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American Journal of OtolaryngologyHead and Neck Medicine and Surgery 29 (2008) 75 82 www.elsevier.com/locate/amjoto

Original contributions

Nasal septal deformities in ear, nose, and throat patients: An international study
ujic , MDa, Ranko Mladina, MD, PhDa,4,1, Emil C ubaric , MD, PhDb,2, Katarina Vukovic , MDa Marin S
b a alata-KBC, S alata 4, 10.000 Zagreb, Croatia ORL Klinika S us ORL odjel., Klinic ka bolnica Dubrava, Av. G. S ka bb, 10.000 Zagreb, Croatia Received 17 November 2006

Abstract

Purpose: The purpose of this study was to investigate the incidence and characteristics of nasal septum deformities in ear, nose, and throat (ENT) patients in various geographic regions in the world. Materials and methods: Anterior rhinoscopy without nasal decongestion was performed in 17 ENT centers in 14 countries. The septal deformities were classified according to the classification system proposed by Mladina. Results: A total of 2589 adult ENT patients (1500 males and 1089 females) were examined. Septal deformities were found in 89.2% of subjects. Left-sided deformities were slightly more prevalent than right-sided deformities (51.6% and 48.4%, respectively). The most frequent type of deformity was type 3 (20.4%). Straight septum was found in 15.4% of females and 7.5% of males. Conclusions: Almost 90% of the subjects showed 1 of the 7 types of septal deformity. There were no statistically significant differences in the incidence of their appearance among particular geographic regions. Type 3 was the most frequent type. Straight septum was twice as frequent in females than in males. D 2008 Elsevier Inc. All rights reserved.

1. Introduction There are many articles on nasal septal deformities in the rhinologic literature; however, there lacks a standardized way for describing particular septal deformities. What one can find in most of these articles is just septal deviation or deviated nasal septum , without a precise description of its appearance. Attempts to comprehensively systematize septal deformities started almost 30 years ago at the ear, nose, and throat (ENT) department of the University Hospital Salata in Zagreb, Croatia. They led to a simple classification in 7 types published by Mladina [1] in 1987. This classification was derived from research in Croatia,
alata-KBC, 10000 Zagreb, 4 Corresponding author. ORL Klinika S Croatia. Tel.: +385 1 4810377; fax: +385 1 2347258. E-mail addresses: prof_mladina@yahoo.com (R. Mladina)8 ujic ubaric )8 marin.subaric@kbd.hr (M. S )8 orl_cujic@yahoo.com (E. C ). katarinavukovic@yahoo.com (K. Vukovic 1 Tel.: +385 1 4920012; fax: +385 1 2347258. 2 Tel.: +385 1 290 2401; fax: +385 1 2334856. 0196-0709/$ see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2007.02.002

but what about other populations? Does the classification apply to other geographic regions? Studies have shown great differences in the morphological and cephalometric values in subjects from various geographic regions. Gurr et al [2] showed that there are considerable differences in the geometry of both external nose and nasal cavities among subjects belonging to various races and ethnic groups. This is in accordance with other studies [3,4]. Richardson and Marrett [4] found great differences in facial bone shape between British and West African populations, and Marcellino et al [5] found significant differences in the height of the middle facial massif in 6 South American Indian tribes. Japanese authors found remarkable differences in the thickness of the cranial bones of the Neolithic and modern Japanese population [6], and some authors have also found secular changes in the main skull dimensions [7]. It is known that the angulation of the skull base in humans can act like a sort of bcranial pincerQ and squeeze the splanchnocranial structures, including the nasal septum,

