|Year : 2015 | Volume
| Issue : 4 | Page : 935-940
Endoscopic-aided septal surgery
Omar A Elbanhawy1, Yasser A Khalil1, Ibrahim A Abdelshafy1, Mohamed M Badr MSc 2
1 Otorhinolaryngology Department, Menoufia University Faculty of Medicine, Menoufia, Shebin Elkom, Egypt
2 Hearing and Speech Institute, Giza, Egypt
|Date of Submission||16-Sep-2014|
|Date of Acceptance||24-Dec-2014|
|Date of Web Publication||12-Jan-2016|
Mohamed M Badr
Otorhinolaryngology Department, Menoufia University Faculty of Medicine, Menoufia, Shebin Elkom, 11562
Source of Support: None, Conflict of Interest: None
This study was carried out to assess the role of the endoscope in septal surgery by comparing conventional and endoscopic-aided septal surgeries regarding the operative blood loss, the operative duration, operative complications and assessment of the airway postoperatively through an endoscope using subjective and objective criteria.
A deviated septum is one of the most common causes of nasal block. It also causes contact headache, epistaxis, infection of paranasal sinuses and middle-ear diseases due to eustachian tube blockage.
Materials and methods
This randomized prospective study was conducted among 60 patients with a symptomatic deviated nasal septum. All of the patients underwent nasal examination by anterior rhinoscopy and nasal endoscopy. Patients were divided randomly into two groups, A and B, with 30 cases in each group. Group A underwent endoscopic-aided septal surgery and group B underwent conventional septal surgery. The two groups were compared for the operative duration, the blood loss, postoperative assessment of the nasal airway endoscopically and complications either intraoperatively or postoperatively.
There were statistically significant differences between both groups regarding the operative duration, the blood loss, postoperative persistent posterior deviations, persistent spurs and persistant contact with turbinates in favour of endoscopic-aided septal surgery, wherein P values were 0.001, 0.001, 0,038, 0.020 and 0.011 consecutively.
Endoscopic-aided septal surgery is superior to conventional septal surgery in terms of less time consumption, less blood loss, correction of posterior deviations and spurs, less dissection and less intra- and postoperative complications, and it is also a valuable teaching tool.
Keywords: conventional septal surgery, deviated nasal septum, endoscopic-aided septal surgery
|How to cite this article:|
Elbanhawy OA, Khalil YA, Abdelshafy IA, Badr MM. Endoscopic-aided septal surgery. Menoufia Med J 2015;28:935-40
| Introduction|| |
Nasal obstruction is the most common complaint in rhinologic practice and a deviated nasal septum is the most common cause of nasal obstruction  . In addition to nasal obstruction, a significantly deviated nasal septum has been implicated in epistaxis, sinusitis, obstructive sleep apnoea and headaches, attributable to contact points with structures of the lateral nasal wall  . The progress of surgery on a deviated nasal septum witnessed significant advances from radical removal of the cartilage and the mucosa and radical removal of the cartilage only by submucous resection to the modern techniques of septoplasty  . Traditional headlight septoplasty is the technique of choice by most rhinologists around the world; however, in recent years, indications and advantages of the endoscopic approach have been advocated by many authors ,,, . An ideal surgical correction of the nasal septum should satisfy the following criteria: it should relieve the nasal obstruction, should be conservative, should not produce iatrogenic deformity, should not compromise the osteomeatal complex and must have the scope for a revision surgery, if required later. Traditional surgeries of the nasal septum improve the nasal airway, but do not fulfil the above-mentioned criteria in most instances  . Endoscopic septoplasty is an attractive alternative to traditional septoplasty, the primary advantage of which is the reduced morbidity and postoperative swelling in isolated septal deviations by limiting the dissection to the area of the deviation. In addition, endoscopic septoplasty provides improved visualization, particularly in posterior septal deformities, improved surgical transition between septoplasty and sinus surgery, preservation of the septum structure to provide adequate support of the nasal framework and to resist the effects of scarring. Moreover, it provides a significant clinical and an excellent teaching tool when used in conjunction with video monitors over traditional approaches  . It is an excellent tool for outpatient surveillance after septoplasty during the initial postoperative healing period and beyond  . Therefore, the aim of the present study was to assess the role of endoscopy in septal surgery by comparing endoscopic-aided and conventional septal surgeries using subjective and objective criteria and conclude whether there may be a specific indication for endoscopy in septal surgery.
| Materials and methods|| |
This study was conducted on patients complaining of nasal obstruction. Out of these patients, 60 patients were diagnosed to have septal deviations to a significant degree during the period from October 2012 to August 2013. They were divided randomly into groups A and B, with 30 cases in each group. Group A underwent endoscopic-aided septal surgery, whereas group B underwent conventional septal surgery. Inclusion criteria included patients with a symptomatic deviated nasal septum, whereas exclusion criteria included cases with allergic rhinitis, systemic diseases such as DM and hepatic diseases, cases with previous nasal surgeries and Patients with granulomatous diseases such as rhinoscleroma, etc.
