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Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 219-223

The coexistence of concha bullosa and nasal septum deviation in adult Nigerians

Department of Human Anatomy and Cell Biology, Delta State University, Abraka, Nigeria

Date of Submission12-Dec-2021
Date of Acceptance23-Mar-2022
Date of Web Publication17-Sep-2022

Correspondence Address:
Dr. Beryl Shitandi Ominde
Department of Human Anatomy, Delta State University, P.M.B. 1, Abraka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_379_21

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BACKGROUND: Concha bullosa (CB) with an associated nasal septum deviation (NSD) compromises the paranasal sinus drainage through the osteomeatal complex hence predisposing to sinus disease. This study aimed at elucidating the concomitant existence of CB and NSD in adult Nigerians.
MATERIALS AND METHODS: Following institutional ethical approval, brain computed tomography images of 336 patients (199 males and 137 females) aged ≥ 20 years were analyzed for CB and NSD in the Radiology Department of a Teaching Hospital. Using the Statistical Package for the Social Sciences software version 23, the prevalence of these variants was expressed in percentages, and their association was probed using the Chi-square test. The angle of septum deviation was summarized in means and standard deviations. The differences in deviation angle in the presence of either ipsilateral or contralateral CB were assessed using the independent t-test. P < 0.05 was considered statistically significant.
RESULTS: The prevalence of coexisting CB and NSD was 77, 22.9%. There was a significant preponderance of NSD away from a unilateral or dominant CB (54, 84.4%) (P = 0.022). This deviation occurred at a significantly higher angle (11.82° ± 2.21°) than deviation toward a CB (9.86° ± 2.63°) (P = 0.036).
CONCLUSION: The awareness of the association between CB and NSD in our population emphasizes on mandatory preoperative radiological evaluation to aid in planning for safe endoscopic surgeries through the nose.

Keywords: Concha bullosa, deviation, nasal septum

How to cite this article:
Ominde BS, Igbigbi PS. The coexistence of concha bullosa and nasal septum deviation in adult Nigerians. Indian J Health Sci Biomed Res 2022;15:219-23

How to cite this URL:
Ominde BS, Igbigbi PS. The coexistence of concha bullosa and nasal septum deviation in adult Nigerians. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Sep 25];15:219-23. Available from: https://www.ijournalhs.org/text.asp?2022/15/3/219/356279

  Introduction Top

The nasal cavity is divided by a midline nasal septum into two symmetrical compartments.[1] This osteocartilagenous structure plays a role in the physiological function and support of the nose.[2] Its malalignment from the center is described as nasal septum deviation (NSD), a frequent structural variation within the nasal cavity that is commonly due to pressure and expansion during growth of the septum from the ethmoid ossification center.[1] This nasal deformity may also be caused by genetics, trauma, irregular growth of facial structures, and thumb sucking.[2],[3] The variant alters the flow of air and subsequently affect the nasal cycle and mucociliary clearance. Individuals with NSD are commonly asymptomatic. However, NSD may be associated with sleep apnea, difficulty in breathing, repeated sneezing, mouth breathing, nasolacrimal duct obstruction, otitis media, and chronic sinusitis.[1],[4]

The ethmoid air cells may extend into the middle turbinate and aerate it hence forming concha bullosa (CB).[4] This variant occurs either unilaterally or bilaterally.[1] According to Al-Rawi et al.,[5] trauma, NSD and mouth breathing predispose to CB. Majority of the individuals with CB are asymptomatic.[6] Occasionally, a large CB may compromise the osteomeatal complex by compressing the uncinate process against the lateral boundary of the nasal cavity hence narrowing the ethmoid infundibulum and obstruting the middle meatus.[7] This impedes mucociliary drainage of the anterior sinus group, namely maxillary, frontal and anterior ethmoid sinuses leading to sinus disease.[5] The severity of symptoms is associated with the extent of pneumatization.[7]

The NSD may cause a decline in the airflow and capacity of the nasal cavity.[2] Consequently, the contralateral turbinates hypertrophy to fill the compartment with an expanded air channel.[1] In the event where CB develops first, its mass effect may cause the septum to deviate away from the side of CB.[2] Previous studies have documented a correlation between a CB and deviation of the nasal septum towards the contralateral side.[4],[8],[9] This co-occurrence is lower in the pediatric age-group and tends to increase with age.[2] The coexistence of CB and DNS interfere with the nasal air flow and cause sinonasal obstruction hence predisposing to sinus disease.[1],[5],[10] These variants of the NC are easy to identify and may possibly be utilized to strengthen anthropological estimations during forensic identification of unknown human remains. Their recognition during the comparison of antemorterm and postmorterm radiological features may aid in forensic investigations.[3]

Computed tomography (CT) is widely acknowledged as the imaging modality of choice in the identification of sinonasal variants and diagnosis of pathologies in the sinonasal complex.[5] There is a paucity of data regarding the relationship between CB and NSD in Delta State Nigeria; therefore, this study aimed elucidating the concomitant occurrence of CB and NSD in adult Nigerians.

