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Outcomes of septoplasty in young adults: the Nasal Obstruction Septoplasty Effectiveness study
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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 189 – 192 www.elsevier.com/locate/amjoto
Outcomes of septoplasty in young adults: the Nasal Obstruction Septoplasty Effectiveness study Behroz Gandomi, MD, Akbar Bayat, MD⁎, Tayebe Kazemei, MD Department of Otolaryngology-Head and Neck Surgery, Khalili Hospital, Shiraz University of Medical Sciences, Iran Received 8 November 2008
Abstract
The goal of this study was to compare the outcome of septoplasty in our patients with previous reports. We found some different outcomes of septoplasty at our center compared with the reports in the literature. One of the major differences between this and previous studies is in the mean age of patients undergoing surgery, 22.44 years in our study vs more than 40 years in most studies. In this study, 86 patients with septal deviation were asked using an outcomes instrument (the Nasal Obstruction Symptom Evaluation scale) before and 3 and 6 months after septoplasty. Seventy-seven patients (89.5%) reported a subjective improvement in their nasal obstruction, which is more than the experience of most authors. There was a significant improvement in mean Nasal Obstruction Symptom Evaluation score at 3 months after septoplasty, and some symptom improvement continued to 6 months. We conclude that younger patients who have nasal obstruction with septal deviation benefit more from septoplasty. © 2010 Elsevier Inc. All rights reserved.
1. Introduction Nasal obstruction is the most common complaint symptom in nasal and sinus disease [1]. Although symptoms of nasal obstruction can have several etiologies, such as mucosal congestion, turbinate hypertrophy, adenoid hypertrophy, nasal mass, and others, deviation of the nasal septum is a very common cause. Surgical correction of a deviated septum—nasal septoplasty—is the definitive treatment for septal deviation [2,3]. Septoplasty is the third most commonly performed surgical procedure by otolaryngologists in the United States and is generally performed to improve quality of life (QOL). The outcomes of this procedure and its impact on QOL have never been clearly established [4]. A number of studies have described both subjective and objective measures of outcome after septoplasty, but most were retrospective [2,5-7].
⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, Khalili Hospital, Shiraz University of Medical Sciences, Shiraz 71566-83599, Iran. Tel.: +98 1989122393866. E-mail address: [email protected] (A. Bayat). 0196-0709/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2009.02.023
Multiple outcomes-based studies have demonstrated poor correlation between QOL and physical or anatomic findings, and measurements such as rhinometry do not consistently correlate with patient reports of nasal obstruction and can be inconsistent for predicting septoplasty outcome [2-4,8]. In some studies, a validated disease-specific health status instrument was developed and used for patients with nasal obstruction [2-4,8,9]. We found some different outcomes of septoplasty at our center compared with reports in the literature. These may help to discuss some different outcome in patients. In this study, we used the Nasal Obstruction Symptom Evaluation (NOSE) scale to study our patients undergoing septoplasty with or without partial turbinectomy and compare the result with other centers. 2. Methods A prospective multicenter nonrandomized prospective observational study was performed in consecutive patients presenting to Khalili and Dastgheyb Hospitals, Shiraz, Iran, for septoplasty during a 24-month period (June 20, 2006, through June 19, 2008). A total of 103 patients were
190
B. Gandomi et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 189–192
entered into the study, and 86 patients were available for statistical analysis. Inclusion criteria were as follows: at least 15 years old, septal deviation consistent with presenting symptom of chronic nasal obstruction, symptoms lasting at least 3 months, and persistent symptoms after a 4-week trial of medical management, including topical nasal steroids, topical or oral decongestants, or an oral antihistamine/ decongestant combination. Patients with histories of sinonasal malignancy, radiation therapy to the head and neck, history or clinical evidence of chronic sinusitis, allergic rhinitis, septal perforation, craniofacial syndrome, acute nasal trauma or fracture in the past 3 months, nasal valve collapse, adenoid hypertrophy, sarcoidosis, Wegener granulomatosis, uncontrolled asthma, pregnancy, and those patients who had undergone other ENT procedures such rhinoplasty and sinus surgery concomitant