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Efficiency of external nasal dilators in pediatric nasal septal deviation
International Journal of Pediatric Otorhinolaryngology 78 (2014) 1522–1525
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Efficiency of external nasal dilators in pediatric nasal septal deviation Ziya Salturk *, Muzafer Inan, Tolgar Lutfi Kumral, Yavuz Atar, Guven Yildirim, Yavuz Uyar Okmeydani Training and Research Hospital, ENT Clinic, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 April 2014 Received in revised form 13 June 2014 Accepted 16 June 2014 Available online 24 June 2014
Inroduction: Nasal septal deviation results from irregular development of the nasomaxillary complex and trauma. Treatment of nasal septal deviation in pediatric patients is one of the biggest challenges in rhinology. Surgery may alter craniofacial growth patterns, and so it may be indicated only in the selected cases. The use of external nasal dilators is a relatively new treatment modality in nasal obstruction. Objective: This study was performed to assess the efficacy of external nasal dilator in pediatric nasal septal deviation patients. Methods: Seventy-six children who were diagnosed with nasal septal deviation at our outpatient clinic were included in the study. The patients were divided into 2 groups: the external nasal dilator group was composed of 48 children that had used an external nasal dilator for at least 1 month and still been using, while the control group was comprised of 28 children that had not received any treatment and had not used an external nasal dilator. The parents of the children were asked to complete the obstructive sleep apnea 18 questionnaire. In addition, the external nasal dilator group was asked to complete the questionnaire after stopping external nasal dilator use for 2 weeks and the control group also repeated the obstructive sleep apnea 18 questionnaire. Results: The obstructive sleep apnea 18 questionnaire results were significantly different between the external nasal dilator group and the control group at the beginning of the study (i.e., when patients in the external nasal dilator group were still using their dilators, P = 0.000). On the other hand, there was no difference between the 2 groups after the patients in the external nasal dilator group had stopped using their external nasal dilator (P = 0.670). Conclusion: External nasal dilator use relieved nasal septal deviation, which narrows the nasal valve. The results of this study suggest that external nasal dilator could be used in patients that are not candidates for septoplasty. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Nasal septal deviation External nasal dilator Septoplasty Children Nasal valve
1. Introduction Nasal septal deviation (NSD), the most common deformity in humans, results from irregular development of the nasomaxillary complex and trauma [1–3]. NSD causes recurrent rhinosinusitis, upper airway infections, and middle ear problems [4]. Obligate mouth breathing also causes malocclusion and disruption of facial skeleton development in growing children [5]. The reported prevalence of NSD in children varies between 0.93% in newborns and 40.6% in 15–18-year-olds [6,7]. As various classifications have been used and different age groups can show different results, there is a wide degree of variation in NSD prevalence
itim ve Araştırma Hastanesi KBB Klinig i * Corresponding author at: Okmeydanı Eg _ Darulaceze cad. Şişli/Istanbul,Turkey. Tel.: +90 505 5836146. E-mail address: [email protected] (Z. Salturk). http://dx.doi.org/10.1016/j.ijporl.2014.06.025 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
between studies [8]. As maxillofacial development is completed after 20 years of age, the prevalence does not change then [9]. Treatment of NSD in pediatric patients is one of the biggest challenges in rhinology. Surgery may alter craniofacial growth patterns, and so it may be indicated only in select cases [10,11]. Therefore, many otolaryngologists tend to avoid surgical treatment. The use of external nasal dilators (ENDs) is a relatively new treatment modality in nasal obstruction. ENDs were designed to slightly enlarge the anterior aspect of the nasal valve, which contributes significantly to resistance in the upper airway [12,13], and they have been used to treat snoring problems and increase the quality of sleep in adults [14]. On the other hand, there has been limited number of studies in pediatric population [15–17]. Two recent studies were performed to assess efficacy of ENDs on adolescent athletes and both of them showed that ENDs improved oxygen intake and reduced respiratory effort [15,16]. Another study which was aimed to asses efficacy of ENDs at newborns concluded that it reduced obstructive respiratory events [17]. There has been
Z. Salturk et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1522–1525
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Table 1 Types of septal deviations according to Baumann classification. Septal deviation types
END Group Control Group Total
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Total
8 (16.7%) 6 (21.4%) 14 (18.4%)
16 (33.3%) 8 (28.6%) 24 (31.6%)
11 (22.9%) 6 (21.4%) 17 (22.4%)
2 (4.2%) 2 (7.1%) 4 (5.3%)
7 (14.6%) 4 (14.3%) 11 (14.5%)
4 (8.3%) 2 (7.1%) 6 (7.9%)
48 (100.0%) 28 (100.0%) 76 (100.0%)
Chi2 = 0.983; END: external nasal dilator.
