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Relationship between nasal septum morphology and nasal obstruction symptom severity: computed tomography study

Natasa Janovic Aleksa Janovic Biljana Milicic Marija Djuric About the authors

Abstract

Introduction

The impact of the nasal septum morphology on the severity of obstruction symptoms has not been fully explored.

Objective

This study aimed to investigate whether the morphology of the deviated nasal septum assessed by computed tomography may explain nasal obstruction severity.

Methods

The study included 386 patients who were referred to the computed tomography examination of the paranasal sinuses. Patient selection criteria were the absence of facial anomalies, facial trauma, nasal surgery, and sinonasal tumors. Computed tomography images were used to estimate deviated nasal septum prevalence, the prevalence of Mladina's seven types of deviated nasal septum, and to measure the deviated nasal septum angle. Nasal obstruction severity was assessed by the nasal obstruction symptom evaluation, NOSE scale. The relationship between NOSE score, deviated nasal septum morphology, and deviated nasal septum angle was performed by a statistical regression model on the reduced sample of 225 patients.

Results

The prevalence of deviated nasal septum was 92.7%. Type 7 deviated nasal septum was the most frequent (34.2%) followed by type 5 (26.2%) and type 3 (23.6%). The worst NOSE scores were recorded in the type 2 deviated nasal septum (45.00 ± 28.28). The mean deviated nasal septum angle in patients with nasal obstruction was 8.5° ± 3.24. NOSE scores were not significantly associated with deviated nasal septum types and angles.

Conclusion

Patients with different types of deviated nasal septum have different NOSE scores. Computed tomography morphology of the deviated nasal septum could not fully explain the severity of nasal obstruction.

Keywords
Nasal septal deviation; Morphology; Computed tomography; Nasal obstruction; NOSE scale

Resumo

Introdução

O impacto da morfologia do septo nasal na gravidade dos sintomas obstrutivos nasais ainda não foi totalmente explorado.

Objetivo

Investigar se a morfologia do desvio do septo nasal avaliada pela tomografia computadorizada pode explicar a gravidade da obstrução nasal.

Método

O estudo incluiu 386 pacientes encaminhados para exame tomográfico de seios paranasais. Os critérios de seleção dos pacientes foram: ausência de anomalias faciais, trauma facial, cirurgia nasal e tumores nasossinusais. Imagens de tomografia computadorizada foram usadas para estimar a prevalência de desvios do septo nasal, a prevalência dos sete tipos de desvios do septo nasal de Mladina e para medir o ângulo do desvio septal. A gravidade da obstrução nasal foi avaliada pela escala Nasal Obstruction Symptom Evaluation, NOSE. A relação entre o escore da NOSE, a morfologia e o ângulo do desvio septal foi verificada por um modelo de regressão estatística em uma amostra reduzida de 225 pacientes.

Resultados

A prevalência de desvios do septo nasal foi de 92,7%. O desvio septal do tipo 7 foi o mais frequente (34,2%), seguido do tipo 5 (26,2%) e do tipo 3 (23,6%). Os piores escores da escala NOSE foram registrados nos desvios septais tipo 2 (45,00 ± 28,28). O ângulo médio do desvio em pacientes com obstrução nasal foi de 8,5° ± 3,24. Os escores da escala NOSE não foram significativamente associados aos tipos e ângulos do desvio septal.

Conclusão

Pacientes com tipos diferentes de desvios do septo nasal apresentam diferentes escores na escala NOSE. A morfologia do desvio septal à tomografia computadorizada não conseguiu explicar totalmente a gravidade da obstrução nasal.

Palavras-chave
Desvio do septo nasal; Morfologia; Tomografia computadorizada; Obstrução nasal; Escala NOSE

Introduction

Nasal septal deviation (NSD) is a frequent finding in both clinical and radiological examinations, with prevalence up to 89.2% in the general population.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82. Patients with NSD-related nasal obstruction are often candidates for septoplasty.22 Van Egmond MM, Rovers MM, Hendriks CT, van Heerbeek N. Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial. Trials. 2015;16:500. Surgical correction of the deviated nasal septum is the most frequent procedure performed in adults by otorhinolaryngologists.22 Van Egmond MM, Rovers MM, Hendriks CT, van Heerbeek N. Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial. Trials. 2015;16:500.