to septal surgery were excluded from this study. All patients met eligibility criteria and agreed to participate, gave signed informed consent, and enrolled in the study. The patients were asked about their symptoms and disease-specific QOL, as measured on the validated NOSE scale (Fig. 1), before surgery in the clinic and subsequently were contacted 3 and 6 months after surgery. They were contacted up to 5 times for follow-up. The operation technique was a hemitransfixion incision followed by mucoperichondrium elevation in one or both sides, addressing all areas of deviation, with reshaping and/ or removal of the deviated portion. Internal splints and packing were not mandatory. Turbinectomy was defined as a surgical procedure on the inferior nasal turbinate intended to decrease its size, including direct excision, elevation of mucosal flaps with removal of bone only, or cauterization. Turbinectomy was performed according to the physician's recommendation and the patient's wishes; no treatment allocation, randomization, or other attempt to modify treatment was made. All physicians were blinded to the patient's NOSE scores, both before and after Fig. 1 Items on the NOSE scale Not a Very mild Moderate Fairly bad Severe problem problem problem problem problem Nasal obstruction Mouth breathing Mouth dryness Anosmia Rhinorrhea Epistaxis Trouble sleeping Snoring Being concern about nasal problem
0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4
Over the past 1 month, how much of a problem were the following conditions fo you? Please circle the most correct response.
Table 1 Frequency of obstruction scores at baseline and at 3 months and 6 months after the date of surgery
Score
0 1 2 3 4
Baseline
After 3 month
0 0 16 (18.6%) 28 (32.6%) 42 (48.8%)
34 (39.5%) 44 (51.2%) 3 (3.5%) 2 (2.3%) 3 (3.5%)
After 6 month 41 (47.7%) 39 (45.3%) 1 (1.2%) 3 (3.5%) 2 (2.3%)
treatment, and the physicians did not collect follow-up data from their patients. Nonparametric analysis (Wilcoxon signed rank test) was used to compare baseline and follow-up NOSE scores. Treatment groups (septoplasty alone vs septoplasty with turbinate procedure) were compared using the nonparametric Wilcoxon rank sum test. A P value less than .05 was considered statistically significant.
3. Results One hundred three patients met eligibility criteria and underwent surgery. At the end of the data collection period, 86 patients (83.49%) completed their follow-up surveys and were available for data analysis. There were no statistically significant differences in age, sex, and nasal-specific symptoms score between the study group and those who did not complete their follow-up surveys. The mean age was 22.44 years (SD, 5.56; range, 1542 years); 49 patients (57%) were male, and 37 patients (43%) were female. Mean duration of nasal obstruction was 6.61 years (SD, 3.57). The NOSE scale (which scaled from 0 to 4) was used to assess disease-specific QOL according to Fig. 1. Baseline obstruction scores, and those at 3 and 6 months after surgery, are shown in Table 1. Sixty-two patients (72.1%) had turbinate manipulation with septoplasty, and 22 patients (27.9%) had septoplasty alone. No statistically significant differences in age, sex, and duration of nasal obstruction were observed between these 2 groups. Patients had significant decreases in nasal obstruction, trouble sleeping, snoring, and mouth dryness in the morning at 3 months after septoplasty (P b .001), there were statistically significant differences between the 3- and 6-month scores. Only in the turbinectomy subgroup, a decrease in the frequency of epistaxis at 6 months after surgery was statistically significant (P b .05). Patients had statistically significant decreases in mouth breathing during the day at 3 months after septoplasty (P b .001). This problem was reduced further at the end of the sixth month (P b .001). Decrease in anosmia was reported after 3 months, which was statistically significant (P b .001). By comparing the third and sixth month scores in the subset of patients who had
B. Gandomi et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 189–192
septoplasty without turbinate surgery, statistically significant improvement of anosmia has been showed (P b .005). In the subset of patients who had turbinate manipulation, rhinorrhea was significantly reduced at 3 months after septoplasty (P b .001). But the comparison between 3- and 6-month scores was not statistically significant. In the subset who had septoplasty alone, no statistically significant changes had occurred at 3 months after surgery, but a significant improvement of rhinorrhea was detected after 6 months (P b .05). Complications occurred in 4 patients. Two patients required reoperation within 12 months. One had septal perforation but refused reoperation for repair.
