ORIGINAL ARTICLE
Effect of Deviated Nasal Septum Type on Nasal
Mucociliary Clearance, Olfactory Function, Quality of
Life, and Efficiency of Nasal Surgery
Güler Berkiten, MD, Tolgar Lütfi Kumral, MD, Ziya Saltürk, MD, Yavuz Atar, MD,
Güven Yildirim, MD, Yavuz Uyar, MD, Imran Aydoğdu, MD, and Ahmet Arslanoğlu, MD
Objective: The aim of this study was to analyze the influence of
deviated nasal septum (DNS) type on nasal mucociliary clearance,
quality of life (QoL), olfactory function, and efficiency of nasal
surgery (septoplasty with or without inferior turbinate reduction and
partial middle turbinectomy).
Methods: Fifty patients (20 females and 30 males) with septal
deviation were included in the study and were divided into 6 groups
according to deviation type after examination by nasal endoscopy
and paranasal computed tomography. The saccharin clearance test
to evaluate the nasal mucociliary clearance time, Connecticut
Chemosensory Clinical Research Center smell test for olfactory
function, and sinonasal outcome test-22 (SNOT-22) for patient
satisfaction were applied preoperatively and postoperatively at
the sixth week after surgery.
Result: Nasal mucociliary clearance, smell, and SNOT-22 scores
were measured before surgery and at the sixth week following
surgery. No significant difference was found in olfactory and
SNOT-22 scores for any of the DNS types (both convex and
concave sides) (P > 0.05). In addition, there was no difference
in the saccharin clearance time (SCT) of the concave and convex
sides (P > 0.05). According to the DNS type, the mean SCT of the
convex sides showed no difference, but that of the concave sides
showed a difference in types 3, 4, 5, and 6. These types had a
prolonged SCT (P < 0.05). Olfactory scores revealed no
difference postoperatively in types 5 and 6 but were decreased
significantly in types 1 to 4 (P < 0.05). There was no significant
difference in the healing of both the mucociliary clearance (MCC)
and olfactory functions. SNOT-22 results showed a significant
decrease in type 3.
Conclusion: All DNS types disturb the QoL regarding nasal MCC
and olfaction functions. MCC values, olfactory function, and QoL
scores are similar among the DNS types. Both sides of the DNS
types affect the MCC scores symmetrically. Septal surgery
improves olfaction function and QoL at the sixth week following
From the Okmeydani Training and Research Hospital Ear Nose and Throat
Clinic, Şişli, Istanbul, Turkey.
Received December 20, 2015.
Accepted for publication February 13, 2016.
Address correspondence and reprint requests to Güler Berkiten, Okmeydani
Trainining and Research Hospital Ear Nose and Throat Clinic,
Kaptanpaşa Mah. Darülaceze Cad., 34384 Şişli, Istanbul, Turkey;
E-mail: gulerberkiten@gmail.com
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002696
The Journal of Craniofacial Surgery  Volume 27, Number 5, July 2016
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
surgery but disturbs nasal MCC; thus, the sixth week is too early to
assess nasal MCC.
Key Words: Mucociliary clearance, saccharine test, septal
deviation classification, septoplasty, smell test, SNOT-22
(J Craniofac Surg 2016;27: 1151–1155)
A deviated nasal septum (DNS) remains asymptomatic, although
they may cause nasal obstruction, nasal discharge, facial pain,
epistaxis, and disturbance of smell. The location, severity, and type
of DNS are the factors that affect the dynamics of airflow in the
nasal cavity. Compensatory hypertrophy of the mucosa of the lateral
nasal wall on the opposite side may also cause disturbance of
olfactory functions, a decrease in nasal mucociliary clearance
(MCC) and obstruction of the osteomeatal complex, leading to
sinusitis. These changes in the sinonasal cavity impair the quality of
life (QoL) and may lead to septum and sinus surgery.1 However,
recently published studies have revealed conflicting results follow-
ing surgery for DNS.2 Medical history and clinical assessment are
crucial to decide surgery and prevent unnecessary surgical inter-
ventions. Differences between patients’ expectations and phys-
icians’ perception are one of the major handicaps to attaining
success; therefore, a preoperative detailed assessment is important
both for making decisions concerning surgery and the success of
surgery. Anatomic localization of septal deviations, classification
of DNS types, and quality of life (QoL) questionnaires guide
surgeons regarding the indication and estimating the functional
outcomes of surgery.3
The aim of this study was to analyze the influence of the DNS
type on MCC, QoL, olfactory functions, and efficiency of nasal
surgery (septoplasty with or without inferior turbinate reduction and
partial middle turbinectomy).
METHODS
Patients and Treatment
International Review Board approval was obtained from the
Okmeydani Training and Research Hospital Ethical Committee.
Fifty patients who were diagnosed with DNS at the Okmeydani
Training and Research Hospital, Department of Otorhinolaryngol-
ogy–Head and Neck Surgery (Istanbul, Turkey) between January
2014 and July 2014 were included in the study. Nasal examinations
of the patients were performed by 2 specialists using anterior
rhinoscopy and transnasal endoscopy. Patients aged older than
18 years who had a surgical indication for nasal septal surgery
and experienced nasal obstruction for more than 3 months were
included in the study. The exclusion criteria were as follows: a
history of previous nasal surgery, the use of pharmacological agents
affecting MCC, the presence of nasal polyposis, sinonasal
1151
Berkiten et al The Journal of Craniofacial Surgery  Volume 27, Number 5, July 2016