3 Gandomi B, Bayat A, Kazemei T. Outcomes of septoplasty in young adults: the nasal obstruction septoplasty effectiveness study. Am J Otolaryngol. 2010;31:189-192.
-44 Moor M, Eccles R. Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review. Clin Otolaryngol. 2011;36:106-113. Recent epidemiological studies reported that 260,000 and 10,000−95,000 septoplasties are performed annually in the USA and European countries respectively.22 Van Egmond MM, Rovers MM, Hendriks CT, van Heerbeek N. Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial. Trials. 2015;16:500.,55 Bauman I. Quality of life before and after septoplasty and rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010;9:6.

6 Bhattacharyya N. Ambulatory sinus and nasal surgery in the United States: demographic and perioperative outcomes. Laryngoscope. 2010;120:635-638.
-77 Thomas A, Alt J, Gale C, Vijayakumar S, Padia R, Peters M, et al. Surgeon and hospital cost variability for septoplasty and inferior turbinate reduction. Int Forum Allergy Rhinol. 2016;20:1-6.

Clinicians and, more recently, health insurance companies have been searching for a diagnostic method that could serve as an objective indicator of the nasal obstruction severity, and thus strongly supporting the decision for septoplasty. Computed tomography (CT) was suggested as a method of choice to give detailed insight into the septum morphology and to provide one or more parameters that could potentially predict nasal obstruction severity. However, the few studies that correlated CT images and subjective nasal obstruction symptoms reported conflicting results about which morphological characteristics of the NSD, if any, should be recommended as an indicator of the symptom severity.88 Savovic S, Kljaic V, Buljacik Cupic M, Jovancevic L. The influence of nasal septum deformity degree on subjective nasal breathing assessment. Med Pregl. 2014;67:61-64.

9 Lee DC, Shin JH, Kim SW, Kim SW, Kim BG, Kang JM, et al. Anatomical analysis of nasal obstruction: nasal cavity of patients complaining of stuffy nose. Laryngoscope. 2013;123:1381-1384.
-1010 Ardeshirpour F, McCarn KE, McKinney AM, Odland RM, Yueh B, Hilger PA. Computed tomography scan does not correlate with patient experience of nasal obstruction. Laryngoscope. 2016;126:820-825. Besides contradictory results, CT was used only for NSD angle and cross-sectional area measurement in the different parts of the nasal cavity. An advantage of the CT to show the detailed morphology of the deviated septum was not fully utilized. It is still unclear whether the complex morphology of NSD (e.g. spurs, S-shaped, “gutter” form) may have any influence on the subjective sensation of the nasal obstruction severity.

Although there are numerous classifications of NSD in clinical practice, Mladina's classification is considered the most detailed.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82. This comprehensive classification includes complicated anatomical variants of the nasal septum usually omitted by other simplified classifications and divides NSD into seven types.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82.

This study aimed to investigate the association between nasal obstruction symptom severity assessed by the NOSE scale and CT morphology of NSD and the angle of NSD. Anatomical variants of the NSD, including spurs, S-shaped, and “gutter” form of NSD were classified according to Mladina's classification. An additional goal of the study was to estimate the prevalence of NSD in the Serbian population. We hypothesized that the morphology of the NSD may explain the severity of nasal obstruction symptoms and that patients with a higher angle of NSD have more severe nasal obstruction.

Methods

Patients

This study was conducted at the Department of Diagnostic Radiology. A total of 386 participants were successively selected among patients referred to the CT examination of the maxillofacial region due to various rhinologic or odontogenic diseases. The sample size was calculated according to the standard method for prevalence studies.1111 Daniel WW. 7th ed. John Wiley & Sons; New York: 1999. Biostatistics: A Foundation for Analysis in the Health Sciences.,1212 Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci. 2006;1:9-14. Patient selection criteria for this part of the study were: the nasal cavity in the field of view on CT scans, the absence of facial anomalies, history of facial trauma, nasal surgery, and sinonasal tumors. All participants were older than 18 years and gave written informed consent for participation in the study. The study was approved by the Ethics Committee of the Faculty of Medicine, nº 29/V-1.

