International Journal of Otorhinolaryngology and Head and Neck Surgery

Chandra S et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Oct;3(4):1046-1051

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DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20174330
Original Research Article

A comparative study of endoscopic versus conventional septoplasty:

an analysis of 50 cases
Sagar Chandra1, Nitish Baisakhiya2*

Department of ENT, 1MMMC, Solan, Himachal Pradesh, 2MMIMSR, Mullana, Ambala, Haryana, India

Received: 12 July 2017

Revised: 29 August 2017
Accepted: 30 August 2017

*Correspondence:
Dr. Nitish Baisakhiya,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Nasal obstruction is the most common complaint in ENT practice. Surgical correction of deviated nasal
septum has been performed by a variety of techniques of which sub mucous resection and Septoplasty procedures of
surgical correction of nasal septum play a prime role in management of patients of nasal obstruction. Nasal endoscope
is very useful tool to visualize posterior part of septum and do the surgery more precisely and with less complication
as compare to conventional method. The objectives of the study were to compare the outcomes of conventional and
endoscopic septoplasty, to evaluate the advantages, disadvantages and complications of both endoscopic and
conventional septoplasty
Methods: 50 cases (between (Oct. 2014 - March 2016) of deviated nasal septum selected in this prospective study
and they were randomly divided equally in 2 groups for endoscopic (A) and conventional (B) septoplasty
respectively.
Results: The study included 50 cases. Majority of patients in this study were males 84% (n=42) and 16% (n=18) were
female. 46% (n=23) patients had DNS to right side and 54% (n=27) patients had left side, anterior deviation (48%). C
and S shaped deviations (14%). Spur was present in 22% (n=11) of cases and 10% (n=5) patients presented with
thickening. After completing 2 months of follow up 92% (n=23) of group A and 88% (n=22) of group B were
relieved from nasal discharge, while nasal obstruction was absent in 96% (n=24) patients of group A and 80% (n= 20)
of group B. 4% cases (n=1) in endoscopic septoplasty was having persistent deviated nasal septum and 16% (n=4)
patients of conventional septoplasty belong to this group.
Conclusions: Endoscopic septoplasty has an obvious edge over the conventional approach due to better illumination
which enables to identify the pathology accurately, excise the deviated part of septum precisely and realignment of
the cartilage for best results.

Keywords: Septoplasty, Endoscopic septoplasty, DNS

INTRODUCTION nasal wall.1 Surgical correction of deviated nasal septum

has been performed by a variety of techniques of which
Nasal obstruction is the most common complaint in sub mucous resection and Septoplasty procedures of
rhinologic practice and a deviated nasal septum is the surgical correction of nasal septum play a prime role in
most common cause of nasal obstruction. A significantly management of patients of nasal obstruction. After the
deviated nasal septum has been implicated in epistaxis, invention of nasal endoscopes tremendous changes have
sinusitis, obstructive sleep apnea and headache evolved in the field of septal surgery. Now a day’s
attributable to contact points with structures of the lateral endoscopes are being used in performing septal surgery

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so as to allow access in performing endoscopic sinus Study population

surgery where it is was termed as Endoscopic
Septoplasty.2 Septoplasty is a surgical procedure that 50 patients were selected and randomly allotted into 2
corrects a deformity of the nasal septum. The usual groups consisting to 25 patients each.
purpose is to improve the nasal breathing. When
compared with standard head light technique, endoscopic Inclusion criteria
septoplasty provides important advantages which include
adequate visualization, room for instrumentation during Inclusion criteria were age more than 14 years; patient
functional endoscopic sinus surgery, access to para nasal with symptomatic deviated nasal septum, nasal
sinuses and for other surgeries like trans-septal approach obstruction, chronic rhinosinusitis, patient suffering with
to the sphenoid sinus, visualization and stoppage of complications like epistaxis, headache, snoaring.
postnasal bleeds. But before introduction of functional
endoscopic sinus surgery, majority of septoplasties were
Exclusion criteria
done for nasal airway obstruction. Furthermore in
complex deformities, better correction is possible with
Exclusion criteria were age less than 14 yrs; external
the help of an endoscope since we can clearly see the
posterior deviations.1 Whereas patients undergoing deviation with deviated nasal septum, patients with acute
traditional septoplasty require a longer stay due to rhinitis or allergic rhinitis or vasomotor rhinitis, patients
bleeding or lip edema than those undergoing endoscopic above 65 yrs.
septoplasty. Endoscope also aided limited resection and
thus more conservation by guiding precise shaving of The ethical clearance for the study was obtained from
septal cartilage.3 Endoscopic septoplasty is a fast Institutional Ethics of MMIMSR, Mullana, Ambala.
developing concept and gaining popularity with an
increasing trend towards the endoscopic surgeries.4 A group of fifty patients with deviated nasal septum
Endoscopic technology greatly enhances visualization refractory to medical treatment with long term nasal
during septoplasty. Discrete septal pathologies such as obstruction and headache were selected as per the
isolated deflections, spurs, perforations and contact points inclusion criteria from in patient department of
can be addressed in a directed fashion.5 Endoscopic Otorhinolaryngology. A well informed written consent
septoplasty has several advantages over traditional was taken. Preoperative assessment was done, a detailed
headlight septoplasty which include superior history was taken, patients were examined clinically and
visualization, accommodation of limited and minimally endoscopically and preoperative findings were noted.
invasive septoplasty and usefulness as an effective Preoperative medication was given to the patients and
teaching tool with video imaging. they were taken for surgery.

