Anatomical variation of the nasal septum: Correlation among septal components

The Quadrangular Cartilage in Rhinoplasty: A Surgically Focused CT Dimensional Analysis of Black African and Caucasian Populations

The apparent lack of quadrangular cartilage in Black African noses is commonly observed both from a radiological and clinical point of view. To the best of our knowledge, only a few research papers have been conducted on the facial proportions and structural anatomy of black people of Southern and Eastern Africa. The aim of this retrospective comparative study is a radiological assessment of the total amount of septal quadrangular cartilage by measuring its area in sagittal CT views, in two selected Black South African and Caucasian (CA) samples and the comparison with the literature in our hands. Statistical analysis was conducted, categorical variables are shown as frequencies and percentages, while continuous variables as means and standard deviations. Normal distribution of variables was verified using the Shapiro-Wilk test or by means of skewness and kurtosis values. Differences among unpaired groups were evaluated using the independent Student's t-test for normally distributed data (complemented by the Cohen's d to show the effect size with the following cutoff: d = 0.2, "small" effect size; d = 0.5, "medium" effect size; d = 0.8, "large" effect size) and Mann-Whitney U test in case of non-normal distribution. Statistical significance was defined as p < 0.05 setting the α-error probability at 5%. This study shows that, on average, there is 30% more cartilage available in CA compared with Black African noses and confirms the apparent lack of quadrangular cartilage and in Black African noses which is commonly observed in surgery. The need for an adequate amount of autologous septal cartilage makes cartilage availability a major concern before surgery and being able to preoperative accurately measure the amount of septal cartilage that is available to be harvested for other grafts in the surgery is essential.

[Measurement of nasal septum area in 128 Chinese patients with nasal septum deviation]

Objective:Establish the anatomical parameters of the nasal septum and the area of each component in patients with nasal septum deviation, for the sake of guiding the scope of surgical resection for correction of nasal septum deviation. Methods:This is a retrospective study of 128 cases of sinus computer tomography images of patients with nasal septum deviation, marked 9 nasal septal anatomical locations, measured the area of the nasal septum and its components, and analyzed the trend of the percentage of the area of the nasal septum cartilage in the total area of the nasal septum with age. Results:The total area of the nasal septum in the 128 patients with nasal septum deviation is: （2951.96±305.91） mm², the area of nasal septal cartilage: （961.89±229.64） mm², the area of the vertical ethmoid plate: （1123.96±214.17） mm², the area of the vomerine: （652.77±108.09） mm². The area of male septum is larger than that of female. As age increases, the nasal septal cartilage gradually decreases, and the percentage of the nasal septal cartilage area in the total area of the nasal septum gradually decreases. Conclusion:Elderly people who undergo nasal septum correction should be carefully considered to grasp the scope of resection, and the influence of gender on the area of nasal septum should also be paid attention.

Properties of the Nasal Cartilage, from Development to Adulthood: A Scoping Review

OBJECTIVE

Nasal septum cartilage is a hyaline cartilage that provides structural support to the nasal cavity and midface. Currently, information on its cellular and mechanical properties is widely dispersed and has often been inferred from studies conducted on other cartilage types such as the knee. A detailed understanding of nasal cartilage properties is important for several biological, clinical, and engineering disciplines. The objectives of this scoping review are to (1) consolidate actual existing knowledge on nasal cartilage properties and (2) identify gaps of knowledge and research questions requiring future investigations.

DESIGN

This scoping review incorporated articles identified using PROSPERO, Cochrane Library (CDSR and Central), WOS BIOSIS, WOS Core Collection, and ProQuest Dissertations and Theses Global databases. Following the screening process, 86 articles were considered. Articles were categorized into three groups: growth, extracellular matrix, and mechanical properties.

RESULTS

Most articles investigated growth properties followed by extracellular matrix and mechanical properties. NSC cartilage is not uniform. Nasal cartilage growth varies with age and location. Similarly, extracellular matrix composition and mechanical properties are location-specific within the NSC. Moreover, most articles included in the review investigate these properties in isolation and only very few articles demonstrate the interrelationship between multiple cartilage properties.

