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Table of Contents - Current issue
July-December 2021
Volume 11 | Issue 2
Page Nos. 71-156
Online since Thursday, March 31, 2022
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EDITORIAL
Editorial Message
p. 71
Reda Kamel, Ahmed El-Farouk
DOI
:10.4103/pajr.pajr_28_21
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ORIGINAL ARTICLES
Strategy of endoscopic skull base reconstruction in endoscopic transsphenoidal approaches
p. 72
Osama Hassan, Maha Zaki, Aly El Garem, AbdEl Rhman Younes
DOI
:10.4103/pajr.pajr_13_21
Introduction
Endonasal endoscopic approaches gained acceptance in managing many benign skull base tumors. Cerebrospinal fluid (CSF) leak is a common and serious complication with high risk of morbidities or mortality. Identification and management of intraoperative CSF leak is a critical step in these approaches. Various methods and materials had been described for a skull base reconstruction. The size of arachnoid defect plays a crucial role in selecting the proper method of reconstruction.
Patients and methods
This is a prospective analytical study in which 67 patients with benign skull base lesions who were candidates for endoscopic transnasal transsphenoid surgery were included. All cases were subjected to detailed assessment protocol preoperatively and postoperatively. Intraoperative CSF leak was meticulously observed and graded according to the size of arachnoid defect, and then reconstruction was done according to grade of CSF leak by grafts or flaps or combination of them.
Results
This study included 67 patients with sellar–suprasellar tumors who were managed by endoscopic transsphenoid approach. Intraoperative CSF leak occurred in 23 (34.3%) cases. A total of nine (13.4%) cases had grade 1 CSF leak, and all cases were reconstructed with abdominal fat with success rate of 100%;six (8.9%) cases had grade 2 CSF leaks, and all cases were repaired with pedicled nasal flap with success rate (83%); and grade 3 CSF leak occurred in eight (11.9%) cases, and all were repaired with multilayer technique, with success rate of 75%. The incidence of postoperative CSF leak in this study was 4.5%, that is, three patients.
Conclusion
The strategy of skull base reconstruction depending on grade of intraoperative CSF leak according to size of arachnoid defect produces a promising result in decreasing the incidence of postoperative CSF leak and saving the need of unnecessary flaps.
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Intranasal splint removal after septal surgery: optimum timing
p. 77
Mohammed E Hassan, Hamada F Hashem, Alaa M Abdelsamei, Ayman A Mohamdy
DOI
:10.4103/pajr.pajr_14_20
Introduction
Insertion of intranasal splints (INSs) after septal surgery with or without turbinate surgery can cause significant pain and discomfort. To date, there is no evidence on the accepted optimal time for INS removal.
Aim
This study aimed to investigate the optimal time for INS removal in patients undergoing septal surgery.
Patients and methods
A prospective randomized clinical study was carried out in Benha University Hospital from April 2018 to February 2019. It included 60 patients who underwent septoplasty with or without turbinoplasty. All patients had been splinted by a silicone nasal splint bilaterally. Patients were allocated into three groups (A, B, and C) according to the time of splint removal (3, 5, and 7 days, respectively). The three groups were compared on bleeding, pain, infection, septal hematoma, septal perforation, crustation, and adhesions.
Results
The median pain score was significantly higher in group C than group A (
P
=0.031). The median pain score was significantly higher in group C than group B (
P
=0.045). Adhesions showed a statistically insignificant difference between the three groups (
P
=0.766). Crustations showed a statistical insignificant difference between the three groups (
P
=0.863). Bleeding showed a statistically insignificant difference between the three groups (
P
=0.863). Infection showed a statistically insignificant difference between the three groups (
P
=0.766). No septal perforation or hematoma was recorded.
Conclusion
Early removal of INSs significantly affects patient comfort and decreases pain. However, the incidence of other postoperative complications increased with short splint duration, but this was statistically insignificant. Therefore, we recommend INS removal after 5 days as an optimal removal time.
