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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 63-68

Effectiveness of isolated septal surgeries in nasal septal deviations: A prospective study with reference to the nasal obstruction symptom evaluation scale


Department of Otorhinolaryngology and Head and Neck Surgery, Meenakshi Medical College and Hospital, Kanchipuram, Tamil Nadu, India

Date of Submission12-Jun-2019
Date of Acceptance20-Oct-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Dr. Saai Ram Thejas
Department of Otorhinolaryngology and Head and Neck Surgery, Meenakshi Medical College and Hospital, Karaipettai Post, Enathur, Kanchipuram - 631 552, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_14_19

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  Abstract 


Introduction: Nasal septal deviation is a common diagnosis made by an otorhinolaryngologist, and septoplasty or submucous resection is among the most common daycare procedures practiced in the clinic. Aims and Objectives: The aim of this study was to assess clinically if at all, there is any change in the symptoms of a person post an isolated septal surgery without dealing with the external contour and cosmetic appeal. Materials and Methods: One hundred patients with complaints of nasal obstruction, trouble breathing through the nose, and headache were selected for the study. The initial preoperative assessment was done based on a symptomatic score (Nasal Obstruction Symptom Evaluation Scale [NOSE]). The presence of a septal deviation (cartilaginous or bony) was confirmed with a computed tomography of the paranasal sinuses and a diagnostic nasal endoscopy. Surgery was then performed to correct the pathology based on the location of the deviation. The postoperative assessment was done after 12 weeks based on the NOSE Scale. The results were analyzed and documented. Observations and Results: It was found that the symptomatic picture was better post surgery. Conclusion: The conclusion obtained from the study was that septoplasty and submucous resection as isolated surgical procedures are still relevant in today's world for symptomatic betterment and a healthier lifestyle.

Keywords: Nasal Obstruction Symptom Evaluation scale, nasal septal deviation, septal correction, septoplasty, submucous resection


How to cite this article:
Thejas SR, Mohan S. Effectiveness of isolated septal surgeries in nasal septal deviations: A prospective study with reference to the nasal obstruction symptom evaluation scale. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2019;3:63-8

How to cite this URL:
Thejas SR, Mohan S. Effectiveness of isolated septal surgeries in nasal septal deviations: A prospective study with reference to the nasal obstruction symptom evaluation scale. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2019 Dec 9];3:63-8. Available from: http://www.aiaohns.in/text.asp?2019/3/2/63/271596




  Introduction Top


Headache is a very important symptom in the livelihood of a human being as it directly deals with the general outlook and mood of the individual who is affected by it and he/she immediately seeks medical assistance. Most of these patients need multispecialty workups such as a visit to a neurologist, ophthalmologist, dentist, and an otorhinolaryngologist.

The most important otorhinolaryngological cause of headache is a septal deviation. It also causes nasal obstruction and is a prevalent problem in the general population. Nasal septal deviations are very commonly found in regular nasal examinations. The prevalence of nasal septal deviations varies in different populations, and the classification schemes are very complex.[1]

Not all the deviations are symptomatic, and thus, the need of a surgical correction is not always a must. It is difficult to say for sure that the symptoms will improve after surgery in patients, especially with isolated mucosal contact points between inferior turbinate and septum and without nasal obstruction. Thus, proper screening becomes important. The various screening methods available in daily practice are the NOSE Scale, SNOT-22 among others.

The need of an otorhinolaryngologist is a must if the patient also complains of other nasal symptoms without the presence of an evident nasal inflammatory process.[2]

Septoplasty is an effective and well-tolerated procedure. This procedure has a long history with multiple variations, but the core principles have remained unchanged for decades.[3]

Written accounts describing the correction of nasal septal deformities date back to the beginning of medical literature in the Egyptian papyri. The Edwin Smith papyrus suggests treating the broken nose by placing two plugs of linen coated with grease within each nostril and then applying stiff rolls of linen externally to fix the fracture.[4]

Killian described the importance of accessing the subperichondrial plane.[5] Freer highlighted the importance of the L-shaped cartilaginous strut to provide nasal support.[6]

The symptoms of septal deviation vary from patient to patient and can range from a simple headache to a recurrent epistaxis. The Nasal Obstruction Symptom Evaluation (NOSE) scale was designed by Stewart and associates in 2004 and has been widely used in day-to-day practice ever since.[7] Health-related quality of life (QoL) questionnaires are among the most recent and innovative methodologies for assessing chronic diseases. They were developed either for general applications or to assess a specific disease, function, or symptom.[8]

Improper patient selection for septal surgery often has been found to result in therapeutic failure, and there needs to be an objective assessment of nasal obstruction before the surgery and for postoperative follow-up that can be applied in the routine otolaryngology practice.[9]

The aim of our study was to assess clinically if at all, there is any change in the symptoms of a person post an isolated septal surgery without dealing with the external contour and cosmetic appeal. The standardized NOSE Scale[7] was used by us for the preoperative and postoperative assessment (after 12 weeks).