4. Discussion Of the prospective studies on septoplasty, many used physical examination findings and/or objective measures such as rhinometry [2,10-12]. Many have suggested that rhinometry has little value in a clinical setting. Rhinometry testing demonstrated suboptimal test-retest consistency, which may be associated with the nasal cycle and may be affected by various mediators of nasal congestion [4,13-15]. Physical examination findings are subjective and vulnerable to examination bias. Objective measures often do not correlate well with each other or with patient symptoms [2]. Stewart et al [3] completed the validation of a diseasespecific instrument designed to assess nasal obstruction: the NOSE scale. He noted that it could be used for comparing disease-specific health status between groups of patients before and after treatment or to assess differences in outcome when different surgical techniques are used [3]. We used NOSE scale and other nasal symptoms to evaluate patients. Patients who underwent concomitant turbinate reduction were included to represent a typical population presenting with nasal airway symptoms. We found some different outcomes of septoplasty at our center compared with the reports in the literature. The literature has reported success rates between 63% and 85% depending on the length of follow-up and the method of assessment of results [4,11,16-20]. In our study, 77 patients (89.5%) have reported a subjective improvement in their nasal obstruction, which is more than the experience of most authors. One of the major differences between this study and previous studies is the mean age of patients undergoing surgery, 22.44 years (SD, 5.56; range, 15-42 years) in our study vs more than 40 years in most studies [2-5,7]. This may be due to the lower mean age of Iranian people (more than 50% of the population are b25 years old). High success rate in our study may suggest that younger patients who have nasal obstruction with septal deviation benefit more from septoplasty. Nasal obstruction of these young patients may be more anatomical dependent, so this group may gain more
191
success from surgery, and dynamic causes may be more important in older patients. Stewart et al have reported that patients with nasal obstruction and septal deformity who undergo nasal septoplasty have very significant improvement in nasal obstruction at 3 months, and this result is sustained at 6 months after surgery [2]. In our study, patients reported the same outcome. Also in our study, patients reported a statistically significant decrease in trouble sleeping, snoring, and mouth dryness after sleep at 3 months. These results are sustained at 6 months after surgery. Hence, many of the patients' symptoms have very significant improvement at 3 months, which are sustained at 6 months after operation. Mouth breathing during the day decreased significantly at 3 months, and this result improved 6 months after surgery, which was statistically significant, indicating that some patients need more time to adapt to the new condition. Anosmia was significantly reduced at 3 months, but the comparison between 3- and 6-month scores was statistically significant only in the septoplasty subgroup. However, the number of patients undergoing septoplasty alone was small, and the possibility of a type I error exists for this comparison. So some of the symptoms may need more time to be decreased, and we can expect some improvement in patients' symptoms even after 3 months. Rhinorrhea in septoplasty with the turbinectomy subgroup reduced significantly at 3 months with no significant change at 6 months. But in the septoplasty-alone subgroup, the score had no change at 3 months but decreased at 6 months, which was statistically significant. So the patients undergoing septoplasty with turbinectomy appear to have earlier improvement of this symptom than patients undergoing septoplasty alone. Although no increase or decrease in epistaxis was noted in septoplasty-alone subgroup, in the turbinectomy subgroup, decrease in the frequency of epistaxis at 6 months after surgery was statistically significant. In