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1 DOI /s RHINOLOGY Nasal soft tissue obstruction improvement after septoplasty without turbinectomy Yasser Haroon Hala Aly Saleh Ahmed H. Abou-Issa Received: 29 June 2012 / Accepted: 22 November 2012 Ó Springer-Verlag Berlin Heidelberg 2013 Abstract The objective of the study was to evaluate the outcome of septoplasty without inferior turbinectomy in patients with septum deviation and nasal obstruction. After exclusion of allergic rhinitis, this study included 30 patients with deviated nasal septum and hypertrophied inferior nasal turbinate who were prepared for septoplasty without turbinectomy. After full history taking and complete otorhinological examination, all patients graded their extent of obstruction using the Nasal Obstruction Symptoms Evaluation scale and underwent CT scans to evaluate the side and shape of deviation, thickness of the medial and lateral mucosa and inferior conchal bone on both the concave and convex sides. Postoperative (PO) follow-up consisted of evaluation of surgical outcome, nasal obstruction grading and patient s satisfaction. CT imaging was repeated for evaluation of the previous items and to compare with preoperative data. All surgeries were conducted smoothly without intraoperative complications and all were managed as day surgery. The mean duration of follow-up was 20.1 ± 4.4 months. All patients showed progressive significant decline of nasal obstruction symptoms and only eight patients still had mild symptoms. Patients satisfaction scores showed significant progressive increase reaching a peak at the 12th month. Preoperative CT confirmed the presence of hypertrophied mucosa on the concave septal side with significantly thicker medial and non-significantly thicker lateral mucosa on the concave side compared to the convex side. At the 12th month PO, mean medial mucosal thickness significantly decreased on the concave side with significant increase on the convex side, but the effect was significantly pronounced on the concave side. Mean lateral mucosal thickness was significantly decreased on the concave and non-significantly increased on the convex side. Conchal bone thickness showed non-significant change despite the diminution on both sides In the absence of allergic rhinitis, septoplasty without turbinectomy significantly improves nasal obstruction-related manifestations and approaches high patient satisfaction with associated reduction of hypertrophied mucosa and spares turbinectomy-related complications. Keywords Septoplasty Turbinectomy CT Mucosal thickness Introduction Y. Haroon (&) Otorhinolaryngology Department Faculty of Medicine, Benha University, Kaliobeya, Egypt yaseer.haroon@yahoo.com H. A. Saleh Medical Imaging Department, Zagazig University, Zagazig, Egypt A. H. Abou-Issa Medical Imaging Department, Mansoura University, Mansoura, Egypt Breathing well is a condition directly related to quality of life. A good breathing demands good permeability of the nasal airways, the physiological entry door of airflow. Chronic nasal obstruction is a symptom responsible for most patients visit to otorhinolaryngologists in their daily practice [1]. Nasal turbinates are arch-like bony structures that lay anteroposteriorly in the nasal cavities, having a border attached to the lateral nasal wall and a free medial ledge. The inferior turbinate, being larger and the one more easily