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Role of open reduction and semirigid internal fixation in management of displaced pediatric mandibular fractures
p. 83
Mohamed El Sayed Hassan, Hossam Abd El Hay Gad, Wael H. G. Abd Elkawy
DOI
:10.4103/pajr.pajr_37_20
Background
Injuries in children are very common, and nine million children from birth to the age of 19 years are treated every year in the emergency departments for accidental injuries, costing $87 billion. Involuntary injury is ranked as the number one cause of illness and death in children 1 year and older. Facial fractures are relatively rare in children and account for 1–15% of all facial fractures.
Aim
To evaluate the efficacy of open reduction and semirigid internal fixation in the management of displaced pediatric mandibular fractures.
Patients and methods
This study was conducted on 25 patients who have mandibular fracture. All cases were subjected to open reduction and semirigid internal fixation mandibular fractures. This study was carried out at the Otorhinolaryngology Department at Benha University Hospital and El Galaa Military Medical Complex in the period from May 2019 to May 2020.
Results
Fixation was done in all of the cases by 1.5-mm titanium miniplates and 1.5-mm diameter 7- or 9-mm length titanium screws, with plate removal after 6 months.
Conclusion
Open reduction and semirigid internal fixation with titanium miniplates is a reliable and a safe method in the treatment of displaced fractures of the pediatric mandible, with no danger regarding the erupted or unerupted tooth follicles.
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Detection of TNF-α as a cofactor in the pathogenesis of nasal polypi
p. 89
Masoud Mohammed A, Kamal Tarek M, Abdelnazer Zeinab R, Maarouf Ahmed M
DOI
:10.4103/pajr.pajr_1_21
Background
Nasal polyposis (NP) is a multifactorial disorder that is correlated with multiple inflammatory, environmental, as well as genetic factors. Moreover, tumor necrosis factor (TNF)-alpha is regarded as the most prominent pro-inflammatory cytokine that contributes to the pathogenesis of NP. Multiple polymorphisms of that gene can influence its function.
Aim
The aim of this study was to detect TNF-α polymorphism in patients with nasal polypi to determine its contribution to the pathogenesis of nasal polypi in the Egyptian population.
Methods
This is a case–control study, in which 25 patients with NP as well as 25 healthy participants were included, who attended Ain Shams University hospital. Participants were examined and prepared for the study. Participants were subjected to DNA extraction, and restriction fragment length polymorphism–polymerase chain reaction was administrated to detect polymorphism. The comparison of the genotype frequency distribution and the TNF-alpha gene alleles with NP was done using
χ
2
test.
Results
The results showed a statistically marked difference between the G/G genotype in the two groups (
P
=0.0001). In addition, the presence of allele A in the patient group and control group was 10 and 1%, respectively, which is statistically significant (
P
=0.0001). The genotype G/G, A/A, as well as G/A frequency in the NP group was 8, 40, and 52%, and it was 76, 1, and 5% in the control group, respectively. The findings of the present study showed that the polymorphism in TNF-alpha gene is probably an important NP risk agent in the Egyptian population. The presence of the TNF-alpha G308A allele in our study was to some extent higher compared with the other populations in other previous studies.
Conclusion
According to the scientific evidence for G/A 308 polymorphism related to the promoter of TNF-α gene in Egypt, the genotypic pattern distribution in all regions appears to be the same. Nonetheless, the amount of allele A was higher in the current research than in the control group, in addition to the incidence of the NP-associated G/A genotype. However, to obtain accurate findings, larger samples are required. Regarding the results of the present study, this polymorphism may be determined as a risk agent for NP susceptibility in relation to the Egyptian population.
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Effect of combined septal and turbinate injection of botulinum toxin type A in allergic rhinitis
p. 95
Mostafa Ismail, Alaa Nabil, Mostafa Nasr, Balegh Abdelhak, Osama G Awad, Khalaf Hamead
DOI
:10.4103/pajr.pajr_7_21
Objective
Allergic rhinitis (AR) has increased in prevalence recently, and traditional treatment strategies sometimes show limited effectiveness for patients with intractable AR. Botulinum toxin type A (BTX-A) is among the increasingly used alternative treatment options. This study was carried out with the aim of performing a clinical assessment of the effect of combined septal and turbinate injection of BTX-A for the management of uncontrolled AR.