CONCLUSIONS

This scoping review presents a first comprehensive description of research on NSC properties with a focus on NSC growth, extracellular matrix and mechanical properties. It additionally identifies the needs (1) to understand how these various cartilage properties intersect and (2) for more granular, standardized assessment protocols to describe NSC.

Time-course changes in active stiffness of the supraspinatus muscle after arthroscopic rotator cuff repair

PURPOSE

This study aimed to investigate the time-course changes in the active stiffness of the supraspinatus muscle after arthroscopic rotator cuff repair.

METHODS

Eight male patients (mean age 61.5 ± 9.4 years) who underwent arthroscopic rotator cuff repair for small to medium tears were recruited for this study. Movement tasks included 30° shoulder isometric abduction and maximal voluntary isometric contraction of shoulder abduction in the scapular plane. The stiffness of the supraspinatus (anterior superficial, anterior deep, posterior superficial, and posterior deep regions), upper trapezius, and middle deltoid muscles in bilateral shoulders was recorded using ultrasound shear wave elastography. For each subject, the measurement was performed preoperatively and 3, 6, and 12 months postoperatively.

RESULTS

The stiffness of the affected anterior superficial region of the supraspinatus muscle 12 months postoperatively was significantly higher than that measured preoperatively and 3 months postoperatively (p < 0.05); it was significantly higher at 6 months postoperatively than at 3 months postoperatively (p < 0.05). Further, the maximal voluntary isometric contraction had significantly improved 12 months postoperatively compared to that measured preoperatively and 3 months postoperatively (p < 0.05). The stiffness of the affected upper trapezius and middle deltoid muscles 12 months postoperatively was significantly lower than that preoperatively (p < 0.05).

CONCLUSION

The maximal voluntary isometric contraction 12 months postoperatively possibly increased because of improvement in the active stiffness of the anterior superficial region. Active stiffness of the anterior superficial region may improve 6 months rather than 3 months postoperatively because of the different stages of muscle force, structural repair tendon strength, and remodeling.

The Anatomical Study of the Nasal Septal Cartilage with its Clinical Implications

BACKGROUND

Several rhinoplasty and nasal reconstruction procedures require cartilage. Various studies have reported on the nasal septal cartilage as a donor site for Caucasian and Asian populations. However, studies regarding the Thai nasal septal cartilage dimensions are rare. This study aimed to examine the length, height, area, and thickness of the nasal septal cartilage, along with implications of the size and quantity of the available cartilage, for grafting in Thai cadavers.

METHODS

We analyzed the nasal septal cartilage in 42 Thai cadavers. The length, height, area, and thickness were digitally measured using ImageJ 1.52 software, along with the size and area of the available cartilage for grafting after preserving a 10-mm L-strut. Data were compared between sexes.

RESULTS

The mean height, length, and area of the nasal septal cartilage were 30.96 ± 5.90 mm, 26.13 ± 6.90 mm, and 636.10 ± 196.13 mm², respectively. The length did not differ significantly between sexes. However, the height and area in male cadavers were greater than those in female cadavers. The mean thickness ranged from 0.77 to 1.02 mm depending on the area, with the thickest and thinnest areas being the superoposterior and inferoposterior parts, respectively. The mean height, length, and area of the harvestable cartilage were 20.96 mm, 16.13 mm, and 384.84 mm², respectively, after excluding the L-strut.

CONCLUSION

Our results provide major anatomical data of the Thai nasal septal cartilage. Its implication for use of the septal cartilage for grafting is 21 mm in height and 16 mm in length, which is sufficiently safe to maintain nasal support.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Anatomical Characteristics of the Perpendicular Plate of the Ethmoid: An Analysis of Paranasal Sinus Computed Tomography via Three-Dimensional Reconstruction

In recent years, the perpendicular plate of the ethmoid (PPE) has emerged as a new autogenous grafting material in rhinoplasty and septoplasty of nasal deviation. However, no studies have outlined the precise size, shape, and morphologic features of the PPE. Therefore, this study aimed to provide detailed information on the anatomical and morphologic characteristics of the PPE to assist surgeons in performing surgeries that are more precise. About 104 Chinese patients who underwent paranasal computed tomography were assessed in this study. By analyzing the features of the PPE reconstructed with 3-dimensional models, the characteristics of the PPE at different stages of development and according to sex were observed. The PPE had a flat shape, and its lower part was relatively thin. It usually developed horizontally with age, which contributed to expansion of the PPE area. The dimensions of the PPE were significantly larger in male patients than in female patients. Through the reconstruction and measurement of Chinese patients' PPE, the authors have established precise information about the PPE's anatomical and morphologic features. The flat shape and proper size, which are similar to those of nasal septum cartilage, make the PPE an ideal alternative to conventional autogenous grafting materials. The findings might be useful to surgeons in helping them perform surgeries that are more precise.

