Septoplasty: long-term evaluation of results

Fibromyalgia symptoms before and after septoplasty: A cross-sectional study

This study aimed to investigate the impact of septoplasty on fibromyalgia symptoms in patients with septum deviation. Patients who were over 18 years of age, had been diagnosed with nasal septum deviation, and indicated for septoplasty were selected consecutively and included in the study. Patients were evaluated twice, at baseline and after septoplasty at 3 months. The patients' widespread pain and symptom severity scores were calculated according to the American College of Rheumatology 2016 Revised Fibromyalgia Diagnostic Criteria. A Revised Fibromyalgia Impact Questionnaire was filled out to evaluate the patients' fibromyalgia symptoms. The Pittsburgh Sleep Quality Index was used to assess the sleep quality of patients. Thirty-five patients, 21 (60.0%) male and 14 (40.0%) female, were accepted to the study. Nine (25.9%) patients had fibromyalgia at the beginning, and none of the patients met the fibromyalgia criteria after the surgery. After septoplasty, a statistically significant decrease was detected in the patients' widespread pain index, symptom severity scale, total score, and Pittsburgh Sleep Quality Index and Revised Fibromyalgia Impact Questionnaire scores (P = .006, P = .004, P = .028, P = .014, and P < .001, respectively). As a result of the study, it was observed that fibromyalgia symptoms of patients with septum deviation improved after surgical correction of the deviation.

An adjoint-based approach for the surgical correction of nasal septal deviations

Deviations of the septal wall are widespread anatomic anomalies of the human nose; they vary significantly in shape and location, and often cause the obstruction of the nasal airways. When severe, septal deviations need to be surgically corrected by ear-nose-throat (ENT) specialists. Septoplasty, however, has a low success rate, owing to the lack of suitable standardized clinical tools for assessing type and severity of obstructions, and for surgery planning. Moreover, the restoration of a perfectly straight septal wall is often impossible and possibly unnecessary. This paper introduces a procedure, based on advanced patient-specific Computational Fluid Dynamics (CFD) simulations, to support ENT surgeons in septoplasty planning. The method hinges upon the theory of adjoint-based optimization, and minimizes a cost function that indirectly accounts for viscous losses. A sensitivity map is computed on the mucosal wall to provide the surgeon with a simple quantification of how much tissue removal at each location would contribute to easing the obstruction. The optimization procedure is applied to three representative nasal anatomies, reconstructed from CT scans of patients affected by complex septal deviations. The computed sensitivity consistently identifies all the anomalies correctly. Virtual surgery, i.e. morphing of the anatomies according to the computed sensitivity, confirms that the characteristics of the nasal airflow improve significantly after small anatomy changes derived from adjoint-based optimization.

Long-Term Outcomes of Septoplasty With or Without Turbinoplasty: A Systematic Review

BACKGROUND

Septoplasty is used to correct nasal obstruction from nasal septum deviation. However, the long-term efficacy of septoplasty is unclear, and no literature reviews have examined long-term outcomes of septoplasty with or without turbinate modification. This systematic review aimed to evaluate the long-term efficacy of septoplasty with or without turbinate modification in improving nasal obstruction.

DATA SOURCES

PubMed, EMBASE, Cochrane CENTRAL.

METHODS

A systematic review of the literature was conducted using the aforementioned databases. Studies reporting outcomes 12+ months after functional septoplasty with or without turbinate surgery for nasal obstruction were included. Septorhinoplasties, concurrent sinus surgery, pediatric studies, and studies where septoplasty was performed for indications other than nasal obstruction were excluded.

RESULTS

After screening, 35 studies with 4,432 patients were included. Mean weighted post-operative follow-up time was 29.1 months (range 12-120 months). All studies reported significant improvement in subjective and objective outcomes at long-term follow-up compared to baseline. When comparing short-term (<12 months) to long-term (≥12 months) outcomes, four studies noticed that subjective outcomes worsened slightly over time, but no study found a significant change in objective outcomes over time. In addition, 23 studies reported patient satisfaction and/or improvement rates, with 75.4% (2,348/3,113) of patients expressing satisfaction/improvement at an average of 27.0 months after surgery.

CONCLUSIONS

Overall, septoplasty with or without turbinate modification shows significant improvement in obstructive symptoms at long-term follow-up per both objective and subjective measures. Whether outcomes may worsen slightly over time remains indeterminate based on mixed results in the literature.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2525-2537, 2024.

Functional assessment of septo(rhino)plasty revision surgery

INTRODUCTION

Functional septo(rhino)plasty incurs a 17-25% rate of revision for persistent symptoms.

OBJECTIVES

The main study objective was to assess functional results before and after surgical revision. The secondary objective was to describe the shortcomings or excesses of the prior surgeries, with a-posteriori comparison of efficacy for the surgical techniques requiring revision.

MATERIAL AND METHODS

A single-center retrospective study included functional salvage septo(rhino)plasties. Data comprised epidemiology, intraoperative anatomic abnormalities indicative of prior surgery, operative correction maneuvers, and pre- and post-intervention NOSE and RhinoQoL scores and satisfaction on VAS.

RESULTS

Eighty-two patients were included. Anatomic abnormalities comprised deviated posterior septum (81.7%) and chondroethmoidal junction (58.5%), valve stenosis (54.9%), and obstructive boney spur or crest (46.3%). Prior surgeries comprised 33 submucosal resections, 29 septorhinoplasties, 14 Cottle septoplasties and 5 Killian procedures. Complete septoplasty was performed in 80% of cases, with associated maneuvers in 15%. All scores showed improvement taking the whole population together (P<10-5), but on subgroup analysis improvement concerned only revision of septorhinoplasty (P<10-4) and of submucosal resection (P<10-3), while 17% of patients showed no change in scores.

CONCLUSION

Functional nasoseptal salvage surgery enables most patients to recover respiratory comfort, with the exception of a few cases despite a perfectly straight nasal septum.

Effectiveness of septoplasty compared to medical management in adults with obstruction associated with a deviated nasal septum: the NAIROS RCT

Background

The indications for septoplasty are practice-based, rather than evidence-based. In addition, internationally accepted guidelines for the management of nasal obstruction associated with nasal septal deviation are lacking.

Objective

The objective was to determine the clinical effectiveness and cost-effectiveness of septoplasty, with or without turbinate reduction, compared with medical management, in the management of nasal obstruction associated with a deviated nasal septum.

Design

This was a multicentre randomised controlled trial comparing septoplasty, with or without turbinate reduction, with defined medical management; it incorporated a mixed-methods process evaluation and an economic evaluation.

Setting

The trial was set in 17 NHS secondary care hospitals in the UK.

Participants

A total of 378 eligible participants aged > 18 years were recruited.

Interventions

Participants were randomised on a 1: 1 basis and stratified by baseline severity and gender to either (1) septoplasty, with or without turbinate surgery (n = 188) or (2) medical management with intranasal steroid spray and saline spray (n = 190).

Main outcome measures

The primary outcome was the Sino-nasal Outcome Test-22 items score at 6 months (patient-reported outcome). The secondary outcomes were as follows: patient-reported outcomes - Nasal Obstruction Symptom Evaluation score at 6 and 12 months, Sino-nasal Outcome Test-22 items subscales at 12 months, Double Ordinal Airway Subjective Scale at 6 and 12 months, the Short Form questionnaire-36 items and costs; objective measurements - peak nasal inspiratory flow and rhinospirometry. The number of adverse events experienced was also recorded. A within-trial economic evaluation from an NHS and Personal Social Services perspective estimated the incremental cost per (1) improvement (of ≥ 9 points) in Sino-nasal Outcome Test-22 items score, (2) adverse event avoided and (3) quality-adjusted life-year gained at 12 months. An economic model estimated the incremental cost per quality-adjusted life-year gained at 24 and 36 months. A mixed-methods process evaluation was undertaken to understand/address recruitment issues and examine the acceptability of trial processes and treatment arms.

Results

At the 6-month time point, 307 participants provided primary outcome data (septoplasty, n = 152; medical management, n = 155). An intention-to-treat analysis revealed a greater and more sustained improvement in the primary outcome measure in the surgical arm. The 6-month mean Sino-nasal Outcome Test-22 items scores were -20.0 points lower (better) for participants randomised to septoplasty than for those randomised to medical management [the score for the septoplasty arm was 19.9 and the score for the medical management arm was 39.5 (95% confidence interval -23.6 to -16.4; p < 0.0001)]. This was confirmed by sensitivity analyses and through the analysis of secondary outcomes. Outcomes were statistically significantly related to baseline severity, but not to gender or turbinate reduction. In the surgical and medical management arms, 132 and 95 adverse events occurred, respectively; 14 serious adverse events occurred in the surgical arm and nine in the medical management arm. On average, septoplasty was more costly and more effective in improving Sino-nasal Outcome Test-22 items scores and quality-adjusted life-years than medical management, but incurred a larger number of adverse events. Septoplasty had a 15% probability of being considered cost-effective at 12 months at a £20,000 willingness-to-pay threshold for an additional quality-adjusted life-year. This probability increased to 99% and 100% at 24 and 36 months, respectively.

