Proceeding S.Z.P.G.M.I. vol: 19(1) : PP- 7-11, 2005.

Management of Deviated Nasal Septum by Septoplasty Sarfraz Latif and Naveed Aslam

Department of EN T, Shaikh Zayed Hospital, Lahore

ABSTR.\CT

This is a prospective study for the management of deYiated nasal sep~ by septoplasty. Fifty patients in age group 4-40 years were selected for this study. There "ere 3.! mas 68"e and 10 females 32% . All cases had deviated nasal septum with or without extemaJ canii2gi:::ous deformity of nose . Maj or etio logical factor causing deviated nasal septum was idiopafhic o; deo"C:U.. ta! m our srudy. After thorough preoperative and peroperative assessment all patients v.:ere operated upon by septplasty under general anesthesia at Shaikh Zayed Hospital Lahore. The success rate in 50 patients was evaluated with minimum follow up period of 8 weeks. The present study showed improvement in nasal obstruction 84%, post nasal drip 73%, headache 70% hyposomia in 58% and external nasal deform ity of nose '' ith deviated nasal septum 83% by septoplasty. The results were obtained by comparing the pre and post operative compla ints with rhino logical examination. Regarding post operative complications septa} adhes ions were noted in 8 patients (16%) septa! perforation (1%) secondary hemorrhage in 2 patients (4%) and 6 patients had residual deviated nasal septum ( 12% )- From th is study it was concluded that conservation at the septa) frame work rather than resection is much better as it gives lesser complications, a llows concomitant rhinoplasty or revis ion surgery and conservative surgery can be safely performed in children without fear of poor development of mid face. The objective of this study was to assess the results and complications of the septoplasty.

INTRODUCTION

Deviated nasal septum is a common disease encountered in ENT practice. Most patients has

complained of nasal obstruction, and complications in the respiratory tract like s inus itis, Pharyngitis , Tons illitis, Laryngitis etc . They also had headache, recurrent epistaxis and external deformity of nose. Impaired olfactory functions may also be · present due to deviation of nasal septum 1•

Septa! deformities may be developmental or congenital in high percentage of cases some septal deformities are traumatic or acc idental. Deviated nasal septum can involve at any age and sex, but males suffer more as compared to females. The age at which syrnptornus develop is usually adolesence and adult age.

Septa! diformitics can be divided into simple septa! dev iation spur formation and tension septum with or without external deformity of nose. The symptoms of nasal obstruction may also be due to

defect in external nares, columella, and obstruction at nasal valve in addition to deviate nasal septum.

There is no satisfactory medical treatment for this condition the treatment is surgical, to correct the defect and to prevent complications.

T he basic principle of surgery is division of septum into anterior and posterior segment by a vertical line drawn between the nasal process of frontal bone a nd anterior maxillary spine. Di vis ion in posterior segme nt can be easily and effectively treated by c lass ical ki llian submucosal resection operation (SMR) Whereas those in anterior segment should be treated by a more conservative septplasty technique. Septoplasty is one of the most frequently performed surgery in otorhinolaryngology now a days.

Indications include deviation of septum, as a part of rhino plasty, as an approach pitulary fossa, and to improve access to middle meatus in endoscopic sinus surgery. Surgery on a deviated nasal septum has bee n seen several modification

S. Latif and N. Aslam

since its inception starting from radical septa! resection to mucosa! preservation and subsequent preservation of septa! frame work. Recemly the emphasis has been on conservation rather than resection as the former gives rise to lesser complications. Septoplasty is an operation designed to mobilize and replace the deviated nasal septum into rnidposation by dividing almost all its attachment leaving the quadrilateral carti I age attached to flap of mucose to preserve its viabi I ity. According to our experience submucous resection (S.M.R.) can · not be done in every case, but septoplasty can be done at any age group and in every type of deviation of septum.

