Septal Deflection Research Articles

Exploring the Relationships Between Clinical Examination Findings, Subjective Reported Symptoms and Objective Nasal Patency Measures in Nasal Obstruction: A Baseline NAIROS Sub-Study Analysis.

The role of objective nasal airflow measures using peak nasal inspiratory flow (PNIF) and rhinospirometry in supporting clinical examination findings when offering patients septoplasty remain undefined. To explore the baseline relationships between clinical examination findings, subjective reported symptoms and objective nasal patency measures in nasal obstruction. This is a sub-study of the NAIROS trial. Participants with nasal obstruction secondary to septal deviation were included in this NAIROS sub-study. The side of septal deviation, enlargement of inferior turbinate (IT), the need for IT reduction if septoplasty was being performed, the area of septum deflecting into the airway and observer rated airway block (ORAB-arbitrarily divided by <50% and >50% blockage) were assessed by clinicians. The subjective score of nasal obstruction was assessed using the Double Ordinal Assessed Subjective Scale (DOASS). Objective nasal patency measures (e.g., nasal partitioning ratio, [NPR] and PNIF) were measured using PNIF and rhinospirometry. The mean NPR for left-sided, both-sided and right-sided septal deviation was -0.35, -0.02 and 0.51, respectively (p < 0.001). There was very weak correlation between the requirement for IT reduction and PNIF change (0.13, p < 0.01). There was no difference in mean PNIF (94 L/min vs. 93 L/min) and mean DOASS (0.33 vs. 0.38) for participants with ORAB rated <50% and >50%. The mean NPR for participants with ORAB >50% was higher than for those with ORAB <50% (0.51 vs. 0.41, p = 0.002). There was strong correlation between the DOASS and NPR (+0.737, p < 0.001). The mean DOASS score for right-sided, both-sided and left-sided septal deviation was 0.32, 0.05 and -0.29, respectively (p < 0.001). This study identified strong relationships between the clinician rated side of septal deflection, the patient reported DOASS and the objective NPR measurements. NPR and the clinician rated degree of airway blockage were concordant.

Nasal Airway Obstruction Study (NAIROS): a phase III, open-label, mixed-methods, multicentre randomised controlled trial of septoplasty versus medical management of a septal deviation with nasal obstruction

BackgroundSeptoplasty (surgery to straighten a deviation in the nasal septum) is a frequently performed operation worldwide, with approximately 250,000 performed annually in the US and 22,000 in the UK. Most septoplasties aim to improve diurnal and nocturnal nasal obstruction. The evidence base for septoplasty clinical effectiveness is hitherto very limited.AimsTo establish, and inform guidance for, the best management strategy for individuals with nasal obstruction associated with a deviated septum.Methods/designA multicentre, mixed-methods, open label, randomised controlled trial of septoplasty versus medical management for adults with a deviated septum and a reduced nasal airway. Eligible patients will have septal deflection visible at nasendoscopy and a nasal symptom score ≥ 30 on the NOSE questionnaire. Surgical treatment comprises septoplasty with or without reduction of the inferior nasal turbinate on the anatomically wider side of the nose. Medical management comprises a nasal saline spray followed by a fluorinated steroid spray daily for six months. The recruitment target is 378 patients, recruited from up to 17 sites across Scotland, England and Wales. Randomisation will be on a 1:1 basis, stratified by gender and severity (NOSE score). Participants will be followed up for 12 months post randomisation. The primary outcome measure is the total SNOT-22 score at 6 months. Clinical and economic outcomes will be modelled against baseline severity (NOSE scale) to inform clinical decision-making. The study includes a recruitment enhancement process, and an economic evaluation.DiscussionThe NAIROS trial will evaluate the clinical effectiveness and cost-effectiveness of septoplasty versus medical management for adults with a deviated septum and symptoms of nasal blockage. Identifying those individuals most likely to benefit from surgery should enable more efficient and effective clinical decision-making, and avoid unnecessary operations where there is low likelihood of patient benefit.Trial registrationEudraCT: 2017–000893-12, ISRCTN: 16168569. Registered on 24 March 2017.

Triangular excision and submucosal rejoining to correct horizontally folded caudal nasal septum.