our study, we identified a greater improvement in the subgroup of patients who had septoplasty and turbinectomy. However, this study was not designed to test that hypothesis definitively, so these results provide pilot data for a future study on this point. In contrast to some studies showing a general tend to rate the results of their septal surgery less positively as the postoperative period increased [5,9,21,22], in our study, most of the symptoms improved or was unchanged as the postoperative period increased, and overall patient satisfaction became better. The strengths of this study are its prospective design and evaluation of younger patients. Because the physician did not personally retrieve the follow-up outcome data from the patient and the data were not returned to the physician's office, the possibility of bias introduction at that level was minimized. The study also had a good follow-up rate. Although this study aimed to evaluate septoplasty outcome in a natural clinical setting in younger patients,
192
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the results of this study should be evaluated with some caution. First, only 83.49% of eligible patients had followup. There were no statistically significant differences in general health and nasal-specific health between the group with follow-up data and the group who did not complete their surveys. Second, a follow-up period of 6 months may be considered short-term. A 9-year follow-up study has shown that both subjective and objective changes in nasal airway patency take place over time [5]. Finally, a weakness of the study is the lack of a control group. However, there is no alternative treatment for a deviated nasal septum other than surgical correction, so clinical equipoise does not allow for randomization away from septoplasty to sham or placebo surgery or nonsurgical treatment. Of course, enrollment criteria required that medical therapy had failed for each patient; therefore, all patients in the study had a trial of nonsurgical treatment before septoplasty.
5. Conclusions 1. Younger patients who have nasal obstruction with septal deviation benefit more from septoplasty. Nasal obstruction of these patients may be more anatomical dependent, so this group may gain more success from surgery; and in older patients, dynamic causes may be more important. 2. Some of the symptoms need more time to reduce, and we can expect more improvement in patients' symptoms even 3 months after septoplasty. 3. A greater improvement in the subgroup of patients who had septoplasty and turbinectomy may be expected, but that needs further investigations. Acknowledgments The authors thank Shiraz University of Medical Sciences for its financial and editorial support and Mrs Elham Rezaee for her cooperation. References [1] Kim CS, Moon BK, Jung DH, et al. Correlation between nasal obstruction symptoms and objective parameters of acoustic rhinometry and rhinomanometry. Auris Nasus Larynx 1998;25:45-8.
[2] Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE). Otolaryngol Head Neck Surg 2004;130:283-90. [3] Stewart MG, Witsell DL, Smith TL, et al. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004;130:157-63. [4] Siegel NS, Gliklich RE, Taghizadeh F, et al. Outcomes of septoplasty. Otolaryngol Head Neck Surg 2000;122:228-32. [5] Jessen M, Ivarsson A, Malm L. Nasal airway resistance and symptoms after functional septoplasty: comparison of findings at 9 months and 9 years. Clin Otolaryngol 1989;14:231-4. [6] Stewart EJ, Robinson K, Wilson JA. Assessment of patient's benefit from rhinoplasty. Rhinology 1996;34:57-9. [7] Broms P, Jonson B, Malm L. Rhinomanometry: a pre- and postoperative evaluation in functional septoplasty. Acta Otolaryngol 1982; 94:523-9. [8] Uppal S, Nadig S, Back G, et al. Evaluation of patient benefit from nasal septal surgery for nasal obstruction. Auris Nasus Larynx 2005;32:129-37. [9] Konstantinidis I, Triaridis S, Triaridis A, et al. Long term results following nasal septal surgery focus on patients' satisfaction. Auris Nasus Larynx 2005;32:369-74. [10] Pirila T, Tikanto J. Unilateral and bilateral effects