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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 10  |  Page : 1372-1377

Evaluating surgical outcomes of conventional versus endoscopic septoplasty using subjective and objective methods


Department of ENT, Government Medical College, Patiala, Punjab, India

Date of Acceptance16-May-2019
Date of Web Publication14-Oct-2019

Correspondence Address:
Dr. M Singh
Department of ENT, GMC Patiala, H.No. 2213, Sector 38-C, Chandigarh - 160 014 (U.T)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_101_19

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   Abstract 


Objectives: The aim of the study is to compare the pre- and post-operative symptomatology, endoscopic findings, and nasal patency and to evaluate the postoperative outcomes of conventional compared to endoscopic septoplasty (ES). Materials and Methods: This prospective study was conducted at Rajindra Hospital, Patiala, Punjab, India, on 50 patients aged between 18 and 60 years having symptomatic deviated nasal septum and refractory to medical treatment. The patients were divided into two groups: Group A, which included 25 patients in whom conventional septoplasty (CS) was performed, and Group B, which included 25 patients in whom ES was conducted. The postoperative assessment was carried out at once weekly for 1 month and twice weekly for another 2 months. Results: Nasal obstruction was relieved in 79.1% cases belonging to Group A and 91.3% cases to Group B. Headache was relieved in 62.5% cases belonging to Group A and 93.3% cases to Group B. Postnasal drip was relieved in 73.3% cases in Group A and 94.1% cases in Group B. The results were found to be statistically significant. An improvement in visual analog scale score was observed in both groups, but statistically significant difference was seen at 2nd and 4th week. Postoperative nasal patency improvement was observed in both groups by the Gertner plate, and the results were found to be statistically significant. Postoperative hemorrhage was observed in 24% cases in Group A and 12% cases in Group B. Septal perforation, septal hematoma, and mucosal tear were observed in 4%, 4%, and 8% of cases, respectively, in Group A. No such complication was reported in Group B. Conclusion: ES is more effective in terms of relief of symptoms and improvement of nasal patency. It is best for isolated spur, posterior deviation, and revision surgery, but anterior caudal dislocation is best handled with CS. Both these techniques should be taken as an adjuvant to each other.

Keywords: Conventional septoplasty, deviated nasal septum, endoscopic septoplasty, nasal obstruction, postnasal drip, spur, visual analog scale


How to cite this article:
Doomra S, Singh M, Singh B, Kaushal A. Evaluating surgical outcomes of conventional versus endoscopic septoplasty using subjective and objective methods. Niger J Clin Pract 2019;22:1372-7

How to cite this URL:
Doomra S, Singh M, Singh B, Kaushal A. Evaluating surgical outcomes of conventional versus endoscopic septoplasty using subjective and objective methods. Niger J Clin Pract [serial online] 2019 [cited 2019 Dec 15];22:1372-7. Available from: http://www.njcponline.com/text.asp?2019/22/10/1372/269003




   Introduction Top


Nose, being the most prominent part of the face, is vulnerable to trauma right from the intrauterine life. Nasal trauma usually involves the septum; thus, it is unusual to find a straight septum in an adult.

Many methods have been described for correction of different type of septal deviations [Figure 1] shows endoscopic view of DNS. The concept of submucosal resection was made popular and modified by Killian [1] and Freer [2] separately in the early 20th century. However, increasing incidence of complications of septal surgery led to the adoption of more conservative septoplasty.[3] First elucidated by Cottle in 1947, conventional septoplasty (CS) is a traditional surgery in which only the deviated part is taken out, leaving behind as much cartilage and bone as possible.[4] It has increased morbidity because of poor visualization, poor illumination, relative inaccessibility, need for nasal packing, difficulty in evaluation of the exact pathology, unnecessary manipulation, resection, and overexposure of the septal framework reducing the scope for a revision surgery.[5]
Figure 1: Endoscopic view of DNS

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It is study of Lanza et al. Stammberger reported endoscopic correction of septal deformity in 1991.[6] Endoscopic septoplasty (ES) offers a number of advantages over conventional headlight septoplasty such as better visualization, more focused flap dissection with resection of isolated deformities, lesser possibility of flap tears, and a more natural transition when the method is combined with endoscopic sinus surgery.[7],[8] Despite several benefits, ES can be difficult because of frequent soiling of the lens of the endoscope by blood from the incision site and difficulty in finding enough space for the endoscope and dissectors in narrow septal mucosal tunnels.