Surgical correction of severe caudal deviation of nasal septum using an endonasal approach is challenging for surgeons. Among cases of severe caudal septal deflection, fracture lines along the horizontal direction are occasionally encountered during the surgery. We devised a simple and efficient technique called "triangular excision and submucosal rejoining" to address this kind of deformity. A total of 9 patients with severe caudal septal deflection underwent "triangular excision and submucosal rejoining." After the removal of the deformed posteroinferior portion of the quadrangular cartilage, 2 incision lines were made on the remaining caudal septum, starting from a point at the most anterior portion of the fracture line and diverging posteriorly above and below the fracture line. After removing a triangular cartilaginous piece, the upper and lower remaining cartilage segments were approximated using a single or 2 simple interrupted sutures. Sutures exiting the mucosa were re-entered from the exit point so that all the sutures were buried underneath the mucosa while the mucosal flap was elevated only unilaterally. This technique was effective in all cases. Septal batten grafts were applied in 3 patients, in whom the remaining quadrangular cartilage was weak and thin. One patient showed a mildly recurred septal deviation, but the nasal cavities remained patent with no symptoms. Serious complications such as dorsal saddling or tip ptosis did not occur in any cases. "Triangular excision and submucosal rejoining" may be a safe and efficient septoplasty technique to correct a horizontally folded caudal septum.

A simple, single stage technique to harvest optimal ethmoid bone grafts for caudal septal deflections.

Curvature of the caudal septum is a challenging area to surgically address because it is a tip supporting structure. Several methods to straighten the caudal septal deviation have been described to date. One commonly described technique is the placement of a bony septal batten graft. However, the harvest and subsequent ex vivo shaping of the bone graft can be difficult and lead to fracture of the graft superstructure. Here we discuss a novel single stage endoscopic approach to harvest a preformed batten graft and apply it to correct a caudal septal curvature deformity. Description of a novel endoscopic technique for the single stage harvest of a bone graft for the correction of a caudal septal deflection utilizing an open Jansen-Middleton septum forceps. We have successfully utilized this technique in 10 patients with a caudal septal curvature deformity with no complications. All patients had symptomatic improvement of nasal obstruction symptoms. The open Jansen-Middleton septum forceps allow for a reproducible, single stage, harvest of a bone graft from the perpendicular plate or vomer when addressing a caudal septal deformity using an endoscopic septoplasty approach.

Measuring the breath of life

The inability to breathe freely and clearly is a major source of concern to patients and a common symptom in many sinonasal conditions (1). There are of course some semantic differences between terms such as ‘obstruction’, congestion’ and ‘blockage’, which have to be clarified when taking a clinical history as the presence of inflammation may produce the sensation of congestion without actually being associated with mechanical obstruction to airflow (2). Notwthstanding this, nasal obstruction is the commonest complaint in chronic rhinosinusitis with and without nasal polyps (3) and is a major feature of conditions from the common cold and acute bacterial rhinosinusitis to allergic and non-allergic rhinitis, septal deformity or a tumour. Paradoxically, many people, myself included, go through life largely oblivious to a significant septal deflection. It therefore begs the question as to why an individual with a long-standing anatomical variant such as this, suddenly presents with the symptom of nasal blockage and it is important that we do not simply focus on the septum (or turbinate) but rather ask ourselves ‘Why now?’ instead of simply listing the patient for septal surgery.

Does Correction of Caudal Septal Deflection Affect Nasal Angle Parameters?

Objectives: Verify whether one’s external appearance may change after correction of caudal septal deflection by estimating nasal angle parameters. Methods: Correction of caudal septal deflection was performed by first releasing the caudal septal cartilage along the maxillary crest and excising excessive portions. The incised cartilage was sutured, and the detached ventral cartilage of caudal septum was fixed at the midline. Preoperative and postoperative photographs (lateral view) were taken at postoperative 6 months. Nasolabial angle (NLA) and nasal tip angle (NTA), as well as the angle between the columella and a perpendicular line to the Frankfort line (CFL), were evaluated. The visual analogue score (VAS) for nasal obstruction was evaluated at pre- and post-operation. Results: A total of 35 patients per protocol were included in this study. The mean preoperative NLA was 98.67±9.17° and the mean NLA at postoperative 6 months was 98.64±9.27°; the NTA changed from 84.41±6.96° to 84.33±7.07°; the CFL changed from 80.06±7.91° to 80.08±8.02°. All parameters showed no significant change between pre- and post-operation. Subjective saddle nose or other external deformities were not reported. VAS score of subjective nasal obstruction decreased significantly from 7.89±1.37 to 1.80±1.05. Conclusions: After correction of caudal septal deflection, nasal angle parameters were not changed and VAS score was significantly improved. Therefore, caudal septal deflection can be safely and satisfactorily corrected through proper surgical methods.

