A Study of Nasal Septal Deviation, External Nasal Deformities, and their Correlation with the Severity of Sino-Nasal Symptoms Using Sino Nasal Symptoms Score Questionnaire

Background/Rationale: The human nose is structurally complex and this complexity results in nasal shape and shape variations. Midline deformities such as hump nose, saddle nose, tip deformities and lateral nasal deformities such as crooked nose, deviated nose, alar depression are common forms of deformity affecting the external nose. Internal nasal valve (INV) is a key anatomical landmark of nasal cavity. Any obstructions in this region have tremendous effects on inspiratory and expiratory currents. This study aims to assess the nasal septal deviation and external nasal deformities and correlate the severity of sino nasal symptoms. Methods: This Prospective observational study will include total 50 patients with nasal septal deviation. Patients will undertake Sino Nasal Test -22 questionnaire. Investigations like Diagnostic nasal endoscopy with 30 degree nasal endoscope, X-ray PNS Water’s view and complete blood count including absolute eosinophilic count will be carried out. Data will be analysed using appropriate statistical tests. Study Protocol Sunnychan and Deshmukh; JPRI, 33(64B): 316-322, 2021; Article no.JPRI.81036 317 Expected Results: A significant correlation is expected between Nasal Septal Deviation, External Nasal Deformities, and Severity of Sino-nasal Symptoms. Conclusion: This study will reflect on internal nasal valve and it’s correlation with etiopathological process of upper respiratory tract. It will also guide clinicians in choosing appropriate surgical approach.


INTRODUCTION
One of the most fragile organs in our body is the nose, the central structure of face. The outer nose serves the cosmetic purpose by improving an individual's personality and attractiveness [1].
The nose is the primary mammalian breathing route and serves important functions, including nasal respiration, defence of the lower respiratory tract by inspired air filtration, air conditioning, mucociliary function, sneeze reflex and humidification, vocal resonance, olfactory resonance and an outlet to lacrimation [2].
The nasal cavity is divided by nasal septum into two air filled spaces. Each side of the cavity is divided by three conchae, or turbinates [3]. In both the appearance and function of the nose, the nasal septum plays an important role. Deviation of the cartilage and/or bony structure of the nasal septum from the midline can cause various nasal symptoms, such as nasal obstruction. Deviated nasal septum (DNS) incidence is due to numerous causes, including ethnic factors, septum birth moulding during parturition, trauma and septum developmental deformities [1].
The internal nasal valve (INV) is a major anatomical landmark and is the circumscribed region in the nares. It is a cross sectional area defined medially by the dorsal septum, laterally by caudal part of the upper lateral cartilage, and inferiorly by the head of inferior concha. A triangle's area is 1⁄2 per base per height. Therefore a decrease in any sides, the area would be decreased by almost 25-30% of the total space of the triangle. Hence any decrease in this already crowded area will have a noticeable impact on the inspiratory and expiratory currents [3].
The human nose is structurally complex and this complexity results in nasal shape and shape variation. Midline deformities such as hump nose, saddle nose, tip deformities and lateral nasal deformities such as crooked nose, deviated nose, alar depression are common forms of deformity affecting the external nose [2].External nasal deformities was categorised by YongJo Jang's into five types. It was focused on the bony pyramid orientation with the cartilaginous vault [4]. One of the most mundane symptoms observed in the primary care and specialty centers is nasal obstruction. Nasal obstruction pathophysiology, best explained as perceived sense of decreased airflow through nose or a feeling of fullness of face. One of the most frequently encountered structural causes of nasal obstruction include septal deviation. Of course, septal variance often causes decreased airflow and nasal obstruction symptoms/perceptions. There is however, considerable anatomical variation among individuals; most of the impact on the airflow is on the anterior deflections affecting the nasal valve, while in the middle and lower portion of the nares has no impact on resistance to airflow [5].
Nasal obstruction is well known to be a common and highly subjective complaint, but information obtained from objective observation does not always correspond with the symptoms of patients. Several studies have been used to substantiate clinical, qualitative & instrumental questionnaires to determine nasal obstruction levels. In this regard, the American Academy of Otolaryngology's Declaration of clinical consensus stated that the INV plays a legitimate part in nasal obstruction, segregated from other anatomical problems and/or disorders, including allergies [6].
Internal nasal valve constitute an important anatomical land mark and is the circumscribed region of the nares. Any decline in this already crowded region would have a conspicuous impact on the inspiratory and expiratory currents [3].The internal nasal valve is endoscopically accessed in various nasal septal deviations with or without external nasal deformities in this research.

