Introduction
Limited septal deviations and septal spurs have previously been treated with conventional septoplasty. However, with the philosophy of maximum conservation of body tissues gaining momentum, endoscopic septoplasty is now replacing the former, classical technique. We define limited septal deviation as septal deviation in the limited part of the septum, usually in Cottle's areas I, II and/or III. A septal spur which impinges on the lateral wall at the level of the ostio-meatal complex and sphenoethmoidal recess may cause nasal obstruction, mucociliary clearance problems and chronic sinusitis, and may also impede the introduction of instruments during functional endoscopic sinus surgery (especially in cases with a deviated nasal septum or spur of Cottle's area III (i.e. the turbinate area)).
In cases of limited septal deviation, the advantages of endoscopic septoplasty are as follows: the incision is made more posteriorly on the septum, being placed just caudal to the area of deviation; the extent of flap elevation required (either submucoperichondrial or submucoperiosteal) is negligible; and disarticulation of the vomerochondrial and ethmoidochondrial junction is often unnecessary. In addition, unlike conventional septoplasty, endoscopic septoplasty reduces morbidity and post-operative swelling by limiting dissection in the area of deviation. Endoscopic septoplasty is also a minimally invasive procedure suitable for treating septal deviations in children. In patients requiring revision septal surgery, in whom the flaps are frequently found to be adherent, endoscopic septoplasty is beneficial as the amount of dissection is limited. In children in whom conventional septoplasty is controversial because of a fear of resulting facial deformity, endoscopic septoplasty may be preferred. Endoscopic evaluation of the nasal cavity also permits visualisation without physical distortion of the cavity; this is not possible with a nasal speculum. If the endoscopic septoplasty instead of conventional one is carried out with functional endoscopic sinus surgery, the frequent changeover between head light and endoscope is avoided. Also the endoscopic surgery is an excellent teaching tool when viewed on monitor.
Patients and methods
After approval of the relevant ethical committee, this prospective study was conducted on a group of 80 patients who presented to the ENT out-patient department of Lady Hardinge Medical College and its associated hospitals, New Delhi, with limited septal deviation and/or septal spur. The study was interventional in nature, and a randomised block design method was used. Each block comprised two patients of similar age and sex, with one patient undergoing endoscopic septoplasty and the other conventional septoplasty. This block pairing was replicated 40 times, and the operative procedure, results and complications were compared clinically and statistically. The study was conducted from April 2002 to March 2006.
Firstly, a detailed history was taken of all selected patients, using a specially designed proforma. Then, a thorough examination was undertaken and objective evaluation performed by nasal endoscopy and active anterior rhinomanometry, using a Rhinoscreen© rhinomanometer (Jaeger, Würzburg, Germany).
In cases undergoing endoscopic septoplasty, an initial incision was placed just caudal to the deformity; submucoperichondrial and submucoperiosteal flaps were then elevated using suction elevator. Septal cartilage was incised a few millimetres posterior to the mucosal incision, and contralateral mucoperichondrial and/or mucoperiosteal flaps were then raised. Deviated septal cartilage was excised using small Luc's or Blakesley nasal forceps. Any deviated portion of the vomer and perpendicular plate of the ethmoid was removed if necessary. Finally, the septal flap was repositioned and quilting sutures used wherever possible.
In cases with a septal spur, the incision was placed on the same side, parallel to the floor of the nose on the apex of the spur. Flaps were elevated superiorly and inferiorly with an elevator to expose the underlying bone or the cartilaginous spur. An osteotome was used against the base of the spur to chisel out the bony protrusion, and the cartilaginous portion of the spur was removed with the help of small Luc's forceps, after placing an incision at its base.
Patients were followed up one month, three months and one to two years post-operatively, and a subjective assessment for nasal patency (using a visual analogue scale) and an objective assessment (by nasal endoscopy and active anterior rhinomanometry) conducted.
Results and complications were analysed statistically, using Fisher's exact test and the chi-square test, to evaluate improvement in terms of obstruction, self-assessment questionnaire, active rhinomanometry and nasal endoscopic appearance.