Retrospective Analysis of Endoscopic Septoplasty

Received June 16, 2012 Revised August 20, 2012 Accepted August 21, 2012 Address for correspondence Soo Kweon Koo, MD Department of Otorhinolaryngology, Busan St. Mary’s Hospital, 538-41 Yongho-dong, Nam-gu, Busan 608-838, Korea Tel +82-51-933-7214 Fax +82-51-956-1956 E-mail koosookweon@naver.com Background and ObjectivesZZWe reviewed retrospective data of patients who underwent endoscopic septoplasty over 5 years and provide clinical information about endoscopic septoplasty. Subjects and MethodZZThe medical records of patients who underwent endoscopic septoplasty were reviewed retrospectively for clinical symptoms, surgical methods, intraoperative technique, operation time, postoperative complications and results. ResultsZZNasal obstruction was the most common presenting symptom. Among patients, endoscopic septoplasty alone was performed in 290 cases. Among 290 cases, 57 cases were of broad based septal defection, 13 cases septal deflection with septal spur, 16 cases isolated septal spur and 4 cases limited posterior septal deflection. The mean operation time was 32.48 ±2.76 minutes. No major complication occurred in the immediate postoperative period. Minor complications included septal hematoma (3.79%) and postoperative hemorrhage (1.03%). Sixty-five patients received statistically validated measures of Visual Analog Scale (VAS) at 1 month and 6 months after surgery. VAS score decreased statistically from 7.75 to 0.81 at 6 months after operation (p<0.05). ConclusionZZEndoscopic septoplasty is a relatively safe and effective technique used to treat various types of septal pathology such as classical septal deviation, septal spur and isolated septal deflection. Endoscopy with video imaging system is valuable for education. Korean J Otorhinolaryngol-Head Neck Surg 2012;55:559-64

A Study into the Benefits of Bilateral Packing for Epistaxis

Objective: Theoretically there is a safety benefit in using bilateral nasal packs in managing epistaxis. Our study aims to show an additional benefit in this practice: the reduction to the deformity caused across the nasal septum with bilateral packing, therefore creating a safer and more pleasant patient experience. Method: We created a simple nasal model to illustrate the nasal septal cartilage as a structure that is anchored inferiorly, superiorly, and posteriorly, but with a free anterior edge. Using 7.5 cm Arthrocare RapidRhino packs and a manometer, we measured the septal deflection created using different pack pressures, unilaterally and bilaterally. Results: By measuring the anterior deflection of the cartilage analogue (3 mm wide silicone sheeting) at 3 different fixed points along the anterior edge, we were able to demonstrate significantly less septal deflection when using bilateral packing with the same pressures, compared with unilateral packing. The dynamic nature of the model meant that the maximum deflection points varied between repetitions of the study, yet less septal deflection was seen with bilateral packing, particularly with higher inflation pressures, regardless of the starting deformity. Conclusion: Our simple model shows that the nasal septal deformity with bilateral packing is reduced, compared with unilateral packing. We theorize that the reduced deformity shown with bilateral packing will make for greater patient comfort. We have commissioned a model with pressure sensors across the nasal septum to analyze this theory.

Rhinoplastic techniques for the nasal valve for the patient with sleep apnea

Treatment of nasal blockage is necessary to facilitate therapy of obstructive sleep apnea and improve continuous positive airway pressure tolerance. The importance of the nasal valve in controlling inspiratory airflow has been well documented. Defining the nasal valve region and correlating physiology with its anatomic and surgical findings can be confusing. Reliable interpretation of the different types of nasal valve dysfunction can be correlated with effective surgical repair to reduce nasal airway resistance. A simplified approach to standardizing surgical treatment of nasal valve problems is presented.