2 seen, has its own bone, called inferior nasal concha, anchored to the maxilla, lacrimal, ethmoid and palatine bones. This turbinate tail has a posterior boneless protuberance that bulges into the choana and is formed almost exclusively by vascular erectile tissue, which is usually hypertrophic in nasal diseases [2]. The nasal lateral wall, formed by the turbinates and the meatus, has a rather important role in nasal physiology as far as balancing temperature, moisture and also filtering of suspended particles present in inhaled air are concerned. Diseases that cause chronic nasal obstruction basically involve the lateral wall of the nasal cavity, causing changes to both the mucosa and the submucosa of the nasal turbinates [3]. As much as % of the general population is estimated to exhibit some type of anatomical deformity of the nose, most commonly a deviated nasal septum. This deviation is often associated with overgrowth of the inferior turbinate, which occupies much of the contralateral nasal cavity. Accordingly, turbinate surgery is routinely performed in conjunction with septoplasty in patients with nasal obstruction and septum deviation. However, the indications for turbinate surgery are not well defined, and surgical techniques vary substantially among rhinologic surgeons [4, 5]. The present study aimed to evaluate the outcome of septoplasty without inferior turbinectomy in patients with non-allergic nasal obstruction and septum deviation. Patients and methods The present prospective study was conducted at the Otorhinolaryngology Department, Benha University Hospital through the period from November 2007 to November 2009 to allow a minimum follow-up period of 12 months for the last case operated upon. After approval of the study protocol by the local ethical committee and obtaining fully informed written patients consent, the study was assigned to include 30 patients with deviated nasal septum with hypertrophied inferior nasal turbinate and prepared for septoplasty without turbinectomy. Patients with allergic rhinitis were excluded. After full history taking and complete otorhinological examination which was performed on different occasions to confirm the persistent nature of nasal obstruction, all patients graded their extent of obstruction using the Nasal Obstruction Symptoms Evaluation scale 6. It evaluates obstruction, nasal discharge and headache; each symptom was evaluated using a 4-point grading scale (Table 1) and a collective score was determined. Also, patients were asked to comment on their maintenance local therapy. All patients underwent CT scans for evaluation of nasal obstruction. Before decongestion with 0.05 oxymetazoline, coronal CT slices for paranasal sinuses were obtained using either primary coronal acquisition (patient prone with hyperextended neck) or reconstructed images (patient supine with neutral neck position using isotropic capability of multislice CT to reconstruct the coronal images). The inferior turbinate was divided into three portions: anterior, middle and posterior thirds, by dividing the number of slices showing the whole length of turbinate by three (if it appears on 18 coronal slices, then every third has 6 slices). The thickest site in each third is selected to measure the thickness of the bone, and medial and lateral mucosa. This process was repeated on the side of deviation (Fig. 1). All surgeries were conducted under general inhalational anesthesia using cuffed endotracheal tube for prevention of aspiration. Prophylactic broad-spectrum antibiotic was given intravenously prior to induction of anesthesia. A cotton pledge soaked with adrenaline 1:100,000 was placed in both nostrils to induce mucosal shrinkage and vasoconstriction. The septum was exposed from one side only; exposure occurred through a unilateral traditional hemitransfixion incision. Submucoperiochondrial and submucoperiosteal flaps were elevated by dissection around the anterocaudal septum to fully expose the deviated segments of cartilage and bone [7]. If the anterior nasal spine of the maxilla or maxillary crest is deviated, it must be fractured and repositioned in the midline before cutting the lower border of septal cartilage to assess the actual length needed for septoplasty. The lower border of the cartilage is dislocated from its osseous groove. If the bony septum is deviated, a vertical incision is made through the posterior end of the septal cartilage, and the mucosal flap in the opposite side of the bony part is dissected and elevated. The posterior part can now be removed or fractured and repositioned in the midline. If there is angulation of cartilage, a narrow strip of cartilage is removed along the line of deviation and repositioned in the midline. If the septal lesion is severe and needs supporting cartilage or bone, a free bone graft from the perpendicular plate of the ethmoid or vomer is used to fill the defect. If the septum still deviates after the procedure, multiple incisions in the cartilage are made followed by sutures in a figure of 8. At the end, dressing was put into the nose to bring the mucosa together. Postoperative follow-up consisted of evaluation of surgical outcome and patients were asked to re-grade their sense of obstruction and the need of local medications and to grade their satisfaction using a numerical scale of 5 = completely relieved and highly satisfied, 4 = highly satisfied, 3 = satisfied, 2 = acceptable outcome, 1 = poor outcome and 0 = sense of no change. Clinical follow-up was conducted 3 monthly for at least 12 months and CT imaging was repeated for evaluation of the previous items and comparing it versus preoperative data.

Table 1 Nasal Obstruction Symptoms Evaluation scale [6] Score Obstruction Nasal discharge Headache 0 No No No 1 Mild (causing no disturbance in patient s daily life) 2 Moderate (forcing the patient