Limitations

COVID-19 had an impact on participant-facing data collection from March 2020.

Conclusions

Septoplasty, with or without turbinate reduction, is more effective than medical management with a nasal steroid and saline spray. Baseline severity predicts the degree of improvement in symptoms. Septoplasty has a low probability of cost-effectiveness at 12 months, but may be considered cost-effective at 24 months. Future work should focus on developing a septoplasty patient decision aid.

Trial registration

This trial is registered as ISRCTN16168569 and EudraCT 2017-000893-12.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/226/07) and is published in full in Health Technology Assessment; Vol. 28, No. 10. See the NIHR Funding and Awards website for further award information.

Value of Opening the Middle Meatus in Patients With Nasal Airway Obstruction

OBJECTIVES

While surgeries to correct the anatomical malformations that cause nasal airway obstruction (NAO) are generally successful, the outcomes of such procedures are often unsatisfactory. The aim of the present study was to assess the value of opening the middle meatus in patients with NAO.

METHODS

Thirty-four patients with nasal obstruction due to nasal septal deviation were included in this study. After randomization, the middle meatus was either opened or not opened during septoplasty. The patients were evaluated through pre- and postoperative rhinomanometry and acoustic rhinometry. The Visual Analog Scale (VAS) scores of subjective symptoms along with responses to the 20-item Sinonasal Outcome Test (SNOT-20) were obtained before surgery and three months after surgery.

RESULTS

The VAS scores and SNOT-20 responses improved significantly in both groups after surgery. The effective treatment rate based on the nasal congestion score (NCS) was 64.7% in the single group (septoplasty alone) and 100% in the combined group (septoplasty in conjunction with opening the middle meatus), and the difference was statistically significant (P = .018). In both groups, surgery significantly improved nasal flow, resistance, minimal cross-sectional area, cross-sectional area 6 cm (CA6) from the anterior nostril and nasal volume. Nasal volume and CA6 after surgery were statistically different between the 2 groups (P = .004 and .019, respectively).

CONCLUSIONS

Opening the middle meatus may further improve the subjective perception of patency on the basis of septoplasty.

Effectiveness of out-fracture of the inferior turbinate with reduction nasal bone fracture

BACKGROUND

The nasal bone, being the most protruding bone in the center of the facial bones, is particularly susceptible to damage. Nasal bone fractures can often result in secondary deformation and dysfunction of the nose, including septal fractures. Studies on functional or intra-nasal complications have been rarely reported after nasal bone fracture reduction.

AIM

To evaluate the severity of nasal obstruction and its improvement following nasal bone fracture reduction using inferior turbinoplasty.

METHODS

We conducted a retrospective review of data from 50 patients with symptomatic nasal obstruction between January to December 2010. All patients underwent preoperative Computed tomography evaluation, and symptom changes and nasal cavity volume were analyzed using a visual analog scale and acoustic rhinometry before and after surgery. Closed reduction and out-fracture of both inferior turbinates performed by the same surgeon. Treatment outcomes were assessed by comparing changes in the nasal airway volume measured using acoustic rhinometry before and after surgery. The minimal cross-sectional area (MCA) was also analyzed based on the Stranc classification.

RESULTS

Before reduction, the mean MCA for all cases was 0.59 ± 0.06 cm2, which represented an 11% decrease compared to the average size of a Korean adult (0.65 ± 0.03 cm2). The MCA for frontal impact was 0.60 ± 0.02 cm2 and for lateral impact, it was 0.58 ± 0.03 cm2. After reduction via inferior turbinoplasty, the MCA improved to 0.64 ± 0.04 cm2.

CONCLUSION

This study suggests that turbinoplasty is helpful in addressing nasal obstruction. Out-fracture of the inferior turbinate is an effective and durable technique that can be easily performed to enlarge the nasal airway with minimal morbidity.

Surgical Outcomes of Endoscopic Versus Conventional Septoplasty

The most common cause of nasal obstruction is a deviated nasal septum. It causes breathing difficulties and may eventually also cause sinusitis, epistaxis, sleep disturbances and snoring. The traditional surgeries of the nasal septum improve the nasal airway but do not fulfil the essential criteria in most instances. Endoscopic septoplasty is a fast-developing concept and gaining popularity as it provides a direct targeted approach to the septal anatomic deformity allowing a minimally invasive procedure under excellent visualization. The aim of this study is to compare the post-operative morbidity among conventional and endoscopic septoplasty. The present prospective study was conducted on 50 patients having deviated nasal septum. Patients were randomly divided into two groups of 25 each. Out of 50 patients, in 25 patients (Group A) Conventional septoplasty was done, whereas in other 25 patients (Group B) endoscopic septoplasty was done. The patients were followed up post-operatively at 2 weeks, 4 weeks and 8 weeks. Study Design: comparative study. The mean of operating time (min) in Group A was 60.47 ± 8.16 which was significantly higher as compared to Group B (39.7 ± 6.73). (p value < .0001). The Mean of blood loss (mL) was significantly higher in Group A (88.67 ± 8.77) as compared to Group B. (54.6 ± 7.18). (p value < .0001). Post-operative NOSE score at one month was 7.33 ± 1.5 in group A which was significantly higher as compared to Group B (5 ± 1.41). (p value = 0.0007) whereas post-operative NOSE score at 3 months in Group A was 6.53 ± 1.25 which was significantly higher as compared to Group B (4.4 ± 1.78). Proportion of post-operative complications was comparable in Group A and Group B (No complication 80% vs. 92% respectively). According to the present study, both the conventional and endoscopic septoplasty procedures were effective in relieving nasal obstruction in the patients. Endoscopic septoplasty showed significantly better result than conventional septoplasty in terms of time taken for surgery, blood loss during the surgery, post-operative complications and in terms of quality of life as assessed by NOSE Score.

Impact of the Location of Nasal Septal Deviation on the Nasal Airflow and Air Conditioning Characteristics

The location of nasal septal deviation (NSD) directly impacts nasal physiology. The objective is to examine, using computational fluid dynamics (CFD), the difference in the airflow and air conditioning characteristics according to the location of NSD. Twenty patients with septal deviation were divided into two: 10 caudal septal deviation (CSD) and 10 posterior septal deviation (PSD). Physiological variables were compared and numerical models for nasal cavity were created with CT scans. Cases with CSD had distinctive features including restricted airflow partition, larger nasal resistance, and decreased surface heat flux in the more obstructed side (MOS), and lower humidity and air temperature in the lesser obstructed side (LOS). Physiological differences were observed according to the location of septal deviation, CSD cases exhibit significantly more asymmetric airflow characteristics and air conditioning capacity between LOS and MOS.

How do different climatic conditions affect the quality of life of patients following septoplasty or septorhinoplasty?

OBJECTIVES

The effects of different climatic conditions on the quality of life (QoL) of patients following septoplasty or septorhinoplasty were investigated.

METHODS

A total of 89 patients (47 males and 42 females) underwent either septoplasty or septorhinoplasty during the summer (summer group, n = 42) or winter (winter group, n = 47) season. To assess QoL, SinoNasal Outcome Test (SNOT)-22, Nasal Obstruction Symptom Evaluation (NOSE) scale, and Visual Analogue Scale were used. Postoperative (PO) pain, bleeding, and symptoms related to nasal packing (eating and sleep problems) were also evaluated.

RESULTS

PO pain scores were lower in the winter group than that in the summer group (p<0.05). After pack removal, there was a slight serohemorrhagic nasal discharge in 2.1% of the patients in the winter group, but no patient required intervention. Slight leakage was detected in 47.6% of the patients and 2.4% of the patients called for intervention (p<0.05) in the summer group. The SNOT-22 values did not differ between the groups (p>0.05). NOSE scores in the winter group were higher than that in the summer group (p<0.05). In each group, SNOT-22 (p_adjusted<0.175) and NOSE scores (p<0.05) were lower at 1 month after surgery. The winter group patients rated headache, facial pain, and nasal crusting higher than those in the summer group did (p<0.05). However, nasal discharge and loss of smell were less troubling in the summer group than that in the winter group (p<0.05).

CONCLUSION

Regardless of climate or season, septoplasty or septorhinoplasty increases patients' QoL. However, problematic PO bleeding was detected at a higher frequency in patients who underwent surgery in summer. The advantage of surgery in winter is that it leads to less frequent problematic bleeding PO.

The Effect of Segmentation Threshold on Computational Fluid Dynamic Analysis of Nasal Airflow

BACKGROUND

The objective analysis of nasal airflow stands to benefit greatly from the adoption of computational fluid dynamic (CFD) methodologies. In this emerging field, no standards currently exist in regard to the ideal modeling parameters of the nasal airway. Such standards will be necessary for this tool to become clinically relevant.