pathologies, nasal discharge and allergic rhinitis, a history of
subjective olfactory disorder, upper respiratory tract infections
within the last 4 months, systemic disease that impairs ciliary
activity, nasal septal perforation after surgery, and a smoking habit.
Patients underwent preoperative ear, nose, and throat examin-
ation; nasal endoscopy; and coronal and sagittal plane computed
tomography. The surgical procedure was septoplasty with or with-
out inferior turbinate reduction and partial middle turbinectomy
under general anesthesia. Patients were instructed to irrigate their
nose with normal saline regularly for 1 week.
Patients were classified based on the type of septal deviation.
The saccharin clearance time (SCT) for nasal MCC, Connecticut
Chemosensory Clinical Research Center (CCCRC) olfactory test,
and sinonasal outcome test-22 (SNOT-22) were administered pre-
operatively and at the sixth week postoperatively.
EVALUATION OF OBSTRUCTION
Deviated Nasal Septum Classification
The DNS status of all patients was classified into 6 groups
according to Baumann and Baumann classification.4 The side of
DNS, absence of deflection, pathologic findings such as anterior
subluxation of the septum, vomeral spur, deviated nasal crest, and
high septal deviation were recorded. Accompanying choncal hyper-
trophy or chonca bullosa was recorded.
deiodinized water. Each concentration was presented along with
a water control in a double-blind, forced-choice paradigm. The
threshold is defined as the dilution at which the butanol bottle was
correctly identified in 4 consecutive trials. Seven olfactory stimuli
(baby powder, chocolate, cinnamon, coffee, mothballs, peanut
butter, and soap) and 3 stimuli (ammonia, Vicks Vaporub [Ecza-
cibasi drug company, Istanbul, Turkey] and wintergreen) were used
to analyze the sensory function of the trigeminal nerve. Olfactory
tests were conducted individually and were scored out of 7 (0: worst
olfaction; 7: best olfaction).6
Measurement of Mucociliary Clearance:
Saccharin Clearance Time
Mucociliary clearance was measured using SCT, which was
described by Rutland and Cole.7 Patients were informed not to
receive anesthetics, analgesics, barbiturates, tranquilizers, anti-
depressants, as well as not to consume alcohol, caffeinated bev-
erages or foods for 12 hours before the test. Patients were asked to
sit on a medical procedure chair with minimal head extension, and
not to speak, sniff, sneeze, or cough. A quarter tablet of saccharin
was placed 0.5 cm behind the anterior end of the inferior turbinate.
Patients were asked to swallow every 60 seconds. The time between
placement of the tablet and perception of the sweet taste of
saccharin was noted. A normal SCT was considered between 7
and 15 minutes, SCT over 20 minutes was considered pathologic.8

