J Cosmet Med 2022; 6(2): 72-77
Published online December 31, 2022
Yeong Joon Kim, MD1 , Chang Hoi Kim, MD2 , Jooyeon Kim, MD, PhD1 , Gilsoon Choi, MD, PhD3 , Yeong Wook Jeong, MD1 , Jaehwan Kwon, MD, PhD1
1Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, Rep. of Korea, 2Department of Otolaryngology-Head and Neck Surgery, Dongguk University Gyeongju Hospital, Gyeongju, Rep. of Korea, 3Department of Internal Medicine, Kosin University College of Medicine, Busan, Rep. of Korea
Correspondence to :
Jaehwan Kwon
E-mail: entkwon@hanmail.net
© Korean Society of Korean Cosmetic Surgery & Medicine
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Data on structural modifications caused by septal deviation may help otolaryngologists make informed decisions on the inclusion of turbinate surgery with septoplasty as well as identify the part of the inferior turbinate that requires more attention during surgery.
Objective: This study aimed to compare the dimensions of the ipsilateral and contralateral sides of the inferior turbinate and the septal deviation in a Korean population.
Methods: We retrospectively analyzed the facial computed tomography (CT) scans of 111 patients who underwent septoplasty between January 2012 and December 2017 for the anterior, posterior, and maximally deviated sites of the inferior turbinate.
Results: Statistical analyses revealed differences in the medial mucosa and the total thickness of the anterior and maximally deviated sites between the ipsilateral and contralateral sides. The medial mucosal portion of the anterior site was 4.64±2.12 mm on the contralateral side and 4.14±1.75 mm on the ipsilateral side (p=0.03). The total thickness of the anterior site was 9.72±4.25 mm on the contralateral side and 8.58±3.36 mm on the ipsilateral side (p=0.02). The medial mucosal portion of the maximally deviated site was 5.09±2.52 mm on the contralateral side and 4.39±2.05 mm on the ipsilateral side (p=0.04). The total thickness of the maximally deviated site was 9.58±4.06 mm on the contralateral side and 8.81±3.50 mm on the ipsilateral side (p=0.04). No significant differences were found in the measurements between the two sides of the posterior site or in the bone thickness at any of the sites. The inferior turbinate did not show any significant relationship with the deviation angle.
Conclusion: A conservative submucosal turbinoplasty without bone removal may be favorable.
Level of Evidence: Level IV
Keywords: nasal cavity, nasal septum, turbinates
The septum of the nasal cavity is a major structure located centrally in the nose, comprising cartilage in the anterior part and bone in the posterior part [1]. The anatomical and morphological features of the bony and cartilaginous parts of the septum play a significant role in structural support and breathing [2]. Owing to its importance in respiration, structural abnormalities of the nasal septum could cause nasal symptoms like repetitive sneezing, epistaxis, sleep apnea, sinusitis, and breathing difficulty [3]. Some studies consider septal deviation to be associated with olfaction, and structural abnormalities may affect the growth of the nasal bone and alter the facial morphology [4]. The inferior turbinate is the most vulnerable to hypertrophic change among the three turbinates [1]. Variable degrees of inferior turbinate hypertrophy as a consequence of septal deviation is common findings in patients with septal deviation [1,5]. Both mucosal and bony hypertrophy in the deviated nasal septum have been associated with compensatory inferior turbinate hypertrophy [6,7]. It was also reported that a positive correlation was shown between the deviation angle of the nasal septum and the bone thickness [7]. This may lead to the hypothesis that the more deviation the angle of the septum has, the thicker the inferior turbinate, necessitating the extensive intervention of the inferior turbinate in cases of severe septal deviation.
In Korea, reduction surgery of the inferior turbinate is often performed in conjunction with septoplasty. Data on structural modification caused by septal deviation may help otolaryngologists make informed decisions on the inclusion of turbinate surgery with septoplasty as well as identify the part of the inferior turbinate that requires more attention during surgery. This study aimed to compare the thickness of the medial and lateral mucosa and bony portion between the two sides of the inferior turbinate at the anterior, posterior, and maximal septal deviation sites in patients with septal deviation. Furthermore, we aimed to identify the relationship between the structural hypertrophy of the inferior turbinate and the deviation angle of the nasal septum.
This retrospective study analyzed preoperative facial computed tomography (CT) scans of patients who underwent septoplasty in the Department of Otolaryngology-Head and Neck Surgery at Kosin University Gospel Hospital between January 2012 and December 2017. Patients with a history of previous septoplasty or inferior turbinoplasty, facial trauma, chronic sinusitis, a nasal cavity tumor, or an S-shaped deviation were excluded. Of the 499 patients who underwent septoplasty, 111 were included in the study. The CT images and patient data were reviewed, and demographic data were obtained from medical records. This study was approved by the Institutional Review Board of Kosin University (approval number: 2022-02-008).
Measurements were performed by two otolaryngologists, and the average was calculated to ensure the accuracy of the results. The side of deviation, which was the convex part of the septum, was considered the ipsilateral side, while the opposite side was considered the contralateral side.
