Nigerian Journal of Clinical Practice

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 22  |  Issue : 9  |  Page : 1196--1200

The correlation of computed tomography in the evaluation of septoplasty patients


A Yazici1, HC Er2,  
1 Department of Otorhinolaryngology, Faculty of Medical, University of Gaziantep, Gaziantep, Turkey
2 Department of Radiology, University of Gaziantep, Gaziantep, Turkey

Correspondence Address:
Dr. A Yazici
Department of Otorhinolaryngology, Faculty of Medical, University of Gaziantep, Sehitkamil 27310, Gaziantep
Turkey

Abstract

Background: Septoplasty is one of the frequently applied nasal surgical procedures. There is still no gold standart objective method to evaluate the patients whom suffers from nasal blockage. To evaluate the septoplasty candidate with a Paranasal Computerised Tomography (PNCT) is one of the most discussed topic in the otorhinolaryngology surgical philosophy. Objectives: In this study, we aim to interpret the value of nasal valve areas measured by PNCT for both septoplasty candidates and the control population. We believe that this information could be useful for the evaluation of patients before undergoing a septoplasty procedure. Material and Methods: 600 coronal and axial tomography sections performed between May 2014 and February 2018 at the University Of Gaziantep Radiology Dept. were assessed. These tomography sections were divided into two groups called the septoplasty and the control. The septoplasty group was made up of three hundred paranasal sinus tomography images scanned before patients' septoplasty operations. The control group was created by screening 300 maxillofacial tomography's which were taken due to the suspicion of trauma at the University Of Gaziantep Emergency Clinic between May 2014 and January 2018. Results: There were 192 (64%) patients with left nasal septal deviation and 108 (36%) patients with right nasal septal deviation. The Independent Sample T-Test revealed that the mean internal nasal valve angle in the left septoplasty group was significantly lower than that of the control group (P < 0.005). A comparison of the right side nasal values revealed a significant statistical change according to the Independent Sample T-Test between the value of the right septoplasty and the control groups (P < 0.005). Conclusion: The sectional areas of nasal tomography images may show different values. However, it is still difficult to say that the clinical application of tomography images could be used as one of the indication criteria for the septoplasty procedure.



How to cite this article:
Yazici A, Er H C. The correlation of computed tomography in the evaluation of septoplasty patients.Niger J Clin Pract 2019;22:1196-1200


How to cite this URL:
Yazici A, Er H C. The correlation of computed tomography in the evaluation of septoplasty patients. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 16 ];22:1196-1200
Available from: http://www.njcponline.com/text.asp?2019/22/9/1196/266170


Full Text



 Introduction



The nose is one of the essential parts of the respiratory system. Nasal obstruction is the most common symptom leading to the decision to carry out septoplasty procedures.[1] Nasal obstruction symptoms can be related to several etiologic factors such as nasal septal deviation, turbinate hypertrophy, and nasal valve incompetence.[2]

The internal and the external nasal valve are the two distinct locations which play an essential role in maintaining physiological nasal airflow. The internal nasal valve area (INVAr) is defined by the nasal septum medially, upper lateral cartilage, and the head of the lower concha laterally. The external nasal valve area borders are the nasal septum, the medial and lateral crura of the lower lateral cartilages, and the surrounding nostril tissues.[3] Numerous methods have been designed for the evaluation of these valve areas, such as acoustic rhinomanometry, paranasal computerized tomography (PNCT), and optical coherence tomography.[4],[5],[6] There is no gold standard for evaluating nasal obstruction, however, most studies have claimed that acoustic rhinomanometry is more reliable than others in the evaluation of nasal airflow in vivo.[4],[7] In the literature, the PNCT values of nasal valves were found to be consistent with the values of the nasal valves which were found through acoustic rhinomanometry.[4]

In this study, we aimed to interpret the value of nasal valve areas measured by PNCT for both septoplasty candidates and the control population. We believe that this information could be useful for the evaluation of patients before undergoing a septoplasty procedure.