CT examination

CT examination was performed on Siemens Somatom Sensation 16 device (Munich, Germany). Patients were lying in a supine position. The Frankfurt’s line of the head was set perpendicular to the horizontal plane. Patients were scanned in 3 mm thick axial sections (tube current 270 mAs, voltage of 120 kV). Additional multi-planar reformation images were reconstructed from the raw data in 0.75 mm thick axial sections using bone window settings.

CT evaluation of NSD

The presence of the NSD on CT images was recorded and classified by an experienced head and neck radiologist. Classification of the NSD was made according to Mladina’s classification scheme.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82. Briefly, types 1 and 2 are deviations of the anterior or cartilaginous part of the nasal septum in the nasal valve region. Type 3 is situated inside the nasal cavity at the level of the middle turbinate that resembles the letter C. Type 4 is double curved septum similar to the letter S. The anterior curve is usually placed in the region of the nasal valve, while the posterior curve is situated more inside in the nasal cavity. Type 5 is located in the bony septum and contains a bony spur. Type 6 is parallel to the horizontal plate that has a protuberance on one side and gutter on the other side. Type 7 is a combination of the two or more abovementioned types.

The maximum degree of the NSD angle was also measured directly on the Siemens CT workstation. The angle was measured on the single coronal CT section where NSD was the most prominent. The standard CT technique for the NSD angle measurement was applied (Fig. 1).88 Savovic S, Kljaic V, Buljacik Cupic M, Jovancevic L. The influence of nasal septum deformity degree on subjective nasal breathing assessment. Med Pregl. 2014;67:61-64.,1313 Kim YM, Rha KS, Weissman JD, Hwang PH, Most SP. Correlation of asymmetric facial growth with deviated nasal septum. Laryngoscope. 2011;121:1144-1148. Briefly, the angle was measured between two lines of reference. The first line running from the nasal septum insertion in the maxillary crest and the junction point of the perpendicular and the cribriform plate corresponded to the midline. The second line was run from the junction point of the perpendicular and the cribriform plate to the most prominent point of the NSD. For double curved NSD (type 4) greater value was taken into account.

Figure 1
Measurement of the NSD angle on coronal CT image.

Nasal obstruction symptom evaluation

In order to investigate the association between nasal obstruction severity and septum morphology, additional exclusion criteria were applied. Patients who had a history and/or CT finding of any condition that may cause nasal obstruction were excluded from the first study group. These conditions included: anatomical variations of the nasal cavity structures (e.g. paradoxical middle turbinate, concha bullosa), turbinate hypertrophy, rhinosinusitis, nasal polyps, adenoid hypertrophy, asthma, chronic obstructive lung disease. Therefore, the study group was reduced to 225 patients. These patients fulfilled the NOSE questionnaire validated for the Serbian population (Table 1) and self-assessed severity of the nasal obstruction experienced in the last month.1414 Janovic N, Maric G, Dusanovic M, Janovic A, Pekmezovic T, Djuric M. Introducing Nasal Obstruction Symptom Evaluation (NOSE) scale in clinical practice in Serbia: validation and cross-cultural adaptation. Vojnosanit Pregl. 2020;77:704-709. A sum of the five-question responses is calculated and multiplied by 5 so that the total NOSE score had a range between 0 (no obstruction) and 100 (the most severe obstruction).1515 Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004;130:157-163.

Table 1
The Serbian version of the Nasal Obstruction Symptom Evaluation (NOSE-s) scale.

Statistical analysis

Statistical analyses were performed in SPSS for Windows, version 15.0 (SPSS, Inc., Chicago, IL). The Kolmogorov-Smirnov test assessed the normality of data distribution. The severity of the nasal obstruction symptoms expressed by NOSE score and parameters obtained from CT images of the nasal cavity were evaluated using appropriate descriptive statistical methods. Frequencies of septal deviation among genders were compared by Chi-square test. The Kruskal-Wallis test was used to analyze NOSE scores in relation to the different types of NSD. Association between NOSE scores, types of NSD, and angle of NSD were thoroughly analyzed using linear regression analysis. The power of the study was 0.8. The statistical significance was set at a level of 0.05.