3 Table 1 Nasal Obstruction Symptoms Evaluation scale [6] Score Obstruction Nasal discharge Headache 0 No No No 1 Mild (causing no disturbance in patient s daily life) 2 Moderate (forcing the patient to breathe through the mouth) 3 Severe (causing sleep disturbances and decrease in voice quality) Mild (1 4 nose blowing/day) Moderate (5 10 nose blowing/day) Severe (continuous nasal discharge) Mild (not requiring analgesia for headache relief) Moderate (requiring non-narcotic analgesics for headache relief) Severe (requiring narcotic analgesics for headache relief) Fig. 1 Coronal CT scan shows measurement of conchal bone, (a) medial and lateral mucosal thickness (b, c) of the inferior turbinate Statistical analysis Results were expressed as mean ± SD, range, numbers and percentages. Results were analyzed using paired t test. Statistical analysis was conducted using SPSS statistical program (Version 10, 2002). p value \ 0.05 was considered to be statistically significant. Results The study included 30 patients: 21 males and 9 females with an age range of years. 17 patients had left deviated septum and 13 patients had right deviated septum. All enrolled patients had C-shaped septum, so as to equalize the sides for comparisons. All patients were on medical treatment, but with unsatisfactory obstruction relief (Table 2). All surgeries were conducted smoothly without intraoperative complications and with minimal acceptable bleeding, and all were managed as day surgery and returned home on the first postoperative day. The mean duration of follow-up was 20.1 ± 4.4; range months. At the end of the 12 months follow-up period, all patients showed progressive significant decline of nasal obstruction symptoms (Fig. 2) and only eight patients still had mild obstruction symptoms, but all became independent on medical treatment. In parallel, the extent of patients satisfaction scores showed significant Table 2 Enrollment data of 30 patients included in this study Age (years) B30 5 (16.7 %) [ (76.6 %) [40 2 (6.7 %) Gender Males 21 (70 %) Females 9 (30 %) Side of deviation Left 17 (56.6 %) Right 13 (43.4 %) Data are presented as mean ± SD and numbers; ranges and percentages are in parenthesis progressive increase reaching a peak at the 12th month visit (Table 3, Fig. 3). Preoperative evaluation of CT images confirmed the presence of hypertrophied mucosa on the concave side of the septum manifested as significantly (p = 0.009) thicker medial and non-significantly (p [ 0.05) thicker lateral mucosa on the concave side compared to the convex side. At 12-m PO, mean mucosal thickness significantly decreased on the concave side (p = 0.001) with compensatory significant (p = 0.003) increase on the convex side, but the effect was significantly (p = 0.003) pronounced on the concave side (Fig. 4). As regards the lateral mucosa, at 12-m PO, mean mucosal thickness was significantly (p = 0.01) decreased on the concave side with non-

4 significantly increased lateral mucosal thickness on the convex side and so with significant (p = 0.008) change on the concave side. On the contrary, conchal bone thickness showed non-significant change despite the diminution on both sides (Table 4, Figs. 5, 6). Discussion Preoperative evaluation of CT images confirmed the presence of hypertrophied mucosa on the concave side of the septum manifested as significantly thicker medial and nonsignificantly thicker lateral mucosa with non-significantly thicker conchal bone on the concave side compared to the convex side. These findings indicated mucosal hypertrophy of the contralateral mucosa and/or diminution of thickness of the mucosa on the deviated side, while the changes in the bony turbinate was non-significant. These data support the hypothesis of pathogenesis of hypertrophied inferior turbinate in association with deviated septum as compensation to deflection of the nasal septum, because the hypertrophy protects the more patent passage from excess airflow which has drying and crusting effects on the nasal mucous membranes [8 10]. As a further support of this assumption, the current study based on septoplasty without inferior turbinectomy Score Pre op 3-m 6-m 9-m 12-m Fig. 2 Time course change of the extent of nasal obstruction Table 3 Mean sense of obstruction and satisfaction scores recorded throughout the study duration Data are presented as mean ± SD. PO postoperative, p 1 significance versus baseline p 2 significance versus 3-m PO, p 3 significance versus 6 m, p 4 significance versus 9 m Sense of obstruction score Baseline 3-m PO 6-m PO 9-m PO 12-m PO 6 ± ± ± ± ± 1.2 t p 1 \0.001 \0.001 \0.001 \0.001 t p 2 \0.001 \0.001 \0.001 t p 3 \0.001 \0.001 t p 4 Satisfaction score \ ± ± ± ± 0.5 t p 2 \0.001 \0.001 \0.001 t p 3 \0.001 \0.001 t p 4 Score m 6-m 9-m 12-m Fig. 3 Time course satisfaction scores \0.001

5 Fig. 4 Preoperative (left) and postoperative (right) CT images of nasal septum and turbinate in five different patients. Preoperative images show deviated nasal septum with hypertrophied inferior turbinate on the concave side. 12-month postoperative images show corrected nasal septum with widening of nearly equal nasal air columns and diminution of the inferior turbinate size on the concave side and slightly increased inferior turbinate size on the convex side

