Nasal blockage is a common otolaryngologic symptom with various mucosal and structural etiologies.1 One of its common structural causes is nasal septal deviation, which is characterized by changes in bony and cartilaginous structures that lead to reduced nasal airflow.2 The prevalence of nasal septal deviation ranges from 30.9% to 65%, depending on the criteria used to define a deviated septum.3 Although nasal septal deviation may be asymptomatic, it can also result in nasal obstruction, rhinosinusitis symptoms, and sleep disorders such as snoring, mouth breathing, daytime somnolence, and fatigue, which may have significant physical and social consequences and can impact quality of life.4–6 In symptomatic patients, a deviated septum needs to be corrected surgically to relieve the symptoms and improve quality of life.2 Nasal septoplasty refers to the surgical correction of a nasal septal deviation to widen the nasal passages, thereby improving nasal airflow.7 Inferior turbinate reduction is frequently performed along with nasal septoplasty to reduce the size of a hypertrophied inferior turbinate, thus improving the outcome of surgery. Although nasal septoplasty is commonly performed in Otolaryngology (ORL) practice, its effectiveness has been questioned, and current evidence is equivocal.8 Some studies have reported moderate to excellent outcomes,9,10 whereas others have reported unsatisfactory results.11 This is the first study conducted in Saudi Arabia to assess the postoperative quality of life of patients undergoing nasal septoplasty with or without turbinoplasty for nasal septum deviation correction, using the Nasal Obstructive Symptoms Evaluation (NOSE) questionnaire and nasal symptoms 3 months after the surgery and comparing them to controls. The study also aimed to assess the associations of sex, age, smoking status, and comorbidities such as allergic rhinitis and asthma with surgical outcomes.
PATIENTS AND METHODS
Study Design and Setting
This prospective observational case-control study was conducted between July 1, 2020, and June 30, 2021, at the ORL Clinics of King Saud Hospital, Unaizah, Qassim, Saudi Arabia.
Definitions of Cases and Controls
The cases were patients aged 18 years or older with chronic nasal obstruction caused by nasal septum deviation undergoing nasal septoplasty after showing no clinical improvement with medical treatment. Patients with sinonasal tumors, nasal bone fracture or trauma, previous nasal surgery, or nasal septum perforation were excluded. In addition, patients who need either functional or corrective septorhinoplasty were also excluded. The controls were recruited from patients presenting to the ORL clinics with complaints other than nasal obstruction and were age-matched (±3 y) and sex-matched to the cases.
Data Collection
Data were collected through face-to-face interviews and clinical examination conducted by a trained physician. A questionnaire was designed based on the literature and formal discussions with experts.7,10,12,13 A pilot study involving 12 participants (6 male and 6 female) was conducted to test the validity of the questionnaire and to estimate the time needed to complete it. The collected data included the following:
- Demographic and personal data (age, sex, and smoking status).
- Medical history (bronchial asthma and allergic rhinitis).
- Nasal Obstructive Symptoms Evaluation scores. The NOSE is a validated questionnaire used to determine patients’ subjective severity of nasal obstruction and quality of life.[12] It is particularly useful because it is quick and straightforward and can help otolaryngologists determine the possible benefits of nasal septoplasty and inferior turbinate reduction. Furthermore, postoperative NOSE scores can help quantify symptom improvement.14 The NOSE score ranges from 0 to 100, with higher scores indicating more severe nasal obstruction.11
- Nasal symptoms (nasal discharge, headaches, facial pressure, loss of smell, epistaxis, nasal obstruction, and postnasal drip).
- Clinical examinations, including endoscopic examination [nasal septal deviation (anterior, posterior, or both), caudal dislocation, contact point, and any other relevant findings, such as inferior turbinate hypertrophy].
- Type of surgery (nasal septoplasty with or without turbinoplasty). The surgery was conducted by closed approach and was performed by 2 surgeons.
Statistical Analysis
Statistical analysis was performed using Stata v17.Categorical variables were expressed as numbers and percentages, and continuous variables were expressed as means and SD. Comparisons between Categorical variables were performed using the χ2 test, or Fischer exact test as appropriate and comparisons between continuous variables were performed using the unpaired t tests or paired t tests, as appropriate. A P-value ≤0.05 were considered statistically significant.
Ethical Considerations
This study was approved by the Research Ethics Committee of Qassim Region, Saudi Arabia (1441-1903964). Written informed consent was obtained from each patient after being informed about the purpose and methods of the study.
RESULTS
The study included 40 cases matched with 160 controls in age (±3 y) and sex.
Descriptive statistics of the case and control groups are provided in Supplemental Table 1, Supplemental Digital Content 1, https://links.lww.com/SCS/E676. Physical examinations showed that 72.5% of the cases had hypertrophied inferior turbinates, and 55% presented with deviated anterior and posterior septa. As shown in Supplemental Table 2, Supplemental Digital Content 1, https://links.lww.com/SCS/E676, there was a statistically significant difference between preoperative and postoperative NOSE scores in the case group (P<0.001). However, the postoperative nasal score did not reach to control nasal score (P=0.377). As shown in Supplemental Table 3, Supplemental Digital Content 1, https://links.lww.com/SCS/E676, the mean postoperative scores of the cases were significantly lower than the preoperative scores for all 5 items of the NOSE questionnaire. Only the “postoperative nasal blockade or obstruction” and “trouble breathing through the nose” scores were significantly higher than those of the controls. The case group showed a statistically significant reduction in all nasal symptoms postoperatively (P<0.05; Supplemental Table 4, Supplemental Digital Content 1, https://links.lww.com/SCS/E676). Moreover, the mean postoperative NOSE scores according to patient characteristics were significantly lower than the preoperative scores, except for smokers (Supplemental Table 5, Supplemental Digital Content 1, https://links.lww.com/SCS/E676).