Results

Estimation of NSD prevalence

Among 386 patients who participated in the first part of the study, 153 (39.6%) were males, and 233 (60.4%) were females. Mean age was 55.08 ± 16.09 years (mean ± SD). The estimated prevalence of NSD was 92.7% (358/386). The prevalence of each type of NSD according to Mladina's classification system in this population is presented in Table 2. The most prevalent type was type 7 (34.9%). Types 5 and 3 were also frequent, with percentages of 24.9% and 23.7%, respectively. The least frequent type was type 2 (0.6%) (Table 2). The Chi-square test showed no significant difference in NSD frequencies among genders (Pearson Chi-Square = 1.545, p= 0.214).

Table 2
Prevalence of NSD types according to Mladina's classification.

Association between Mladina's NSD types and NOSE scores

Table 3 displays the frequencies of each Mladina's type of NSD in the group of 225 patients who participated in the second part of the study. The similar prevalence distribution of NSD types was noted as in the original study population. The most common was type 7, while the least frequent was type 2 (Table 3). The mean NOSE scores for all 225 patients as well as the mean NOSE scores in each type of NSD are also shown in Table 3. According to NOSE scores, patients with type 2 NSD reported the worst symptoms with the mean value of 45.00 ± 28.28 (Table 3). As confirmed by the Kolmogorov-Smirnov test, the distribution of the NOSE score data was not normal (p< 0.001). Observed differences in NOSE scores among different NSD types were not statistically significant (Chi-Square 7.303, p= 0.294).

Table 3
Distribution of NSDs types and NOSE scores for 225 patients according to Mladina's classification.

Linear regression analysis did not reveal a statistically significant association between NSD types and the total NOSE score (Table 4).

Table 4
Results of linear regression analysis.

Association between NSD angle and NOSE scores

The estimated angle of NSD ranged from 2.5° to 22.6° with a mean value of 8.6° ± 3.4 (mean ± SD). Linear regression analysis did not find a statistically significant influence of the NSD angle on the subjective perception of nasal obstruction (Table 4). It was interesting that the mean NSD angle was slightly higher in the group of patients who did not complain of nasal obstruction (Table 5).

Table 5
The angle of NSD in patients with and without nasal obstruction.

Discussion

The prevalence of NSD in the adult population varies among different studies. In our sample, the prevalence of the NSD was slightly higher in comparison to previous studies. Similar inter-study differences in the NSD prevalence also exist in relation to gender and Mladina's types of NSD. A few authors have reported a slightly higher NSD prevalence in males.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82.,1616 Rao JJ, Kumar EC, Babu KR, Chowdary VS, Singh J, Rangamani CV. Classification of nasal septal deviations-relation to sinonasal pathology. Indian J Otolaryngol Head Neck Surg. 2005;57:199-201.,1717 Wee JH, Kim DW, Lee JE, Rhee CS, Lee CH, Min YG, et al. Classification and prevalence of nasal septal deformity in Koreans according to two classification systems. Acta Otolaryngol. 2012;132:S52-S57. In our study, however, NSD was more commonly encountered in females (60.4%), although this gender difference was not statistically significant. This could be due to the higher number of females in the study sample because participants were consecutively enrolled as they came to the CT examination. Our results also showed a predominance of Mladina's type 7, type 5, and type 3 NSD in decreasing order (Table 2). By contrast, an international study conducted by Mladina et al.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82. found type 3 as the most prevalent (20.4%), followed by type 2 (16.4%) and type 1 (16.2%). Type 7 in their sample was the least frequent.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82. However, type 1 NSD has been the most frequently diagnosed in Koreans, Indians, and Saudi Arabs.1616 Rao JJ, Kumar EC, Babu KR, Chowdary VS, Singh J, Rangamani CV. Classification of nasal septal deviations-relation to sinonasal pathology. Indian J Otolaryngol Head Neck Surg. 2005;57:199-201.