Transnasal Endoscopic Surgery of the Pituitary: Modifications and Results Over 10 Years

A 10-year retrospective review of three endoscopic approaches used by the authors for pituitary gland surgery is presented. We review our results and complications and outline the advantages and disadvantages of each. The variations in nasal anatomy that factor in the endoscopic approach are tabulated and discussed. A chart review and examination of computed tomography and magnetic resonance imaging scans of patients who have had endoscopic pituitary surgery by the authors was performed. We gathered specific details of the operative approach, nasal-sinus anatomy, tumor location, required ancillary nasal procedures, and postoperative complications. Ninety patients had endoscopic pituitary surgery. Operative reports and review of radiographic studies were possible for 75 patients. The surgical approach progressed over 10 years from endoscopic transseptal (42) to bilateral transostial (13) to unilateral transostial (20). Adequate exposure for the degree of resection was achieved in all patients. Complications included hemorrhage requiring return to the operating room (1), transient visual field loss (2), and transient diabetes insipidus (7). Four patients subsequently had craniotomy to resect suprasellar tumor extension. The average follow-up was 6 years. One patient required revision endoscopic resection 3 years later for tumor recurrence. Anatomic findings included nasal septal deflections in 36 (48%) of the patients, abnormalities of the turbinates in 42 (56%), and variances of the sphenoid sinus septum in 59 (79%) of the patients. In the unilateral transostial approach, the operative side was often determined by anatomic factors. The authors have exclusively used endoscopic surgery of pituitary gland tumors for over 10 years. Modifications to the approach have occurred as a result of increased surgeon experience and improved technology. The unilateral transostial approach is safe, effective, and recommended.

Crohnʼs Disease Manifested as Rhinitis

This vignette relates an extremely rare manifestation of Crohn's disease and underscores the neccesity of considering Crohn's disease as the underlying cause of symptoms of obscure etiology. Past medical history was obtained, and physical examination and biopsies were performed ona patient with complaints of rhinitis. A 54 year old female with a history of active Crohn's colitis presented to her otolaryngologist with a complaint of rhinitis. She had persistent upper respiratory symptoms of cough and nasal congestion for several months that did not respond to various non-prescription medications. She also noted pain and irritation, localized to the inside of the right nostril, increasing in intensity over the last two to three weeks with small amounts of clear nasal discharge. Physical examination revealed a well appearing female in no distress. She was normotensive and afebrile. She was noted only to have bilateral high septal deflections. No facial tenderness or purulent discharge was noted. Her serum chemistries and complete blood count were within normal limits. Nasal endoscopy was normal. Biopsy, however, showed edema, giant cells and multiple noncaseating granulomas in the right nasal passage. Extraintestinal manifestations of Crohn's disease of the gastrointestinal tract are a well recognized phenomena. Biopsy typically shows edema of the lamina propria, perivascular inflammation with infiltrates and noncaseating granulomas with multinucleated Langerhans type giant cells. The differential diagnosis in this case included Wegener's granulomatosis and Crohn's disease. Nasal involvement is extremely rare. To date, only five cases of nasal Crohn's disease have been reported and is typified by chronic mucosal inflammation, obstruction, bleeding and occasionally septal perforation. All prior five patients were treated with oral steroids and or systemic corticosteroids with good results. Nasal involvement in Crohn's disease is extremely rare. Its findings after benign physical and endoscopic examination of the nasal passages suggest that this may be an underreported phenomenon.

