A prospective cohort study assessing the clinical utility of the Cottle maneuver in nasal septal surgery

Süreyya-Dani technique, a new technique to address notching of soft triangle and opening external nasal valve

Introduction

While different methods are employed for fixing narrowed nasal valves and preventing the notching of soft triangles, this study aims to demonstrate the effectiveness of a new technique called Süreyya-Dani Technique.

Methods

This prospective study composed 100 patients who underwent rhinoplasty using the Süreyya-Dani technique. All patients presented with either notching of the soft triangle and/or external nasal valve dysfunction. Patients with the absence of soft triangle notching and external nasal valve dysfunction were excluded from this study. Facial analysis was conducted for all patients to identify any asymmetry in the face, and all nasal defects were identified. Descriptive statistics were calculated for different variables. Analytical statistics, namely Chi-Square test, was conducted with a significance level set at P < 0.05.

Results

In the current study, 100 patients were involved, out of which 63 (63%) were female and 37 (37%) were male. The participants' ages ranged from 18 to 46 years, with a mean age of 30 years. various chief complaints were found among patients, with the majority 37(37%) expressing cosmetic concerns. A statistically significant difference was found for the association of nasal tip defects with genders, intraoperative findings, and chef complaints, and the association between the degree of external valve insufficiency and crural weakness (P-value < 0.05).

Conclusion

Despite many techniques that have been put forward to fix narrowed nasal valves and prevent notching of the soft triangle, the Süreyya-Dani Technique could work to prevent its occurrence successfully.

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.

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.

Efficacy of Septoplasty in Patients with Nasal Obstruction: A Systematic Review and Meta-analysis

OBJECTIVE

Septoplasty is the most frequently performed ENT surgery to correct nasal septal deviation (NSD). The present study aimed to quantify the effectiveness of septoplasty with or without turbinate surgery according to NOSE questionnaire scores, with the hypothesis that it is able to clinically improve patient-reported nasal obstructive symptoms in the post-operative follow-up.

METHODS

An electronic search was performed on PubMed/MEDLINE, Embase, and Cochrane Library. The primary outcome was the change in NOSE score at 6 months after surgery. It was assessed with the mean difference (MD) between baseline and postoperative results.

RESULTS

A total of 2577 patients (males: 65.1%, 95% CI: 59.9-70.2) with a mean age of 33.3 years (n = 1456, 95% CI: 30.4-36.2) were included in this meta-analysis. The pooled baseline NOSE mean score was 68.1 (n = 2577, 95% CI: 64.3-71.9). The pooled MD in NOSE score at 6-months follow-up compared to baseline was -48.8 (n = 1730, 95% CI: -54.6 to -42.9).

CONCLUSIONS

Functional septoplasty with or without turbinate surgery shows a critical improvement of obstructive symptoms and quality of life according to the validated NOSE score.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:3237-3246, 2023.

A Comparison of Symptom Improvement and Outcomes After Septoplasty Alone Versus Septoplasty With Turbinoplasty

Background Various causes can lead to nasal obstruction, with the most frequent anatomical cause being deviated nasal septum. It seriously affects patients' quality of life. As a result, septoplasty is performed to enhance the nasal airways. This study aimed to compare the improvement of nasal symptoms following septoplasty with or without turbinoplasty and evaluate the surgical outcomes in both different groups. Methodology A retrospective study was conducted at a tertiary hospital among patients who had undergone septoplasty with or without turbinoplasty between 2020 and 2022. Data regarding demographics, clinical features, surgical data, and complications were collected from patient files. The Nasal Obstruction Symptom Evaluation (NOSE) scale score was assessed through structured interviews. Results In our analysis of 209 patients who underwent surgery for deviated nasal septum, septoplasty was done in 110 (52.6%) patients, whereas the remaining 99 (47.4%) underwent septoplasty with turbinoplasty. The mean NOSE score was found to be 32.94 ± 35.67%. Patients who underwent septoplasty alone significantly showed higher mean scores (56.36 ± 34.62%) compared to those who underwent septoplasty with turbinoplasty (11.14 ± 18.93%) (p < 0.001). The long-term complications showed revision surgery was done in 13 patients, which was comparatively more often done in patients who underwent a septoplasty. Other long-term complications were found to be significantly higher in patients who underwent septoplasty (76.9%) compared to those who underwent septoplasty with turbinoplasty (23.1%). Conclusions Patients who underwent additional turbinoplasty experienced an improvement in nasal symptoms than those who underwent septoplasty alone. In addition, more long-term complications were noted in patients who underwent septoplasty alone.

The Use of Infrared Thermal Imaging to Determine Functional Nasal Adequacy: A Pilot Study

Objective

The goal of this study was to establish a numeric threshold to separate functional from substantially obstructed noses using comparisons of thermal imaging and subjective scores.

Study Design

An inexpensive smartphone application and hardware attachment that uses infrared thermal imaging was tested to differentiate between substantial nasal blockage from an adequately functioning nose.

Setting

Sequential adult participants who presented to a public hospital otolaryngology clinic between June and August 2018 were asked to complete the Nasal Obstruction Symptom Evaluation (NOSE) tool.