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causing the onset of a particular septal deformity. Because the shape of the skull base obviously differs in different populations, the question arises of whether there are also differences in the incidence of septal deformities in subjects from various geographic regions. The aim of this multi-institutional and multinational study was to investigate the relative frequencies of particular types of septal deformity in ENT patients from various geographic regions and to see whether one and the same classification is applicable to these regions. At the same time, we took the opportunity to investigate the incidence of these septal deformities regarding sex, age, and the side of the deformity. 2. Methods The following ENT centers and colleagues were involved in this study: ENT Department, University alata, Zagreb, Croatia (R Mladina); ENT Hospital S Department, Firat and Ondokuz Mayis University Medical Faculties, Samsun, Turkey (Y Tanyeri); Tokyo Medical and Dental University Graduate School, Tokyo, Japan (M Hasegawa); ENT Department, Tokyo University Branch Hospital, Tokyo, Japan (K Ichimura); ENT Department, University Hospital, Toulouse, France (E Serrano); ENT Department, Al-Azhar Faculty of Medicine, Cairo, Egypt (E El-Mallah), ENT Department, Kasturba Hospital, Manipal-Karnataka, India (M Satyanarayana), ENT Department,

Fig. 1. Left-sided type 1 septal deformity.

Table 1 Sex of study subjects according to ENT centers and appearance or absence of nasal septum deformities Parameter Sex Male Female Total

ENT centers Zagreb, Croatia 188 (12.5) 200 (18.4) 292 (11.3) Samsun, Turkey 40 (2.7) 45 (4.1) 85 (3.3) Tokyo 1 and 2, Japan 118 (7.9) 100 (9.2) 218 (8.4) Toulouse, France 47 (3.1) 35 (3.2) 82 (3.2) Cairo, Egypt 201 (13.4) 99 (9.1) 300 (11.6) Manipal-Karnataka, India 78 (5.2) 38 (3.5) 116 (4.5) Tehran, Iran 50 (3.3) 42 (39) 92 (3.5) Fuzhou-Fujian, China 380 (25.3) 128 (11.7) 508 (19.6) Rio de Janeiro, Brazil 148 (9.9) 144 (13.2) 292 (11.3) Barcelona, Spain 31 (2.1) 63 (5.8) 94 (3.6) Haifa, Israel 35 (2.3) 5 (0.46) 40 (1.5) Erlangen, Germany 44 (2.9) 21 (1.9) 65 (2.5) Beachwood, OH, 103 (6.9) 122 (11.2) 225 (6.9) and Temple, TX London 1 and 2, UK 37 (2.5) 47 (4.3) 84 (3.24) Total 1500 (100.00) 1089 (100.00) 2589 (100.00) Appearance or absence of NSD D 1388 (92.5) 921 (84.6) 2309 (89.2) X 112 (7.5) 168 (15.4) 280 (10.8) Statistics : v 2 = 40.63; df = 1; P b .001. Data are expressed as number (percentage). NSD indicates nasal septum deformity; D, appearance of NSD; X, absence of NSD.

School of Medicine, Tehran University of Medical Sciences, Tehran, Iran (J Mehdizadeh), ENT Department, Fujian Provincial Hospital, Fuzhou-Fujian, Peoples Republic of China (DX Wang, XH Wang), ENT Department, Escola Paulista de Medicina, Rio de Janeiro, Brazil (RM Neves Pinto), ENT Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (JM Fabra), ENT Department, Haifa Carmel Hospital, Haifa, Israel (E Greenberg), ENT Department, University Hospital of Erlangen, Erlangen, Germany (W Schneider), Royal National Throat, Nose & Ear Hospital, University College and Middlesex School of Medicine, London, UK (V Lund), ENT Department, Charing Cross Hospital, London, UK (I Mackay), the Mount Sinai Center for Ear, Nose, Throat & Facial Surgery, Beachwood, OH (H Levine), ENT Private Clinic, Temple, TX (P Arbour). 2.1. Study design The investigation was planned as a rough screening of the incidence of septal deformities based on examination of the nose (anterior rhinoscopy) without the use of nasal decongestion, superficial mucosal anesthesia, or an endoscope. The desired number of subjects per center was at least 100; 7 of the 17 centers did not meet this number (Table 1). The classification of septal deformities was based on the classification system proposed by Mladina to precisely define the clinical finding of the nasal septum in a particular patient and to maximally standardize the examination of the nose in the various ENT centers. The subjects were not specially selected but had come to see an ENT physician because of various, general ENT complaints. The age range was from 18 to 80 years. There

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change the physiologic valve angle (158) and therefore usually plays just a mild role in the nasal pathophysiology (Fig. 1). Type 2 refers to a unilateral vertical septal ridge in the valve region that touches the nasal valve, thus diminishing the physiologic valve angle ( b 158) (Fig. 2). Type 3 refers to a unilateral vertical ridge that is located more deeply in the nasal cavity, opposite the head of the middle turbinate (Fig. 3). Type 4 refers to a bilateral deformity consisting of type 2 on one side and type 3 on the other (Fig. 4A and B).