MATERIAL AND METHOD

This was a prospective study carried our at the department of ENT and head anq Neck surgery Shaikh Zayed Postgraduate Medical Institute Lahore from 2"d August, 1999 to 3 l '' March, 200 I. The patient input was mainly from urban population of Lahore. Fifty consective cases of deviated nasal septum were admitted for septoplasty.

Following was the inclusion criteria for this study.

Inclusion criteria ( l) There was no age restriction for the patients

including in study. (2) Patients having both anterior and posterior

devotion were included. (3) We also included patients having deviated

nasal septum with external cartilaginous deformity w hich was cosmetically unacceptable.

Exclusion criteria We excluded patients having

(1) Allergies rhinitis (2) Acute infection of nose and paranasal sinuses

till recovery (3) Atrophic rhinitis (4) Chronic specific infection like syphils, T.B,

and leprosy. (5) We excluded patients having uncontrolled D.

M, hypertension and other major illness like respiratory or cardiac problem

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(6) Patients w ith bleeding disorders were also excluded from study.

(7) Patients with benign and maligmcnt conditions of nose as well as nasal polyp were also exclude

All patients were evaluated as. History and clinical examination Laboratory investigation and radiological investigation where indicated.

All these symptoms and c linical finding were noted on a performa pre operatively as well as post operatively. All patients operated under general anesthesia after informed consent of general anesthesia, procedure, their outcome and possible complications of both.

In our technique after infiltration with Injection of 2% xylocaine with I : 100,000 adrenalline . Usually we trimmed vibrissac.

The mucoperichondrium flap was elevated cancave side of septum, both along the cartilaginous and boney septum A strip of cartilage was removal inferiorly to mobilization of the septum and creating space in between the two flaps.

The cartilaginous septum was separated posteriorly from vomer and perpend icu Jar plate of ethmoid. The boney space along floor and bony deflection posterionly i.e. vomer was a lso removed. The carti lag inous septum was straightned by scoring (criss cross on concave s ide of cartilage or by removing a strip of cartilag a long acute angulation. Now straight cartilaginous septum assessed and if it was too long then few milimetor cartilage was trimmed along caudel and so that it fitted into columellar pocket. The closure was done by 2/0 chromic catgut. We routinely use nasal splints which stiched at columcra and anterior nasal packing wes done for 24 hours which was in impragenated w ith Vaseline and liquid paraffin.

All patients were followed up in out patients department for minimus period of 8 weeks. Results of surgery were assessed by asking the patients about improvement in their post operative symptoms and clin ical examination.

All preoperative and post operative findings were recorded on questionnaire Performa.

Management of Deviated Nasal Septum by Septoplasty

RESULTS

This study was carried out at department of ENT and head neck surgery Shaikh Zayed Hospital Lahore for 2"d August 1 999 to 31st March 2001 to assess the results and complications of scptoplasty for the treatment of deviated nasal septum Fifty consecutive cases were selected for the study. Among them there were 34 male (68%) and 16 female(32%) (Table 1 ).

Age range was 4-40 years (Table· 2) Regarding the etiology of the deflected nasal

septum 38 patients (76%) had idiopathic or ·developmental cause, 20% had history of trauma and road traffic accident. Two patients (4%) had iatragenic cause following surgery (Tab le 3).

Table I:

Sex

Male Female

Sex distribution.

Number

34 16

Percent

68% 32%

TABLE 2: Age distribution.

Age (Years) Number Percent

0-10 6 12% 11-20 24 40% 21 -30 13 26% 3 1-40 07 14%

Table 3: Etiology of deviated nasal septum.

No of Male Female Percent Cause Patients

38 26 12 76% Develop mental

10 7 3 20% Traumatic 2 I I 4% Iatrogenic

Regarding the presenting complaints of patients 50 patients had complain of nasal obstruction (100%) forty two patients (84%) had complaint of post nasal drip, 31, patients(62%) had headache, 12 patients (24%) had external nasal deformity of nose, along with deflected nasal

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septum, 2 patients (4%) had epistaxis and 12 patients (24%) had hyposomia (Table 4).