Quality of Life Statistical Analysis

The clinical symptom severity scores were graded on the SNOT-
22 questionnaire. Sinonasal outcome test-22 was compared pre-
operatively and postoperatively for each DNS type.5
Olfactory Function Measurement
The CCCRC test was used to test olfactory cognition.
Connecticut Chemosensory Clinical Research
Center Smell Test
The CCCRC test was performed using a commercially available
test kit in an odor-free room under standardized conditions. The
CCCRC test is composed of 2 sections: identification of the odor
and detection of the threshold. All steps were carried out for each
nasal passage, while the other nasal airway was obstructed. The
detection of the threshold was measured with a series of bottles
containing 9 concentrations of n-butyl alcohol. The maximum
concentration of n-butyl alcohol was 4% (bottle 0). Each subsequent
bottle contained a threefold dilution of n-butyl alcohol with
Statistical analyses of the data were conducted using SPSS 17
(SPSS Inc, Chicago, IL). Data were analyzed using descriptive
statistical methods (mean and standard deviation). Parametric
paired sample t test was used for the comparison of 2 dependent
groups. Results were evaluated using the 95% confidence intervals,
and the level of significance was set at a P value less than 0.05.
Analysis of variance (ANOVA) was used to analyze the DNS types.
Statistical post hoc Tukey analysis was used for intergroup com-
parison of data that were normally distributed.
RESULTS
Fifty subjects were recruited for the study. These patients were
divided into 6 groups based on the type of septal deviation.
Deformities of types 1 through 6 occurred in 7 (14%), 11 (22%),
8 (16%), 12 (24%), 8 (16%), and 4 (8%) patients. The most common
type was type 4, and the least common was type 6 (Table 1).
SCT, olfactory function, and SNOT-22 of the convex and
concave sides were measured before surgery and at 6 weeks
following surgery.

TABLE 1. Deviated Nasal Septum Types and Leading and Concomitant Pathologies4

Septal Pathology Leading

DNS Type N % Pathology Concomitant Pathologies Turbinal Pathology

Type 1 7 14 Septal crest Ipsilateral vomeral spur Contralateral turbinal hyperplasia

Type 2 11 22 Cartlilaginous deviated nose Ipsilateral subluxatio contralateral vertical septal deviation Ipsilateral turbinal hyperplasia
Type 3 8 16 High septal deviation Contralateral septal crest Bilateral turbinal hyperplasia
contralateral concha bullosa
Type 4 12 24 Caudally inclined septum Contralateral subluxatio, ipsilateral vertical septal deviation, Contralateral turbinal hyperplasia
ipsilateral septal crest ipsilateral vomeral spur contralateral concha bullosa
Type 5 8 16 Septal crest Contralateral vomeral spur Bilateral turbinal hyperplasia
Type 6 4 8 Caudally inclined septum contralateral subluxatio, ipsilateral vertical septal deviation, bilateral turbinal hyperplasia
contralateral septal crest, contralateral vomeral spur

DNS, deviated nasal septum.

1152 # 2016 Mutaz B. Habal, MD

Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 27, Number 5, July 2016 Effect of Deviation on Nasal Functions

TABLE 2. Preoperative and Postoperative Deviated Convex Side Saccharin Clearance Time and Nondeviated Concave Contralateral Side Saccharin Clearance Time

Preop Deviated Postop Deviated Preop Nondeviated Postop Nondeviated

Convex Side SCT Convex Side SCT Concave Side SCT Concave Side SCT

þ þ
Group MeanSD MeanSD P MeanSD MeanSD P

Type 1 (n ¼ 7) 9.57  3.51 12,5000  4.14 0.111 8.14  2.12 13.14  4.14 0.035
Type 2 (n ¼ 11) 11.55  5.52 13.46  6.12 0.069 10.09  4.95 12.00  5.78 0.006
Type 3 (n ¼ 8) 13.75  5.80 12.50  5.53 0.448 11.13  6.42 11.00  4.93 0.936
Type 4 (n ¼ 12) 11.92  4.42 11.67  6.67 0.860 9.25  4.63 11.00  5.74 0.131
Type 5 (n ¼ 8) 10.38  3.96 11.25  4.92 0.622 9,63  3.11 11.13  4.22 0.354
Type 6 (n ¼ 4) 18.00  2.83 21,50  3.11 0.077 17.50  5.57 15.75  10.63 0.653
Total (n ¼ 50) 12.04  4.94 13.12  5.92 0.091 10.30  4.99 11.92  5.58 0.009
P 0.079 0.076 0.051 0.730