Measurements of the inferior turbinate were performed at the anterior, posterior, and maximally deviated septal sites. At the above-mentioned sites, the thicknesses of the medial and lateral mucosa and bony portion were measured on both sides of the inferior turbinate. Anterior site measurements were performed at the level of the second middle turbinate cut on CT. Measurements of the posterior site were performed immediately before the end of the bony portion of the inferior turbinate. Measurements of the maximally deviated site were conducted in the plane of the maximal septal deviation (Fig. 1).
On coronal CT, the deviation angle of the septum was calculated by measuring the angle between the maximally deviated area and the midline. We defined the midline as the line starting from the initial point of the crista galli towards the maxillary crest (Fig. 2). Based on the deviation angle of the septum, the patients were categorized into the following three groups: group 1: mild (0°–9°); group 2: moderate (10°–15°); and group 3: severe (>15°) [4]. The relationship between the structural dimension of the contralateral inferior turbinate and the deviation angle was also analyzed.
Statistical analyses were conducted using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). The normality of the data was verified using the Kolmogorov–Smirnov test. Parametric comparisons of the two groups (left and right sides) were performed using the paired t-test, and the Kruskal–Wallis test was used to compare the three groups (groups 1–3). Spearman’s correlation test was used for correlational analysis between the two variables. The data are presented as mean±standard deviation with p-values <0.05 considered statistically significant.
This study enrolled 111 patients with a septal deviation, of whom 44 (39.6%) showed a left-sided deviation and 67 (60.4%) a right-sided deviation. No significant differences were found in terms of age and deviation angle between the left- and right-sided deviation groups (p=0.333 and p=0.546, respectively).
The deviation angle of the septums of the participants was in the range of 7.00°–27.20°. The mean deviation angle of the septum was 15.75°±6.00° and 16.07°±6.93° in the right- and left-sided deviation groups, respectively.
Table 1–3 show the dimensions of the inferior turbinate measured on both sides. Table 1 shows the measurements of the anterior inferior turbinate site. The medial mucosal portion was 4.64±2.12 mm on the contralateral side and 4.14±1.75 mm on the ipsilateral side (p=0.03). The bony portion was 1.93±1.91 mm on the contralateral side and 1.76±1.01 mm on the ipsilateral side (p=0.37). The lateral mucosal portion was 3.13±2.60 mm on the contralateral side and 2.68±2.61 mm on the ipsilateral side (p=0.07). The total thickness was 9.72±4.25 mm and 8.58±3.36 mm on the contralateral and ipsilateral sides, respectively (p=0.02). At the anterior site of the inferior turbinate, statistical analysis showed that the thickness of the medial mucosa and the total thickness were significantly greater on the contralateral side than on the ipsilateral side. However, there were no differences in the thickness of the lateral mucosa and bony portion between the contralateral and ipsilateral sides.
Table 1 . Measurements of the contralateral and ipsilateral sides at the anterior site of the inferior turbinate
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value |
---|---|---|---|
Medial | 4.64±2.12 | 4.14±1.75 | 0.03* |
Bone | 1.93±1.91 | 1.76±1.01 | 0.37 |
Lateral | 3.13±2.60 | 2.68±2.61 | 0.07 |
Total | 9.72±4.25 | 8.58±3.36 | 0.02* |
Values are presented as mean±SD.
*p-values <0.05 are statistically significant.
Table 2 . Measurements of the contralateral and ipsilateral sides at the posterior site of the inferior turbinate
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value* |
---|---|---|---|
Medial | 5.87±2.55 | 5.70±3.31 | 0.63 |
Bone | 1.49±0.73 | 1.45±1.06 | 0.86 |
Lateral | 3.58±1.57 | 3.33±1.66 | 0.17 |
Total | 10.44±3.64 | 10.31±3.10 | 0.63 |
Values are presented as mean±SD.
*p-values <0.05 are statistically significant.
Table 3 . Measurements of the contralateral and ipsilateral sides at the maximal deviated site of the inferior turbinate
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value |
---|---|---|---|
Medial | 5.09±2.52 | 4.39±2.05 | 0.04* |
Bone | 1.64±1.14 | 1.59±0.90 | 0.52 |
Lateral | 2.84±1.75 | 2.82±1.83 | 0.90 |
Total | 9.58±4.06 | 8.81±3.50 | 0.04* |
Values are presented as mean±SD.
*p-values <0.05 are statistically significant.
Table 2 shows the measurement results for the posterior sites. The medial mucosal portion was 5.87±2.55 mm on the contralateral side and 5.70±3.31 mm on the ipsilateral side (p=0.63). The bony portion was 1.49±0.73 mm on the contralateral side and 1.45±1.06 mm on the ipsilateral side (p=0.86). The lateral mucosal portion was 3.58±1.57 mm on the contralateral side and 3.33±1.66 mm on the ipsilateral side (p=0.17). The total thickness was 10.44±3.64 mm and 10.31±3.10 mm on the contralateral and ipsilateral sides, respectively (p=0.63). There were no statistical differences between the contralateral and ipsilateral sides of the posterior inferior turbinate.