Evaluation of the Effectiveness of an Alar Transfixion Suture for the Correction of a Vestibular Web and Alar-Facial Groove: A Photogrammetric Analysis

BACKGROUND

Alar transfixion sutures are commonly used for vestibular web correction. The purpose of this study was to evaluate the long-term results of the use of alar transfixion sutures in patients with a unilateral cleft lip nasal deformity using photogrammetric analysis.

METHODS

The study included 42 patients who were divided into child and adult groups. A total of 4 measurement items were evaluated from a basal view by photogrammetry using standardized clinical photographic techniques preoperatively, immediately postoperatively, 3 months postoperatively, and 6 months postoperatively.

RESULTS

When the preoperative and last postoperative values were compared, no significant changes in any measurement items were noted in the adult group. In the child group, the proportional index (the ratio of the cleft side to the noncleft side) of the alar slope line inclination was significantly increased, but other measurement items showed no significant change. When the measurement items were compared between time points, no significant changes in any measurement items were noted in the adult group. In the child group, the proportional indexes of the alar length, the width between the subnasale and the alare, and the webbing degree were significantly decreased immediately postoperatively compared with the preoperative values. However, these significant changes were diminished at 3 months postoperatively. The proportional index of the alar slope line inclination was significantly increased at 3 months postoperatively compared with the preoperative value, but the significant change was diminished at 6 months postoperatively.

CONCLUSIONS

The alar transfixion suture procedure is not effective for correcting a vestibular web and alar-facial groove.

The Caucasian Nasal Septum: An In Vivo Computed Tomography Study

BACKGROUND

The nasal septum is composed of cartilaginous and bony components and an understanding of each component volume is essential in both functional and cosmetic surgery.

OBJECTIVES

We sought to radiographically measure septal dimensions on cross sectional computer tomography (CT) images, establishing average parameters for normal anatomy among a single, Caucasian population group.

METHODS

One hundred and fifty consecutive sinus CT scan images were examined and 100 cases with appropriate sagittal views were included in the study. On each septum, the sagittal CT images were assessed and 14 points were identified and 23 lengths measured and tabulated. Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles which constituted the components of the nasal septum.

RESULTS

Measurements from 100 patients were included, with a mean age of 50.2 years, constituting 47 males and 53 females. Our surface area mapping established the following areas for both males and females respectively (mm2): quadrangular cartilage 1148 and 981; vomer 894 and 741; perpendicular plate of ethmoid bone 1244 and 1006; and total surface area 3287 and 2728. Our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were compared, highlighting reducing size with age (P = 0.04).

CONCLUSIONS

The study presents the largest published data series representing nasal septal measurements on CT images in a living Caucasian population. Our data demonstrates that septal size remains constant after adolescence, throughout our age-varied series (18-79 years), except in the female population where the quadrilateral cartilage reduces in size with age.

LEVEL OF EVIDENCE 4

Morphological Patterns and Variations of the Nasal Septum Components and Their Clinical Implications

The aim of this study was to clarify the morphological patterns and proportions of the components of the nasal septum. Anatomical examinations were performed on 70 nasal septums of embalmed Korean adult cadavers. The septal deviation was checked before cutting the nasal cavity midsagittally with the aid of a laryngoscope. The shape of each component of the nasal septum was identified, and photographs were taken from a midline sagittal view. A line was drawn on each photograph between the septal components, and then the area of each septal component was measured using software. The mean area proportions of the septal cartilage (SC), the perpendicular plate of the ethmoid bone (PPE), the vomer, and the nasal crest of the maxilla relative to the total area of the nasal septum were 25.6%, 43.0%, 25.8%, and 5.6%, respectively. The morphology of the nasal septum was classified into 3 main patterns according to the proportion of each septal component. The proportions of the SC, the PPE, the vomer, and the nasal crest of the maxilla were similar to the mean values of the present study in 45.7%. The proportions of the SC, the PPE, and the vomer were similar to each other (with a difference of <15%) in 24.3%. The proportion of the PPE exceeded 50% of the total area of the nasal septum in 22.9%. The results reported herein provide detailed anatomical knowledge that can be used as a valuable reference for rhinoplasty procedures.