METHODS

Human nasal airways were modeled from a healthy control, segmented, and analyzed with an in-house immersed boundary method. The segmentation Hounsfield unit (HU) threshold was varied to measure its effect in relation to airflow velocity magnitude and pressure change.

FINDINGS

Surface area and volume have a linear relationship to HU threshold, whereas CFD variables had a more complex relationship.

INTERPRETATION

The HU threshold should be included in nasal airflow CFD analysis. Future work is required to determine the optimal segmentation threshold.

Improvements in airflow characteristics and effect on the NOSE score after septoturbinoplasty: A computational fluid dynamics analysis

Septoturbinoplasty is a surgical procedure that can improve nasal congestion symptoms in patients with nasal septal deviation and inferior turbinate hypertrophy. However, it is unclear which physical domains of nasal airflow after septoturbinoplasty are related to symptomatic improvement. This work employs computational fluid dynamics modeling to identify the physical variables and domains associated with symptomatic improvement. Sixteen numerical models were generated using eight patients' pre- and postoperative computed tomography scans. Changes in unilateral nasal resistance, surface heat flux, relative humidity, and air temperature and their correlations with improvement in the Nasal Obstruction Symptom Evaluation (NOSE) score were analyzed. The NOSE score significantly improved after septoturbinoplasty, from 14.4 ± 3.6 to 4.0 ± 4.2 (p < 0.001). The surgery not only increased the airflow partition on the more obstructed side (MOS) from 31.6 ± 9.6 to 41.9 ± 4.7% (p = 0.043), but also reduced the unilateral nasal resistance in the MOS from 0.200 ± 0.095 to 0.066 ± 0.055 Pa/(mL·s) (p = 0.004). Improvement in the NOSE score correlated significantly with the reduction in unilateral nasal resistance in the preoperative MOS (r = 0.81). Also, improvement in the NOSE score correlated better with the increase in surface heat flux in the preoperative MOS region from the nasal valve to the choanae (r = 0.87) than in the vestibule area (r = 0.63). Therefore, unilateral nasal resistance and mucous cooling in the preoperative MOS can explain the perceived improvement in symptoms after septoturbinoplasty. Moreover, the physical domain between the nasal valve and the choanae might be more relevant to patient-reported patency than the vestibule area.

Do Mean Values of the Peak Inspiratory Nasal Flowmeter Vary According to the Severity, Direction and Type of Nasal Septum Deviation?

The aim is to investigate the contribution of the PNIF test in daily clinical practices in the objective evaluation of the early postoperative functional results of septoplasty and the effect of the severity, direction, and type of nasal septum deviation on mean PNIF values. Nasal septum deviation (NSDs) of the cases were grouped according to the Mladina classification and the severity of NSDs. An objective evaluation of the nasal airway was conducted via a peak flowmeter device in the preoperative and postoperative first month. When examining the mean PNIF values according to genders, it was observed that the values determined in male cases in the preoperative and postoperative period were higher. In the intragroup evaluation performed according the Mladina classification, a statistically significant increase was observed in the preoperative and postoperative PNIF values of the cases in Types 1-4. In the intragroup evaluation performed according to the severity of NSD, there was a significant increase in the preoperative and postoperative PNIF values of the mild and moderate cases. When comparing the preoperative and postoperative PNIF values of the groups in terms of the severity of NSD, it was observed that there was a significant difference. The PNIF can be used in routine clinical practices to evaluate the septoplasty results objectively. In the evaluation of functional results, the change in the mean PNIF values may also vary according to the direction and severity of septum deviation and the Mladina classification other than age, gender and ethnic origin.

Changes in inflammatory biomarkers in the nasal mucosal secretion after septoplasty

Deviated nasal septum (DNS) is suggested to be associated with nonspecific inflammation of the nasal mucosa. The authors hypothesized septoplasty may reduce nasal mucosal inflammation, therefore the authors aimed to measure various inflammatory biomarkers in the nasal secretion following septoplasty. Prospectively, 17 patients undergoing elective septoplasty were included. Symptomatic changes after septoplasty were evaluated with Sino-nasal Outcome Test (SNOT-22) and Nasal obstruction symptom evaluation (NOSE) scores. Using acoustic rhinometry, changes of the nasal airway volume were measured. Nasal secretion was collected within 2 weeks and 3 months before and after septoplasty, respectively. The inflammatory biomarker high-mobility group box 1 (HMGB1) and vasoactive intestinal peptide (VIP), and inflammatory cytokines including tumor necrosis factor α (TNF α), interferon γ (IFN-γ), interleukin-4 (IL-4), eotaxin-1, and regulated upon activation, normal T cell expressed and presumably secreted (RANTES) were quantified in the nasal secretion by enzyme-linked immunosorbent assays or multiplex bead array assays. The patients' mean age was 30.5 ± 6.8 (ranging from 19 to 43), consisting of 15 male and 2 female patients. The median SNOT-22 and NOSE scores changed from 54 to 14 and 78 to 15, respectively, both showing a significant decrease. In acoustic rhinometry, nasal cavity volume of convex side significantly increased after septoplasty, whereas significant discrepancy of nasal airway volume between concave and convex sides became insignificant. No significant difference was noted both before and after septoplasty between the concave and convex sides in all seven biomarkers. The HMGB1, RANTES, IL-4, and TNF-α concentrations following septoplasty showed significant decrease in 34 nasal cavities of 17 patients (all p < 0.05). However, when the 17 concave and 17 convex sides were analyzed separately, the significant reduction in four biomarkers were only significant in the concave sides (all p < 0.05), but not significantly reduced in convex sides. Septoplasty may have benefited not only in normalizing the nasal airflow and symptom improvement, but also in nonspecific inflammation attenuation in the nasal airway.

Correlation of Nasal Mucosal Temperature and Nasal Patency—A Computational Fluid Dynamics Study

OBJECTIVES

Recent evidence suggests that detection of nasal mucosal temperature, rather than direct airflow detection, is the primary determinant of subjective nasal patency. This study examines the role of nasal mucosal temperature in the perception of nasal patency using in vivo and computational fluid dynamics (CFD) measurements.

METHODS

Healthy adult participants completed Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS) questionnaires. A temperature probe measured nasal mucosal temperature at the vestibule, inferior turbinate, middle turbinate, and nasopharynx bilaterally. Participants underwent a CT scan, used to create a 3D nasal anatomy model to perform CFD analysis of nasal mucosal and inspired air temperature and heat flux along with mucosal surface area where heat flux >50 W/m² (SAHF50).

RESULTS

Eleven participants with a median age of 27 (IQR 24; 48) were recruited. Probe-measured temperature values correlated strongly with CFD-derived values (r = 0.87, p < 0.05). Correlations were seen anteriorly in the vestibule and inferior turbinate regions between nasal mucosal temperature and unilateral VAS (r = 0.42-0.46; p < 0.05), between SAHF50 and unilateral VAS (r = -0.31 to -0.36; p < 0.05) and between nasal mucosal temperature and SAHF50 (r = -0.37 to -0.41; p < 0.05). Subjects with high patency (VAS ≤10) had increased heat flux anteriorly compared with lower patency subjects (VAS >10; p < 0.05).

CONCLUSION

Lower nasal mucosal temperature and higher heat flux within the anterior nasal cavity correlates with a perception of improved unilateral nasal patency in healthy individuals.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1328-1335, 2023.

Functional Nasal Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective.

SUMMARY

The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

Evidence of Nasal Cooling and Sensory Impairments Driving Patient Symptoms With Septal Deviation

OBJECTIVES/HYPOTHESIS

About 260,000 septoplasties are performed annually in the US to address nasal septal deviation (NSD). Yet, we do not consistently understand what aspects of NSD result in symptoms.

STUDY DESIGN

Blinded cohort study.

METHODS

Two fellowship-trained surgeons blindly reviewed computerized tomography (CTs) of 10 confirmed NSD patients mixed with 36 healthy controls. All patients were correctly identified, however, 24/36 controls were falsely identified by both surgeons as patients (33.3% specificity), which were grouped as asymptomatic NSD (aNSD), while the remaining controls as non-NSD (healthy). Acoustic rhinometry, rhinomanometry, individual CT-based computational fluid dynamics and nasal sensory testing were applied to address the puzzling questions of why these aNSD had no symptoms and, more fundamentally, what caused symptoms in sNSD patients.

