SRC JCCS 20 053 PDF
SRC JCCS 20 053 PDF
SRC JCCS 20 053 PDF
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Assistant Registrar, ENT, Bangladesh Medical College
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Assistant Professor, ENT, Bangladesh Medical College
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Assistant Registrar, ENT, Bangladesh Medical College
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Assistant registrar, ENT, National Institute of ENT
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Resident Surgeon, Bangladesh Medical College Hospital
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Resident Surgeon, Bangladesh Medical College Hospital
*Corresponding author
Md. Ashraful Islam, MBBS, FCPS, FICS, FACS, FRCS (Glasgow) Professor and Head Department of Otolaryngology-Head & Neck Surgery,
Bangladesh Medical College & Hospital, Dhaka, Bangladesh. E-mail: ashrafis123@yahoo.com; website: www.entbmc.com
Received: June 03, 2020; Accepted: June 15, 2020; Published: June 20, 2020
ABSTRACT
Objective: Conventional septal surgery based on head light improves the nasal airway but leaves some complications, but with recent advancement in
endoscopic approach limits the complication and improves the outcome. This is due to better visualization, improved illumination, unnecessary manipulation,
limited exposure and scope for second surgery if required.
Material and method: A prospective study was done on 120 patients of symptomatic deviated nasal septum who were refractory to medical treatment
underwent septal surgery. Patients were equally divided into two groups with 60 patients each. Patients were randomly selected on each group.
Results: In this prospective study, though the complication rate is higher in conventional septoplasty group but there was a significant difference in functional
outcome in the endoscopic septoplasty group.
Conclusion: The use of endoscope in septal surgery improves visualization, illumination, and thus reduces complication with improved functional outcome.
It can be performed in other diseases of nose and para nasal sinus diseases in the perspective of functional endoscopic sinus surgery.
Keywords: Deviated nasal septum, Endoscope, Conventional The use of endoscope in septal surgery has significantly changed
Septoplasty the concepts of septal surgery. It is a fast-developing concept and
gaining popularity among the ENT surgeons. Nasal endoscopes
Introduction were first used for septoplasty by Lanza et al. and Stammberger
Nasal obstruction is one of the most common presenting complaint in 1991 [2,3]. Endoscopic septoplasty is a conservative surgery
to the otolaryngologist in their daily practice. Deviated nasal in which only the deviated portion of septum is removed leaving
septum (DNS) is the most common structural malformation behind as much cartilage and bone as possible to maintain the
causing nasal obstruction of one or both nostrils. Different surgical structural and functional integrity of the nose.
techniques have been evolved so far for the correction of deviated
septum by different surgeons since its inception. In 1947 Cottle It is a minimally invasive surgery that helps us to correct the
described first conventional septoplasty [1]. It can be performed septal deformity under direct visualization, using a naso-
under local or general anesthesia using either a fiberoptic or a endoscope. Endoscopic approach under excellent illumination and
standard headlight. It is a conservative surgery in which only the magnification lessens the chance of injury to vital structures and
deviated part of the septum is removed leaving behind as much hence lessens the complication [4]. This approach is particularly
cartilage and bone as possible. helpful for correction of posterior and high deviation and also
helpful for any relevant nasal surgery if necessary.
Aim and objective deviated part of the underlying exposed cartilage and bone were
To assess the functional outcome of endoscopic septoplasty over removed along with conchoplasty/turbinoplasty, when required.
conventional septoplasty The flaps were then repositioned back and were stitched together
from posterior to anterior directing to the upper part to avoid septal
Materials and method hematoma. Nasal merocele packs were given in both the nasal
This study was carried out in the department of Otolaryngology– cavities without any nasal splints.
Head & Neck Surgery of Bangladesh Medical College Hospital
and Popular Medical College specialized Hospital over a period Techniques for conventional septoplasty
of 5 years. After infiltration with 2% xylocaine with adrenaline into septum and
floor of the nasal cavity under headlight, hemitransfixion incision
Total 120 patients of symptomatic DNS were selected and was made as the same to endoscopy group. The mucoperichondrial
underwent septoplasty. Total procedure was described to the patient and periosteal flaps were elevated upto perpendicular plate of
and their attendants/party; and adequate consent were obtained. ethmoid. The osseocartilaginous junction was dislocated. A 0.5
Patients were randomly selected for surgical procedure and were cm of the anterior margin of perpendicular plate of ethmoid was
divided into 2 equal groups of 60 patients. It was a prospective removed with Luc’s forceps. An inferior cartilaginous strip of 0.5
randomized study. Computed Tomography (CT) scanning was cm was removed with turbinectomy scissors. The incision was
done in all endoscopically selected group. closed using chromic catgut (3-0), nasal splints were applied in
both nasal cavities and anterior nasal packing were done with
Study design: Prospective comparative study on functional out antibiotic impregnated ribbon gauze.