Regarding types of deflection (2 1) patients ( 42%) had anterior septal deviation, 17 patients (34%) had posterior septal deviation, wh ile 12 patients (24%) had Ext. deformity of nose with DNS (Table 5).

Regarding procedure all patients were operated septoplasty (Table 6).

Table 4. Presenting complaints of patients.

Complaints ~o. of ;\lale Female Percent Patients

Nasal Obstruction 50 3-l 16 100% Post Nasal Drip ~J ~ i

.>- 10 84% Headache 3 1 :!O 11 62% Hyposmia 12 09 03 2.:l~o

Ext.Dcformity+DNS 12 08 0-l 2-io ;, Epistaxis 2 02 Nrl 4°0

Table 5: Types of deflection.

Types of deflection No of Male Female Percent Patients

Anterior Septal 21 17 4 42% deviation Posterior Septal 17 10 7 34% Deviation Ext.Oeformty+DNS 12 8 4 24%

Table 6: Procedure

Procedure Number Percent

Scptoplasty + Sphints 50 100%

Post-operative resul ts were collected by asking the patients by self assessment data and rhinological examination of the patients. Each complaint and anatomical pathology was assessed. Pre-operatively and post-operatively patients response appreciably good and fair enough mean satisfied results as each complaint assessed separately (Table 7).

Regarding the post operative complications, septa I adhesion were noted in 8 patients ( 16%)

S. Latif and N. Aslam

septa I perforation m I patients (2%) secondary hemorrhage in 2 patients (4%) while 6 patients had residual deviated septum(l2%) (Table 8).

Table 7: Postoperative results.

Complaints Appreciably Fair Not Results good Enough Satisfied

Nasal 38 Obstruction Post Nasal 29 Drip Head Ache 20 Hyposmia 5 Ext. 8 Deformity+ DNS Epistaxis 2

Table 8: Complications.

Complications

Septa] Adhesions Deviated septum after surgery Secondary Haemorrhage Septa] Perforation

4

2

2 2 2

Nil

Number

81 6 2 I

DISCUSSION

8

!I

9 5 2

Nil

84%

73%

70% 58.3% 83%

100%

Percent

16% 12% 4% 2%

Various techniques have been described for correction of a deviated septum4

• The. concept of sub mucous resection was popularized and refined by Killian5 and Freer6 separately in early twentieth century. However an increasing incidence of complications of septa! surgery led to more and more conservative septoplasty.

Metzenbam (1929)7 described the swing door technique for caudal dislocation and sublaxation. Gallowary8 removed entired nasal cartilage and replaced it as a single auto graft. Refinment in septa! surgery have be popularized by Cottle9 Maran4 has described septoplasty, but used a more radical technique in the terms of remove! of honey septum to make septum free infteriorly by and posteriorly. It is also essential to know the biochemical behaviour of the cartilaginous septum as described by Murakami et al. 10 As for concerning our study in 50

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patients, We found satisfactory results. In our patients 84% nasal obstruction, 73%

post nasal drip 70% headache, 58% hyposamia and external deformity with deviation improved in 83% patients.

Comparison of our results with international" data showed satisfactory results. Fjermedal

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reported 63% success rate of septoplasty in 478 patients in relieving nasal obstruction. Another study by Makitic et al. 12 reported that septoplasty has 88% successful results in nasal obstruction and also improvement in relieving nasal discharge sneezing, recurrent headache, and chronic rhino smusps.

There were few complications and short term results were good. Out of 50 patients reported in follow up with nasal adhesion were 16%. Adhesions formation following septa] surgery were also reported by Shone and Clegg13 reported an incidence (11 %) and Tallat et al 14 reported 6%. These patients were treated by adhesion breakdown in out patients department during suction clearure of nose and mild and nasal paking done for 24 hours.

