Totally endoscopic versus conventional septoplasty assisted by endoscope

INTRODUCTION

Nasal septum is considered a major structure for the nasal stability and functions.¹  Septal deviations are the most common cause of nasal obstruction.² Nasal septoplasty is a common surgical intervention, directed to improve nasal breathing Karlsson TR et al.³ and sleep disturbances.⁴ Approaches for correcting nasal septal abnormalities have experienced various changes since their inception, ranging from extreme septal resection to the retention of the septal structure and nasal mucosa. Septal abnormalities are frequently linked to lateral wall disorders or are the cause of them. Epistaxis, sinusitis, obstructive sleep apnea, and migraines have all been linked to a severely deviated nasal septum due to contact with lateral nasal wall components.⁵ As a result, rectification of septal abnormalities is inextricably linked to the therapy of lateral wall problems. Endoscopic septoplasty can thus be used to

address symptomatic abnormalities as well as to improve intraoperative surgical access to lateral nasal wall procedures (e.g., dacryocystorhinostomy, functional endoscopic sinus surgery).⁶ Endoscopic septoplasty is a minimally invasive treatment for correcting DNS that was created as an alternative to standard submucosal excision. By confining the excision to the area of deviation in the affected area, the exceptional visualization of this method is thought to reduce morbidity and postoperative edema.⁷

the aim of this work is to evaluate the effectiveness of the endoscopic septoplasty for correction of different types of septal deformity( deviation_ spur ) compared to endoscopic assisted conventional septoplasty.

PATIENTS AND METHODS

This  prospective  study was  conducted   on  60 patients of  both sexes , who  attached  to  the  out-patient E.N.T clinic at Bab El Sharaya (Sayed Galal) Hospital from April of  2021 to  March of 2022 . All the patients  suffering  from nasal obstruction due to a significant  septal deviation.  All the study groups signed informed consents before surgery.

Inclusion criteria:

Age of paients range from 20 to 50 years old. Patients having different type of nasal septal deformity( deviation e.g.( c shaped – s shaped) - spur). patients presented with or without turbinate hypertrophy.

Exclusion criteria:

Inflammatory :- chronic or fungal rhinosinusites Allergic nasal polyposis – antrochoanal polyp.

Neoplastic:- Inverted papilloma – squamous cell carcinoma.

Certain types of septal deviation e.g. dislocation, impaction.

Patients with associated co-morbidity (diabetes mellitus, hepatitis, renal disorders, hypertension, cardiac diseases, bleeding disorder, anemia (Hb less than 10 gm %), malnutrition).

All patients were subjected to: Careful history taking; Personal history : name ,age, sex ,occupation and residence.

Complaint and history of present illness regarding the nasal obstruction which was the main complaint of all patients with emphasis on onset, course, and duration of the nasal obstruction, the side of the obstruction, postnasal discharge, epistaxis and hyposmia.

Past history  of using nasal decongestant drops or any other medical treatment and its effect.

Examination: Meticulous preoperative examination was done by anterior rhinoscopy. Nasal patency examination and diagnostic nasal endoscopy for all patients was conducted to meticulously assess the type and severity of the septal deviation. CT scans of the paranasal sinuses was done only when chronic sinusitis was suspected.

Investigations: Pre-operative routine investigations as complete blood count, bleeding time, coagulation time, prothrombin time, partial prothrombin time, random blood sugar, liver enzyme, serum creatinine, ECG, and chest X-ray were done.

The patients were randomly distributed into two groups: Group A 30 patients underwent  totally endoscopic septoplasty and Group B 30 patients underwent conventional  septoplasty assisted by endoscope.

Both procedures were carried out under general anaesthetic with a cuffed endotracheal tube in order to avoid blood aspiration or swallowing. At the start of the procedure, a five-minute pack soaked in adrenaline in saline solution (1: 200,000) was introduced into the nostril. The patients were positioned supine on the surgical table, with the head end lifted. both nasal cavities were packed using merocel packs at the end of operation in both techniques.