no study performed to evaluate effects of ENDs on pediatric population and this study was performed to assess the efficacy of ENDs in pediatric NSD patients. 2. Materials and methods Internal Review Board approval was obtained for this study from the Okmeydani Training and Research Hospital Ethics Committee. Between January 2014 and March 2014, 76 children who were admitted to our outpatient clinic for nasal obstruction, mouth breathing during sleep, snoring and attacks of apnea and were diagnosed with NSD were included in the study. Following history taking, the patients were examined endoscopically. Children with adenoid hypertrophy that obstructed the nasal choana by more than 50% endoscopically, a history of allergic rhinitis, a congenital craniofacial deformity, or a sinonasal infection were excluded. The patients were divided into 2 groups: the END group was composed of 48 children that had used an END for at least 1 month and still been using, while the control group was comprised of 28 children that had not received any treatment and had not used an END. All of the patients had used Breathe Right for Children (Glaxo Smith Kline) which is the only commercial product in Turkey. NSD was analyzed according to the classification described by Baumann and Baumann [18]. Baumann and Baumann [18] divided septal deviations into 6 types according to their clinical and anatomical properties. They defined septal pathology and concomitant pathology together— type 1: septal crest and ipsilateral vomeral spur; type 2: cartilaginous deviated nose and ipsilateral subluxation, contralateral vertical septal deviation; type 3: high septal deviation and contralateral septal crest; type 4: caudally inclined septum and contralateral subluxation, ipsilateral vertical septal deviation, ipsilateral septal crest, ipsilateral vomeral spur; type 5: septal crest contralateral and vomeral spur; and type 6: caudally inclined septum and contralateral subluxation, ipsilateral vertical septal deviation, contralateral septal crest, contralateral vomeral spur. The parents of the children were asked to complete the Obstructive Sleep Apnea 18 (OSA 18) questionnaire which is a useful tool that can be used for the subjective evaluation of obstructive disorders and was claimed to be used in diagnosis of obstructive sleep apnea [19]. In addition, the END group was asked to complete the questionnaire after stopping END use for 2 weeks and the control group also repeated the OSA 18 questionnaire. The results were subjected to statistical analysis.
with regard to age or sex distribution (P > 0.05). There were 3 and 4 children who had apnea attacks described by caregivers in END and control groups, respectively. There were no differences in septal deviation type between the 2 groups (Table 1). The OSA 18 questionnaire results were significantly different between the END group and the control group at the beginning of the study (i.e., when patients in the END group were still using their dilators; P = 0.000). On the other hand, there was no difference between the 2 groups after the patients in the END group had stopped using their ENDs (P = 0.670) (Table 2). In addition, there was a significant difference in the OSA 18 results of the END group at the end of the study compared to the initial results (P = 0.000). There was no such difference in the results for the control group (P = 0.925) (Table 2). There were no differences in the efficacy of ENDs according to the type of septal deviation. Although the OSA 18 score in type 3 septal deviation patients was slightly lower than that in patients with other types of deviations, the difference was not statistically significant (Table 3). 4. Discussion Surgery on the growing nasal septum has always been a matter of discussion [11,20]. Different techniques have been introduced; however, straightening of a deviated or deformed caudal septum is the most critical component in all of these methods [21]. Animal studies in rodents indicated that resection of the mucoperichondrium in addition to cartilage caused significant deformity and growth retardation [22,23]. These observations suggest that septoplasty and rhinoplasty in children would lead to unfavorable results [24–26]. The revision rate following septoplasty in children is also very high [27–29]. On the other hand, preservation and reinsertion of remodeled cartilage had no unfavorable effect. Therefore, patient selection and conservative approaches are important in pediatric patients [11,20]. ENDs are devices that alter the nasal geometry by acting on the lower border of the upper lateral cartilage [30]. Nigro et al. [31] reported that ENDs enabled a significant increase in cross-
Table 2 Obstructive sleep apnea 18 questionnaire results.