come
Study population: Patients presenting with symptomatic deviated Nasal pack/nasal splints
nasal septum at the outdoor department of ENT in Bangladesh Endoscopic group: Merocele pack was removed on the same/
Medical College Hospital and Popular Specialized Medical following day and the patient was discharged on the next day.
College Hospital. Conventional group: Nasal pack was removed after 24 to
48 hours and discharged after 48 hours. Nasal splints were
Study sample: 120 patients, randomly allotted into 2 groups removed on the 7th day in the outpatient department under
consisting to 60 patients each. local anesthesia.
Sampling technique: Simple random sampling Saline nasal douching was advised after removal of nasal
Study period: 5 years (2014-2019) packs.
Study places: Follow-up
Bangladesh Medical College Hospital Nasal cleaning with suction machine was done on 3rd, 7th
Popular Medical College Hospital and 14th day to prevent nasal synechiae or any associated
infections
Inclusion criteria Then all patients were followed up monthly, 3 monthly and
Age more than 14 years. 6 monthly for 01 year
Patient with- symptomatic deviated nasal septum e.g. nasal At each follow up visit, subjective and objective assessment
obstruction, snoring, obstructive sleep apnea, headache etc. were done.
Patient reported with epistaxis. Objective assessment was done by Gertner-Podoshin plate
and diagnostic nasal endoscopy.
Exclusion criteria
Patients with acute rhinitis or allergic rhinitis or vasomotor Following parameters were noted on postoperative follow up
rhinitis or upper respiratory tract infection. Subjective
External deformity with deviated nasal septum. Nasal obstruction
Patients unfit for surgeries. Headache
Patients not giving consent. Nasal discharge
Hyposmia
Procedure Nasal bleeding
Technique for Endoscopic septoplasty
This procedure was performed under general anesthesia. After Objective
endotracheal intubation, both the nasal cavities were packed with Persistence of anterior/posterior deviation or spur.
a solution made with 3 ampule inj. Adrenaline (1:1000) and 15cc Formation of synechiae.
2% Xylocaine for 10 minutes to achieve nasal decongestion. Then Persistent pathology of turbinate
the septum was infiltrated with a prepared solution of 2% xylocaine Presence of discharge in middle meatus.
mixed adrenaline in a 1:10,000 to 1: 200,000 concentration Any change in external nasal appearance.
depending on the age and co-morbidity of the patient using 0°
rigid 4 mm endoscope. The injection was given from the posterior Results
to anterior including the floor of the nasal cavity on both sides of In this study the male to female ratio for deviated nasal septum was
the septum. Hemitransfixation was made on the convex side 5 mm 1.8:1 (Table 1). The most commonly affected subjects belonged
away from the mucocutaneous junction. The mucoperichondrial to the 2nd and 3rd decade of life in both sexes. In the group that
and mucoperiosteal flaps were elevated using a suction elevator underwent conventional septoplasty, youngest patient was 16 year
under direct visualization with an endoscope up to the floor to and the oldest was 55 year old. Among the patients who underwent
expose the deviated part of the septum completely as depicted endoscopic septoplasty, the youngest patient was 09 year and the
on CT radiograph. Similarly the flaps were elevated from the oldest was 60 year old.
opposite site with great precaution of septal flap tear. The most
Table I: Sample distribution of subjects according to age belonged to conventional and 57 of the 60 patients (95%) belonged
and gender (n 120) to endoscopic septoplasty group. Headache was improved in
Gender 10-20 21-30 31-40 41-50 51-60 Total 75.68% (28/37) patients of conventional septoplasty group and
years years years years years 86.5% (32/37) patients of endoscopic septoplasty group. Snoring
Male 25 34 8 7 3 77 was improved in 79.5% (35/44) & 88.6% (39/44) of patients in
(20.8%) (28.3%) (6.6%) (5.8%) (2.5%) both groups respectively. Table 3 shows the symptoms relived
postoperatively Symptoms relief of both the groups are shown
Female 15 19 5 3 1 43
(12.5%) (15.8%) (4.2%) (2.5%) (0.8%)
in Table V.