Materials and methods
A single-arm pilot study enrolled 40 patients with moderate to severe uncontrolled AR recruited between October 2018 and August 2019. Each patient received 45 units of BTX-A injected into three fixed points of each side of the nose: inferior turbinate (15 IU), middle turbinate (15 IU), and nasal septum (15 IU). All patients were evaluated in terms of nasal hypersecretions, congestion, and sneezing with a visual analog scale before treatment and at weeks 1, 2, 4, 8, and 12 during the follow-up period.
Results
Throughout the 12-week follow-up period, a significant difference in the degree of nasal hypersecretions could be identified before and after BTX-A injection. Sneezing differed significantly only in the first 4 weeks, while nasal congestion did not differ significantly before and after BTX-A injection. BTX-A was well tolerated by the patients, with no serious adverse or systemic effects.
Conclusion
Combined septal and turbinate injection of BTX-A, in patients with uncontrolled AR, may be a long-lasting therapeutic option for the treatment of nasal hypersecretions, but not as effective as for sneezing and nasal congestion.
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Alterations in serum iron markers in allergic fungal rhinosinusitis
p. 100
Mohamed M Osman, Mohamed I Seddik, Mohamed O. A. Gad
DOI
:10.4103/pajr.pajr_4_21
Background
There is a debate concerning serum iron markers in fungal infections in patients with different diseases, and so far, none has assessed their level in fungal rhinosinusitis. Therefore, this study aimed to detect whether allergic fungal rhinosinusitis is associated with alterations in serum iron markers.
Patients and methods
Patients of this study were classified into two groups: group A included 35 patients with allergic nasal polyps, and group B included 31 patients with allergic fungal rhinosinusitis. Computerized tomography of paranasal sinuses was performed for all patients. Serum iron and total iron-binding capacity (TIBC) of all patients were measured, and unsaturated iron-binding capacity (UIBC) and transferrin saturation (TSAT) were calculated.
Results
Both the TIBC and UIBC were significantly higher in the allergic fungal rhinosinusitis group than the nasal polyps group. No significant differences were detected in the levels of serum iron and TSAT between the two groups.
Conclusion
Allergic fungal rhinosinusitis is associated with higher TIBC and UIBC, suggesting a possible role of iron in the pathogenesis of allergic fungal rhinosinusitis.
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Prevalence of unified airway disease in Saline Water Conversion Corporation Society
p. 105
Osama A Elsayad, Ayman Khater
DOI
:10.4103/pajr.pajr_34_20
Background
Saline Water Conversion Corporation (SWCC) is the main source of water in the Red Sea coast in Jeddah, KSA, the workers and their families are exposed to vapor and chemicals that affect their upper respiratory tract.
Aim
Our aim was to study the prevalence of unified airway disease [allergic rhinitis (AR) and bronchial asthma] in SWCC Society accommodations, serum immunoglobulin E (IgE) level and its relation to the duration of bronchial asthma, and duration of living in the accommodations.
Patients and methods
This randomized study included 400 patients with bronchial asthma, the included patients comprised two groups: group I (GI) (
n
=200) from SWCC Society accommodations and group II (GII) (
n
=200) patients from outside the accommodations. Both groups were classified according to Allergy Classification of allergic rhinitis and its impact on asthma and blood samples for IgE taken from them.
Results
According to the classification of allergic rhinitis and its impact on asthma, the persistent and moderate–severe allergy were more common in GI (80%) and the intermittent allergy and mild severity was 20%, while the persistent and moderate–severe allergy were less common in GII (22%) and the intermittent allergy and mild severity was 78%. GI patients experienced a significantly high IgE level compared with GII, higher in males than females, and increases with the duration of living in the accommodations and duration of bronchial asthma.
Conclusion
Unified airway disease is common in SWCC Society with a high level of IgE compared with outside the accommodations.
