Anat Cell Biol 2022; 55(4): 423-432
Published online December 31, 2022
Copyright © Korean Association of ANATOMISTS.
Gisma Ahmed Madani1 , Wael Amin Nasr El-Din2,3 , Asmaa S. Essawy4 , Khamrunissa Hussain5 , Islam Omar Abdel Fattah3
1Department of Anatomy, Faculty of Medicine, The National University, Khartoum, Sudan, 2Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain, 3Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, 4Department of Human Anatomy and Embryology, Faculty of Medicine, Menoufia University, Menoufia, Egypt, 5Department of Family and Community Medicine, Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia
Correspondence to:Islam Omar Abdel Fattah
Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia 41511, Egypt
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
The nasal septum is a crucial supporting factor for the nasal cavity and may develop several anatomical variants including septal deviation, spur and pneumatization. These variants could be associated with a higher incidence of sinusitis due to structural and functional alterations. So, the aim of this study was to assess the prevalence of nasal septal deviation (NSD), nasal septal spur (NSS) and nasal septal pneumatization (NSP) among the Saudi adult population and their links with the incidence of sinusitis by using computed tomography (CT). A retrospective study was achieved over a twenty-two months period on 681 adult Saudi subjects (420 males and 261 females) aged 20 years or older, referred for coronal CT evaluation of the paranasal sinuses. NSD and NSS were significantly more prevalent in males than females (80.0% vs. 67.4% respectively for NSD, and 34.5% vs. 24.9% respectively for NSS), while there was no statistical difference in frequency of NSP regarding gender (P=0.670). The incidence of sinusitis was significantly higher in presence of NSD and/or NSS (P<0.001 for both). On the contrary, NSP was not associated with a significant increase in the prevalence of sinusitis (P=0.131). In conclusion, NSD and NSS are more prevalent in males than females among the Saudi population with no statistical difference between both genders regarding the presence of septal pneumatization. Furthermore, sinusitis is more prevalent with the occurrence of NSD and NSS, and not related to the incidence of NSP.
Keywords: Nasal septal variation, Saudi population, Sinusitis, Computed tomography
Computed tomography (CT) of the nose and paranasal sinuses is currently considered the imaging modality of choice for radiological diagnosis of nasal and paranasal disorders . Unlike plain radiography, CT provides an excellent idea about the soft tissue and bony anatomical details. Understanding the details of sinonasal anatomy helps to reach the proper diagnosis and hence the guidance for safe surgery .
The nasal septum is a crucial supportive component of the nasal cavity which is composed of bony and cartilaginous parts and divides the nasal cavity into two sides . The bony component is made up of the vomer and perpendicular plate of ethmoid bones, contributing more than 70% of the whole nasal septum . Although a perfectly straight nasal septum is extremely rare, some degree of deviation can be clinically accepted . In contrast, a higher percentage of nasal septal deviation (NSD) is a potent risk factor for nasal cavity obstruction and sinusitis . Moreover, significant NSD can produce compensatory hypertrophy of inferior turbinate and concha bullosa of the middle turbinate at the contralateral side, aggravating the obstruction, or additionally causing hypoplasia of the ipsilateral turbinates. According to the side, NSD can be classified as right-sided, left-sided or S-shaped variants .
Nasal septal spur (NSS) is a popular anatomical variation that is frequently associated with NSD. If prominent, NSS may interfere with the surgical access to the nasal cavity and also could narrow the middle meatus or ethmoid infundibulum . In addition, the pressure between mucosal surfaces in the region of NSS can be a source of excruciating pain . Another anatomical variation of the nasal septum is its pneumatization which could block the osteomeatal complex and thus potentially predispose to various sinonasal mucosal diseases . Commonly the nasal septal pneumatization is produced as an extension of the air cells from the sphenoid sinus or crista galli to the nasal septum. Nevertheless, it usually does not cause any clinical relevance but may be contributed to some sort of narrowing of the sphenoethmoidal recess . Thus, most anatomical nasal septal variations could finally lead to chronic or recurrent rhino-sinusitis due to obstruction of osteomeatal complex and affection of the mucocilliary clearance .
Hence, this study aimed to use coronal CT scan imaging of the nasal cavity and paranasal sinuses to investigate the prevalence of NSD, NSS and nasal septal pneumatization (NSP) among adult Saudi population, and their possible association with the incidence of sinusitis.
