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139]

Original Article

Evaluating Surgical Outcomes of Conventional Versus Endoscopic

Septoplasty Using Subjective and Objective Methods
S Doomra, M Singh, B Singh, A Kaushal

Department of ENT, Objectives: The aim of the study is to compare the pre‑  and post‑operative

Abstract
Government Medical College,
Patiala, Punjab, India
symptomatology, endoscopic findings, and nasal patency and to evaluate the
postoperative outcomes of conventional compared to endoscopic septoplasty (ES).
Materials and Methods: This prospective study was conducted at Rajindra
Hospital, Patiala, Punjab, India, on 50  patients aged between 18 and 60  years
having symptomatic deviated nasal septum and refractory to medical treatment.
The patients were divided into two groups: Group A, which included 25  patients
in whom conventional septoplasty  (CS) was performed, and Group  B, which
included 25  patients in whom ES was conducted. The postoperative assessment
was carried out at once weekly for 1  month and twice weekly for another
2  months. Results: Nasal obstruction was relieved in 79.1% cases belonging to
Group  A and 91.3% cases to Group  B. Headache was relieved in 62.5% cases
belonging to Group  A and 93.3% cases to Group  B. Postnasal drip was relieved
in 73.3% cases in Group A and 94.1% cases in Group  B. The results were found
to be statistically significant. An improvement in visual analog scale score was
observed in both groups, but statistically significant difference was seen at 2nd and
4th  week. Postoperative nasal patency improvement was observed in both groups
by the Gertner plate, and the results were found to be statistically significant.
Postoperative hemorrhage was observed in 24% cases in Group A and 12% cases
in Group B. Septal perforation, septal hematoma, and mucosal tear were observed
in 4%, 4%, and 8% of cases, respectively, in Group  A. No such complication
was reported in Group  B. Conclusion: ES is more effective in terms of relief of
symptoms and improvement of nasal patency. It is best for isolated spur, posterior
deviation, and revision surgery, but anterior caudal dislocation is best handled with
CS. Both these techniques should be taken as an adjuvant to each other.

Date of Acceptance: Keywords: Conventional septoplasty, deviated nasal septum, endoscopic

16-May-2019 septoplasty, nasal obstruction, postnasal drip, spur, visual analog scale

Introduction However, increasing incidence of complications of

N ose, being the most prominent part of the face, is
vulnerable to trauma right from the intrauterine
life. Nasal trauma usually involves the septum; thus, it is
unusual to find a straight septum in an adult.
Many methods have been described for correction
of different type of septal deviations Figure 1 shows
endoscopic view of DNS. The concept of submucosal
resection was made popular and modified by Killian[1]
and Freer[2] separately in the early 20th century.
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septal surgery led to the adoption of more conservative
septoplasty.[3] First elucidated by Cottle in 1947,
conventional septoplasty (CS) is a traditional surgery
in which only the deviated part is taken out, leaving
behind as much cartilage and bone as possible.[4] It has
Address for correspondence: Dr. M Singh,
Department of ENT, GMC Patiala, H.No. 2213, Sector 38-C,
Chandigarh - 160 014 (U.T), India. 
E‑mail: drmanjitsingh62@yahoo.com
This is an open access journal, and articles are distributed under the terms of the
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For reprints contact: reprints@medknow.com

DOI: 10.4103/njcp.njcp_101_19

How to cite this article: Doomra S, Singh M, Singh B, Kaushal A. Evaluating

PMID: ******* surgical outcomes of conventional versus endoscopic septoplasty using
subjective and objective methods. Niger J Clin Pract 2019;22:1372-7.

