European Journal of Cardiovascular Medicine

The nasal septum is a complex osseocartilaginous structure that divides the nose into two nasal passages. ^[1] Generally, it is rare to have a symmetrical nasal cavity, and some degree of deviation is considered a normal anatomical variation. ^[2] However, nasal septum deviation (NSD) can be either developmental which is generally a smooth “C-shaped or S-shaped” deformity, or a result of trauma which is usually more dislocated and irregular. ^[3]

The wide variation of NSD structure, symptoms and associated comorbidities has evolved the development of classification systems. NSD can be classified according to extent of the nasal deviation on the inferior turbinate. ^[4] This classification has three degrees, degree I comprises a septal deviation without reaching the inferior turbinate, degree II represents a deviation reaching the inferior turbinate, and degree III involves a septal deviation reaching and compressing the inferior turbinate. ^[5] Another classification relies on the commonly noticed deviation patterns such as S-shaped and C-shaped deviations. ^[6] Mladina’s classification system has been proposed to classify the NSD according to the characteristics of the nasal septum seen horizontally and vertically on rhinoscopy or cone-beam computed tomography (CBCT). ^[7]

Mladina’s system classifies nasal septum deviation into seven types; type I involves the vertical ridge without reaching the nasal dorsum; type II involves the vertical ridge reaching the nasal dorsum; type III involves the vertical ridge in a deeper area; type IV involves the anterior and the deeper areas of the vertical ridge; type V manifests as a horizontal deformity on one side of the nose with the other being flat; type VI manifests a bilateral involvement of the septum with dislocation of one side and deviation of the other side; type VII represent as a combination of two or more types. ^[8]

Computed Tomography (CT) is the workhorse in the nose and paranasal sinus imaging and depicts not only the complex three-dimensional anatomy, but also the extent of disease and the wide range of anatomic normal variations that are of great importance to the endoscopic septal and sinus surgery. Septoplasty is the common surgical procedure performed in nasal septal deviation. Nasal obstruction is the most frequent presentation to the otolaryngologist all over the world with septal deviation. Patients usually presented with headache, facial pain, epistaxis, snoring, obstructive sleep apnea (OSA), ophthalmological, otological, upper and lower respiratory tract infections; and many more.  ^[9]

Coronal CT reveals nasal septal deviation by measuring a distance from the midline above to the nasal floor. ^[10] There are some anatomical variants of the structures in the nasal cavities responsible for nasal obstruction such as hypertrophied inferior turbinate (HIT), concha bullosa (CB) and other pathologies in the paranasal sinuses namely chronic rhinosinusitis (CRS), nasal polyps, mucocele, mucous retention cyst in the paranasal sinus, tumors, adenoid hypertrophy and many more may be associated with septal deviation. Physical examination, anterior rhinoscopy (AR) and nasal endoscopy (NE) are considered the “gold standard” to evaluate septal deviation and primarily used in the diagnosis of the nose and paranasal sinus diseases. ^[11]

A cross sectional study conducted in the Department of  patients ENT who have been evaluated in rhinology clinic for several reasons, over a period of 1 year, and were investigated with computed tomography (CT) and have no previous history of sinonsasal surgeries. The LundMackay staging system was used to assess the osteomeatal complex (OMC) and all paranasal sinuses disease staging, if present. The sample divided into two groups, group one are those with normal nasal septum, and group two are those with deviated septum. The relation between the sinuses disease and the status of the nasal septum studied and the two groups findings compared.

Inclusion criteria

Inclusion criteria were all adult rhinology clinic patient who underwent CT scan for nose and paranasal sinuses with cuts equal or less than 1.5 mm and has no past history of sinonasal surgery.

Exclusion criteria

Exclusion criteria were all patients with incomplete records, those who have history of sinonasal surgery and those with diffuse or destructive disease affecting the septum.

SPSS.v22 is used for data analysis.

A total of 90 patients met our inclusion criteria, 46 males and 44 females, of them 60 (control) found to have central septum (66.7%) and 30 (cases) found to have deviated nasal septum (33.3%), 20 to the right and 10 to the left (Table 1).

            Various sinuses pathology was present in 20-42% of the candidates, least in sphenoid sinus, and highest in maxillary sinuses.

            The frontal sinus was normal in average of 70% of those who have normal nasal septum and less likely to be affected by DNS, as it is normal in 76-79% of those who have DNS.

            The maxillary sinus was normal in average of 55.5% of those with normal nasal septum. With DNS to the right side, the sinus was normal in 64.3% in the right sinus and 61.9%% in left sinus. With DNS to the left, the right sinus was normal in 53.1% and the left sinus was normal in 50%.

            Anterior ethmoid sinuses (Ant Eth) were normal in average of 60% of those with normal nasal septum. With deviated septum, equal incidence of bilaterally normal anterior ethmoid sinuses, 55% in case of right side deviation and 60% in left side deviation (Table 2 and 3).

Table 1: The incidence of deviated nasal septum and gender distribution.

Table 2: The relation between diseased right anterior ethmoid sinuses and deviated nasal septum.