A retrospective blinded study was conducted on 681 adult subjects who underwent CT imaging of the nasal cavity and paranasal sinuses to evaluate the nasal septum and the possible associated sinusitis indicated by mucosal thickening. According to gender, 420 (61.7%) were males and 261 (38.3%) were females. All study subjects were Saudi with the exclusion of individuals younger than 20 years old, or with a history of congenital anomalies, facial trauma, nasal surgery or any other pathological issue. The current study was carried out at the Medical Imaging Department, Saudi German Hospitals Group, Jeddah, Kingdom of Saudi Arabia, in the period between May 2020 and March 2022. This study was conducted under the institutional research committeeʼs ethical standards in conformity with standard recommendations indicated in the Declaration of Helsinki laid down in 1975 and its later amendments. Informed consents were waived because the nature of the retrospective study
Subjects underwent coronal CT imaging with a Phillips 64-slice CT machine [kilo voltage peak (kVp)=100, Milli-Ampere seconds (Mas)=200, rotation time=0.4 second, field of view (FOV)=240 mm, slice thickness=1 mm, reconstruction interval=0.3 mm, pitch=0.399; Philips, Australia]. The anatomical variations of the nasal septum, including NSD, NSS and NSP, were carefully examined and recorded on CT scan along with the evaluation of sinus mucosa. Measurement of the septal angle was achieved by measuring the angle between two lines. The first line was corresponding to the midline running from the maxillary crest (point A) to the junction point of the perpendicular and the cribriform plate of ethmoid bone (point B), while the second line was connecting the junction point of the perpendicular and the cribriform plate, and the most prominent point of the deviated septum (point C) (Fig. 1A, B). For S-shaped septal deviation the greater value of both septal curves was only taken into account (Fig. 1C) . According to the angle of NSD, its severity was classified into :
Normal nasal septum: when its angle is less than 5°
Mild NSD: when the angle is ranging between 5° and 10°
Moderate NSD: when the angle is ranging between 10° and 15°
Severe NSD: when the angle is greater than 15°
The data analysis was carried out using IBM SPSS Statistics for Windows (version 27.0; IBM Corp., Armonk, NY, USA). Qualitative variable frequencies were presented as numbers and percentages, and correlated by applying the Chi-Square test. Unpaired Student’s
The current study included subjects aged between 20 and 71 years old with a mean of 44.7±14.3 years old. NSD was present in 512 cases (75.2%), while normal septum was present only in 169 subjects (24.8%). NSD was more frequent in males than females (80.0% vs. 67.4% respectively), with a significant difference in-between (
The frequency of NSS was significantly higher in males than females (34.5% vs. 24.9% respectively) (
There was no statistical difference between the frequency of NSP regarding gender (
In the current study, coronal CT scans of 681 adult Saudi subjects (420 males and 261 females) were used to evaluate their nasal septa and paranasal sinuses. Our results revealed that the most common nasal septal variation was NSD (in 75.2% of cases), followed by NSS (in 30.8% of cases) and then NSP (in 23.6% of cases). Both NSD and NSS were significantly correlated to the incidence of sinusitis (
Regarding the present study, the NSD incidence was significantly higher in males than in females (80.0% vs. 67.4%) which is in contrast to the results of Smith et al.  who revealed that NSD was more prevalent in females. Moreover, Bora et al.  and Shrestha et al.  found that there is no statistical difference between frequencies of septal deviation in both genders (Table 9).
The previously reported prevalence of NSD varies widely due to the differences in the applied criteria to consider that the nasal septum is deviated, the used populations and study samples. In the present study, the prevalence rate of NSD was 75.2% in the Saudi population in which we considered that septal deviation was defined when the septal angle is 5° or more. Our result was higher than the results of Badia et al.  and Smith et al.  who considered NSD is defined when the septal angle is more than 4°. So, Badia et al.  found that NSD frequencies are 13%–20% in Caucasians and 7%–8% in Chinese, while, Smith et al.  found that NSD prevalence is 19.4% of the American population (Table 9). Furthermore, a lower prevalence was reported by Sazgar et al.  (62.9% in Iranians), Devareddy and Devakar  (62.0% in Indians), Turna et al.  (59.1% in Turkish), Qureshi and Usmani  (56.0% in Pakistanis), Adeel et al.  (26.0% in Pakistanis), Onwuchekwa and Alazigha  (20.2% in Nigerians), and Espinosa et al.  (20.0% in Filipinos) (Table 9).
