www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
An
often
neglected
area
in
crooked
nose:
middle
turbinate
pneumatization
夽
Fatih
Özdo˘
gan
∗,
Halil
Erdem
Özel,
Erkan
Esen,
Erdem
Altıparmak,
Selahattin
Genc
¸,
Adin
Selc
¸uk
DerinceResearchandTrainingHospital,DepartmentofOtolaryngology,Kocaeli,Turkey
Received5April2016;accepted30June2016 Availableonline20July2016
KEYWORDS
Turbinate; Crookednose; Rhinoplasty; Nasalairway
Abstract
Introduction:Crookedordeviatednoseisadeviationofthenosefromthestraightvertical position oftheface. Extensive pneumatizationofthe middleturbinate, alsocalled concha bullosaorbullousmiddleturbinate(BMT)isknowntobeoneofthepossibleetiologicfactors innasal obstruction, recurrentsinusitis,andheadache. Thereisnostudy concerning alink betweenBMTandcrookednose.
Objective: ToinvestigatetheassociationbetweencrookednoseandthepresenceofaBMT.
Methods:A total of 199 patients who underwent open septorhinoplasty were retrospec-tivelyanalyzed.PreoperativeparanasalComputerizedTomography(CT)findings,preoperative photodocumentation,andanteriorrhinoscopicexaminationfindingsweredocumented.Ofthe 199patients,169werefoundtomeetthecriteriaandwereincludedinthestudy.CTscanswere examinedtonotethepresenceofBMT,inferiorturbinatehypertrophy,andseptumdeviation (SD).SDsandcrookednoseswereclassified.
Results:Ninety-fourof169patients(56%)presentedacrookednosedeformityandseventy-five of169patients (44%)presentedastraightnose. While49(52%)crookednosepatientshada bulbousandextensiveBMT,20patients withstraightnose(26.6%)hadaBMT.Astatistically significantrelationshipwasfoundbetweenthepresenceofcrookednoseandBMT,regardless ofthesideofthedisease(p=0.011).
Conclusion: ThisstudyrevealedalinkbetweencrookednoseandBMT.
© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:Özdo˘ganF,ÖzelHE,EsenE,AltıparmakE,Genc¸S,Selc¸ukA.Anoftenneglectedareaincrookednose:middle
turbinatepneumatization.BrazJOtorhinolaryngol.2017;83:563---7.
∗Correspondingauthor.
E-mail:ozdogan.fatih@gmail.com(F.Özdo˘gan).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
http://dx.doi.org/10.1016/j.bjorl.2016.06.006
1808-8694/©2016Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen
Nariztorto; Rinoplastia;
Viarespiratórianasal
Resumo
Introduc¸ão:Onariztortoouonarizcomdesvioéumnarizcomumdesviodaposic¸ãovertical retadaface.Apneumatizac¸ãoextensadaconchamédiatambémchamadadeconchabolhosa ouconchamédiabolhosa(CMB)éconhecidaporserum dospossíveisfatoresetiológicosda obstruc¸ãonasal,sinusiterecorrenteecefaleia.Nãohánenhumestudorelativoaumaassociac¸ão entreCMBenariztorto.
Objetivo:Investigaraassociac¸ãoentreonariztortoeapresenc¸adeCMB.
Método: Foramanalisados retrospectivamente 199 pacientesque se submeteram a septor-rinoplastia aberta. Achados pré-operatórios paranasais àtomografia computadorizada (TC), fotodocumentac¸ão pré-operatória e exame rinoscópico anterior foramregistrados. Dos 199 pacientes, observou-se que169 atendiam aos critérios e foramincluídos no estudo. AsTC foramexaminadasparaobservarapresenc¸adeCMB,hipertrofiadeconchasinferioresedesvio desepto(DS).OsDSenarizestortosforamentãoclassificados.
