Braz J Otorhinolaryngol. 2017;83(3):256---260
Brazilian Journal of
OTORHINOLARYNGOLOGY
www.bjorl.org
ORIGINAL ARTICLE
Difficult septal deviation cases: open or closed
technique?夽
Sultan Şevik Eliçora ∗ , Duygu Erdem, Hüseyin Işık, Murat Damar, Aykut Erdem Dinç
Zonguldak Bülent Ecevit University, Faculty of Medicine, Department of Otorhinolaryngology, Zonguldak, Turkey
Received 16 December 2015; accepted 18 March 2016
Available online 29 April 2016
KEYWORDS
Nasal septum;
Nasal surgical
procedures;
Intranasal surgery
Abstract
Introduction: The aim of this study is to compare the functional aspects of open technique
(OTS) and endonasal septoplasty (ENS) in ‘‘difficult septal deviation cases’’.
Methods: 60 patients with severe nasal obstruction from S-shaped deformities, multiple deformities, high deviations etc. were included in the study. The OTS was used in 30 patients and the
ENS was performed in 30 patients. The Nasal Obstruction Symptom Evaluation (NOSE) scale was
administered preoperatively and at first month following surgery. Patients were also evaluated
for pain postoperatively with Visual Analog Scale (VAS).
Results: The mean NOSE score was decreased 62.5---11.0 in the OTS group and 61.3---21.33 in
the ENS group. Improvement of the symptoms following the two surgical techniques is similar
and no statistically significant difference was found between both techniques. Also there was
no statistically significant difference in postoperative pain between the OTS and ENS groups
evaluated by VAS.
Conclusion: ENS is as successful as the OTS in management difficult septal deviation cases.
In patients with severe septal deformities type of the surgical technique should be selected
according to the surgeon’s experience and the patient’s preference.
© 2016 Published by Elsevier Editora Ltda. on behalf of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Casos difíceis de desvio septal: técnica aberta ou fechada?
Septo nasal;
Procedimentos
cirúrgicos nasais;
Cirurgia endoscópica
Resumo
Introdução: O objetivo deste estudo é comparar os aspectos funcionais da Septoplastia entre a
técnica aberta (STA) e a endonasal (SEN) em ‘‘casos difíceis de desvio de septo nasal’’.
夽 Please cite this article as: Şevik Eliçora S, Erdem D, Işık H, Damar M, Dinç AE. Difficult septal deviation cases: open or closed technique?
Braz J Otorhinolaryngol. 2017;83:256---60.
∗ Corresponding author.
E-mail: drsultan@mynet.com (S. Şevik Eliçora).
Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.
http://dx.doi.org/10.1016/j.bjorl.2016.03.015
1808-8694/© 2016 Published by Elsevier Editora Ltda. on behalf of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Difficult septal deviation cases
257
Método: Foram incluídos 60 pacientes com obstrução nasal devido a deformidades em forma
de S, múltiplas deformidades, desvios altos etc. A STA foi usada em 30 pacientes e a SEN em 30.
A escala de avaliação do sintoma de obstrução nasal (NOSE) foi administrada no pré-operatório
e no primeiro mês após a cirurgia. Os pacientes também foram avaliados com Escala Visual
Analógica (EVA) para dor no pós-operatório.
Resultados: O escore médio de NOSE foi reduzido de 62,5-11,0 no grupo da STA e de 61,321,33 no grupo da SEN. Houve melhora dos sintomas com as duas técnicas cirúrgicas e não foi
encontrada diferença estatisticamente significativa entre elas. Também não houve diferença
estatisticamente significativa nos graus de dor no pós-operatório que tenha sido avaliada pela
EVA entre o grupo de STA e o de SEN.
Conclusão: De acordo com nossos dados, a SEN é tão bem-sucedida quanto a STA no tratamento
de casos difíceis de desvio de septo nasal. Em pacientes com deformidades septais graves,
o tipo de técnica cirúrgica deve ser escolhido de acordo com a experiência do cirurgião e a
preferência do paciente.
© 2016 Publicado por Elsevier Editora Ltda. em nome de Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Este é um artigo Open Access sob uma licença CC BY
(http://creativecommons.org/licenses/by/4.0/).
Introduction
Septoplasty is a common procedure in daily ear nose and
throat practice. Various methods of surgical treatment are
defined in nasal deformities that cause nasal obstruction:
endoscopic septoplasty for posterior nasal obstruction, Cottle’s septoplasty for septum’s luxation and deviation on the
premaxilla area, septoplasty with spreader grafts for dorsum cartilage deviations, extracorporeal septoplasty with a
new septum cartilage frame for the complex deviations.1
The mostly used technique is still the one that defined by
Cottle in 1958.2
Severe septal deviations, caudal deformities, anterior
deviations, S-shaped deviations, high deviations and middorsal abnormalities are the ones that are defined as
‘‘difficult septal deviations’’. In such cases endonasal septoplasty can be used by some surgeons but also open technique
septoplasty can be preferred to increase angle of vision.
