|Ahead of print publication
Evaluation of endoscopic septoplasty outcomes using nasal obstruction symptom evaluation scale
T GS Basappa Varun, Angshuman Dutta, Rahul Naga, DK Gupta, Sunil Mathews
Department of ENT-HNS, INHS ASVINI, Mumbai, Maharashtra, India
|Date of Submission||04-Jan-2023|
|Date of Acceptance||09-Jan-2023|
|Date of Web Publication||15-Mar-2023|
T GS Basappa Varun,
Chitra 13D, NOFRA, Colaba, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Inroduction: Nasal obstruction is the most common complaint in an average ENT practice, and a deviated nasal septum is the most common cause of nasal obstruction. The deformities of the septum are usually congenital, developmental, traumatic, or iatrogenic in nature with traumatic and iatrogenic being the most common. The aim of the study was to evaluate patient-based outcomes on subjective-based opinion in patients undergoing endoscopic septoplasty. Methods: This study was conducted in a tertiary care hospital setting in western Maharashtra. This was a prospective observational study.The present study was conducted on 50 patients who presented with signs and symptoms attributed to septal deviation who underwent endoscopic septoplasty and followed up in the department of otorhinolaryngology, head and neck surgery, tertiary care hospital, Mumbai, Maharashtra.The results of our study were analyzed on SPSS Software using “Paired t-test”. Results: On the statistical analysis of the Nasal Obstruction Symptom Evaluation score of patients (n = 50) at baseline and at postoperative 3- and 6-month follow-up, mean + standard deviation was 61.2 ± 11.18, 9.1 ± 5.32, and 8.1 ± 4.51, respectively, with P < 0.0001 preoperative and 3-month postoperative follow-up which is highly significant and P > 0.05 for 3- and 6-month follow-up and hence insignificant. Conclusion: Endoscopic septoplasty results in significant improvement in disease-specific quality of life with high patient satisfaction.
Keywords: Nasal Septum, Endoscopic Septoplasty, Deviation
| Introduction|| |
Nasal obstruction is one of the most common presenting complaints reported in the otolaryngology outpatient department (OPD). The symptoms can be consequences of anatomical problems or functional problems. However, nasal obstruction remains a diagnostic challenge mainly due to the discrepancies between the objective findings and the subjective symptoms. The definitive management for correction of septal deviation is through surgical interventions in the form of septoplasty.
Perception of nasal obstruction depends on many psychological and physiological factors. The decision depends on the patient and doctor's satisfaction, cost-effectiveness as well as on medicolegal issues. It is also very difficult to say that the symptoms will improve in all patients after surgery.
In this study, we have tried to assess the disease-specific quality-of-life outcomes of patients undergoing endoscopic septoplasty using a questionnaire Nose Obstruction Symptom Evaluation (NOSE) Scale. [Table 1].
The objective of this study was to assessing the disease-specific quality-of-life outcomes of endoscopic septoplasty by means of a questionnaire using the NOSE Scale in a tertiary care center.
| Subjects and Methods|| |
This prospective observational study was conducted on 50 candidates between October 2020 and October 2022 in a tertiary care hospital setting in western Maharashtra to assess the benefits of endoscopic septoplasty in terms of patient satisfaction, documented with the help of the NOSE Scale Score. Patients between 18 and 50 years, with a history suggestive of symptomatic DNS, symptoms persisting for more than 3 months, and failure of medical management (topical nasal decongestants and steroids, oral antihistaminics, and decongestants) were included in this study. Patients who underwent septoplasty with concurrent sinus surgery, sleep apnea surgery and rhinoplasty, nasal fracture, adenoid hypertrophy, history of chronic sinusitis, allergic rhinitis, prior nasal surgery, and uncontrolled asthma were excluded from our study.
Study was approved by the institutional human ethics committee. Informed written consent was obtained from all the study participants, and only those participants willing to sign the informed consent were included in the study. The risks and benefits involved in the study and the voluntary nature of participation were explained to the participants before obtaining consent. The confidentiality of the study participants was maintained.
A detailed and comprehensive evaluation of each patient was made as per the proforma of the study design. Relevant history was taken from each patient and recorded on standard proforma designed for the purpose. The baseline NOSE score was documented. The patients were followed up for a minimum period of 6 months to record postoperative symptom improvement rate by NOSE score at 3 and 6 months.
