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Table of Content - Volume 12 Issue 2 - November 2019

 

Outcome of reduction of hypertrophied inferior turbinate during septoplasty

 

Sushant Kumar1*, M K Bose2

 

1Senior Resident, Associate Professor2, Department of ENT, Darbhanga Medical College and Hospital, Bihar, INDIA

Email: sushant.28@gmail.com

 

Abstract               Deviated nasal septum towards one side is often associated with overgrowth of inferior turbinate, which occupies expansive space on contralateral nasal cavity. It is assumed that this counter balanced mechanism characterised by compensatory hypertrophy originates to protect the more patent nasal side from excess airflow with its drying and crusting effects. septoplasty alone can treat nasal obstruction in patients with deviated nasal septum ,to know whether hypertrophied turbinate needs to be addressed in patients with deviated nasal septum. And also to know the effectiveness of reduction of hypertrophied turbinate together with septoplasty for the treatment of nasal obstruction in patients with deviated nasal septum. Methods: It was prospective randomised clinical study based on nasal obstruction symptom evaluation scale (NOSE) for patient subjective evaluation of symptoms. 60 patients with septal deviation and contralateral inferior turbinate hypertrophy were recruited in the study. Study was conducted in the department of ENT, Darbhanga Medical College and Hospital during the period of 2018-2019. Results: The results of study showed that both following septoplasty and TRS post operative results were highly significant but among these two groups, patient who underwent septoplasty along with TRS had better result. Among different type of TRS Turbinectomy has the best results. Conclusion: we conclude that hypertrophied turbinate needs to be addressed in chronic cases of nasal obstruction with deviated nasal septum and contralateral turbinate hypertrophy. And in these patient TRS should be done in addition to septoplasty. Hypertrophied Turbinate reduction in addition to septoplasty are highly effective modality for the treatment of nasal obstruction in patients with deviated nasal septum. NOSE score can be used as an objective tool for symptomatic measurement of patients with nasal obstruction. Nasal spirometry can be used for objective measurement of nasal patency.

Key Word: hypertrophied inferior turbinate.

 

 

INTRODUCTION

Nasal obstruction is a common presenting symptom which an otorhinolaryngologists encounters in daily clinical practice. It affects 9.5-15% of general population.1There can be many etiology for chronic nasal obstruction like deviated nasal septum with or without turbinate hypertrophy, only turbinate hypertrophy, allergic rhinitis, vasomotor rhinitis, infective rhinitis, nasal polyposis, granulomatous disease or nasal tumours, adenoid hypertrophy.2,3 Among these etiology for nasal obstruction one of the most commonest is deviated nasal septum.2 Deviated nasal septum towards one side is often associated with overgrowth of inferior turbinate, which occupies expansive space on contralateral nasal cavity. It is assumed that this counter balanced mechanism characterised by compensatory hypertrophy originates to protect the more patent nasal side from excess airflow with its drying and crusting effects. The turbinates hypertrophy can be due to mucosal element or bony expansion.3,4 Many authors believes that once septoplasty is done compensatory hypertrophy regresses on its own.5 Inferior turbinate hypertrophy due to rhinitis is amenable to medical treatment. However long standing chronic cases associated with nasal septal deviation may become irreversible. This may be due to dilated submucosal venous sinuses becoming varicose and unresponsive to sympathetic stimulation or medical treatment or because of fibrosis or because bony expansion of turbinates. As such these patients are refractory to medical management and complains of persistent symptoms.6,7 Despite its well known clinical occurrence this intriguing phenomenon has received little attention in the literature. Furthermore, the available studies lack quantative and qualitative information regarding the composition and typical histological features of hypertrophic turbinate compared to normal ones. Likewise, there are not enough studies or data to substantiate whether these changes are permanent or reversible. Many otorhinolaryngologists perform septoplasty with or without turbinate reduction surgery and surgical methods relies largely on clinical judgement, as the effectiveness of procedure is relatively unknown, the indications and technique applied vary considerably.

 

METHODS

Source of data:                 Patients presenting to ENT outpatient department of A J Institute of Medical Sciences Mangalore.

Inclusion criteria: All patients above 18years of age presenting to ENT outpatient department with history of nasal obstruction for at least 3months and clinically diagnosed to have deviated nasal septum with inferior turbinate hypertrophy.