Therefore, the selection of best method for correction of the deviated nasal septum (DNS) is still controversial; hence, we aimed to compare the outcomes of endoscopic and conventional approaches for septoplasty and also the postoperative results and complications between the two [Figure 2] showing intraoperative image of conventional septoplasty [Figure 3] showing intraoperative image of endoscopic septoplasty.
Figure 2: Intraoperative image of conventional septoplasty

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Figure 3: Intra operative image of endoscopic septoplasty

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Aims and objectives

The study was conducted to compare the (1) pre- and post-operative symptomatology (subjective evaluation) in traditional and ES, (2) pre- and post-operative endoscopic results and nasal patency (objective evaluation) in traditional and ES, and (3) outcomes of CS compared to ES.


   Materials and Methods Top


This study comparing CS and ES was conducted from 2016 to 2019 at the Ear, Nose, and Throat Department, Rajindra Hospital, Patiala, Punjab, India. Fifty patients with DNS were recruited and they were randomly divided into Groups A and B: 25 cases in each group. Group A underwent CS, whereas Group B underwent ES.

Inclusion criteria

The inclusion criteria were as follows: (1) patients aged 18–60 years; (2) patients with symptomatic DNS such as nasal obstruction, hyposmia, nasal discharge, postnasal drip, and headache; (3) symptomatic patient refractory to medical management; (4) patient with DNS complications; and (5) informed consent given.

Exclusion criteria

The exclusion criteria were as follows: (1) patients with allergic rhinitis; (2) patients with acute upper respiratory tract infection; (3) patients with sinonasal polypi; (4) patients with sinonasal malignancy; (5) patients with mucoceles protruding from sinuses into the nasal cavity; (6) patients with radiation therapy of head and neck; and (7) patients with any medical condition that precludes elective surgery (including pregnancy).

Detailed history was obtained from every patient. Clinical assessment was conducted for all patients preoperatively, and all patients underwent subjective and objective assessments.

Subjective assessment

Nasal obstruction was assessed subjectively using a visual analog scale (VAS). The scores were determined on a 0–10 cm (100 mm) scale.[9] The VAS scoring used in this study is as follows: 0 – no obstruction; 1–3 – mild obstruction; 4–7 – moderate obstruction; and 8–10 – severe obstruction.[10]

Objective assessment

Nasal obstruction was assessed objectively by performing anterior rhinoscopic examination, diagnostic nasal endoscopy using a 0° adult nasal endoscope, and nasal patency assessment by the Gertner plate. The instrument itself is a 10 cm × 12 cm polished metal chrome-coated plate. The plate is marked with arches 1 cm apart. The method is based on measuring the area of vapor condensed on the plate. The area fogged was calculated using the following formula:[11]



where S is the surface area. Postoperative data regarding relief of symptoms, any complication, and hospital stay were collected. Subjective (VAS) and objective (Gertner plate) assessments of nasal patency were conducted at 1, 2, 3, 4, 6, 8, 10, and 12 weeks postoperatively. The data were compiled and analyzed statistically using a paired t-test and Chi-square-test [Figure 4] showing Nasal patency by Gertner's plate.
Figure 4: Nasal patency by Gertner's plate

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   Results Top


In this study, majority of cases presented with bilateral nasal obstruction (Group A, 56%; Group B, 60%). Nasal obstruction was not observed in one patient belonging to Group A and two patients belonging to Group B [Table 1]. These three cases were operated for nasal bleeding complaint.
Table 1: Distribution of type of nasal obstruction

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All the patients in this study had nasal septal deviation, and the most prevalent was C-shaped deviation (Group A, 68%; Group B, 60%) [Table 2].
Table 2: Distribution of type of deviated nasal septum

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[Table 3] shows that after 3 months' follow-up, all the symptoms improved in Group B compared to Group A, but the comparative results were significant for nasal obstruction (P = 0.032), postnasal drip (P = 0.045), and headache (P = 0.044). Nasal bleeding was relieved all the cases in both groups.
Table 3: Postoperative symptoms relieved

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A comparison of VAS scores of Groups A and B shows that mean improvement is better in Group B patients compared to Group A patients for all weeks, but significant improvement is only seen at the 2nd week (P = 0.019) and 4th week (0.042) [Figure 5].
Figure 5: Comparison of nasal obstruction by visual analog scale score in Groups A and B