Objective Patients were randomized into 2 groups by

randomization, a total of 50 envelops were taken
1) To compare the outcomes of endoscopic and consisting of 25 chits marked as endoscopic septoplasty
conventional septoplasty. and 25 marked as conventional septoplasty. Prior to
2) To evaluate the advantages, disadvantages and operation, in the operation theater, envelop was opened
complications of both endoscopic and conventional and type of septoplasty was decided.
septoplasty.
Techniques for conventional septoplasty
METHODS
After infiltration with 2% xylocaine with adrenaline into
Study design columella and septum under headlight, incision
(hemitransfixion incision) was made at caudal border.
Hospital based prospective comparative study. The mucoperichondrial and periosteal flaps were elevated
upto perpendicular plate of ethmoid. The osseo-
Study area cartilaginous junction was dislocated. A 0.5 cm of the
anterior margin of perpendicular plate of ethmoid was
Patient presenting with symptomatic deviated nasal removed with Luc’s forceps. An inferior cartilaginous
septum to the department of ENT in MMIMSR, Mullana, strip of 0.5 cm was removed if necessary. The incision
Ambala. was closed using chromic catgut (3-0) and nasal packing
was done.
Sample size
Technique for endoscopic septoplasty
50 patients were taken for the study.
The procedure was performed under local or general
Study duration anaesthesia. The septum was injected with 2% xylocaine
in 1: 20,000 epinephrine on the convex side of the most
One and half years (October 2014 - March 2016) deviated part of the septum using 0° rigid 4 mm

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endoscope. Hemitransfixation incision was made. right side and 54% (n=27) patients to left side. 48%
Incision was extended superiorly and inferiorly just as (n=24) patients had anterior deviation. C and S shaped
needed to expose the most deviated part. A sub- deviations were present in 14% (n=7) and 6% (n=3)
mucoperichondrial flap was raised using a suction respectively. Spur was present in 22% (n=11) of cases
elevator under direct visualization with an endoscope, and 10% (n=5) patients presented with mucosal
underlying bone was exposed and the most deviated part thickening. After completing 2 months of follow up in
was removed. The flap was repositioned back after our 50 patients, revealed that 92%(n=23) of group A and
suction clearance and edges of the incision were just 88% (n=22) of group B were relieved from nasal
made to lie closely without the need to suture. The nasal discharge, while nasal obstruction was improved in
cavity was packed with Vaseline nasal packs. 96%(n=24) patients of group A and 80% (n= 20) of group
B. Headache and post nasal discharge was improved in
Intra-operatively following parameters were noted: 100%(n=25) patients of group A and 88% (n=22) patients
of group B. In this study 4% of patients (n=1) in
a) Duration of surgery. endoscopic septoplasty was having synechiae and 8% (n=
b) Blood loss during surgery. 2) patients with conventional septoplasty. 4% cases (n=1)
c) Associated turbinate procedure. in endoscopic septoplasty was having persistant Deviated
nasal septum and 16% (n=4) patients of conventional
Nasal packing was done for all cases in both groups with septoplasty belong to this group. There were no
Vaseline nasal packs and I.V. antibiotics were started. complications of epistaxis and crusting in endoscopic
septoplasty but in case of conventional septoplasty 4%
Patients of both groups were discharged with one week of (n=1) patient was having anterior epistaxis and 8% (n=2)
antibiotics and analgesics, decongestant nasal drops were were having crusting (Figure 4).
given for 3 days followed by saline nasal drops till next
visit.
12