Exclusion criteria: Patients with nasal obstruction diagnosed to have allergic rhinitis, vasomotor rhinitis, infective rhinitis, nasal polyps, granulomatous disease or nasal tumors or those patients unfit for surgery.

Method of collection of data: 60 patients with septal deviation and contralateral inferior turbinate hypertrophy were recruited in the study. Detailed history and clinical examination was done. After taking informed consent, Patients were asked to fill questionnaires relating to severity of their symptoms using Nasal Obstruction Symptom Evaluation(NOSE) scale. Patients were then randomly divided into two groups. In group A, reduction of inferior turbinate was performed to treat hypertrophied inferior turbinate together with septoplasty. In group B, only septoplasty was done. Post-operative patient's symptoms were again evaluated using Nasal Obstruction Evaluation Scale (NOSE) at 1, 3 and 6 months. Nasal airway was objectively evaluated using nasal spirometry. Data was analysed using tables, graph, percentage. And test of significance like paired t-test, student t-test, one-way anova was used. SPSS Microsoft software version.16 was used for test of analysis.

Nose Score- Used for subjective measurement of symptoms-

Scores taken pre-operatively,1month post-operatively,3months post-operatively,6months post-operatively. Total 5 symptoms, each symptoms is given points from 0 to 4 depending on severity of symptom.0 minimum severity,4-maximum severity. So total maximum points 5x4=20.

Total point=Q1+Q2+Q3+Q4+Q5.This is divided by 20 and multiplied by 100,to get score out of 100.i.e

Total Score= Q1+Q2+Q3+Q4+Q5x100

 20

Total score from 0 to 100.

0-minimum severity

100- maximum severity.

Change in pre to post operative at 1, 3 and6 months is compared between group Ai. eSeptoplasty + TRS and group B-Septoplasty only. Each group consists of 30 patients. Among TRS+ septoplasty group further subdivided into 3 groups of 10 each undergoing SMD+ Septoplasty,Turbinoplasty+septoplasty,Turbinectomy+septoplasty.

Different TRS are compared among themselves.

Nasal Spirometry-used for objective measurement of the nasal obstruction .It was done pre-operatively,1month post-operatively,3months post-operatively.

SPIROMETRY APPARATUS

Modified Endotracheal tube. Objective assessment of nasal patency was done using Spirometry apparatus in the pulmonary medicine department. Endotracheal tube (ET) was used to check the patency in each nostril by ET of size No.8 alternatively. The mouthpiece of the spirometer and the endotracheal tube were connected by using an air-tight seal light body condensation silicone prosthetic material.


 RESULTS

1

Figure 1: Sex distribution; Figure 2: Sex Distribution For different surgeries

 

 

Table 1: Mean NOSE Score

Procedure

Pre-operative

1-month

3-month

6-month

1.Septoplasty

70.33

31**

19.5**

18**

2.Turbinate+septoplasty Reduction

71.66

12.83**

10.66**

11.83**

a)Submucosal+septoplasty diathermy

70.5

15**

20**

24.5**

b)Turbinoplasty+septoplasty

70.5

16.5**

10.5**

9.5**

c)Turbinectomy+septoplasty

72.5

7**

1.5**

1.5**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 2: Mean Changes In Nose Score

Procedure

Changes at

1 –month

Changes at

3-month

Changes at

6-month

1.Septoplasty

39.33**

50.83**

52.33**

2.Turbinate+septoplasty

Reduction

58.83**

61**

59.83**

a)Submucosal+septoplasty

diathermy

55.5**

50.5**

46**

b)urbinoplasty+septoplasty

54**

60.5**

61.5**

c)Turbinectomy+septoplasty

65.5**

71**

71**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

2

Figure 3: Mean NOSE score Septoplasty VS TRS+Septoplasty

Analysing patient symptomatic improvement using NOSE score following observations were made (table1andtable2):

  1. Patients undergoing septoplasty improvement in NOSE score at 1month was 39.33,at 3months 50 and at 6months 52.33.
  2. Patients who underwent combined procedure of septoplasty with turbinate reduction(TRS) NOSE score at 1month was 58.83,at 3months61,at 6months 59.83

