Yasser Haroun Mohamed Abo

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Yasser Haroun Mohamed Abo
Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-012-2304-0
RHINOLOGY
Nasal soft tissue obstruction improvement after septoplasty
without turbinectomy
Yasser Haroon • Hala Aly Saleh • Ahmed H. Abou-Issa
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increase reaching a peak at the 12th month. Preoperative
CT confirmed the presence of hypertrophied mucosa on the
concave septal side with significantly thicker medial and
non-significantly thicker lateral mucosa on the concave
side compared to the convex side. At the 12th month PO,
mean medial mucosal thickness significantly decreased on
the concave side with significant increase on the convex
side, but the effect was significantly pronounced on the
concave side. Mean lateral mucosal thickness was significantly decreased on the concave and non-significantly
increased on the convex side. Conchal bone thickness
showed non-significant change despite the diminution on
both sides In the absence of allergic rhinitis, septoplasty
without turbinectomy significantly improves nasal
obstruction-related manifestations and approaches high
patient satisfaction with associated reduction of hypertrophied mucosa and spares turbinectomy-related complications.
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Abstract The objective of the study was to evaluate the
outcome of septoplasty without inferior turbinectomy in
patients with septum deviation and nasal obstruction. After
exclusion of allergic rhinitis, this study included 30 patients
with deviated nasal septum and hypertrophied inferior
nasal turbinate who were prepared for septoplasty without
turbinectomy. After full history taking and complete
otorhinological examination, all patients graded their
extent of obstruction using the Nasal Obstruction Symptoms Evaluation scale and underwent CT scans to evaluate
the side and shape of deviation, thickness of the medial and
lateral mucosa and inferior conchal bone on both the
concave and convex sides. Postoperative (PO) follow-up
consisted of evaluation of surgical outcome, nasal
obstruction grading and patient’s satisfaction. CT imaging
was repeated for evaluation of the previous items and to
compare with preoperative data. All surgeries were conducted smoothly without intraoperative complications and
all were managed as day surgery. The mean duration of
follow-up was 20.1 ± 4.4 months. All patients showed
progressive significant decline of nasal obstruction symptoms and only eight patients still had mild symptoms.
Patients’ satisfaction scores showed significant progressive
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Received: 29 June 2012 / Accepted: 22 November 2012
Ó Springer-Verlag Berlin Heidelberg 2013
Keywords Septoplasty Turbinectomy CT Mucosal thickness
Introduction
Y. Haroon (&)
Otorhinolaryngology Department Faculty of Medicine,
Benha University, Kaliobeya, Egypt
e-mail: [email protected]
H. A. Saleh
Medical Imaging Department, Zagazig University,
Zagazig, Egypt
A. H. Abou-Issa
Medical Imaging Department, Mansoura University,
Mansoura, Egypt
Breathing well is a condition directly related to quality of
life. A good breathing demands good permeability of the
nasal airways, the physiological entry door of airflow.
Chronic nasal obstruction is a symptom responsible for
most patients’ visit to otorhinolaryngologists in their daily
practice [1].
Nasal turbinates are arch-like bony structures that lay
anteroposteriorly in the nasal cavities, having a border
attached to the lateral nasal wall and a free medial ledge.
The inferior turbinate, being larger and the one more easily
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Eur Arch Otorhinolaryngol
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Patients and methods
The present prospective study was conducted at the Otorhinolaryngology Department, Benha University Hospital
through the period from November 2007 to November
2009 to allow a minimum follow-up period of 12 months
for the last case operated upon. After approval of the study
protocol by the local ethical committee and obtaining fully
informed written patients’ consent, the study was assigned
to include 30 patients with deviated nasal septum with
hypertrophied inferior nasal turbinate and prepared for
septoplasty without turbinectomy. Patients with allergic
rhinitis were excluded.
