Deviated septum ct scan vs normal

Indian J Otolaryngol Head Neck Surg. 2019 Nov; 71(Suppl 3): 2004–2010.

Abstract

Computerized tomographic imaging of the nasal and paranasal regions has become an indispensable tool for the endoscopic sinonasal surgery. The case control study was carried out on 120 patients for pilot study and 800 patients for the main study. The cases were selected with a clinical diagnosis of chronic rhino sinusitis. They were referred for a sinus CT scan by otolaryngologists and controls from the normal population. The patients were separated into males and females and anatomical variations were assessed. Increased prevalence of left sided nasal septal deviation and type II nasal septal deviation was seen in males belonging to cases group in our study. Knowledge about the nasal septum anatomical variations provides understanding about the upper limit of surgical dissection and aids in road mapping the confident direction for the functional endoscopic surgeons.

Keywords: Computerized tomography scan, Chronic rhino sinusitis, Deviated nasal septum, Naso septal angle, Concha bullosa

Introduction

The nasal cavity is an uneven space located between the roof of the oral cavity and the cranial base divided by a median vertical septum made up of osseous and cartilaginous entity. The septum constitutes superiorly perpendicular plate of the ethmoidal bone and inferiorly vomer, palatine bone and crest of maxilla along with septal cartilages. It is the pertinent anatomical midline structure and forms a vital supportive foundation for the nasal cavity. When there is a deviation of the nasal septum, it produces alteration in the air flow and affect the mucociliary clearance into the nasal cavity [1–3].

On each side of the nasal cavity, there exists a superior, middle, and inferior concha. The middle concha may begin to get pneumatized at this point by the posterior ethmoid air cells. Partial or total pneumatization of the middle concha is termed as concha bullosa. On CT scan, it appear as an air space of the middle turbinate surrounded by an oval bony rim [1, 4–7].

CT scan is the technique of choice for the study of nasal septum. Unlike the routine radiography, CT scores both bone and cartilage portion and offers detailed anatomical information of bony nasal structures. Septal deformities are the prime causative factor in patients suffering from chronic sinusitis [1, 3]. The aim of our study is to assess the side of nasal septum deviation, its relationship with concha bullosa and type of naso septal deviation angle.

Materials and Methods

Study Design

An observational, case–control study was carried out in our medical institution. For pilot study 120 patients were selected. They were segregated into 60 patients in cases group, who had chronic rhino sinusitis. They are were referred for a paranasal air sinus CT scan by the otolaryngologists. The control group constitutes 60, who were selected from the non ENT and neurology clinics. The age group ranged from 18 to 65 years. The patients were sorted into males and females and radiological assessment was done. Later, for the main study, 800 patients out of which 400 are cases group and 400 of control group (200 males and 200 females) were selected, under each category. Informed consent has been taken from all participants in this study.

Methodology

For this study, Siemens AG, Somatom Spirit spiral scanner has been utilised for the imaging purpose [2, 3]. For every case, systematic imaging of the nasal sinus region was performed in coronal and axial slices using bone algorithm with 3-mm interval. The images were reconstructed using radiant software. This study was approved by institutional review board. (Ethical committee approval No: kmc/cert./10-2015/36).

The study parameters were prevalence of nasal septum deviation and variations in the nasal septal angle for cases and controls group in both the genders. The angulations of nasal septal deviation at the level of the osteomeatal complex (OMC) were estimated on both coronal and axial sections. A systematic analysis to identify and measure the nasal septal deviation angle on CT scan was done.

Deviation of the nasal septum was measured by drawing a line from crista galli to maxillary crest and another line to the maximum deviation of nasal septum. Deviation angles were calculated according to the angle between crista galli and the most prominent point of the deviation. The angle formed is calculated using the radiant software [8, 9]. Anatomical findings of each patient was carefully scrutinized and recorded on the patient’s data sheet.

The nasal septal deviation angle are classified into four categories according to the degree of its deviation [10–12].

• Type I (normal)—naso septal angle less than 5°

• Type II (mild)—naso septal angle from 5° to 10°

• Type III (moderate)—naso septal angle from 10° to 15°

• Type IV (severe)—naso septal angle more than 15°

Statistical analysis

The results were entered into MS excel sheet. SPSS version 16 software were used for data analysis. Results were calculated in terms of the number and percentage for the prevalence of nasal septal deviation and angle of deviation. Chi square test was implied to assess the relationship of concha bullosa influencing the prevalence of nasal septal deviation.