From above observation we can conclude both following septoplasty surgery alone andthose undergoing TRS with septoplasty had highly significant post-operative improvement (p<0.001) at 1month and 3monthsand6months There was highly significant (p<0.001) difference in patients undergoing combined TRS and septoplasty to those undergoing septoplasty alone at post-op 1and 3months with difference of19.5 and 10.17 respectively. Significant difference was observed at 6months with difference of 7. So patients undergoing TRS with septoplasty has more symptomatic relief compared to those undergoing septoplasty alone. But the difference which was significantly higher at immediate post-op1 month of 19.5 which was reduced to 10.17 at 3months and 7.5 at 6months, which was however still significant So patients undergoing septoplasty alone gradually shows symptomatic improvement over the period of 6month,whereas patient undergoing septoplasty with turbinate reduction definitely had overall greater improvement symptomatically compared to septoplasty alone, but their high post-op improvement remained static and did not improve over the period.

Comparing data among turbinate reduction surgeries-

  1. Patients undergoing septoplasty with SMD improvement in NOSE score at1month was 55.5, at 3months 50.5,and at 6months 46
  2. Patients undergoing septoplasty with turbinoplasty improvement in NOSE score at 1month was 54,at 3months 60.5andat 6months 61.5
  3. Patients undergoing septoplasty with turbinectomy improvement in NOSE score at 1month was 65.5,at 3months 71andat 6months 71

Patients undergoing submucosal diathermy together with septoplasty had similar symptomatic improvement compared to those undergoing turbinoplasty along with septoplasty at 1month with minimal difference of 1.5 in favour of SMD, but when compared to patient undergoing turbinectomy together with septoplasty ,they had less improvement with significant difference of 10 (P<0.05) in favour of patient undergoing turbinectomy with septoplasty. But in patients undergoing SMD improvement gradually decreases over a period of 6months with change in score of 50.5 and46 respectively at 3 and 6months, scoring value of which was 5 and 9 less compared to 1st month. So patients undergoing SMD had maximum improvement at 1month and then the symptoms detoriated at 6month but still they had significant improvement in NOSE score at 6months. Patients undergoing turbinoplasty with septoplasty has showed slight gradual improvement over 6months which was 14.5 greater than SMD with septoplasty and9.5 less than those undergoing turbinectomy with septoplasty at 6month.          Patients undergoing turbinectomy with septoplasty had highest improvement in NOSE score compared among all 3 turbinate surgeries with difference of 10 and 11.5 scoring value at 1month compared to SMD +septoplasty and turbinoplasty+septoplasty, which gradually over 6month showed significantly (p<0.05) greater difference of 25 compared to SMD+septoplasty. And almost static difference of 9.5 compared to turbinoplasty+septoplasty.

Compared to mean among these 3 TRS it has 11.17 point difference: So we can conclude maximum symptomatic relief is provided by patient undergoing turbinectomy+septoplasty and minimum with SMD+septoplasty.

 

 

 

Table 3: Mean Symptom-wise NOSE score-Septoplasty

Symptoms

Pre-operative

1-month

 

3-month

6-month

Nasal congestion

60.83

40*

30*

29.17*

Nasal blockage or Obstruction

88.33

38.33**

27.5**

26.66**

Trouble breathing through nose

85.83

36.67**

22.5**

20.83**

Trouble sleeping

65.83

26.67**

12.5**

9.16**

Unable to get enough Air during exertion

50.83

16.66**

5**

4.17**

 

 

 

 

 

 

 

 

 

symbol* and** indicates significant values at p<0.05 and P<0.01

 

Table 4: Mean Symptom-wise NOSE score -Turbinate Reduction

Symptoms

Pre-operative

1-month

 

3-month

6-month

Nasal congestion

60.83

14.2**

8.33**

8.33**

Nasal blockage or obstruction

90

21.67**

18.33**

20.83**

Trouble breathing through nose

90

20**

15.83**

17.5**

Trouble sleeping

65

7.5**

7.5**

8.33**

Unable to get enough Air during exertion

50

2.5**

3.33**

4.17**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 5: Mean Symptom-wise Change in NOSE score-Septoplasty

Symptoms

Change at

1-month

Change at

3-month

Change at

6-month

Nasal congestion

20.83*

30.83*

31.66**

Nasal blockage or obstruction

50**

60.83**

61.67**

Trouble breathing through nose

49.16**

63.33**

65**

Trouble sleeping

39.16**

53.33**

56.67**

Unable to get enough Air during exertion

34.17**

45.83**

46.66**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 6: Mean Symptom-wise Change in NOSE score-Turbinate Reduction