Results
In our study, 48 (60 per cent) patients were male and 32 (40 per cent) female. Patients' ages ranged between eight and 42 years, with the average age being 24.8 years. Nasal obstruction was the most common presenting symptom, being found in 72 (90 per cent) patients. The duration of presenting symptoms varied from two months to 15 years, with an average of 43.7 months.
Pre-operative nasal endoscopic evaluation located nasal septum deviations in Cottle's area II in 16 (20 per cent) patients and in Cottle's area III in 36 (45 per cent). A spur was also found in 38 (47.5 per cent) patients. On active anterior rhinomanometry, a nasal resistance of >0.45 Pa/cm3/sec at 150 Pa pressure in adults and 75 Pa pressure in children in at least one nasal cavity was considered high. We found a high pre-operative nasal airway resistance in 95 per cent (n = 38) of patients undergoing conventional septoplasty and in 85 per cent (n = 34) undergoing endoscopic septoplasty. A high pre-operative nasal airway resistance with severely impaired air flow was found in all the children (age range eight to 14 years).
Our study found no major complications in the immediate post-operative period. Minor complications, such as haemorrhage, infraorbital oedema and nasal pain, were slightly more frequent following conventional septoplasty compared with endoscopic septoplasty (Table I). Duration of hospital stay was also longer (i.e. more than 48 hours) after conventional septoplasty compared with endoscopic septoplasty.
Immediate complications of conventional and endoscopic septoplasty
CS = conventional septoplasty; ES = endoscopic septoplasty; hrs = hours
One to two years post-operatively, the results of the procedures were re-evaluated both subjectively and objectively. Patients' subjective assessments (Feeling of degree of nasal obstruction), using a visual analogue scale of one to 10 (with one to three considered poor, four to seven fair and eight to 10 good to excellent results) revealed poor results in four cases in both groups, and fair results in 14 conventional septoplasty cases and 12 endoscopic septoplasty cases. In the remaining cases, good to excellent results were obtained.
At two years' post-operative follow up, endoscopic re-assessment found residual or recurrent deviation in four conventional septoplasty patients and two endoscopic septoplasty patients. Synechiae persisted in only two patients in each group.
Active anterior rhinomanometry conducted one to two years' post-operatively showed improvement in nasal flow and nasal resistance compared with pre-operative findings. These findings are shown in Table II.
Subjective and rhinomanometric findings at 1–2 years' follow up
CS = conventional septoplasty; ES = endoscopic septoplasty
Discussion
Since its introduction, the deviated nasal septum correction procedure has had numerous modifications, starting from radical septal resection to now possible preservation of septal framework and nasal mucosa. According to Brennan et al. Reference Brennan and Parkes1 the ideal objective in septal surgery is permanent correction of deviation with avoidance of any complication. Four basic principles are consistent with this objective: good exposure; safe elevation of flaps; resection of only a limited, necessary amount of septum; and elimination of aetiological dynamic forces. Of these four principles, the first three are best achieved by an endoscopic approach to the septum. After the invention of the Hopkins' rod telescope, the introduction of functional endoscopic sinus surgery was a major breakthrough in nasal surgery. The basic approach to achieving a good result in endoscopic septoplasty with sinus surgery is the correction of abnormality in the lateral wall and septum, when it interferes with sinus ventilation and mucociliary transport. Chung et al. Reference Chung, Batra, Citardi and Lanza2 found that 34.5 per cent of patients required endoscopic septoplasty only for access.
Castelnuovo et al. Reference Castelnuovo, Pagella, Cerniglia and Emanuelli3 and CantrellReference Cantrell4 preferred incision on the convex side for small spurs and limited septal deviations, whereas Hwang et al. Reference Hwang, McLaughlin, Lanza and Kennedy5 incised the concave side. We incised the convex side in adult cases undergoing endoscopic septoplasty. This offered the advantage of complete resection with limited flap elevation, but increased the chances of synechiae formation if functional endoscopic sinus surgery was also performed on the same side. Thus, at one month post-operatively we encountered more synechiae in patients who had undergone endoscopic septoplasty, compared with other studies. During conventional septoplasty, we always incised on the left side as this was easier for a right-handed surgeon.