Table 3 shows the results for the maximally deviated site. The medial mucosal portion was 5.09±2.52 mm on the contralateral side and 4.39±2.05 mm on the ipsilateral side (p=0.04). The bony portion was 1.64±1.14 mm on the contralateral side and 1.59±0.90 mm on the ipsilateral side (p=0.52). The lateral mucosal portion was 2.84±1.75 mm on the contralateral side and 2.82±1.83 mm on the ipsilateral side (p=0.90). The total thickness was 9.58±4.06 mm and 8.81±3.50 mm on the contralateral and ipsilateral sides, respectively (p=0.04). At the maximally deviated site, the thickness of the medial mucosa and the total thickness of the inferior turbinate between the contralateral and ipsilateral sides differed.
Table 4 shows the relationship between the contralateral inferior turbinate dimension and nasal septum deviation angle. Angle measurements of the septal deviation indicated mild deviation in 15 patients (group 1), moderate deviation in 42 patients (group 2), and severe deviation in 54 patients (group 3). The contralateral inferior turbinate dimensions did not show any significant relationship with the deviation angle. The patients in the three groups did not show any significant differences in the measurement results of the anterior, posterior, and maximally deviated sites with respect to the thickness of the medial and lateral mucosa, bony portion thickness, and total thickness.
Table 4 . Relationship between the contralateral inferior turbinate dimension and nasal septum deviation angle
Variable | Group 3 (mm) | Group 2 (mm) | Group 1 (mm) | p-value* |
---|---|---|---|---|
Ant. lateral | 2.96±1.63 | 3.45±3.27 | 2.95±2.04 | 0.77 |
Ant. bone | 1.97±1.68 | 1.87±0.96 | 1.94±1.22 | 0.42 |
Ant. medial | 4.96±1.95 | 4.4±2.05 | 4.29±2.64 | 0.21 |
Ant. total | 9.89±4.30 | 9.70±4.13 | 9.20±4.38 | 0.44 |
Post. lateral | 3.32±1.27 | 3.31±1.97 | 3.40±1.95 | 0.59 |
Post. bone | 1.38±0.60 | 1.58±0.83 | 1.43±0.83 | 0.66 |
Post. medial | 5.6±1.80 | 5.29±2.41 | 5.75±3.36 | 0.46 |
Post. total | 10.60±4.70 | 10.16±3.36 | 10.60±4.83 | 0.33 |
Max. lateral | 2.85±1.61 | 2.49±1.30 | 3.60±2.64 | 0.24 |
Max. bone | 1.6±1.14 | 1.7±0.91 | 1.75±1.50 | 0.81 |
Max. medial | 5.42±2.60 | 4.92±1.81 | 4.52±3.45 | 0.13 |
Max. total | 9.85±4.10 | 9.11±2.69 | 9.82±6.03 | 0.48 |
Values are presented as mean±SD.
Group 1 (n=54): mild (0°–9°); Group 2 (n=42): moderate (10°–15°); Group 3 (n=15): severe (>15°).
Ant., anterior; Post., posterior; Max, maximal.
*p-values <0.05 are statistically significant.
The correlation between the deviation angle of the septum and the total thickness of the contralateral inferior turbinate at the anterior, posterior, and maximally deviated sites showed a weak positive correlation, but this was not statistically significant (r=0.064, p=0.503; r=0.017, p=0.860; and r=0.06, p=0.952; respectively) (Fig. 3). Although the degree of deviation increased, no significant differences were observed.
Studies indicate that when a deviation of the nasal septum exists on a particular side, the hypertrophied nasal turbinate occupies the nasal cavity on the opposite side [5]. Hence, intervention strategies for the inferior turbinate are warranted during septoplasty [6]. A non-randomized trial showed that contralateral inferior turbinoplasty with septoplasty is superior to septoplasty alone [5,8]. Hence, it is the preferred surgical method. There are advocations for the excision of the bony turbinate [6,7]. However, no consensus has been established on the extent of resection of the inferior turbinate or the precise location of the inferior turbinate that needs attention [7]. To determine the optimal surgical method, knowledge of the nature of the predominant hypertrophied tissue of the inferior turbinate (the bony portion or soft tissue) and the precise location of the inferior turbinate (anterior, posterior, or maximally deviated site) is important. Assessment of the inferior turbinate on CT in patients with nasal septum deviation may provide key information to answer questions about the most optimal surgical method and the part of the inferior turbinate to be resected [5]. So, the analysis of the CT images can help decide between turbinectomy including bone and submucosal turbinoplasty. A study reported statistically significant differences in the width of the medial and lateral mucosal portions and the bony portion of the concha between patients with septal deviation and the normal control group [5]. This justified their decision to perform inferior turbinate bone excision during septoplasty. Another study found that compensatory hypertrophy of the inferior turbinate is caused by both mucosal and bony hypertrophy, which supports surgical methods for handling the bony portion. The study also reported a statistically significant positive correlation between the deviation angle and bony thickness [7].
This study was conducted to answer questions regarding the three sites on both sides of the inferior turbinate. We evaluated the medial and lateral mucosa and bony portion at the anterior, posterior, and maximally deviated sites in Korean patients with septal deviation. Furthermore, we aimed to identify the relationship between the structure of the inferior turbinate and the deviation angle of the nasal septum.