Symptoms

Change at

1-month

Change at

3-month

Change at

6-month

Nasal congestion

46.63**

52.5**

52.5**

Nasal blockage or obstruction

68.33**

71.67**

69.17**

Trouble breathing through nose

70**

74.17**

72.5**

Trouble sleeping

57.5**

57.5**

56.67**

Unable to get enough Air during exertion

47.5**

46.67**

45.83**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table7: Mean Symptom-wise NOSE score-Turbinectomy

Symptoms

Pre-operative

1-month

3-month

6-month

Nasal congestion

62.5

0**

0**

0**

Nasal blockage or obstruction

90

15**

2.5**

2.5**

Trouble breathing through nose

90

15**

2.5**

2.5**

Trouble sleeping

70

15**

2.5**

2.5**

Unable to get enough Air during exertion

50

7.5**

0**

0**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 8: Mean Symptom-wise NOSE score-Turbinoplasty

Symptoms

Pre-operative

1-month

3-month

6-month

Nasal congestion

62.5

27.5**

12.5**

12.5**

Nasal blockage or obstruction

90

25**

22.5**

20**

Trouble breathing through nose

90

22.5**

15**

12.5**

Trouble sleeping

60

7.5**

2.5**

2.5**

Unable to get enough Air during exertion

50

0**

0**

0**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 9: Mean Symptom-wise NOSE score-Submucosal Diathermy

Symptoms

Pre-operative

1-month

3-month

6-month

Nasal congestion

57.5

15**

12.5**

12.5**

Nasal blockage or obstruction

90

25**

30**

40*

Trouble breathin through nose

90

22.5**

30**

37.5**

Trouble sleeping

65

7.5**

17.5**

20**

Unable to get enough Air during exertion

50

5**

10**

12.5**

 

Table 10: Mean Symptom-wise Change in NOSE score-Turbinectomy

Symptoms

Change at

1-month

Change at

3-month

Change at

6-month

Nasal congestion

62.5**

62.5**

62.5**

Nasal blockage or obstruction

75**

87.5**

87.5**

Trouble breathing through nose

75**

87.5**

87.5**

Trouble sleeping

55**

67.5**

67.5**

Unable to get enough Air during exertion

42.5**

50**

50**

symbol * and ** indicates significant values at p<0.05 and p<0.01

Table 11: Mean Symptom-wise Change in NOSE score-Turbinoplasty

Symptoms

Change at

1-month

Change at

3-month

Change at

6-month

Symptoms

Nasal congestion

35*

50**

50**

Nasal congestion

Nasal blockage or obstruction

65**

67.5**

70**

Nasal blockage or

obstruction

Trouble breathing through nose

67.5**

75**

77.5**

Trouble breathing through nose

Trouble sleeping

52.5**

57.5**

57.5**

Trouble sleeping

Unable to get enough Air during exertion

50**

50**

50**

Unable to get enough

Air during exertion

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 12: Mean Symptom-wise Change in NOSE score-Submucosal Diathermy

Symptoms

Change at

1-month

Change at

3-month

Change at

6-month

Nasal congestion

42.5 **

45**

45**

Nasal blockage or Obstruction

65**

60**

50**

Trouble breathing through nose

67.5**

60**

52.5**

Trouble sleeping

57.5**

47.5**

45**

Unable to get enough Air during exertion

45**

40**

37.5**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 13: FEV-1 Comparison

 

Deviated septum side

Fev-1

Turbinate hypertrophy

Side fev-1

Procedure

Pre –

Operative

At-1

Month

At-3

Month

Pre –

Operative

At-1

Month

At-3

Month

1.Septoplasty

0.46

1.03**

1.04**

0.56

0.54

0.65

2.Turbinate reduction

0.49

0.86**

0.88**

0.5

0.85**

0.8**

a)Submucosal Diathermy

0.45

0.77**

0.82**

0.43

0.73**

0.62*

b)Turbinoplasty

0.5

0.93**

0.93**

0.5

0.77**

0.73**

c)Turbinectomy

0.52

0.89**

0.9**

0.57

1.05**

1.05**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 14: Change FEV-1 Following Surgery

 