  Materials and Methods Top

This cross-sectional study adopted the purposive sampling technique. We retrospectively searched the Picture Archiving and Communications System (PACS) for brain CT images taken in the Radiology Department of a Teaching Hospital within a 5-year duration (June 1, 2015–June 30, 2020) for reasons such as headache, stroke, and intracranial space-occupying lesions. These images were taken using a 64 slice CT scanner (Toshiba Aquillon, 2009, Japan) with an imaging protocol that encompassed 3–5 mm axial sections, 120 kV and 300 mA. The acquired axial slices were reformatted to multiplanar coronal and sagittal images using 1.5 mm slice thickness and 1.5 mm table increment for reconstruction. Ethical clearance was obtained from Delta State University Teaching Hospital's Health Research Ethics Committee EREC/PAN/2020/030/0371 dated 29.07.2020. Brain CT images of adult patients aged 20 years and above and with full demographic information were utilized herein. The exclusion criteria comprised images with facial trauma, features suggestive of sinonasal infection for instance mucosal thickening and air fluid levels, presence of sinonasal lesions such as polyps and tumors, craniofacial congenital anomalies, and evidence of previous sinonasal surgery. Moreover, images of patients aged below 20 years were excluded.

The images of 336 patients; 199 males and 137 females, aged between 20 and 99 years were analyzed by a single consultant radiologist with 9 years' experience. The NSD was identified as a convexity of the nasal septum with respect to the midline; a vertical line drawn from anterior nasal spine to the crista galli.[10] The direction of NSD was determined by the side with the convexity of the septum.[1] The coronal slices were also evaluated for any evidence pneumatization of the middle turbinate (CB) and the side of its occurrence. In the event whereby both middle turbinates were aerated, the larger CB was labeled as a dominant CB. Using the protractor provided by PACS, the deviation angle of the nasal septum in subjects with CB was measured between the NS convexity and the midline.[2]

Statistical analysis was accomplished using the Statistical Package for the Social Sciences (SPSS) software version 23 IBM® Armonk, New York, USA. The prevalence of the variants was expressed in percentages, whereas the NSD angle was presented in means and standard deviations. Independent t-test was employed to establish whether there is a difference between the NSD angle in patients with unilateral or dominant CB on the same side of NSD or on the contralateral side. The association between the existence of an aerated middle concha and NSD was evaluated using the Chi-square test. P < 0.05 was considered statistically significant.

  Results Top

We analyzed brain CT scan images of 336 patients; 199 males (59.2%) and 137 females (40.8%). The patients' average age was 53.29 ± 18.18 years (Range 20–99 years). The NSD was observed in 136 patients (40.5%) with a preponderance of left-sided deviation (72, 52.9%). At least one CB was recognized in 96 (28.6%) patients and more frequently occurring unilaterally (56, 58.3%) than bilaterally (40, 41.7%). Majority of the bilateral occurrence had a dominant CB (24, 60%) while equal CB was observed in 16 patients (40%). The prevalence of unilateral CB and dominant CB was 80, 23.8% while remaining 256 patients (76.2%) had equal bilateral CB and absent unilateral CB.

This study reports the concomitance of CB and NSD in 77 patients (22.9%). Of these participants, one-sided CB was observed in 50 (64.9%) and while the remaining 27 (35.1%) patients had aeration of both middle turbinates [Table 1]. This study reports at least one CB in 56.6% of patients with NSD and deviation of the nasal septum in 80.2% of participants with at least one CB [Table 2]. We observed a NSD in 80% (64) of the patients with one-sided and a dominant CB while the remaining 72 NSD cases had equal bilateral CB or no unilateral CB [Table 3].
Table 1: The number of patients with concha bullosa and nasal septum deviation

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Table 2: Prevalence of nasal septum deviation in patients with concha bullosa

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Table 3: Prevalence of concha bullosa in patients with nasal septum deviation

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In images with either unilateral or dominant CB, we report a preponderance of an accompanying NSD in the opposite direction of the CB location (54, 84.4%) [Figure 1]. For instance, a left CB coexisted with NSD to the right (22 patients) while the right CB occurred simultaneously with NSD to the left (32 patients). In patients with either unilateral CB or dominant CB, 15.6% (10) had NSD toward the ipsilateral side [Table 4]. The prevalence of NSD away from an aerated middle concha was higher than the deviation toward a CB. This difference was statistically significant (P = 0.022). All the images with CB manifested an air channel between the medial surface of the aerated concha and the adjacent nasal septum surface.
Figure 1: Coronal reformatted image depicting a right unilateral concha bullosa with nasal septum deviation to the left

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Table 4: Direction of nasal septum deviation in patients with concha bullosa

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Both unilateral and dominant CB caused a larger angle of deviation of the nasal septum in the opposite direction (11.82° ± 2.21°) compared to a deviation toward the aerated concha (9.86° ± 2.63°). Furthermore, this difference in the degree of deviation was statistically significant (P = 0.036).

