| Deviated nasal septum | 100 |
| Mucopurulent/purulent nasal discharge | 85 |
| Edematous nasal mucosa | 71 |
| Inferior turbinate hypertrophy | 51 |
| Post nasal drip | 36 |
| Sinus tenderness | 20 |
| Antrochonal polyp | 02 |
Table 3.
Incidence of findings on nasal endoscopy
| DNS | 100 |
| Nasal discharge in middle meatus chonae | 90 |
| Mucosal oedema | 80 |
| Inferior turbinate hyp | 51 |
| Antrochonal polyp | 2 |
Table 4.
Lund Mackay ct scoring
| Mladina type | Total | |||||||
|---|---|---|---|---|---|---|---|---|
| I | II | III | IV | V | VI | VII | ||
| Lund group | ||||||||
| 0 | 2 | 2 | 4 | 4 | 2 | 2 | 0 | 16 |
| 1–4.0 | 12 | 13 | 4 | 2 | 2 | 2 | 0 | 35 |
| 5–8.0 | 4 | 6 | 3 | 2 | 3 | 3 | 1 | 22 |
| 9–12.0 | 3 | 3 | 2 | 1 | 2 | 0 | 0 | 11 |
| 13–16.0 | 1 | 1 | 2 | 4 | 0 | 1 | 0 | 9 |
| 17–20.0 | 0 | 0 | 1 | 2 | 2 | 2 | 0 | 7 |
| Total | 22 | 25 | 16 | 15 | 11 | 10 | 1 | 100 |
Table 5.
Correlation between different grades of NSD as per Mladina’s classification and rhinosinusitis
| Type | Number | Rhinosinusitis | % of rhino sinusitis |
|---|---|---|---|
| I | 22 | 20 | 90.9 |
| II | 25 | 23 | 92 |
| III | 16 | 12 | 75 |
| IV | 15 | 11 | 73 |
| V | 11 | 9 | 81.8 |
| VI | 10 | 8 | 80 |
| VII | 01 | 1 | 100 |
| Total | 100 | 84 |
Discussion
The vast comprehensive knowledge of muco-ciliary clearance and pathophysiology of inflammatory diseases of paranasal sinus, combined with the accessibility of high definition CT and advancement of endoscopically used instruments, makes it necessary for the otorhinolaryngologist to have a concise mastery on the subject of anatomy of nose and paranasal sinuses with their variations and diseases.
Diagnostic nasal endoscopic examination in combination with CT scan has made diseases of sino nasal area approachable as well as precise, peculiar and well reasoned.
CT scan because of its magnificient potential of exhibiting bone and soft tissues, has become the present day investigation of choice for diagnosis of sinonasal disease.
Maximum 43 (%) cases were found in age group of 21–30 years. Mean age found to be was 31.71 with standard deviation of 11.69. Whereas study conducted by Smith et al. [7] had age within range of 4–99 years.
There were 52% males and 48% females (ratio 1.38:1) in the present study showing male predominance over females. In study conducted by Smith et al. [7] they found 43.6% of patients were males and 56.3% patients were females (ratio 1.30:1).
In our study we found frequency of symptoms were as follows at the time of presentation- Anterior nasal discharge 80%, nasal obstruction 62%, headache in 37%, post nasal drip in 37%. Mendiratta et al. [8] studied the symptoms and disease severity in chronic rhinosinusitis and concluded that common symptom of presentation was nasal discharge (85%) and headache (70%) in their study of 40 patients in CRS.
In our study we found As per Mladina’s classification vertical deviations accounted for majority of patient’s septal deviations with 25 (25%) cases of type II NSD and 22 (22%) cases of type I NSD. This was in accordance to study conducted by Bist et al. [9] who found 31 (27.1%) cases of type II NSD and 24 (21.1%) cases of type I NSD. Kanmadi et al. [10] in their study found type I and type V being the most common variations.
In Our study we found that hypertrophy of mucosa of maxillary sinus was seen in 70% patients. Mohebbi et al. [11] in their study found 72.6%, Chaitanya et al. [12] found 88.5% and Suri et al. [13] concluded 66.6% involvement of maxillary sinus hypertrophy.
In Our study of 100 Patients with NSD, rhinosinusitis was found in 84.0% of patients and absent in 16% of patients. NSD to the right side was present in 42% cases. 47.6% of these had RS on same side, 9.5% on opposite side and 12% on both sides. RS was absent in 14.2% cases.
NSD of the left side was found to be in 43% cases. 41.8% of these had RS to same side, 13.9% on opposite side and 30.2% on both sides. RS was absent in 13.9%.
15 patients had S Shaped DNS. 73.3% of these had rhinosinusitis on both sides.
Thus, there were 84% of total number of patients with NSD and rhinosinusitis.
38 (45.2%) patients were found to have Rhinosinusitis ipsilateral to NSD, 10 (11.9%) patients were found to have Rhinosinusitis contralateral to NSD and 25 (29.7%) patients were found to have Rhinosinusitis bilateral of NSD.
16% of patients had no sinus pathology on CT scan despite having septal deviation.