Deviated septum side

Fev-1

Turbinate hypertrophy

Side fev-1

Procedure

Change-1

Month

Change-3

Month

Change-1

Month

Change-3

Month

1.Septoplasty

0.57**

0.58**

-0.02

0.09

2.Turbinate reduction

0.37**

0.39**

0.35**

0.3**

a)Submucosal Diathermy

0.32**

0.37**

0.30**

0.19*

b)Turbinoplasty

0.43**

0.43**

0.27**

0.23**

c)Turbinectomy

0.37**

0.38**

0.48**

0.48**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 15: Finfv comparison

 

deviated septum side

( finfv)

Turbinate hypertrophy

side (finfv)

Procedure

Pre –

Operative

At-1

Month

At-3

Month

Pre –

Operative

At-1

Month

At-3

Month

1.Septoplasty

0.53

1.00**

1.04**

0.62

0.62

0.71

2.Turbinate reduction

0.64

0.89**

0.91**

0.64

0.89**

0.90**

a)Submucosal Diathermy

0.70

0.82*

0.85*

0.60

0.82*

0.82*

b)Turbinoplasty

0.59

0.91**

0.92**

0.60

0.90**

0.82*

c)Turbinectomy

0.61

0.96**

0.96**

0.74

0.96**

1.07**

symbol * and ** indicates significant values at p<0.05 and p<0.01

 

Table 16: Change FINFV Following Surgery

 

Deviated septum side

Finfv

Turbinate hypertrophy

Side - finfv

Procedure

Change-1

Month

Change-3

Month

Change-1

Month

Change-3

Month

1.Septoplasty

0.47**

0.51**

0

0.09

2.Turbinate reduction

0.25**

0.27**

0.25**

0.26**

a)Submucosal Diathermy

0.12*

0.15*

0.22*

0.22*

b)Turbinoplasty

0.32**

0.33**

0.30**

0.22*

c)Turbinectomy

0.35**

0.35**

0.22*

0.33**

symbol * and ** indicates significant values at p<0.05 and p<0.01

FINFV

    • Comparing FINFV among patients undergoing septoplasty alone to those undergoing septoplasty+TRS .We can conclude that patient undergoing septoplasty alone had significant improvement of 0.47 and 0.51 at 1 and 3 months on DSSand but almost no improvement at 1and 3months with values of 0 and 0.9on THS.
    • -whereas patients undergoing TRS has significant improvement in FINFV on both DSS and THS, with change on DSS of 0.25 and0.27at 1 and 3 months respectively And 0.25 and 0.26 on THS at 1 and3months respectively.
    • Among those undergoing TRS along with septoplasty change in FINFV among different TRS on DSS was almost similar ranging from 0.12 to 0.35 at 1month and 0.15 to 0.35 at 3months.But on THS highest change was among those undergoing turbinectomy with changes of 0.33 at 3months.
    • -Patients undergoing SMD+ septoplasty and those with turbinoplasty with septoplasty had lesser change in value postoperatively of 0.22 at 3months.

    Table 17: MVV Comparison

     

    Deviated septum side

    Mvv

    Turbinate hypertrophy

    Side mvv

    Procedure

    Pre –

    Operative

    At-1

    Month

    At-3

    Month

    Pre –

    Operative

    At-1

    Month

    At-3

    Month

    1.Septoplasty

    11.13

    20.27**

    21.07**

    13

    12.93**

    14.46**

    2.Turbinate reduction

    12.7

    18.67**

    19.23**

    12.9

    18.53**

    18.03**

    a)Submucosal Diathermy

    12.5

    17.6**

    18.2**

    12.7

    17.2*

    15.3*

    b)Turbinoplasty

    12.8

    20.2**

    20.8**

    12.4

    16.7*

    16.4*

    c)Turbinectomy

    12.8

    18.2**

    18.7**

    13.6

    21.7**

    22.4**

    symbol * and ** indicates significant values at p<0.05 and p<0.01

     

    Table 18: Change MVV Following Surgery

     

    Deviated septum side

    Turbinate hypertrophy

    Side

    Procedure

    Change-1

    Month

    Change-3

    Month

    Change-1

    Month

    Change-3

    Month

    1.Septoplasty

    9.14**

    9.94**

    0.07

    1.46

    2.Turbinate reduction

    5.97**

    6.53**

    5.63**

    5.13**

    a)Submucosal Diathermy

    5.1**

    5.7**

    4.5**

    2.6*

    b)Turbinoplasty

    8**

    7.4**

    4.3**

    4**

    c)Turbinectomy

    5.4**

    5.9**

    8.1**

    8.8**

    symbol * and ** indicates significant values at p<0.05 and p<0.01

     