3. Results The mean period for which patients had used an END was 72 days (range 30–90 days). The END group consisted of 22 females and 26 males, with a mean age of 10.08 2.95 years (range 3–14 years). The control group consisted of 10 females and 18 males with a mean age of 9.42 3.50 years (range 3–14 years). There were no statistically significant differences between the 2 groups
END Group Control Pa
At the beginning of the study Mean SD
At the end of the study Mean SD
Beginning–end change Pb
20.50 9.99
38.88 7.95
0.000*
38.00 7.28 0.000*
38.07 7.77 0.670
0.925
SD: standard deviation; END: external nasal dilator. * p < 0.01. a Independent t-test. b Paired Sample t-test.
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Z. Salturk et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1522–1525
Table 3 OSA 18 scores of END group according to type of septal deviation.
Type Type Type Type Type Type
1 2 3 4 5 6
Total
N
Mean SD
8 16 11 2 7 4
24.00 3.30 20.00 14.40 14.27 6.31 31.00 5.66 25.57 4.24 18.50 1.73
48
20.50 9.98
studies with long-term follow-up are required to reach definitive conclusions. P
References 0.081*
OSA 18: obstructive sleep apnea18; END: external nasal dilator. * P > 0.05.
sectional area 2, which refers to the nasal valve, and a slight increase in cross-sectional area 1, which refers to the nostrils. The nasal valve regulates nasal airflow and resistance, and is responsible for 70% of nasal resistance [32]. Small deformities in the nasal valve region result in marked increases in nasal resistance and disturbance during sleep [33]. The improvements seen in patients are most likely due to widening of the nasal valve by ENDs. Pevernagie et al. [34] performed a sleep study and emphasized that external nasal dilator might have proven to be a valid therapeutic choice for snoring in the setting of chronic rhinitis and possibly other causes of impaired nasal breathing. Another sleep study which was performed by Todorova et al. [35] also supported that END had relieved snoring. Although the use of ENDs for pediatric patients has become more common [16,36], there is a lack of clinical evidence regarding its efficacy. The results of the present study indicate that ENDs have positive effects. In particular, patients with a Baumann type 3 deviation showed the greatest relief of symptoms because they had a narrowed nasal valve, although the effect was not statistically significant. On the other hand, patients with a type 4 deviation had the highest OSA 18 scores while using ENDs. OSA 18 scores obtained in this study was not as high as the studies which had aimed to asses obstructive sleep apnea [19,37,38] caused by adenotonsillary hypertrophy which was excluded from the study. On the other hand, our results showed that NSD had negative impact on quality of life which caused parents to seek medical help, even if it is not accompanied by severe adenotonsillary hypertrophy and OSA 18 scores reflected this effect. All of the patients included in our study were admitted to outpatient clinic with obstructive symptoms. A literature search indicated that an elongated face is not unique to septal deviation but may be caused by adenoid and tonsillar hypertrophy [39]. Thus, resolving nasal obstruction by ENDs may prevent facial deformity. To confirm this suggestion, long-term follow-up with anthropometric measurements is required. ENDs are effective as long as they are used consistently and do not prevent possible future surgery. However, ENDs prevent difficulties and possible complications of surgery. Maxillofacial deformities may be prevented by using ENDs until the completion of maxillofacial development. In addition, Ulfberg and Fenton [40] concluded that END had no deleterious side effect and we think that it is the major advantage of END. None of our patients experienced an adverse effect. The main limitation of the present study is the lack of objective data. However, due to the importance of NSD with regard to symptoms and complications, it was not practical to obtain such data in a pediatric population. 5. Conclusions END use relieved NSD which narrows the nasal valve. The results of this study suggest that ENDs could be used in patients that are not candidates for septoplasty. However, additional
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[13] V.A. Hinton, D.W. Warren, W.M. Hairfield, D. Seaton, The relationship between nasal cross-sectional area and nasal air volume in normal and nasally impaired adults, Am. J. Orthod. Dentofacial Orthop. 92 (1987) 294–298. [14] J.S.J. Haight, P. Cole, The site and function of nasal valve, Laryngoscope 93 (1983) 49–55. [15] D.J. Macfarlane, S.K.K. Fong, Effects of an External Nasal Dilator on Athletic Performance of Male Adolescents, Canadian J. Appl. Physiol. 29 (2004) 579–589. [16] R.R. Dinardi, C.R. de Andrade, C. Cda. Ibiapina, Evaluation of the effectiveness of the external nasal dilator strip in adolescent athletes: a randomized trial, Int. J. Pediatr. Otorhinolaryngol. 77 (2013) 1500–1505. [17] M.B. Scharf, D.V. Berkowitz, M.D. McDannold, R. Stover, D. Brannen, R. Reyna, Effects of an external nasal dilator on sleep and breathing patterns in newborn infants with and without congestion, J. Pediatr. 129 (1996) 804–808. [18] I. Baumann, H. 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Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Efficiency of external nasal dilators in pediatric nasal septal deviation Ziya Salturk *, Muzafer Inan, Tolgar Lutfi Kumral, Yavuz Atar, Guven Yildirim, Yavuz Uyar Okmeydani Training and Research Hospital, ENT Clinic, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 April 2014 Received in revised form 13 June 2014 Accepted 16 June 2014 Available online 24 June 2014