In study conducted by Bist et al. [9] they found that from 57 patients of DNS and sinusitis, 13 (11.4%) had features of sinusitis on same side as DNS, 14 (12.28%) on opposite side and 30 (26.31%) on both sides of septal deviation.
Conclusion
Rhinosinusitis is an extremely prevalent disorder that has a significant impact on the quality of life of affected individuals. When taking into consideration about the healthy respiratory function of nose, morphological as well as anatomical features of cartilaginous and bony portions of nasal septum play a significant role. The extent of sinonasal inflammatory pathology, important anatomic landmarks and their variations can be easily detected on CT scan which provided a reliable road map for endoscopic sinus surgery.
Type II and Type I deviations according to Mladina system were found out to be most common type of deviations.
We have found significant statistical correlation between the presence of nasal septal deviation and rhinosinusitis.
Type II and Type I deviations were found to have highest incidence of rhinosinusitis. These deviations were vertical deviations that affected the nasal valve area.
Type V deviation was next in frequency showing predisposition for rhinosinusitis. Type V includes horizontal deviations that push the middle turbinate laterally thereby affecting the osteomeatal area.
We hereby conclude that in a case of DNS, co-existent rhinosinusitis should be ruled out, first by detailed history taking and then if warranted by CT-PNS. Such chronic patients treated by septoplasty alone may never be relieved of their symptoms. Thus combined septopasty and FESS is advisable.
Acknowledgements
I would like to extend my thanks to my mentor Dr. Ginni Datta for her support and guidance throughout this tedious task. I would also like to give thanks to Dr. Gurchand Singh for his guidance during this endeavor.
Funding
No funding sources.
Compliance with Ethical Standards
Conflict of interest
The authors decare that they have no conflict of interest.
Ethical Approval
The study was approved by the Institutional Ethics Committee.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Poorey VK, Gupta N. Endosopic and CT evaluation of influence of nasal septal deviation on lateral wall of nose and its relation to sinus diseases. Indian J of Otolaryngol Head Neck Surg. 2014;41:103–106. doi: 10.1007/s12070-014-0726-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Passali D, Ferri R, Becchini G, Passali C, Bellussi L. Alterations of nasal mucociliary transport in patients with hypertrophy of the inferior turbinates, deviations of the nasal septum and chronic sinusitis. Eur Arch Otorhinolaryngol. 1999;256:335–337. doi: 10.1007/s004050050158. [DOI] [PubMed] [Google Scholar]
- 3.Kern RC, Liddy W (2015) Rhinosinusitis. Flint PW, Lund V, Thomas JR, Robbins KT et al. Cummings otolaryngol head neck surgery, 2nd ed. Elsevier, Amsterdam, pp 837–841
- 4.Llyod GAS, Lund VJ, Scadding GK. CT of the paranasal sinuses and functional endoscopic surgery: a critical analysis of 100 symptomatic patients. J Laryngol Otol. 1991;105:181–185. doi: 10.1017/S0022215100115300. [DOI] [PubMed] [Google Scholar]
- 5.Watelet JB, Van Cauwenberge P. Applied anatomy and physiology of the nose and paranasal sinuses. Allergy. 1999;54(57):14–25. doi: 10.1111/j.1398-9995.1999.tb04402.x. [DOI] [PubMed] [Google Scholar]
- 6.Meserklinger W. Endoscopy of the nose. Baltimore: Urban and Schwarzenberg; 1978. [Google Scholar]
- 7.Smith K, Edwards P, Saini T, Norton N. The prevalence of concha bullosa and nasal septal deviation and their relationship to maxillary sinusitis by volumetric tomography. Int J Dent. 2010;2010:1–5. doi: 10.1155/2010/404982. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Mendiratta V, Baisakhiya N, Singh D, Datta G, Mittal A, Mendiratta P. Sinonasal anatomical variants: CT and endoscopy study and its correlation with extent of disease. Indian J Otolaryngol Head Neck Surg. 2015;68(3):352–358. doi: 10.1007/s12070-015-0920-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Prasad S, Varshney S, Bist SS, Mishra S, Kabdwal N. Correlation study between nasal septal deviation and rhinosinusitis. Indian J Otolaryngol Head Neck Surg. 2013;65(4):363–366. doi: 10.1007/s12070-013-0665-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Atik Ahmed M, Kanmadi S. Role of computed tomography in evaluation of congenital anatomical variations in paranasal sinuses. Int J Biol Med Res. 2015;6(1):4775–4781. [Google Scholar]
- 11.Mohebbi A, Ahmad A, Maryam E, Manouchehr S, Shadi G. An epidemiologic study of factors associatedwith nasal septum deviation by computed tomography scan: a cross sectional study. BMC Ear Nose Throat Disord. 2012;12:1–5. doi: 10.1186/1472-6815-12-15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chaitanya CS, Raviteja A. Computed tomographic evaluation of diseases of paranasal sinuses. Int J Recent Sci Res. 2015;6(7):5081–5085. [Google Scholar]
- 13.Suri N, Janardhan T, Parmar H. Correlation of anatomical variations of paranasal sinuses and chronic rhinosinusitis. Int Arch Integr Med. 2016;3(12):84–88. [Google Scholar]