1372 © 2019 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow

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Doomra, et al.: Surgical outcomes of conventional versus endoscopic septoplasty
increased morbidity because of poor visualization, poor
illumination, relative inaccessibility, need for nasal
packing, difficulty in evaluation of the exact pathology,
unnecessary manipulation, resection, and overexposure
of the septal framework reducing the scope for a revision
surgery.[5]
It is study of Lanza et  al. Stammberger reported
endoscopic correction of septal deformity in
1991.[6] Endoscopic septoplasty  (ES) offers a number
of advantages over conventional headlight septoplasty
such as better visualization, more focused flap dissection
with resection of isolated deformities, lesser possibility
of flap tears, and a more natural transition when the
method is combined with endoscopic sinus surgery.[7,8]
Despite several benefits, ES can be difficult because of
frequent soiling of the lens of the endoscope by blood
from the incision site and difficulty in finding enough
space for the endoscope and dissectors in narrow septal
mucosal tunnels.
Therefore, the selection of best method for correction of
the deviated nasal septum  (DNS) is still controversial;
hence, we aimed to compare the outcomes of endoscopic
and conventional approaches for septoplasty and also the
postoperative results and complications between the two
Figure 2 showing intraoperative image of conventional
septoplasty Figure 3 showing intraoperative image of
endoscopic septoplasty.
Aims and objectives
The study was conducted to compare the  (1) pre‑  and
post‑operative symptomatology (subjective evaluation)
in traditional and ES, (2) pre‑  and post‑operative
endoscopic results and nasal patency (objective
evaluation) in traditional and ES, and  (3) outcomes of
CS compared to ES.
Materials and Methods
This study comparing CS and ES was conducted from
2016 to 2019 at the Ear, Nose, and Throat Department,
Rajindra Hospital, Patiala, Punjab, India. Fifty patients
with DNS were recruited and they were randomly divided
into Groups  A and B: 25  cases in each group. Group  A
underwent CS, whereas Group B underwent ES.
Inclusion criteria
The inclusion criteria were as follows: (1) patients
aged 18–60  years; (2) patients with symptomatic DNS
such as nasal obstruction, hyposmia, nasal discharge,
postnasal drip, and headache; (3) symptomatic patient
refractory to medical management; (4) patient with DNS
complications; and (5) informed consent given.
Exclusion criteria
The exclusion criteria were as follows: (1) patients
Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 10  ¦  October 2019
with allergic rhinitis; (2) patients with acute upper
respiratory tract infection; (3) patients with sinonasal
polypi; (4) patients with sinonasal malignancy; (5)
patients with mucoceles protruding from sinuses into
the nasal cavity;  (6) patients with radiation therapy
of head and neck; and (7) patients with any medical
condition that precludes elective surgery (including
pregnancy).
Detailed history was obtained from every patient.
Clinical assessment was conducted for all patients
preoperatively, and all patients underwent subjective and
objective assessments.
Subjective assessment
Nasal obstruction was assessed subjectively using a
visual analog scale  (VAS). The scores were determined
on a 0–10  cm  (100  mm) scale.[9] The VAS scoring
used in this study is as follows: 0  –  no obstruction;
1–3 – mild obstruction; 4–7 – moderate obstruction; and
8–10 – severe obstruction.[10]
Objective assessment
Nasal obstruction was assessed objectively by
performing anterior rhinoscopic examination, diagnostic
nasal endoscopy using a 0° adult nasal endoscope, and
nasal patency assessment by the Gertner plate. The
instrument itself is a 10  cm  ×  12  cm polished metal
chrome‑coated plate. The plate is marked with arches
1  cm apart. The method is based on measuring the area
of vapor condensed on the plate. The area fogged was
calculated using the following formula:[11]
Horizontal Distance (cm) Vertical Distance ( cm )
S= π × ×
2 2
where S is the surface area. Postoperative data regarding
relief of symptoms, any complication, and hospital stay
were collected. Subjective (VAS) and objective (Gertner
plate) assessments of nasal patency were conducted at
1, 2, 3, 4, 6, 8, 10, and 12  weeks postoperatively. The
data were compiled and analyzed statistically using a
paired t‑test and Chi‑square‑test Figure 4 showing Nasal
patency by Gertner's plate.
Results
In this study, majority of cases presented with bilateral
nasal obstruction  (Group  A, 56%; Group  B, 60%).
Nasal obstruction was not observed in one patient
belonging to Group A and two patients belonging to
Group B [Table  1]. These three cases were operated for
nasal bleeding complaint.
All the patients in this study had nasal septal
deviation, and the most prevalent was C‑shaped
deviation (Group A, 68%; Group B, 60%) [Table 2].
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Doomra, et al.: Surgical outcomes of conventional versus endoscopic septoplasty

Figure 1: Endoscopic view of DNS Figure 2: Intraoperative image of conventional septoplasty

Figure 4: Nasal patency by Gertner's plate

Figure 3: Intra operative image of endoscopic septoplasty

35

30.74
30.37
30.15
29.76
29.27
28.67
27.96
7.84

26.64

30 25.25

25.28
7.24

24.85

8
23.67

24.02
23.69
23.4
22.02

7 25
Mean Score

16.97
16.78

6 20
Mean Score

5 Group A
15 Group A
4 Group B
10 Group B
3
2.08

1.36
1.24
1.6

2 5
0.92

0.76

0.72

0.72
0.76

0.036
0.36

0.24
0.24

1
0.2

0.2

0.2

0
0
Pre-Treatment

1st Week

2nd Weeks

3rd Weeks

4th Weeks (1 Month)

