Abstract
Nasal obstruction due to Deviated Nasal Septum (DNS) is a commonly encountered condition by the Otorhinolaryngologist. This leads to chronic hypoxia which in turn leads to stimulation of platelets. This change can be assessed by estimation of the Mean Platelet Volume (MPV) which is a commonly available investigation while ordering a haemogram. As there is a lot of conflicting data about the relationship between DNS and MPV, this study was undertaken to evaluate if there is a relationship between these two parameters. A 1-year observational study was done and after adhering to the inclusion and exclusion criteria, there were 50 cases of deviated nasal septum and 50 controls who attended the ENT Out-Patient Department of a tertiary care hospital who were evaluated. Blood was drawn and the Mean Platelet Volume was estimated. It was found that there was no statistical significance between the cases and controls. Contradictory to other studies done in literature, our study did not find any correlation. This could be due to the type of septal deviation cases that were part of our study. Hence, multicentric studies with larger samples need to be studied in order to establish sound conclusions.
Keywords: Deviated nasal septum, Mean platelet volume, Nasal obstruction
Introduction
Nasal obstruction can be caused due to multiple factors. Of these common causes are nasal septal deviation followed by others such as turbinate hypertrophy, adenoid hypertrophy and nasal polyposis [1, 2].
Septal deviation leads to chronic hypoxia by virtue of causing resistance in the upper respiratory tract which leads to alveolar hypoventilation [3]. It is postulated that chronic hypoxia and hypercarbia lead to hypercoagulopathy [4].
Mean Platelet Volume (MPV) is a value which reflects the average size of the platelets found in blood and is a part of routine haemogram. It is elevated in conditions such as myeloproliferative disorders, immune thrombocytopenic purpura, Bernard Soulier syndrome and various obstructive airway pathologies [5]. Lower values are seen in conditions such as aplastic anemia. The normal value ranges from 7.5 to 11.5 fl [4].
Mean platelet volume is a marker of platelet reactivity and the pro-thrombotic potential of platelets increases due to larger size due to presence of metabolically and enzymatically dense granules. This results in atherosclerosis which is a precursor of conditions such as myocardial infarction and stroke [6]. Although the exact mechanism of platelet activation is unclear, it is suggested that this could be secondary to increased circulating catecholamines caused due to persistent alveolar hypoxia which triggers an augmented sympathetic over activity [7].
Aim and Objective
To evaluate the relationship between Mean Platelet Volume (MPV) and nasal obstruction due to deviated nasal septum.
Materials and Method
Type of Study
Prospective Observational Study.
Sample Size
100–50 cases and 50 controls.
Source of Data
Patients attending the ENT out patient department of KLEs Dr. Prabhakar Kore Hospital & MRC with symptomatic deviated nasal septum were studied as cases and those attending with other complaints related to the ear and throat were studied as controls.
Inclusion Criteria
The study included patients aged 18 years and above. Patients with symptomatic deviated nasal septum diagnosed on the basis of anterior rhinoscopy and confirmed by nasal endoscopy were included.
Exclusion Criteria
Hypertension, coronary artery disease, hypercholesterolemia, chronic heart failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, renal diseases, hepatic dysfunction, thyroid disorders, autoimmune diseases, patients on antithrombotic agents, selective serotonin reuptake inhibitors and those with systemic inflammatory diseases such as psoriasis, rheumatoid arthritis and bronchial asthma with were excluded from the study.
Methodology
After obtaining consent from the participants, blood was drawn and sent to the Pathology department for estimation of the Mean Platelet Volume (MPV). The report was documented and analysed for the cases and controls by applying the T-test using IBM Statistical Package for Social Sciences (SPSS) version 24.
Results
Majority of the patients among the cases were in the age group of 20–29 years (38%) as seen in the Fig. 1.
Fig. 1.