Fig. 2. Left-sided type 2 septal deformity.

were 2 exclusive criteria: first, previous septal surgery, which permanently changes the appearance of a particular nasal septum and thus invalidates the use of classification; second, diffuse nasal polyposis, which usually obstructs the view to the whole nasal septum, thus making a comprehensive assessment of the septal form impossible. 2.2. Classification proposed by Mladina Type 1 refers to a unilateral vertical septal ridge in the valve region that does not reach the valve itself; it does not

Fig. 3. Right-sided type 3 septal deformity.

Fig. 4. (A) Type 3 in the right nasal cavity. (B) Type 2 in the left nasal cavity.

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This type is also known in the literature as an S-shaped septum. Type 5 refers to an almost horizontal septal spur that sticks laterally and deeply into the nasal cavity. The opposite side of the nasal septum is always flat (Fig. 5A and B). Type 6 refers to a massive unilateral intermaxillary bone wing with a bgutterQ between it and the rest of the septum on this septal side. On the other septal side, there is an anteriorly positioned basal septal crest (Fig. 6A and B). Type 7 is a very variable combination of the previous types (Fig. 7A and B).

Fig. 6. (A) Basal septal crest in the most anterior parts of the nasal septum. (B) Typical septal gutter and remarkable intermaxillary bone wing (red arrow).

Fig. 8 presents types 1 to 4 in birds-eye view and types 5 and 6 in the anteroposterior view. 2.3. Recording system A standard form was delivered to all the ENT centers involved in the study. The septal deformities were entered as follows: type 1 as 1L or 1R (the letters L and R stand for left and right , respectively, referring to the side of the deformity); type 2 as 2L or 2R; type 3 as 3L or 3R; type 4 as 4L or 4R (depending on the side of the more anteriorly located deformity); type 5 as 5L or 5R

Fig. 5. (A) Straight septum in the right nasal cavity. (B) Horizontal but still ascendant septal spur in the left nasal cavity.*

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was used for statistical analysis, with P b .05 considered as significant. The v 2 procedure was not applied when the value of the expected frequency in the contingency tables was 5 or less. 3. Results The study was carried out on a total of 2589 subjects (1500 males and 1089 females). 3.1. General incidence The general incidence of septal deformity was 89.2% (Table 1). It was slightly higher in males (92.5%) than in females (84.6%). 3.2. Incidence of particular types Type 3 was the most frequent type (20.4%). Types 2 and 1 were of almost equal frequency (16.4% and 16.2%, respectively). Type 5 was also relatively frequent

Fig. 7. (A) Bizarre deformity in the right nasal cavity. (B) Almost vertical deformity in the valve region of the left nasal cavity.

(depending on the side of the septal spur); type 6 as 6L or 6R (depending on the side of the gutter between the intermaxillary bone wing and the septum); and type 7 as just 7 because it is not possible to determine the side in this type. The letter X was entered for subjects with a straight septum. 2.4. Investigated parameters The study investigated the general incidence of septal deformity, the incidence of particular types of septal deformity, the incidence regarding sex, age, and the prevalence of right- or left-sided deformities. The v 2 test

Fig. 8. A schematic depiction of the 7 types of septal deformities. The first 4 types are presented in birds-eye view, whereas types 5 and 6 are presented in an anteroposterior view.