After full history taking and complete otorhinological
examination which was performed on different occasions to
confirm the persistent nature of nasal obstruction, all patients
graded their extent of obstruction using the Nasal Obstruction Symptoms Evaluation scale 6. It evaluates obstruction,
nasal discharge and headache; each symptom was evaluated
using a 4-point grading scale (Table 1) and a collective score
was determined. Also, patients were asked to comment on
their maintenance local therapy. All patients underwent CT
scans for evaluation of nasal obstruction.
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Before decongestion with 0.05 oxymetazoline, coronal
CT slices for paranasal sinuses were obtained using either
primary coronal acquisition (patient prone with hyperextended neck) or reconstructed images (patient supine with
neutral neck position using isotropic capability of multislice CT to reconstruct the coronal images). The inferior
turbinate was divided into three portions: anterior, middle
and posterior thirds, by dividing the number of slices
showing the whole length of turbinate by three (if it
appears on 18 coronal slices, then every third has 6 slices).
The thickest site in each third is selected to measure the
thickness of the bone, and medial and lateral mucosa. This
process was repeated on the side of deviation (Fig. 1).
All surgeries were conducted under general inhalational
anesthesia using cuffed endotracheal tube for prevention of
aspiration. Prophylactic broad-spectrum antibiotic was
given intravenously prior to induction of anesthesia. A cotton pledge soaked with adrenaline 1:100,000 was placed in
both nostrils to induce mucosal shrinkage and vasoconstriction. The septum was exposed from one side only;
exposure occurred through a unilateral traditional hemitransfixion incision. Submucoperiochondrial and submucoperiosteal flaps were elevated by dissection around the
anterocaudal septum to fully expose the deviated segments
of cartilage and bone [7]. If the anterior nasal spine of the
maxilla or maxillary crest is deviated, it must be fractured
and repositioned in the midline before cutting the lower
border of septal cartilage to assess the actual length needed
for septoplasty. The lower border of the cartilage is dislocated from its osseous groove. If the bony septum is deviated, a vertical incision is made through the posterior end of
the septal cartilage, and the mucosal flap in the opposite side
of the bony part is dissected and elevated. The posterior part
can now be removed or fractured and repositioned in the
midline. If there is angulation of cartilage, a narrow strip of
cartilage is removed along the line of deviation and repositioned in the midline. If the septal lesion is severe and needs
supporting cartilage or bone, a free bone graft from the
perpendicular plate of the ethmoid or vomer is used to fill the
defect. If the septum still deviates after the procedure,
multiple incisions in the cartilage are made followed by
sutures in a figure of 8. At the end, dressing was put into the
nose to bring the mucosa together.
Postoperative follow-up consisted of evaluation of surgical outcome and patients were asked to re-grade their
sense of obstruction and the need of local medications and
to grade their satisfaction using a numerical scale of
5 = completely relieved and highly satisfied, 4 = highly
satisfied, 3 = satisfied, 2 = acceptable outcome, 1 = poor
outcome and 0 = sense of no change. Clinical follow-up
was conducted 3 monthly for at least 12 months and CT
imaging was repeated for evaluation of the previous items
and comparing it versus preoperative data.
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seen, has its own bone, called inferior nasal concha,
anchored to the maxilla, lacrimal, ethmoid and palatine
bones. This turbinate tail has a posterior boneless protuberance that bulges into the choana and is formed almost
exclusively by vascular erectile tissue, which is usually
hypertrophic in nasal diseases [2].
The nasal lateral wall, formed by the turbinates and the
meatus, has a rather important role in nasal physiology as
far as balancing temperature, moisture and also filtering of
suspended particles present in inhaled air are concerned.
Diseases that cause chronic nasal obstruction basically
involve the lateral wall of the nasal cavity, causing changes
to both the mucosa and the submucosa of the nasal turbinates [3].
As much as 75–80 % of the general population is estimated to exhibit some type of anatomical deformity of the
nose, most commonly a deviated nasal septum. This
deviation is often associated with overgrowth of the inferior turbinate, which occupies much of the contralateral
nasal cavity. Accordingly, turbinate surgery is routinely
performed in conjunction with septoplasty in patients with
nasal obstruction and septum deviation. However, the
indications for turbinate surgery are not well defined, and
surgical techniques vary substantially among rhinologic
surgeons [4, 5].