Nose Obstruction Symptom Evaluation Scale
It is a disease-specific quality-of-life instrument for the assessment of nasal obstruction and is valid, reliable, and sensitive in the evaluation of nasal obstruction. It includes a set of five questionnaires based on a four-point scale, with scores reported on a scale of 0 to 100 by multiplying the raw score by 5. A severity classification of the NOSE Scale was developed (mild: 5–25, moderate: 30–50, severe: 55–75, and extreme: >80) which had almost 90% sensitivity and specificity in the evaluation of patients with nasal airway obstruction.
| Results|| |
The results of our study were analyzed on SPSS Software using “Paired t-test”
In our study of 50 patients, the majority of patients, i.e., 24 (48%) were aged between 21 and 30 years. Twelve (24%) patients were recorded in the age group of 31–40 years, eight (16%) patients were recorded in the age group of 41–50 years, and six (12%) patients were recorded in the age group of 18–20 years. The youngest patient was 18 years old and the eldest patient was 50 years of age. The mean age of presentation was 30.66 with a standard deviation (SD) of 8.8. Twenty-seven patients (54%) were males and 23 patients (46%) were females with a male-to-female ratio of 1.17:1. In our series of patients (n = 50), the preoperative NOSE scores of all the patients were compared to the postoperative NOSE scores to know the functional outcome of the surgical procedure. On the statistical analysis of the NOSE score of patients [Figure 1] and [Table 2] (n = 50) at baseline and at postoperative 3- and 6-month follow-up, the mean + SD was 61.2 ± 11.18, 9.1 ± 5.32, and 8.1 ± 4.51, respectively, with P < 0.0001 preoperative and 3-month postoperative follow-up which is highly significant and P > 0.05 for 3- and 6-month follow-up and hence insignificant.
|Figure 1: Descriptive statistics of nose score at preoperative, postoperative 3 months, and postoperative 6 months of study subjects|
Click here to view
|Table 2: Descriptive statistics of Nasal Obstruction Symptom Evaluation score of study subjects|
Click here to view
| Discussion|| |
There are many factors involved in septal deviation some of them being genetics, environment, race, and trauma. Diagnosing and deciding on whether a patient needs surgical correction or not remains an area for discussion. These inappropriate septal surgery indications were found to be major factors for patient dissatisfaction. Similarly, the success of surgical correction depends mainly on the relief of symptoms and improvement of the quality of life of the patient in society postsurgery. Nasal obstruction is one of the common symptoms forcing the patient to visit ENT OPD for consultation. The modality of treatment for these cases of septal deviation remains surgical.
Stewart et al. in a prospective observational study to assess the disease-specific quality-of-life outcomes after nasal septoplasty in adults with nasal obstruction using the NOSE Scale found that there was a significant improvement in mean NOSE score at 3 months after septoplasty (67.5 vs. 23.1, P < 0.0001) and this improvement was unchanged at 6 months.
Kahveci et al. in a prospective observational study of 27 patients with nasal septal deviations who underwent surgery found that the patients had significant improvement in nasal obstruction symptoms after septoplasty operation (P < 0.01) with mean preoperative NOSE score as 60.2 (SD, 17.45) and mean postoperative score as 11.28 (SD, 10.45).
There are other disease specific quality of life questionnaires available to assess the nasal complaints like the Sino Nasal Outcome Test 22, the Chronic Sinusitis Survey, the Rhinosinusitis Disability Index, the Rhino conjunctivitis Quality of Life Questionnaire and the Allergic Outcome Survey (AOS). None of them is specific to assess the nasal obstruction only.
In our study, as the P values calculated for baseline and 3 months postoperative were below 0.01, i.e., (P < 0.01), a statistically highly significant improvement was achieved in patients, meaning that there was a very significant improvement in the obstructive symptoms of all patients after surgical intervention at 3 months and this improvement was unchanged at 6 months. Our observations concerning the postoperative assessment of outcomes associated with endoscopic septoplasty are quite consistent with the observations recorded by the abovementioned authors.
Persistence of nasal obstruction following septoplasty can be due to various factors. In a study, it was seen that 42% of the population have septal deviation with compensatory turbinate hypertrophy. However, only 25% of these patients suffer from nasal obstruction. This indicates that not every nasal obstruction coming along with septal deviation is due to deviation. Other factors such as concha bullosa or protruding inferior concha can also act as breathing barriers. Insufficient nasal valve functioning that is not diagnosed before surgery can also contribute to the persistence of nasal obstruction. Grymer and Rosborg in a retrospective study of 42 patients noted that alar insufficiency accounted for the lack of postoperative improvement in nasal obstruction.