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Table 2 Types of nasal septum deformity according to sex Sex Types of nasal septum deformity4 1 Female Male Total 187 (17.2) 231 (15.4) 418 (16.2) 2 145 (13.3) 281 (18.7) 426 (16.4) 3 258 (23.7) 269 (17.9) 527 (20.4) 4 88 (8.1) 138 (9.2) 226 (8.7) 5 133 (12.2) 229 (15.3) 362 (14.0) 6 70 (6.4) 174 (11.6) 244 (9.4) 7 40 (3.7) 66 (4.4) 106 (4.1) X 168 (15.4) 112 (7.5) 280 (10.8) 1089 (100.0) 1500 (100.0) 2589 (100.0) Total

Statistics: v 2 = 83.56; df = 7; P b .001. Data are expressed as number (percentage). 4 According to the criteria described in reference [1].

(14.0%). Types 6, 4, and 7 were less frequent (9.4%, 8.7%, and 4.1%, respectively). The full results are shown in Table 2. 3.3. The incidence regarding sex Types 2, 5, and 6 were more frequent in males than in females. Type 2 appeared in 18.7% of males and 13.3% of females, and type 5 in 15.3% of males and 12.2% of females. The greatest difference was in type 6, which appeared in 11.6% of males and 6.4% of females. Type 3 and straight septum were more frequent in females. Type 3 appeared in 23.7% of females and 17.9% of males. Straight septum appeared in 15.4% of females and 7.5% of males (Table 2). 3.4. The incidence regarding age In the first group (1830 years), the most frequent types were types 1 (18.5%), 3 (16.2%), and 2 (15.9%). In the second group (3140 years), the most frequent types were types 3 (20.3%) and 2 (18.4%). The incidence of type 3 rose with age from 16% in the first group (1830 years) to 30.6% in the oldest group (7180 years). The full results are shown in Table 3. 3.5. Side of the deformity Deformity could be determined by side in 2203 subjects. Left-sided deformities were slightly more prevalent than right-sided deformities overall (51.6% and 48.4%, respectively). They were also slightly more prevalent in females (53.4%) than in males (50.5%). The full results are shown in Table 4.

4. Discussion 4.1. The general incidence The general incidence of septal deformity found in the investigation was almost 90%. This is much higher than the incidence (around 70% in adults) reported in the literature over the past decades [8]. Only a recent study by Rao et al [9] in the Hyderabad region in India, based on the same classification as in our study, has shown an incidence higher than 90%. The reason for the high incidence in our study and that of Rao et al could be that they were based on welldefined types of septal deformities rather than unclearly defined septal bdeviations.Q 4.2. The incidence of particular types Type 3 was clearly the most frequent type in our study, whereas type 1 was clearly the most frequent type in the Indian study and in the Korean nationwide study on the prevalence of septal deformities by Min et al [10], also based on Mladinas classification. The same result was obtained in the recent Polish study by Zielnik-Jurkiewicz and Olszewska-Sosinska [11]. They investigated the incidence of septal deformities according to Mladinas classification in 288 children aged 3 to 17 years and found type 1 (and type 5) to be the most frequent type. They stressed that the incidence of type 1 decreases with age. Type 5 is the only type that is deeply positioned and can be easily overlooked during examination of the nose without the use of decongestants owing to mucosal edema in some patients. The Indian study showed 63% of symptomatic individuals to have either type 5 or type 6, whereas only 2%

Table 3 Number (percentage) of types of nasal septal deformity according to age group Age group (y) Types of nasal septum deformity4 1 1830 3140 4150 5160 6170 7180 Total 139 84 87 70 32 6 418 (18.5) (12.1) (14.9) (18.7) (23.7) (12.3) (16.2) 2 120 128 94 57 22 5 426 (15.9) (18.4) (16.1) (15.3) (16.3) (10.2) (16.5) 3 122 141 131 89 29 15 527 (16.2) (20.3) (22.5) (23.8) (21.5) (30.6) (20.3) 4 72 58 47 33 13 3 226 (9.6) (8.3) (8.1) (8.8) (9.6) (6.1) (8.7) 5 111 97 95 42 12 5 362 (14.8) (13.9) (16.3) (11.2) (8.9) (10.2) (14.0) 6 64 81 55 31 1 5 237 (8.5) (11.6) (9.4) (8.3) (0.8) (10.2) (9.1) 7 37 30 21 15 8 2 113 (4.9) (4.3) (3.6) (4.0) (5.9) (4.1) (4.4) X 87 77 53 37 18 8 280 (11.6) (11.1) (9.1) (9.9) (13.3) (16.3) (10.8) 752 696 583 374 135 49 2589 (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) Total