    MVV

    • Comparing MVV among patients undergoing septoplasty alone to those undergoing septoplasty+TRS .We can conclude that patients undergoing septoplasty alone had significant improvement of 9.14 and 9.94 at 1 and 3 months on DSS and but almost no improvement on THS with change of 0.07 and1.46 at 1 and 3 months.
    • Whereas patients undergoing TRS has significant improvement in FEV-3 on both DSS and THS, with change on DSS of 5.97 and 6.53 at 1 and 3 months respectively And 5.63 and5.13 on THS.
    • Among those undergoing TRS along with septoplasty change in MVV among different TRS on DSS was almost similar ranging from 5.1 to 7.4 at 1month and 3monthsrespectively.But on THS highest change was among those undergoing turbinectomy with changes of 8.1 and8.8 at 1 and 3months respectively.
    • Patients undergoing SMD+ septoplasty although had high change at 1month of 4.5,it detoriated over 3months to 2.6.

     

    Table 19: Comparison in Mean change in NOSE score with change in FEV-1

     

    Nose score

    Deviated septum side

    Fev-1

     

    Turbinate

    Hypertrophy side fev-1

    Procedure

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    1.Septoplasty

    39.33

    50.83

    0.57

    0.58

    -0.02

    0.09

    2.Turbinate reduction+septoplasty

    58.83

    61

    0.37

    0.39

    0.35

    0.3

    a)Submucosal diathermy+septoplasty

    55.5

    50.5

    0.32

    0.37

    0.30

    0.19

    b)Turbinoplasty +septoplasty

    54

    60.5

    0.43

    0.43

    0.27

    0.23

    c)Turbinectomy +septoplasty

    65.5

    71

    0.37

    0.38

    0.48

    0.48

    symbol * and ** indicates significant values at p<0.05 and p<0.01

    Table 20: Comparison in Mean change in NOSE score with change in FEV-3

     

    Nose score

    Deviated septum side

    Fev-3

    Turbinate

    Hypertrophy side fev-3

    Procedure

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    1.septoplasty

    39.33

    50.83

    0.57

    0.62

    -0.02

    0.11

    2.Turbinate reduction+septoplasty

    58.83

    61

    0.39

    0.41

    0.41

    0.38

    a)Submucosal diathermy+septoplasty

    55.5

    50.5

    0.36

    0.43

    0.33

    0.21

    b)Turbinoplasty +septoplasty

    54

    60.5

    0.46

    0.46

    0.27

    0.23

    c)Turbinectomy +septoplasty

    65.5

    71

    0.35

    0.35

    0.65

    0.72

    symbol * and ** indicates significant values at p<0.05 and p<0.01

     

    Table 21: Comparison in Mean change in NOSE score with change in FINFV

     

    Nose score

    Deviated septum side Finfv

    Turbinate

    Hypertrophy side –finfv

    Procedure

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    1.septoplasty

    39.33

    50.83

    0.47

    0.51

    0

    0.09

    2.Turbinate reduction+septoplasty

    58.83

    61

    0.25

    0.27

    0.25

    0.26

    a)Submucosal diathermy+septoplasty

    55.5

    50.5

    0.12

    0.15

    0.22

    0.22

    b)Turbinoplasty +septoplasty

    54

    60.5

    0.32

    0.33

    0.30

    0.30

    c)Turbinectomy +septoplasty

    65.5

    71

    0.35

    0.35

    0.22

    0.33

    symbol * and ** indicates significant values at p<0.05 and p<0.01

     

    Table 22: Comparison in Mean change in NOSE score with change in MVV

     

