Comparative study of outcomes of conventional and endoscopic septoplasty

INTRODUCTION

Nasal obstruction is one of the most common complaint that brings the patient to an otorhinolaryngologist.¹ Among these patients, deviated nasal septum is often the cause for nasal obstruction. Patients with the symptomatic deviated nasal septum are advised septal correction surgery, which has undergone several modifications since its inception.

Conventional septoplasty includes surgical correction of the deviated nasal septum using Bull’s lamp and head mirror or electric head light, which gives very limited illumination and visualization of deeper parts of the nose during surgery.

With the introduction of endoscopes in otorhinolaryngology, efforts were being made to use it for correction of deviated nasal septum targeting surgical procedure to only deviated part of nasal septum with the preservation of most of its anatomy.

Use of an endoscope has definite advantages of better illumination, little manipulation and minimal post-operative complication so conventional septal surgery has been replaced by endoscopic surgery in last few decades.

Objectives

Objectives of the study were to study the conventional and endoscopic septoplasty and to compare outcome in conventional and endoscopic septoplasty.

METHODS

Study type

Prospective observational was the study type.

Sample size

Sample size was calculated by using open EPI software considering the proportion of complication (nasal obstruction) in conventional surgery and endoscopy 90% from previous study.

Level of significance (that is alpha) 99%, power (that is beta)-95%, percent of unexposed (conventional) with outcome-30%, percent of exposed (endoscopy) with outcome-90%, total-sample size-48, each group, conventional septoplasty-24, endoscopic septoplasty-24 and it was conducted in ENT department at Surat Municipal Institute of Medical Education and Research (SMIMER).

Inclusion criteria

Patients with symptomatic deviated nasal septum between age of 10-60 years were included in the study.

Exclusion criteria

Patients with age 60 years, allergic rhinitis, vasomotor rhinitis, DNS with nasal polyposis and patients with acute nasal infection were excluded from study.

The study was conducted in 48 patients having symptomatic deviated nasal septum willing for the surgery. It was conducted in the department of otorhinolaryngology (ENT) and head and neck surgery at Surat Municipal Institute of Medical Education and Research (SMIMER), Surat, Gujarat, India, over a period of two years i.e., Oct 2018 to Oct 2020. This study was approved by the institutional review board. Patients were selected by simple random sampling and then randomly divided into two groups: group A (n=24) underwent endoscopic septoplasty and group B (n=24) underwent conventional septoplasty. Randomization of the study was done on alternate basis of admission. All patients selected for the study, were assessed for subjective and objective evaluation using descriptive statistical method.

Along with detailed history been taken, for subjective assessment patients were given questionnaire (Table 1) and all patients were requested to fill according to the severity and discomfort they felt.

A thorough clinical examination was performed including nasal patency test and anterior rhinoscopy followed by diagnostic nasal endoscopy. Selective patients were advised CT PNS as well post examination.

Then the patients underwent surgical intervention, i.e., endoscopic/conventional septoplasty under local anaesthesia or general anaesthesia.

All the patients were assessed pre-operatively and post-operatively on the 7^th day, 1 month and 3 months by subjective assessment and by objective assessments. Subjective assessment was done by patient’s complaints and objective assessment by anterior rhinoscopy and post-operative diagnostic nasal endoscopy. For subjective assessment, patients were given NOSE (Nose obstruction symptoms evaluation) questionnaire, and they were asked to fill the questionnaire for the post-operative improvement.

RESULTS

Results of 24 cases of conventional septoplasty and 24 cases of endoscopic septoplasty were assessed under the following criteria: 1) Patient particulars, 2) chief complaints, 3) nasal examination findings and 4) surgical results.

*p value calculated by paired t test.

*p value calculated by paired t test.

*p value calculated by paired t test.

DISCUSSION

In our study, found most common age group affected was between 11-20 years which accounts for approximately 44% and mean of age group in conventional and endoscopic is 26 years and our study’s outcomes are consistent with previously carried out studies.³

As per literature present till now neither incidence of DNS nor the outcome of surgery depends upon male and female difference and our study’s outcomes are consistent with the literature.⁴

Most common complaints of patients with septal deflections were nasal obstruction, anterior nasal discharge, headache, anosmia, and our study’s outcomes are consistent with previously carried out studies.⁵

It was observed that there were definite intra-op advantages of endoscopic septoplasty over conventional septoplasty: Endoscopic septoplasty facilitates accurate identification of the pathology due to better illumination, improved accessibility to remote areas and magnification. It allows limited incision and elevation of the flaps and simultaneously not compromising with adequate exposure of the pathological site. Visualization of surgical space was good in all the 24 (100%) cases included in the endoscopic group when compared with the conventional septoplasty group where the visibility of surgical space was poor in 20 cases and 4 cases had fair visibility.^6,7 Total unilateral tear was seen in 16 (66%) of patient of conventional group compared to 3 (12.5%) of patient in endoscopic group. The result was consistent with the previous studies and is statistically significant with p value less than 0.05.

When we compared the post-operative duration of stay in both the groups, we found that majority of the patients had post-operative stay between 48-72 hours in both the groups which was not similar to the previous study however the number of patients staying for more than 72 hours was more in the conventional group compared to the endoscopic group which was similar to the result of previous study.⁸

Post-operative complications like residual deviation, mucosal tear and synechia formation were found more with conventional septoplasty compared to endoscopic septoplasty. There were no septal perforation, post-operative hematoma or external nose deformity seen in either of the group.

There were subjective post-operative improvements in the NOSE scores across all the participants and within both groups, with no differences found between groups.⁹

However, it was found that objective outcomes such as operative time, and intra-operative complications favoured the endoscopic group.⁹

So, the endoscopic approach for septoplasty may be considered superior to the traditional approach for the correction of septal deviation.⁹

CONCLUSION

We conclude that: there is no significant difference in the terms of functional outcome (improvement of nasal symptoms), complications and postoperative hospital stay, in conventional septoplasty group and endoscopic septoplasty group.

There are technical advantages of using endoscope during septoplasty as it is definitely superior in the terms of illumination, preciseness and surgery, visualization of deeper accurate parts of nasal cavity and resection of posterior deviation and spur especially in isolated septal spur.

Endoscopic septoplasty can be performed with minimal limited incision and manipulation, which results in minimal tissue trauma and septum resection, especially in isolated septal spur. Moreover, bleeding which especially occurs during maxillary crest removal that can be easily treated with endoscope and easily controlled using the electro cautery or bone wax.

We also noticed that finding the sub mucoperichondrial plane after putting the incision over the caudal border of septum (Freer’s incision) is very difficult. So, we first identified plane using Thudicum’s nasal speculum and Freer’s elevator under top-light or conventional headlight. Once the plane is obtained, we used endoscope for doing the all over steps of septoplasty.

Finally, while transitioning to endoscopic septoplasty from traditional headlight technique may seem more time consuming, the operative time becomes similar after gaining familiarity with this procedure. In fact, for isolated spur, endoscopic septoplasty can be done faster compare to conventional approach. Ultimately, improved illumination hence the visualization is what this technique so appealing for treating deviated nasal septum.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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