Our data showed a significant increase in the thickness of the medial mucosa and the total thickness of the contralateral side at the anterior and maximally deviated sites. The total thickness also differed significantly, which seemed to be mainly due to medial mucosal hypertrophy. We did not find any difference in bone thickness between the ipsilateral and contralateral sides at the anterior, posterior, and maximally deviated sites. Moreover, although the deviation angle of the septum and thickness of the inferior turbinate, showed weak positive correlations, the data were statistically insignificant. The results suggest that septal deviation mainly affects mucosal thickening rather than the bony portion of the inferior turbinate and that the thickness of the bony turbinate did not show a significant relationship with the deviation angle of the septum, which is contrary to the conclusions of the aforementioned studies that support the significant bony thickness of the contralateral inferior turbinate.
A study conducted by Passàli et al. [9] showed the long-term outcomes of submucosal resection with or without turbinate lateralization and turbinectomy. Submucosal resection with turbinate lateralization showed the most favorable improvement in airflow and breathing function and the lowest risk of long-term side effects. Among the available surgical methods, submucosal inferior turbinate resection is the most convenient. If bony hypertrophy of the inferior turbinate is not significant, submucosal resection, which is relatively conservative, may be more favorable. Considering that the anterior aspect and the maximally deviated portion of the medial mucosa were significantly thickened, these parts may be the target for turbinoplasty. Especially for the anterior aspect, the inferior border of the internal nasal valve, which is the narrowest portion of the nasal cavity, is composed of the head of the inferior turbinate [10-12]. Hence, a conservative approach focusing on mucosal hypertrophy of the anterior and maximally deviated portion of the inferior turbinate may be appropriate and help to achieve optimal outcomes with fewer side effects.
The fact that the results of this study were contrary to those of previously reported studies may be due to the limitations of this study. First, the thickness of the mucosal layer can be altered by physiological changes and other causes, such as allergic rhinitis. Nonetheless, data regarding bony hypertrophy still requires attention. Another point to be considered is that our data were collected from a unilateral tertiary center, which may not accurately represent the characteristics of the general Korean population. Thus, to evaluate the cause of the contrary result, additional studies targeting participants from multiple centers to show the characteristics of the general population and a comparison with the results from other population groups are needed.
Another reason for our data showing contrary results to the hypothesis is that the deviation angle of the septum and the thickness of the inferior turbinate would show a positive correlation, which may be related to the measurement method of the deviation angle. Our definition of the midline was the line starting from the initial point of the crista galli down towards the maxillary crest; cases with prominent septal deviation at the upper part of the nasal septum tended to show a larger deviation angle than cases with prominent deviation at the lower septum. Thus, alternative methods for comparing the degree of septal deviation may yield different results.
Based on the findings of this study, we suggest that conservative submucosal resection of the inferior turbinate should be considered, with more attention paid to the volume reduction of the anterior and maximally deviated sites of the inferior turbinate, especially the mucosal portion of the contralateral inferior turbinate during septoplasty.
In conclusion, our study revealed significant differences in the thickness of the medial mucosa and the total thickness of the anterior and maximally deviated sites of the inferior turbinate; no significant differences were found in the bony thickness at any of the sites. No significant correlation was found between the deviation angle of the septum and the thickness of the inferior turbinate. Therefore, a conservative procedure for turbinoplasty without bone removal may be considered more favorable.
The authors have nothing to disclose.
J Cosmet Med 2022; 6(2): 72-77
Published online December 31, 2022 https://doi.org/10.25056/JCM.2022.6.2.72
Copyright © Korean Society of Korean Cosmetic Surgery & Medicine.
Yeong Joon Kim, MD1 , Chang Hoi Kim, MD2 , Jooyeon Kim, MD, PhD1 , Gilsoon Choi, MD, PhD3 , Yeong Wook Jeong, MD1 , Jaehwan Kwon, MD, PhD1
1Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, Rep. of Korea, 2Department of Otolaryngology-Head and Neck Surgery, Dongguk University Gyeongju Hospital, Gyeongju, Rep. of Korea, 3Department of Internal Medicine, Kosin University College of Medicine, Busan, Rep. of Korea
Correspondence to:Jaehwan Kwon
E-mail: entkwon@hanmail.net
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Data on structural modifications caused by septal deviation may help otolaryngologists make informed decisions on the inclusion of turbinate surgery with septoplasty as well as identify the part of the inferior turbinate that requires more attention during surgery.
Objective: This study aimed to compare the dimensions of the ipsilateral and contralateral sides of the inferior turbinate and the septal deviation in a Korean population.
Methods: We retrospectively analyzed the facial computed tomography (CT) scans of 111 patients who underwent septoplasty between January 2012 and December 2017 for the anterior, posterior, and maximally deviated sites of the inferior turbinate.
Results: Statistical analyses revealed differences in the medial mucosa and the total thickness of the anterior and maximally deviated sites between the ipsilateral and contralateral sides. The medial mucosal portion of the anterior site was 4.64±2.12 mm on the contralateral side and 4.14±1.75 mm on the ipsilateral side (p=0.03). The total thickness of the anterior site was 9.72±4.25 mm on the contralateral side and 8.58±3.36 mm on the ipsilateral side (p=0.02). The medial mucosal portion of the maximally deviated site was 5.09±2.52 mm on the contralateral side and 4.39±2.05 mm on the ipsilateral side (p=0.04). The total thickness of the maximally deviated site was 9.58±4.06 mm on the contralateral side and 8.81±3.50 mm on the ipsilateral side (p=0.04). No significant differences were found in the measurements between the two sides of the posterior site or in the bone thickness at any of the sites. The inferior turbinate did not show any significant relationship with the deviation angle.
