Postoperative complications verified in 45% (9) of patients in study group (ESS + SP + RP), but most of them had little significant impact on surgery result. Two patients had periorbital ecchymosis and major epistaxis that prolonged hospitalization, 1 patient had nasal dorsum depression, 2 patients had periorbital ecchymosis and minor epistaxis, 1 patient had periorbital ecchymosis and transient hyposmia, 1 patient had periorbital ecchymosis, minor epistaxis and transient hyposmia, 2 patients had periorbital ecchymosis only. In control group (ESS + SP) postoperative complications rate was 10% (2 patients) in which 1 patient had transient hyposmia and 1 had minor epistaxis. The OR was 7.3636 with a 95% confidence interval, extending from 1.3372 to 40.5492 and P value obtained was 0.0195 (P < 0.05). The OR > 1 confirms that concurrent ESS, SP, and RP could be implicated in increasing of postoperative complications and also the small P value suggests that there is an association between concurrent ESS, SP, and RP and postoperative complications, due to proper invasiveness of RP.
Postoperative improvement of nasal obstruction had been a success in both groups, with a rate of 90% in the study group (18 patients) and a rate of 100% (20 patients) in the control group. OR was 0.1805 and its confidence interval was 95%, extending from 0.0081 to 4.0096. McNemar exact test obtained a P value of 1.0000 (P > 0.05), and the difference between study group and control group was not statistically significant. Moreover, there was no association between concurrent ESS, SP, and RP, and postoperative improvement of nasal obstruction that was similar in both groups.
Persistence of CRS symptoms in the follow-up after surgical treatment was different between the 2 groups: 13 patients (65%) had persisting symptoms in the study group, 8 patients (40%) in the control group, with a OR of 0.4643, with a 95% confidence interval extending from 0.0766 to 2.8129, and a P value of 0.0547 (P > 0.05). The obtained difference was not statistically significant enough; therefore, there was no association between concurrent ESS, SP, and RP and persistence of CRS symptoms.
The most persisting symptoms, evaluated with a modification of Rhinosinusitis Symptom Inventory questionnaire were anterior rhinorrhea and/or postnasal drip (6 patients) and facial pain/pressure (5 patients) in the study group, and nasal obstruction/blockage (5 patients) and headache (3 patients) in the control group. Arithmetic mean was calculated only among patients presenting the symptoms, not considering patients who gave score 0 to the different symptoms.
The need of revision surgery showed a rate of 5% in study group (1 patient required a revision of SP to reposition of septal cartilage graft) and a rate of 15% in the control group (3 patients required revision of ESS because of an inadequate correction of sinus disease), with an OR of 0.2982, with a 95% confidence interval extending from 0.0283 to 3.1458 and a P value of 0.9375 (P > 0.05). There was no statistically significant difference between the 2 groups, and no association between concurrent ESS, SP, and RP and needs of revision surgery was found.
Patients’ satisfaction was considered as patients unsatisfied about received treatment. Dissatisfaction rate in the study group was 10% (2 patients) and 5% (1 patient) in the control group. Obtained OR was 2.1111 with a 95% confidence interval extending from 0.1758 to 25.3499 and obtained P value was 0.5000. No statistically significant difference was found between the 2 groups, suggesting there was no association between concurrent ESS, SP, and RP and patients’ dissatisfaction.
This study shows that there is no significant difference between patients who underwent concurrent ESS, SP, and RP and patients who underwent concurrent ESS and SP only, as regards outcomes like postoperative improvement of respiratory symptoms, persistence of CRS symptoms in the follow-up, need of revision surgery, patient’s satisfaction, but presents a statistically significant difference as regards the postoperative complications. The ESS done for tumor lesions, being generally more extensive, should be considered separately for high risk of complication rate.15
The postoperative improvement of respiratory symptoms shows an OR < 1 and P > 0.05. Symptoms, indeed, seem to improve the same way in both groups of patients and additional RP does not nullify the effect of CRS and septal deformity treatment.