  Materials and Methods Top


This study “Effectiveness of isolated Septal Surgeries in Nasal Septal Deviations: A Prospective Study with reference to the NOSE Scale” was conducted in and by the Department of Otorhinolaryngology and Head and Neck Surgery, Meenakshi Medical College and Hospital, Kanchipuram, Tamil Nadu, between April 2017 and March 2019 over a period of 24 months.

Study design

This was prospective study.

Inclusion criteria

  • Nasal septal deviation with or without spur
  • Age group 18–45 years
  • Patients who give consent for surgery
  • Patients who agree to be a part of the study.


Exclusion criteria

  • Patients with comorbidities
  • Septal deviation predisposing to sinusitis
  • Extremes of age
  • Other space-occupying lesions of the nasal cavity
  • Patients unfit for anesthesia
  • Symptoms due to non-otorhinolaryngological causes.


Method of statistical analysis

All statistical analyses were performed using SPSS Statistics 19 for Windows (IBM Corp., Armonk, NY, USA). Samples were compared and evaluated by means of a Paired t-test. P < 0.05 was considered statistically significant. The confidence interval was set at 95%.

Sample size

The sample size was 100.

Selection of patients

All the patients visiting the Department of Otorhinolaryngology and Head and Neck Surgery, Meenakshi Medical College and Hospital with any sort of nasal complaints were clinically evaluated, and a proper examination was performed.

Preoperative assessment

After proper identification of patients based on the strict inclusion and exclusion criteria, the patients were subjected to a detailed NOSE questionnaire [Figure 1]. Each patient was asked to clearly read the questionnaire and give a score for each symptom– 0 being the lowest and 4 being the highest. The Likert Scale assessment was then used wherein each response is added up and multiplied by 5 to reach a score of 100.
Figure 1: The Nasal Obstruction Symptom Evaluation Questionnaire

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After obtaining a written consent for surgery, the patients were prepared with thorough blood tests along with radiological [Figure 2] and [Figure 3] and local examinations [Figure 4].
Figure 2: Computed tomography (axial view) showing a septal deviation to the left with a bony spur

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Figure 3: Computed tomography (coronal view) showing a septal deviation to the left with a bony spur

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Figure 4: Preoperative picture showing a deviated nasal Septum

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Out of a total of 100, 50 patients were prepared for septoplasty and 50 patients were prepared for submucosal resection. A vertical line drawn from the nasion to the nasal spine of maxilla divides the cartilaginous nose into an anterior and posterior half. This line is referred to as the Cottle's line.[10] The anterior half is essential to maintain the integrity of the external architecture of the nose, and thus, the deviation here, i.e., anterior to the Cottle's line are treated with septoplasty. The deviations posterior to the Cottle's line can be treated with a submucosal resection.

Surgical procedure

All the surgeries were performed by the same surgeon, under general anaesthesia, and using the same set of instruments. The local anesthetic used was 1% lidocaine in 1:200000 epinephrine. Deviations anterior to the Cottle's line were treated with a Septoplasty and posterior to the same were treated by a Submucosal Resection. Based on the need, Freer's incision[6] or Killian's incision[5] was used. No turbinate or sinus procedure was performed. After surgery, the nasal cavity was packed with antibiotic soaked gauze by means of a horizontal step ladder anterior pack. Postoperatively, all the patients were treated with nonsteroidal anti-inflammatory drugs, antibiotics, and antihistamines. The nasal pack was removed after 48 h, and nasal cavity was cleared of any crusting, adhesions, and synechiae. Patients were discharged and were asked to review once a week for the next 2 weeks and then again at the end of 12 weeks.

Postoperative review

After 12 weeks, the NOSE Scale chart was again given to the patient, and he/she was asked to score the same way in which it was done preoperatively.


  Observations and Results Top


Among the study group of 100, 44 were female and 56 were male [Figure 5].
Figure 5: Gender distribution

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The mean age of the patients in the group of septoplasty was 29.68 years, and the SMR group was 30.62 years. The overall mean age was found to be 30.15 years.