Conclusion: A conservative submucosal turbinoplasty without bone removal may be favorable.
Level of Evidence: Level IV
Keywords: nasal cavity, nasal septum, turbinates
The septum of the nasal cavity is a major structure located centrally in the nose, comprising cartilage in the anterior part and bone in the posterior part [1]. The anatomical and morphological features of the bony and cartilaginous parts of the septum play a significant role in structural support and breathing [2]. Owing to its importance in respiration, structural abnormalities of the nasal septum could cause nasal symptoms like repetitive sneezing, epistaxis, sleep apnea, sinusitis, and breathing difficulty [3]. Some studies consider septal deviation to be associated with olfaction, and structural abnormalities may affect the growth of the nasal bone and alter the facial morphology [4]. The inferior turbinate is the most vulnerable to hypertrophic change among the three turbinates [1]. Variable degrees of inferior turbinate hypertrophy as a consequence of septal deviation is common findings in patients with septal deviation [1,5]. Both mucosal and bony hypertrophy in the deviated nasal septum have been associated with compensatory inferior turbinate hypertrophy [6,7]. It was also reported that a positive correlation was shown between the deviation angle of the nasal septum and the bone thickness [7]. This may lead to the hypothesis that the more deviation the angle of the septum has, the thicker the inferior turbinate, necessitating the extensive intervention of the inferior turbinate in cases of severe septal deviation.
In Korea, reduction surgery of the inferior turbinate is often performed in conjunction with septoplasty. Data on structural modification caused by septal deviation may help otolaryngologists make informed decisions on the inclusion of turbinate surgery with septoplasty as well as identify the part of the inferior turbinate that requires more attention during surgery. This study aimed to compare the thickness of the medial and lateral mucosa and bony portion between the two sides of the inferior turbinate at the anterior, posterior, and maximal septal deviation sites in patients with septal deviation. Furthermore, we aimed to identify the relationship between the structural hypertrophy of the inferior turbinate and the deviation angle of the nasal septum.
This retrospective study analyzed preoperative facial computed tomography (CT) scans of patients who underwent septoplasty in the Department of Otolaryngology-Head and Neck Surgery at Kosin University Gospel Hospital between January 2012 and December 2017. Patients with a history of previous septoplasty or inferior turbinoplasty, facial trauma, chronic sinusitis, a nasal cavity tumor, or an S-shaped deviation were excluded. Of the 499 patients who underwent septoplasty, 111 were included in the study. The CT images and patient data were reviewed, and demographic data were obtained from medical records. This study was approved by the Institutional Review Board of Kosin University (approval number: 2022-02-008).
Measurements were performed by two otolaryngologists, and the average was calculated to ensure the accuracy of the results. The side of deviation, which was the convex part of the septum, was considered the ipsilateral side, while the opposite side was considered the contralateral side.
Measurements of the inferior turbinate were performed at the anterior, posterior, and maximally deviated septal sites. At the above-mentioned sites, the thicknesses of the medial and lateral mucosa and bony portion were measured on both sides of the inferior turbinate. Anterior site measurements were performed at the level of the second middle turbinate cut on CT. Measurements of the posterior site were performed immediately before the end of the bony portion of the inferior turbinate. Measurements of the maximally deviated site were conducted in the plane of the maximal septal deviation (Fig. 1).
On coronal CT, the deviation angle of the septum was calculated by measuring the angle between the maximally deviated area and the midline. We defined the midline as the line starting from the initial point of the crista galli towards the maxillary crest (Fig. 2). Based on the deviation angle of the septum, the patients were categorized into the following three groups: group 1: mild (0°–9°); group 2: moderate (10°–15°); and group 3: severe (>15°) [4]. The relationship between the structural dimension of the contralateral inferior turbinate and the deviation angle was also analyzed.
Statistical analyses were conducted using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). The normality of the data was verified using the Kolmogorov–Smirnov test. Parametric comparisons of the two groups (left and right sides) were performed using the paired t-test, and the Kruskal–Wallis test was used to compare the three groups (groups 1–3). Spearman’s correlation test was used for correlational analysis between the two variables. The data are presented as mean±standard deviation with p-values <0.05 considered statistically significant.
This study enrolled 111 patients with a septal deviation, of whom 44 (39.6%) showed a left-sided deviation and 67 (60.4%) a right-sided deviation. No significant differences were found in terms of age and deviation angle between the left- and right-sided deviation groups (p=0.333 and p=0.546, respectively).
The deviation angle of the septums of the participants was in the range of 7.00°–27.20°. The mean deviation angle of the septum was 15.75°±6.00° and 16.07°±6.93° in the right- and left-sided deviation groups, respectively.
