Rahman A

Rahman A, Tasleem M, Arif S H in Aligarh performed a study on Effect of Septoplasty on Mean Platelet Volume in Patients of Deviated Nasal Septum . A total of 50 patient was included in the study and MPV was investigated preoperative and postoperative for patient with septal deviation posted for septoplasty in a prospective study .It was found that Mean platelet volume corresponds to average size of platelets . So studies proved that large platelets are enzymatically and metabolically more active and have prothrombotic potential. Chronic upper airway obstruction like marked nasal septal deviation leads to higher Mean platelet volume and vice versa septoplasty operation lowers the volume of the platelets over a period of time and hence reduces other associated comorbidities. Data obtained was analysed using paired t-test and it was statistically proved that after Septoplasty, Mean Platelet Volume was significantly lowered in patients who had Marked Nasal Septal Deviation. And so concluded that Septoplasty plays an important role in reducing the MPV value in cases with Marked nasal septal deviation and thus other comorbid conditions can be prevented by doing septoplasty in these patients.70
Impact of Septoplasty on Mean Platelet Volume Levels in Patients with Nasal Septal Deviation study was conducted by Sulthan A R A, Saravanan V , Karthick A at Coimbatore Medical College and Hospital . Relation between septal deviation and Mean Platelet Volume (MPV) and its effect on surgical correction of deviated septum was studied . One among the most common nasal pathology for nasal obstruction being Septal deviation it has got strong association with chronic alveolar hypoxia.MPV is used now a days as a marker for chronic hypoxia widely . Ninety-eight patients with symptomatic nasal septal deviation were included in the study and operated. Mean Platelet Volume (MPV) were noted and entered pre-operatively as well as postoperatively . . Results was pre-operative Mean Platelet Volume (MPV) levels of the patients who underwent septal surgery were significantly higher than the post operative Mean Platelet Volume (MPV) levels. So study was concluded that Mean Platelet Volume (MPV) as a helpful marker for ENT surgeons to evaluate chronic hypoxia . And by doing so we may able to evaluate chronic hypoxic complication which is caused by elevated MPV as a result of nasal obstruction.74
A prospective study by Rahmana A, Hashmia S F, Hasana S A, Arifb S H in utterpradesh was carried out by investigating preoperative and postoperative MPV of 50 patient . Role of septoplasty in reducing the incidence of comorbidities associated with elevated levels of mean platelet volume was studied. The blood samples of the selected patients were sent in EDTA vial for preoperative MPV determination before septoplasty and were evaluated for MPV again postoperatively after a period of 4–12 weeks. Data obtained from preoperative and postoperative blood investigation were analyzed and it was statistically proved that, after septoplasty, the MPV was significantly lowered in patients who had septal deviation . Therefore according to this study Septoplasty plays an important role in reducing the MPV value in cases with marked septal deviation, and thus other comorbid conditions can be prevented by performing septoplasty in such patients.75

NASAL VALVE ANGLE & NASAL VALVE AREA
The internal nasal valve is the narrowest portion of the nasal cavity, any compromise of the components of the valve creates symptoms of nasal obstruction. The angle is bound medially by the septum & laterally by the inferior edge of the upper lateral cartilage & anterior aspect of the inferior turbinate. This angle widens & narrows with nasal muscular contraction & relaxation on inspiration & expiration. The nasal valve is normally 10-15 degrees. Deformities of the adjacent nasal septum or loss of anatomic support structures can predispose the valve to collapse or narrowing causing nasal obstruction. The external valve is a laterally based space boxed by the piriform aperture, the upper lateral & lower lateral cartilage attachments & the caudal septum. Obstruction as a result of external valve compromise may be a post-rhinoplasty, result of aging process or a result of caudal septal dislocation or trauma. Figure 13

FIGURE 13: NASAL VALVE

TURBINATE OBSTRUCTION
It can be classified as either bony or mucosal. Aetiology for mucosal turbinate hypertrophy includes both allergic & non-allergic (vasomotor) rhinitis. Hypertrophy is generally seen bilaterally & sense of obstruction is relieved with topical decongestants. Primary treatment includes anti-histamine & decongestants use as well as topical steroid management. Surgery is reserved for those who still complain of nasal obstruction. When nasal mucosal decongestion does not elicit intranasal airway changes or symptomatic improvement, bony turbinate hypertrophy, along with deviation of the septum & nasal valve compromise, should be considered. This obstruction is generally constant . The midline nasal septum causes lack of structural resistance during development ,is the bases of one theory of bony turbinate hypertrophy . The bony conchal & mucosal hypertrophy is considered compensatory & can be
found in the patient having significant septal deviation from the enlarged turbinate. The turbinate mucosa & underlying bone enlarge into the more open nasal passage in pursuit of normalizing nasal airway resistance. Correction of the deviated nasal septum & trimming of the enlarged turbinate are performed together to relieve obstructive complaints.14 figure 14