Both techniques have different limitations that affect their
success. In the open septoplasty, the longer duration of the
operation and the formation of postoperative columellar
incision scar limit the technique.3 On the other hand in the
endonasal septoplasty, narrow angle of vision and for that
more limited intervention area emerges as a disadvantage.
In this study we aim to compare the functional results of the
open and the endonasal septoplasty techniques in difficult
septal deviation cases.
(Table 1). Among these patients who have had Mladina
type 4, 6 and 7 deviations were included in the study. The
patients with insufficient nasal tip support were excluded
from the study. Before the surgery, informed consent was
obtained from all patients. The columellar incision was
explained particularly. Patients who have needed an additional surgery such as adenoidectomy, endoscopic sinus
surgery or turbinate surgery were not included to the study.
Revision cases and patients whose age was <16 years were
also excluded. Open technique was proposed to all patients,
and the patients who agreed the open technique were
Table 1
Mladina’s classification
Type I
Type II
Type III
Type IV
Methods
This study was designed as a prospective nonrandomized
longitudinal study and approved by ethical committee (Number: 2014-119-01/07). All participants signed an informed
consent agreement. Patients who were applied to our
ENT clinic because of nasal obstruction and diagnosed as
nasal septal deviation between September 2014 and May
2015 were classified according to Mladina’s classification4
Mladina’s classification of deviated septum nasi.
Type V
Type VI
Type VII
Presence of a unilateral crest which does not
disturb the function of the nasal valve. It is
situated in the area of the valve.
Disturbance of the valve function is caused by
the unilateral crest. Positive Cottle’s symptom
can be observed after raising of the nostril,
which gives a subjective and objective
improvement in the nose patency.
One unilateral crest at the level of the head of
the middle nasal concha
Defines two crests --- one at the level of the
head of the middle nasal concha, and the
other on the opposite side in the valve area,
disturbing the valve functions.
A unilateral ridge on the base of the septum,
while on the other side the septum is straight.
A unilateral sulcus running through the
caudal-ventral part of the septum, while on
the other side there is a ridge and
accompanying asymmetry of the nasal cavity.
A mix of types from I to VI.
258
Table 2
Şevik Eliçora S et al.
The Nose Obstruction Symptom Evaluation (NOSE) scale.
Over the past 1 month, how much of a problem were the following conditions for you? Please circle the most correct response
1
2
3
4
5
Nasal congestion or stuffiness
Nasal blockage or obstruction
Trouble breathing through my nose
Trouble sleeping
Unable to get enough air through my
nose during exercise or exertion
Not a
problem
Very mild
problem
Moderate
problem
Fairly bad
problem
Severe
problem
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
assigned to the open septoplasty group. The patients who
rejected the open technique generally because of the incision scar were included in the endonasal septoplasty group.
The study was completed when the patient number reached
to 30 in each group.
All surgical operations were carried out by the same
team. To evaluate the functional results of the operations
the NOSE scale (Table 2) was administered preoperatively
and at first month following surgery. The NOSE scale is a
symptom specific scale, developed by Stewart et al. in which
the patients scored five different symptom specific questions, with 0 meaning ‘‘not a problem’’ and 4 meaning
‘‘severe problem’’. At the end, these answers were calculated with a total score always between 0 and 20. We then
multiplied this score by five and completed it to 100. Higher
scores mean the symptom severity was higher. The scale was
translated into Turkish, and its reliability in the Turkish population was demonstrated by Kahveci et al. by a previous
study. To get the baseline NOSE scores, the patients were
asked about the nasal obstruction symptoms prior to the
operation.
Midazolam was administered as premedication and
surgeries were performed under general anesthesia with
Remifentanil and inhalant anesthetic for all patients.
For Mladina type 4 deviations spreader grafts were placed
after separation of the cartilage from vomer and nasal crest
in open technique. In closed technique an inverted v shaped
excision and partial thickness scorings were performed on
the posterior concave side of the deviated cartilaginous
septum, excision is performed to inferior deviation and
relaxation and minimal cartilage excision was applied to
anterior deviation.
For Mladina type 6 deviations after elevation of bilateral
mucoperichondrial flaps maxillary crest and a small portion
of the cartilage was resected. Then cartilage was fixed in
midline and suturated to the soft tissue around the maxillary
crest in suitable cases.
Combination of these methods was used for Mladina type
7 deviations.
No nasal packing was needed. Bilateral internal silicon
splints were used for all patients. For the postoperative
pain Diclofenac sodium was used. In order to analyze postoperative pain, the Visual Analog Scale (VAS) was used at
the postoperative first day. VAS is a tool by which patients
indicated their general satisfaction with the operation, with
1 meaning least and 10 meaning maximum satisfaction on a
10 cm line. Early follow up examinations were performed
with anterior rhinoscopy and endoscopic examination on
the first and the third weeks postoperatively. Patients were
called to follow-up examination and for a survey on nasal
obstruction symptoms at the postoperative first month.
Patients were followed up at least 6 months postoperatively.