RESULTS

aNSD reported no nasal symptoms - Nasal Obstruction Symptom Evaluation score (sNSD: 60.50 ± 13.00; aNSD: 5.20 ± 5.41; non-NSD: 6.66 ± 7.17, P < .05); 22-item Sino-Nasal Outcome Test score (sNSD: 32.60 ± 14.13; aNSD: 10.04 ± 10.10; non-NSD: 9.08 ± 12.42, P < .001). No significant differences in measured nasal resistance, minimum cross-sectional area (MCA), degree of septal deviation, and nasal airflow distributions were found between sNSD and aNSD groups. Only three variables differentiate sNSD versus aNSD: anterior averaged heat flux on deviated side, inferior turbinate peak heat flux on non-deviated side, and nasal cool sensitivity measured by menthol lateralization threshold, with no significant differences among these variables found between the two healthy groups (aNSD vs. non-NSD). These variables by themselves or combined can differentiate sNSD from controls with higher specificity than the physicians (ROC area under the curve = 0.84 with 70% sensitivity and 91.6% specificity).

CONCLUSIONS

This study sheds light on the potential mechanisms of NSD symptomatology: distorted nasal cooling due to NSD exacerbated by poorer nasal mucosal sensitivity. It further supports our previous hypothesis that nasal obstruction complaints do not result directly from obstruction, rather from the capacity of our nose to subjectively sense airflow cooling.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:509-517, 2022.

Toward automatic atlas-based surgical planning for septoplasty

PURPOSE

Surgery for nasal airway obstruction (NAO) has a high failure rate, with up to 50% of patients reporting persistent symptoms postoperatively. Virtual surgery planning has the potential to improve surgical outcomes, but current manual methods are too labor-intensive to be adopted on a large scale. This manuscript introduces an automatic atlas-based approach for performing virtual septoplasties.

METHODS

A cohort of 47 healthy subjects and 26 NAO patients was investigated. An atlas of healthy nasal geometry was constructed. The automatic virtual septoplasty method consists of a multi-stage registration approach to fit the atlas to a target NAO patient, automatically segment the patient's septum and airway, and deform the patient image to have a non-deviated septum.

RESULTS

Our automatic virtual septoplasty method straightened the septum successfully in 18 out of 26 NAO patients (69% of cases). In these cases, the ratio of the higher to the lower airspace cross-sectional areas in the left and right nasal cavities improved from 1.47 ± 0.45 to 1.16 ± 0.33 in the region surrounding the septal deviation, showing that the nasal airway became more symmetric after virtual septoplasty.

CONCLUSION

This automated virtual septoplasty technique has the potential to greatly reduce the effort required to perform computational fluid dynamics (CFD) analysis of nasal airflow for NAO surgical planning. Future studies are needed to investigate if virtual surgery planning using this method is predictive of subjective symptoms in NAO patients after septoplasty.

Quality of Life in Patients with Nasal Obstruction after Septoplasty: A Single Institution Prospective Observational Study

Introduction  Nasal obstruction is a common symptom in otorhinolaryngological practice. It can impact significantly on the quality of life of the individual. Objective  The primary goal of the present study was to evaluate quality of life after septoplasty in adults with nasal obstruction. A secondary goal was to assess the effectiveness of septoplasty. Methods  This was a single institution prospective observational study. Patients had experienced septal deviation and symptomatic nasal obstruction with no benefit from medical treatment. There were 51 patients who completed the Nasal Obstruction Symptom Evaluation (NOSE-POL) scale as well as theVisual Analogue Scale (VAS) before undergoing septoplasty, 3 months later, and finally 7 months after surgery. Patients evaluated changes in their nasal obstruction and changes in their quality of life using the Clinical Global Impression Scale (CGI-S). Results  There was a significant improvement in nasal obstruction after septoplasty. Before septoplasty, the mean score on NOSE was 60.3 ± 20.4; 3 months after surgery, it was 32.9 ± 16.8; and 7 months after surgery it was 39.6 ± 33.2. The VAS results also proved a significant enhancement in nasal obstruction after septoplasty. Patients reported an improvement in nasal obstruction as well as a positive change in quality of life, confirming the effectiveness of septoplasty. Conclusions  In patients with deformed septum, septoplasty contributes to high satisfaction of the patient and a compelling improvement in disease-specific quality of life. The NOSE-POL questionnaire is a useful tool for measuring the outcomes of this procedure.

Our Septoplasty Results: Evaluation with the Nose Scale

OBJECTIVE

The aim of this study was to evaluate the effectiveness of septoplasty and septoplasty +  bilateral radio frequency ablation of inferior turbinate (b-RFAIT) according to the type of operation, age groups, gender of patients, and the duration of control period by using Nasal Obstruction Symptom Evaluation (NOSE) Scale.

MATERIALS AND METHODS

Prospective observational study was undertaken in the otolaryngology department of a training hospital. Using the NOSE scale, the study prospectively compared the results of septoplasty only and septoplasty with b-RFAIT in the treatment of nasal obstruction caused by the combination of septal deviation and turbinate hypertrophy. Patients were divided into 2 groups. The first group had only septoplasty and the second group had septoplasty with b-RFAIT. General and local anesthesia were applied in both groups. To review clinical success, all patients were controlled at the 1st week, 1st month, and 3rd month.

RESULTS

One hundred seventy-eight adult patients (male/female: 127/51) with chronic nasal obstruction complaint were enrolled in this prospective study. Our data demonstrated significant improvement from baseline after 24 months for the NOSE scores in both the septoplasty and septoplasty + b-RFAIT groups. No statistical difference was noted in the amount of postoperative improvement between the 2 treatment groups (P = 0.306). No significant difference was observed between general and local anesthesia with respect to patients' preop and postop mean scores (P > 0.05). There was a significant difference between the age of patients' postoperative mean (P < 0.001). There were 4 postoperative means with respect to control time. There was an 82.29% decrease in the complaints of patients at 0 to 6 months, 80.51% decrease at 7 to 12months, 76.1% decrease at 13 to 18 months, and 59.67% decrease at 19 to 24 months. Only the last group had a significant difference regarding mean change in scores (P < 0.001).

CONCLUSIONS

This study shows that septoplasty + bilateral turbinate radiofrequency should be applied to patients who suffer from septum deviation with concha hypertrophy. Postoperative NOSE scale shows that the success of operation does not depend on the gender of patients and operation types (general or local anesthesia). We conclude that younger patients (18-40 age) who have obstruction with septal deviation and septum deviation with concha hypertrophy benefit more from operation than older patients do.

Correlation between nasal mucosal temperature change and the perception of nasal patency: a literature review

BACKGROUND

The mechanism of nasal airflow sensation is poorly understood. This study aimed to examine the role of nasal mucosal temperature change in the subjective perception of nasal patency and the methods by which it can be quantified.

METHOD

Medline and PubMed database searches were performed to retrieve literature relevant to the topic.

RESULTS

The primary mechanism producing the sensation of nasal patency is thought to be the activation of transient receptor potential melastatin family member 8 ('TRPM8'), a thermoreceptor that is activated by nasal mucosal cooling. Computational fluid dynamics studies have demonstrated that increased airflow and heat flux are correlated with better patient-reported outcome measure scores. Similarly, physical measurements of the nasal cavity using temperature probes have shown a correlation between lower nasal mucosal temperatures and better patient-reported outcome measure scores.

CONCLUSION

Nasal mucosal temperature change may be correlated with the perception of improved nasal patency. Future research should quantify the impact of mucosal cooling on the perception of nasal airway obstruction.

An Overview of Computational Fluid Dynamics Preoperative Analysis of the Nasal Airway

Evaluation of the nasal airway is crucial for every patient with symptoms of nasal obstruction as well as for every patient with other nasal symptoms. This assessment of the nasal airway comprises clinical examination together with imaging studies, with the correlation between findings of this evaluation and symptoms reported by the patient being based on the experience of the surgeon. Measuring nasal airway resistance or nasal airflow can provide additional data regarding the nasal airway, but the benefit of these objective measurements is limited due to their lack of correlation with patient-reported evaluation of nasal breathing. Computational fluid dynamics (CFD) has emerged as a valuable tool to assess the nasal airway, as it provides objective measurements that correlate with patient-reported evaluation of nasal breathing. CFD is able to evaluate nasal airflow and measure variables such as heat transfer or nasal wall shear stress, which seem to reflect the activity of the nasal trigeminal sensitive endings that provide sensation of nasal breathing. Furthermore, CFD has the unique capacity of making airway analysis of virtual surgery, predicting airflow changes after trial virtual modifications of the nasal airway. Thereby, CFD can assist the surgeon in deciding surgery and selecting the surgical techniques that better address the features of each specific nose. CFD has thus become a trend in nasal airflow assessment, providing reliable results that have been validated for analyzing airflow in the human nasal cavity. All these features make CFD analysis a mainstay in the armamentarium of the nasal surgeon. CFD analysis may become the gold standard for preoperative assessment of the nasal airway.