The present study aimed to evaluate the outcome of
septoplasty without inferior turbinectomy in patients with
non-allergic nasal obstruction and septum deviation.
Eur Arch Otorhinolaryngol
Table 1 Nasal Obstruction
Symptoms Evaluation scale [6]
Score
Obstruction
Nasal discharge
Headache
0
No
No
No
1
Mild (causing no disturbance in
patient’s daily life)
Mild (1–4 nose
blowing/day)
Mild (not requiring analgesia for
headache relief)
2
Moderate (forcing the patient to
breathe through the mouth)
Moderate (5–10
nose blowing/day)
Moderate (requiring non-narcotic
analgesics for headache relief)
3
Severe (causing sleep disturbances
and decrease in voice quality)
Severe (continuous
nasal discharge)
Severe (requiring narcotic
analgesics for headache relief)
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Fig. 1 Coronal CT scan shows
measurement of conchal bone,
(a) medial and lateral mucosal
thickness (b, c) of the inferior
turbinate
Statistical analysis
Table 2 Enrollment data of 30 patients included in this study
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Age (years)
Results
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Results were expressed as mean ± SD, range, numbers and
percentages. Results were analyzed using paired t test.
Statistical analysis was conducted using SPSS statistical
program (Version 10, 2002). p value \ 0.05 was considered to be statistically significant.
The study included 30 patients: 21 males and 9 females
with an age range of 23–45 years. 17 patients had left
deviated septum and 13 patients had right deviated septum.
All enrolled patients had C-shaped septum, so as to
equalize the sides for comparisons. All patients were on
medical treatment, but with unsatisfactory obstruction
relief (Table 2).
All surgeries were conducted smoothly without intraoperative complications and with minimal acceptable
bleeding, and all were managed as day surgery and
returned home on the first postoperative day.
The mean duration of follow-up was 20.1 ± 4.4; range
12–29 months. At the end of the 12 months follow-up
period, all patients showed progressive significant decline
of nasal obstruction symptoms (Fig. 2) and only eight
patients still had mild obstruction symptoms, but all
became independent on medical treatment. In parallel, the
extent of patients’ satisfaction scores showed significant
B30
[30–40
[40
5 (16.7 %)
23 (76.6 %)
2 (6.7 %)
Gender
Males
Females
21 (70 %)
9 (30 %)
Side of deviation
Left
17 (56.6 %)
Right
13 (43.4 %)
Data are presented as mean ± SD and numbers; ranges and percentages are in parenthesis
progressive increase reaching a peak at the 12th month visit
(Table 3, Fig. 3).
Preoperative evaluation of CT images confirmed the
presence of hypertrophied mucosa on the concave side of
the septum manifested as significantly (p = 0.009) thicker
medial and non-significantly (p [ 0.05) thicker lateral
mucosa on the concave side compared to the convex side.
At 12-m PO, mean mucosal thickness significantly
decreased on the concave side (p = 0.001) with compensatory significant (p = 0.003) increase on the convex side,
but the effect was significantly (p = 0.003) pronounced on
the concave side (Fig. 4). As regards the lateral mucosa, at
12-m PO, mean mucosal thickness was significantly
(p = 0.01) decreased on the concave side with non-
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Eur Arch Otorhinolaryngol
significantly increased lateral mucosal thickness on the
convex side and so with significant (p = 0.008) change on
the concave side. On the contrary, conchal bone thickness
showed non-significant change despite the diminution on
both sides (Table 4, Figs. 5, 6).
Discussion
Preoperative evaluation of CT images confirmed the presence of hypertrophied mucosa on the concave side of the
septum manifested as significantly thicker medial and nonsignificantly thicker lateral mucosa with non-significantly
thicker conchal bone on the concave side compared to the
convex side. These findings indicated mucosal hypertrophy
of the contralateral mucosa and/or diminution of thickness
of the mucosa on the deviated side, while the changes in
the bony turbinate was non-significant. These data support
the hypothesis of pathogenesis of hypertrophied inferior
turbinate in association with deviated septum as compensation to deflection of the nasal septum, because the
hypertrophy protects the more patent passage from excess
airflow which has drying and crusting effects on the nasal
mucous membranes [8–10].