Statistical analyses were performed using commercial
software (IBM SPSS Statistics 20, SPSS Inc., an IBM Co.,
Somers, NY). Two paired sample t-test was used to compare the NOSE scores between baseline and post-operative
periods. Continuous variables were presented as the mean
standard deviation. A p-value < 0.05 was considered as statistically significant.
Results
60 patients were included in the study. Among these patients
30 were treated with the open technique septoplasty and 30
were with the endonasal septoplasty. There were 23 (76.6%)
male and 7 (23.3%) female patients with a mean age of
35.2 ± 12.6 in the endonasal septoplasty group. There were
23 (76.6%) male and 7 (23.3%) female patients with a mean
age of 38.77 ± 15.8 in the open technique group. The distribution of deviations according to Mladina’s classification
among two groups was shown in Table 3. There was no statistically significant difference among Mladina’s classification
between the open septoplasty group and the closed septoplasty group (p = 0.688).
In the open septoplasty group the mean NOSE scores
at baseline and 1 month after surgeries were 62.5 ± 22.2
and 11.0 ± 13.2 and in the endonasal septoplasty group
61.33 ± 20.38 and 21.33 ± 25.4 respectively. The difference
between the baseline and the postoperative scores was
highly significant (p < 0.001), but the difference between
the two groups was not statistically different. In VAS scores
for evaluating postoperative pain there was no difference
Table 3 The distribution of deviations according to Mladina’s classification among two groups.
Type 4
Type 6
Type 7
Total
Open technique
septoplasty
Closed technique
septoplasty
Total
5
4
21
30
3
5
22
30
8
9
43
60
Difficult septal deviation cases
between the two groups (p = 0.106). No major postoperative
complication (e.g., saddling, recurrence, wound infection,
and septal perforation) was seen in any patient. Mild bleeding occurred in one patient at the endonasal group. Minimal
synechia occurred in one patient at the open technique
group. No revision septoplasty surgery was needed in any
patient.
Discussion
Difficulty in nasal breathing is probably the most common
complaint heard in rhinology practice. Among the major
causes are nasal septum deviation and allergic rhinitis.5
Deviation of the nasal septum can result in nasal obstruction,
sinus disease, crooked nose deformity, and other structural
problems. Substantial deviations of the nasal septum may
also affect the humidification, olfaction, air filtering, and
temperature regulation of the nose and finally significantly
reduce the quality of life.6,7
The best management of the patients with nasal septal
deviation is still under debate. There are no evidencebased guidelines for deciding which patients are suitable for
surgery, what kind of operation should be done, and which
patients will benefit the most.8 Especially in difficult septal
deviation cases selection of the surgical technique becomes
harder. In this study we evaluated the results of the open
technique and the endonasal septoplasty particularly in difficult septal deviation cases.
It is hard to choose the exact surgical technique in
these cases but it is also harder to evaluate this techniques’ success. In general, evaluable tools to measure the
septoplasty results can be categorized as objective, such
as rhinomanometry, acoustic rhinometry, computed tomography, and peak nasal inspiratory flow; and subjective,
including patient history, the NOSE scale, questionnaires
incorporating Visual Analog Scale, the Fairlay nasal symptom score, the Nottingham Health profile, and the general
health questionnaire.5,7,9---12 Although no objective method
has been validated yet, the NOSE scale developed by Stewart et al. is a promising and reliable method for use in nasal
obstruction.13,14 This scale’s reliability in the Turkish population was demonstrated by Kahveci et al.9 We also used the
NOSE score for assessment. Each parameter was evaluated
individually and no difference was determined between the
two groups among parameters. We found that the patients
with nasal obstruction and septal deformity who undergone
nasal septoplasty have very significant improvement in nasal
obstruction at first month.
In our study we also evaluated the postoperative pain
degree by VAS between both surgical techniques. Normally
in the open septoplasty because much dissection was done
in soft tissues, it is expected to have much postoperative
pain.15 But there was no statistically significant difference
in postoperative pain degrees between the two groups.
The present study has clear limitations. Major limitations
of this study include the fact that only a small number of
patients were surveyed and the lack of randomization. The
lack of blindness could be explained obviously due to the
external scar in the open technique septoplasty group.
Another limitation of our study is the use of a subjective
evaluation method for comparison of different septoplasty
259
techniques. There are many studies in the literature that
evaluates the efficacy of septoplasty procedure by several
more objective methods such as rhinomanometry, acoustic
rhinometry or peak nasal inspiratory flow. But in previous
studies the NOSE scale alone was found as effective as all
those methods.9
Another limitation of our study is that in the endonasal
technique, external deformities accompanying to septal
deviation could not be fixed precisely. But in the beginning of
the study we informed the patients about the outcomes and
complications of both techniques and the patient selected
one of them. And also in that study we only evaluate the
functional results not the esthetic outcomes.
Conclusion
We can say that the two different techniques can be performed properly in ‘‘difficult septal deviation cases’’ for
functional result. In such difficult cases the closed septoplasty technique is at least as successful as open technique
in experienced hands. The surgical technique must be chosen according to the specific conditions and the preference
of the patient or the experience of the surgeon.
Conflicts of interest
The authors declare no conflicts of interest.
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