FIGURE 14: CLINICAL PHOTOGRAPH OF INFERIOR TURBINATE HYPERTROPHY

RHINOSINUSITIS
Its group of disorders characterized by inflammation of the mucosa of the nose and the paranasal sinuses. An inflammatory response is an expected sequel of an infection process. Inflammation in the nose and the sinuses can occur from a variety of causes which can result in sinus ostia obstruction and predispose to the development of an infection. Many factors have been described such as genetic factors like immotile cilia syndrome or cystic fibrosis; anatomic abnormalities such as a concha bullosa, septal spur, or paradoxical turbinate; systemic disease or medical treatments that predispose individuals to infection, allergic or immune disorders. Rhinosinusitis may also develop in relationship to environmental factors, bacterial, fungal, viral infections.
Primary or secondary tobacco smoke exposure, chronic or acute irritants or noxious chemicals or iatrogenic factors including surgery, medications, nasal packing or nasogastric tube placement. Typically, acute rhinosinusitis develops in conjunction with an acute viral upper respiratory tract infection. The occlusion or obstruction of the sinus ostia is caused as a result of mucosal thickening due to infection . A reduce mucociliary transport can occure as a result of reduction in oxygen tension along with reduced transudation of fluid into the sinuses. The other main contributing factor for changes in mucosa becoming more viscous is inflammation which in turn result alterations in cilia beat frequency. All these chances together contribute to form bacterial colonization in the nasal-sinus environment by mucostasis . If the sinuses remain obstructed or the mucociliary transport system does not return to normal, a bacterial infection can ensue .Diagnosis is by the presence of symptoms such as facial pain, facial fullness, nasal obstruction, nasal discharge, anosmia & signs such as mucopurulent discharge in the middle meatus, sinus tenderness. First line of treatment is medical management; surgery is preferred when the patient is not responding to the medical line of treatment.12 figure 15
Koç S, Eyibilen A, Erdo?an A conducted a study in Turkey and reported that MPV is a inflammatory maker. They concluded that platelets have a role in CRS as chronic rhinosinusitis is inflamotory disorder. This study was done aiming to investigate the levels of hematological parameters such as red blood cells (RBC), haemoglobine (Hb), haematocrit (Htc), white blood cells (WBC), platelet (PLT), and mean platelet volume (MPV) in patients with synptoms of chronic rhinosinusitis. Patient with h/o CRS without nasal polyposis is only included in the study . Peripheral venous blood samples were taken from patients with CRS after overnight fasting ,measured the complete blood count (CBC) parameters in a blood sample collected in etilendiamintetraasetik asit (EDTA). Same is done with control group. Laboratory data were screened with computerised database and data was analysed . It was found that CRS group consisted a total of 90 patients. Among 90, 34 (38%) male . In control group also it consisted of 90 patients, 44 (49%) male. Blood parameters like total count , WBC, RBC,haemoglobin and Htc levels were similar in patient and control groups. Compared to control group MPV were higher among CRS group .However, platelet count compared with CRS group and control was found to be borderline higher. 7

FIGURE 15: PUS IN THE MIDDILE MEATUS (RHINOSINUSITIS)

POLYP
Nasal polyps are a part of an inflammatory reaction involving the mucous membrane
of the nose and the paranasal sinuses. They are non-neoplastic masses that can either
be multiple or single, unilateral or bilateral. Aetiological factors are they can occur in
patients with allergic fungal sinusitis, allergic rhinitis, cystic fibrosis, aspirin triad
(nasal polyposis, asthma & aspirin intolerance), Kartageners syndrome, Young’s
syndrome. Mainly the presence and the secondary infection is the main cause for
nasal obstruction. Treatment includes intranasal steroids ; functional endoscopic
surgery.12 figure 16

FIGURE 16: CLINICAL PHOTOGRAPH OF NASAL POLYP