Resultados: Dos169pacientes,94(56%)apresentavamumadeformidadedenarize75(44%) apresentavamnarizreto.Enquanto49(52%)pacientescomnariztortotinhamCMBextensa, 20pacientescomnarizreto(26,6%)tinhamCMB. Umarelac¸ãoestatisticamentesignificativa foiencontradaentreapresenc¸adenariztortoeCMB,independentementedoladodadoenc¸a (p=0,011).
Conclusão:Esteestudorevelouumarelac¸ãoentreonariztortoeCMB.
© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Crookedordeviatednoseisadeviationofthenosefromthe straightverticalpositionoftheface.Inadditiontoesthetic deformity,functionalproblemsduetoobstructionofthe air-waycanbeseenindeviatednose.Crookednoseisassociated withnasal obstruction, sinus headaches, and sinus infec-tions.Mostdeviationsinvolveseveralstructuresofthenose, andfailuretocorrectalltheabnormalitiesoftenresultsin disappointing outcomes.Therefore, it is essential to con-sider both the internal nasal structuressuch as thenasal valveandturbinates,andtheexternalnasalframe.1,2
Extensivepneumatizationof themiddleturbinate, also calledconchabullosaorbullousmiddleturbinate(BMT),is knowntobeoneof thepossible etiologicfactors innasal obstruction, recurrent sinusitis, and headache.3,4 Several studieshavebeenfocusedontherelationbetweenseptum deviations(SD)thatcanbeoneofthemaincausesofnasal airairwayobstructionandBMT.5,6However,tothebestof ourknowledge,thereisnostudyconcerningalinkbetween BMTandcrookednose.Themainobjectiveofthisstudyis toinvestigatetheassociationbetweencrookednoseandthe presenceofaBMT.
Methods
A total of 199 patients who underwent open Septorhino-plasty (SRP) between May 2011 and February 2015 were retrospectively analyzed. This study was approved by thelocalethicscommittee (KAEK2014-232).Preoperative
paranasal CT findings, preoperative photodocumentation, and anterior rhinoscopy examination findings were docu-mented. The patients who underwent previous sinonasal surgeryandhadamajornasaltraumawereexcludedfrom thestudy(onlypatientswithtype1nasalinjuryhistorywere included).7Atotalof169patientswithanasalSDwhohad undergoneSRPwereincludedinthestudy.Paranasalsinus CTscansof169patientswerestudiedretrospectively.Image sectionswere1mmthick.
Allpatientsunderwentadetailedotolaryngologic exam-inationandpreoperativephotography,consistingoffrontal, basal,lateral,andobliqueviews.Thecriteriausedforthe classificationofcrookednosewereasfollows(Fig.1A---C)8:
TypeI---Deviationofthelowertwo-thirdsofnose; TypeII---Deviationofthewholenoseinthesamedirection; TypeIII---Deviationofthewholenosewithacurvedrhinion.
CTscanswereexaminedtonotethepresenceofaBMT, inferior turbinate hypertrophy, and SD.BMTs were classi-fiedintothreetypesaccordingtotheshapeofthebullous change:lamellarBMT,bulbousBMTandextensiveBMT.Only bulbous and extensive types of BMTwere included in the study(Fig.2A---C).9
Figure1 (A)TypeIcrookednose(deviationofthelowertwo-thirdsofnose).(B)TypeIIcrookednose(deviationofthewhole noseinthesamedirection).(C)TypeIIIcrookednose(deviationofthewholenosewithacurvedrhinion).
Figure2 (A)LamellarBMT(asterisk:pneumatizedmiddleturbinate).(B)BulbousBMT(asterisk:pneumatizedmiddleturbinate). (C)ExtensiveBMT(asterisk:pneumatizedmiddleturbinate).
patients having inferior turbinate hypertrophy were per-formedradiofrequencythermalablation.
DatawereanalyzedwithStatisticalProductandService Solutions(SPSS),predictiveanalyticssoftware(PASW),and Statistics21(SPSSInc.,Chicago,IL,USA).Chi-squaretests wereappliedforthemeasurements;p<0.05wasconsidered statisticallysignificant.