 Materials and Methods



Study design

In this retrospective study, 600 coronal and axial tomography sections performed between May 2014 and February 2018 at the Radiology Department of the University of Gaziantep Medical Faculty were assessed. These tomography sections were divided into two groups called the septoplasty group and the control group. Before septoplasty operations, three hundred paranasal sinus tomography images were scanned which creates the septoplasty group. The indications of the septoplasty operation were decided by considering the patient complaint of the nose blockage, a positive Cottle's maneuver, the physical examination of the nose, and the evaluation of PNCT. All septoplasty operations were performed under general anesthesia with conventional or endoscopic techniques. According to the direction of the nasal septum deviation, the septoplasty group was also divided into two groups, namely, the right septoplasty and the left septoplasty groups. The control group was created by screening 300 coronal and sagittal sections of maxillofacial tomographies with the same technical details as PNCT, which were taken due to the suspicion of trauma at the University of Gaziantep Emergency Department between May 2014 and January 2018. The indications for the maxillofacial computerized tomographies were determined as cranial traumas, traffic accidents with suspected cranial damage, and assaults which may result in a cranial injury. The maxillofacial tomography sections of the control group with adequate details which determined the internal nasal valve on both sides, the nasal septum and the nasal base of both nostrils were included in this study. The clinical exclusion criteria in this study were; being under 18 year old, over 65 years old, neoplastic mass in the nasal cavity, allergic rhinitis, nasal polyposis, any nasal endoscopic surgery, nasal septal perforation, and any trauma that has disrupted the nasal bone or external nasal cartilages, LeFort I, LeFort II, or LeFort III maxillofacial fractures, and nasal septum perforations. In addition, patients who had applied to an otorhinolaryngology clinic as recorded in the medical report system were also excluded from the control group. This study has been approved by the Local Committee of Ethics at University of Gaziantep with an approval number of 2018/67.

Image assessment

Anatomic factors

Nasal parameters were identified from the computerized tomography (CT) images between the skull base and the most caudal edge of the lateral crus of the lower lateral cartilage. Three specific points were identified with the calculations of the coronal, and the axial sections of PNCT and maxillofacial CTs were defined as internal nasal valve angle, INVAr, and external nasal base area. The internal nasal valve angle was calculated between the upper lateral nasal cartilages and the nasal septum, which was displayed in the coronal section of tomography images [Figure 1]. The external nasal base area was determined in the axial image sections by measuring the area between the medial and lateral crus of the lower lateral cartilage and the posterior part of nasal vestibulum [Figure 2]. The INVAr was measured in the axial images by identifying the nasal septum, upper lateral cartilage, and the head of the lower nasal concha [Figure 3].{Figure 1}{Figure 2}{Figure 3}

Radiological analysis

All of the nasal parameters were assessed by an experienced radiologist from University of Gaziantep, Radiology Department and by a clinician of University of Gaziantep, Otorhinolaryngology Department. Both the axial and coronal plane images of maxillofacial and paranasal tomographies were acquired with a collimation of 0.625 mm, 100 kV, and 80–140 mA; a rotation time of 0.5 s; and a field of view of 29.5 cm by 64-slice multidetector CT scanner (General Electric Lightspeed, VCT-XTe; GE, Milwaukee, USA).

Statistical analysis

Both groups' mean, median, and standard deviation scores were obtained using 95% confidence intervals. The numeric data of the internal nasal valve angles, INVArs, and external nasal valve areas of both the control and septoplasty group means were compared with the independent samples t-test to define whether there was any statistical significance between the left and right septoplasty groups and the control group. P < 0.005 was considered to be statistically significant. All the statistical tests were performed using SPSS version 22 software program (SPSS Inc, IBM Chicago, IL, USA).