Postoperatively second week, fourth week, eighth, follow 10

up was done and following points were noted on
diagnostic nasal endoscopy: 8

a) Persistence of anterior/posterior deviation or spur. 6

b) Formation of synechiae.
c) Persistent pathology of turbinates. 4
d) Presence of discharge in middle meatus.
e) Cold spatula test. 2
f) Any change in external appearance.
0
Endoscopic Conventional age <20yrs
Data collected was entered in Microsoft excel. Data was age 21-30yrs
analyzed by using SPSS version 20 for calculating “p” age 31-40years
value and other statistical analysis. age >40yrs

RESULTS Figure 1: Age distribution.

The study included 50 cases. Age range varied from (16- 45

54 years) with a mean age of 28 years. Most common age
40
group involved was 21-30 years with (n=18) involving
36% of cases. The least common age group was patients 35
>40 years (n=6) involving 12% of cases (Figure 1). 30
Majority of patients in this study were males 84% (n=42) 25
and 16% (n=18) were female Patients with male to
20
female ratio was 4:1 (Figure 2). Clinical assessment was
done in all 50 patients after dividing them into 2 groups 15
out of which 25 underwent endoscopic septoplasty and 25 10
conventional septoplasty. 5
0
Nasal obstruction was the commonest symptom in both
the groups involving (n=21) 84% in group A and (n=18)
NO. OF MALE NO. OF FEMALE
72% in group B. Equal no. of patients (n=4) 16% were
seen in both the groups presenting with sneezing.
Hyposmia was the least common feature in both the
groups (Figure 3). 46% (n=23) of patients had DNS to Figure 2: Gender distribution.

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precisely diagnose the pathological abnormalities of the

4% nasal septum.8
8%
26% Olphen described that Cottle in 1963 gave the concept of
10% NASAL
conventional septoplasty which is done in 6 phases:
DISCHARGE
a) Gaining access to the septum
11% b) Correction of pathology
NASAL
OBSTRUCTIO c) Removing pathology
N d) Shaping removed cartilage and bone
e) Reconstruction of the septum
41% f) Stabilizing the septum

But this septoplasty technique have also seen ended with

many post-op complications.9
Figure 3: Analysis of nasal symptoms.
Thus the advent of nasal endoscope facilitates the
5
accurate identification of the septal deviations with
4
limited mucoperichondrial flap elevation, minimal
cartilage resection as well as proper realignment of the
No. of cases

3 septum and thus the endoscopic septoplasty is a

convincing alternative to the conventional septoplasty.10
2
Table 1: Comparative incidence of nasal obstruction
1 in different studies.
0 ENDOSCOPIC CONVENTIONAL Present study Salama MA11
BLEEDING 0 0 Nasal obstruction 78% 90%
SYNECHIAE 1 2
DNS 1 4
EPISTAXIS 0 1
In our study, the average patient age at the time surgery
CRUSTING 0 2 was >20 years to <40 years, and maximum number of
patients fell in the age group of 21-30 years. This is in
Figure 4: Post-operative complications. concordance with Salama.11 There were 84% (21/25)
males and 16% (4/25) females in group A, and 84%
DISCUSSION (21/25) males and 16% (4/25) females in group B. Our
observation was that overall deviated nasal septum is
more common in males. The most common symptom
Surgery on a deviated nasal septum has seen several
with which our patients presented was nasal obstruction.
modifications since its inception, starting from radical
84% in Group A and 72% in Group B. Overall incidence
septal resection to mucosal preservation and subsequent
of nasal obstruction was 78%. These were also in
preservation of the possible septal framework. Various
accordance to the observation done by Salama and
techniques have been described for the correction of
Peacock (Table 1).11,12 Nasal discharge was present in
different types of septal deviations in the past. The
concept of SMR was popularized and refined by Killian 52% cases of Group A and 48% cases of Group B.
Headache were seen in both the groups (20%) in each
and Freer separately in the early twentieth century. 6
group. Thus both our study groups were comparable and
However an increasing incidence of complications of
homogenous in terms of the patient symptomatology.
septal surgery led to the more conservative septoplasty.
Bleeding was seen in 14% of patients similar results were
also seen in a study done by Gulati, Al Tawy.13,14
Nasal obstruction is one of the most frequent among the
Anterior rhinoscopic findings were analyzed and can be
nasal symptoms affecting the human population.
compare with previous studies. 54% patients were found
Deviated nasal septum apart from producing nasal
to have DNS to right. Further in different types of DNS.
obstruction also may be the cause for Epistaxis, sinusitis,
48% patients had anterior deviation and spur was seen in
obstructive sleep apnea and headaches attributable to
22% of patients (Table 2). 92% (n=23) of group A and
contact points with structures of the lateral nasal wall.7
88% (n=22) of group B were relieved from nasal
discharge, while nasal obstruction was improved in 96%
Present day evaluation of septal deviation depends on
(n=24) patients of group A and 80% (n=20) of group B in
physical examination and imaging. Refinement in the
our study. Harley et al was observed significant
diagnosis and treatment of nasal obstruction is possible
improvement in patients with nasal obstruction and
with the use of the endoscope. Apart from the
headache in endoscopic group as compared to
abnormalities of lateral nasal wall nasal endoscopy can
conventional group.18 In a study by Nayak et al, the