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Evaluation of preoperative naso-alveolar molding in correction of unilateral complete cleft lip and palate associated with nasal deformity
p. 110
Mahmoud El-Bestar, Mamdouh Aboulhassan, Nermin Z Fahmy, Adel El-Antably
DOI
:10.4103/pajr.pajr_11_21
Objectives
Complete cleft lip and palate (CLP) is a common congenital middle-third facial defect, which has considerable medical, economic, social, and psychological consequences for the affected individuals and their families. Many surgical techniques had evolved for correction, but the displacement of the lower lateral nasal cartilage is considered a challenge for the surgeon. Preoperative naso-alveolar molding (NAM) aims at alignment of tissues, thus improving the surgical outcome. The aim of the current study was to assess the outcome of the use of NAM as a presurgical orthodontic modality for the treatment of patients with unilateral complete CLP associated with nasal deformity.
Patients and methods
This prospective controlled study was conducted on 16 randomly selected patients with unilateral complete CLP associated with nasal deformity. They were divided randomly into two equal groups. One group included eight patients who underwent presurgical NAM therapy, and the other one included eight patients who underwent surgical repair only as a control.
Results
A statistically significant difference was found regarding the hemicolumellar height ratio. Although alar base width values were slightly smaller in presurgical NAM therapy group, no statistically significant difference was found for the alar base width values or the domal angles.
Conclusion
Presurgical NAM proved superior postsurgical nasal symmetry compared with controls regarding the nostril height. The parents of patients with unilateral complete CLP associated with nasal deformity should be counselled to have presurgical NAM to improve the surgical outcome.
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Prevalence of anosmia in coronavirus disease 2019-confirmed cases
p. 118
Hossam M Abdelazeem, Amira E Esmail, Alaa M Abdelsamie
DOI
:10.4103/pajr.pajr_12_21
Objectives
The current study aims to evaluate the prevalence of anosmia and the factors affecting it in coronavirus disease 2019 (COVID-19)-confirmed cases.
Patients and methods
A cross-sectional, multicenter study was conducted on 400 COVID-19-confirmed patients. The clinical data were collected from patients, either hospitalized in COVID-19 units of different isolation hospitals or home-quarantined, in Egypt. Data were collected through a predesigned survey-based 16 questionnaire, available in two forms, one in a written form and the other was online-designed by Google forms.
Results
The prevalence of anosmia was 68.8% in COVID-19-confirmed cases. About 41.1% of the patients had isolated anosmia. There were no significant differences between those with anosmia and those without as regards smoking and chronic rhinological status,
P
values were 0.118 and 0.132, respectively.
Conclusion
As a prevalent symptom of COVID-19 patients, anosmia will raise the suspicion index of health staff in developing countries with limited access to the COVID-19 test.
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Antrochoanal polyp: a review of 57 patients
p. 125
Ahmed A Nassar
DOI
:10.4103/pajr.pajr_8_21
Objectives
To detect the site of attachment of the antral part of the polyp and the prevalence of coexisting sinonasal anatomical variations in the antrochoanal polyp (ACP) side.
Patients and methods
A retrospective study of 57 patients treated for ACP was conducted between 2018 and 2020 in the Department of Otolaryngology of Kasr Alainy Hospital, Cairo University. All patients underwent a complete history, head and neck examination, nasal endoscopy, and computed tomography. Factors, including age, gender, associated symptoms, imaging findings, surgical approach, and the site of attachment of the antral part of the polyp, were recorded.
Results
This study included a total of 57 patients (33 males and 24 females). The mean age of the patient was 22±12.9 (range, 9–59) years. Mean age was 21.8 years for males and 23.6 for females. The major symptoms seen were constant and unilateral nasal obstruction in 34 (59.6%) patients. The exact origins of the polyps were located in different positions within the maxillary sinus and were able to be detected in 39 sides. It was detected in the anteroinferior antral wall on 16 sides, in the inferior antral wall on six sides, in the medial antral wall on six sides, in the lateral antral wall on six sides, and in the posterior antral wall on five sides.
Conclusion
Endoscopic approach for complete removal of the choanal polyps is an extremely safe and effective procedure. Despite the different approaches of ACP excision, the recurrence rates are still high.