Inroduction: Nasal septal deviation results from irregular development of the nasomaxillary complex and trauma. Treatment of nasal septal deviation in pediatric patients is one of the biggest challenges in rhinology. Surgery may alter craniofacial growth patterns, and so it may be indicated only in the selected cases. The use of external nasal dilators is a relatively new treatment modality in nasal obstruction. Objective: This study was performed to assess the efficacy of external nasal dilator in pediatric nasal septal deviation patients. Methods: Seventy-six children who were diagnosed with nasal septal deviation at our outpatient clinic were included in the study. The patients were divided into 2 groups: the external nasal dilator group was composed of 48 children that had used an external nasal dilator for at least 1 month and still been using, while the control group was comprised of 28 children that had not received any treatment and had not used an external nasal dilator. The parents of the children were asked to complete the obstructive sleep apnea 18 questionnaire. In addition, the external nasal dilator group was asked to complete the questionnaire after stopping external nasal dilator use for 2 weeks and the control group also repeated the obstructive sleep apnea 18 questionnaire. Results: The obstructive sleep apnea 18 questionnaire results were significantly different between the external nasal dilator group and the control group at the beginning of the study (i.e., when patients in the external nasal dilator group were still using their dilators, P = 0.000). On the other hand, there was no difference between the 2 groups after the patients in the external nasal dilator group had stopped using their external nasal dilator (P = 0.670). Conclusion: External nasal dilator use relieved nasal septal deviation, which narrows the nasal valve. The results of this study suggest that external nasal dilator could be used in patients that are not candidates for septoplasty. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Nasal septal deviation External nasal dilator Septoplasty Children Nasal valve
1. Introduction Nasal septal deviation (NSD), the most common deformity in humans, results from irregular development of the nasomaxillary complex and trauma [1–3]. NSD causes recurrent rhinosinusitis, upper airway infections, and middle ear problems [4]. Obligate mouth breathing also causes malocclusion and disruption of facial skeleton development in growing children [5]. The reported prevalence of NSD in children varies between 0.93% in newborns and 40.6% in 15–18-year-olds [6,7]. As various classifications have been used and different age groups can show different results, there is a wide degree of variation in NSD prevalence
itim ve Araştırma Hastanesi KBB Klinig i * Corresponding author at: Okmeydanı Eg _ Darulaceze cad. Şişli/Istanbul,Turkey. Tel.: +90 505 5836146. E-mail address: [email protected] (Z. Salturk). http://dx.doi.org/10.1016/j.ijporl.2014.06.025 0165-5876/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
between studies [8]. As maxillofacial development is completed after 20 years of age, the prevalence does not change then [9]. Treatment of NSD in pediatric patients is one of the biggest challenges in rhinology. Surgery may alter craniofacial growth patterns, and so it may be indicated only in select cases [10,11]. Therefore, many otolaryngologists tend to avoid surgical treatment. The use of external nasal dilators (ENDs) is a relatively new treatment modality in nasal obstruction. ENDs were designed to slightly enlarge the anterior aspect of the nasal valve, which contributes significantly to resistance in the upper airway [12,13], and they have been used to treat snoring problems and increase the quality of sleep in adults [14]. On the other hand, there has been limited number of studies in pediatric population [15–17]. Two recent studies were performed to assess efficacy of ENDs on adolescent athletes and both of them showed that ENDs improved oxygen intake and reduced respiratory effort [15,16]. Another study which was aimed to asses efficacy of ENDs at newborns concluded that it reduced obstructive respiratory events [17]. There has been
Z. Salturk et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1522–1525
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Table 1 Types of septal deviations according to Baumann classification. Septal deviation types
END Group Control Group Total
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Total
8 (16.7%) 6 (21.4%) 14 (18.4%)
16 (33.3%) 8 (28.6%) 24 (31.6%)
11 (22.9%) 6 (21.4%) 17 (22.4%)
2 (4.2%) 2 (7.1%) 4 (5.3%)
7 (14.6%) 4 (14.3%) 11 (14.5%)
4 (8.3%) 2 (7.1%) 6 (7.9%)
48 (100.0%) 28 (100.0%) 76 (100.0%)
Chi2 = 0.983; END: external nasal dilator.