Technique of totally endoscopic septoplasty using the endoscope, submucosal infiltration of the nasal septum was done. An incision was performed directly on   deviated part then a mucoperichondrial flap was dissected  at the proper cleavage plane to minimize bleeding, using a Cottle elevator in the right hand and endoscope in the left hand .The septal cartilage was then incised posterior to the mucosal incision. The dissection of the contralateral mucoperichondrial flap was then performed.  In cases of spur only, the incision was done directly over the spur using a sickle knife under endoscopic vision especially for posterior spurs.

Fig.1: Infiltration of the nasal septum using 1:200,000 adrenaline in saline solution. (NS= Nasal septum.  MT= Middle turbinate. IT= Inferior turbinate).

Fig.2: Flap elevation on the left side.

Technique of conventional septoplasty assisted by endoscope:

The conventional approach involves headlight illumination and visualization with nasal speculum. After injection, a Killian incision was made using a No. 15 blade. The incision was performed on the side of the deviation. Then the submucosal flaps were elevated, and the deviated segment was removed. In the end of operation we used 0 degree 4 mm endoscope to observe and remove any remnants of deviated  nasal septum.

Postoperative care: Patients were kept under observation in the hospital for 24 for any sign of nasal bleeding. Antibiotics and oral anti-inflammatory were prescribed for all cases. After removal of nasal packs, patients were discharged and were kept on a regimen of alkaline nasal douche for one month. The nasal splint, if used, was removed after one week.

Postoperative evaluation: All patients were evaluated, once weekly for the first month then every 2 weeks    for 3 months, then monthly till 6 months, regarding    the    nasal obstruction whether improved or not, and the degree of the   improvement (no, mild, moderate, severe),  also  , the   accompanying  symptoms as   a headache, snoring, postnasal discharge, epistaxis and hyposmia, whether disappeared or still persistent. Patients were checked out for any complications such as epistaxis, or any new symptoms that were not present preoperatively.  They   were   also examined using nasal endoscope for any residual deformity of nasal septum or spurs, septal perforation, septal hematoma, nasal adhesion. In   cases complicated with adhesions they were managed by cutting the adhesions and insertion of a corticosteroid pack for few days. Both groups were compared objectively using the nasal endoscope regarding the healing process and the incidence of complications.

Statistical analysis

Prior to statistical analysis, the data were checked for normality using the Kolmogorov-Smirnov test. Continuous variables were defined by range, mean, and standard deviation, while categorical variables were described by number and percent (N, percent) (SD). The chi-square test and Fisher exact test were used to compare categorical variables, while the t-test was used to analyze continuous variables. Statistical significance was defined as a two-tailed p 0.05. The IBM SPSS 20.0 program was used to conduct all of the analyses.

RESULTS

There was no statistically significant difference in age and sex of both groups. (P-value was 0.379 & 0.196 respectively). Mean age of group A was 29.77 ± 6.58 years with range among 20 and 44 years and Mean age of Group B was 31.27 ± 6.51 years with range among 20 and 50 years . 30 patients (group A) who underwent endoscopic septoplasty, 17 (56.7%) were males and 13 (43.3%) were female patients. Likewise, among 30 patients (group B) who underwent conventional septoplasty, 12 (40.0%) were males and 18 (60.0%) were female patients.

Types of the septal deformity showed no statistically significant difference between both groups, (P-value 0.651). In group A: 9 (30%) patients had c shaped septal deviation, whereas 12 (40%) patients had an isolated spur deviation, and 9 (30%) patients had s shaped septal deviation. In group B: 12 (40%) patients had c shaped deviated septum, whereas 9 (30%) patients had an isolated spur deviation, and 9 (30%) patients had s shaped deviated septum..

Table 1: operative findings of both groups.

Regarding duration of surgery  and intra operative blood loss there is statistically significant between both groups (p value  > 0.001).

N.B.( Intraoperative blood loss was calculated by subtracting the volume of total irrigation used during the surgery  from the total amount of fluid in the suction canister at the end of surgery).

Table 2: Pre-operative Assessment of  nasal manifestations in both groups.

There is no  statistically significant in  pre-operative assessment of  nasal manifestations in both groups.

Table 3: Post-operative improvement of  nasal manifestations after 3 months.

There is no statistically significant between both groups in Post-operative improvement of  nasal manifestations after 3 months.

Table 4: Post-operative complications in both groups.

Regarding post-operative complications in both groups there is not statistically significant between both groups.