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endoscopic-aided septoplasty group was found to be to have higher incidence of synechiae formation (2 case)
more effective in correction of nasal symptoms such as in coventional as compare to 1 case in endoscopic
nasal obstruction and headache.19 In some studies septoplasty. Study conducted by Rao revealed 14%
regarding the relief of symptoms of nasal symptoms it synechiae formation in conventional group when
was reported that simultaneous surgical procedures in the compared to 4.67% in endoscopic group.21 Another study
nose using an endoscope either in the form of resection of by Talluri revealed synechiae formation in 18.6% of
middle turbinate or others improves relief of nasal conventional septoplasty group and 4% of endoscopic
symptoms.20 Follow up of our patients revealed that group.22
patients undergoing conventional septoplasty were found
Table 2: Comparative incidence of spur in different studies.

Present Krishna Dipak Ranjan Nishi Salma Ritesh Shelkhar

study Chaitanya et al15 Nayak et al16 Gupta1 MA11 et al 17
Spur 22% 35% 59% 20% 22% 21%

Table 3: Post op persistent DNS in different studies.

Present study Talluri KK22

Endoscopic Conventional Endoscopic Conventional
septoplasty septoplasty septoplasty septoplasty
DNS 4% 16% 6.6% 13.3%

Persistant deviated nasal septum was present in 1 (4%) operatively endoscopy revealed residual high deviated
patient in endoscopic group and 4 (16%) patients in nasal septum in 4 patients of conventional group and 1 in
conventional group. A study conducted by Talluri endoscopic group. Also the complications like epistaxis,
revealed that around 13.3% had incomplete correction in crusting and synechiae were found to be more common in
conventional septoplasty and 6.6% had incomplete conventional group.
correction in endoscopic septoplasty (Table 3).22
We conclude from this study that the endoscopic
Crusting and epistaxis was absent in group A but was Septoplasty is safe, effective and conservative approach
present in 2% and 1% patients of group B. Another study with better results and less complications as compared to
conducted by Gulati concludes that there is better conventional group. We recommend this technique as
symptomatic relief in endoscopic septoplasty when procedure of choice in these patients. As it provides
compared to conventional septoplasty.13 A similar study direct vision, and means that only small flaps need to be
done by Kaushik concluded that improvement in elevated to remove malformations, thus making only
symptoms are better in endoscopic septoplasty compared minor alterations to the nasal pathology.
to conventional septoplasty.3
The final result is better patient compliance, a shorter
CONCLUSION recovery time as trauma and bleeding are reduced, and
greater stability as those parts of the septum not affected
All the 50 patients chosen were followed up for a by deviation are spared.
minimum period of 2 months postoperatively and the
results were assessed in terms of symptomatic Funding: No funding sources
improvement (subjective), endoscopic findings Conflict of interest: None declared
(objective) and complications, if any. There were 84% Ethical approval: The study was approved by the
males and 16% females in Group A, and 84% males and Institutional Ethics Committee
16% females in Group B. Conclusion of higher
prevalence of deviated nasal septum in males can be REFERENCES
drawn. The commonest symptom was nasal obstruction,
1. Gupta N. Endoscopic septoplasty. Indian J
seen in almost all the patients in both groups, 84% in
Otolaryngol Head Neck Surg. 2005;57(3):240-3.
Group A 72% in Group B. 2nd and 3rd most predominant
symptoms were found to be that of nasal discharge and 2. Hwang PH, Mclaughlin RB, Lanza DC, Kennedy
headache. The right sided high deviated nasal septum was DW. Endoscopic septoplasty: Indications,
technique, and results. Otolaryngology--Head Neck
found to be more common than left deviation on
Surgery. 1999;120(5):678-82.
preoperative endoscopic examination. Post-operatively
3. Kaushik S, Vashistha S, Jain NK. Endoscopic vs
96% and 92% patients of endoscopic group got relieved
conventional septoplasty:a comparative study.
from nasal obstruction and nasal discharge respectively.
While only 80% and 88% go relief of nasal obstruction Clinical Rhinol Int J. 2013;6(2):84-7.
and nasal discharge in conventional group. Post-