17 Wee JH, Kim DW, Lee JE, Rhee CS, Lee CH, Min YG, et al. Classification and prevalence of nasal septal deformity in Koreans according to two classification systems. Acta Otolaryngol. 2012;132:S52-S57.
-1818 Daghistani KJ. Nasal septal deviation in Saudi patients: a hospital based study. J Kau Med Sci. 2002;10:39-46.

Potential reasons for the significant discrepancy in NSD frequencies between studies might be due to different techniques used to diagnose NSD, and due to inter-study differences in target populations. Techniques such as anterior rhinoscopy and endoscopy were frequently-used diagnostic tools for NSD. The disadvantage of anterior rhinoscopy is that posterior parts of the nasal septum cannot be fully visualized, and consequently, some posterior deviations might be omitted. Therefore, it could be expected that studies in which anterior rhinoscopy was an examination technique of choice underestimate real prevalence of NSD. Although endoscopy allows visualization of the complete nasal septum, the angle of the NSD could not be measured with great accuracy and repeatability.99 Lee DC, Shin JH, Kim SW, Kim SW, Kim BG, Kang JM, et al. Anatomical analysis of nasal obstruction: nasal cavity of patients complaining of stuffy nose. Laryngoscope. 2013;123:1381-1384.,1919 Aziz T, Biron VL, Ansari K, Flores-Mir C. Measurement tools for the diagnosis of nasal septal deviation: a systematic review. J Otolaryngol Head Neck Surg. 2014;43:11. Concerning the types of NSD, Mladina pointed out that type 5 can be easily overlooked by anterior rhinoscopy.11 Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82. A higher percentage of type 5 NSD in our sample could be explained by a more comprehensive evaluation of the nasal septum by CT.

Although CT is not recommended for routine NSD diagnosis and evaluation, it is superior to anterior rhinoscopy and endoscopy because it visualizes the whole septum in three planes. Thus, septal morphology can be carefully examined, the angle of NSD can be precisely measured, and none of the seven types of NSD can be misjudged. It also allows an accurate measurement of the nasal valve angle, which is essential for the differentiation between type 1 and 2 NSD. The CT assessment of the nasal valve angle could be the reason for a different frequency of type 1 and type 2 in the current study in comparison to other studies.

Previous studies that investigated NSD prevalence were conducted in ENT clinics where the number of patients that suffer from NSD can be significantly higher. Furthermore, it might falsely present harsh nasal obstruction symptoms in the majority of patients with NSD. However, it is well known that not all patients with NSD have nasal obstruction symptoms.22 Van Egmond MM, Rovers MM, Hendriks CT, van Heerbeek N. Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial. Trials. 2015;16:500.,88 Savovic S, Kljaic V, Buljacik Cupic M, Jovancevic L. The influence of nasal septum deformity degree on subjective nasal breathing assessment. Med Pregl. 2014;67:61-64. Out of 225 patients in the current study, symptomatic NSD was recorded in 167 (74.2%) patients. Therefore, we focused on a normal unbiased population, who presented with a wide range of NOSE scores and CT morphology of the nasal septum. Patients were selected at the Department of Diagnostic Radiology in order to target the most general population. This way, a more representative sample was obtained by omitting ENT clinics and implementing well-defined exclusion criteria. Therefore, it was possible to accurately investigate the real presence and severity of NSD induced nasal obstruction and whether different morphological characteristics of NSD influence the nasal obstruction symptoms.