6th Weeks

8th Weeks (2 Month)

10th Weeks

12th Weeks (3 Month)

Pre-Treatment

10th Weeks

12th Weeks
2nd Weeks

3rd Weeks

6th Weeks
4th Weeks

8th Weeks
(2 Month)

(3 Month)
1st Week

(1Month)

Duration

Figure 5: Comparison of nasal obstruction by visual analog scale score Duration

in Groups A and B
Figure 6: Comparison of nasal patency by Gertner plate in Groups A
and B on the right side
Table  3 shows that after 3  months’ follow‑up, all the
symptoms improved in Group  B compared to Group A, A comparison of VAS scores of Groups  A and B
but the comparative results were significant for nasal shows that mean improvement is better in Group B
obstruction (P  =  0.032), postnasal drip  (P  =  0.045), and patients compared to Group  A patients for all weeks,
headache (P  =  0.044). Nasal bleeding was relieved all but significant improvement is only seen at the
the cases in both groups. 2nd week (P = 0.019) and 4th week (0.042) [Figure 5].

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Doomra, et al.: Surgical outcomes of conventional versus endoscopic septoplasty

28.62

24%
28.37
27.91
27.65
27.19
30 25%

26.76
26.17
25.31

20%

20%
23.34
23.16
22.74
22.45
22.21
21.95
25

21.03
21.03
20%
Group A

16%
16.71

20
Mean Score

14.66

Group B

Percentage
15%

12%
15

10

8%

8%
Group A 10%

8%
Group B
5

4%

4%

4%
5%
0

0%

0%

0%
4th Weeks (1 Month)

8th Weeks (2 Month)

Pre-Treatment

1st Week

2nd Weeks

3rd Weeks

6th Weeks

10th Weeks

12th Weeks (3 Month)

0%

Septal Hematoma
Mucosal Tear
Hemorrage

Persistent Deviation

Synechiae

Crusting

Septal Perforation
Duration

Figure 7: Comparison of nasal patency by Gertner plate in Groups A and B

Post Op Complication

Figure 8: Postoperative complications/endoscopic findings in Groups A

Table 1: Distribution of type of nasal obstruction and B
Nasal obstruction Cases (%)
Group A Group B Total Figure  7 shows the comparison of nasal patency on
Unilateral the left‑side nasal cavity between Groups  A and B.
Right 2 (8) 2 (8) 4 (8)
The nasal patency is improved in both the groups
Left 8 (32) 6 (24) 14 (28)
postoperatively, but there is a significant improvement in
Bilateral 14 (56) 15 (60) 29 (58)
Group B (P = 0.013 at 12 weeks) compared to Group A
Not present 1 (4) 2 (8) 3 (6)
Total 25 (100) 25 (100) 50 (100)
at all weeks on the left side.
Figure 8 shows Postoperative complications/endoscopic
findings in Groups A and B. In our study, postoperative
Table 2: Distribution of type of deviated nasal septum hemorrhage was encountered in 24% cases in Group  A
Septal deviation Cases (%) and 12% cases of Group  B. Persistent deviation was
Group A Group B Total observed in 20% cases in Group  A and 8% cases in
C type 17 (68) 15 (60) 32 (64) Group  B. Synechiae were observed in 20% cases in
S type 8 (32) 10 (40) 18 (36) Group  A and 8% in Group  B; 16% cases in Group  A
and 4% in Group  B showed crusting. Septal perforation
was observed only in one case belonging to Group A
Table 3: Postoperative symptoms relieved and none of the patient in Group  B. Only two cases
Symptom Group A Group B χ2 P
of Group  A had mucosal tear. Septal hematoma was
CS (%) ES (%)
observed in only one case in Group  A. There was no
Nasal obstruction 19/24 (79.1)
5.83 0.032 (S) 21/23 (91.3)
Headache 5/8 (62.5)
4.05 0.044 (S) 14/15 (93.3)
case of mucosal tear and septal hematoma in Group  B
Nasal discharge 17/20 (85)
0.11 0.074 (NS) 19/20 (95) on diagnostic nasal endoscopy on postoperative visit at
PND 11/15 (73.3)
4.04 0.045 (S) 16/17 (94.1) the 12th  week. The patients of both groups presented
Hyposmia 0/1 (0)
1.33 0.248 (NS) 1/3 (33.3) with complications, but the incidence was higher
Nasal bleed 2/2 (100)
0.00 1.000 (NS) 1/1 (100) in the CS group and the difference was statistically
Mouth breathing 5/8 (62.5)
0.03 0.773 (NS) 5/7 (71.4) significant (P = 0.018).
Excessive 2/6 (33.3)
0.28 0.598 (NS) 4/7 (57.1)
sneezing Discussion
S=Significant; NS=Not significant; PND=Postnasal drip; This study was conducted on 50  patients belonging
CS=Conventional septoplasty; ES=Endoscopic septoplasty
to both sexes aged 18–60  years. There were 34  male
and 16  female. Majority of cases taken up for the
Figure  6 shows the comparison of nasal patency on study presented with a chief complaint of nasal
the right‑side nasal cavity between Groups  A and B. obstruction  (94%) and 58% cases had bilateral nasal
The nasal patency is improved in both the groups obstruction. Most common type of DNS in our
postoperatively, but there is a significant improvement in study was C‑shaped deviation  (64%), followed by
Group B (P = 0.004 at 12 weeks) compared to Group A S‑shaped deviation  (36%), associated anterior caudal
at all weeks on the right side. dislocation (14%), and associated spur (60%).