Our patients with limited septal deviation or spur together with chronic sinusitis first underwent functional endoscopic sinus surgery on their unobstructed side, followed by septoplasty and then functional endoscopic sinus surgery on their obstructed side. This order was chosen so that at least the sinus surgery, when performed on the unobstructed side, had a bloodless field. CantrellReference Cantrell4 and Hwang et al. Reference Hwang, McLaughlin, Lanza and Kennedy5 also performed the procedure in this way.
In our study, the time required for surgery could not be analysed because our cases required different combinations of surgical procedures. However, small spurs took much less time to correct endoscopically compared with the classical method. For large spurs and gross deviations, the surgery time was comparable for both groups, as elevation of the flap was difficult in such cases and repeated contamination of the endoscope with blood blurred the surgeon's vision.
The advantage of endoscopic septoplasty over conventional septoplasty, when performed along with functional endoscopic sinus surgery, was that the repeated, time-consuming, inconvenient transition between headlight and nasal endoscope was avoided. We performed 12 conventional septoplasties or spurectomies together with functional endoscopic sinus surgery, during which we required an average of four to five transitions between headlight and nasal endoscope. An average such transition took 2 minutes, so a conventional septoplasty plus functional endoscopic sinus surgery took approximately 10 minutes longer. Endoscopic septoplasty required nearly the same instruments as functional endoscopic sinus surgery; however, conventional septoplasty required some additional instruments, which was inconvenient.
In conventional septoplasty cases conducted together with functional endoscopic sinus surgery, suctioning over the elevated mucoperichondrial flap obscured the endonasal view. A similar problem was reported by Castelnuovo et al. Reference Castelnuovo, Pagella, Cerniglia and Emanuelli3
Conventional septoplasty required the use of a nasal speculum, which at times distorted the nasal anatomy, especially in the narrower nose. In contrast, during endoscopic septoplasty it was possible to gain an accurate idea of the degree of improvement in septal deviation. The endoscopic view allowed microtears in the mucoperichondrial flap to be easily identified, which was not possible with conventional septoplasty. We found micotears in 10 cases during endoscopic septoplasty. Of these cases, six developed post-operative synechiae, which were asymptomatic and able to be divided during post-operative endoscopic examination.
We performed four revision septoplasties – two using the conventional method and two with the help of an endoscope. Raising flaps was more difficult with conventional septoplasty, as these were found to be adherent due to prior submucosal dissection and cartilage resection; however, with endoscopic septoplasty, during which only limited flaps were raised, this process was relatively easier. Hwang et al. Reference Hwang, McLaughlin, Lanza and Kennedy5 have reported a similar experience.
The main disadvantage of endoscopic septoplasty is contamination of the endoscope with blood, which obscures the endoscope view. Also, as one hand is required to hold the nasal endoscope, other instruments must be manipulated with a single hand, which can be difficult.
Although we found no immediate, statistically significant differences in post-operative complications, there was a definite clinical difference between the two groups; study of a larger group is therefore required. Castelnuovo et al. Reference Castelnuovo, Pagella, Cerniglia and Emanuelli3 and Hwang et al. Reference Hwang, McLaughlin, Lanza and Kennedy5 encountered no major post-operative complications, confirming our findings; however, Hwang et al. Reference Hwang, McLaughlin, Lanza and Kennedy5 did encounter one case of septal hematoma (in a study of 111 endoscopic septoplasty cases).
Most of our patients stayed in hospital for less than 48 hours. However, more conventional septoplasty patients had longer durations of stay, compared with endoscopic septoplasty patients (25 vs 5 per cent, respectively). Although this difference was statistically insignificant (p = 0.18, Fisher's exact test), endoscopic septoplasty patients tended clinically to have a shorter duration of hospital stay. Furthermore, in order to detect any clinical differences in this outcome between paediatric and adult patients, we merged both conventional and endoscopic septoplasty groups (as each subgroup was very small). We found that six of 12 (50 per cent) paediatric patients required a longer duration of hospital stay, compared with six of 68 (8.9 per cent) adults. Although no statistically significant difference was found (p = 0.08, Fisher's exact test), due to the small group size, the clinical difference was significant. Castelnuovo et al. Reference Castelnuovo, Pagella, Cerniglia and Emanuelli3 also reported a shorter recovery time after endoscopic septoplasty.