of nasal septum surgery demonstrated with acoustic rhinometry, rhinomanometry, and subjective assessment. Am J Rhinol 2001;15:127-33. [11] Jessen M, Malm L. The importance of nasal airway resistance and nasal symptoms in the selection of patients for septoplasty. Rhinology 1984;22:157-64. [12] Arunachalam PS, Kitcher E, Gray J, et al. Nasal septal surgery: evaluation of symptomatic and general health outcomes. Clin Otolaryngol 2001;26:367-70. [13] Mygind N. Measurement of nasal airway resistance, is it only for article writers? Clin Otolaryngol 1980;5:161-3. [14] Courtiss EH, Goldwyn RM. The effects of nasal surgery on airflow. Plast Reconstr Surg 1983;72:9-19. [15] Hardcastle PF, White A, Prescott RJ. Clinical or rhinometric assessment of the nasal airway—which is better? Clin Otolaryngol 1988;13:381-5. [16] Dommerby H, Rasmussen OR, Rosborg J. Long-term results of septoplastic operations. ORL J Otorhinolaryngol Relat Spec 1985;47: 151-7. [17] Fjermedal O, Saunte C, Pedersen S. Septoplasty and/or submucous resection? J Laryngol Otol 1988;102:796-8. [18] Samad I, Stevens HE, Malony A. The efficacy of nasal septal surgery. J Otolaryngol 1992;21:88-91. [19] Sipila J, Suopaa J. A prospective study using rhinomanometry and patient clinical satisfaction to determine if objective measurements of nasal airway resistance can improve the quality of septoplasty. Eur Arch Otorhinolaryngol 1997;254:387-90. [20] Holmstrom M, Kumlien J. A clinical follow-up of septal surgery with special attention to the value of preoperative rhinomanometric examination in the decision concerning the operation. Clin Otolaryngol 1988;13:115-20. [21] Bitzer EM. The patients view on outcomes of septal surgery. Rhinology 2004;42:250-2. [22] Bitzer EM, Doming H, Schwartz FW. Clinical success of surgical correction of the nasal septum. Laryngorhinootologie 1996;75:649-56.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 189 – 192 www.elsevier.com/locate/amjoto
Outcomes of septoplasty in young adults: the Nasal Obstruction Septoplasty Effectiveness study Behroz Gandomi, MD, Akbar Bayat, MD⁎, Tayebe Kazemei, MD Department of Otolaryngology-Head and Neck Surgery, Khalili Hospital, Shiraz University of Medical Sciences, Iran Received 8 November 2008
Abstract
The goal of this study was to compare the outcome of septoplasty in our patients with previous reports. We found some different outcomes of septoplasty at our center compared with the reports in the literature. One of the major differences between this and previous studies is in the mean age of patients undergoing surgery, 22.44 years in our study vs more than 40 years in most studies. In this study, 86 patients with septal deviation were asked using an outcomes instrument (the Nasal Obstruction Symptom Evaluation scale) before and 3 and 6 months after septoplasty. Seventy-seven patients (89.5%) reported a subjective improvement in their nasal obstruction, which is more than the experience of most authors. There was a significant improvement in mean Nasal Obstruction Symptom Evaluation score at 3 months after septoplasty, and some symptom improvement continued to 6 months. We conclude that younger patients who have nasal obstruction with septal deviation benefit more from septoplasty. © 2010 Elsevier Inc. All rights reserved.
1. Introduction Nasal obstruction is the most common complaint symptom in nasal and sinus disease [1]. Although symptoms of nasal obstruction can have several etiologies, such as mucosal congestion, turbinate hypertrophy, adenoid hypertrophy, nasal mass, and others, deviation of the nasal septum is a very common cause. Surgical correction of a deviated septum—nasal septoplasty—is the definitive treatment for septal deviation [2,3]. Septoplasty is the third most commonly performed surgical procedure by otolaryngologists in the United States and is generally performed to improve quality of life (QOL). The outcomes of this procedure and its impact on QOL have never been clearly established [4]. A number of studies have described both subjective and objective measures of outcome after septoplasty, but most were retrospective [2,5-7].
⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, Khalili Hospital, Shiraz University of Medical Sciences, Shiraz 71566-83599, Iran. Tel.: +98 1989122393866. E-mail address: [email protected] (A. Bayat). 0196-0709/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2009.02.023
Multiple outcomes-based studies have demonstrated poor correlation between QOL and physical or anatomic findings, and measurements such as rhinometry do not consistently correlate with patient reports of nasal obstruction and can be inconsistent for predicting septoplasty outcome [2-4,8]. In some studies, a validated disease-specific health status instrument was developed and used for patients with nasal obstruction [2-4,8,9]. We found some different outcomes of septoplasty at our center compared with reports in the literature. These may help to discuss some different outcome in patients. In this study, we used the Nasal Obstruction Symptom Evaluation (NOSE) scale to study our patients undergoing septoplasty with or without partial turbinectomy and compare the result with other centers. 2. Methods A prospective multicenter nonrandomized prospective observational study was performed in consecutive patients presenting to Khalili and Dastgheyb Hospitals, Shiraz, Iran, for septoplasty during a 24-month period (June 20, 2006, through June 19, 2008). A total of 103 patients were
190
B. Gandomi et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 189–192
entered into the study, and 86 patients were available for statistical analysis. Inclusion criteria were as follows: at least 15 years old, septal deviation consistent with presenting symptom of chronic nasal obstruction, symptoms lasting at least 3 months, and persistent symptoms after a 4-week trial of medical management, including topical nasal steroids, topical or oral decongestants, or an oral antihistamine/ decongestant combination. Patients with histories of sinonasal malignancy, radiation therapy to the head and neck, history or clinical evidence of chronic sinusitis, allergic rhinitis, septal perforation, craniofacial syndrome, acute nasal trauma or fracture in the past 3 months, nasal valve collapse, adenoid hypertrophy, sarcoidosis, Wegener granulomatosis, uncontrolled asthma, pregnancy, and those patients who had undergone other ENT procedures such rhinoplasty and sinus surgery concomitant to septal surgery were excluded from this study. All patients met eligibility criteria and agreed to participate, gave signed informed consent, and enrolled in the study. The patients were asked about their symptoms and disease-specific QOL, as measured on the validated NOSE scale (Fig. 1), before surgery in the clinic and subsequently were contacted 3 and 6 months after surgery. They were contacted up to 5 times for follow-up. The operation technique was a hemitransfixion incision followed by mucoperichondrium elevation in one or both sides, addressing all areas of deviation, with reshaping and/ or removal of the deviated portion. Internal splints and packing were not mandatory. Turbinectomy was defined as a surgical procedure on the inferior nasal turbinate intended to decrease its size, including direct excision, elevation of mucosal flaps with removal of bone only, or cauterization. Turbinectomy was performed according to the physician's recommendation and the patient's wishes; no treatment allocation, randomization, or other attempt to modify treatment was made. All physicians were blinded to the patient's NOSE scores, both before and after Fig. 1 Items on the NOSE scale Not a Very mild Moderate Fairly bad Severe problem problem problem problem problem Nasal obstruction Mouth breathing Mouth dryness Anosmia Rhinorrhea Epistaxis Trouble sleeping Snoring Being concern about nasal problem
0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4
Over the past 1 month, how much of a problem were the following conditions fo you? Please circle the most correct response.
Table 1 Frequency of obstruction scores at baseline and at 3 months and 6 months after the date of surgery
Score
0 1 2 3 4
Baseline
After 3 month
0 0 16 (18.6%) 28 (32.6%) 42 (48.8%)
34 (39.5%) 44 (51.2%) 3 (3.5%) 2 (2.3%) 3 (3.5%)
After 6 month 41 (47.7%) 39 (45.3%) 1 (1.2%) 3 (3.5%) 2 (2.3%)
treatment, and the physicians did not collect follow-up data from their patients. Nonparametric analysis (Wilcoxon signed rank test) was used to compare baseline and follow-up NOSE scores. Treatment groups (septoplasty alone vs septoplasty with turbinate procedure) were compared using the nonparametric Wilcoxon rank sum test. A P value less than .05 was considered statistically significant.