no study performed to evaluate effects of ENDs on pediatric population and this study was performed to assess the efficacy of ENDs in pediatric NSD patients. 2. Materials and methods Internal Review Board approval was obtained for this study from the Okmeydani Training and Research Hospital Ethics Committee. Between January 2014 and March 2014, 76 children who were admitted to our outpatient clinic for nasal obstruction, mouth breathing during sleep, snoring and attacks of apnea and were diagnosed with NSD were included in the study. Following history taking, the patients were examined endoscopically. Children with adenoid hypertrophy that obstructed the nasal choana by more than 50% endoscopically, a history of allergic rhinitis, a congenital craniofacial deformity, or a sinonasal infection were excluded. The patients were divided into 2 groups: the END group was composed of 48 children that had used an END for at least 1 month and still been using, while the control group was comprised of 28 children that had not received any treatment and had not used an END. All of the patients had used Breathe Right for Children (Glaxo Smith Kline) which is the only commercial product in Turkey. NSD was analyzed according to the classification described by Baumann and Baumann [18]. Baumann and Baumann [18] divided septal deviations into 6 types according to their clinical and anatomical properties. They defined septal pathology and concomitant pathology together— type 1: septal crest and ipsilateral vomeral spur; type 2: cartilaginous deviated nose and ipsilateral subluxation, contralateral vertical septal deviation; type 3: high septal deviation and contralateral septal crest; type 4: caudally inclined septum and contralateral subluxation, ipsilateral vertical septal deviation, ipsilateral septal crest, ipsilateral vomeral spur; type 5: septal crest contralateral and vomeral spur; and type 6: caudally inclined septum and contralateral subluxation, ipsilateral vertical septal deviation, contralateral septal crest, contralateral vomeral spur. The parents of the children were asked to complete the Obstructive Sleep Apnea 18 (OSA 18) questionnaire which is a useful tool that can be used for the subjective evaluation of obstructive disorders and was claimed to be used in diagnosis of obstructive sleep apnea [19]. In addition, the END group was asked to complete the questionnaire after stopping END use for 2 weeks and the control group also repeated the OSA 18 questionnaire. The results were subjected to statistical analysis.
with regard to age or sex distribution (P > 0.05). There were 3 and 4 children who had apnea attacks described by caregivers in END and control groups, respectively. There were no differences in septal deviation type between the 2 groups (Table 1). The OSA 18 questionnaire results were significantly different between the END group and the control group at the beginning of the study (i.e., when patients in the END group were still using their dilators; P = 0.000). On the other hand, there was no difference between the 2 groups after the patients in the END group had stopped using their ENDs (P = 0.670) (Table 2). In addition, there was a significant difference in the OSA 18 results of the END group at the end of the study compared to the initial results (P = 0.000). There was no such difference in the results for the control group (P = 0.925) (Table 2). There were no differences in the efficacy of ENDs according to the type of septal deviation. Although the OSA 18 score in type 3 septal deviation patients was slightly lower than that in patients with other types of deviations, the difference was not statistically significant (Table 3). 4. Discussion Surgery on the growing nasal septum has always been a matter of discussion [11,20]. Different techniques have been introduced; however, straightening of a deviated or deformed caudal septum is the most critical component in all of these methods [21]. Animal studies in rodents indicated that resection of the mucoperichondrium in addition to cartilage caused significant deformity and growth retardation [22,23]. These observations suggest that septoplasty and rhinoplasty in children would lead to unfavorable results [24–26]. The revision rate following septoplasty in children is also very high [27–29]. On the other hand, preservation and reinsertion of remodeled cartilage had no unfavorable effect. Therefore, patient selection and conservative approaches are important in pediatric patients [11,20]. ENDs are devices that alter the nasal geometry by acting on the lower border of the upper lateral cartilage [30]. Nigro et al. [31] reported that ENDs enabled a significant increase in cross-
Table 2 Obstructive sleep apnea 18 questionnaire results.