Although global quality-of-life and health status instruments are an important part of health status assessment, for many conditions, the changes in health status are too subtle or disease-specific to be assessed using the content of a global instrument. Therefore, disease-specific health status instruments are needed. Questionnaire's play a pivotal role in the assessment and evaluation of surgical outcomes. For appropriate use in clinical practice, the questionnaires should be clear and comprehensive for the patients, and then the validity and reliability have to be proven. In the assessment of surgical outcomes, the applied instrument should provide the sensitivity to detect changes due to intervention. This feature of a questionnaire is called responsiveness. Like many similar instruments, the NOSE Scale was validated for use in groups of patients. It could be used for comparing disease-specific health status between groups of patients before and after treatment or used to compare the effects of different treatments. Similarly, it could be used to assess differences in outcomes when different surgical techniques are used. It could also be used to compare symptom severity between different groups of patients, for example, those with and without nasal polyps. The NOSE Scale could also be used with a global or generic quality-of-life instrument, to assess the relative impact of the specific disease on different aspects of global quality of life. In our study, we found it to be a greater utility for patients improvement for following endoscopic septoplasty.
Both endoscopic and conventional septoplasty in patients with nasal septum deviation was effective in improving nasal obstruction. However, endoscopic septoplasty had better results in improving nasal obstruction.
| Conclusion|| |
NOSE Score is a valid, reliable and responsive instrument that is brief and easy to complete and has potential use for outcome studies in adults with nasal obstruction. This validated instrument showed that Endoscopic Septoplasty results in significant improvement in disease specific quality of life with high patient satisfaction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: Techniques in septoplasty. Otolaryngol Clin North Am 2009;42:241-52, viii.
Konstantinidis I, Triaridis S, Triaridis A, Karagiannidis K, Kontzoglou G. Long term results following nasal septal surgery. Focus on patients' satisfaction. Auris Nasus Larynx 2005;32:369-74.
Bateman ND, Woolford TJ. Informed consent for septal surgery: The evidence-base. J Laryngol Otol 2003;117:186-9.
Stewart MG, Smith TL, Weaver EM, Witsell DL, Yueh B, Hannley MT, et al.
Outcomes after nasal septoplasty: Results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg 2004;130:283-90.
Dinis PB, Haider H. Septoplasty: Long-term evaluation of results. Am J Otolaryngol 2002;23:85-90.
Kahveci OK, Miman MC, Yucel A, Yucedag F, Okur E, Altuntas A. The efficiency of Nose Obstruction Symptom Evaluation (NOSE) scale on patients with nasal septal deviation. Auris Nasus Larynx 2012;39:275-9.
Piccirillo JF, Merritt MG Jr., Richards ML. Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg 2002;126:41-7.
Gliklich RE, Metson R. Techniques for outcomes research in chronic sinusitis. Laryngoscope 1995;105:387-90.
Benninger MS, Senior BA. The development of the Rhinosinusitis Disability Index. Arch Otolaryngol Head Neck Surg 1997;123:1175-9.
Juniper EF, Guyatt GH. Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Clin Exp Allergy 1991;21:77-83.
Kemker BJ, Corey JP, Branca J, Gliklich RE. Development of the allergy outcome survey for allergic rhinitis. Otolaryngol Head Neck Surg 1999;121:603-5.
Gray LP. Deviated nasal septum. Incidence and etiology. Ann Otol Rhinol Laryngol Suppl 1978;87:3-20.
Baumann I, Baumann H. A new classification of septal deviations. Rhinology 2007;45:220-3.
Becker SS, Dobratz EJ, Stowell N, Barker D, Park SS. Revision septoplasty: Review of sources of persistent nasal obstruction. Am J Rhinol 2008;22:440-4.
Grymer L, Rosborg J. The aging nose: Long-term results following plastic septal surgery. J Larngol Otol 1987;101:363-5.
Lipan MJ, Most SP. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg 2013;15:358-61.
El Nasr AA, Belih MA. Assessment of the nasal obstruction after endoscopic septoplasty compared with conventional technique by computed tomography and Nasal Surgical Questionnaire. Egypt J Otolaryngol 2018;34:272-7. [Full text]
[Table 1], [Table 2]