Total 40 53 13 10 4 120 Table V: Postoperative result: relieved of symptoms (n 120)
(33.3%) (44.1%) (10.8%) (8.3%) (3.3%)
Symptoms Conventional Percentage Endoscopic Percentage
relieved septoplasty % septoplasty %
Nasal obstruction (100%) and snoring (73.33%) were the main
symptoms of the amongst the study group. The clinical presentation Nasal
55/60 91.67 57/60 95
of 120 patients are shown in Table II. obstruction
Headache 28/37 75.68 32/37 86.5
Table II: Distribution of symptoms among study population Nasal 2/8 25 6/8 75
(n 120) discharge
Symptom (n 120) Percentage % Snoring 35/44 79.5 39/44 88.64
Nasal obstruction 120 100 Hyposmia 2/5 40 3/5 60
Headache 74 61.7 Epistaxis 4/4 100 4/4 100
Nasal discharge 16 13.33
Snoring 88 73.33
Postoperative objective assessment of nasal patency was done
by using Gertner-Podoshin plate at first follow up on 7th day and
Hyposmia 10 8.33 later at 1st, 3rd and 6th month.
Epistaxis 8 6.66
Endoscopic assessment were carried out during their postoperative
Anterior rhinoscopy and nasal endoscopic examination were done visit by 0º endoscope after 03 months which is shown in Table VI.
in all the patients. The findings are shown in Table III.
Table VI: Endoscopic assessment at last follow up (n 120)
Table III: Anterior rhinoscopy & diagnostic endoscopic Findings Conventional Percentage Endoscopic Percentage
findings (n 120) septoplasty % septoplasty %
Findings Number Percentage % Persistent
Rt sided deviation 56 46.67 septal 5/60 8.33 2/60 3.33
deviation
Lt sided deviation 47 39.17
Persistent
Anterior deviation 24 20 pathology 8/22 36.36 2/21 9.52
Posterior deviation 14 11.67 of turbinate
Hypertrophied Discharge
43 35.83 in middle 3/7 42.86 0/8 0
inferior
meatus
turbinate Spur 10 8.33
Persistent
Hypertrophied 35 29.16 3/5 60 0/5 0
spur
middle turbinate
In this study, 13 patients in conventional septoplasty group had
In this study group, CT scan was done in those patients who intraoperative hemorrhage and only 2 patients in the endoscopic
had middle turbinate hypertrophy or difficulty in evaluation septoplasty group had this. Mucosal tear occurred in 17 patients
of the middle meatus and posterior nasal cavity on endoscopic belonging to conventional septoplasty group and 3 patients
examination. CT findings are shown in Table IV. belonging to endoscopic septoplasty group which is presented
in Table VII.
Table IV: CT findings (n 76)
Findings Number Percentage Table VII: Intraoperative complications
Concha bullosa 36 47.4 Complications Conventional Percentage Endoscopic Percentage
septoplasty % septoplasty %
Posterior deviation 27 35.5
Hemorrhage 13 21.67 2 3.33
High deviation 15 19.7
Mucosal tear 17 28.33 3 5
Pneumatized septum 02 2.6
Postoperative complications in both the group is presented in
Out of 120 patients with nasal obstruction, 112 patients were
Table VIII
relieved of the symptom of which 55 of the 60 patients (91%)
Table VIII: Postoperative complications (n 120) was found to be more effective in correction of nasal symptoms
Complications Conventional Percentage Endoscopic Percentage such as nasal obstruction and headache [18]. Condition of snoring
septoplasty % septoplasty % improved in conventional groups (7.5%) and in the endoscopy
Septal
group in 88.64% of patients. Epistaxis was relived in patients
2 3.33 0 0 belonging to both groups. Concha bullosa, high and posterior
perforation
deviation of the septum, pneumatic as well as thickened septum
Synechie 4 6.67 0 0 as evidenced on CT scanning (Table IV) can easily be addressed
Delayed in endoscopic septoplasty [19,20]. The patients presented with
healing at 2 3.33 3 5 snoring along with associated symptoms were relieved almost
incision site completely by endoscopic septoplasty which has been documented
in this study.