As a further support of this assumption, the current study
based on septoplasty without inferior turbinectomy
5
3.5
4
2.5
3.5
Score
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Score
3
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4.5
3
2
1.5
2.5
2
1.5
1
0
Pre op
3-m
6-m
9-m
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1
0.5
12-m
Table 3 Mean sense of
obstruction and satisfaction
scores recorded throughout the
study duration
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Fig. 2 Time course change of the extent of nasal obstruction
0.5
0
3-m
6-m
9-m
12-m
Fig. 3 Time course satisfaction scores
Baseline
3-m PO
6-m PO
9-m PO
12-m PO
Sense of obstruction score
4.8 ± 0.8
3.6 ± 1.3
2.4 ± 1.7
0.7 ± 1.2
t
6 ± 1.1
5.809
13.293
15.375
17.710
p1
\0.001
\0.001
\0.001
\0.001
t
13.676
15.052
18.137
p2
\0.001
\0.001
\0.001
t
7.077
10.792
p3
\0.001
\0.001
t
5.757
p4
\0.001
Satisfaction score
2.6 ± 0.7
Data are presented as
mean ± SD. PO postoperative,
p1 significance versus baseline
p2 significance versus 3-m PO,
p3 significance versus 6 m, p4
significance versus 9 m
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t
p2
3.3 ± 0.7
3.9 ± 0.6
4.6 ± 0.5
5.460
7.779
12.577
\0.001
\0.001
\0.001
t
7.871
11.948
p3
\0.001
\0.001
t
6.433
p4
\0.001
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Fig. 4 Preoperative (left) and
postoperative (right) CT images
of nasal septum and turbinate in
five different patients.
Preoperative images show
deviated nasal septum with
hypertrophied inferior turbinate
on the concave side. 12-month
postoperative images show
corrected nasal septum with
widening of nearly equal nasal
air columns and diminution of
the inferior turbinate size on the
concave side and slightly
increased inferior turbinate size
on the convex side
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Eur Arch Otorhinolaryngol
4.4
Table 4 Mean thickness (in mm) of the medial and lateral mucosa
and conchal bone before and after septoplasty
Lateral
mucosa
Conchal
bone
Concave side
Baseline
4.6 ± 0.77
2.52 ± 0.56
2.88 ± 0.25
12-m PO
Statistical analysis
2.93 ± 0.98
2.74 ± 0.59
2.86 ± 0.32
t
6.906
2.770
0.412
p1
=0.001
=0.01
[0.05
3.4
3.2
3
2.8
2.6
2.4
2.2
2
2.3 ± 0.42
2.95 ± 0.3
12-m PO
4 ± 0.83
2.38 ± 0.43
2.83 ± 0.38
Statistical analysis
t
5.385
0.975
1.078
p1
=0.003
[0.05
[0.05
t
4.387
1.828
1.064
p2
=0.009
[0.05
[0.05
t
5.406
4.395
0.752
p3
=0.003
=0.008
[0.05
Data are presented as mean ± SD
5
Medial
Lateral
4.7
4.4
3.8
3.5
3.2
2.9
2.6
2.3
2
Pre
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4.1
Conchal
PO
Fig. 5 Changes in thickness of the concave side medial and lateral
mucosa and conchal bone before and after septoplasty
recorded significant diminution of mucosal thickness on
the concave side and increased mucosal thickness on the
convex side at 12 months after surgery. These data indicated that the deviation correction allowed normal bilateral
airflow, so there was no need for the compensation of the
other nostril. Subsequently, the associated mucosal hypertrophy became non-sense and so started to withdraw.