    Nose score

    Deviated septum side Mvv

    Turbinate

    Hypertrophy side mvv

    Procedure

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    Change

    1month

    Change

    3month

    1.Septoplasty

    39.33

    50.83

    9.14

    9.94

    0.07

    1.46

    2.Turbinate reduction+septoplasty

    58.83

    61

    5.97

    6.53

    5.63

    5.13

    a)Submucosal diathermy+septoplasty

    55.5

    50.5

    5.1

    5.7

    4.5

    2.6

    b)Turbinoplasty +septoplasty

    54

    60.5

    8

    7.4

    4.3

    4

    c)Turbinectomy +septoplasty

    65.5

    71

    5.4

    5.9

    8.1

    8.8

    symbol * and ** indicates significant values at p<0.05 and p<0.01\

    DISCUSSION

    Nasal obstruction is one of the most common complaints by patient which an otorhinolaryngologists encounters in day to day practice. It’s affecting 9.5-15% of general population1.Nasal septum deviation and associated turbinate hypertrophy is one of its most frequent causes. The present study was carried out to know whether septoplasty alone can treat nasal obstruction in patients with deviated nasal septum, to know whether hypertrophied turbinate needs to be addressed in patients with deviated nasal septum. And also to know the effectiveness of reduction of hypertrophied turbinate together with septoplasty for the treatment of nasal obstruction in patients with deviated nasal septum. In this study NOSE score was used for subjective evaluation and nasal spirometry for evaluating objectively. The present study showed highly significant result for post operative improvement for both septoplasty and septoplasty + turbinate reduction. According to NOSE score patients undergoing TRS with septoplasty has more symptomatic relief compared to those undergoing septoplasty alone. Patients undergoing septoplasty alone gradually shows symptomatic improvement over the period of 6months, whereas patient undergoing septoplasty with turbinate reduction definitely had overall greater improvement symptomatically compared to septoplasty alone, but their high post-op improvement remained static and does not improved over the period but at 6 month it was still significantly greater than septoplasty alone. The results of our study is concomitant with majority of studies which favours TRS in addition to septoplasty. The study by Devseren N, Ecevit MC, Erdag TK, Ceryan Kin 2010-11 on 42 patients with deviated septum and compensatory contralateral turbinate hypertrophy ,concluded that the subjective symptoms were better in patients undergoing TRS in addition to septoplasty, in this study acoustic rhinometry and rhinomanometry tests were conducted for an objective evaluation of nasal patencyanda visual analog scale (VAS) was applied for the subjective evaluation of nasal obstruction complaints8. In a study done by Jun BC J, Kim SW, Cho JH, Park YJ, Yoon HR in St.Mary’s hospital ,South Korea computed tomography of sinuses of 20 patients was done, the volume of the inferior turbinate was measured from the three-dimensional reconstruction, it was concluded that, the inferior turbinate on the concave side had a significantly greater volume and hence septoplasty and concomitant inferior turbinate surgery to manipulate conchal bone and soft tissues are necessary for treatment of those patients with unilateral nasal septal deviation and compensatory hypertrophy of the contralateral inferior turbinate9. In a study done by Gilead Berger, lan Hammel, Rachel Berger, Shabtai Avraham, Dov Ophir to know the histopathology of inferior turbinate with compensatory hypertrophy in patients with deviated nasal septum, it was found that , the inferior turbinate bone underwent a twofold increase in thickness, result supported the decision to excise inferior turbinate bone at time of septoplasty because of significant bony expansion and relative minor role of mucosal hypertrophy4. But in another study by P. Illum, No influence of turbinate surgery was detectable11.In a study done by Nunez DA, Bradely also showed Contralateral inferior turbinectomy does not add to the relief of nasal obstruction beyond that attained by septal surgery in these patients13. The study by Stewart et.al also has used NOSE score for subjective evaluation, as was used in our studyand they concluded, in patients with septal deformity, nasal septoplasty results in significant improvementin disease-specific quality of life, high patients satisfaction, and decreased medication use11. Similar to majority of above mentioned studies our study also conclude that TRS in addition to septoplasty offers greater symptomatic relief compared to those undergoing septoplasty alone. Other studies where no significant improvement was found when TRS was added to septoplasty are in favour of longer follow up. Similar to present study, according to Stewart et.al NOSE score can be used for subjective measurement of nasal obstruction, which can be used for pre to post operative improvement and also for comparison among different surgeries. In a study by Jones AS, Wight RG, Kabil Y, Buckingham E, It has been suggested that submucosal diathermy would not be effective in a group of patients developing hypertrophic rhinitis where the nasal submucosal is infiltrated with fibrous tissue rendering it incapable of decongestion .This may be due to fibrosis. In a study by J Richardson ,it was concluded that long standing swelling may become irreversible. This may be due to dilated submucosal venous sinuses becoming varicose and unresponsive