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Doomra, et al.: Surgical outcomes of conventional versus endoscopic septoplasty
Nasal obstruction was relieved in 79.1% cases of CS and
91.3% cases of ES, and the difference was statistically
significant  (P  =  0.032). Headache was relieved in
62.5% cases of CS and 93.3% cases of ES, and the
difference was statistically significant  (P  =  0.044). This
is comparable with the study conducted by Suligavi
et  al.,[12] in which nasal obstruction was relieved in
80% cases of CS group and 96% cases of ES group,
and headache was relieved in 85.71% cases of CS and
94.4% cases of ES group.
In this study, the mean improvement in the VAS score
in Group  A was 1.85  ±  1.89 and that in Group  B was
1.15 ± 1.01. On comparing both the groups, it was found
that Group  B had a higher improvement in the VAS
score, but statistically significant result was observed
only at 2nd (P  =  0.019) and 4th week (P  =  0.042)
postoperatively. A  similar study conducted by Hsu
et  al.[13] recorded mean VAS scores of 2.12  ±  1.42,
2.10 ± 1.79, and 2.42 ± 2.02, respectively, at 3rd, 6th, and
12th  postoperative months, and the results were highly
significant (P = 0.001). Another similar study conducted
by Chung et al.[8] showed mean VAS score improvement
of 2.93  ±  2.02 after septoplasty, which was highly
significant (P = 0.001).
The comparison of nasal patency on the right‑side nasal
cavity between Groups A and B showed that the nasal
patency improved in both the groups postoperatively,
but significant improvement was observed in
Group B (P = 0.004 at 12 weeks) at all weeks.
The comparison of nasal patency on the left‑side nasal
cavity between Groups A and B showed that the nasal
patency improved in both groups postoperatively,
but significant improvement was observed in
Group B (P = 0.013 at 12 weeks) at all weeks.
The comparative study conducted by Sathyaki et  al.[14]
showed that preoperatively, three cases of CS and four
cases of ES had nasal airflow of 0–1 cm. Three cases of
CS and two cases of ES had nasal airflow of 6–9  cm.
Postoperatively, there was no case in 0–1  cm nasal
airflow category, whereas five cases of CS and 12  cases
of ES had nasal airflow of 6–9  cm, that is, higher
improvement in nasal patency was observed in ES, but
P = 0.099 (nonsignificant).
In another study conducted in the CS group, seven
patients had airflow of 2–3  cm, eight patients had
4–5 cm, and three patients had 6–9 cm. In the ES group,
two patients had airflow of 2–3 cm, 17 had 4–5 cm, and
15 had 6–9  cm. The patency was same on the 10th‑day,
1st‑month, and 3rd‑month follow‑ups. The difference in
improvement was insignificant. Above two studies had
considered only length in cm of condensed area on
1376 Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 10  ¦  October 2019
gertner's plate but our study recorded area in sq. cm of
fogging on gertner's plate.
In this study, on comparison of both groups, the difference
in the VAS scores  (subjective assessment) between
two groups was significant only at 2nd (P  =  0.019) and
4th week (P  =  0.042), but the difference between the
two groups on the Gertner plate (objective assessment)
was significant at all weeks. This could be because each
patient has his or her own individual scale of feeling in
relation to resistance. It is possible that the causes of
nasal airway resistance are different from those of the
feeling of airflow because factors other than resistance
affect this feeling; for example, the use of topical
anesthetics on the nasal mucosa produces a feeling of
nasal obstruction that is not accompanied by decreased