In contrast, others reported a higher prevalence of NSD than in the current study. For example, NSD frequency in the Spanish population was 80.0% as revealed by Pérez-Piñas et al.  when diagnosed NSD with any detected angle of deviation. In addition, the prevalence of septal deviation was higher than our results according to Clark et al.  (76.0% in Americans), Janovic et al.  (92.7% in Serbians), Bora et al.  (79.7% in Turkish) and Chandel et al.  (78.9% in Indians) (Table 9).
In this study, the most frequent type of NSD was left-sided then right-sided and followed by the S-shaped one (45.9, 44.0, and 10.2% respectively). These results were matched with the results of both Bagri et al. , Madani et al. , and Poorey and Gupta  who found that left-sided NSD is more prevalent than right. Whereas, Stallman et al. , Shrestha et al.  and Turna et al.  revealed that the right NSD is more frequent than the left one. In addition, Shrestha et al.  and Earwaker  showed that the rate of unilateral NSD is significantly higher than the S-shaped one (Table 9).
In the present results, the presence or absence of sinusitis was significantly linked to the presence or absence of NSD (<0.001). This was in accordance with studies conducted by Elahi et al.  and Hatipoglu et al.  who reported that an increased incidence of sinusitis was noted with the existence of NSD. Conversely, Mohibbi et al. , Bagari et al. , and Smith et al.  reported that there is no significant association between NSD and sinusitis. In addition, our study revealed that there was an increased incidence of sinusitis associated with mild and moderate NSDs which may be due to their high association with the presence of NSS providing an additional risk factor for sinusitis.
NSS is frequently concomitant with the NSD that is, if prominent, can make any surgical access difficult and also narrows the middle meatus or ethmoid infundibulum . In the present study NSS was found in 30.8% of subjects which closely matches the prevalence of 32.0% and 29.0% reported by Alshaikh and Aldhurais  in Saudi population, and Bagari et al.  in Indians respectively. Whereas, these results are higher than those found by other authors such as Alsubael and Hegazy , Perez-Pinas et al. , Turna et al.  and Chandel et al.  where the prevalence was 7.0% in Saudi population, 18.0% in Spanish, 19.9% in Turkish and 11.7% in Indian populations respectively (Table 9). Furthermore, our results showed a significantly higher prevalence of NSS in males compared to females (
NSP is an important anatomical variation occurring mainly at the bony part of the nasal septum due to air extension from the sphenoid sinus or crista galli. Usually, it has no health effect but it may cause narrowing in the sphenoethmoidal recess . Nevertheless, it is not widely described in the literature because of its low prevalence rates and its weak clinical relevance. In the same context, we found that there is no significant link between the presence or absence of NSP and the presence or absence of sinusitis (
The prevalence of NSP in the present study was 23.6% which closely matches the prevalence reported by Al-Qudah  as 27.0% in Jordanians. On the other hand, higher frequencies were reported by Turna et al.  as 34.8% in Turkish, while lower prevalence rates were observed by Biswas et al.  as 12.0% in Indians, Alshaikh and Aldhurais  as 15.0% in Saudi, Onwuchekwa and Alazigha  as 8.2% in Nigerians, Shrestha et al.  as 6.5% in Nepali, and Bora et al.  as 1.3% in Turkish. Moreover, no case with NSP was revealed by Adeel et al.  in Pakistanis (Table 9). Chandel et al.  and Shrestha et al.  noted that NSP is more in the males compared to females in Indians and Nepali respectively which is concomitant with our results in the Saudi population.
As noted, the wide variability of percentages of the incidence of nasal septal variations and their link with the incidence of sinusitis among various studies could be due to different types of used CT for assessment, the different number of involved subjects or different included populations according to their age, gender and ethnicity.
As our study was a retrospective one, many limitations were related, including the absence of data concerning the occupation, lifestyle, height, weight and body mass index of the subjects that may be correlated to the findings concerning the conditions of nasal septum and sinuses.
In conclusion, the findings of the current study revealed that NSD and NSS were frequently prevalent among the Saudi population and commonly associated with sinusitis. Nevertheless, NSP was less prevalent and not related to the incidence of sinusitis. Knowledge of the details of these anatomical variations and their relation with the incidence of sinusitis may provide useful radiological data for otolaryngologists that help them in the management of nasal diseases.
Conceptualization: GAM, WAN, ASE, KH, IOA. Data acquisition: GAM, ASE, KH. Data analysis or interpretation: IOA, WAN, GAM. Drafting of the manuscript: WAN, ASE, KH. Critical revision of the manuscript: IOA, WAN, GAM. Approval of the final version of the manuscript: all authors.
No potential conflict of interest relevant to this article was reported.