DNS, deviated nasal septum; SCT, saccharin clearance time; SD, standard deviation.
Dependent samples t test (þP < 0.05).
ANOVA (P < 0.05).

Significant P value.

There was no difference in SCT scores at the convex and
concave sides preoperatively among the deviation subtypes
(P > 0.05) (Table 2). There was no difference in the convex side
between the pre- and postoperative results (RP > 0.05). On the other
hand, the concave side showed a difference in type 1 and 2
deviations (RP < 0.05) but not in the others (RP > 0.05). In
addition, the mean postoperative SCT values in the concave side
were higher than the preoperative values (RP ¼ 0.009) (Table 2).
There was no difference in preoperative results between the convex
and concave sides (P > 0.05) (Table 2).
There was no significant difference in the olfactory test results
preoperatively among the groups (P > 0.05). Comparison of the
pre- and postoperative scores revealed a statistically significant
difference (RP < 0.05) according to the deviation type: types 1, 2,
3, and 4 showed a significant increase, but types 5 and 6 did not
differ (RP > 0.05). In addition, there was no statistically significant
difference among the deviation subtypes postoperatively (P > 0.05)
(Table 3).
There was no significant difference in the SNOT results pre-
operatively among the groups (P > 0.05). Comparison of the pre-
and postoperative scores revealed a statistically significant decrease
(RP < 0.05) according to deviation type: types 2, 3, 4, and 5 showed
a decrease (RP < 0.05), but types 1, 5, and 6 did not show a
difference (RP > 0.05). In addition, there was no statistically sig-
nificant difference among the deviation subtypes postoperatively
(P > 0.05) (Table 3).
There was no difference among the deviation subtypes in the
mean changes of SCT at both the concave and convex sides
(P > 0.05). There was also no difference in olfactory score changes
(P > 0.05). On the other hand, SNOT changes showed significant
differences. A post hoc Tukey test revealed that type 3 showed more
differences than the other groups (P < 0.05). However, improve-
ment of other types did not show a significant difference among the
subtypes (P > 0.05) (Table 4).
DISCUSSION
Success of septal surgery depends on many factors, with the type of
septal deformity being one of the most important. Nasal examin-
ation and subjective symptoms of patients affect the decision
making for surgery.9 The effects of septal deformity type on
symptoms have not been evaluated to date. The present study
evaluated the effects of septal deformity type on MCC, olfaction
function, and QoL. Classification for DNS can be a guide for
planning surgery and to avoid unnecessary and complicated inter-
ventions.4 Many studies have been conducted on the classification
of DNS, but none of these classifications is widely accepted.

TABLE 3. Preoperative and Postoperative Evaluation of Olfaction by Sinonasal Outcome Test-22

Preop Smell Postop Smell Preop SNOT-22 Postop SNOT-22

þ þ
Mean  SD Mean  SD P MeanSD Mean SD P


Type 1 (n ¼ 7) 3.32  0.92 4.86  0.45 0.000 34.29  8.81 27.00  12.03 0.103
Type 2 (n ¼ 11) 4.27  0.76 5.41  0.56 0.000 39.18  12.55 23.09  7.22 0.000
Type 3 (n ¼ 8) 3.81  0.82 5.19  0.69 0.001 53.38  10.82 26.38  10.78 0.000
Type 4 (n ¼ 12) 3.83  0.81 5.02  0.88 0.000 43.25  24.88 31.25  17.51 0.005
Type 5 (n ¼ 8) 3.97  1.09 4.66  1.15 0.066 43.50  22.89 28.88  18.98 0.000
Type 6 (n ¼ 4) 3.00  0.61 4.75  0.87 0.067 43.75  17.71 25.25  8.06 0.051
Total (n ¼ 50) 3.81  0.89 5.03  0.80 0.000 42.80  17.978 27.22  13.34 0.000
P 0.120 0.383 0.453 0.810

DNS, deviated nasal septum; SNOT-22, sinonasal outcome test-22.