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[Figure 6] shows the comparison of nasal patency on the right-side nasal cavity between Groups A and B. The nasal patency is improved in both the groups postoperatively, but there is a significant improvement in Group B (P = 0.004 at 12 weeks) compared to Group A at all weeks on the right side.
Figure 6: Comparison of nasal patency by Gertner plate in Groups A and B on the right side

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[Figure 7] shows the comparison of nasal patency on the left-side nasal cavity between Groups A and B. The nasal patency is improved in both the groups postoperatively, but there is a significant improvement in Group B (P = 0.013 at 12 weeks) compared to Group A at all weeks on the left side.
Figure 7: Comparison of nasal patency by Gertner plate in Groups A and B

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[Figure 8] shows Postoperative complications/endoscopic findings in Groups A and B. In our study, postoperative hemorrhage was encountered in 24% cases in Group A and 12% cases of Group B. Persistent deviation was observed in 20% cases in Group A and 8% cases in Group B. Synechiae were observed in 20% cases in Group A and 8% in Group B; 16% cases in Group A and 4% in Group B showed crusting. Septal perforation was observed only in one case belonging to Group A and none of the patient in Group B. Only two cases of Group A had mucosal tear. Septal hematoma was observed in only one case in Group A. There was no case of mucosal tear and septal hematoma in Group B on diagnostic nasal endoscopy on postoperative visit at the 12th week. The patients of both groups presented with complications, but the incidence was higher in the CS group and the difference was statistically significant (P = 0.018).
Figure 8: Postoperative complications/endoscopic findings in Groups A and B

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   Discussion Top


This study was conducted on 50 patients belonging to both sexes aged 18–60 years. There were 34 male and 16 female. Majority of cases taken up for the study presented with a chief complaint of nasal obstruction (94%) and 58% cases had bilateral nasal obstruction. Most common type of DNS in our study was C-shaped deviation (64%), followed by S-shaped deviation (36%), associated anterior caudal dislocation (14%), and associated spur (60%).

Nasal obstruction was relieved in 79.1% cases of CS and 91.3% cases of ES, and the difference was statistically significant (P = 0.032). Headache was relieved in 62.5% cases of CS and 93.3% cases of ES, and the difference was statistically significant (P = 0.044). This is comparable with the study conducted by Suligavi et al.,[12] in which nasal obstruction was relieved in 80% cases of CS group and 96% cases of ES group, and headache was relieved in 85.71% cases of CS and 94.4% cases of ES group.

In this study, the mean improvement in the VAS score in Group A was 1.85 ± 1.89 and that in Group B was 1.15 ± 1.01. On comparing both the groups, it was found that Group B had a higher improvement in the VAS score, but statistically significant result was observed only at 2nd (P = 0.019) and 4th week (P = 0.042) postoperatively. A similar study conducted by Hsu et al.[13] recorded mean VAS scores of 2.12 ± 1.42, 2.10 ± 1.79, and 2.42 ± 2.02, respectively, at 3rd, 6th, and 12th postoperative months, and the results were highly significant (P = 0.001). Another similar study conducted by Chung et al.[8] showed mean VAS score improvement of 2.93 ± 2.02 after septoplasty, which was highly significant (P = 0.001).

The comparison of nasal patency on the right-side nasal cavity between Groups A and B showed that the nasal patency improved in both the groups postoperatively, but significant improvement was observed in Group B (P = 0.004 at 12 weeks) at all weeks.

The comparison of nasal patency on the left-side nasal cavity between Groups A and B showed that the nasal patency improved in both groups postoperatively, but significant improvement was observed in Group B (P = 0.013 at 12 weeks) at all weeks.

The comparative study conducted by Sathyaki et al.[14] showed that preoperatively, three cases of CS and four cases of ES had nasal airflow of 0–1 cm. Three cases of CS and two cases of ES had nasal airflow of 6–9 cm. Postoperatively, there was no case in 0–1 cm nasal airflow category, whereas five cases of CS and 12 cases of ES had nasal airflow of 6–9 cm, that is, higher improvement in nasal patency was observed in ES, but P = 0.099 (nonsignificant).

In another study conducted in the CS group, seven patients had airflow of 2–3 cm, eight patients had 4–5 cm, and three patients had 6–9 cm. In the ES group, two patients had airflow of 2–3 cm, 17 had 4–5 cm, and 15 had 6–9 cm. The patency was same on the 10th-day, 1st-month, and 3rd-month follow-ups. The difference in improvement was insignificant. Above two studies had considered only length in cm of condensed area on gertner's plate but our study recorded area in sq. cm of fogging on gertner's plate.