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The relation between serum vitamin D deficiency and allergic rhinosinusitis
p. 129
Samer B Kamel, Ahmed A. S. El-Hamshary, Ahmed S El-Kady, Naslshah G Kazem, Hafez A. M. Lamasha
DOI
:10.4103/pajr.pajr_17_20
Background
It has been reported that the prevalence of allergic diseases, including asthma, food allergy, and allergic rhinitis (AR), is strongly associated with vitamin D deficiency. This study was conducted to evaluate the relation between vitamin D levels and AR in Egyptian patients.
Patients and methods
A total of 100 AR cases and 50 healthy controls were included. Cases were subjected to complete history taking and ENT examination. Vitamin D and immunoglobulin E levels were ordered for both cases and controls.
Results
No significant difference was detected between cases and controls regarding demographics. Regarding total nasal symptom score, it was mild in 44 cases, whereas 56 cases had moderate to severe scores. Serum vitamin D levels were significantly lower in cases compared with controls (16.9 vs. 28.3 ng/ml –
P
<0.001). Besides, vitamin D had lower levels in cases with higher total nasal symptom score. Conversely, immunoglobulin E was significantly higher in rhinitis cases compared with controls (1071.4 vs. 208.7 IU/ml –
P
<0.001). With a cutoff value of 13.6 ng/ml, lower vitamin D levels had sensitivity and specificity of 95.7 and 82.2%, respectively, to identify AR cases.
Conclusion
It is evident that low vitamin D levels are associated with AR. Moreover, the more deficiency detected in its levels, the more severe symptoms experienced by patients.
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Pulmonary function tests after septoplasty with inferior turbinectomy
p. 134
Naslshah Galal Eldin Kazem, Sayed Atia Elfayoumi, Shaimaa Magdy Abo Youssef, Huda Saad Abdel Aziz, Yasser Mohammed Hassan Mandour
DOI
:10.4103/pajr.pajr_19_21
Background
Deviated nasal septum causes variable resistance to inspired air currents, which directly and indirectly influences the efficiency of pulmonary functions.
Aim
To compare pulmonary function tests performed before and following septoplasty with turbinectomy in patients complaining of nasal obstruction caused by a deviated septum with hypertrophic inferior turbinate.
Patients and methods
The study was conducted on 60 patients diagnosed with deviated nasal septum with hypertrophied inferior turbinate. All were subjected to complete history taking, external nasal examination, and anterior rhinoscopy, which was performed with a nasal speculum. Additionally, all patients in this study underwent a nasal endoscopy, computed tomography, and spirometry. Septoplasty and turbinectomy were performed for all cases with regular follow-up, and the spirometry was repeated after 3 months.
Results
After surgery, the preoperative forced vital capacity (FVC) of 3.14±0.70 increased to 4.43±1.01, with a highly statistically significant difference (
P
<0.001). Forced expiratory volume in the first second (FEV1) was significantly greater postoperatively (2.66±0.55) than preoperatively (3.96±0.81) (
P
<0.001). The preoperative FEV1/FVC ratio of 85.08±5.47% improved to 90.39±8.75% after surgery, with a statistically significant increase (
P
=0.001). The preoperative peak expiratory flow rate of 5.57±1.47 increased to 7.07±2.26 following surgery, a difference that was highly statistically significant (
P
<0.001). The preoperative forced expiratory flow of 25–75% of vital capacity of 2.73±1.13 increased to 3.73±1.28 after surgery, a change that was highly statistically significant (
P
<0.001).
Conclusion
FVC, FEV1, FEV1/FVC, PEF, and forced expiratory flow of 25–75% showed a significant increase after operation.
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Role of Cinnarizine as an adjuvant treatment in cases of postviral hyposmia
p. 139
Tamer M Attia, Venus Rawat
DOI
:10.4103/pajr.pajr_22_21
Background
Odor identification is a complex process involving different neuronal mechanisms. It is important from different aspects of quality of life. Postviral neuritis is one of the leading causes of hyposmia. Attention to it has increased in the last year due to the coronavirus disease 2019 pandemic. Systemic steroids are presumed to benefit such cases through its anti-inflammatory mechanism of action. Cinnarizine, being a multimodal mechanism of action drug with a potent cerebral vasodilator effect, is assumed to have a great potential to be used as adjuvant treatment to systemic steroids.