Pie chart showing the age distribution of the cases with Deviated Nasal Septum
There were 50 cases of which there were 14 (28%) females and 36 (72%) males. Amongst the 50 controls, there were 19 (38%) females and 31 (62%) males. The male:female ratio amongst the cases and controls was 2.57 and 1.63 respectively as seen in Table 1.
Table 1.
Gender distribution among cases and controls
| Female | Male | Total | |
|---|---|---|---|
| Cases | 14 (28%) | 36 (72%) | 50 |
| Controls | 19 (38%) | 31 (62%) | 50 |
According to Cottle’s classification, 42 (84%) of the cases were of simple type of DNS and 8 (26%) were of obstructive type. The MPV observed is as seen in Table 2.
Table 2.
Type of Deviated Nasal Septum and Mean Platelet Volume (fl)
| Simple (42) | Obstructed (8) | Controls (50) | |
|---|---|---|---|
| Mean Platelet Volume | 7.91 + 1.01 fl | 7.99 + 0.61 fl | 8 + 0.61 fl |
The MPV was 7.9 + 0.96 fl amongst the cases and 8 + 0.61 fl amongst the controls as seen in Table 3.
Table 3.
Mean Platelet volume (fl) in cases and controls
| Female | Male | Combined | |
|---|---|---|---|
| Cases | 8 + 1.09 fl | 7.8 + 0.92 fl | 7.9 + 0.96 fl |
| Controls | 8 + 0.53 fl | 7.9 + 0.66 fl | 8.0 + 0.61 fl |
Discussion
Nasal septal deviation is one of the frequently encountered conditions in routine practice in patients with nasal obstruction. The chronicity of the condition leads to a plethora of conditions landing the patient up in serious potentially life threatening conditions. Chronic hypoxia leads to respiratory acidosis leading to increased effort by the right ventricle to circulate blood due to hypoxia and hypercarbia induced vasoconstriction. This leads to pulmonary hypertension, right ventricular failure and cor pulmonale [4].
Mean Platelet Volume is one of the most reliable, affordable and accurate measure about the size and function of platelets [7]. Association of increased MPV and resultant narrowing of the vascular lumen due to inflammatory damage and atherosclerosis thus contributing to coronary artery diseases is well documented [8–10].
According to a study done by Sagit et al. and Ulu et al. there is an association between deviated nasal septum and MPV. Most of our patients were in the age group of 20–29 years as this is the time when the septum has just finished modelling and has attained its final shape. Further changes in the angulation/deviation rarely occur after patients end their teens. This is also one reason why many of them start developing symptoms which are persistent and fail to resolve upon taking medical therapy for prolonged periods and seek attention from the ENT surgeons. The higher male:female ratio in our study could be attributed to the fact that males are more likely to experience nasal trauma either during childhood or during the prime of their age in their teens due to extensive socialising and due to the right to obtain driving license and commit or succumb to road traffic accidents frequently. The higher male:female ratio has also been observed in studies conducted by Poorey et al. [7].
However, unlike most of the studies [7, 11, 12] wherein a strong positive correlation is observed between deviated nasal septum and increasing mean platelet values, we have not observed the same in our study. This could be due to the fact that 84% of our cases (42 out of 50) were of simple type of deviated nasal septum. Poorey et al. in their study established a positive correlation between DNS and MPV wherein 50.79% cases were obstructed and 30.15% cases were impacted type of deviated nasal septum. This could explain that greater the deviation, higher is the correlation observed with the MPV. But our assessment suggests that the Cottle’s classification cannot be used as a sole indicator to carry out and establish such conclusions as there are other ways of classifying DNS which also need to be taken into account. Also the geographical variations need to be considered as India is a diverse country. Due to vast variations in the altitude of our landscape, it is possible that people acclimatised to living in higher altitude have a higher MPV due to chronic hypoxia but they might be having a simple DNS otherwise. Therefore we need to look into regional variations and different classifications and conduct similar studies with larger samples at different centres inorder to establish sound conclusions.