All the 60 patients included in our study were subjected to history taking, full ENT examination including anterior rhinoscopy and nasal endoscopy, operative procedures (either endoscopic-aided or conventional septal surgeries), postoperative care and postoperative evaluation by endoscopy. The two groups were compared for the operative duration, the blood loss, postoperative assessment of the nasal airway endoscopically and complications (either intraoperatively or postoperatively). The study was approved by the ethical committee of the hospital and the patients gave informed consent.
The technique for endoscopic-aided septal surgery
The procedure was performed under general anaesthesia. Infiltration of the nasal septum was performed using 1 : 200 000 adrenaline in saline solution. In cases of a septal spur, we injected at the spur itself using a 0° 4-mm endoscope. A Killian incision was used ([Figure 1]) except in patients who had a broadly deviated septum or a septal spur. Mucoperichondrial flap elevation was performed with a Cottle or a suction elevator under direct visualization with the endoscope ([Figure 2]). The septal cartilage was then incised posterior to the mucosal incision, followed by contralateral mucoperichondrial flap elevation under endoscopic vision. The flap elevation is continued bilaterally until the complete extent of the septal deformity had been dissected. At this time, a pair of angled scissors were introduced and used to cut through the septal cartilage in a direction that was parallel to and at least 0.5 cm posterior to the nasal dorsum. We removed only the obstructing cartilage, leaving at least the caudal and the dorsal struts to maintain support of the nasal dorsum and the columella. The cartilage was removed with Luc's forceps or a Ballenger's swivel knife under endoscopic vision. We could also use punches or forceps; any deviated bone only in the vertical plate of the ethmoid was then removed with punches or forceps ([Figure 3]). If the maxillary crest was deviated, we elevated the flaps of the maxillary crest and vomer under endoscopic vision, and then removed it with a gouge and hammer. In cases of spur only, the incision was made directly over the spur, especially for posterior spurs. Exposure was carried out by elevating the flaps with the sharp end of a Cottle elevator superiorly and inferiorly. Then, the spur was removed either by a straight biting forceps or by an osteotome.
|Figure 2 Mucoperichondrial flap elevation with a Cottle or a suction elevator.|
Click here to view
|Figure 3 Removal of deviated bone in the vertical plate of the ethmoid with punches or forceps.|
Click here to view
At the end of the operation, we fixated the septum by absorbable trans-septal mattress sutures. Then, suturing the edges of the incision by 4-0 absorbable interrupted simple sutures was performed. Also, if there was any mucosal tear, it was sutured with 4-0 absorbable sutures. We restricted the septal splinting only to cases in whom a flap tear had occurred. Then, both nasal cavities were packed with vaseline or merocel packs. We used nearly the same technique for conventional septal surgery, but we used a headlight instead of an endoscope. The packs were removed after 24 h, and nasal splints, if used, were removed after 1 week; then, all patients were subjected to early evaluation after 1 week and delayed evaluation after 3 months postoperatively ([Figure 4], [Figure 5], [Figure 6], [Figure 7]).
|Figure 5 An endoscopic view after correction of the septal deviation by endoscopic septoplasty|
Click here to view
|Figure 7 The postoperative endoscopic view after correction by conventional septoplasty.|
Click here to view
Data were collected, tabulated, and statistically analysed using the mean, SD, and the χ2 -test was performed by statistical package for the social science program for windows, version 20 (SPSS Inc., Chicago, Illinois, USA). P values of less than 0.05 were considered statistically significant and values less than 0.01 were considered highly significant.