Objective
The aim of the study is to assess if there is any role of Cinnarizine as an adjuvant treatment to steroids in cases of postviral hyposmia.
Patients and methods
This is a single-blinded, randomized, controlled trial including 82 patients with postviral hyposmia. Patients were distributed equally into two groups according to the given therapy with group I receiving 25 mg oral prednisolone per day for 2 weeks along with budesonide nasal spray/64 μg per puff in a dose of two puffs for each nostril twice daily for 1 month, in addition to our drug of study Cinnarizine 25 mg given postoperative TDS for 1 month. Group II received the same but without Cinnarizine. Both groups were compared regarding the number and percentage of patients having their smell identification test score improved either partially or fully back to normal.
Results
Cinnarizine intake as an adjuvant treatment to steroids had a significant effect on improving the smell identification test scores in patients with postviral hyposmia (
P
<0.05). However, among the improved patients in both groups, there was a nonsignificant difference between the two groups regarding the degree of recovery whether complete or partial (
P
=0.78).
Conclusion
Cinnarizine has a beneficial effect as an adjuvant treatment to steroids in cases of postviral hyposmia.
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Pterygopalatine fossa: a computed tomography analysis and classification
p. 145
Mohammad W El-Anwar, Diaa B Eldib, Mohamed S Haggag, Rania M Almolla, Mohammad El-Sayed Abd Elbary, Taha M Abdelaal, Alaa O Khazbak
DOI
:10.4103/pajr.pajr_25_21
Objective
To find out the various dimensions, measurements, and grading of the pterygopalatine fossa (PPF) that were not antecedently published using computed tomography (CT).
Patients and methods
This study was carried on the included 200 paranasal CT scans (400 sides). Axial images were acquired with multiplanar reformates to obtain delicate details in coronal and sagittal planes for all participants.
Results
Within 200 CTs (400 sides), the mean anteroposterior dimension of the PPF was 7.33±1.3 mm (range=3.8–11.6), the mean PPF transverse diameter was 12.5±2.09 mm (range=7.25–22.1), and the mean PPF height was 16.99±2.83 mm (range=10–22.2), without reported significant differences between both sides in all PPF dimensions.
Conclusion
This study improves surgeons' awareness of PPF variations in the endoscopic field and can be of help to residents in training.
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Electron microscope of the nasal septal body versus the inferior turbinate
p. 151
Yasser M. H. Mandour, Ahammed Allam, Hossam A Gad, Eslam Farid, Nesrine Ebrahim, Samr Badie
DOI
:10.4103/pajr.pajr_24_21
Background
The nasal septal body is located superior to the inferior turbinate and consists of septal cartilage thicker than the rest of septal mucosa.
Object
To clear the ultrastructural relation between nasal septal body and inferior turbinate using electron microscope.
Patients and methods
Biopsies of the nasal septal body and inferior turbinate were stained with hematoxylin–eosin and with Masson's trichrome stain and Periodic acid–Schiff (PAS) stain. Photomicrography with morphometric analysis was used to determine the relative area proportions of each tissue type.
Results
Nasal septal body has a prominence of glandular tissues with a mean proportion of 19.89%, in contrast to inferior turbinate, which had 7.89%. Inferior turbinate was found to have a prominence of collagen fibers with a mean proportion of 26.58%, in contrast to the septal body, which had 13.76%. By electron microscope, epithelium of the septal body had a large number of cilia and microvilli, the junctional complex between the cells were the tightly sealed zone (tight junction), while inferior turbinate mucosa had less number of cilia than that of septal body epithelial cells.
Conclusion
The presence of venous sinusoids and abundant seromucinous glands in the nasal septal swell body and its histological and ultrastructural similarity to inferior turbinate should guide to surgically reduce nasal septal body volume.
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