6 Table 4 Mean thickness (in mm) of the medial and lateral mucosa and conchal bone before and after septoplasty Concave side Medial mucosa Lateral mucosa Conchal bone Baseline 4.6 ± ± ± m PO 2.93 ± ± ± 0.32 Statistical analysis t p 1 =0.001 =0.01 [0.05 Convex side Baseline 3.5 ± ± ± m PO 4 ± ± ± 0.38 Statistical analysis t p 1 =0.003 [0.05 [0.05 t p 2 =0.009 [0.05 [0.05 t p 3 =0.003 =0.008 [0.05 Data are presented as mean ± SD PO postoperative, p 1 significance versus baseline, p 2 significance versus baseline on concave side, p 3 significance versus 12-m PO on the concave side (mm) Pre Medial Lateral Conchal Fig. 5 Changes in thickness of the concave side medial and lateral mucosa and conchal bone before and after septoplasty recorded significant diminution of mucosal thickness on the concave side and increased mucosal thickness on the convex side at 12 months after surgery. These data indicated that the deviation correction allowed normal bilateral airflow, so there was no need for the compensation of the other nostril. Subsequently, the associated mucosal hypertrophy became non-sense and so started to withdraw. Moreover, septoplasty allowed the release of mucosal blood supply on the convex side with subsequent development and increased thickness of the mucosa. The reported significant decrease of medial mucosal thickness on the concave side is in accordance with Berger et al. [11], who analyzed the quantitative and qualitative characteristics of the hypertrophic inferior turbinate histopathologically and reported that the hypertrophic inferior turbinate was significantly wider and the medial mucosal layer was significantly thickened and made the greatest contribution to the total increase in the width of the inferior turbinate, while the enlargement in width of the lateral mucosal layer was of borderline statistical significance. Furthermore, the current study reported non-significant conchal bone change which also supported the mucosal hypertrophy assumption as an etiological base for inferior turbinate hypertrophy and refuted the assumption concerning primary unilateral growth of the turbinate bone, which can be genetic or caused by trauma in early life [12, 13]. In accordance with the obtained results, Kim et al. [14] measured the effect of septoplasty on the volume of inferior turbinate in patients with a deviated nasal septum and found inferior turbinate hypertrophy, especially in the medial mucosa, may reverse after septoplasty. Lindemann et al. [15] tried to determine the early effect of septoplasty with or without bilateral turbinoplasty on intranasal heating and humidification and reported that patients seemed to overall benefit from nasal surgery, with or without preserving bilateral turbinoplasty, because intranasal air conditioning was improved after surgery. At the end of a mean duration of follow-up of 20.1 (12 29) months, all patients showed a progressive significant decline of the sense of obstruction and in parallel the extent of patients satisfaction scores showed significant progressive increase. These findings illustrated the successful outcome of septoplasty without turbinectomy on both short and long terms. These data were superior to that reported by Bandos et al. [16] who evaluated the clinical and histological results obtained after partial inferior PO (mm) Pre Medial Lateral Conchal PO Fig. 6 Changes in thickness of the convex side medial and lateral mucosa and conchal bone before and after septoplasty