Moreover, even the persistence of CRS symptoms does not experience any negative change in patients who underwent concurrent triple surgery (ESS, SP, RP) compared with subjects who underwent ESS and SP only, as confirmed by OR < 1 and P value (> 0.05). Besides the not statistically significant difference that may be attributable to the small sample, it can be assumed that the trend of major rate of persistence of CRS symptoms in the study group could be due to a more severe CRS in the study group. Therefore, the result related to the persistence of CRS symptoms could also be the result of chance. A larger study, with larger cohorts, could suggest the less favorable outcome of RP in addition to ESS and SP or completely disprove it.
The need of revision surgery does not show statistically significant differences between the 2 groups (P > 0.05) and compared with which obtained by Kim et al.13 (ESS + SP + OR group 8.8%) and Shafik and Youssef12 (ESS + SP + RP group 10%), our patients had less postoperative complications (study group ESS, SP, RP 5%), and we should consider that even if our statistic sample was not large; however, it was comparable to them as well (57 versus 57 patients in the study by Kim et al.13, 20 versus 20 patients in the study by Shafik and Youssef12).
Patients with severe CRS were not excluded from both groups. This could explain the higher rate of revision in the control group and the observed trend of persistence of CRS symptoms in study group as mentioned above.
The rate of patients’ satisfaction is similar in the 2 groups, with a major percentage in the control one, an OR > 1 and a P value > 0.05. In study group, 2 patients were dissatisfied about surgery and reason was the aesthetic result. They did not mention problems related to respiratory function. In control group, just 1 patient was dissatisfied about the functional result. Compared with Kim’s experience where the successful outcome related to ESS + SP + OR group was 82.5% with an unsuccessful outcome of 17.5%,13 our result appears to be the better in our study group (concurrent ESS, SP, RP) with a satisfaction rate of 90% and a dissatisfaction rate of 10%.
An ostensible negative but predictable result regards postoperative complications. Obtained P value (P < 0.05) and OR (OR > 1) seem to be directed toward a contraindication of additional RP to concurrent ESS and SP surgery. This result could seem alarming. Nevertheless, if we consider that RP is an invasive procedure, which brings an increase of postoperative time, risk of infections, bleeding and ecchymosis, when we analyze the reported complications above, we can see that most of them are minor complications that do not have negative effects on the results of the surgery.
If complications are considered divided between major5,16 and minor,17,18 it is obtained that patients with major complications in study group were 3 with a rate of 15% (2 patients with periorbital ecchymosis and major epistaxis that prolonged hospitalization and 1 patient with nasal dorsum depression), whereas in control group, no patient reported major complication (0%), with a not statistically significant difference (P > 0.05). As regards minor complications, in study group 6 patients were involved, with a rate of 30% (2 patients with periorbital ecchymosis and minor epistaxis, 1 patient with periorbital ecchymosis and transient hyposmia, 1 patient with periorbital ecchymosis, minor epistaxis and transient hyposmia, and 2 patients with periorbital ecchymosis), whereas in control group, only 2 patient had minor complications with a rate of 10% (1 with minor epistaxis and 1 with transient hyposmia) and with a not statistically significant difference (P > 0.05). Hence, the difference that is obtained is not statistically significant if major complications and minor complication are considered separately and minor complications have not a high impact on the outcome of the surgery and on the patient’s quality of life. If considering that, in study group where an extra surgical procedure is performed (rhinoplasty), in our opinion, it is acceptable an increasing of minor complications, even performing a closed rhinoplasty.
A summary of the previous literature can be observed in Table 4, modified from Patel et al.19
Therefore, we can assume that concurrent ESS, SP, and RP could be considered, in the light of all previous literature and relying on our results, an affordable, reliable, and safe association that can be used to reduce operative time, general anesthetic, and recovery period, stress of patients who undergoing a single surgical session.
The additional RP leads to an increase in postoperative complications when globally considered, but if analyzed separately, many of these are considered minor from literature.17,18 Hence, the result of surgery and the patient’s quality of life are not excessively compromised and in our opinion they could be considered acceptable.
Our statistic sample was not so large, but it was comparable to other authors’ samples. A future study with a larger sample, however, could better define a stronger evidence of how RP affects outcomes of concurrent ESS and SP.
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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
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