Discussions
Nasal airway obstruction with or without snoring is one of the main In a study conducted by Park DH et al. complications were seen in
complaints faced largely by the otolaryngologists in their day to 14.3 % of the patients who underwent conventional septoplasty as
day practice. Deviated nasal septum is the major cause of nasal compared to 0 % in endoscopic correction of deviated nose [21].
obstruction. Correction of the deviated nasal septum has been done In another study conducted by R Bothra et al. minor complications
with various surgical procedures since its inception, starting from like hemorrhage, infra orbital edema and nasal pain were more
radical septal resection to mucosal preservation and subsequent in patients who underwent conventional septoplasty [22]. In this
preservation of the possible septal framework [5]. However, the study, 13 (21.7%) patients in conventional septoplasty group had
concept of SMR was popularized; and refined by Killian and Freer intraoperative excessive hemorrhage while only 2 (3.33%) patients
separately in the early twentieth century had become the surgery in the endoscopic septoplasty group. Under endoscopic guidance
of the septum [6]. But an increasing incidence of complications peroperative bleeding points can easily be identified and controlled
of septal surgery led to the more conservative surgical approach effectively; thus reduce the incidence of hemorrhage. Mucosal
coined the term septoplasty and this technique have also been tear occurred in 17 (28.33%) patients belonging to conventional
ended with many post-op complications [7]. septoplasty group and on the endoscopic septoplasty group, it was
3 (5%). Regarding septal perforation, patients belonging to the
With the advent of nasal endoscope in the field of rhinology, it conventional group had 2(3.33%) and none 0% in the endoscopic
facilitates the accurate identification of the septal deviations, group. 4 (6%) patients belonging to conventional septoplasty
controlled elevation of the mucoperichondrial/mucoperosteal group reported with synechie formation but none in endoscopic
flap, removal of the only deviated part of the septum as well as group (Table VIII). This rate of complication was almost similar
proper reposition of the remaining septum draws the functional to several existing literatures [23-25].
outcome better than previous conventional septoplasty with
negligible complications. Then the endoscopic septoplasty is In this study it has been observed that due to clear visualization,
now a convincing alternative to the conventional septoplasty in isolated spurs can easily be seen that to avoid mucosal tear in
the era of septal surgery [7-10]. endoscopic technique comparison to conventional septoplasty.
The flaps inferior and posterior to the spur is relatively invisible
In the present study, male to female ratio was 1.8:1 and the most leading to mucosal tears and excessive manipulation of tissues
common affected group were of younger age from 2nd & 3rd leading to synechiae formation in conventional method.
decades (Table I). This was in concordance with the study of
Rao et al [11]. It is observed from this study that overall deviated Conclusion
nasal septum is more common in males because of the fact that From this study, it is evident that endoscopic procedure possess
in a country like ours this group tried to enroll themselves in the the following advantages over conventional septoplasty
defense or allied services where many of them become unfit due Minimal manipulation
to septal deviation. Minimal damage to the tissues
Minimal removal of septum, hence precise reconstruction
The most common presentation (Table II) was nasal obstruction Stability of the septum is not compromised
(100%) which also was found in the study done by Saleim and Mucosal tears are avoided, hence less chance of synechie
Peacock [12,13]. Snoring was present in 73.33% cases and formation
headache was seen in 61.7% cases respectively. Hyposmia and Reduced incidence of hemorrhage
epistaxis were seen in 8.33% and 6.66% of patients respectively; Easier to correct posterior deviation, high deviation and
similar results were also seen in a study done by Gulati, Al Tawy isolated spurs
and others [14-16].
At the end, endoscopic septoplasty can be considered as an effective
The relieved of symptoms such as the nasal obstruction was teaching tool. When viewed over a monitor, the procedure provides
improved in 91.67% (55/60) patients of conventional group and an excellent opportunity for observing and studying anatomy,
95% (57) of endoscopy group, while relieved from post nasal pathology and surgical techniques that help in the training of
discharge 25% (2/8) of the conventional group and 75% (6/8) of assisting surgeons, graduate specialists, postgraduate and under
endoscopy group were recorded in our study. The headache was graduate medical students.
improved in 75% (28/37) & 86.5% (32/37) in both the patient
groups respectively (Table V). Harley et al was observed significant Disclosure
improvement in patients with nasal obstruction and headache in The authors have no funding, financial relationships, or conflicts
endoscopic group as compared to conventional group [17]. In a of interest to disclose.
study by Nayak et al, the endoscopic-aided septoplasty group