4 According to the criteria described in reference [1].

R. Mladina et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 29 (2008) 7582 Table 4 Types of nasal septal deformity according to side of the deformity and sex Parameter Side/sex Types of nasal septum deformity 1 2 204 (47.9) 222 (52.1) 426 (100.0) 68 (46.9) 77 (53.1) 145 (100.0) 136 (48.4) 145 (51.6) 281 (100.0) 3 246 (46.7) 281 (53.3) 527 (100.0) 115 (44.6) 143 (55.4) 258 (100.0) 131 (48.7) 138 (51.3) 269 (100.0) 4 124 (54.9) 102 (45.1) 226 (100.0) 50 (56.8) 38 (43.2) 88 (100.0) 74 (53.6) 64 (46.4) 138 (100.0) 5 175 (48.3) 187 (51.7) 362 (100.0) 69 (51.9) 64 (48.1) 133 (100.0) 106 (46.3) 123 (53.7) 229 (100.0) 6 111 (45.5) 133 (54.5) 244 (100.0) 25 (35.7) 45 (64.3) 77 (100.0) 86 (49.4) 88 (50.6) 174 (100.0) Total

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All study subjects4 Right 205 (49.0) Left 213 (51.0) Total 418 (100.0) Femaley Right 84 (44.9) Left 103 (55.1) Total 187 (100.0) Malez Right 21 (52.4) Left 110 (47.6) Total 231 (100.0)

1065 (48.4) 1138 (51.6) 2203 (100.0) 411 (46.6) 470 (53.4) 881 (100.0) 654 (49.5) 668 (50.5) 1322 (100.0)

Statistics: v 2 = 5.35; df = 5; P = .375. Data expressed as number (percentage). 4 Except those with type 7 and straight septum. y All female study subjects except those with type 7 and straight septum. z All male study subjects except those with type 7 and straight septum.

had type 1. The high incidence of type 5 could be explained by the fact that Rao and collaborators used topical decongestants while examining the nose. The question arises, therefore, whether the percentage of type 5 will be higher if the examination of the nose was performed by means of an endoscope (particularly a flexible one) after decongestion of the mucosa instead of by means of a simple anterior rhinoscopy. The answer to this question requires a separate comparative study. The other types in Mladinas classification are easily recognizable during a simple anterior rhinoscopy and do not require an endoscopic examination or decongestion. This makes this classification easy to apply. 4.3. Sex Type 2 was more frequent in males (18.7%) than in females (13.3%). This type is typically a trauma-caused deformity, and it is generally accepted that males are more exposed to nasal trauma than females. Type 6 was also more frequent in males (11.6%) than in females (6.4%). This finding is not easy to explain, particularly because this type has been proven to be inheritable [12]. Further research in this matter is required. Type 3, on the other hand, was more frequent in females (23.7%) than in males (17.9%). In a study of children and adolescents in Zagreb, Croatia [13]), type 3 was strikingly more frequent in females (76.9%) than in males (23.1%). This raises the question of whether type 3 is a femaletype deformity. 4.4. Age A comparison of our results obtained in ENT patients and the results of secondary school and university groups ubaric and Mladinas study [13] (non-ENT population) in S shows a great degree of similarity in the incidence of all types except for types 1 and 4, which we cannot explain at present. Some differences in the incidence of types 3, 5, and