Moreover, septoplasty allowed the release of mucosal
blood supply on the convex side with subsequent development and increased thickness of the mucosa.
PO
Fig. 6 Changes in thickness of the convex side medial and lateral
mucosa and conchal bone before and after septoplasty
The reported significant decrease of medial mucosal
thickness on the concave side is in accordance with Berger
et al. [11], who analyzed the quantitative and qualitative
characteristics of the hypertrophic inferior turbinate histopathologically and reported that the hypertrophic inferior
turbinate was significantly wider and the medial mucosal
layer was significantly thickened and made the greatest
contribution to the total increase in the width of the inferior
turbinate, while the enlargement in width of the lateral
mucosal layer was of borderline statistical significance.
Furthermore, the current study reported non-significant
conchal bone change which also supported the mucosal
hypertrophy assumption as an etiological base for inferior
turbinate hypertrophy and refuted the assumption concerning primary unilateral growth of the turbinate bone,
which can be genetic or caused by trauma in early life [12,
13].
In accordance with the obtained results, Kim et al. [14]
measured the effect of septoplasty on the volume of inferior turbinate in patients with a deviated nasal septum and
found inferior turbinate hypertrophy, especially in the
medial mucosa, may reverse after septoplasty. Lindemann
et al. [15] tried to determine the early effect of septoplasty
with or without bilateral turbinoplasty on intranasal heating
and humidification and reported that patients seemed to
overall benefit from nasal surgery, with or without preserving bilateral turbinoplasty, because intranasal air conditioning was improved after surgery.
At the end of a mean duration of follow-up of 20.1
(12–29) months, all patients showed a progressive significant decline of the sense of obstruction and in parallel the
extent of patients’ satisfaction scores showed significant
progressive increase. These findings illustrated the successful outcome of septoplasty without turbinectomy on
both short and long terms. These data were superior to that
reported by Bandos et al. [16] who evaluated the clinical
and histological results obtained after partial inferior
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PO postoperative, p1 significance versus baseline, p2 significance
versus baseline on concave side, p3 significance versus 12-m PO on
the concave side
Pre
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3.5 ± 1.1
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Baseline
(mm)
Conchal
3.6
Convex side
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Lateral
3.8
(mm)
Medial
mucosa
Medial
4.2
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2. Lee HY, Kim CH, Kim JY, Kim JK, Song MH, Yang HJ, Kim
KS, Chung IH, Lee JG, Yoon JH (2006) Surgical anatomy of the
middle turbinate. Clin Anat 19(6):493–496
3. Farmer SE, Eccles R (2006) Chronic inferior turbinate enlargement and the implications for surgical intervention. Rhinology.
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4. Mlynski G (2006) Surgery of the nasal septum. Facial Plast Surg
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5. Miles BA, Petrisor D, Kao H, Finn RA, Throckmorton GS (2007)
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specimens. Otolaryngol Head Neck Surg 136(3):362–368
6. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B,
Hannley MT (2004) Development and validation of the Nasal
Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol
Head Neck Surg 130(2):157–163
7. Van Olphen AF (1998) The Septum. Laryngoscope 108(7):
1025–1032
8. Berger G, Hammel I, Berger R, Avraham S, Ophir D (2000)
Histopathology of the inferior turbinate with compensatory
hypertrophy in patients with deviated nasal septum. Laryngoscope 110(12):2100–2105
9. Uzun L, Savranlar A, Beder LB (2004) Enlargement of the bone
component in different parts of compensatory hypertrophied
inferior turbinate. Am J Rhinol. 18(6):405–410
10. Lindemann J, Tsakiropoulou E, Vital V, Keck T, Leiacker R,
Pauls S, Wacke F, Wiesmiller KM (2009) Influence of the turbinate volumes as measured by magnetic resonance imaging on
nasal air conditioning. Am J Rhinol Allergy. 23(3):250–254
11. Berger G, Gass S, Ophir D (2006) The histopathology of the
hypertrophic inferior turbinate. Arch Otolaryngol Head Neck
Surg 132(6):588–594
12. Gray LP (1978) Deviated nasal septum: incidence and etiology.
Ann Otol Rhinol Laryngol Suppl 87(3, pt 3) (suppl 50):3–20
13. Eccles R (2007) Query, concerning mechanism of inferior turbinate enlargement. Arch Otolaryngol Head Neck Surg 133(6):
624–625
14. Kim DH, Park HY, Kim HS, Kang SO, Park JS, Han NS, Kim HJ
(2008) Effect of septoplasty on inferior turbinate hypertrophy.