Table 3: The relation between diseased left anterior ethmoid sinuses and deviated nasal septum.

Table 4: The relation between diseased right posterior ethmoid sinuses and deviated nasal septum.

Table 5: The relation between diseased left posterior ethmoid sinuses and deviated nasal septum.

Septum

Posterior ethmoid sinuses (Post Eth) were normal in 63.3% of those with normal nasal septum. With DNS to the right side, the sinus was normal in 60% in the right sinus and 65% in left sinus. With DNS to the left, the right sinus was normal in 70% and the left sinus was normal in 60% (Table 4 and 5).

The sphenoid sinus was normal in average of 78% of those with normal nasal septum. With DNS to the right side, the sinus was normal in 78.6% in the right sinus and same percentage in left sinus. With DNS to the left, the right sinus was normal in 71.9% and the left sinus was normal in 75%.

A total of 90 patients were enrolled in the study between 15 and 60 years old. All the patients presenting with symptoms of deviated nasal septum and rhinosinusitis of more than 12 weeks duration with 2 major and one minor or 2 minor symptoms were included in the study. Patients diagnosed as cases of rhinosinusitis based on TFR criteria. There are three theories explaining pathophysiological relation between the nasal septal deviation and chronic rhinosinusitis.

The first of these is the mechanical theory which states that secretions accumulate in the sinus as a result of narrowing of the ostiomeatal complex and thus infections ensue in the retained secretions and causes chronic rhinosinusitis.

The second theory is the aerodynamic theory. According to this theory, the mucociliary activity decreases following the nasal flow rate increase and mucosal dryness in relation with the nasal septal deviation and consequently, chronic rhinosinusitis develops. 

The third theory is the Bachert’s pressure theory. According to this theory, deviation of the posterior nasal septum causes chronic rhinosinusitis by creating pressure and air flow changes within the maxillary sinuses.

In the present study the incidence of DNS was more in male than female with an approximate ratio of 1.6:1 which is in agreement to a study done by Nayak. ^[12-18]

In a study by Madani et al, there were 68.3% male and 31.7% female with a mean age of 29.13±15.21 years. Ozkurt et al in his study observed that incidence was more in male as compared to female. ^[19]

In the study conducted by Ishwar Singh (2010) headache was the predominant symptom seen in 80% of patients, nasal blockage was seen in 76.66%, nasal discharge was seen in 43.33%, facial pain in 40% patients. ^[20] 

While in the study by Venkatachalam et al (2000) the commonest symptoms were nasal obstruction in 87%, nasal discharge in 70% of patients and the other symptoms were post nasal drip in 41% and abnormalities in sensation of smell in 36% of patients. ^[21] In another study by Nayak et al (1991) nasal discharge was the commonest complaint seen in 78.2%, while nasal blockage and headache was seen in 75.6% of patients. ^[22]

In a study by Mohebbi et al, bilateral maxillary sinusitis presentation was seen in 27% of patients while unilateral presentation was seen in 18.4%, similarly unilateral frontal sinus involvement was seen in 12.5% and bilaterally in 11.2%, bilateral ethmoidal sinusitis was seen in 36.1% and unilateral ethmoidal sinusitis was seen in 18.1%, bilateral sphenoidal sinusitis was seen in 12.3%, unilateral sphenoid sinusitis was seen in 13%. ^[23]

In a study by Madani et al, involvement of maxillary sinuses is seen in 41.6% followed by ethmoidal sinuses in 22.9%, then sphenoidal sinusitis in18%, frontal sinuses in17.3%.

In this study, C shaped DNS was more prevalent on the left in 22 patients (44%). In a study by Young Ju Jang et al, type I deformity, which may correspond to the C-shaped ,concave dorsal deformity was the most common deformity, accounting for 32% of the case. ^[24]

In our study, we found that simple type was DNS was more prevalent in 20 patients (40%) followed by obstructed DNS in 10 patients (20%) followed by impacted DNS in 3 patients accounting to 6%. In a study by Vinay Kumar Poorey and Pooja et al, Obstructed type of DNS was more prevalent in 50%, followed by impacted DNS in 30% and simple DNS in 19% of study population. ^[25] In this study, Obstructed type of DNS was associated with left anterior ethmoiditis in 15 patients (30%) and right Osteomeatal complex block in 7 patients (14%) Also, In our study we found that patients with anterior and posterior ethmoiditis had significant association with Impacted type of DNS. Also right sphenoid sinusitis and right Osteomeatal complex block was significantly associated with impacted type of DNS.

Chronic rhinosinusitis is most common rhinological problem encountered worldwide which has greater propensity to cause morbidity. Deviated nasal septum can be associated with significant sinonasal disease, especially a S-shaped obstructed and impacted type of DNS which showed statistically significant correlation with sinus disease in our study. Also, DNS to left, in general, was associated with higher incidence of sinuses disease than DNS to right. This study brings to light various presentations of DNS implicated in causation of chronic sinusitis which will influence the treatment decisions and also reduce the morbidity caused by it.

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