Results
Ninety-fourof169patients(56%)presentedacrookednose deformityandseventy-fiveof169patients(44%)presented astraight nose.SDwaspresent inallpatients, whichwas confirmed byCT.Among patientswitha crookednose, 61 (65%)weremalesand33(35%)werefemales,withamean age of 27.2 years(range18---50 years). Among thosewith astraightnose,42patients(66%)weremalesand33(44%) werefemales,withameanageof29.8years(range18---54 years).Themostcommoncrookednosetypewastype3---47 patients(50%),followedbytype2---28patients(29.7%),and type1---19patients(20.2%)(Table1).
BulbousandextensiveBMTwasdetectedin49outofthe 94patientswhohadacrookednose(52%)andin20outofthe
75patientswhohadastraightnose(26.6%).Astatistically significantrelationshipwasfoundbetweenthepresenceof crookednoseandBMTregardlessofthesideofthecondition (p=0.011).Nosignificantcorrelationwasobservedbetween thetypeofnasalaxisdeviationandthepresenceofBMT.The distributionofpatientsaccording tothepresenceofnasal axisdeviationandtypeofBMTispresentedinTable2.
Nosignificantcorrelationwasobservedbetweentheside ofnasalaxisdeviationandthesideofBMT(p=0.469).The distributionofpatientsaccordingtothenasalaxisdeviation andsideofBMTispresentedinTable3.
Discussion
Extensive pneumatization of the middle turbinate, also calledconchabullosaorbullousmiddleturbinate(BMT),is knowntobeoneof thepossible etiologicfactors innasal obstruction,recurrentsinusitis,andheadache.3,4BMTisone ofthemostcommonanatomicalvariationsthatcanbeseen inthenasalcavity.10
Crookednose Straightnose
n(%) n(%)
Gender
Male 61(65) 42(66)
Female 33(35) 33(44)
Total 94(56) 75(44)
Age 18---50(27.2) 18---54(29.8)
Nasaldeviationtype
Type1 19(20.3)
---Type2 28(29.7)
---Type3 47(50)
---Nasaldeviationside
Not-exist --- 75
Left 47(50)
---Right 47(50)
---Septumdeviationside
Left 55(58.5) 44(58.6) Right 39(41.4) 31(41.3)
Bullousmiddleturbinatetype
Not-exist 30(31.9) 42(56) Lamellar 15(15.9) 13(17.3) Bulbousandextensive 49(52.1) 20(26.6)
Bullousmiddleturbinateside
Not-exist 30(31.9) 42(56)
Left 29(30.8) 4(5.3)
Right 14(14.8) 11(14.6) Bilateral 21(22.3) 18(24)
Inferiorturbinatehypertrophia
Not-exist 30(31.9) 28(37.3)
Left 18(19.1) 7(9.3)
Right 19(20.2) 15(15.9) Bilateral 27(28.7) 25(33.3)
Table2 Distributionofpatientsaccordingtopresenceof nasalaxisdeviationandtypeofbullousmiddleturbinate.
ND BMTn(%) p
n(%) Not-exist Lamellar Bulbousand Extensive
Not-exist 42(56) 13(17.3) 20(26.6) 0.011
Exist 30(31.9) 15(15.9) 49(52.1)
Total 72(42.6) 28(16.6) 69(40.8)
ND, nasal deviation; BMT, bullous middleturbinate; p-values weredeterminedusingtheChi-squaredtest.
type,aircellswerenotedtopneumatizetheinferioror bulb-oussegmentof theturbinate.Inthethirdtype,extensive pneumatizationwasobserved in thelamellar andbulbous portion of the turbinate.4 The incidence of BMT mostly ranges from 14% to 53% in the literature11 Khojastepour etal.12determinedBMTvariationin189(67.3%)of281 rhino-plastycasesintheirpreoperativeparanasalCTanalysis.This proportionwas40%inallcasesinourstudy.
bullousmiddleturbinate.