Arch Otolaryngol Head Neck Surg 134(4):419–423
15. Lindemann J, Keck T, Leiacker R, Dzida R, Wiesmiller K (2008)
Early influence of bilateral turbinoplasty combined with septoplasty on intranasal air conditioning. Am J Rhinol. 22(5):542–545
16. Bandos RD (2006) Rodrigues de Mello V, Ferreira MD, Rossato
M, Anselmo-Lima WT: Clinical and ultrastructural study after
partial inferior turbinectomy. Braz J Otorhinolaryngol 72(5):
609–616
17. Li HY, Lin Y, Chen NH, Lee LA, Fang TJ, Wang PC (2008)
Improvement in quality of life after nasal surgery alone for
patients with obstructive sleep apnea and nasal obstruction. Arch
Otolaryngol Head Neck Surg 134(4):429–433
18. Dursun E, Battal B (2009) Clinical outcomes of nasal septal
surgery at high altitude. Eur Arch Otorhinolaryngol
266(10):1579–1581
19. Bulcun E, Kazkayasi M, Ekici MA, Tahran FD, Ekici M (2010)
Effects of septoplasty on pulmonary function tests in patients
with nasal septal deviation. J Otolaryngol Head Neck Surg
39(2):196–202
20. Baumann I (2010) Quality of life before and after septoplasty and
rhinoplasty. Laryngorhinootologie 89(Suppl 1):S35–S45
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turbinectomy for the treatment of chronic nasal obstruction
and reported that clinical results proved to be satisfactory
for the relief of nasal obstruction on short-term follow-up
for 8–12 months, but unsatisfactory after long-term followup for more than 24 month. They concluded that surgery
proved to be effective on a short-term but not on a longterm basis, and histological recovery did not accompany
improvement of clinical signs and symptoms.
The improved nasal obstruction scores and thus patients’
satisfaction were in line with results obtained even in more
complicated cases. Li et al. [17] evaluated the impact of
nasal surgery alone on the quality of life in patients with
obstructive sleep apnea and nasal obstruction and reported
significantly improved nasal obstruction symptoms with
concomitant significant improvement in the Snore Outcomes Survey and Epworth Sleepiness Scale scores. Dursun and Battal [18] reported improvement and of nasal
obstruction in 79.6 % and no change was seen in 20.4 % of
the patients after septoplasty in patients with nasal
obstruction and living in high altitudes. Bulcun et al. [19]
investigated the effects of septoplasty on pulmonary
function tests and bronchial hyper-responsiveness in
patients who had no previous pulmonary diseases and
reported an improvement in both nasal symptoms and
pulmonary function tests values after surgical treatment for
nasal septal deviation. They concluded that septoplasty
may be considered as having favorable effects on bronchial
hyper-responsiveness. Also, Baumann [20] reported that
most of the septoplasty patients evaluated the operation as
being successful with regard to quality of life improvement.
It could be concluded that in the absence of allergic
rhinitis; septoplasty without inferior turbinectomy significantly improves nasal obstruction-related manifestations
and approaches high patient satisfaction with associated
reduction of hypertrophied mucosa and spares turbinectomy-related complications. However, wider-scale studies
with longer follow-up duration are mandatory for establishment of the obtained results.
References
1. Rozsasi A, Leiacker R, Knemann S, Lindemann J, Kappe T,
Rettinger G, Keck T (2007) The impact of septorhinoplasty and
anterior turbinoplasty on nasal conditioning. Am J Rhinol
21(3):302–306
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