Other complications including residual DNS following septoplasty 12%. Our data showed that all these patients were operated by Resident surgeons. It means the expertise of surgeon also influences the results of septa! surgery.

It literature it has been reported 12% patients are more satisfied, by operated by senior consultants. This emphasizes that septa] surgery require years of learning and supervision for satisfactory results. Two patients complained with secondary hemorrhage treated conservatively giving intravenous antibiotics, analgesics and anterior nasal packing. One patients had septa! perforation, this was small and asymptomatic and needed to treatment our complication rate was about the same as or even better than other repots.

Buckley et al. 15 Murthy and McKerrow 16•

Bens on Mitchell et al 17·

Concluding remarks of our study showed that conservation of the septa) from work rather than resections is better as it gives lesser complications, allow comitant rhinoplasty or revision surgery and more even conservative surgery can be safely performed in children with out fear of a possible poor development of mid face.

Management of Deviated Nasal Septum by Septoplasty

REFERANCES

1. Goldwyn nasal septum in paparella scumrick otolaryngsology, vol. III 2"d edition 1968: p. 2054

2. Gil et al. Septoplasty corrective rhinoplasty 1980, Vol I Ist edition, p. 143.

3. Andrew C, Uraquhart MD, · Fernando Bersalona MD. The laryngoscope. Lipponcott Raven Publishers Philadelphia 1997. The American Largngological Rhinoatilogical Society.

4. Maran AGO. Septoplasty. J. Laryngolosy and Otology 1974; 00:393-42.

5. Killian, G. Die submucose Fensterreseklin der nasencheid ev and. Archi':', ur larynglogie and Rhinologie 1904; 16: 362.

6. Freer 0 .. The Correction of deflections of the nasal septum with a minimum traunation. Journal of American Medical Association 1902; 38: 636.

7. Metzenbacum, M. Replacement of the lower end of dislocated cartilage versus submucous resection of the otolarynogology 1929; 9: 282

8. Gallowary T. Plastic repair of deflected nasal septum. Archives of Lynogolgy 1946; 44: 141.

9. Cottle MH, Fisher GG, Gaynon IE. The Maxilla- Pre maxilla approach to extensive nasal septa! surgery, Archives of Otolanyngolegy i 958; 68: 301.

10. Murakami WT, Wong LW, Davidson TM. Applications of the biomechamical behaviour of cartilage to nasal septop\astic Surgery . Laryngo Scope 1982; 92:300-9.

11. Fjermedal C, Saunte S. Pe<.icrsen, Comparison of the results of submucous resection and septoplasty. J Laryngology and Oto logy 1988, 102: 796-98.

12. Makitiea, Aaltonen M~ Hytonen M, Malberg H. Postopertive infection following nasal

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septoplasty. Acte Otolaryngol Suppl 2000; 5433: 165-66.

13. Shone GR, Clegg Rt. Nasal adhesions J Laryngology and otology 1987, 101 :555-57.

14. Tallat ur, El. Sabaway E, Bakey F, Raheem A. Submucous diathermy of inf turbinates in chronic hypertrophic rhinitis. J Laryngology and Otology 1987, I 0 I: 452-60

15. Buckley JG, Mitchell DB, Hickey SA. Fitzgerlad septum as an out patients procedure, Journal of Laryngology and Oto logy l 10: 129.

16. Murthy P, Mckerrow WS. Nasal Septa) surgery is rountine follow up. Necessaary Jounral of Otolarynogology 1995; I 09: 320-23 .

17. Bersin- Mitchell, R., Kenyon, G., Gatland, D. Septoplasty, as a day case procedure two centre study JLO 1996; 110: 129-31.

The Authors:

Sarfraz Latif, Senior Registrar Department of ENT, Shaikh Zayed Hospital, Lahore.

Naveed Aslam Associate Professor Department of ENT, Shaikh Zayed Hospital, Lahore.

Address for Correspondence:

Sarfraz Latif, Senior Registrar Department of ENT, Shaikh Zayed Hospital , Lahore.