  Discussion Top

The existence of NSD was observed in 40.5% of the study sample, also documented in a previous study.[11] This was higher than 20.9% documented by Onwuchekwa and Alazigha[12] in Rivers State Nigeria. Our finding was also higher than 37.3% documented by Ahmed[1] in Egypt. Conversely, some studies have documented a higher frequency of NSD compared to the finding herein.[4],[7],[9],[10] We report a preponderance of NSD toward the left (52.9%) than the right (47.1%) side. This was similar to the reports by Lopes et al.[4] and contrary to the findings of Kele's et al.,[2] Balikci et al.,[13] Ahmed,[1] and Ahmmed et al.[7] The discrepancies in literature regarding the prevalence and direction of NSD could be attributed to genetic, ethnic, geographical, and environmental factors. Moreover, the dissimilarities in the sample size and definitions of NSD may also contribute to the variations.[14]

The prevalence of CB was 28.6%, also documented in a previous study.[15] This was lower than the findings of Lopes et al.,[4] Onwuchekwa and Alazigha,[12] Kucybała et al.,[10] Ahmed,[1] Ahmmed et al.[7] Consistent with the reports of Balikci et al.,[13] and Ahmmed et al.,[7] this variant occurred more unilaterally than bilaterally. Congruent with the findings of Balikci et al.[13] and Shiekh et al.,[9] majority of the bilateral CB comprised one dominant CB. However, Kucybała et al.[10] in Poland documented a higher prevalence of equal bilateral CB. The frequency of both unilateral and dominant CB herein was lower than the findings of Balikci et al.[13] and Shiekh et al.[9] On the contrary, we observed a higher prevalence of equal bilateral CB and absent unilateral CB compared to the reports of Shiekh et al.[9] The variation in the occurrence of CB in literature is ascribed to dissimilarities in the sample size and sample composition whereby some authors used patients with sinonasal symptoms.[2],[10] In addition, the variances in the definition of CB based on the extent of aeration or part of middle concha aerated could also contribute to the discrepancies.[14],[16],[17]

A CB with concomitant NSD had a prevalence of 22.9% which was lower than the finding by Kucybała et al.[10] Consistent with the findings of these authors, we observed a higher prevalence of NSD with an associated unilateral CB than bilateral CB. Our study found out that in the patients with NSD, 56.6% had CB while 80.2% with CB had a concomitant NSD. These were higher than 35.7% and 33.3%, respectively, documented by Ahmed[1] in Egpyt. These differences could be attributed to the smaller sample size used by this author.

In the majority of the images that manifested unilateral or dominant CB (80%), a NSD was observed and this was parallel to the reports of Balikci et al.[13] and Shiekh et al.[9] Furthermore, NSD was observed in 28.1% of the images with either equal CB or absent unilateral CB. This was lower than 45.8% and 56.04% documented by Balikci et al.[13] and Shiekh et al.[9] We report a higher prevalence of contralateral than ipsilateral NSD in the occurrence of a unilateral and dominant CB. This was consonant with the reports of Keles et al.[2] and Shiekh et al.[9] Similar to the reports from previous studies, unilateral and dominant CB showed a statistically significant association with a contralateral NSD (P = 0.022).[1],[6],[9],[13],[18] According to Shokri et al.[19] there exists an inductive link between CB and NSD subsequently causing the NSD to almost always occur away from either a unilateral CB or dominant concha in bilateral CB. According to Kucybała et al.,[10] the space created by the concavity of the nasal septum provides room for the pneumatization of the middle concha.

All the images with pneumatized middle concha manifested an air channel between the medial side of the CB and the adjacent NS. According to Shokri et al.,[19] this implies that the NSD is not attributable to the mass effect of the turbinate pushing the septum. Similarly, Bhandary and Kamath[6] and Shiekh et al.[9] reported that a nasal cavity with NSD has a roomier compartment in the side with CB. On the contrary, Lopes et al.[4] did not establish any association between pneumatization of the middle turbinate and NSD to the opposite side hence concluded that DNS did not favour the middle turbinate pneumatization. Similarly, El-Anwar et al.[17] reported no significant correlation between CB and either NSD toward or away from the existing aerated concha, suggesting that CB and NSD are coincidental variations. The identification of the simultaneity of these variants in the apparently normal sinonasal CT images in this study proposes that there could be no specific association between their occurrence and pathogenesis of sinonasal disease. This was in agreement with El-Anwar et al.[17] who further inferred that the pathogenesis of rhinosinusitis could significantly be due to local, systemic, environmental, and intrinsic mucosal factors rather than strictly anatomical. Furthermore, some scholars have documented no significant association between these variants and sinonasal malady.[1],[2],[13]