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 Chandra S et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Oct;3(4):1046-1051

4. Giles WC, Gross CW, Abraham AC, Greene WM, surgery provide benefit in patients of deviated nasal
Avner TG. Endoscopic septoplasty. Laryngoscope. septum? Scholars J Applied Med Sci.
1994;104:1507-9. 2014;2(5a):1514-6.
5. Getz AE, Hwang PH. Endoscopic septoplasty. Curr 16. Nayak DR, Balakrishnan R, Murty KD, Hazarika P.
opin otolaryngol Head Neck Surg. 2008;16(1):26- Endoscopic septoturbinoplasty. Indian J
31. Otolaryngology Head Neck Surg. 2002;54:20-4.
6. Freer O. The correction of deflections of the nasal 17. Shelkar R, Ekhar E, Anand A, Rane S, Rachana
septum with a minimum of traumation. J Am Med Gangwani R, Lanjewar K. Study of indication,
Association. 1902;38:636. complication and functional outcome in endoscopic
7. Tan LKS, Calhoun KH. Epistaxis. Medical Clinics septoplasty. J Evol Med And Dent Sci.
of North America. 1999;83(1):43-56. 2014;3:3455-9.
8. Clerico DM. Pneumatized superior turbinate as a 18. Harley DH, Powitzky ES, Duncavage.
cause of referred migraine headache. Laryngoscope. Otolaryngology head & neck surgery. J Clin
1996;106(7):874-9. Outcomes Surg Treatment Sinonasal Headache.
9. Olphen AFV, Gleesan M, Browning GG, Burtan 2003;129(3):217-21.
MJ, Hibbert J, Jones NS. Septum. In: scott brown’s 19. Nayak DR, Balakrishnan R, Murty KD. An
Otorhinolaryngology Head Neck Surg. 7th ed. endoscopic approach to the deviated nasal septum- a
Volume 2. Butterworth: Edword Arnold; 2008; preliminary study. J Laryngol Otol. 1998;112:934-9.
1577-1578. 20. Toffel PH. Septoplasty: its place in modern
10. Jain L, Jain M, Chouhan AN, Harshwardhan R. management of chronic nasal and sinus Obstructive
Conventional septoplasty verses endoscopic disease. Rhinology and sinus disease:a problem-
septoplasty:a comparative study. People’s J Sci Res. oriented approach, Mosby; 1998: 55-60.
2011;4(2):24-8. 21. Manjunath Rao SV. Inferior Turbinectomy For
11. Salama MA. Endoscopic aided septoplasty versus Nasal Obstruction-Study of 219 Cases. National J
conventional septoplasty. World J Med Sci. Otorhinolaryngol Head Neck Surg.
2014;11(1):33-8. 2013;1(10):1370-5.
12. Peacock M. Submucous resection of the nasal 22. Talluri KK, Motru B. Correction of deviated nasal
septum. J Laryngol Otol. 1981;95:341. septum:conventional vs endoscopic septoplasty. J
13. Gulati SP, Wadhera R, Ahuja N, Garg A, Ghai A. Dental Med Sci. 2014;13:14-5.
Comparative evaluation of endoscopic with
conventional septoplasty. Indian J Otolaryngol Head
Neck Surg. 2009;61:27-9.
14. Tawy MAAF, Seleim A, elMonem MA, el Cite this article as: Chandra S, Baisakhiya N. A
galilragab ABD. Endoscopic septoplasty :techniques comparative study of endoscopic versus conventional
and results. Al-azhar Assiut Med J. 2014;12(2). septoplasty: an analysis of 50 cases. Int J
15. Chaitanya VK, Janardhan N, Rajesh KS, Rakesh G. Otorhinolaryngol Head Neck Surg 2017;3:1046-51.
Does the use of an endoscope in conventional septal

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