In this study, on comparison of both groups, the difference in the VAS scores (subjective assessment) between two groups was significant only at 2nd (P = 0.019) and 4th week (P = 0.042), but the difference between the two groups on the Gertner plate (objective assessment) was significant at all weeks. This could be because each patient has his or her own individual scale of feeling in relation to resistance. It is possible that the causes of nasal airway resistance are different from those of the feeling of airflow because factors other than resistance affect this feeling; for example, the use of topical anesthetics on the nasal mucosa produces a feeling of nasal obstruction that is not accompanied by decreased transnasal airflow. These observations corroborate our results. However, as interpretation of an observer is subjective, it is more accurate, especially when it is performed by a single observer and at a fixed point of time at every follow-up, as done in our study.


   Conclusion Top


It is concluded that ES is more effective in terms of symptoms relief and improvement of nasal patency. The incidence of postoperative morbidity is also less with ES because of fewer incidences of postoperative complications that are due to more focused flap dissection with resection of the septal framework and less chances of flap tears. ES is best for isolated spur, posterior deviation, and revision surgery, but anterior caudal dislocation is best handled with CS.

Both these techniques should be taken as an adjuvant to each other, as there may be need to convert ES into CS at any point of time during surgery, for example, during excessive intraoperative hemorrhage, which leads to frequent soiling of endoscopic lens. Thus, every ES surgeon must have a good experience of CS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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2.
Freer O. The correction of deflections of the nasal septum with a minimum of traumation. J Am Med Assoc 1902;38:636.  Back to cited text no. 2
    
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Maran AG, Lund VJ. Trauma to nose and sinuses. In: Clinical Rhinology. 1st ed. New York: Thieme; 1990. p. 110-39.  Back to cited text no. 4
    
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Jain L, Jain M, Chouhan AN, Harshwardhan R. Conventional septoplasty verses endoscopic septoplasty: A comparative study. People J Sci Res 2011;4:24-8.  Back to cited text no. 5
    
6.
Lanza DC, Kennedy OW, Zinriech SJ. Nasal endoscopy and its surgical applications. In: Essential Otolaryngology: Head and Neck Surgery, 5th Ed. Lee KJ, Ed. Medical Examination Pub!. Co., 1991. p. 373-87.  Back to cited text no. 6
    
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Getz AE, Hwang PH. Endoscopic septoplasty. Curr Opin Otolaryngol Head Neck Surg 2008;16:26-31.  Back to cited text no. 7
    
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Chung BJ, Batra PS, Citardi MJ, Lanza DC. Endoscopic septoplasty: Revisitation of the technique, indications, and outcomes. Am J Rhinol 2007;21:307-11.  Back to cited text no. 8
    
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Aitken RC. Measurement of feelings using visual analogue scales. Proc R Soc Med 1969;62:989-93.  Back to cited text no. 9
    
10.
Roopa Manjunatha G, Mahapatra DR, Prakash S, Rajanna K. Validation of polyvinylidene fluoride nasal sensor to assess nasal obstruction in comparison with subjective technique. Am J Otolaryngol 2015;36:122-9.  Back to cited text no. 10
    
11.
Gertner R, Podoshinm L, Fradis M. A simple method of measuring the nasal airway in clinical work. J Laryngol Otol April 1984;98:351–5.  Back to cited text no. 11
    
12.
Suligavi SS, Darade MK, Guttigoli BD. Endoscopic septoplasty: Advantages and disadvantages. Clin Rhinol 2010;3:27-30.  Back to cited text no. 12
    
13.
Hsu HC, Tan CD, Chang CW, Chu CW, Chiu YC, Pan CJ, et al. Evaluation of nasal patency by visual analogue scale/nasal obstruction symptom evaluation questionnaires and anterior active rhinomanometry after septoplasty: A retrospective one-year follow-up cohort study. Clin Otolaryngol 2017;42:53-9.  Back to cited text no. 13
    
14.
Sathyaki DC, Geetha C, Munishwara GB, Mohan M, Manjuanth K. A comparative study of endoscopic septoplasty versus conventional septoplasty. Indian J Otolaryngol Head Neck Surg 2014;66:155-61.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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