Conclusion
Deviated Nasal Septum (DNS) causes chronic hypoxia and as a result of this there is long term morbidity associated with it. Mean Platelet Volume (MPV) is a simple, affordable and easily available surrogate to assess the long-term effect of chronic nasal obstruction caused due to DNS and educate the patient regarding septal correction and also undergo the same. Although many studies have found a positive correlation, we did not find any significant correlation in the present study. Larger sample size and multicentric studies need to be done. Variations in the type of DNS being studied, and confounding factors due to regional/geographical differences in altitude also need to be taken into consideration before conclusively suggesting that a positive correlation exists between DNS and MPV.
Funding
None.
Availability of Data and Material
Not applicable.
Compliance with Ethical Standards
Conflict of interest
None.
Consent to Participate
Written informed consent was obtained from the relatives/ legal guardians of the study participant.
Code Availability
Not applicable
Ethics Approval
Approval was obtained from the ethics committee of KLE Academy of Higher Education and Research. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Murray JAM, Maran AG, Mackenzie IJ, et al. Open versus closed reduction of the fractured nose. Arch Otolaryngol. 1984;110:797–802. doi: 10.1001/archotol.1984.00800380027008. [DOI] [PubMed] [Google Scholar]
- 2.McKenzie M. Manual of diseases of the nose and the throat. London, UK: Churchill; 1880. [Google Scholar]
- 3.Nagata Y, et al. Proplatelet formation of megakaryocytes is triggered by autocrine estradiol. Genes Dev. 2003;17:2864–2869. doi: 10.1101/gad.1128003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rahman A, Hashmi SF, Hasan SA, Arif SH. Role of septoplasty in reducing the incidence of comorbidities associated with elevated levels of mean platelet volume. Egypt J Otolaryngol. 2016;32:156–160. doi: 10.4103/1012-5574.186542. [DOI] [Google Scholar]
- 5.Liu S, Ren J, Han G, Wang G, Gu G, Xia Q, Li J. Mean platelet volume: a controversial marker of disease activity in Crohn’s disease. Eur J Med Res. 2012;17:27. doi: 10.1186/2047-783X-17-27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Pizzuli L, Yang A, Martin JF, et al. Changes in platelet size and count in unstable angina pectoris compared to stable or non-cardiac chest pain. Eur Heart J. 1998;19:80–84. doi: 10.1053/euhj.1997.0747. [DOI] [PubMed] [Google Scholar]
- 7.Poorey VK, Thakur P. Effect of deviated nasal septum on mean platelet volume: a prospective study. Indian J Otolaryngol Head Neck Surg. 2014;66(4):437–440. doi: 10.1007/s12070-014-0748-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lance MD, et al. Mean platelet volume as a diagnostic marker for cardiovascular disease: drawbacks of preanalytical conditions and measuring techniques. Clin Appl Thromb Hemost. 2012;18(6):561–568. doi: 10.1177/1076029612458147. [DOI] [PubMed] [Google Scholar]
- 9.Leader A, et al. Are platelet volume indices of clinical use? A multidisciplinary review. Ann Med. 2012;44(8):805–816. doi: 10.3109/07853890.2011.653391. [DOI] [PubMed] [Google Scholar]
- 10.Gasparyan AY, et al. Mean platelet volume: a link between thrombosis and inflamation. Curr Pharm Des. 2011;17:47–58. doi: 10.2174/138161211795049804. [DOI] [PubMed] [Google Scholar]
- 11.Sagit M, et al. Septoplasty decreases the Mean Platelet Volume levels in patients with marked septal deviations. J Craniofac Surg. 2012;23(4):974–976. doi: 10.1097/SCS.0b013e31824e2c08. [DOI] [PubMed] [Google Scholar]
- 12.Ulu S, et al. Evaluating the relationship between nasal obstruction and mean platelet volume by using acoustic rhinometry in patients with septum deviation. Rhinology. 2013;51(3):249–252. doi: 10.4193/Rhino12.169. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Not applicable.