NDside BMTsiden(%) p
n(%) Right Left Total
Not-exist 16(17) 14(14.9) 30(31.9) 0.469 Right 8(8.5) 6(6.4) 14(14.9)
Left 11(11.7) 18(19.1) 29(30.9) Bilateral 12(12.8) 9(9.6) 21(22.3)
Total 47(50) 47(50) 94(100)
ND, nasal deviation; BMT,bullous middle turbinate; p-values weredeterminedusingtheChi-squaredtest.
The relationship betweenSD andBMT hasbeen known for a longtime.The incidence ofcoexistence of nasalSD andBMT ishigh. The relationship betweenBMT andnasal SD hasbeen reported byAktas etal.,5 Bhandaryet al.,13 and Yigit et al.6 However, to the bestof our knowledge, thereisnostudyconcerningalinkbetweenBMTandcrooked nose. In our case series, we determined 49 crookednose patients(52%)havingabulbous andextensiveBMTand20 patientswithastraightnose(26.6%)andbulbousand exten-sive BMT.Thisassociation between BMTandcrookednose maybeassumedasaconditionthatcanoccuraftertrauma bythedeteriorationofthenasalairwaydynamics.
Externallynasaldeviationalwaysresultsinadeviationof thenasalseptum.Sauletal.14reportedperpendicularplate deviationdistortedtothereverse sideofthedeviation of thedeviatednosein79%ofthepatients.Themostcommon SDtypeinourpatientswhohadacrookednosewasposterior verticaldeviation23patients(24.4%).
Preoperativeevaluationandsurgicalmanagementofthe nasalairwayinrhinoplastypatientsareessential.According toaquestionnaireappliedto671membersoftheAmerican SocietyofPlasticSurgeonsbyAfifietal.,15thequestion‘‘in yourpreoperativeexammiddleturbinateroutinelyassess?’’ wasansweredas‘‘yes’’by39.9%oftheparticipants.In addi-tion,24.1%oftheparticipantsansweredthequestion‘‘Ifa patientpresentingforanestheticrhinoplastyhascomplaints ofdifficultywithbreathingthroughthenose,wouldyou per-formtheprocedure?’’as‘‘dotheestheticrhinoplastyanda thoroughseptoplastyand turbinateresection.’’The ques-tion of ‘‘how often do you address the middle turbinate duringrhinoplasty?’’wasansweredasneverby71%ofthe participants.Theseresultssuggestthatthemiddleturbinate is often neglected in rhinoplasty. In our study, intranasal endoscopicexaminationwasperformedinallpatientsprior toperforming SRPand preoperative CT.Forpatients hav-ingaBMT,partialresectionoftheturbinatewasperformed simultaneouslyaswell.
SRP,amongelectivefacialsurgeries,isoneofthemost frequentcausesforlitigation.Airwayproblemsarethemain concerns in several of these cases. Nasal obstruction is remarkablyassociatedwithadecreaseinqualityoflifein thesepatients.15
Therefore, in patients scheduled for SRP (particularly witha crooked nose), the presence of BMTis oneof the factorsaffectingthepatient’s nasalobstructionthatmust bedetectedasapreoperativeinterventionandmanaged.
Conclusion
Sufficient information is unavailable in the literature on theincidenceofthecoexistenceofcrookednoseandBMT. Unfortunately, the presence of BMT in deviated nose has beenignoredbymostoftherhinoplastysurgeon.Ourresults indicate that BMT incidence is higher in patients with a crookednose,forwhomSRPhasbeenplanned,thaninthose withastraightnose.Therefore,inthesepatients,adetailed preoperative examination should beperformed, the pres-enceofBMTmustbedetectedandshownwithaparanasal CTscan,andBMTinterventionshouldbeconducted simulta-neouslywithSRP.Themostimportantlimitationofthisstudy isthatpostoperativeairwayandnasaldrynesswerenot eval-uated.Postoperativefunctionalresultscanbeevaluatedby prospectivestudies.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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