to sympathetic nervous system stimulation or medical treatment7. In a study by Jones and Lancer showed that although submucosal diathermy provides good relief from nasal obstruction in the short term, but if patients who do not have concurrent medical treatment in most the inferior turbinates rehypertrophy within15 months and subjective obstruction returns14. In a study Wight, Jones and Clegg showed anterior trimming of the inferiorturbinate, whilst being an objective success in decreasing nasal resistance, frequently failed to produce a significant fall in subjective obstruction in the first 2 months15.In a study by Mabry in 1982,He found the major difference between total turbinectomy and inferior turbinoplasty was the flap of tissue left behind in the latter procedure to form a neoturbinate. He postulated the functional difference in the two procedures is explained by the presence of the inferior neoturbinate acting as a baffle to preserve a more normal airflow16. In a non-randomised trial of inferior turbinoplasty and septoplasty versus septoplasty alone Hilberg et al.found that two-thirds of patients who underwent contralateral turbinoplasty plus septoplasty reported satisfaction with the patency of the nasal cavity that had hadturbinate hypertrophy whereas none who underwent septoplasty alone reported satisfaction with the patency of this nasal cavity17. In Hooper RC study individuals with and without nasal symptoms underwent forced inspiratory nasal flow–volume (FINFV) curve measurements. Similar to this study FINFV was used as one of nasal spirometry parameter18. Moore M and Eccles R study reviews why there is no normal range of nasal patency available when assessing nasal obstruction and also the factors that influence nasal patency they concluded population is better defined with nasal anthropometric measures such as nasal index. In our present study also, we could not detrmined normal range of nasal spirometry parameters, as it varies on size of nasal cavity which is different for different individual and depends on age ,sex, height, weight, race. And to find out normal range we have to stratify into groups depending upon above factors and probably a larger sample size is required for significance19. In another study by Moore M. andEccles, they reviewed on the objective evidence for the efficacy of surgical management of the deviated septum. They concluded that septal surgery improves objective measures of nasal patency and that improved nasal airflow20. Fyrmpas G, Kyrmizakis D, Vital V and Constantinidis J studied the role of bilateral simultaneous nasal spirometry (BSNS) in the preoperative selection of patients for septoplasty. They concluded that, this test offers valuable information along with clinical assessment of the nasal airway in the preoperative assessment of candidates for septoplasty when other objective methods are not available21. In a study by Harar R, Kalan .A, Kenyon.G, the reproducibility of nasal spirometry was assessed, concluded that FEV1 as their derived variables of flow-volume loops can be used in the assessment of nasal patency. In our present study also FEV-1 was used as one of the nasal spirometry parameter22. Similar to our study the above mentioned studies shows that nasal spirometry can be used as effective ,simple tool for measuring nasal patency in patient with complaints of nasal obstructionand can be used for comparing results pre to post operative improvement and hence for comparing objective improvement among different types of surgery, finally to conclude which modality of surgery is better. In our study we concluded TRS when done in addition to septoplasty has better objective improvement as measured by nasal spirometry. The present study proved that although both groups of patient i.e those undergoing septoplasty alone and those undergoing TRS in addition to septoplasty had highly significant post –operative improvement. But those undergoing TRS had the best result, hence TRS should be done in addition to septoplasty and turbinectomy is the best modality among TRS. This study also showed the correlation between both symptomatic and objective improvement as assessed by NOSE score and nasal spirometry respectively. In a study by Fairley JW, Durham LH, Ell SR also showed subjective sensation of nasal patency is strongly correlated with objective nasal patency. The present study results are comparable to previously published data. However longer follow up, larger sample size can be considered for further studies.

     

    CONCLUSION

    The results of study showed that hypertrophied turbinate need to be addressed in chronic cases of nasal obstruction with deviated nasal septum and contralateral turbinate hypertrophy. And in these patient TRS should be done in addition to septoplasty.

    • Hypertrophied Turbinate reduction in addition to septoplasty are highly effective modality for the treatment of nasal obstruction in patients with deviated nasal septum.
    • Among turbinate reduction surgery turbinectomy is the best modality
    • Submucosal diathermy over longer period had least favourable outcome among turbinate reduction surgeries.
    • NOSE score can be used as a subjective tool for symptomatic measurement of patients with nasal obstruction
    • Nasal spirometry can be used for objective measurement of nasal patency.
    • There is correlation between subjective improvement and objective measurement of improvement nasal obstruction.

     

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