Table 1–3 show the dimensions of the inferior turbinate measured on both sides. Table 1 shows the measurements of the anterior inferior turbinate site. The medial mucosal portion was 4.64±2.12 mm on the contralateral side and 4.14±1.75 mm on the ipsilateral side (p=0.03). The bony portion was 1.93±1.91 mm on the contralateral side and 1.76±1.01 mm on the ipsilateral side (p=0.37). The lateral mucosal portion was 3.13±2.60 mm on the contralateral side and 2.68±2.61 mm on the ipsilateral side (p=0.07). The total thickness was 9.72±4.25 mm and 8.58±3.36 mm on the contralateral and ipsilateral sides, respectively (p=0.02). At the anterior site of the inferior turbinate, statistical analysis showed that the thickness of the medial mucosa and the total thickness were significantly greater on the contralateral side than on the ipsilateral side. However, there were no differences in the thickness of the lateral mucosa and bony portion between the contralateral and ipsilateral sides.
Table 1 . Measurements of the contralateral and ipsilateral sides at the anterior site of the inferior turbinate.
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value |
---|---|---|---|
Medial | 4.64±2.12 | 4.14±1.75 | 0.03* |
Bone | 1.93±1.91 | 1.76±1.01 | 0.37 |
Lateral | 3.13±2.60 | 2.68±2.61 | 0.07 |
Total | 9.72±4.25 | 8.58±3.36 | 0.02* |
Values are presented as mean±SD..
*p-values <0.05 are statistically significant..
Table 2 . Measurements of the contralateral and ipsilateral sides at the posterior site of the inferior turbinate.
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value* |
---|---|---|---|
Medial | 5.87±2.55 | 5.70±3.31 | 0.63 |
Bone | 1.49±0.73 | 1.45±1.06 | 0.86 |
Lateral | 3.58±1.57 | 3.33±1.66 | 0.17 |
Total | 10.44±3.64 | 10.31±3.10 | 0.63 |
Values are presented as mean±SD..
*p-values <0.05 are statistically significant..
Table 3 . Measurements of the contralateral and ipsilateral sides at the maximal deviated site of the inferior turbinate.
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value |
---|---|---|---|
Medial | 5.09±2.52 | 4.39±2.05 | 0.04* |
Bone | 1.64±1.14 | 1.59±0.90 | 0.52 |
Lateral | 2.84±1.75 | 2.82±1.83 | 0.90 |
Total | 9.58±4.06 | 8.81±3.50 | 0.04* |
Values are presented as mean±SD..
*p-values <0.05 are statistically significant..
Table 2 shows the measurement results for the posterior sites. The medial mucosal portion was 5.87±2.55 mm on the contralateral side and 5.70±3.31 mm on the ipsilateral side (p=0.63). The bony portion was 1.49±0.73 mm on the contralateral side and 1.45±1.06 mm on the ipsilateral side (p=0.86). The lateral mucosal portion was 3.58±1.57 mm on the contralateral side and 3.33±1.66 mm on the ipsilateral side (p=0.17). The total thickness was 10.44±3.64 mm and 10.31±3.10 mm on the contralateral and ipsilateral sides, respectively (p=0.63). There were no statistical differences between the contralateral and ipsilateral sides of the posterior inferior turbinate.
Table 3 shows the results for the maximally deviated site. The medial mucosal portion was 5.09±2.52 mm on the contralateral side and 4.39±2.05 mm on the ipsilateral side (p=0.04). The bony portion was 1.64±1.14 mm on the contralateral side and 1.59±0.90 mm on the ipsilateral side (p=0.52). The lateral mucosal portion was 2.84±1.75 mm on the contralateral side and 2.82±1.83 mm on the ipsilateral side (p=0.90). The total thickness was 9.58±4.06 mm and 8.81±3.50 mm on the contralateral and ipsilateral sides, respectively (p=0.04). At the maximally deviated site, the thickness of the medial mucosa and the total thickness of the inferior turbinate between the contralateral and ipsilateral sides differed.
Table 4 shows the relationship between the contralateral inferior turbinate dimension and nasal septum deviation angle. Angle measurements of the septal deviation indicated mild deviation in 15 patients (group 1), moderate deviation in 42 patients (group 2), and severe deviation in 54 patients (group 3). The contralateral inferior turbinate dimensions did not show any significant relationship with the deviation angle. The patients in the three groups did not show any significant differences in the measurement results of the anterior, posterior, and maximally deviated sites with respect to the thickness of the medial and lateral mucosa, bony portion thickness, and total thickness.
Table 4 . Relationship between the contralateral inferior turbinate dimension and nasal septum deviation angle.