3. Results The mean period for which patients had used an END was 72 days (range 30–90 days). The END group consisted of 22 females and 26 males, with a mean age of 10.08 2.95 years (range 3–14 years). The control group consisted of 10 females and 18 males with a mean age of 9.42 3.50 years (range 3–14 years). There were no statistically significant differences between the 2 groups
END Group Control Pa
At the beginning of the study Mean SD
At the end of the study Mean SD
Beginning–end change Pb
20.50 9.99
38.88 7.95
0.000*
38.00 7.28 0.000*
38.07 7.77 0.670
0.925
SD: standard deviation; END: external nasal dilator. * p < 0.01. a Independent t-test. b Paired Sample t-test.
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Table 3 OSA 18 scores of END group according to type of septal deviation.
Type Type Type Type Type Type
1 2 3 4 5 6
Total
N
Mean SD
8 16 11 2 7 4
24.00 3.30 20.00 14.40 14.27 6.31 31.00 5.66 25.57 4.24 18.50 1.73
48
20.50 9.98
studies with long-term follow-up are required to reach definitive conclusions. P
References 0.081*
OSA 18: obstructive sleep apnea18; END: external nasal dilator. * P > 0.05.
sectional area 2, which refers to the nasal valve, and a slight increase in cross-sectional area 1, which refers to the nostrils. The nasal valve regulates nasal airflow and resistance, and is responsible for 70% of nasal resistance [32]. Small deformities in the nasal valve region result in marked increases in nasal resistance and disturbance during sleep [33]. The improvements seen in patients are most likely due to widening of the nasal valve by ENDs. Pevernagie et al. [34] performed a sleep study and emphasized that external nasal dilator might have proven to be a valid therapeutic choice for snoring in the setting of chronic rhinitis and possibly other causes of impaired nasal breathing. Another sleep study which was performed by Todorova et al. [35] also supported that END had relieved snoring. Although the use of ENDs for pediatric patients has become more common [16,36], there is a lack of clinical evidence regarding its efficacy. The results of the present study indicate that ENDs have positive effects. In particular, patients with a Baumann type 3 deviation showed the greatest relief of symptoms because they had a narrowed nasal valve, although the effect was not statistically significant. On the other hand, patients with a type 4 deviation had the highest OSA 18 scores while using ENDs. OSA 18 scores obtained in this study was not as high as the studies which had aimed to asses obstructive sleep apnea [19,37,38] caused by adenotonsillary hypertrophy which was excluded from the study. On the other hand, our results showed that NSD had negative impact on quality of life which caused parents to seek medical help, even if it is not accompanied by severe adenotonsillary hypertrophy and OSA 18 scores reflected this effect. All of the patients included in our study were admitted to outpatient clinic with obstructive symptoms. A literature search indicated that an elongated face is not unique to septal deviation but may be caused by adenoid and tonsillar hypertrophy [39]. Thus, resolving nasal obstruction by ENDs may prevent facial deformity. To confirm this suggestion, long-term follow-up with anthropometric measurements is required. ENDs are effective as long as they are used consistently and do not prevent possible future surgery. However, ENDs prevent difficulties and possible complications of surgery. Maxillofacial deformities may be prevented by using ENDs until the completion of maxillofacial development. In addition, Ulfberg and Fenton [40] concluded that END had no deleterious side effect and we think that it is the major advantage of END. None of our patients experienced an adverse effect. The main limitation of the present study is the lack of objective data. However, due to the importance of NSD with regard to symptoms and complications, it was not practical to obtain such data in a pediatric population. 5. Conclusions END use relieved NSD which narrows the nasal valve. The results of this study suggest that ENDs could be used in patients that are not candidates for septoplasty. However, additional
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