Inspiratory and Fixed Nasal Valve Collapse: Clinical and Rhinometric Assessment

Acoustic rhinometry (AR) has been used to assess nasal valve obstruction. Standard AR measurement of the cross-sectional area (CSA) of the nasal valve is done in the apneic phase, whereas collapse often occurs on inspiration. We used the ratio of the CSA obtained during active inspiration and during apnea to compute a more meaningful method of diagnosing nasal valve collapse. AR was performed in 40 patients without nasal valve obstruction and 47 patients diagnosed with nasal valve obstruction. Patients with septal deflection or anterior inferior turbinate hypertrophy were excluded. The internal and external nasal valve area was observed during apnea and on active inspiration. AR measurement of the CSA of both nasal valves was performed during the apneic phase and during active inspiration and the CSA (inspiratory)/CSA (apneic) ratio was calculated. The CSA (inspiratory)/CSA (apneic) ratio was > or = 1 in normal patients and in patients with fixed nasal valve collapse. The ratio was <1 in patients with inspiratory collapse. Data from history, physical examination, and dual-mode AR testing successfully differentiated patients into (1) normal valves, (2) fixed valve collapse, and (3) inspiratory valve collapse. A large number of patients with collapse had both internal and external valve obstruction and a large number also had a combination of inspiratory and fixed collapse. Dual-mode AR testing is an effective tool in more precisely identifying nasal valve obstruction and is the first objective test shown to be highly diagnostic of inspiratory nasal valve collapse.

Abordajes transnasales para los tumores de región hipofisaria. nuestra experiencia

AbstractTranssphenoidal approach is the most commonly employed surgical technique for the resection of pituitary tumors. We present our experience in the transnasal-transsphenoidal approach in 30 patients undergoing pituitary surgery from 1998 to 2002. Ten patients underwent surgery via a sublabial-transeptaltranssphenoidal approach, 15 patients via a transeptal -transsphenoidal approach and 5 patiens via a pure endoscopic transnasal - transsphenoidal. The pathological study showed 29 pituitary adenomas and 1 Rathe´s cleft cyst. We conclud that the pure endoscopic transnasal- transsphenoidal approach guided by a navigator-system is safest and more effective approach. We reserved the transeptaltranssphenoidal approach for cases with obstructive septal deflection and poor pneumatized sphenoid sinuses. We do not recommend the use of the sublabial- trans-sphenoidal approach.

Correction of severe caudal deflections with a cartilage "plating" rigid fixation graft.

To evaluate a technique for correction of severe caudal septal defects. For all patients, preoperative photographs were analyzed and subjective nasal airway patency surveys were conducted. The caudal septal defects were then repaired with the cartilage "plating" rigid fixation technique. The intraoperative findings were documented in pictorial diagrams. Postoperative photographs and repeated airway surveys were obtained during the subsequent follow-up visits. Preoperative data and long-term postoperative data were compared and analyzed. Private practice, ambulatory surgical center. Thirty-six patients had significant caudal septal deviations and functional airway obstruction. Accuracy and stability of the correction, airway improvement, patient satisfaction, and morbidity. Since 1988, 36 patients were treated for severe caudal septal defects using cartilage plating rigid fixation. Follow-up visits have ranged from 3 to more than 9 years. All patients have maintained an accurate correction of their caudal septal deflections. All patients have also noted subjective improvement of their nasal airway. No complication has been encountered. Cartilage plating rigid fixation seems to be an effective method of correcting the functional problems associated with severe caudal septal deformities.

Treating the caudal septal deflection.

Caudal septal deflection can be a challenging nasal deformity. Although there are a number of maneuvers available to manage this functional and aesthetic abnormality, each approach is effective in only a limited number of cases. For over 25 years, the senior author (N.J.P.) has employed a "modified swinging door" technique for treatment of the deviated caudal septum. Using this technique, the septal cartilage along the maxillary crest is dissected free but is not excised. Instead, the caudal septum is flipped over the nasal spine, which acts as a "doorstop" and secures the caudal septum in a straighter position. This maneuver may be useful in the armamentarium of the surgeon managing this potentially difficult technical challenge.

Controversies in the management of inferior turbinate hypertrophy: a comprehensive review.

Nasal obstruction must frequently be addressed during functional rhinoplasty. Even after a properly performed septorhinoplasty correcting septal deflection and/or nasal valve collapse, nasal obstruction may persist due to turbinate hypertrophy. Turbinates have many important functions, including warming and humidification of inspired air, and numerous factors can contribute to pathologic enlargement. Management of inferior turbinate hypertrophy has been actively debated for more than a century. The primary goal of therapy is to maximize the nasal airway for as extended a period as possible while minimizing complications of therapy, such as nasal drying and hemorrhage. This review describes the various medical and surgical therapeutic modalities widely used today, with emphasis placed on surgical management of the inferior turbinates. Advantages, disadvantages, complications, and controversies of each form of treatment are reviewed and discussed. A staged protocol of increasingly invasive interventions is proposed.