| Results|| |
In the present study, the demographic data are shown in [Table 1]. The duration of the operation was variable in group A from 20 min in isolated septal spur up to 50 min in broadly based deflection or more than one septal deformity with a mean of 39.75 ± 9.24 min, but in group B, it ranged from 35 to 65 min, with a mean of 52.25 ± 9.10 min. There was a highly significant difference between the two groups as the P value was 0.001. Blood loss during operation was variable in group A from 25 to 65 ml, with a mean of 41.50 ± 11.7 ml. In group B, it ranged from 45 to 90 ml, with a mean of 70.75 ± 15.06 ml. It was statistically a highly significant difference between the two groups as the P value was 0.001. The intraoperative flap tear was insignificantly less in group A compared with group B, with a P value of 0.136 ([Table 2]).
|Table 1 Age and sex distribution of the studied cases (demographic data) |
Click here to view
|Table 2 The operative duration, blood loss, nasal packing, the intraoperative flap tear and septal splinting |
Click here to view
Early postoperative complications (epistaxis, synechiae, mild pain and discomfort, bad odour, septal haematoma and perforation) were insignificantly lesser in group A than in group B ([Table 3]), where P values were 0.166, 0.228, 0.166, 0.228, 0.313 and 0.313 consecutively.
Nasal endoscopic findings at the last available follow-up after 3 months showed that Posterior deviation, spur, and persistent contact with turbinates were significantly higher in group B than in group A as P values were 0.038, 0.020, and 0.011 consecutively. Also, synechiae, perforation and crustations were higher in group B than in group A, but the P value was insignificant as it was 0.157, 0.313, and 0.389 consecutively ([Table 4]).
|Table 4 Nasal endoscopic findings at the last available follow-up after 6 months |
Click here to view
| Discussion|| |
In our study, we did not find any significant difference in the preoperative results between both groups regarding age, sex and types of septal deformities, indicating that any expected difference between the postoperative results of both groups was not dependent on these factors.
Cantrell  reported that the average time of limited endoscopic septoplasty was 12 min. Comparatively, the time required for a classic Cottle septoplasty was nearly three-folds at 35 min in the same report. In our study, the operative duration and the blood loss were highly significantly lesser in endoscopic group than in the conventional group, as we subtracted the time consumed for intermittent cleaning of the endoscopic tip. Endoscopic septal surgery consumed 20 min in isolated septal spur and up to 50 min in broadly based deflection or more than one septal deformity. However, in conventional septal surgery, it ranged from 35 to 65 min. We found that the amount of blood loss ranged from 25 to 65 ml in group A whereas it ranged from 45 to 90 ml in group B. Regarding intraoperative flap tear, we encountered five cases (16.7%) in group A. However, this complication occurred in 10 cases (33.3%) in group B, and this was an insignificant difference. Our study concurs with the study by Kaushik et al.  , as they reported an intraoperative flap tear in three cases (10%) in the conventional group and in two cases (6.67%) in the endoscopic group. However, this difference was statistically insignificant. Suligavi et al.  found that the flap tear represents a significant difference between the endoscopic and the conventional groups as they reported a flap tear in 18 (36%) out of 50 cases in the conventional group and in 10 (20%) out of 50 cases in the endoscopic group. Concerning early postoperative complications, our study showed better results and lesser complications in the endoscopic group as compared with the conventional group, as endoscopy gave better illumination and improved the access to high DNS, allowed limited incision, limited flap elevation and achieved correction with least resection. This technique causes lesser trauma to the septum, thus reducing postoperative complications. We agree with the study by Kaushik et al.  In that study, early postoperative complications were insignificantly less in the endoscopic group than in the conventional group. However, Suligavi et al.  reported that early complications had a significant P value in favour of the endoscopic group. Sousa et al.  reported that out of 2730 power-assisted endoscopic septoplasties, complication rates over a short period of 3-6 weeks were as follows: septal haematoma in 1.8%, septal perforation in 0.7%, slight postoperative deviation in 1.8% and severe deviation in 0.8%. There were no accounts of postoperative haemorrhage or infection. Hwang et al.  in their retrospective study of 111 patients who underwent endoscopic septoplasty reported haematoma in 0.9%, asymptomatic perforation in 0.9% and synechiae formation in 4.5% of the patients. In a retrospective study on 116 patients, Chung et al.  described transient dental pain/hyperaesthesia in 4.3%, asymptomatic septal perforation in 3.4%, synechiae formation in 2.6%, epistaxis 0.9%, septal haematoma in 0.9% and persistent septal deviation requiring revision septoplasty in 0.9% of the patients. These rates were similar to those reported in the literature for traditional headlight septoplasty.