Aim
To study endoscopically the internal nasal valve in various nasal septal deviations with/ without external nasal deformities. Those patients included in this study will be evaluated as follows:

Objectives
1) Comprehensive clinical examination of ear, nose and throat.
 Diagnostic nasal endoscopy with 30 degree nasal endoscope to measure the angle of internal nasal valve with the nasal septum before surgery.  X-ray PNS Water's view.  Complete blood count including absolute eosinophilic count.
Based on the above pre-operative work up with the result will be used to access the effect of different types of nasal septal deviation and external nasal deformities on internal nasal valve.

Study Size:
For the purpose of the study we are including 50 patients in the study during this period.
Statistical Methods: Statistical analysis will be done with the help of Chi square test.

EXPECTED RESULTS
Descriptive Data: It is a cross-sectional study involving 50 patients with or without external nasal deformity with nasal septal deviation who were referred to the ENT department of AVBRH Sawangi (M), Wardha from November 2020 to November 2022.
Outcome Data: 1) Findings thus obtained will be entered in the proforma. 2) Photographic documentation of some interesting cases will be done wherever needed. 3) Data will be analyzed and subjected to statistical analysis.

DISCUSSION
The area of nasal valve has a paramount part in nasal respiration. Physiological studies show that both nasal airflow and nasal resistance are substantially regulated by this complex region [2]. In fact, seventy percent of nasal respiratory resistance & forty four percent of total inspiratory resistance are due to the nasal valve. Even small deformities in this region may transform into significant increases in inspiratory resistance, thereby compromising the subject's efficiency especially during physical effort, and sometimes causing sleep disturbances [6].
The anatomical outlining of the external & internal element of the nasal valve is the crosssectional portion of the nares which excerpt pronounced all in all resistance to the flow of air, serving as one of the prime most factor of nasal inspiration. The INV or ostium internum nasi is situated roughly 1.3 cm from the nares & refers to the location below the upper lateral cartilages [7]. It is constrained by dorsal septum medially, inferior concha head inferiorly, & upper lateral cartilage laterally [8]. In a Caucasian, the average angle of the INV varies from 9° to 15° and due to the scale of the inferior turbinate, inter-racial variation is well known [9].
Acceleration occurs when air reaches these narrow parts, which leads to a decline in the pressure intra-luminally (The principle of Bernoulli). This conduce the lateral wall of nares to collapse , whereas slight septal variations, malformed lateral crura / damaged soft tissues can have a major effect on the airflow of nasal cavity [8].
Most of the fundamental configuration of nasal septum must be a straight plane which separates nose into 2 cavities, but the fact is it is seldom straight. It is common for 62 per cent of people [2]. Numerous authors have attempted to define nasal septal deformity on the basis of location and type, helping to recognise their role in associated pathologies and patient management.
In 1987, Mladina proposed the classification of nasal septal deformities into vertical and horizontal forms. The vertical deformities was further divided into four types (types 1,2,3 and 4) and horizontal deformities into two types (type v,vi) [10,11] Type 1 : Midline septum / mild deviations in vertical/horizontal plane, which do not extend throughout the vertical length of the septum. In type 2-6 the side of the deviation is marked L (Left) / R (Right). In type 4 whichever side is anterior deviation is marked L / R.
Various techniques have been identified in international literature to correct nasal obstruction caused by impaired nasal valve function, but there are no randomised trials to study endoscopically the internal nasal valve in various septal deviations and external nasal deformities. This association is studied by measuring the internal nasal valve angle with the nasal septum, in patients with different nasal septal deformities and external nasal deformities during diagnostic nasal endoscopy preoperatively. Few of the related studies were reviewed [12][13][14][15][16].
In 2017, a prospective study was performed in regard with nasal obstruction by the Royal National Throat Nose & Ear Hospital, London, and a static INV rating was established for the visibility of the middle turbinate. INV is determined in the anterior rhinoscopy, on the basis of a horizontal line at the head of inferior concha [7].
Grade 0: the head of the middle concha is visible easily. Grade i: the middle concha is partially obscured. Grade ii: the middle concha is not visible.
The research investigated and evaluated the validity of the grading system and compared it with objective and subjective rhinological results as calculated by the Nasal Obstruction Symptom Evaluation Score(NOSE) & Sinonasal Outcome Tool (SNOT-23) both pre-and post-operatively [7].
However the investigation has not been expanded to correlate the various causes of structural nasal obstruction such as DNS, INV obstruction, etc [7]. So this research aims to broaden the investigation of, the association between INV and various nasal septal deviations with or without external nasal deformities.

CONCLUSION
Conclusion will be drawn from the outcome of the study CONSENT As per international standard or university standard, Participants' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
It is not applicable.