6, whose incidence is almost 0 in preschool and primaryschool group and then rises with age, suggest that these types could be influenced by the growth of the splanchnocranial bones and the final angulation of the skull base during puberty and adolescence. Genetic precondition may also be an influence. 4.5. The side of the deformity Left-sided deformities were found to be slightly more prevalent than right-sided deformities (51.6% and 48.4%, respectively). A similar result was observed in the Korean study (56.0% for left-sided and 39% for right-sided deformities). Perhaps the finding of Quante et al [14] on Caucasian newborns could explain this prevalence: a certain degree of overlapping between right and left parietal bones can occur as a result of delivery circumstances and the position of the babys head in the delivery canal. They found that the right parietal bone was higher in about 50% of newborns, whereas the left was higher in only 20%; an equal level was found in about 30% of the newborns. Furthermore, they found that the incidence of nasal obstruction was about 20% in adults whose parietal bones had an unequal level, whereas it was remarkably lower (up to 6%) in those with an equal level. 5. Conclusions Examination by anterior rhinoscopy showed that almost 90% of the ENT patients in the various geographic regions in the world had 1 of the 7 types of septal deformities. Type 3 was the most frequently observed type. Its frequency rose with age. It is more frequent in female ENT patients than in male ENT patients. Type 6, in contrast, was twice as frequent in male ENT patients than in female ENT patients. Straight septum was twice as frequent in females.

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R. Mladina et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 29 (2008) 7582 [4] Richardson A, Marrett D. British and West African facial form in ideal occlusion. Ann Hum Biol 1988;4:367 - 74. [5] Marcellino AJ, Da Rocha FJ, Salzano FM. Size and shape differences among six South American Indian tribes. Ann Hum Biol 1978; 5:69 - 74. [6] Ishida H, Dodo Y. Cranial thickness of modern and Neolithic population in Japan. Hum Biol 1990;62:389 - 401. [7] Morita S, Ohtsuki F. Secular changes of the main head dimensions in Japanese. Hum Biol 1973;45:151 - 65. [8] Strambis G. The incidence of nasal deformities in young populations. Proceedings of the XV Congress of European Rhinology Society, Amsterdam; 1988. p. 60. [9] Rao JJ, Vinay Kumar EC, Ram Babu K, et al. Classification of nasal septal deviationsrelation to sinonasal pathology. Indian J Otolaryngol Head Neck Surg 2005;57:199 - 201. [10] Min YG, Jung HW, Kim CS. Prevalence study of nasal septal deformities in Korea: results of a nation-wide survey. Rhinology 1995;33:61 - 5. [11] Zielnik-Jurkiewicz B, Olszewska-Sosinska O. The nasal septum deformities in children and adolescents from Warsaw, Poland. Int J Pediatr Otorhinolaryngol 2006;70(4):731 - 6. ubaric M. Are some septal deformities inherited? Type 6 [12] Mladina R, S revisited. Int J Pediatr ORL 2003;67:1291 - 4. ubaric M, Mladina R. Nasal septum deformities in children and [13] S adolescents: a cross sectional study of children from Zagreb, Croatia. Int J Pediatr Otorhinolaryngol 2002;63:41 - 8. [14] Quante M, Franzen G, Strauss P. The correlation between permanent septal deformities and nasal trauma during birth. Rhinology 1976; 14:141 - 4.

Left-sided septal deformities were slightly more frequent than right-sided ones, particularly in females, but the differences are not statistically significant. Acknowledgments The investigation was performed as a part of the scientific project of the Ministry of Health of Republic of Croatia No 3-01.011, led by Prof Dr Ranko Mladina. The authors are very grateful to Prof Dr E Huizing (Utrecht, The Netherlands), Prof Dr Wolfgang Pirsig (Ulm, Germany), Prof Dr Wolf Mann (Mainz, Germany), Prof Dr E Kern (Buffalo, NY), Prof Dr B Wang (Irvine, CA), and Prof Dr R Kamel (Cairo, Egypt) for their precious suggestions. References
[1] Mladina R. The role of maxillar morphology in the development of pathological septal deformities. Rhinology 1987;25:199 - 205. [2] Gurr P, Diver J, Morgan N, et al. Acoustic rhinometry of the Indian and Anglo-Saxon nose. Rhinology 1996;34:156 - 60. [3] Ohki M, Naito K, Cole P. Dimensions and resistance of the human nose: racial differences. Laryngoscope 1991;101:276 - 8.

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