nasal septal deformities in ear, nose, and throat patients

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Original contributions

Nasal septal deformities in ear, nose, and throat patients:An international study

Ranko Mladina, MD, PhDa,4,1, Emil Cujic, MDa,Marin Subaric, MD, PhDb,2, Katarina Vukovic, MDa

aORL Klinika Salata-KBC, Salata 4, 10.000 Zagreb, Croatia

bORL odjel., Klinicka bolnica Dubrava, Av. G. Suska 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 ENTcenters 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 standard-

ized way for describing particular septal deformities. What

one can find in most of these articles is justseptal 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,

but what about other populations? Does the classification

apply to other geographic regions?

Studies have shown great differences in the morpholog-

ical 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] foundsignificant 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,

0196-0709/$ see front matterD 2008 Elsevier Inc. All rights reserved.

doi:10.1016/j.amjoto.2007.02.002

4 Corresponding author. ORL Klinika Salata-KBC, 10000 Zagreb,

Croatia. Tel.: +385 1 4810377; fax: +385 1 2347258.

E-mail addresses: [email protected] (R. Mladina)8

[email protected] (E. Cujic)8 [email protected] (M. Subaric)8

[email protected] (K. Vukovic).1 Tel.: +385 1 4920012; fax: +385 1 2347258.2 Tel.: +385 1 290 2401; fax: +385 1 2334856.

American Journal of OtolaryngologyHead and Neck Medicine and Surgery 29 (2008) 7582

Available online at www.sciencedirect.com

www.elsevier.com/locate/amjoto


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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

Hospital Salata, Zagreb, Croatia (R Mladina); ENT

Department, Firat and Ondokuz Mayis University MedicalFaculties, 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, Man-

ipal-Karnataka, India (M Satyanarayana), ENT Department,

School of Medicine, Tehran University of Medical Scien-

ces, 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 Depart-

ment, 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 endo-scope. 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

Table 1

Sex of study subjects according to ENT centers and appearance or absenceof nasal septum deformities

Parameter Sex Total

Male Female

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,

and Temple, TX

103 (6.9) 122 (11.2) 225 (6.9)

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 : v2 = 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.

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

R. Mladina et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 29 (2008) 758276


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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 comprehen-

sive 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

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 (b158) (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.

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.

R. Mladina et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 29 (2008) 7582 77


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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. 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 5RFig. 5. (A) Straight septum in the right nasal cavity. (B) Horizontal but still

ascendant septal spur in the left nasal cavity.*

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).



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(depending on the side of the septal spur); type 6 as 6L or6R (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 v2 test

was used for statistical analysis, with P b .05 considered as

significant. The v2 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.

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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(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, whichappeared 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%, respec-

tively). 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 higherthan 90%. The reason for the high incidence in our study

and that of Rao et al could be that they were based on well-

defined 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 inci-

dence of septal deformities according to Mladinas classi-

fication 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 2

Types of nasal septum deformity according to sex

Sex Types of nasal septum deformity4 Total

1 2 3 4 5 6 7 X

Female 187 (17.2) 145 (13.3) 258 (23.7) 88 (8.1) 133 (12.2) 70 (6.4) 40 (3.7) 168 (15.4) 1089 (100.0)

Male 231 (15.4) 281 (18.7) 269 (17.9) 138 (9.2) 229 (15.3) 174 (11.6) 66 (4.4) 112 (7.5) 1500 (100.0)

Total 418 (16.2) 426 (16.4) 527 (20.4) 226 (8.7) 362 (14.0) 244 (9.4) 106 (4.1) 280 (10.8) 2589 (100.0)

Statistics: v2 = 83.56; df = 7; P b .001. Data are expressed as number (percentage).

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

Table 3

Number (percentage) of types of nasal septal deformity according to age group

Age group (y) Types of nasal septum deformity4 Total

1 2 3 4 5 6 7 X

1830 139 (18.5) 120 (15.9) 122 (16.2) 72 (9.6) 111 (14.8) 64 (8.5) 37 (4.9) 87 (11.6) 752 (100.0)

3140 84 (12.1) 128 (18.4) 141 (20.3) 58 (8.3) 97 (13.9) 81 (11.6) 30 (4.3) 77 (11.1) 696 (100.0)

4150 87 (14.9) 94 (16.1) 131 (22.5) 47 (8.1) 95 (16.3) 55 (9.4) 21 (3.6) 53 (9.1) 583 (100.0)

5160 70 (18.7) 57 (15.3) 89 (23.8) 33 (8.8) 42 (11.2) 31 (8.3) 15 (4.0) 37 (9.9) 374 (100.0)

6170 32 (23.7) 22 (16.3) 29 (21.5) 13 (9.6) 12 (8.9) 1 (0.8) 8 (5.9) 18 (13.3) 135 (100.0)

7180 6 (12.3) 5 (10.2) 15 (30.6) 3 (6.1) 5 (10.2) 5 (10.2) 2 (4.1) 8 (16.3) 49 (100.0)

Total 418 (16.2) 426 (16.5) 527 (20.3) 226 (8.7) 362 (14.0) 237 (9.1) 113 (4.4) 280 (10.8) 2589 (100.0)

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



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had type 1. The high incidence of type 5 could be explainedby 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 strikinglymore frequent in females (76.9%) than in males (23.1%).

This raises the question of whether type 3 is a female-

type deformity.

4.4. Age

A comparison of our results obtained in ENT patients

and the results of secondary school and university groups

(non-ENT population) in Subaric and Mladinas study [13]

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 primary-school group and then rises with age, suggest that these

types could be influenced by the growth of the splanchnoc-

ranial 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.

Table 4

Types of nasal septal deformity according to side of the deformity and sex

Parameter Types of nasal septum deformity Total

Side/sex 1 2 3 4 5 6

All study subjects4

Right 205 (49.0) 204 (47.9) 246 (46.7) 124 (54.9) 175 (48.3) 111 (45.5) 1065 (48.4)

Left 213 (51.0) 222 (52.1) 281 (53.3) 102 (45.1) 187 (51.7) 133 (54.5) 1138 (51.6)

Total 418 (100.0) 426 (100.0) 527 (100.0) 226 (100.0) 362 (100.0) 244 (100.0) 2203 (100.0)Femaley

Right 84 (44.9) 68 (46.9) 115 (44.6) 50 (56.8) 69 (51.9) 25 (35.7) 411 (46.6)

Left 103 (55.1) 77 (53.1) 143 (55.4) 38 (43.2) 64 (48.1) 45 (64.3) 470 (53.4)

Total 187 (100.0) 145 (100.0) 258 (100.0) 88 (100.0) 133 (100.0) 77 (100.0) 881 (100.0)

Malez

Right 21 (52.4) 136 (48.4) 131 (48.7) 74 (53.6) 106 (46.3) 86 (49.4) 654 (49.5)

Left 110 (47.6) 145 (51.6) 138 (51.3) 64 (46.4) 123 (53.7) 88 (50.6) 668 (50.5)

Total 231 (100.0) 281 (100.0) 269 (100.0) 138 (100.0) 229 (100.0) 174 (100.0) 1322 (100.0)

Statistics: v2 = 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.



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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.

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