Results

The results of the anatomical variations of nasal septum for pilot study is shown in Tables 1 and ​2.

Table 1

Prevalence of nasal septum deviation for cases and controls group in both the genders for the pilot study (n—120)

Higher prevalence of left sided nasal septal deviation (73.4%) was seen in males of cases group

Table 2

Distribution of nasoseptal angle classification for cases and controls group in both the genders fort the pilot study

Higher prevalence of type II nasal septal deviation (76.7%) was seen in males of cases group

The results of the anatomical variations of nasal septum for main study is shown in Table 3.

Table 3

Prevalence of nasal septum deviation for cases and controls group in both the genders for the main study (n—800)

The deviated nasal septum was highly prevalent in males of cases group towards left side (75%)

Prevalence of concha bullosa for cases and controls group in both the genders for the pilot and main study is shown in Tables 4 and ​5.

Table 4

Prevalence of concha bullosa for cases and controls group in both the genders for the pilot study (n—120)

Higher prevalence of bilateral concha bullosa (33.3%) was seen in females of cases group

Table 5

Prevalence of concha bullosa for cases and controls group in both the genders for the main study (n—800)

Higher prevalence of bilateral concha bullosa (26%) was seen in females of cases group

Relationship between deviated nasal septum and concha bullosa for the cases and control group for both the genders are shown in Table 6.

Table 6

Relationship between deviated nasal septum and concha bullosa are tabulated for the cases and control group for both the genders

Discussion

Chronic rhino sinusitis is a pathological entity leading to untoward morbidity. Septal deformities are the prime causative factor in patients suffering from chronic sinusitis. It disturbs the drainage pathways and affects the mucociliary function by contact and obstruction in all sinuses by disturbing normal mucosal drainage [8, 10].

CT scan plays an enormous role in identifying the anatomical variations of the nasal septum and provides a uplifting hand for the surgeons to decide the pathway for the functional endoscopic surgical procedures. Nasal septum is an pertinent anatomical landmark to be envisioned first on their surgical map to delineate the accessibility for the sinonasal variations impeding the mucociliary drainage patterns. The aim of this study was to define the anatomical variations of the nasal septal configurations. In our pilot study of 120 patients, we found high prevalence of left sided nasal septal deviation when compared to the right inclination as seen in Table 1. In our main study comprising of 800 patients, 75% belonging to males of cases group showed higher prevalence of septal deviation as shown in Table 3. A meta-analysis of nasal septal deviation is elaborately given in Table 7.

Table 7

Met analysis of prevalence of deviated nasal septum

A coronal CT scan image showing the osteo meatal complex was utilized for calculation of direction and degree of septal deviation. The superior insertion of the nasal septum is at the crista galli and inferior insertion is at the level of the anterior nasal spine. The direction of deviation was termed by the convexity of the nasal septal curvature. In cases with an S-shaped deflection, the larger angle to the left or right was taken into consideration [5, 9].

Coronal sections are preferable compared to axial sections to evaluate the increased angulation of septal deviation (Fig. 1). It aids in determining the severity of lateral nasal wall abnormalities. In our pilot study, type II nasal septal deviation angle was seen in males of cases group (Table 2) for pilot study. From our main study results, the distribution of naso septal deviation angle (Fig. 2) for cases group and for the control group (Fig. 3) are represented. Higher prevalence of type II (110) classification was seen males of the cases group and type I (134) for females of the control group.

a–c Coronal section of CT scan showing type I, II, III measurements of nasoseptal angle in degrees

Distribution of nasoseptal deviation angle in the cases group—males (200) and females (200)

Distribution of nasoseptal deviation angle in the control group—males (200) and females (200)

The deviation of the nasal septum occurs frequently due to injury during the intrauterine life or secondary traumatic events in later life. It is of congenital and acquired type. These nasoseptal variations are frequently associated with chronic rhino sinusitis. Septal deviation leads to modification in the air flow pattern, nasal cycle and mucociliary clearance of the nasal cavity. Major differences in middle turbinates and lateral nasal wall abnormalities were identified contra lateral to the direction of septal deviation. Javarashid et al. [12] studies showed type II in cases group and type I in control group. In few studies, groupII and III were prevalent [9] and 31.1% belong to type I in a study done by Ozkurt et al. [11]. In study done by Mohebbi et al. [10]. Type III with deviation towards right.