3. Results One hundred three patients met eligibility criteria and underwent surgery. At the end of the data collection period, 86 patients (83.49%) completed their follow-up surveys and were available for data analysis. There were no statistically significant differences in age, sex, and nasal-specific symptoms score between the study group and those who did not complete their follow-up surveys. The mean age was 22.44 years (SD, 5.56; range, 1542 years); 49 patients (57%) were male, and 37 patients (43%) were female. Mean duration of nasal obstruction was 6.61 years (SD, 3.57). The NOSE scale (which scaled from 0 to 4) was used to assess disease-specific QOL according to Fig. 1. Baseline obstruction scores, and those at 3 and 6 months after surgery, are shown in Table 1. Sixty-two patients (72.1%) had turbinate manipulation with septoplasty, and 22 patients (27.9%) had septoplasty alone. No statistically significant differences in age, sex, and duration of nasal obstruction were observed between these 2 groups. Patients had significant decreases in nasal obstruction, trouble sleeping, snoring, and mouth dryness in the morning at 3 months after septoplasty (P b .001), there were statistically significant differences between the 3- and 6-month scores. Only in the turbinectomy subgroup, a decrease in the frequency of epistaxis at 6 months after surgery was statistically significant (P b .05). Patients had statistically significant decreases in mouth breathing during the day at 3 months after septoplasty (P b .001). This problem was reduced further at the end of the sixth month (P b .001). Decrease in anosmia was reported after 3 months, which was statistically significant (P b .001). By comparing the third and sixth month scores in the subset of patients who had
B. Gandomi et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 189–192
septoplasty without turbinate surgery, statistically significant improvement of anosmia has been showed (P b .005). In the subset of patients who had turbinate manipulation, rhinorrhea was significantly reduced at 3 months after septoplasty (P b .001). But the comparison between 3- and 6-month scores was not statistically significant. In the subset who had septoplasty alone, no statistically significant changes had occurred at 3 months after surgery, but a significant improvement of rhinorrhea was detected after 6 months (P b .05). Complications occurred in 4 patients. Two patients required reoperation within 12 months. One had septal perforation but refused reoperation for repair.
4. Discussion Of the prospective studies on septoplasty, many used physical examination findings and/or objective measures such as rhinometry [2,10-12]. Many have suggested that rhinometry has little value in a clinical setting. Rhinometry testing demonstrated suboptimal test-retest consistency, which may be associated with the nasal cycle and may be affected by various mediators of nasal congestion [4,13-15]. Physical examination findings are subjective and vulnerable to examination bias. Objective measures often do not correlate well with each other or with patient symptoms [2]. Stewart et al [3] completed the validation of a diseasespecific instrument designed to assess nasal obstruction: the NOSE scale. He noted that it could be used for comparing disease-specific health status between groups of patients before and after treatment or to assess differences in outcome when different surgical techniques are used [3]. We used NOSE scale and other nasal symptoms to evaluate patients. Patients who underwent concomitant turbinate reduction were included to represent a typical population presenting with nasal airway symptoms. We found some different outcomes of septoplasty at our center compared with the reports in the literature. The literature has reported success rates between 63% and 85% depending on the length of follow-up and the method of assessment of results [4,11,16-20]. In our study, 77 patients (89.5%) have reported a subjective improvement in their nasal obstruction, which is more than the experience of most authors. One of the major differences between this study and previous studies is the mean age of patients undergoing surgery, 22.44 years (SD, 5.56; range, 15-42 years) in our study vs more than 40 years in most studies [2-5,7]. This may be due to the lower mean age of Iranian people (more than 50% of the population are b25 years old). High success rate in our study may suggest that younger patients who have nasal obstruction with septal deviation benefit more from septoplasty. Nasal obstruction of these young patients may be more anatomical dependent, so this group may gain more
191