DISCUSSION
Nasal septoplasty, with or without inferior turbinate surgery, is one of the most commonly performed ORL procedures. Nasal obstruction is a crucial indication for nasal septoplasty. The success of the operation depends on the patient’s subjective satisfaction with the functional outcome. In this study, inferior turbinate hypertrophy was a common finding, which is consistent with a previous study conducted in the same center.15 Our results showed significant improvements in NOSE scores 3 months postoperatively. The mean postoperative score reflected mild symptoms on NOSE score scale, although it remained higher than the mean score of the control group, suggesting that nasal septoplasty resulted in improved disease-specific quality of life. This finding is consistent with previous studies reporting significant reductions in NOSE scores and improvements in disease-specific quality of life after nasal septoplasty with or without turbinate reduction.10,16–19 Likewise, a recent study assessing the outcomes of nasal septoplasty in 51 patients using NOSE scores found significant improvements in nasal obstruction 3 and 7 months postoperatively. The mean preoperative and 3- and 7-month postoperative NOSE scores were 60.3±20.4, 32.9±16.8, and 39.6±33.2, respectively.20. By comparison, the mean 3-month postoperative score in this study (15.0±18.6) was considerably lower. This might be because of performing only septoplasty, whereas in the present study, turbinoplasty performed along with nasal septoplasty and also selection criteria of the patients as those who need either functional or corrective septorhinoplasty were excluded. Another study evaluating the postoperative quality of life of patients with nasal septal deviation using the Sino Nasal Outcome Test-20 reported significant improvements at 6 postoperative months, although quality of life did not reach the same level as that of healthy subjects.2 Despite using a different score, our results are consistent with that study result. In this study, there were significant improvements in nasal symptoms, including nasal obstruction and discharge, postnasal drip, loss of smell, epistaxis, facial pressure, and headaches, after surgery. This result is consistent with several studies reporting that the correction of nasal obstruction with nasal septoplasty improved associated symptoms and health-related quality of life.17,21,22 Bugten et al2 found that nasal septoplasty led to significant improvements in nasal septal deviation symptoms, with patients reaching the same level as healthy controls in terms of headaches, facial pain, sneezing, rhinosinusitis, cough, and snoring. Similarly, Gandomi et al17 reported a statistically significant decrease in nasal discharge, mouth breathing, trouble sleeping, snoring, and mouth dryness after surgery. Furthermore, another study showed improvement in smell perception after nasal septoplasty.23 In this study, we found that age, sex, allergic rhinitis, and asthma did not affect the nasal septoplasty outcomes. This finding is in line with previous studies.10,18,24,25 Conversely, smoking significantly affected the surgical outcomes, which may be because of its effect on the nasal mucosa, as it reduces nasal mucociliary clearance, ciliary motility, the number of goblet and ciliated cells, and the time of ciliary movement.26 However, other studies have found no significant effect of smoking.10,24,25,27,28 Further studies are needed to clarify the role of smoking, considering duration and intensity. In terms of age, our findings indicate greater improvements in NOSE scores among patients aged under 30 years. This is in line with a previous study reporting better nasal septoplasty outcomes in patients of an average age of 22.44 years than in patients aged 40 years or older.17 In patients with allergic rhinitis, mucosal hypertrophy contributes to airway narrowing. Nasal septoplasty can increase the cross-sectional area of the nasal airway, but the increase is not sufficient to offset the effect of allergic rhinitis.29 However, in this study, although patients with allergic rhinitis had the highest preoperative NOSE scores, the condition had no significant effect on surgical outcomes. This is in line with some previous studies2,25,29 but inconsistent with other studies reporting that allergic rhinitis was associated with poorer outcomes.27,30 The benefits of nasal septoplasty with and without turbinate reduction surgery are still being debated. Stewart et al10 and Uppal et al31 found no statistically significant differences in outcomes between nasal septoplasty with turbinoplasty and nasal septoplasty without turbinoplasty. Conversely, Hong et al25 reported that nasal septoplasty with turbinoplasty showed better outcomes 1 month postoperatively than nasal septoplasty alone. The differences in outcomes between the 2 types of surgery were no longer significant at 3 and 6 months. The authors concluded that nasal septoplasty with turbinoplasty resulted in faster and maintained symptom relief. Nilsen et al21 compared the surgical outcomes of nasal septoplasty, radiofrequency therapy of the inferior turbinate (RFIT), and combined nasal septoplasty and RFIT and found that nasal septoplasty with RFIT resulted in less postoperative nasal congestion. Another benefit of concomitant inferior turbinate surgery is the reduced possibility of revision surgery.32 In this study, the mean postoperative NOSE score of patients undergoing nasal septoplasty with turbinoplasty was better than that of patients undergoing nasal septoplasty alone. The major strength of this study is its prospective and case-control design. However, this study also has certain limitations. We obtained NOSE scores only 3 months after surgery. However, several studies have shown no significant changes in NOSE scores between 3 and 6 postoperative months.10,17,33 Another study found no clinically significant differences in NOSE scores between 1 and 6 postoperative months and concluded that follow-up may not be required after the first postoperative month.19 Although there are many studies on the nasal septoplasty, however, criteria for diagnosis and evaluation have many subjective contents, in addition to surgeon experience, which may increase the variability between studies.
CONCLUSIONS
This study shows that nasal septoplasty with or without turbinoplasty leads to improvements in disease-specific quality of life as assessed by NOSE scores and to significantly improved nasal symptoms 3 months after surgery.
ACKNOWLEDGMENTS
The authors thank the Deanship of Scientific Research, Qassim University, for funding the publication of this project.
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