The Simplified Nasal Septal Deviation Evaluation System and Nasal Obstruction Symptom Evaluation Scale Correlation

Nasal septal deviation (NSD) is a common condition in otorhinolaryngology practice. The aim of this study was to investigate the possible relationship between localization and severity of NSD, and related complaints as well as to suggest a simplified assessment method for NSD. Seventy-five patients who complaint nasal obstruction were enrolled this study. The affected nasal cavity was divided into 4 separate sections as follows: antero-superior (AS), antero-inferior (AI), postero-superior (PS), and postero-inferior (PI). Each section was determined according to its relationship to the both superior edge and head of the inferior turbinate. The NSD score was calculated separately for each section according to its relationship with lateral nasal wall. The NSD-related complaints were assessed via the Nasal Obstruction Symptom Evaluation (NOSE) scale. There were 42 male and 33 female patients, with an age range of 18 to 44 years. The mean NSD score was 2.18 ± 0.63 for AS section, 1.92 ± 0.67 for AI section, 1.54 ± 0.70 for PS section, and 1.18 ± 0.60 for PI section. The mean total NSD score was 6.84 ± 1.97 while the mean NOSE score was 12.5 ± 5.11. There was a strong positive correlation between total NSD and NOSE scores when the NSD score was 6 or more (r = 0.9556). This correlation was also present when each section was evaluated separately. The strongest correlation was detected for AS section deviations. Our septal classification system provides a simple and effective evaluation of NSDs. The NSDs which affect internal valve are more related with nasal obstruction and patients' discomfort.

Factors Predictive of Outcome in Inferior Turbinate Surgery

OBJECTIVES

The purpose of the study was to examine the various preoperative predictive factors of inferior turbinate surgery and to find possible factors that predict an optimal subjective response using 3 common surgical techniques-radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT)-in a randomized, prospective study with a 1-year follow-up.

METHODS

The patients filled a visual analogue scale (VAS) questionnaire regarding the severity of nasal obstruction prior to and 1 year after surgery. A VAS score improvement of 3 points or more was chosen as an optimal subjective response. Univariate and multivariate regressions were used to evaluate the effect of the predictive factors. In total, 80 patients attended a 1-year control visit.

RESULTS

In the multivariate analysis, patients without anterior septal deviation had a statistically significantly higher odds ratio of a satisfactory subjective response compared to patients with anterior septal deviation (5.6; 95% CI: 1.4-23.1; P = .02). Patients treated with RFA had a statistically significantly higher odds ratio of an optimal subjective response compared to patients treated with MAIT (9.0; 95% CI: 1.5-54.2; P = .02).

CONCLUSIONS

Anterior septal deviation seems to decrease the likelihood of an optimal subjective response to inferior turbinate surgery, which supports the consideration of concomitant septoplasty at least in clear cases to optimize the subjective response. Radiofrequency ablation had a significantly higher likelihood of an optimal subjective response compared to MAIT. Further investigations regarding the findings are needed.

Comparison of Quality of Life Before and After Septoplasty With Short Form-36

The authors aimed to evaluate quality of life after septal surgery with Short Form-36 survey, and the effectiveness of the survey. Nasal symptoms (nasal obstruction, facial pain, catarrh), and general quality of life (using the Turkish version of the Short Form-36 questionnaire) were assessed preoperatively and at 1st and 6th postoperative months. Acoustic rhinometry and rhinomanometry were assessed preoperatively and at 6th postoperative month. Data from 78 patients were analyzed. This prospective clinical study was conducted on patients complaining of nasal obstruction with nasal septal deviation. Seventy-eight patients were included in the study. Fourty-two patients (53.8%) were male and 36 patients (46.2%) were female. At 1st postoperative month, nasal obstruction, facial pain and catarrh scores significantly improved in all, 46, 18 patients, respectively (P < 0.0001). At 6th postoperative month, scores nonsignificantly worsened by 1 point in 12, 6, 12 patients, respectively. Nasal volume significantly increased and total resistance significantly decreased at 6th month (P < 0.0001). Compared to preoperative values, all items except social function and bodily pain significantly increased at 1st postoperative month. Compared to values at 1st postoperative month, only bodily pain score decreased at 6th postoperative month. One patient presented with septal perforation. Septoplasty is a well-established technique to reduce nasal obstruction and improve quality of life. SF-36 may be used as a reliable measure of changes in quality of life after septal surgery.

Rhinomanometry Versus Computational Fluid Dynamics: Correlated, but Different Techniques

BACKGROUND

Past studies reported a low correlation between rhinomanometry and computational fluid dynamics (CFD), but the source of the discrepancy was unclear. Low correlation or lack of correlation has also been reported between subjective and objective measures of nasal patency.

OBJECTIVE

This study investigates (1) the correlation and agreement between nasal resistance derived from CFD (R_CFD) and rhinomanometry (R_RMN), and (2) the correlation between objective and subjective measures of nasal patency.

METHODS

Twenty-five patients with nasal obstruction underwent anterior rhinomanometry before and after mucosal decongestion with oxymetazoline. Subjective nasal patency was assessed with a 0-10 visual analog scale (VAS). CFD simulations were performed based on computed tomography scans obtained after mucosal decongestion. To validate the CFD methods, nasal resistance was measured in vitro (R_EXPERIMENT) by performing pressure-flow experiments in anatomically accurate plastic nasal replicas from 6 individuals.

RESULTS

Mucosal decongestion was associated with a reduction in bilateral nasal resistance (0.34 ± 0.23 Pa.s/ml to 0.19 ± 0.24 Pa.s/ml, p = 0.003) and improved sensation of nasal airflow (bilateral VAS decreased from 5.2 ± 1.9 to 2.6 ± 1.9, p < 0.001). A statistically significant correlation was found between VAS in the most obstructed cavity and unilateral airflow before and after mucosal decongestion (r = -0.42, p = 0.003). Excellent correlation was found between R_CFD and R_EXPERIMENT (r = 0.96, p < 0.001) with good agreement between the numerical and in vitro values (R_CFD/R_EXPERIMENT = 0.93 ± 0.08). A weak correlation was found between R_CFD and R_RMN (r = 0.41, p = 0.003) with CFD underpredicting nasal resistance derived from rhinomanometry (R_CFD/R_RMN = 0.65 ± 0.63). A stronger correlation was found when unilateral airflow at a pressure drop of 75 Pa was used to compare CFD with rhinomanometry (r = 0.76, p < 0.001).

CONCLUSION

CFD and rhinomanometry are moderately correlated, but CFD underpredicts nasal resistance measured in vivo due in part to the assumption of rigid nasal walls. Our results confirm previous reports that subjective nasal patency correlates better with unilateral than with bilateral measurements and in the context of an intervention.

Side asymmetry in nasal resistance correlate with nasal obstruction severity in patients with septal deformities: Computational fluid dynamics study

OBJECTIVES

The objective of this study was to investigate the relationship between side asymmetry in nasal resistance (NR) and severity of the nasal airway obstruction (NAO) in patients with different types of nasal septal deformity (NSD).

DESIGN

Computational fluid dynamics (CFD) study.

SETTING

The study was conducted in a tertiary medical centre.

PARTICIPANTS

The study included 232 patients, who were referred to the CT examination of the paranasal sinuses. Exclusion criteria were sinonasal and respiratory diseases that may interfere with the nasal obstruction. The presence and the type of NSD were recorded according to the Mladina's classification.

MAIN OUTCOME MEASURES

The presence and severity of NAO in each patient were assessed by NOSE questionnaire. Eight computational models of the nasal cavity were created from CT scans. Models represented seven Mladina's NSD types and a straight septum of a symptomless patient. CFD calculated airflow partitioning and NR for each nasal passage. Side differences in NR were calculated by the equation ∆NR = NR_left  - NR_right . The relationship between NOSE scores, airflow partitioning and side differences in NR was explored using Spearman's correlation analysis.

RESULTS

Mladina's types of NSD showed differences in airflow partitioning and the degree of side asymmetry in NR. A significant positive correlation was detected between side differences in NR and NOSE scores (R = .762, P = .028). A significant negative correlation was found between the per cent of unilateral airflow and NR (R = -.524, P = .037).

CONCLUSIONS

Our results demonstrated that side asymmetry in NR could explain differences in NAO severity related to the NSD type.

Comparison of visual analogue scale (VAS) and the Nasal Obstruction Symptom Evaluation (NOSE) score in evaluation of post septoplasty patients

Objective

To compare and correlate the efficacy of the NOSE score & the VAS score in determining the symptomatic benefit in patients undergoing septoplasty.

Materials and methods

Eighty patients with deviated nasal septum undergoing septoplasty were included in the study. NOSE score & VAS score (out of 100) was documented before and after surgery. Results were correlated and compared statistically.

Results

In the NOSE score, the most bothersome symptom was trouble breathing through the nose (85.83); followed by Nasal obstruction or blockage (82.50). Wilcoxon test showed significant improvement with NOSE score and VAS score in all patients at 1 month and 3 months. Spearman's coefficient showed a positive correlation between the two, though the score improvement and patient satisfaction rate was significantly high with NOSE score.