Consonant with the reports of Keles et al.,[2] NSD away from an existing CB occurred at a significantly higher angle (11.82° ± 2.21°) than ipsilateral deviation (9.86° ± 2.63°) (P = 0.036). This possibly implies that contralateral deviation has a higher possibility of impairing the sinus drainage through the meatus on the lateral wall of the nasal cavity compared to ipsilateral deviation. This greater degree of contralateral deviation may influence the size of the maxillary sinus hence predisposing to maxillary sinusitis.[20]

The awareness of the concomitant existence of CB and NSD in the studied population is important to radiologists and otorhinolaryngologists. This is because these two variants cause impediment of the osteomeatal complex hence hampering drainage and mucociliary clearance of the anterior ethmoid, frontal, and maxillary sinuses and possibly lead to sinus disease.[1],[21],[22] According to Kucybała et al.,[10] patients with cystic fibrosis, immunocompromised states, intracranial or orbital infections need to be screened for CB and NSD to prevent development of sinusitis. The radiological detection of these variants is paramount since they both may pose a challenge during functional endoscopic sinus surgery leading to iatrogenic injuries.[4],[23],[24] Finally, the identification of both CB and NSD during the comparison of antemortem and postmortem CT images may act as an auxiliary tool in the forensic identification of unknown human skulls.[3]

  Conclusion Top

The awareness of the relationship between CB and NSD in our population emphasizes on their radiological identification before endoscopic surgeries through the nose to aid in surgical planning and minimize complications.

Limitations of study

The study used brain CT images instead of maxillofacial CT images which are acquired in thinner axial slices that offer better resolution. This single-centered study also used purposive sampling technique hence a low sample size was available implying that the results herein cannot be generalized.

Future research

We recommend further studies to evaluate the association of the concomitant CB and NSD with sinus pathology in Nigeria.


We would like to acknowledge Priscilla Ejiroghene and Emmanuel Akpoyibo who assisted with data collection and analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ahmed DF. Prevalence and correlation of nasal septum deviation, concha bullosa and maxillary sinusitis in a group of adult Egyptian population: A retrospective CBCT study. Egypt Dent J 2020;66:143-52.  Back to cited text no. 1
Keles B, Öztürk D, Arbag H, Özer B. Is there any relationship between nasal septum deviation and concha bullosa? Eur J Gen Med 2010;7:359-64.  Back to cited text no. 2
Santos WM, Prado P. Frequency of nasal septum deviation and concha bullosa: Forensic anthropological implications. Braz J Forensic Sci Med Law Bioeth 2017;7:92-100.  Back to cited text no. 3
Lopes S, Moraes M, Coutinho L, Junior M, Gamba T, Flores I. ConeBeam computed tomography analysis of prevalence of nasal septum deviation and its relationship with the presence of middle concha bullosa. Braz Dent Sci 2015;18:38-43.  Back to cited text no. 4
Al-Rawi NH, Uthman AT, Abdulhameed E, Al Nuaimi AS, Seraj Z. Concha bullosa, nasal septal deviation, and their impacts on maxillary sinus volume among Emirati people: A cone-beam computed tomography study. Imaging Sci Dent 2019;49:45-51.  Back to cited text no. 5
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Ahmmed S, Khan N, Hossain Z, Mridha K, Bhuiyan A, Ahmed K. Study of prevalence of concha bullosa, nasal septal deviation and sinusitis based on CT findings. Bangladesh J Otorhinolaryngol 2020;26:18-23.  Back to cited text no. 7
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Shiekh Y, Ali A, Lone A, Bhat I, Ali S. Concha bullosa and its association with DNS and sinusitis. Int J Adv Res 2017;5:362-7.  Back to cited text no. 9
Kucybała I, Janik KA, Ciuk S, Storman D, Urbanik A. Nasal septal deviation and concha bullosa – Do they have an impact on maxillary sinus volumes and prevalence of maxillary sinusitis? Pol J Radiol 2017;82:126-33.  Back to cited text no. 10
Ominde BS, Ikubor J, Igbigbi PS, Nekwu O. Variations of the Nasal septum in adult Nigerians: CT study. Int Arch Otorhinolaryngol 2021;25. In press.  Back to cited text no. 11
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Balikci HH, Gurdal MM, Celebi S, Ozbay I, Karakas M. Relationships among concha bullosa, nasal septal deviation, and sinusitis: Retrospective analysis of 296 cases. Ear Nose Throat J 2016;95:487-91.  Back to cited text no. 13
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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