Dependent samples t test (þP <0.05).
ANOVA (P < 0.05).

Significant P value.

# 2016 Mutaz B. Habal, MD 1153

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Berkiten et al
TABLE 4. Mean Change in Sinonasal Outcome Test-22, Smell and Saccharin Clearance Time According to Deviation Type
SCT, Deviated Convex Side
DNS Types Mean (Post–Pre)
Type 1 (n ¼ 7) 3.57  5.06
Type 2 (n ¼ 11) 1.91  3.11
Type 3 (n ¼ 8) 1.25  4.40
Type 4 (n ¼ 12) 0.25  4.81
Type 5 (n ¼ 8) 0.88  4.79
Type 6 (n ¼ 4) 3.50  2.65
Total (n ¼ 50) 1.08  4.43
P 0.212
SCT, saccharin clearance time; SNOT-22, sinonasal outcome test-22.
ANOVA P <0.05.
Mladina10 modified the classification of Rao et al11 and grouped
DNS under seven types. Guyuron et al12 used a system that
separates DNS into 6 groups depending on whether it is ‘‘S’’ or
‘‘C’’ shaped. Büyükertan et al13 categorized the nasal septum into
10 types, and Jin et al14 categorized them into 6 types according to
CT images; however, anatomic and pathologic variations of turbi-
nates were not considered in these studies. Baumann and Baumann4
classification system is based on septal geometry associated with
turbinate pathologies; therefore, we used the Baumann classifi-
cation, which considers lower and middle turbinate conditions. Rao
et al15 researched the incidence of DNS types, and relationship
between deviation types and sinonasal pathologies. Prasad et al16
analyzed the connection between DNS types and chronic rhinosi-
nusitis. Eren et al9 evaluated relationships between DNS types and
surgical success, and revealed that types 2, 4, and 6 benefit more
from septal surgery. We assessed the relationship between DNS
type and MCC, olfactory function and QoL. Although there was no
difference in MCC and olfactory function according to deviation
subtype, QoL improved significantly in type 3 DNS.
Mucociliary clearance is the main defense mechanism of the
respiratory tract13,17–19. Direct and indirect tests were made to
determine MCC. The saccharin test is a simple, safe, and practical
test to measure the time of MCC. Mucociliary clearance declines
with stress, physical exercise, exposure to air pollutants, and
anatomic anomalies of the nose. The results of previous studies
on the effect of DNS on MCC are controversial. The presence of
inflammation, reduced density of cilia, and glandular acini impair
MCC in patients with DNS13. Jang et al13 found that SCT was
prolonged in the concave side of DNS due to increased ciliary loss.
Kamani et al20 found no difference in ciliary loss between both sides
of DNS, but it was stated that clearance was slower in the opposite
side of deviation. Yigit et al21 investigated the mucociliary transport
speed using rhinoscintigraphy on a sided DNS before surgery, and
found that it significantly increased the mucociliary transport speed
on the concave side compared with the convex side and control
group. Polat and Dostbil22 reported no statistically significant
difference between the convex and concave sides before surgery.
In our study, SCT between the convex side (12.04  4.94) and
concave side (10.30  4.99) of DNS showed no statistically sig-
nificant difference preoperatively (P ¼ 0.083). Moreover, analysis
based on septal deformity types revealed no significant difference in
both the convex and concave sides (P ¼ 0.212; P ¼ 0.128).
Polat and Dostbil22 and Sakallioğlu et al23 found no SCT
difference between the preoperative and postoperative first months
in patients who had septoplasty, but SCT values at the postoperative
first month were significantly higher than those at the third month.
1154
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 27, Number 5, July 2016
SCT, Nondeviated Concave Side Smell Change SNOT Change
Mean (Post–Pre) Mean (Post–Pre) Mean (Post–Pre)
5.00  4.87 1.54  0.57 7.29  10.05
1.91  1.81 1.14  0.51 16.09  8.28
0.13  4.22 1.38  0.77 27.00  7.05
1.75  3.72 1.19  0.76 12.00  11.97
1.50  4.28 0.69  0.89 14.63  6.41
1.75  7.04 1.75  1.24 18.50  11.73
1.62  4.24 1.22  0.78 15.58  10.73