Conclusions

NOSE score and the VAS score both provide effective framework for evaluating treatment responses after septoplasty. However, the NOSE score showed higher improvement and better patient satisfaction rate when used to measure of nasal obstruction as compared to the VAS score.

Complication Rates Following Septoplasty With Inferior Turbinate Reduction

Background: Septoplasty with submucous resection of the inferior turbinate (SMRT) is a common correctional surgery performed in patients with deviated nasal septum resulting in nasal obstruction. Although complications are infrequent, studies examining long-term complications following septoplasty with SMRT are rare.

Methods: We conducted a retrospective review of patients electing to undergo septoplasty with SMRT at a tertiary rhinology clinic from January 2007 to December 2015. Demographic data, intraoperative findings, duration of follow-up, and short-term and long-term complications were collected. Exclusion criteria included patients who underwent either septoplasty or turbinate reduction or any other nasal surgery, patients lost to follow-up within 1 year, and patients with incomplete medical records.

Results: A total of 359 patients met inclusion criteria. The majority were males (66.6%), and the average age of the cohort was 36.8 ± 12.3 years. The mean follow-up time was 23.3 months. Short-term complications were postoperative infection (n=12, 3.3%) and epistaxis that required intervention (n=16, 4.5%). Long-term complications occurred in 10 patients (2.8%): revision septoplasty (n=9, 2.5%) and hyposmia (n=1, 0.3%). No instances of synechiae, septal perforation, or saddle nose deformity occurred.

Conclusion: Long-term complications following septoplasty with SMRT are infrequent. The most common long-term complication in this cohort was revision septoplasty.

Is Computed Tomography Imaging of Deviated Nasal Septum Justified for Obstruction Confirmation?

Third-party payers request objective confirmation of the nasal septum deviation (NSD) severity by computed tomography (CT) before authorizing financial support for septoplasty. Previous studies have provided contradictory results related to the link between obstruction severity and CT-measured angle of the NSD. The aim of this study was to investigate whether the diverse CT morphology of NSDs (including previously neglected types and shapes) could predict obstruction severity. The study included 225 patients with NSD. The CT morphology of the septum was analyzed using 5 different classifications of NSD that are commonly used in the clinical practice and research. The angle of NSD was also measured. Nasal obstruction was assessed by the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. A relationship between CT morphology and the angle of the NSD and NOSE scores was analyzed using appropriate regression models. Patients with NSDs located in the anterior part of the septum always have some degree of nasal obstruction, while those with posterior NSDs did not necessarily report obstruction symptoms no matter how complicated NSD they have. Regression analysis did not reveal any causal relationship between NOSE scores and CT morphology and the angle of NSD. The presence of spurs and whether they divide nasal passages have no statistically significant predictive effect on the obstruction severity. The CT morphology and the angle of the NSD could not predict severity of the nasal obstruction. Requesting CT examination just to objectively confirm nasal obstruction is not justified.

Virtual Surgery for the Nasal Airway: A Preliminary Report on Decision Support and Technology Acceptance

Importance

Nasal airway obstruction (NAO) is a common problem that affects patient quality of life. Surgical success for NAO correction is variable. Virtual surgery planning via computational fluid dynamics (CFD) has the potential to improve the success rates of NAO surgery.

Objective

To elicit surgeon feedback of a virtual surgery planning tool for NAO and to determine if this tool affects surgeon decision making.

Design, Setting, and Participants

For this cross-sectional study, 60-minute face-to-face interviews with board-certified otolaryngologists were conducted at a single academic otolaryngology department from September 16, 2016, through October 7, 2016. Virtual surgery methods were introduced, and surgeons were able to interact with the virtual surgery planning tool interface. Surgeons were provided with a patient case of NAO, and open feedback of the platform was obtained, with emphasis on surgical decision making.

Main Outcomes and Measures

Likert scale responses and qualitative feedback were collected for the virtual surgery planning tool and its influence on surgeon decision making.

Results

Our 9 study participants were all male, board-certified otolaryngologists with a mean (range) 15 (4-28) number of years in practice and a mean (range) number of nasal surgeries per month at 2.2 (0.0-6.0). When examined on a scale of 1 (not at all) to 5 (completely), surgeon mean (SD) score was 3.4 (0.5) for how realistic the virtual models were compared with actual surgery. On the same scale, when asked how much the virtual surgery planning tool changed surgeon decision making, mean (SD) score was 2.6 (1.6). On a scale of 1 (strongly disagree) to 7 (strongly agree), surgeon scores for perceived usefulness of the technology and attitude toward using it were 5.1 (1.1) and 5.7 (0.9), respectively.

Conclusions and Relevance

Our study shows positive surgeon experience with a virtual surgery planning tool for NAO based on CFD simulations. Surgeons felt that future applications and areas of study of the virtual surgery planning tool include its potential role for patient counseling, selecting appropriate surgical candidates, and identifying which anatomical structures should be targeted for surgical correction.

Level of Evidence

NA.

Comparison of Airflow Between Spreader Grafts and Butterfly Grafts Using Computational Flow Dynamics in a Cadaveric Model

Importance

Nasal valve compromise is a major cause of nasal obstruction, and multiple methods have been developed to address it.

Objective

To compare nasal airflow resistance, airflow partitioning, and mucosal cooling (heat flux) before and after 2 surgical interventions, butterfly and spreader graft placement, used to treat nasal valve compromise.

Design, Setting, and Participants

In this cadaveric tissue study, 4 fresh cadaveric heads underwent both spreader graft and butterfly graft surgical procedures in alternating sequence in March 2016. Preoperative and postoperative computed tomographic scans were used to generate 3-dimensional (3-D) models of the nasal airway. These models were then used in steady state computational fluid dynamics simulations of airflow and heat transfer during inspiration.

Intervention

Butterfly and spreader graft techniques.

Main Outcomes and Measures

Nasal airflow resistance, airflow partitioning, and heat flux.

Results

Donors 1, 2, and 3 were white males; donor 4, a white female. Computational fluid dynamics simulations during inspiration in 3-D models generated from preoperative and postoperative computed tomographic scans of the 4 cadaveric heads indicated reductions from preoperative values in nasal airflow resistance associated with both butterfly grafts (range, 20%-51%) and spreader grafts (range, 2%-29%). Butterfly grafts were associated with a greater reduction in nasal airflow resistance in models of all 4 cadaveric heads. Changes from preoperative values for heat flux, a biophysical variable that correlates with the subjective sensation of nasal patency, were more variable, ranging from -11% to 4% following butterfly grafts and -9% to 10% following spreader grafts. The preoperative airflow allocation in the left and right nostrils improved consistently with the butterfly graft. With the spreader graft, there were improvements for donors 1 and 4, but the allocations were worse for donors 2 and 3.

Conclusions and Relevance

The results of this study suggest that the more recently developed butterfly graft technique may be associated with a similar level of improved nasal airflow as that observed with the use of a spreader graft in nasal valve compromise. Both interventions were associated with comparable changes in heat flux. Because this study addressed only static internal nasal valve stenosis, even greater differences in air flow and heat flux between the 2 techniques may be anticipated in a dynamic model. Further investigation in patients is warranted.

Level of Evidence

NA.

Use of Neutrophil, Eosinophil, Basophil, and Platelet to Lymphocyte Ratio to Predict Patient Satisfaction After Septoplasty Plus Inferior Turbinate Reduction

AIM

Investigation of the predictive value of neutrophil, platelet, eosinophil, and basophil to lymphocyte ratio (NLR, PLR, ELR, and BLR) in evaluation of patients' satisfaction of septoplasty + inferior turbinate reduction operations.

PATIENTS AND METHODS

Seventy-six patients who were operated because of nasal obstruction were enrolled in the study. They were invited to the hospital and asked to answer a modified nasal obstruction symptom evaluation (NOSE) survey to determine their degree of satisfaction. Patients were divided into 2 groups according to their modified NOSE survey results, dissatisfied and satisfied groups. The 2 groups were compared in terms of demographic data, surgery, and hematological values. In addition, correlation analysis was performed between NLR, PLR, ELR, BLR, and modified NOSE scores.

RESULTS

There were 29 patients in the dissatisfied group and 47 patients in the satisfied group. Both groups were similar in terms of mean age, gender, surgery type, septal deviation type, smoking, hemoglobin, neutrophil, and white blood count (P > 0.05). There were significant differences between the 2 groups in terms of ELR and BLR (P < 0.05). In addition, there were negative and statistically significant correlations between modified NOSE scores and ELR and BLR. As ELR and BLR values increased, the satisfaction rate decreased.

CONCLUSION

Eosinophil to lymphocyte ratio and BLR could be used to predict patient satisfaction after septoplasty and inferior turbinate reduction and for selection of patients.