Methods

A thermal video imaging device was used to record the difference in temperature (ΔT) between inspired (I) and expired (E) air at each nostril. The nostril ΔT between I and E air of patients with severe obstruction by the subjective measure (NOSE score) was compared with that of patients with minimal symptoms.

Results

A total of 26 participants were enrolled in the study. During normal respiration, Total ΔT for the nonobstructed group had a mean of 9.0, whereas the Total ΔT for the obstructed group had a mean of 7.69, a 17% difference that was statistically significant at P = .045. For the worst-performing nostril tested, ΔT for the nonobstructed group had a mean/median of 4°C, while the obstructed group had a mean of 3.23°C (median 3; 23.8% difference, P = .023).

Conclusion

Measures of thermal imaging, particularly at the threshold between the median scores of the worst-performing nostril, may be a useful clinical test to differentiate between a substantially obstructed nose from an adequately functioning nose, although more data are required.

The relationship between the Ottawa Valve Collapse Scale (OVCS) and clinical outcomes in septoplasty patients

The Ottawa Valve Collapse scale (OVCS) was developed to classify the severity of nasal valve collapse (NVC) in patients with nasal obstruction. The goal of this study was to determine, in patients who have nasal obstruction due to a septal deviation, whether those with a higher OVCS grade will have a reduced improvement in patient-centered clinical outcomes at one-year following septoplasty with inferior turbinate diathermy compared to those with a normal or lower OVCS grade. This study was a prospective study of 78 patients who completed an assessment using the NOSE questionnaire before and at one-year following the surgical intervention. A repeated-measures ANOVA was used to asses for differences in scores between OVCS groups. There was a significant improvement in NOSE scores one year post-septoplasty (p < 0.01). There was no difference in NOSE score improvement when comparing the grades of the OVCS at one-year (F = 0.09, p = 0.968). Though the OVCS was designed to categorize the severity of NVC preoperatively, there is no evidence that it is helpful in predicting which patients will demonstrate poor results following septoplasty. Future studies are required to further evaluate the OVCS and whether complimentary assessments will improve its clinical utility.

Diagnosis and management of septal deviation and nasal valve collapse - a survey of Canadian otolaryngologists

BACKGROUND

Management of nasal valve collapse (NVC) in patients with a septal deviation can be challenging. Our objective was to determine the opinions of Canadian Otolaryngologists regarding the diagnosis and management of nasal obstruction in patients with septal deviation and NVC.

METHODS

A twenty-question survey was developed for the purpose of our study. Questions were divided into the following areas: diagnosis, management and prognosis. We included all otolaryngologists who were members of the Canadian Society of Otolaryngology.

RESULTS

The response rate to our survey was 18%. The most commonly identified cause of a failed septoplasty was incomplete septoplasty (41.9%), followed by nasal valve collapse (25.6%). The Cottle manoeuvre (62.8%) and visual inspection (39.5%) were noted to be the most important diagnostic tools for external and internal NVC respectively. However, physicians often rely on a variable number of different examinations when making a diagnosis of nasal valve collapse. When evaluating which patients with a septal deviation also required nasal valve surgery, 27.9% of responders believed the current physical examination methods provided a high accuracy, while 55.8% indicated moderate accuracy and 16.3% indicated low accuracy. Compared to other subspecialties in Otolaryngology, Facial Plastic and Reconstruction Surgeons noted higher septoplasty failure rates in patients with co-morbid NVC.

CONCLUSIONS

NVC is an important concern for otolaryngologists performing septoplasty. Although most physicians believe that the physical exam provides a moderate effectiveness when predicting who requires a functional rhinoplasty, diagnostic methods used for NVC is varied and inconsistent.

Total and Unilateral Peak Nasal Inspiratory Flow and Unilateral Visual Analogue Scale: Rationale in Indication and Outcomes of Septoplasty?

Septoplasty is one of the most frequently performed procedures in otorhinolaryngology. Proper selection of patients for septoplasty as well as examination is essential for good outcome of surgery. The aim of this study was to evaluate the suitability of combination of 2 simple, cheap, and easily performed examinations for indication and outcomes of septoplasty to evaluate the effectiveness in this type of surgery. Seventy patients were enrolled from 2 tertiary centers from the period of April 2017 to March 2018, who all underwent septoplasty for nasal septal deviation. Total and unilateral peak nasal inspiratory flow (PNIF), unilateral visual analogue scale, and nasal endoscopy for indication and outcomes of septoplasty were performed. Furthermore, assessment of possible correlation between subjective and objective data before and 3 months after septoplasty was done. Statistical analysis was carried out on the obtained data. Postoperatively the total and both unilateral PNIF measurements increased significantly compared with corresponding preoperative values and similarly means of visual analogue scale scores on both sides decreased 3 months after the procedure. No significant correlation was seen between objective and subjective outcomes neither before the surgery, nor postoperatively. The study confirmed the suitability of using PNIF as a simple and inexpensive tool that can be a reasonable alternative to rhinomanometry and which is able to reflect changes after septoplasty. Simultaneously, along with the expected improvement in the total PNIF and unilateral PNIF on deviated side, a slight but significant improvement in PNIF values on the nondeviated side was also demonstrated.