Nasal septum configuration as a basis for novel septal splints

The objective is to use anatomical determinations of nasal septum shape and surface area in adults as a design basis for silastic septal splints of universal size and fit and offering maximum possible surface coverage. The objective is also to devise a method of securing the septal splints, so that surface pressure on septal mucosa is distributed as evenly as possible while not interfering with capillary perfusion. Nasal septum area was determined in 21 Caucasian body donors, and nasal septum thickness was measured in 20 CT scans. Septal splints of universal size and shape were prepared from silastic sheeting. The holding force of various neodymium-iron-boron (NdFeB) magnets, and the surface pressure exerted by magnet-containing septal splints was calculated. These septal splints of novel design offer a satisfactory fit in routine clinical practice. The splints can be securely attached with built-in NdFeB magnets, and surface pressure can be distributed evenly across the nasal septum while not interfering with mucosal tissue perfusion. With their simple intranasal insertion, these magnet-containing septal splints of universal size and optimised shape offer maximum possible septum coverage following septoplasty/septorhinoplasty. The absence of interference with septal tissue perfusion means that they are likely to be associated with fewer postoperative complications and better outcomes.

The Clinical Analysis of the Nasal Septal Cartilage by Measurement Using Computed Tomography

BACKGROUND

The nasal septal cartilage is often used as a donor graft in rhinoplasty operations but can vary widely in size across the patient population. As such, preoperative estimation of the cartilaginous area is important for patient counseling as well as operating planning. We aim to estimate septal cartilage area by using facial computed tomography (CT) studies.

METHODS

The study was performed using facial CT images taken from 200 patients between January 2012 to July 2015. Using the mid-sagittal image, the boundary of cartilaginous septum was delineated from soft tissue using the mean difference in signal intensity (or brightness). The area within this boundary was calculated. The calculated area for septal cartilage was then compared across age groups and sexes.

RESULTS

Overall, the mean area of nasal septal cartilage was 8.18 cm² with the maximum of 12.42 cm² and the minimum of 4.89 cm². The cartilage areas were measured to be larger in men than in women (p<0.05). The area decreased with advancing age (p<0.05).

CONCLUSION

Measuring the size of septal cartilage using brightness difference is more precise and reliable than previously reported methods. This method can be utilized as the standard for prevention of postoperative complication.

Are differences in external noses between whites and Koreans caused by differences in the nasal septum?

The nasal septum plays an important role in nose development. East Asians are believed to have inherent hypoplasia of the nasal septum because East Asians have smaller noses than whites do. However, there have been no studies of nasal septum differences between whites and East Asians. We compared the nasal septum and its components in Koreans and whites using computed tomographic scan data. Twenty-seven patients of white origin and 64 patients of Korean origin older than 20 years were enrolled in this study between 2008 and 2012. We evaluated a total of 9 measurement items (5 for the nasal bones and septa as well as 4 for the external nose morphology). Sex differences in whites were the same as those in Koreans. Nasal bridge length and cartilaginous nasal bridge length were significantly longer in whites than in Koreans. However, there were no significant differences in nasal height, nasal tip projection, nasal bone length, total septal area, or most components of the nasal septum between the samples. The relative proportions of the cartilaginous septum divided by the total septal area were negatively correlated with the relative proportions of the perpendicular plate in both groups. Differences in the external nasal morphology between whites and Koreans are not caused by differences in the nasal septum.

Current rehabilitation applications for shoulder ultrasound imaging

The available body of knowledge on shoulder ultrasound imaging has grown considerably within the past decade, and physical therapists are among the many health care professions currently exploring the potential clinical integration of this imaging technology and the knowledge derived from it. Therefore, the primary purpose of this commentary was to review the recent evidence and emerging uses of ultrasound imaging for the clinical evaluation of shoulder disorders. This includes a detailed description of common measurement techniques along with their known clinimetric properties. Specifically provided are critical appraisals of the existing measures used to estimate soft tissue and bony morphometry, muscle contractile states, and lean muscle density. These appraisals are intended to help clinicians clarify the scope of physical therapy practice for which these measurement techniques are effectively utilized and to highlight areas in need of further development.