Based on careful evaluation, 50 patients with an anterior deviation underwent septoplasty [Table 1] and [Table 2], and 50 patients with a posterior deviation underwent submucosal resection [Table 3] and [Table 4]. There was no intention for comparison between the two groups. The symptom which was causing the most problem to all the patients was “Nasal Block/Obstruction,” and the symptom which was causing the least problem was “Trouble sleeping.” The maximum score recorded in the questionnaire was 80, and the best score reached postsurgery was 10 [Figure 6] and [Figure 7]. The P was found to be < 0.5 in both the groups.
Table 1: Paired sample correlations in the septoplasty group

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Table 2: Paired sample statistics in the septoplasty group

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Table 3: Paired sample correlations in the submucous resection group

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Table 4: Paired sample statistics in the Submucous Resection group

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Figure 6: Preoperative (Series 1) and postoperative (Series 2) values of the Nasal Obstruction Symptom Evaluation Scale in the septoplasty group

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Figure 7: Preoperative (Series 1) and postoperative (Series 2) values of the Nasal Obstruction Symptom Evaluation Scale in the submucous resection group

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Both the subjective and objective values improved significantly postsurgery in both the groups of patients who underwent septoplasty and submucous resection.


  Discussion Top


The normal nasal septum is straight and symmetrical. Factors such as genetic, racial, environmental, and trauma have often been identified as the cause of nasal septal deviation.

The NOSE scale is a validated, globally accepted instrument to quantify the burden related to nasal obstruction and change herein following nasal surgery. Cross-cultural adaptation of the NOSE scale makes it a valuable instrument allowing the comparison of outcome results between institutions and to organize multicenter studies.[11]

The NOSE score has become a valuable outcome measure of nasal obstruction treatment. It is a brief, simple, and easily administered QOL instrument specific to nasal obstruction. No normative data or classification system is reported using the NOSE survey. This information would be helpful in many ways. First, patients who do not report nasal obstruction often score above zero on the NOSE questionnaire. Results from these patients provided a context to scores from people who reported nasal obstruction. Second, structuring the NOSE scores of patients with Nasal Obstruction within a classification system gives them a better understanding of the severity of their condition. Third, future studies using the NOSE scale as an outcome measure could use this severity classification system to better define their study population and describe treatment responses.[12]

In a study conducted by Lodder and Leong, it was demonstrated that a combination of brief and easy to complete measurements can be obtained to provide meaningful data for benchmarking, professional appraisal and improve patients' expectations of surgery. The average NOSE score indicated that the study cohort had severe nasal obstruction. The overall improvement in patient perception of nasal obstruction was supported by the significant improvement in the NOSE score after the nasal septal surgery.[13]

It has been reported that there has been a general under-utilization of objective methods across the United Kingdom in the assessment of nasal patency, predominately because of lack of availability, time consumption, and a weak correlation with symptom scores.[14]

The use of validated nasal obstruction outcome measures is essential in assessing the efficacy of interventions to treat obstruction. It is important to understand the different types of measurements available as well as the advantages and limitations of each method to interpret their use in study results and assess one's own surgical outcomes. These validated measures provide the basis of evidence-based treatment of nasal airway obstruction and research.[15]

Various newer methods have been proposed for the evaluation of patients before surgery. The Rhinoplasty Health Inventory and Nasal Outcomes scale was correspondingly developed as a 10-item questionnaire to evaluate outcomes in physical, mental, and social well-being.[16]

It has been reported that subjective and objective measurements of nasal obstruction showed improvement throughout the 1-year follow-up after septoplasty. The visual analog scale (VAS) and NOSE scores were highly correlated before and 3, 6, and 12 months after septoplasty.[17]

In a study conducted by Eren, it was reported that the VAS and NOSE scores of 86 patients with nasal obstruction had significantly decreased 3 months after septoplasty.[18]

Overall assessment of nasal obstruction is very much clinically relevant, but this may sometimes explain a discordance between objective and subjective measurements. It has been reported that patients with symptomatic nasal obstruction also had a greater correlation between objective and subjective measures compared with asymptomatic patients.[19]

In 2010, the professional association of the UK Otorhinolaryngologists noted that some hospital administrations were suggesting to abolish or severely restrict septoplasty because of doubts about its benefits.[20]

Thus, to put it all in perspective, we feel that a subjective evaluation score is needed to assess the improvement in the symptomatology's of any patient undergoing any surgery. It makes it easy for a surgeon to understand the shortcomings of the procedure and also to make changes in the method of operating and the method of follow up.

With the advent of newer surgeries which not only treat the septal deviations but also provide better cosmetic appeal, the thinking of patients, in general, is shifting. In an era where the appearance of various studies to downplay septal correction is on the rise, we have tried to assess its relevance in areas where the awareness is less, and the financial strength is not strong for expensive treatments.