7 turbinectomy for the treatment of chronic nasal obstruction and reported that clinical results proved to be satisfactory for the relief of nasal obstruction on short-term follow-up for 8 12 months, but unsatisfactory after long-term followup for more than 24 month. They concluded that surgery proved to be effective on a short-term but not on a longterm basis, and histological recovery did not accompany improvement of clinical signs and symptoms. The improved nasal obstruction scores and thus patients satisfaction were in line with results obtained even in more complicated cases. Li et al. [17] evaluated the impact of nasal surgery alone on the quality of life in patients with obstructive sleep apnea and nasal obstruction and reported significantly improved nasal obstruction symptoms with concomitant significant improvement in the Snore Outcomes Survey and Epworth Sleepiness Scale scores. Dursun and Battal [18] reported improvement and of nasal obstruction in 79.6 % and no change was seen in 20.4 % of the patients after septoplasty in patients with nasal obstruction and living in high altitudes. Bulcun et al. [19] investigated the effects of septoplasty on pulmonary function tests and bronchial hyper-responsiveness in patients who had no previous pulmonary diseases and reported an improvement in both nasal symptoms and pulmonary function tests values after surgical treatment for nasal septal deviation. They concluded that septoplasty may be considered as having favorable effects on bronchial hyper-responsiveness. Also, Baumann [20] reported that most of the septoplasty patients evaluated the operation as being successful with regard to quality of life improvement. It could be concluded that in the absence of allergic rhinitis; septoplasty without inferior turbinectomy significantly improves nasal obstruction-related manifestations and approaches high patient satisfaction with associated reduction of hypertrophied mucosa and spares turbinectomy-related complications. However, wider-scale studies with longer follow-up duration are mandatory for establishment of the obtained results. References 1. Rozsasi A, Leiacker R, Knemann S, Lindemann J, Kappe T, Rettinger G, Keck T (2007) The impact of septorhinoplasty and anterior turbinoplasty on nasal conditioning. Am J Rhinol 21(3): Lee HY, Kim CH, Kim JY, Kim JK, Song MH, Yang HJ, Kim KS, Chung IH, Lee JG, Yoon JH (2006) Surgical anatomy of the middle turbinate. Clin Anat 19(6): Farmer SE, Eccles R (2006) Chronic inferior turbinate enlargement and the implications for surgical intervention. Rhinology. 44(4): Mlynski G (2006) Surgery of the nasal septum. Facial Plast Surg 22(4): Miles BA, Petrisor D, Kao H, Finn RA, Throckmorton GS (2007) Anatomical variation of the nasal septum: analysis of 57 cadaver specimens. Otolaryngol Head Neck Surg 136(3): Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT (2004) Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 130(2): Van Olphen AF (1998) The Septum. Laryngoscope 108(7): Berger G, Hammel I, Berger R, Avraham S, Ophir D (2000) Histopathology of the inferior turbinate with compensatory hypertrophy in patients with deviated nasal septum. Laryngoscope 110(12): Uzun L, Savranlar A, Beder LB (2004) Enlargement of the bone component in different parts of compensatory hypertrophied inferior turbinate. Am J Rhinol. 18(6): Lindemann J, Tsakiropoulou E, Vital V, Keck T, Leiacker R, Pauls S, Wacke F, Wiesmiller KM (2009) Influence of the turbinate volumes as measured by magnetic resonance imaging on nasal air conditioning. Am J Rhinol Allergy. 23(3): Berger G, Gass S, Ophir D (2006) The histopathology of the hypertrophic inferior turbinate. Arch Otolaryngol Head Neck Surg 132(6): Gray LP (1978) Deviated nasal septum: incidence and etiology. Ann Otol Rhinol Laryngol Suppl 87(3, pt 3) (suppl 50): Eccles R (2007) Query, concerning mechanism of inferior turbinate enlargement. Arch Otolaryngol Head Neck Surg 133(6): Kim DH, Park HY, Kim HS, Kang SO, Park JS, Han NS, Kim HJ (2008) Effect of septoplasty on inferior turbinate hypertrophy. Arch Otolaryngol Head Neck Surg 134(4): Lindemann J, Keck T, Leiacker R, Dzida R, Wiesmiller K (2008) Early influence of bilateral turbinoplasty combined with septoplasty on intranasal air conditioning. Am J Rhinol. 22(5): Bandos RD (2006) Rodrigues de Mello V, Ferreira MD, Rossato M, Anselmo-Lima WT: Clinical and ultrastructural study after partial inferior turbinectomy. Braz J Otorhinolaryngol 72(5): Li HY, Lin Y, Chen NH, Lee LA, Fang TJ, Wang PC (2008) Improvement in quality of life after nasal surgery alone for patients with obstructive sleep apnea and nasal obstruction. Arch Otolaryngol Head Neck Surg 134(4): Dursun E, Battal B (2009) Clinical outcomes of nasal septal surgery at high altitude. Eur Arch Otorhinolaryngol 266(10): Bulcun E, Kazkayasi M, Ekici MA, Tahran FD, Ekici M (2010) Effects of septoplasty on pulmonary function tests in patients with nasal septal deviation. J Otolaryngol Head Neck Surg 39(2): Baumann I (2010) Quality of life before and after septoplasty and rhinoplasty. Laryngorhinootologie 89(Suppl 1):S35 S45

ISSN X (Print) B. G Nagara, Nagamangala Taluk, Mandya District, Karnataka, Karnataka, India

ISSN X (Print) B. G Nagara, Nagamangala Taluk, Mandya District, Karnataka, Karnataka, India Scholars Journal of Applied Medical Sciences (SJAMS) Sch. J. App. Med. Sci., 2016; 4(2C):489-493 Scholars Academic and Scientific Publisher (An International Publisher for Academic and Scientific Resources)