According to NOSE scores, there were measurable differences in nasal obstruction severity between seven types of NSD. Patients with type 2 NSD reported the worst NOSE scores. Since this result was obtained from only two patients, it could not be simply extrapolated to the general population. However, these were not the only cases with type 2 NSD. Almost one-third of the type 7 NSD cases consisted of type 2 and other types of NSD (23/77 patients). Their NOSE scores were also relatively high, but the mean NOSE score for type 7 NSD was lower. Our finding was in accordance with previous clinical studies as well as the airflow dynamics analysis of the nasal valve region.1717 Wee JH, Kim DW, Lee JE, Rhee CS, Lee CH, Min YG, et al. Classification and prevalence of nasal septal deformity in Koreans according to two classification systems. Acta Otolaryngol. 2012;132:S52-S57.,2020 Liu T, Han D, Wang J, Tan J, Zang H, Wang T, et al. Effects of septal deviation on the airflow characteristics: using computational fluid dynamics models. Acta Otolaryngol. 2012;132:290-298.,2121 Onerci TM. Springer; Heidelberg: 2013. Nasal Physiology and Pathophysiology of Nasal Disorders. Many authors argue that deviation in the nasal valve area is critical for nasal obstruction and causes the most burdensome obstruction symptoms. The mechanism behind this was revealed in studies that evaluated nasal airflow resistance in experimental nasal models. Namely, it has been found that constriction in the valvular region results in a higher increase in airflow resistance than narrowing in the middle of the nasal cavity.2121 Onerci TM. Springer; Heidelberg: 2013. Nasal Physiology and Pathophysiology of Nasal Disorders. If there is a combined narrowing in the nasal valve region and the middle nasal cavity (type 7 NSD in Mladina's classification system), the valvular deviation usually has a more significant impact on nasal obstruction.2121 Onerci TM. Springer; Heidelberg: 2013. Nasal Physiology and Pathophysiology of Nasal Disorders. Similar to type 2, the nasal valve angle is also changed in type 1. Patients with this NSD type also reported more severe symptoms than other NSD types (Table 3). However, observed differences in NOSE scores between Mladina's types of the NSD were not statistically confirmed as significant. Such a result could be a consequence of a relatively low number of patients with type 1 and 2 NSD compared to the percentage of other NSD types. This finding may reflect a true low prevalence of isolated types 1 and 2 in our population and/or their coexistence with other types that constitute type 7 NSD.

Based on the NOSE scores, it seems that type 5 is also important for the severity of the obstruction in our patients (Table 3). The presence of a bony spur characterizes this type of NSD. Wee et al.1717 Wee JH, Kim DW, Lee JE, Rhee CS, Lee CH, Min YG, et al. Classification and prevalence of nasal septal deformity in Koreans according to two classification systems. Acta Otolaryngol. 2012;132:S52-S57. reported that, after type 1 and 2, patients with type 5 NSD frequently complained of nasal obstruction, but the symptom severity was not quantified. In general, the impact of spurs on the nasal obstruction was under investigated. Simmen et al.2222 Simmen D, Scherrer JL, Moe K, Heinz B. A dynamic and direct visualization model for the study of nasal airflow. Arch Otolaryngol Head Neck Surg. 1999;125:1015-1021. observed turbulent flow in an experimental cadaveric model of the nose behind the spur. In the computational model of the nasal cavity, Liu et al.2020 Liu T, Han D, Wang J, Tan J, Zang H, Wang T, et al. Effects of septal deviation on the airflow characteristics: using computational fluid dynamics models. Acta Otolaryngol. 2012;132:290-298. found complicated airflow and velocity distribution associated with a spur, but the results were not presented in the paper.

The association between the angle of the NSD and nasal obstruction is not clear. Ardeshirpour et al.1010 Ardeshirpour F, McCarn KE, McKinney AM, Odland RM, Yueh B, Hilger PA. Computed tomography scan does not correlate with patient experience of nasal obstruction. Laryngoscope. 2016;126:820-825. found out that the angle of deviation measured at the anterior, middle, and posterior part of the nasal septum, as well as maximal angle, poorly correlate with NOSE scores. The same author also noticed a poor connection between the more obstructed side of the nose and the side of the deviation.1010 Ardeshirpour F, McCarn KE, McKinney AM, Odland RM, Yueh B, Hilger PA. Computed tomography scan does not correlate with patient experience of nasal obstruction. Laryngoscope. 2016;126:820-825. The opposite conclusion was provided by Lee and his team99 Lee DC, Shin JH, Kim SW, Kim SW, Kim BG, Kang JM, et al. Anatomical analysis of nasal obstruction: nasal cavity of patients complaining of stuffy nose. Laryngoscope. 2013;123:1381-1384. who stated that the angle of NSD measured at the osteomeatal unit level has a significant impact on the subjective symptoms of nasal obstruction. However, the same author failed to detect any connection between nasal valve angle and obstruction symptoms.99 Lee DC, Shin JH, Kim SW, Kim SW, Kim BG, Kang JM, et al. Anatomical analysis of nasal obstruction: nasal cavity of patients complaining of stuffy nose. Laryngoscope. 2013;123:1381-1384. According to Savovic et al.,88 Savovic S, Kljaic V, Buljacik Cupic M, Jovancevic L. The influence of nasal septum deformity degree on subjective nasal breathing assessment. Med Pregl. 2014;67:61-64. a NSD angle greater than 10° has a significant effect on the difficulty of breathing through the deviated side of the nose. In our study, the NSD angle ranged from 2.5° to 22.6°, but regression analysis did not show its significant effect on nasal obstruction. The fact that a slightly higher mean and maximum NSD angle was measured in patients without nasal obstruction symptoms supports this conclusion (Table 5).