success from surgery, and dynamic causes may be more important in older patients. Stewart et al have reported that patients with nasal obstruction and septal deformity who undergo nasal septoplasty have very significant improvement in nasal obstruction at 3 months, and this result is sustained at 6 months after surgery [2]. In our study, patients reported the same outcome. Also in our study, patients reported a statistically significant decrease in trouble sleeping, snoring, and mouth dryness after sleep at 3 months. These results are sustained at 6 months after surgery. Hence, many of the patients' symptoms have very significant improvement at 3 months, which are sustained at 6 months after operation. Mouth breathing during the day decreased significantly at 3 months, and this result improved 6 months after surgery, which was statistically significant, indicating that some patients need more time to adapt to the new condition. Anosmia was significantly reduced at 3 months, but the comparison between 3- and 6-month scores was statistically significant only in the septoplasty subgroup. However, the number of patients undergoing septoplasty alone was small, and the possibility of a type I error exists for this comparison. So some of the symptoms may need more time to be decreased, and we can expect some improvement in patients' symptoms even after 3 months. Rhinorrhea in septoplasty with the turbinectomy subgroup reduced significantly at 3 months with no significant change at 6 months. But in the septoplasty-alone subgroup, the score had no change at 3 months but decreased at 6 months, which was statistically significant. So the patients undergoing septoplasty with turbinectomy appear to have earlier improvement of this symptom than patients undergoing septoplasty alone. Although no increase or decrease in epistaxis was noted in septoplasty-alone subgroup, in the turbinectomy subgroup, decrease in the frequency of epistaxis at 6 months after surgery was statistically significant. In our study, we identified a greater improvement in the subgroup of patients who had septoplasty and turbinectomy. However, this study was not designed to test that hypothesis definitively, so these results provide pilot data for a future study on this point. In contrast to some studies showing a general tend to rate the results of their septal surgery less positively as the postoperative period increased [5,9,21,22], in our study, most of the symptoms improved or was unchanged as the postoperative period increased, and overall patient satisfaction became better. The strengths of this study are its prospective design and evaluation of younger patients. Because the physician did not personally retrieve the follow-up outcome data from the patient and the data were not returned to the physician's office, the possibility of bias introduction at that level was minimized. The study also had a good follow-up rate. Although this study aimed to evaluate septoplasty outcome in a natural clinical setting in younger patients,
192
B. Gandomi et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 189–192
the results of this study should be evaluated with some caution. First, only 83.49% of eligible patients had followup. There were no statistically significant differences in general health and nasal-specific health between the group with follow-up data and the group who did not complete their surveys. Second, a follow-up period of 6 months may be considered short-term. A 9-year follow-up study has shown that both subjective and objective changes in nasal airway patency take place over time [5]. Finally, a weakness of the study is the lack of a control group. However, there is no alternative treatment for a deviated nasal septum other than surgical correction, so clinical equipoise does not allow for randomization away from septoplasty to sham or placebo surgery or nonsurgical treatment. Of course, enrollment criteria required that medical therapy had failed for each patient; therefore, all patients in the study had a trial of nonsurgical treatment before septoplasty.
5. Conclusions 1. Younger patients who have nasal obstruction with septal deviation benefit more from septoplasty. Nasal obstruction of these patients may be more anatomical dependent, so this group may gain more success from surgery; and in older patients, dynamic causes may be more important. 2. Some of the symptoms need more time to reduce, and we can expect more improvement in patients' symptoms even 3 months after septoplasty. 3. A greater improvement in the subgroup of patients who had septoplasty and turbinectomy may be expected, but that needs further investigations. Acknowledgments The authors thank Shiraz University of Medical Sciences for its financial and editorial support and Mrs Elham Rezaee for her cooperation. References [1] Kim CS, Moon BK, Jung DH, et al. Correlation between nasal obstruction symptoms and objective parameters of acoustic rhinometry and rhinomanometry. Auris Nasus Larynx 1998;25:45-8.
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