Variable | Group 3 (mm) | Group 2 (mm) | Group 1 (mm) | p-value* |
---|---|---|---|---|
Ant. lateral | 2.96±1.63 | 3.45±3.27 | 2.95±2.04 | 0.77 |
Ant. bone | 1.97±1.68 | 1.87±0.96 | 1.94±1.22 | 0.42 |
Ant. medial | 4.96±1.95 | 4.4±2.05 | 4.29±2.64 | 0.21 |
Ant. total | 9.89±4.30 | 9.70±4.13 | 9.20±4.38 | 0.44 |
Post. lateral | 3.32±1.27 | 3.31±1.97 | 3.40±1.95 | 0.59 |
Post. bone | 1.38±0.60 | 1.58±0.83 | 1.43±0.83 | 0.66 |
Post. medial | 5.6±1.80 | 5.29±2.41 | 5.75±3.36 | 0.46 |
Post. total | 10.60±4.70 | 10.16±3.36 | 10.60±4.83 | 0.33 |
Max. lateral | 2.85±1.61 | 2.49±1.30 | 3.60±2.64 | 0.24 |
Max. bone | 1.6±1.14 | 1.7±0.91 | 1.75±1.50 | 0.81 |
Max. medial | 5.42±2.60 | 4.92±1.81 | 4.52±3.45 | 0.13 |
Max. total | 9.85±4.10 | 9.11±2.69 | 9.82±6.03 | 0.48 |
Values are presented as mean±SD..
Group 1 (n=54): mild (0°–9°); Group 2 (n=42): moderate (10°–15°); Group 3 (n=15): severe (>15°)..
Ant., anterior; Post., posterior; Max, maximal..
*p-values <0.05 are statistically significant..
The correlation between the deviation angle of the septum and the total thickness of the contralateral inferior turbinate at the anterior, posterior, and maximally deviated sites showed a weak positive correlation, but this was not statistically significant (r=0.064, p=0.503; r=0.017, p=0.860; and r=0.06, p=0.952; respectively) (Fig. 3). Although the degree of deviation increased, no significant differences were observed.
Studies indicate that when a deviation of the nasal septum exists on a particular side, the hypertrophied nasal turbinate occupies the nasal cavity on the opposite side [5]. Hence, intervention strategies for the inferior turbinate are warranted during septoplasty [6]. A non-randomized trial showed that contralateral inferior turbinoplasty with septoplasty is superior to septoplasty alone [5,8]. Hence, it is the preferred surgical method. There are advocations for the excision of the bony turbinate [6,7]. However, no consensus has been established on the extent of resection of the inferior turbinate or the precise location of the inferior turbinate that needs attention [7]. To determine the optimal surgical method, knowledge of the nature of the predominant hypertrophied tissue of the inferior turbinate (the bony portion or soft tissue) and the precise location of the inferior turbinate (anterior, posterior, or maximally deviated site) is important. Assessment of the inferior turbinate on CT in patients with nasal septum deviation may provide key information to answer questions about the most optimal surgical method and the part of the inferior turbinate to be resected [5]. So, the analysis of the CT images can help decide between turbinectomy including bone and submucosal turbinoplasty. A study reported statistically significant differences in the width of the medial and lateral mucosal portions and the bony portion of the concha between patients with septal deviation and the normal control group [5]. This justified their decision to perform inferior turbinate bone excision during septoplasty. Another study found that compensatory hypertrophy of the inferior turbinate is caused by both mucosal and bony hypertrophy, which supports surgical methods for handling the bony portion. The study also reported a statistically significant positive correlation between the deviation angle and bony thickness [7].
This study was conducted to answer questions regarding the three sites on both sides of the inferior turbinate. We evaluated the medial and lateral mucosa and bony portion at the anterior, posterior, and maximally deviated sites in Korean patients with septal deviation. Furthermore, we aimed to identify the relationship between the structure of the inferior turbinate and the deviation angle of the nasal septum.
Our data showed a significant increase in the thickness of the medial mucosa and the total thickness of the contralateral side at the anterior and maximally deviated sites. The total thickness also differed significantly, which seemed to be mainly due to medial mucosal hypertrophy. We did not find any difference in bone thickness between the ipsilateral and contralateral sides at the anterior, posterior, and maximally deviated sites. Moreover, although the deviation angle of the septum and thickness of the inferior turbinate, showed weak positive correlations, the data were statistically insignificant. The results suggest that septal deviation mainly affects mucosal thickening rather than the bony portion of the inferior turbinate and that the thickness of the bony turbinate did not show a significant relationship with the deviation angle of the septum, which is contrary to the conclusions of the aforementioned studies that support the significant bony thickness of the contralateral inferior turbinate.
A study conducted by Passàli et al. [9] showed the long-term outcomes of submucosal resection with or without turbinate lateralization and turbinectomy. Submucosal resection with turbinate lateralization showed the most favorable improvement in airflow and breathing function and the lowest risk of long-term side effects. Among the available surgical methods, submucosal inferior turbinate resection is the most convenient. If bony hypertrophy of the inferior turbinate is not significant, submucosal resection, which is relatively conservative, may be more favorable. Considering that the anterior aspect and the maximally deviated portion of the medial mucosa were significantly thickened, these parts may be the target for turbinoplasty. Especially for the anterior aspect, the inferior border of the internal nasal valve, which is the narrowest portion of the nasal cavity, is composed of the head of the inferior turbinate [10-12]. Hence, a conservative approach focusing on mucosal hypertrophy of the anterior and maximally deviated portion of the inferior turbinate may be appropriate and help to achieve optimal outcomes with fewer side effects.