Progressive high-load strength training compared with general low-load exercises in patients with rotator cuff tendinopathy: study protocol for a randomised controlled trial

Background

Shoulder pain is the third most common musculoskeletal disorder, often affecting people’s daily living and work capacity. The most common shoulder disorder is the subacromial impingement syndrome (SIS) which, among other pathophysiological changes, is often characterised by rotator cuff tendinopathy. Exercise is often considered the primary treatment option for rotator cuff tendinopathy, but there is no consensus on which exercise strategy is the most effective. As eccentric and high-load strength training have been shown to have a positive effect on patella and Achilles tendinopathy, the aim of this trial is to compare the efficacy of progressive high-load exercises with traditional low-load exercises in patients with rotator cuff tendinopathy.

Methods/Design

The current study is a randomised, participant- and assessor-blinded, controlled multicentre trial. A total of 260 patients with rotator cuff tendinopathy will be recruited from three outpatient shoulder departments in Denmark, and randomised to either 12 weeks of progressive high-load strength training or to general low-load exercises. Patients will receive six individually guided exercise sessions with a physiotherapist and perform home-based exercises three times a week. The primary outcome measure will be change from baseline to 12 weeks in the patient-reported outcome Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Discussion

Previous studies of exercise treatment for SIS have not differentiated between subgroups of SIS and have often had methodological flaws, making it difficult to specifically design target treatment for patients diagnosed with SIS. Therefore, it was considered important to focus on a subgroup such as tendinopathy, with a specific tailored intervention strategy based on evidence from other regions of the body, and to clearly describe the intervention in a methodologically strong study.

Trial registration

The trial was registered with Clinicaltrials.gov (NCT01984203) on 31 October 2013.

Analysis of the development of the nasal septum and measurement of the harvestable septal cartilage in koreans using three-dimensional facial bone computed tomography scanning

Background

The septal cartilage is the most useful donor site for autologous cartilage graft material in rhinoplasty. For successful nasal surgery, it is necessary to understand the developmental process of the nasal septum and to predict the amount of harvestable septal cartilage before surgery.

Methods

One hundred twenty-three Korean patients who underwent three-dimensional (3D) facial bone computed tomography (CT) were selected for evaluation of the midsagittal view of the nasal septum. Multiple parameters such as the area of each component of the nasal septum and the amount of harvestable septal cartilage were measured using Digimizer software.

Results

The area of the total nasal septum showed rapid growth until the teenage years, but thereafter no significant change throughout the lifetime. However, the development of the septal cartilage showed a gradual decline due to ossification changes with aging after puberty in spite of a lack of change in the total septal area. The area of harvestable septal cartilage in young adults was 549.84±151.26 mm² and decreased thereafter with age.

Conclusions

A 3D facial bone CT scan can provide valuable information on the septal cartilage graft before rhinoplasty. Considering the developmental process of the septal cartilage identified in this study, septal surgery should not be performed until puberty due to the risk of nasal growth impairment. Furthermore, in elderly patients who show a decreased cartilage area due to ossification changes, septal cartilage harvesting should be performed carefully due to the risk of saddle nose deformity.

Are gender differences in external noses caused by differences in nasal septal growth?

BACKGROUND

The nasal septum plays an important role in nasal growth, but there have been few reports on the relationship between the septum and nasal growth. The authors investigated the relationship between septa and external noses using computed tomography during the growth period.

METHODS

One hundred and ninety-eight patients under the age of 21 were enrolled in this study between 2008 and 2012. The authors evaluated a total of 9 measurement items (five for nasal bones and septa, and four for external noses).

RESULTS

In the final age group, most measurement items were significantly larger in males than in females. However, there was no remarkable difference between male and female growth processes. Nasal bridge length and nasal height were significantly correlated with the nasal bone or septum in almost all age groups. The relative proportion of the cartilaginous septum decreased significantly with age, and was negatively correlated with the perpendicular plate in all age groups.