There are few studies enumerating the developmental influence of concha bullosa on the nasoseptal deviations. In our study, prevalence of concha bullosa for cases and controls group in both the genders for the pilot study was shown in Table 4 and for main study in Table 5. Higher prevalence of bilateral concha bullosa of 33.3% was seen in pilot study results and 26% was seen in the main study results predominance in the females of cases group. In studies conducted by Biswas et al. [5] showed 30%, adeel et al. [13] by 18.2%, Rashid et al. [14] by 49% and Bandarey et al. [15] by 40.3%. Similar to our study, Ahmet kayaguz et al. [7] showed increased prevalence rate in females by 24.2% than males of 21.2% and Hatice et al. [16] by prevalence rate in females of 64.7% than males of 45%.

In our study, there was no statistical difference between the deviated nasal septum and concha bullosa as shown in Table 6 which was in accordance with similar studies done by Mohebbi et al. [10], Smith et al. [17] and Javarashid et al. [12]. On the contratry, research studies done by Mundra et al. [9], Kelis et al. [8] and Aktas et al. [18] showed there was statistical significance between the deviated nasal septum and concha bullosa.

Concha bullosa has been concerned as a potential etiologic factor in recurrent sinusitis, due to its postulated negative influence on paranasal sinus ventilation and mucociliary clearance in the middle meatus region [7, 12, 13, 15]. But in our study, there was no significant relationsip between the concha bullosa and nasal septal deviation. The presence of concha bullosa along with septal deviation reduces roomy space for the mucociliary drainage pathway (Fig. 4).

a Coronal CT image of paranasal sinuses shows the deviated nasal septum towards left (white outlined arrow) and bilateral concha bullosa (white solid arrows). b Axial CT scan showing right concha bullosa (dotted arrow)

Nasal septum pathology is highly prevalent and septoplasty is the best preferred surgical procedure. Based on CT imaging techniques, it is easy to define the type of deviation and provide a pre surgical anatomical map to ward off potential postoperative complications. CT scan is the ideal imaging of choice for the study of nasal septum. Unlike the routine radiography, CT scores both bone and cartilage portion and offers a detailed anatomical information of bony nasal structures. Also, the CT image is reconstructed in coronal plane favours the surgeons convenience of access. It aptly reflects the anatomy, osteomeatal unit and the relationship of the ethmoid roof with the anterior cranial fossa for the otolaryngologist. CT has three main functions in the study of nasal septum. To diagnose the pathology, to provide a preoperative map for anatomical variations of the sinonasal anatomy and to illustrate the complications of surgical consequences [10, 12, 19].

The primary concept that enumerate the pathological association between the nasal septal deviation and chronic rhino sinusitis are mucosal secretions accumulated in the sinus regions leading to narrowness of the osteomeatal complex and perpetuation of chronic rhino sinusitis. According to the aerodynamic theory, decreased mucociliary activity associated with mucosal dryness in cases of nasal septal deviation leads to chronicity of rhino sinusitis. Formation of pressure and air flow changes within the maxillary sinuses leads to nasal blockage and aggravates the chronicity of sino nasal diseases [11, 19].

In addition to the direct effect of septal deviation on the development of sinusitis, it has been proposed that the craniofacial morphology in patients with a deviated septum may differ from that of patients without deviation or less severe deviation [20].

Conclusion

Pathological changes such as hypertrophy, deviation and pneumatization of anatomical structures may affect the drainage system generating abnormalities in the osteomeatal complex and predisposes to obstruction. CT scan has made an enormous impact in regional imaging. It has increased a surgeon’s ability to depict accurately the status of structures within the paranasal sinus region and in delineating the location and extent of sinus disease. Higher prevalence of type II nasal septal deviation angle was seen in males of cases group in both the pilot and main study. Higher prevalence of bilateral concha bullosa was seen in females of cases group in both the pilot and main study. The study shows there is no significant influence of deviated nasal septum in the development of concha bullosa.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Contributor Information

Vinodhini Periyasamy, Email: moc.liamg@ymasayirepinihdoniv.

Shivarama Bhat, Email: moc.liamg@amaravihstahb.

M. N. Sree Ram, Email: moc.liamg@mareersnm.

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