Our postoperative results after 3 months in both groups objectively through an endoscope showed significant differences concerning posterior deviations, spurs and persistent contact with turbinates. As with endoscopy, we can reach remote areas with good illumination, magnification and improved accessibility. Jain et al.  , after objective assessment at the last follow-up, showed that in the conventional group, persistent posterior deviations were present in 12 patients (23%), persistent anterior deviations were present in seven patients (13%), persistent spur was found in seven patients (13%), synechiae was present in 10 patients (20%) and persistent contact with turbinates was found in 19 patients (37%). However, in the endoscopic group, persistent posterior deviations were present in two patients (3%), persistent anterior deviation was present in five patients (10%) and persistent contact with turbinates was found in 10 patients (20%). However, neither spurs nor synechiae were present in this group. We agree with this study regarding posterior deviations and persistent spurs, as it represented statistically significant differences between the two groups. However, persistent contact with middle turbinates was of insignificant P value.
Our results coincide with that concluded by Nayak et al.  concerning the postoperative incidence of persistent deviation, and contact areas were much lower after endoscopic correction compared with that after traditional septal surgery. They found that in the endoscopic group, persistent posterior deviation was present in only one patient (3%), persistent anterior deviations were present in three cases (10%), but neither persistent spurs nor persistent contact with turbinates had been reported. However, in group B, they found seven patients (23%) with persistent posterior deviations, four patients (13%) with persistent spurs, four patients (13%) with persistent anterior deviation and six patients (20%) with persistent contact with turbinates, and the differences, except for persistent anterior deviations, represented significant P values. However, Kaushik et al.  reported more improvement in the endoscopic group concerning posterior deviations and spurs as compared with the conventional group although their results were statistically insignificant. Hence, endoscopic-aided septal surgery is superior to the conventional method as it facilitates accurate identification of the pathology. Also, it allows better visualization and accessibility to posterior deviations and spurs, it is more effective in preventing contact between the septum and the turbinate, it limits the dissecting area, it is an effective teaching tool and helps in the documentation of cases. However, there are some limitations with the use of nasal endoscopy, which include the loss of binocular vision, the inability of the surgeon to operate bimanually and the proximity of the nasal endoscope to the surgical field, which results in frequent tip soiling and the need for intermittent cleaning of the endoscope tip.
| Conclusion|| |
Endoscopic-aided septal surgery is superior to the traditional method in the correction of posterior deviations and septal spurs; it consumes a shorter time than the conventional method, involves less blood loss, prevents contact between the septum and turbinates, and has a lower incidence of complications, and it is also a valuable teaching tool.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Jain L, Jain M, Chouhan AN, Harshwardhan R. Conventional septoplasty verses endoscopic septoplasty: a comparative study. People J Sci Res 2011; 4
Pannu KK, Chadha S, Kaur IP. Evaluation of benefits of nasal septal surgery on nasal symptoms and general health. Indian J Otolaryngol Head Neck Surg 2009; 61
Al-Shehri AM, Amin HM, Necklawy A. Retrospective study of endoscopic nasal septoplasty. Biomed Res 2013; 24
Sousa Ad, Iniciarte L, Levine H. Powered endoscopic nasal septal surgery. Acta Med Port 2005; 18
Raynor EM. Powered endoscopic septoplasty for septal deviation and isolated spurs. Arch Facial Plast Surg 2005; 7
Kaushik S, Vashistha S, Jain NK. Endoscopic vs conventional septoplasty: a comparative study. Clin Rhinol Int J 2013; 6
Nayak DR, Balakrishnan R, Murty K D, Hazarika P. Endoscopic septoturbinoplasty: our update series. Indian J Otolaryngol Head Neck Surg 2002; 54
Sautter NB, Smith TL. Endoscopic septoplasty. Otolaryngol Clin North Am 2009; 42
Cantrell H. Limited septoplasty for endoscopic sinus surgery. Otolaryngol Head Neck Surg 1997; 116
Suligavi SS, Darade MK, Guttigoli BD. Endoscopic septoplasty: advantages and disadvantages. Clin Rhinol Int J 2010; 3
Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW. Endoscopic septoplasty: indications, technique, and results. Otolaryngol Head Neck Surg 1999; 120
Chung BJ, Batra PS, Citardi MJ, Lanza DC. Endoscopic septoplasty: revisitation of the technique, indications, and outcomes. Am J Rhinol 2007; 21
Nayak DR, Balakrishnan R, Murthy KD. An endoscopic approach to the deviated nasal septum - a preliminary study. J Laryngol Otol 1998; 112
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4]