Conclusions

The estimated prevalence of NSD in the Serbian population was high. The most common type of NSD was type 7, while the least frequent was type 2. Patients in the current study showed apparent differences in NOSE scores in relation to the type of NSD. Our results suggest that morphological characteristics of NSD expressed through the Mladina's classification and the NSD angle could not fully explain nasal obstruction severity.

  • Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.

Acknowledgements

We want to express our gratitude and respect to recently deceased Professor Zoran Rakocevic for His invaluable help and support in study conducting.

The authors acknowledge the support from the Ministry of Education and Science of the Republic of Serbia (III45005).

References

  • 1
    Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29:75-82.
  • 2
    Van Egmond MM, Rovers MM, Hendriks CT, van Heerbeek N. Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial. Trials. 2015;16:500.
  • 3
    Gandomi B, Bayat A, Kazemei T. Outcomes of septoplasty in young adults: the nasal obstruction septoplasty effectiveness study. Am J Otolaryngol. 2010;31:189-192.
  • 4
    Moor M, Eccles R. Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review. Clin Otolaryngol. 2011;36:106-113.
  • 5
    Bauman I. Quality of life before and after septoplasty and rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010;9:6.
  • 6
    Bhattacharyya N. Ambulatory sinus and nasal surgery in the United States: demographic and perioperative outcomes. Laryngoscope. 2010;120:635-638.
  • 7
    Thomas A, Alt J, Gale C, Vijayakumar S, Padia R, Peters M, et al. Surgeon and hospital cost variability for septoplasty and inferior turbinate reduction. Int Forum Allergy Rhinol. 2016;20:1-6.
  • 8
    Savovic S, Kljaic V, Buljacik Cupic M, Jovancevic L. The influence of nasal septum deformity degree on subjective nasal breathing assessment. Med Pregl. 2014;67:61-64.
  • 9
    Lee DC, Shin JH, Kim SW, Kim SW, Kim BG, Kang JM, et al. Anatomical analysis of nasal obstruction: nasal cavity of patients complaining of stuffy nose. Laryngoscope. 2013;123:1381-1384.
  • 10
    Ardeshirpour F, McCarn KE, McKinney AM, Odland RM, Yueh B, Hilger PA. Computed tomography scan does not correlate with patient experience of nasal obstruction. Laryngoscope. 2016;126:820-825.
  • 11
    Daniel WW. 7th ed. John Wiley & Sons; New York: 1999. Biostatistics: A Foundation for Analysis in the Health Sciences.
  • 12
    Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci. 2006;1:9-14.
  • 13
    Kim YM, Rha KS, Weissman JD, Hwang PH, Most SP. Correlation of asymmetric facial growth with deviated nasal septum. Laryngoscope. 2011;121:1144-1148.
  • 14
    Janovic N, Maric G, Dusanovic M, Janovic A, Pekmezovic T, Djuric M. Introducing Nasal Obstruction Symptom Evaluation (NOSE) scale in clinical practice in Serbia: validation and cross-cultural adaptation. Vojnosanit Pregl. 2020;77:704-709.
  • 15
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Publication Dates

  • Publication in this collection
    17 Oct 2022
  • Date of issue
    Sep-Oct 2022

History

  • Received
    6 May 2020
  • Accepted
    9 Sept 2020
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