 Results



Six hundred patients' images were classified into septoplasty and control groups. The septoplasty group was also divided into right and left groups depending on the direction of the nasal septum deviation. According to the deviation, there were 192 (64%) patients with left nasal septal deviation and 108 (36%) patients with right nasal septal deviation. There was no significant difference for the age and gender between septoplasty and control groups (P = 0.249). The mean age of this study is 37.38 ± 12.96 years (between the ages of 18–64 years old). The gender distribution was 327 (54.5%) males and 273 (45.5%) females. The mean values were measured for internal and external nasal valve angles and areas on both the coronal and axial views as described in [Table 1].{Table 1}

The independent sample t-test revealed that the mean internal nasal valve angle in the left septoplasty group was significantly lower than that of the control group (P < 0.005). The other values and their statistical significances are exhibited in [Table 2].{Table 2}

A comparison of the right side nasal values, which are displayed in [Table 3], revealed a significant statistical change according to the independent sample t-test between the value of the right septoplasty and the control groups (P < 0.005).{Table 3}

 Discussion



The values of the nasal valve angles and areas scored lower in the septoplasty group compared to the control group in this study The internal nasal valve angle is one of the most frequently studied parameters that has been shown to be correlated with the nasal blockage symptom.[2],[4],[8],[9] A minor change in the internal nasal valve region can have a significant impact on nasal airflow.[10] Despite their variations in different societies, internal nasal valve values are accepted as normal when they are within the limits of 10° and 15° for a Caucasian nose.[11] The control group values of the internal nasal valve in this study were found to be within the normal limits of the Caucasian population. We believe that our internal nasal valve value findings in the control group provide sufficient information to suggest that it represents a sample of the normal population.

The external nasal valve region (ENVR) is a collapsible segment which also plays an important role in maintaining nasal airflow.[12] Many distinct techniques have been addressed in the literature to assess ENVR.[4],[5],[13],[14] Acoustic rhinomanometry is one of the objective methods of detecting ENVR and correlates with PNCT values.[4] Despite the sophisticated data which has been gained through acoustic rhinomanometry, it is an expensive method and needs a technician to interpret the data. Another method of evaluating the ENVR for nasal blockage is PNCT. Bloom et al. showed that there is a correlation between Cottle's maneuver scores and the cross-sectional area of the ENVR.[5] However, Cho et al. did not find a correlation between subjective nasal scores and PNCT images of the ENVR.[13] A unique method created by Bohluli et al. suggested that photographic images taken preoperatively and postoperatively of the ENVR could provide additional information about a nasal blockage.[14] For comprehensive detection of nasal obstruction it should be kept in mind that the ENVR is a volume and responsible for the initial portion of high nasal airflow.[12],[15] Despite all these methods, the nasal blockage could result from different nasal regions. Assuming that the ENVR is a cross-sectional area may hinder understanding of the nasal airflow physiology in three dimensions.

The INVAr is another region which was thought to be related to nasal blockage. The normalized value of the INVAr was described as half of the sum of the left and right INVAr by Moche et al.[16] Despite their results, our findings of INVAr did not show any statistical significance. The INVAr is affected by several factors, such as concha bullosa, turbinate hypertrophy, and mucosal hypertrophy.[17] Many factors could affect the size of the lower turbinate, such as smoking, allergy, infectious diseases, and even the physiologic nasal cycle In the literature, the discussion of these aforementioned factors leading to change in the INVAr remains scarce. To the best of our knowledge, the internal nasal valve angle remains more constant than INVAr.

PNCT may provide additional information for the septoplasty planned patients. A previous study concluded that after the evaluation of PNCTs, further surgical procedures such as concha bullosa or some minor endoscopic procedures were applied to the only 8.3% of septoplasty planned patients [18] On the other side, according to Sharma et al., the idea of using PNCTs as a guide for nasal interventions may not seem to be cost-effective.[19] They found that 46% of PNCTs for the evaluation of nasal interventions before the surgery is inadequate.[19] In addition, the harmful effect of radiation to the tissues of eye lenses, and the thyroid gland is a side effect of PNCT which must be kept in mind with the cost-effectiveness.[20]

The limitation of this study is the fact that the retrospective pattern of this research did not allow us to evaluate the nasal blockage symptom with a scoring system. In addition, we did not have a chance to evaluate these patients with acoustic reflectometry, which could reflect the patterns of nasal airflow in different nasal areas.

 Conclusion



The sectional areas of nasal tomography images may show different values. However, it is still difficult to say that the clinical application of tomography images could be used as one of the indication criteria for the septoplasty procedure. It is our opinion that the tomography sections of the nose may not hold a total capacity to enable evaluation of the nasal physiology, which includes the three-dimensional nasal parts and airflow.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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