No post-operative infection was observed in our study. In contrast, Makitie et al. Reference Makitie, Aaltonen, Hytonen and Malmberg6 found that 12 per cent of conventional septoplasty cases had signs of immediate post-operative infection, whereas Hwang et al. Reference Hwang, McLaughlin, Lanza and Kennedy5 and Castelnuovo et al. Reference Castelnuovo, Pagella, Cerniglia and Emanuelli3 encountered no post-operative infection after endoscopic septoplasty.
Nasal obstruction is one of the main symptoms of deviated nasal septum. Therefore, this symptom was chosen for post-operative objective analysis; both groups were compared. As both treatment groups were very small, we merged mild, moderate and severe cases and considered them all to represent persistent nasal obstruction. At one month post-operatively, 14 (35 per cent) conventional septoplasty patients and 16 (40 per cent) endoscopic septoplasty patients had nasal obstruction. However, this difference was not clinically or statistically significant (p = 0.74, λ2 = 0.11). We also analysed the nasal obstruction data using the FairleyReference Fairley, Yardley and Durham7 nasal symptom score, which grades symptom intensity as asymptomatic, mild, moderate or severe. Post-operative improvement was defined as a decrease in intensity of at least one grade. It was found that 36 conventional septoplasty patients and 34 endoscopic septoplasty patients experienced a symptomatic improvement (p value nearing 1, Fisher's exact test). Two years post-operatively, slightly more endoscopic septoplasty patients (n = 36) than conventional septoplasty patients (n = 32) had experienced an improvement in symptoms.
Allergic rhinitis has been regarded as a relative contraindication for septal surgery;Reference Stoksted and Gutierrez8 however, some authors believe that these patients profit equally from such surgery.Reference Peacock9 We performed endoscopic septoplasty in two patients with allergic rhinitis and conventional septoplasty in one, and found improvement in nasal patency in all three. Although rhinorrhoea and sneezing persisted, the patients felt satisfied with their surgery.
No ideal tool exists for the evaluation of post-septoplasty results; hence, we considered patient's satisfaction as the main criterion. Patients subjectively evaluated their satisfaction on a visual analogue scale of one to 10. Since only a very small number of patients reported fair and good results, patients from these two groups were combined into the same group in order to assess symptomatic improvement. Thus ninety per cent of cases (n = 36) in each group showed symptomatic improvement; statistically, these results were very similar in both conventional and endoscopic septoplasty groups.
In our study, objective post-operative evaluation comprised endoscopic assessment and active anterior rhinomanometry. Endoscopic assessment revealed that 15 per cent (n = 6) of conventional septoplasty patients and 10 per cent (n = 4) of endoscopic septoplasty patients had residual deviation (p value nearing 1, Fisher's exact test). This residual deviation persisted beyond the two-year post-operative period.
Synechiae were observed in two (5 per cent) conventional septoplasty patients and 10 (25 per cent) endoscopic septoplasty patients at one month post-operatively. This difference was not stastically significant (p = 0.18, Fisher's exact test). All synechiae identified in this study were asymptomatic. Nayak et al. Reference Nayak, Balakrishnan and Murty10 found the post-operative incidence of persistent deviation and contact area to be significantly lower following endoscopic septoplasty compared with conventional septoplasty. Our study found a slightly lower rate of persistent deviation, probably because it included only patients with limited septal deviation. We observed the incidence of synechiae to be greater after endoscopic septoplasty in patients with posterior deviation who also required functional endoscopic sinus surgery. This may have been due to the fact that as the incision was made just caudal to the deviation, the area involved was opposite the ostio-meatal complex. These synechiae were excised endoscopically. Two years post-operatively, we found only one patient in each group to have mild, asymptomatic, persistent synechiae (p = 1).