0.128 0.201 0.005
Ohashi et al24 reported that complete regeneration had occurred at
the sixth week after mechanical injury of the nasal mucosa.
Recovery of the nasal mucosa is completed within 5 days after
mechanical injury if the basal cells and basement membrane are not
damaged. The response of the nasal mucosa to mechanical injury is
the recovery of the defect with a stratified epithelium at 1 week,
appearance of new ciliated epithelium at 3 weeks, and total regen-
eration of mucosa at 6 weeks. Our study also revealed that SCT was
prolonged in both the convex and concave sides at 6 weeks post-
operatively compared with the preoperative results. The increase in
SCT in the concave side was statistically significant. This improve-
ment was significant for DNS type 1 and type 2 (P < 0.05). On the
other hand, there was no statistically significant difference in
healing among the deviation subtypes. Therefore, nasal surgical
procedures such as septoplasty impair MCC during the immediate
postoperative period. Following septoplasty, impairment of MCC
improves with time.21,25 We believe that prolonged SCT was
related to the healing period, and 6 weeks postoperatively was
early for the evaluation of SCT. A longer follow-up period
is required.
Olfactory dysfunction can occur with nasal obstruction caused
by DNS and concha hypertrophy. Decreased olfactory functions are
correlated with the severity of septal deviation.26 Studies on olfac-
tory functions after surgery for DNS and concha hypertrophy show
various results. Although surgery can be suggested as the treatment
for some olfactory disorders, nasal surgery may harm olfactory
epithelium and worsen olfactory functions due to direct trauma and
traction.27,28 Studies that analyzed olfactory functions were depen-
dent on subjective data. Pade and Hummel29 assessed the effect of
nasal septal surgery and sinus surgery on olfactory functions and
found that olfactory functions are improved in 13%, impaired in
7%, and unchanged in 81% of patients who underwent septal
surgery. In our study, the preoperative and postoperative outcomes
of olfaction tests showed no significant difference among the DNS
types. The postoperative scores of olfaction tests decreased in 1
(2%) patient, increased in 48 (96%) patients, and did not change in 1
(2%) patient. The preoperative and postoperative olfaction scores
were significantly different (P < 0.05). Olfactory scores were sig-
nificantly different in types 1 to 4 in the pre and postoperative
results, but types 5 and 6 did not show any difference (P < 0.05).
Septoplasty recovered olfactory functions significantly (P ¼ 0.000).
Various methods and useful tests have been designed to classify
the severity of disease, determine the best treatment option, and
assess the treatment outcome.30,31 The SNOT-22 questionnaire is
one of the most specific tools for measuring QoL.32 SNOT-22 was
defined by Browne et al,33 and it covers health, physical status,
# 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 27, Number 5, July 2016
functional limitations, and emotional aspects related to the nasal
functions. In our study, we used SNOT-22 to assess the severity of
symptoms. Preoperative and postoperative SNOT-22 scores
revealed no difference among the DNS types (P > 0.05). A signifi-
cant decline was seen in postoperative SNOT-22 symptom scores
(P ¼ 0.000).
QoL was significantly improved in type 3 deviations compared
with others. Type 3 deviations showed a greater improvement in
QoL after surgery.
CONCLUSION
All DNS types impair MCC, olfaction functions, and QoL. MCC
values, olfactory functions, and QoL scores are similar among the
DNS types. Both convex and concave sides of the DNS types can
affect MCC scores symmetrically. Nasal septal surgery improves
olfactory functions and QoL but prolongs SCT, particularly on the
concave side at the sixth week following surgery; thus, this time
point is too early for assessment of nasal MCC.
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