transnasal airflow. These observations corroborate our
results. However, as interpretation of an observer is
subjective, it is more accurate, especially when it is
performed by a single observer and at a fixed point of
time at every follow‑up, as done in our study.
Conclusion
It is concluded that ES is more effective in terms of
symptoms relief and improvement of nasal patency.
The incidence of postoperative morbidity is also less
with ES because of fewer incidences of postoperative
complications that are due to more focused flap
dissection with resection of the septal framework and
less chances of flap tears. ES is best for isolated spur,
posterior deviation, and revision surgery, but anterior
caudal dislocation is best handled with CS.
Both these techniques should be taken as an adjuvant
to each other, as there may be need to convert ES into
CS at any point of time during surgery, for example,
during excessive intraoperative hemorrhage, which leads
to frequent soiling of endoscopic lens. Thus, every ES
surgeon must have a good experience of CS.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that their
names and initials will not be published and due efforts
will be made to conceal their identity, but anonymity
cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Doomra, et al.: Surgical outcomes of conventional versus endoscopic septoplasty
References
1. Killian  G. Submucosal window resection of nasal septum. Arch
Laryngol Rhinol 1904;16:362.
2. Freer O. The correction of deflections of the nasal septum with a
minimum of traumation. J Am Med Assoc 1902;38:636.
3. Manoukian  PD, Wyatt  JR, Leopold  DA, Bass  EB. Recent trends
in utilization of procedures in otolaryngology‑head and neck
surgery. Laryngoscope 1997;107:472‑7.
4. Maran  AG, Lund  VJ. Trauma to nose and sinuses. In: Clinical
Rhinology. 1st ed. New York: Thieme; 1990. p. 110‑39.
5. Jain  L, Jain  M, Chouhan  AN, Harshwardhan  R. Conventional
septoplasty verses endoscopic septoplasty: A  comparative study.
People J Sci Res 2011;4: 24-8.
6. Lanza DC, Kennedy OW, Zinriech SJ. Nasal endoscopy and its
surgical applications. In: Essential Otolaryngology: Head and
Neck Surgery, 5th Ed. Lee KJ, Ed. Medical Examination Pub!.
Co., 1991. p. 373-87.
7. Getz  AE, Hwang  PH. Endoscopic septoplasty. Curr Opin
Otolaryngol Head Neck Surg 2008;16:26‑31.
8. Chung  BJ, Batra  PS, Citardi  MJ, Lanza  DC. Endoscopic
septoplasty: Revisitation of the technique, indications, and
Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 10  ¦  October 2019
outcomes. Am J Rhinol 2007;21:307‑11.
9. Aitken  RC. Measurement of feelings using visual analogue
scales. Proc R Soc Med 1969;62:989‑93.
10. Roopa Manjunatha  G, Mahapatra  DR, Prakash  S, Rajanna  K.
Validation of polyvinylidene fluoride nasal sensor to assess
nasal obstruction in comparison with subjective technique. Am J
Otolaryngol 2015;36:122‑9.
11. Gertner  R, Podoshinm  L, Fradis  M. A  simple method of
measuring the nasal airway in clinical work. J  Laryngol Otol
April 1984;98:351–5.
12. Suligavi  SS, Darade  MK, Guttigoli  BD. Endoscopic septoplasty:
Advantages and disadvantages. Clin Rhinol 2010;3:27‑30.
13. Hsu HC, Tan CD, Chang CW, Chu CW, Chiu YC, Pan CJ, et al.
Evaluation of nasal patency by visual analogue scale/nasal
obstruction symptom evaluation questionnaires and anterior
active rhinomanometry after septoplasty: A  retrospective
one‑year follow‑up cohort study. Clin Otolaryngol
2017;42:53‑9.
14. Sathyaki  DC, Geetha  C, Munishwara  GB, Mohan  M,
Manjuanth  K. A  comparative study of endoscopic septoplasty
versus conventional septoplasty. Indian J Otolaryngol Head Neck
Surg 2014;66:155‑61.
1377