The fact that the results of this study were contrary to those of previously reported studies may be due to the limitations of this study. First, the thickness of the mucosal layer can be altered by physiological changes and other causes, such as allergic rhinitis. Nonetheless, data regarding bony hypertrophy still requires attention. Another point to be considered is that our data were collected from a unilateral tertiary center, which may not accurately represent the characteristics of the general Korean population. Thus, to evaluate the cause of the contrary result, additional studies targeting participants from multiple centers to show the characteristics of the general population and a comparison with the results from other population groups are needed.
Another reason for our data showing contrary results to the hypothesis is that the deviation angle of the septum and the thickness of the inferior turbinate would show a positive correlation, which may be related to the measurement method of the deviation angle. Our definition of the midline was the line starting from the initial point of the crista galli down towards the maxillary crest; cases with prominent septal deviation at the upper part of the nasal septum tended to show a larger deviation angle than cases with prominent deviation at the lower septum. Thus, alternative methods for comparing the degree of septal deviation may yield different results.
Based on the findings of this study, we suggest that conservative submucosal resection of the inferior turbinate should be considered, with more attention paid to the volume reduction of the anterior and maximally deviated sites of the inferior turbinate, especially the mucosal portion of the contralateral inferior turbinate during septoplasty.
In conclusion, our study revealed significant differences in the thickness of the medial mucosa and the total thickness of the anterior and maximally deviated sites of the inferior turbinate; no significant differences were found in the bony thickness at any of the sites. No significant correlation was found between the deviation angle of the septum and the thickness of the inferior turbinate. Therefore, a conservative procedure for turbinoplasty without bone removal may be considered more favorable.
The authors have nothing to disclose.
Table 1 . Measurements of the contralateral and ipsilateral sides at the anterior site of the inferior turbinate.
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value |
---|---|---|---|
Medial | 4.64±2.12 | 4.14±1.75 | 0.03* |
Bone | 1.93±1.91 | 1.76±1.01 | 0.37 |
Lateral | 3.13±2.60 | 2.68±2.61 | 0.07 |
Total | 9.72±4.25 | 8.58±3.36 | 0.02* |
Values are presented as mean±SD..
*p-values <0.05 are statistically significant..
Table 2 . Measurements of the contralateral and ipsilateral sides at the posterior site of the inferior turbinate.
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value* |
---|---|---|---|
Medial | 5.87±2.55 | 5.70±3.31 | 0.63 |
Bone | 1.49±0.73 | 1.45±1.06 | 0.86 |
Lateral | 3.58±1.57 | 3.33±1.66 | 0.17 |
Total | 10.44±3.64 | 10.31±3.10 | 0.63 |
Values are presented as mean±SD..
*p-values <0.05 are statistically significant..
Table 3 . Measurements of the contralateral and ipsilateral sides at the maximal deviated site of the inferior turbinate.
Variable | Contralateral (mm) | Ipsilateral (mm) | p-value |
---|---|---|---|
Medial | 5.09±2.52 | 4.39±2.05 | 0.04* |
Bone | 1.64±1.14 | 1.59±0.90 | 0.52 |
Lateral | 2.84±1.75 | 2.82±1.83 | 0.90 |
Total | 9.58±4.06 | 8.81±3.50 | 0.04* |
Values are presented as mean±SD..
*p-values <0.05 are statistically significant..
Table 4 . Relationship between the contralateral inferior turbinate dimension and nasal septum deviation angle.
Variable | Group 3 (mm) | Group 2 (mm) | Group 1 (mm) | p-value* |
---|---|---|---|---|
Ant. lateral | 2.96±1.63 | 3.45±3.27 | 2.95±2.04 | 0.77 |
Ant. bone | 1.97±1.68 | 1.87±0.96 | 1.94±1.22 | 0.42 |
Ant. medial | 4.96±1.95 | 4.4±2.05 | 4.29±2.64 | 0.21 |
Ant. total | 9.89±4.30 | 9.70±4.13 | 9.20±4.38 | 0.44 |
Post. lateral | 3.32±1.27 | 3.31±1.97 | 3.40±1.95 | 0.59 |
Post. bone | 1.38±0.60 | 1.58±0.83 | 1.43±0.83 | 0.66 |
Post. medial | 5.6±1.80 | 5.29±2.41 | 5.75±3.36 | 0.46 |
Post. total | 10.60±4.70 | 10.16±3.36 | 10.60±4.83 | 0.33 |
Max. lateral | 2.85±1.61 | 2.49±1.30 | 3.60±2.64 | 0.24 |
Max. bone | 1.6±1.14 | 1.7±0.91 | 1.75±1.50 | 0.81 |
Max. medial | 5.42±2.60 | 4.92±1.81 | 4.52±3.45 | 0.13 |
Max. total | 9.85±4.10 | 9.11±2.69 | 9.82±6.03 | 0.48 |
Values are presented as mean±SD..
Group 1 (n=54): mild (0°–9°); Group 2 (n=42): moderate (10°–15°); Group 3 (n=15): severe (>15°)..
Ant., anterior; Post., posterior; Max, maximal..
*p-values <0.05 are statistically significant..
Tzu-I Wu, MD, Chung-Yu Hao, MD, Yu-Hsun Chiu, MD, MMS
J Cosmet Med 2021; 5(2): 90-93 https://doi.org/10.25056/JCM.2021.5.2.90Tae-Hoon Lee, MD, PhD, MBA
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