  Conclusion Top


At the end of our study, we noticed that the NOSE scale is a very potent method for the assessment of the symptoms of the patients who are undergoing septal surgery. The QOL (with respect to the symptomatic scores) of all our patients in the study improved by an appreciable amount 12 weeks after surgery. Thus, it can be concluded that septoplasty and submucous resection as isolated surgical procedures are still relevant in today's world for symptomatic betterment and a healthier lifestyle.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Salihoglu M, Cekin E, Altundag A, Cesmeci E. Examination versus subjective nasal obstruction in the evaluation of the nasal septal deviation. Rhinology 2014;52:122-6.  Back to cited text no. 1
    
2.
Bilal N, Selcuk A, Karakus MF, Ikinciogullari A, Ensari S, Dere H. Impact of corrective rhinologic surgery on rhinogenic headache. J Craniofac Surg 2013;24:1688-91.  Back to cited text no. 2
    
3.
Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: Techniques in septoplasty. Otolaryngol Clin North Am 2009;42:241-52, viii.  Back to cited text no. 3
    
4.
Bailey BJ. Nasal septal surgery 1896-1899: Transition and controversy. Laryngoscope 1997;107:10-6.  Back to cited text no. 4
    
5.
Killian G. The submucous window resection of the Nasal Septum. Ann Otol Rhinol Laryngol 1905;14:363-93.  Back to cited text no. 5
    
6.
Freer OT. The correction of deflections of the Nasal Septum with a minimum of traumatism. JAMA 1902; 38:636-42.  Back to cited text no. 6
    
7.
Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the nasal obstruction symptom evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004;130:157-63.  Back to cited text no. 7
    
8.
Marro M, Mondina M, Stoll D, de Gabory L. French validation of the NOSE and rhinoQOL questionnaires in the management of nasal obstruction. Otolaryngol Head Neck Surg 2011;144:988-93.  Back to cited text no. 8
    
9.
Sen I, Dutta M, Haldar D, Sinha R. Estimation of partitioning of airflow in septal surgery: A prospective study with reference to the NOSE scale. Ear Nose Throat J 2017;96:E6-12.  Back to cited text no. 9
    
10.
Barelli PA, Loch EE, Kern EB, Steiner A, editors. Rhinology: The Collected Writings of Maurice H, Cottle MD. Warwick, NY: American Rhinologic Society; 1987.  Back to cited text no. 10
    
11.
van Zijl FVWJ, Timman R, Datema FR. Adaptation and validation of the dutch version of the nasal obstruction symptom evaluation (NOSE) scale. Eur Arch Otorhinolaryngol 2017;274:2469-76.  Back to cited text no. 11
    
12.
Lipan MJ, Most SP. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg 2013;15:358-61.  Back to cited text no. 12
    
13.
Lodder WL, Leong SC. What are the clinically important outcome measures in the surgical management of nasal obstruction? Clin Otolaryngol 2018;43:567-71.  Back to cited text no. 13
    
14.
Andrews P, Joseph J, Li CH, Nip L, Jacques T, Leung T. A UK survey of current ENT practice in the assessment of nasal patency. J Laryngol Otol 2017;131:702-6.  Back to cited text no. 14
    
15.
Spataro E, Most SP. Measuring nasal obstruction outcomes. Otolaryngol Clin North Am 2018;51:883-95.  Back to cited text no. 15
    
16.
Lee MK, Most SP. A comprehensive quality-of-life instrument for aesthetic and functional rhinoplasty: The RHINO scale. Plast Reconstr Surg Glob Open 2016;4:e611.  Back to cited text no. 16
    
17.
Hsu HC, Tan CD, Chang CW, Chu CW, Chiu YC, Pan CJ, et al. Evaluation of nasal patency by visual analogue scale/nasal obstruction symptom evaluation questionnaires and anterior active rhinomanometry after septoplasty: A retrospective one-year follow-up cohort study. Clin Otolaryngol 2017;42:53-9.  Back to cited text no. 17
    
18.
Eren SB, Tugrul S, Dogan R, Ozucer B, Ozturan O. Objective and subjective evaluation of operation success in patients with nasal septal deviation based on septum type. Am J Rhinol Allergy 2014;28:e158-62.  Back to cited text no. 18
    
19.
André RF, Vuyk HD, Ahmed A, Graamans K, Nolst Trenité GJ. Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence. Clin Otolaryngol 2009;34:518-25.  Back to cited text no. 19
    
20.
ENT UK. The British Academic Conference in Otolaryngology (BACO) and the British Association of Otorhinolaryngology – Head and Neck Surgery (BAO-HNS). Nasal Septal Surgery: ENTUK position paper 2010.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

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



 

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