One month post-operatively, an improvement in nasal resistance was observed in at least one nasal cavity in 36 patients in each treatment group. However, 22 conventional septoplasty patients and 18 endoscopic septoplasty patients had a higher nasal airway resistance post-operatively (p = 0.527, λ = 0.40, chi-square test). At one to two years post-operatively, an improvement in nasal resistance was observed in at least one nasal cavity in 38 patients in each treatment group. At one to two years post-operatively, an improvement in total nasal flow of at least one grade was found in 38 (95 per cent) patients in each group. Using active anterior rhinomanometry, Broms et al. Reference Broms, Jonson and Malm11 found a higher nasal airway resistance (>0.45 Pa/cm3/sec) in at least one nasal cavity in 72 per cent of pre-septoplasty patients; approximately 90 per cent improved post-septoplasty. Holmstorm and KumlienReference Holmstorm and Kumlien12 found an 81 per cent improvement post-septoplasty. Both these groups justified their use of pre-operative rhinomanometry as an objective tool. We found a higher rate of post-operative nasal airway resistance in our patients, compared with other published series.
We also compared rhinomanometry results with those for subjective assessment of nasal obstruction, by comparing mild, moderate and severe nasal obstruction with mild, moderate and severe nasal flow impairment. We found that only 36 patients (45 per cent) had matched results for rhinomanometry and subjective nasal obstruction assesssment. Jones et al. Reference Jones and Lancer13 were likewise unable to find any correlation between their patients' subjective nasal patency assessments and objective rhinomanometry results. Our patients' active anterior rhinomanometry results were inconsistent, and it was not possible to predict their surgical outcome based on this investigation.
Septoplasty in children is a controversial issue. This study conducted only 12 endoscopic and conventional septoplasty procedures in paediatric patients (aged eight to 12 years) but encountered no complications; this finding is supported by Goumas et al. Reference Goumas, Strambis, Antonakopoulos and Helidonis14 Our patients' post-operative response, evaluated both subjectively and objectively, was comparable for adults and children.
Overall, the study showed better results and fewer complications for endoscopic septoplasty compared with conventional septoplasty, as endoscopy gave better illumination and improved access to high deviations and spurs. We found that deviations in Cottle's area III and small spurs opposite the middle meatal area were best dealt with endoscopically. Cases with large spurs required a long incision, the raising of long flaps and resection of the spur involving a gouge and hammer, and these were difficult to perform endoscopically. In one case of a very long spur, we were not able to resect the whole spur and had to shift from the endoscope to a headlight. Deviation in Cottle's areas I and II can be visualised equally well with a headlight, and if deviation is large then complete resection is not possible via a small incision. In these cases, the endoscope fully occupies one hand but does not greatly improve visualisation.
We found that left-sided deviations were much easier for a right-handed surgeon to deal with via endoscopic septoplasty, as the incision was placed on the left side. During conventional septoplasty, we always preferred to place the incision on the left side.
• Limited septal deviations and septal spurs have been historically treated with conventional septoplasty
• As the philosophy of maximum conservation of body tissues gains momentum, endoscopic septoplasty is now replacing this classical technique
• This study aimed to compare the procedure, results and complications of conventional septoplasty vs endoscopic septoplasty, in cases of limited septal deviation and septal spurs
• There were no statistically significant differences between conventional and endoscopic septoplasty, as assessed by subjective and objective evaluation
Even though we encountered no cases of limited deviated nasal septum in Cottle's areas IV or V, we believe that deviation in these areas should be dealt with endoscopically, as access to these areas is not possible using conventional methods. YanagisawaReference Yanagisawa15 described successful resection of such deviations endoscopically. Although we did not use powered instruments for septoplasty, Getz and HwangReference Getz and Hwang16 found them useful during surgery.
The main limitations of this study were: (1) its small sample size; (2) results for children and adults could not be compared, again due to small study size; and (3) as functional endoscopic sinus surgery was performed along with septoplasty in many cases, the results of one procedure could have affected those of the other.