CONCLUSIONS

Nasal septa and external noses were both larger in males than in females at the beginning of the study period, although not significantly. The differences became significant throughout the study due to differential increases between the sexes during the monitored growth spurts.

The relationship between posterior septum deviation and depth of maxillopalatal arch

OBJECTIVE

To investigate the relationship between depth of maxillopalatal arch and deviation of posterior septum.

METHODS

This study is based on paranasal sinus CT (PNSCT) scan in the coronal plane evaluation, and sinus paranasal scans were obtained from the database. One-hundred and fifty PNSCT scans were randomly chosen among the PNSCT scans which belong to adult (18 and older) patients. All scans were divided to three different groups. The first group constituted by those patients who had more convex deviation. The second group had those patients with either crest or spur deviations. The last group (control group) had no septum deviation. The data collected from each group were statistically compared.

EXCLUSION CRITERIA

CT imaging which has a chronic sinusitis, nasal cavity mass, and nasal polyps.

MAIN OUTCOME MEASURES

angle and distance measures were taken on maxillopalatal arch and posterior nasal septum.

RESULTS

Strongly positive correlation between posterior septum deviation and depth of maxillopalatal arch was determined (r=0.479, p=0.001).

CONCLUSION

These findings suggest that posterior septum deviations are considered as a result of increase in maxillopalatal depth.

Posterior prolongation of the cartilaginous nasal septum: an under-utilised source of autologous graft material

AIM

To assess the clinical and radiological characteristics of the posterior prolongation of the cartilaginous nasal septum, an under-utilised source of autologous cartilage for nasal reconstruction.

MATERIALS AND METHODS

Consecutive patients undergoing primary, external approach rhinoplasty were included. The septal cartilage was assessed intra-operatively prior to routine harvest. Cartilage use was recorded and post-operative cosmesis noted. Computed tomography scans from a separate patient group, with no septal surgery, were used to assess septal cartilage dimensions.

RESULTS

Of the 25 rhinoplasty patients studied, 24 had harvestable septal cartilage, with a posterior prolongation mean length ± standard deviation of 24.3 ± 8.40 mm, mean height of 4.33 ± 0.34 mm and mean width of 1.1 ± 0.35 mm. The mean post-operative cosmesis score was +2.41 ± 0.71 at a mean follow up of 45 ± 8.7 weeks. All 25 radiology patients had visible posterior prolongations on computed tomography (mean length, 18.1 ± 5.1 mm; mean height, 4.2 ± 1.1 mm; mean width 1.5 ± 0.63 mm).

CONCLUSION

Harvesting of the posterior prolongation would increase by 25 per cent the cartilage area available for autologous grafts. Endoscopic guidance aids this process. Cartilage is most commonly used for overlay grafts, with good cosmesis. The posterior prolongation is demonstrated on computed tomography, although dimensions may be underestimated.

The role of septal cartilage in rhinoplasty: cadaveric analysis and assessment of graft selection

BACKGROUND

In addition to providing nearly 50% of total airway resistance via the internal valve, the nasal septum provides support for the cartilaginous portion of the nasal dorsum, and it is responsible for determining the projection of the nasal tip. In modern rhinoplasty, septal cartilage plays an important role as a donor graft material.

OBJECTIVES

The authors evaluate the anatomy of nasal septal cartilage, identifying variations according to certain regions of the septum and proposing a correlation between the topography and morphology of septal cartilage and graft choice.

METHODS

An anatomical study was performed on 14 fresh adult cadavers. The excised septal cartilage was placed on grid paper; digital images were taken; all septal cartilage was divided into nine equivalent quadrants; and quantitative measurements for length, height, and area were calculated and compared. Statistical significance was set at P < .05.

RESULTS

The average length of the septum was 35.14 mm, while the average height was 32.5 mm. The average septal area was 933.11 mm(2). The septal thickness mean values were analyzed in nine quadrants, ranging from 1.04 to 1.71 mm. Statistically-significant differences in mean values were found in 13 of the 14 cadavers. Specifically, the central and cranial areas were thickest, and the area corresponding to the L-strut was thinnest.

CONCLUSIONS

Anatomical variations of the thickness of septal cartilage excisions were found to be statistically significant, and these differences play an important role in the proper selection of the septal grafts.