Autologus ethmoid splint for nasal septal reconstruction

Otolaryncologic literature is full of techniques described to correct the deviated nasal septum. The popular operation of submucosal resection has several potential complication. Moreover the dorsal and caudal septal deflections cannot be corrected by it. The modern trend is towards nasal septal reconstruction, so that the whole septum can be approached and reconstructed. We have used the autologous perpendicular plate of ethmoid as permanent nasal septal splint. The ethmoid plate is rigid enough to be used as splint at the same time it is thin and does not add to the bulk. The Ethmoid splints are effective in correcting septal deviation and prevent redeviation of the reconstructed septum. The technique was successfully used in over 100 patients without any significant complication.

Nasal Resistance and Nasal Valve Area

The nasal valve is considered to be the primary flow-limiting segment of the normal upper airway. We examined subjects with and without nasal pathology to determine whether nasal airway resistance, as determined by rhinomanometry, could be related to clinically measurable geometrical characteristics of the nasal valve. Data was obtained from 26 subjects, 22 with nasal airflow complaints due to valvular or septal abnormalities and four without. Nasal valve area was estimated by triangular approximation, and transnasal airflow resistance was measured using head-out whole-body plethysmography. When all subjects were considered, no clear relationship between nasal resistance and nasal valve area was apparent. However, when patients with severe septal deflection or with a prominent vasomotor response to nasal decongestion were not considered, nasal resistance was found to be significantly negatively correlated to nasal valve area. Further studies are required to relate more posterior pathology to nasal resistance.

The importance of preoperative nasal endoscopy in patients with sinonasal disease

Functional endoscopic sinus surgery (FESS) has popularized the use of telescopes in sinus surgery and has emphasized the importance of nasal endoscopy and computed tomography (CT) in the evaluation of patients with diseases of the nose and paranasal sinuses. Variations in intranasal and sinus anatomy have been implicated in the etiology of chronic and recurrent sinusitis, and CT imaging has become an important diagnostic tool. Despite this, some patients present with symptoms and telescopic examination suggestive of sinonasal disease, yet demonstrate little abnormality on CT scan. The authors reviewed videoendoscopic and CT examinations of 100 consecutive patients with symptoms of sinus disease and found 9% of patients with abnormal telescopic examination in the context of negative CT findings. In those patients whose CT examinations were positive, telescopic nasal endoscopy was especially useful in delineating the type of soft tissue which obscured the area of the middle meatus. In those patients whose CT examinations were negative, telescopic examination demonstrated septal deflections, mucosal edema involving the middle meatus, as well as turbinate and adenoid hypertrophy. These findings demonstrate that telescopic nasal examination is an important diagnostic modality which often yields important information when evaluating patients with sinonasal disease.

The Cocaine User

The current popularity of cocaine use poses special hazards for the patient and the plastic surgeon during rhinoplasty. It is incumbent upon the surgeon to inquire preoperatively about possible recreational use of cocaine. As the preferred site of cocaine administration, the nasal septal mucosa is exposed to both the intense vasoconstrictive action of cocaine and the irritative effects of numerous contaminating additives. Pathologic changes in the septal mucosa should be recognized by preoperative rhinoscopy and evaluated by biopsy. In this series of 13 patients, fewer than half were properly identified as cocaine users during the preoperative consultation. Preoperative rhinoscopic findings varied from grossly unremarkable septal mucosa to visible perforation and microscopic evidence of granulomas, inflammation, and necrosis. Surgical complications consisted of localized septal collapse, delayed mucosal healing, and inadequate correction of septal deflection. Submucous resection and septoplasty should be avoided in patients with a known history of intranasal cocaine application. Although rhinoplasty can be safely performed in selected patients with a history of cocaine use, it may be extremely limited, unfeasible, or hazardous in those with significant mucosal and cartilaginous impairment as well as in those patients who refuse or are unable to relinquish the drug.