Comparison of Olfactory Function and Quality of Life With Different Surgical Techniques for Nasal Septum Deviation

OBJECTIVE

To assess the nasal functions, nasal resistance, olfactory function, and quality of life in different surgical techniques for nasal septum deviation STUDY DESIGN:: Randomized controlled trial.

METHODS

This prospective controlled study was carried out on patients who underwent septoplasty. Patients participating in the study were divided into 2 groups; group 1: classic septoplasty (n: 25) and group 2: extracorporeal septoplasty (n: 14). The sinonasal outcome test-22 (SNOT-22), peak nasal flowmetry, and Connecticut Chemosensory Clinical Research Center test were applied to all patients before and 8 weeks after surgery. Surgical outcomes also assessed to evaluate complications 6 months after surgery.

RESULT

In total, 39 (27 males, 12 females) patients diagnosed with nasal septum deviation were included in this study. A septoplasty was performed in all patients: 25 of them (18 males, 7 females; mean age = 29.4 [range, 23-50] years) underwent classic septoplasties and 14 (9 males, 5 females; mean age = 31.3 [range, 23-50] years) underwent extracorporeal septoplasties. Airway openness was achieved in all patients. As a result, the SNOT-22 scores, peak nasal inspiratory flowmeter results, and smell function scores showed significant improvements (P < 0.001).

CONCLUSION

All corrective surgical methods for a septum deviation have positive effects on nasal airflow, quality of life, and olfaction. The rates of complications were not significantly different between 2 treatment groups.

Normative ranges of nasal airflow variables in healthy adults

PURPOSE

Virtual surgery planning based on computational fluid dynamics (CFD) simulations of nasal airflow has the potential to improve surgical outcomes for patients with nasal airway obstruction (NAO). Virtual surgery planning requires normative ranges of airflow variables, but few studies to date have quantified inter-individual variability of nasal airflow among healthy subjects. This study reports CFD simulations of nasal airflow in 47 healthy adults.

METHODS

Anatomically accurate three-dimensional nasal models were reconstructed from cone beam computed tomography scans and used for steady-state inspiratory airflow simulations with a bilateral flowrate of 250 ml/s. Normal subjective sensation of nasal patency was confirmed using the nasal obstruction symptom evaluation and visual analog scale. Healthy ranges for several CFD variables known to correlate with subjective nasal patency were computed, including unilateral airflow, nasal resistance, airspace minimal cross-sectional area (mCSA), heat flux (HF), and surface area stimulated by mucosal cooling (defined as the area where HF > 50 W/m²). The normative ranges were targeted to contain 95% of the healthy population and computed using a nonparametric method based on order statistics.

RESULTS

A wide range of inter-individual variability in nasal airflow was observed among healthy subjects. Unilateral airflow varied from 60 to 191 ml/s, airflow partitioning ranged from 23.8 to 76.2%, and unilateral mCSA varied from 0.24 to 1.21 cm². These ranges are in good agreement with rhinomanometry and acoustic rhinometry data from the literature. A key innovation of this study are the normative ranges of flow variables associated with mucosal cooling, which recent research suggests is the primary physiological mechanism of nasal airflow sensation. Unilateral HF ranged from 94 to 281 W/m², while the surface area stimulated by cooling ranged from 27.4 to 64.3 cm².

CONCLUSIONS

These normative ranges may serve as targets in future virtual surgery planning for patients with NAO.

A new technique of revision septoplasty using semi-penetrating straight and circular incisions of the nasal septum

OBJECTIVE

This study aimed to investigate endoscopic revision septoplasty with semi-penetrating straight and circular incisions in patients for whom septoplasty was unsuccessful.

METHOD

Patients in this study (n = 14) had a deviation of the nasal septum after septoplasty. Pre-operative and post-operative assessments were performed using a visual analogue scale and nasal endoscope. Semi-penetrating straight and circular incisions in front of the caudal septum and at the margin of the nasal septal cartilage-bone defect, respectively, were made. The mucoperichondrium and mucoperiosteum were bilaterally dissected until interlinkage with the cartilage-bone defect was achieved. Mucous membranes within the circular incision as well as the right mucoperichondrium and mucoperiosteal flaps were protected by pushing them to the right. This exposed the osteocartilaginous framework and allowed correction of the residual deviation. The patients were followed up for 30-71 months.

RESULTS

For nasal obstruction and headaches, a significant improvement was noted in post-operative compared to pre-operative visual analogue scale scores. No patients had septal deviations, saddle nose, false hump nose or contracture of the nasal columella.

CONCLUSION

The technique allowed exposure of the septal osteocartilaginous framework and a broad operational vision, which enabled successful correction of various deformities of the nasal septum.

Prognostic factors for outcome after septoplasty in 888 patients from the Swedish National Septoplasty Register

BACKGROUND

The aim of this study was to identify predictors of outcome after septoplasty in 888 patients from the Swedish National Septoplasty Register.

METHODOLOGY

This is an observational register study analysing data from patients undergoing septoplasty in Sweden between 2015 and 2016. The patients reported severity of nasal obstruction (mild, moderate, severe) pre- and again 12 months postoperatively (none, mild, moderate, severe), unplanned visits within 30 days after surgery. The examining doctor reported co-morbidities such as allergic rhinitis and snoring. The primary end-point was one level improvement of the nasal obstruction 12 months after surgery.

RESULTS

Nasal obstruction had improved in 63% 12 months after surgery. Twelve months after surgery, 81% with severe nasal obstruction and 31% with mild nasal obstruction before surgery had improved. Only 56% reported that the results of the surgery were as they had expected. Higher patient age at surgery, no unplanned visits within 1 month of surgery and activity limitation before surgery were associated with improvements in nasal breathing in the logistic regression model.

CONCLUSION

Septoplasty should be offered to patients with severe nasal obstruction and surgery should be avoided in mild nasal obstruction confirmed by both an improvement in nasal obstruction and patient expectations in this study.

Assessment of non-response in quality control of nasal septal surgery

OBJECTIVE

This study evaluated the effect of mail non-response on the validity of the results of nasal septal surgery.

METHOD

Six months post-operatively, questionnaires with both prospective and retrospective ratings were mailed to patients. Patients who did not respond (non-responders) were contacted by telephone. This study compared two cohorts of patients using different interviewers (a nurse and a surgeon). Cohort one consisted of 182 patients (with 67 per cent mail response), and cohort two consisted of 454 patients (with 64.8 per cent mail response).

RESULTS

In both cohorts, the improvement in obstruction scores was significantly better among mail responders than among non-responders (telephone interviewees) using prospective ratings, but worse using retrospective ratings.

CONCLUSION

Mail responders had better improvement in nasal obstruction after septoplasty than non-responders. Therefore, low response rates may cause an overestimation of the results. The retrospective ratings obtained through telephone interviews are less reliable because they are influenced by memory and the patients' tendency to give socially acceptable answers.

A prospective, non-randomized evaluation of a novel low energy radiofrequency treatment for nasal obstruction and snoring

Background

Weak or inward-bent cartilage of the nasal sidewall at the level of the internal nasal valve (INV) can produce narrowness or collapse of the nasal valve. This is a common cause of impaired nasal breathing during daily activities and there is also an established connection between nasal obstruction and snoring. The condition is often difficult to treat, although even a small enlargement of the lumen at the nasal valve can lead to a significant improvement in the ease of nasal breathing.

Methods

The primary objective of this prospective study was to evaluate the safety and efficacy of the Vivaer system for the treatment of narrowed nasal valves and to measure changes in the symptoms of nasal obstruction and snoring. The Vivaer system uses low energy radiofrequency to remodel the nasal sidewall in order to improve airflow.

Results

The study involved 31 patients presenting from 1st September 2017 to 1st May 2018 with symptoms of nasal obstruction and snoring. In all patients, an improvement was observed in nasal breathing measured by NOSE score, sleep quality by SOS questionnaire and quality of life as measured by EQ-5D and SNOT-22.

Conclusion

Vivaer intranasal remodeling can provide a durable and well-tolerated non-invasive treatment for those patients who are suffering congestion due to narrowness or collapse of the INV.

Common Sites, Etiology, and Solutions of Persistent Septal Deviation in Revision Septoplasty

OBJECTIVES

To investigate the common causes of persistent septal deviation in revision septoplasty and to report the surgical techniques and results to correct them.

METHODS

A total of 100 consecutive patients (86 males) who had revision septoplasty due to persistent septal deviation from 2008 and 2014 were included in the study. Their mean age was 35.6 years and the mean follow-up duration was 9.1 months. Presenting symptoms, sites of persistent septal deviation, techniques used to correct the deviation, and surgical results were reviewed.

RESULTS

The mean interval between primary and revision surgery was 6.2 years. Forty-eight patients received revision septoplasty and 52 received revision septoplasty combined with rhinoplasty. Nasal obstruction was the most presenting symptom in almost all patients. The most common site of persistent septal deviation was middle septum (58%) followed by caudal septum (31%). Correcting techniques included further chondrotomy and excision of deviated portion in 76% and caudal batten graft in 39%. Rhinoscopic and endoscopic exams showed straight septum in 97% and 92 patients had subjective symptom improvement postoperatively.

CONCLUSION

Middle septum and caudal septum were common sites of persistent deviation. Proper chondrotomy with excision of deviated middle septum and correction of the caudal deviation with batten graft are key maneuvers to treat persistent deviation.

A CFD approach to understand nasoseptal perforations

INTRODUCTION

Nasoseptal perforations (NSP) are becoming common in the modern world, and can cause a wide variety of symptoms, including a sensation of nasal obstruction, epistaxis, crusting, dryness, headache, nasal pain and a whistling sound. There is an extensive range of surgical treatment techniques, but reported results were rarely statistically significant. The lack of consistent surgical results may be related to the lack of knowledge about the pathophysiology of NSP and how they affect the nasal flow. Computational fluid dynamics (CFD) has proved to be a very useful tool to study nasal function.

METHODS

We have used CFD software (the program MECOMLAND® and the Digbody® tool for virtual surgery) to investigate the behaviour of the parameters R-[Formula: see text] based on CFD results, when four subjects underwent virtual surgery to induce a septal perforation: two subjects with healthy noses and two patients suffering from nasal airway obstruction. For each case a CFD study was performed, before and after creating an anterior (close to nostrils) or a posterior (close to choanae) NSP.

RESULTS

In all cases analyzed, a posterior septal perforation did not result in a significant volumetric flow rate [Formula: see text] through the perforation between nasal passages. However, for anterior defects only in those nasal cavities considered diseased or unhealthy, high values of [Formula: see text] were found.

CONCLUSION

The induced NSP only rendered significant flow alterations in noses with preexisting nasal airway obstruction alterations, whereas in nasal cavities considered as normal the creation of a NSP did not produce significant differences between both sides. We strongly suggest that this finding can explain the variety of symptoms and the number of asymptomatic patients bearing NSP.

The Four Components of the Nasal Valve

The nasal valve consists of four distinct airflow-resistive components. (i) The vestibule terminates in an airflow-resistive aperture between the septum and the caudal end of the upper lateral cartilage. Its cross-sectional area is stabilized by the cartilaginous structures and by inspiratory isometric contractions of alar dilator muscles. Its walls are devoid of erectile tissues that might otherwise affect its cross-sectional area and airflow resistance. By contrast, (ii) the bony entrance to the cavum is occupied by erectile tissues of both (iii) lateral (turbinate) and (iv) septal nasal walls that modulate the cross-sectional area of the airway and airflow resistance. The body of the cavum offers little resistance to airflow. Valve constrictions induce “orifice flow” of inspiratory air as it enters the body of the cavum, disrupting laminar characteristics and thereby enhancing exchanges with the nasal mucosa of heat, water, and contaminants. Acoustic rhinometric and rhinomanometric measurements show the sites, dimensions, and resistances of the valve constrictions and indicate that it is seldom necessary to extend septal and/or turbinate surgery far beyond the piriform aperture in the treatment of nasal obstruction.

Long-Term Evaluation of Nasal Septoplasty Followed by Inferior Turbinate Cauterization for the Treatment of Nasal Obstruction using Objective and Subjective Methods

Introduction  Nasal septoplasty is considered the treatment of choice for nasal obstruction due to septal deviation. An ongoing discussion among rhinologists is whether it is reasonable to perform objective measurements of nasal patency pre or postoperatively routinely.

Objective  The primary aim of this study was to identify the short- and long-term functional benefits for patients undergoing septal surgery, as assessed by acoustic rhinometry (AR). The secondary goal was to evaluate the short- and long-term perception of symptom relief and disease-specific quality of life (QoL) outcomes on the part of the patients.

Methods  This was a prospective observational study in which AR was utilized for the assessment of nasal patency preoperatively and 1, 6 and 36 months after septoplasty. Total 40 patients who underwent septoplasty filled out the Nasal Obstruction Septoplasty Effectiveness (NOSE) questionnaire and the Glasgow Benefit Inventory (GBI) to assess their subjective improvement in nasal obstruction symptoms and the changes in their QoL.

Results  There were statistically significant improvements in nasal patency, mean postoperative NOSE and GBI scores postoperatively. However, there was no correlation between the mean NOSE and GBI scores and the AR measurements. Furthermore, the GBI scores tended to decrease as the postoperative period increased.

Conclusion  The present study confirms that septoplasty significantly increases nasal patency and causes a significant subjective improvement in nasal obstruction symptoms. The absence of a statistically significant correlation among the objective measurements, the symptom scores, and the patients' low GBI scores indicates that factors other than the anatomical findings may also contribute to the patients' perception of QoL.

Long-term patient-related outcome measures of septoplasty: a systematic review

PURPOSE

Septoplasty is a common rhinological procedure intended to relieve symptoms of chronic nasal obstruction. However, there remains a question as to whether patients obtain symptom improvement and are satisfied with surgical outcomes in the months and years after septoplasty. This review aims to evaluate the long-term efficacy of functional septoplasty for nasal septal deviation.

METHODS

A systematic review of the literature was conducted from November 2014 to March 2016 using the Cochrane, EMBASE, and PubMed databases. Prospective trials concerning functional septoplasty, which assessed subjective outcomes and included long-term follow-up data (≥ 9 month post-septoplasty) were included.

RESULTS

2189 articles were screened with seven meeting the criteria for inclusion. Patient satisfaction was assessed in six studies, with rates of satisfaction provided in three of these, ranging from 69 to 100%. Two studies assessed the degree of patient satisfaction, with one study indicating that 88% of patients were moderately satisfied or better at 1 year post-op, and the other reporting that 50% of patients were satisfied. In assessing symptom relief, several methods were used, including validated questionnaires, with varying degrees of improvement in nasal obstruction reported.

CONCLUSIONS

Septoplasty appears to be a far from perfect treatment for nasal obstruction due to septal deviation. However, given the heterogeneity of data and lack of randomized controlled trials (RCTs), future RCTs and use of validated questionnaires would enable generation of superior levels of evidence. We suggest future prospective trials evaluating prognostic factors in septoplasty, to better inform patients and facilitate the development of guidelines for surgical intervention.

Age and Unplanned Postoperative Visits Predict Outcome after Septoplasty: A National Swedish Register Study

Objective

To study predictors of symptom relief six months after septoplasty using data from the Swedish National Septoplasty Register.

Participants

This is a retrospective register study of adult patients undergoing septoplasty in Sweden in 2003–2012.

Outcome

Relief of nasal symptoms was analysed in relation to age, gender, size of hospital performing the surgery, addition of turbinoplasty, and unplanned postoperative visits to the hospital due to pain, bleeding, or infection.

Results

In all, 76% of the patients (n = 5,865) rated their symptoms as “almost gone” or “gone” six months after septoplasty. With every 10-year increase in the age of the patients, the OR was 1.19, 95% CI 1.15–1.23, for a better result and 1.54, 95% CI 1.38–1.71, if the septoplasty was performed at a county hospital versus a university hospital. If there was no unplanned postoperative visit due to pain, bleeding, or infection, the OR for a better result was 1.6, 95% CI 1.39–1.85.

Conclusion

In this large national cohort of septoplasties, most of the patients felt that their symptoms had gone or almost gone six months after septoplasty. Higher age, surgery at smaller hospitals, and no unplanned visits to the hospital postoperatively predicted a better outcome.

Outcomes of septorhinoplasty: a new approach comparing functional and aesthetic results

The aim of this study was to compare objective and subjective functional results of septorhinoplasty with subjective aesthetic results. A prospective study was performed including global and subgroup analyses (primary versus secondary septorhinoplasty). Three instruments were used to evaluate pre- and postoperative results: rhinomanometry for the objective functional analysis, the Nasal Symptom Obstruction Evaluation (NOSE) scale for the subjective functional analysis, and the Rhinoplasty Outcome Evaluation (ROE) scale for the subjective aesthetic analysis. A septorhinoplasty was performed in all cases. Thirty-five patients were included (22 female), of whom 74% underwent primary septorhinoplasty. The correlation between rhinomanometry, NOSE and ROE scores was analysed. Mean resistance of the two nasal cavities was 4.9 (standard deviation (SD) 8.35) sPa/ml before surgery and 0.8 (SD 0.7) sPa/ml after surgery. NOSE and ROE scores were, respectively, 72.5/100 (SD 21.7) and 7.5/24 (SD 11.3) before surgery and 22/100 (SD 20.6) and 18/24 (SD 17.3) after surgery. Patients complaining of postoperative nasal obstruction had a worse aesthetic evaluation. Correction of the functional disease appears to be as important as aesthetic correction. This study comparing functional and aesthetic results after septorhinoplasty could provide a basis for future studies.