Keywords
nasal obstruction - nasal septum - nasal surgical procedures - quality of life - visual
analogue scale
Introduction
Nasal blockage is a common complaint in otolaryngology outpatient clinics.[1] It can be a consequence of many factors, such as septal deviation and allergic rhinitis.[2] Septoplasty combined with turbinoplasty is frequently chosen as a treatment to relieve
symptoms when other medical treatments have failed.[3]
The subjective evaluation of a nasal obstruction can be performed using scales such
as the Nasal Obstruction Symptom Evaluation (NOSE) and the Visual Analogue Scale (VAS).[3] Nasal obstruction can be responsible for other symptoms including snoring, diurnal
somnolence, and fatigue, which may lead to deterioration of the patient's quality
of life (QoL).[4] There have been few published studies concerning the impact of these surgeries on
QoL and the correlation between the various subjective measures used to evaluate nasal
obstruction.[5] Moreover, factors like poor QoL before surgery, quality of sleep, and psychological
factors may alter QoL perception in these patients.[6]
The correlation between objective measures and the subjective perception of nasal
obstruction is reasonably good.[7]
[8]
[9]
[10]
[11]
[12] However, some patients persist with symptoms despite surgery even when nasal permeability
improvement has been demonstrated by objective measures.
Currently, there is a poor consensus in our country about the utility of subjective
measures of nasal obstruction and the correlation between them. Due to the complexity
of the nasal obstruction, there is a lack of diagnostic tools available to objectively
predict postoperative outcomes after septoplasty plus turbinoplasty. Still, subjective
measures are very valuable because the perspectives and satisfaction of the patients
can give us information about the effectiveness of treatment.[13]
To our knowledge, there is no literature in Colombia about the utility of septoplasty
and turbinoplasty nor research about the main associated factors that could influence
the postoperative outcomes. The aim of the present study was to evaluate the change,
after septoplasty and turbinoplasty, in the patients' nasal obstruction perception
and QoL, through validated subjective scales: the VAS, the NOSE and the Glasgow Benefit
Inventory (GBI). Moreover, to describe the correlation between those scales and the
effect of clinical factors like smoking, body mass index (BMI), age, and allergic
rhinitis in surgery results.
Materials and methods
Study design
A prospective study was conducted. It was approved by the ethics committee (CCEI-8616–2017).
Patients
The participants in our study were patients over 18 years old at two institutions
whose nasal obstructions due to septal deviation were managed with primary septoplasty
paired with turbinoplasty between January 2017 and December 2018. Septal deviation
was diagnosed during an otolaryngology physical examination or an endoscopic examination
after decongestion by an ear nose and throat (ENT) specialist. Also, ENT specialists
diagnosed allergic rhinitis based on symptoms and on the allergic rhinitis and its
impact on asthma (ARIA) classification.[14] Patients with other causes of nasal obstruction such as nasal polyps, sinusitis,
septal perforation, recent nasal trauma, sinonasal tumors and nasal valve stenosis
were excluded.
Surgical procedure
All procedures were performed by different ENT specialists and residents. A hemitransfixion
incision was performed followed by mucoperichondrium elevation in one side and excision
of the posteroinferior septal cartilage. Then, elevation of the mucoperichondrium
on the other side was performed, followed by excision of the deviated portion and
repositioning of the excised cartilage. We also performed an inferior turbinate lateralization
followed by a submucosal electrocautery ablation along with the head, tail, and body
of the inferior turbinate.
Outcomes measures
Information concerning age, gender, weight, height, smoking status, and presence of
allergic rhinitis was collected. Both nasal obstruction scales, the NOSE scale (validated
in Spanish by Larrosa et al.)[15] and the VAS scale, were applied before and 6 to 26 months after surgery; the GBI
scale was applied during the same timeframe after surgery. The scales were applied
by an otolaryngology resident by telephone call or during postoperative consultation
follow-up. The NOSE scale ranges from 0 to 100 (15–25 = mild; 30–50 = moderate; 55–75 = severe,
and > 80 = extreme obstruction), and the VAS scale ranges from 0 (no nasal obstruction)
to 10 (complete nasal obstruction).[16]
The GBI was used as a scale to assess QoL, which is sensitive to change after an otolaryngology
surgery. The GBI is an 18-item postintervention survey, which is divided into 3 domains:
General Benefit (12 questions), Social Support (3 questions), and Physical Health
(3 questions). It results in a score ranging from - 100 (negative benefit) to + 100
(positive benefit) with a score of 0 equaling to no benefit.[17]
Statistical analysis
Statistical analyses were performed using Stata 16 MP (StataCorp LLC., College Station,
Texas, United States) and R 3.6.1 (A Language and Environment for Statistical Computing,
Vienna, Austria). Descriptive analysis of the data was done by calculating the absolute
and relative frequencies for qualitative variables, and central tendency and dispersion
measures were analyzed for quantitative variables.
Bivariate analyses between pre- and postsurgery data for the NOSE and VAS scales were
analyzed by the paired samples Wilcoxon test. On the other hand, quantile regression
was performed to evaluate the effect of surgery on the septoplasty results measured
through the NOSE scale, which had been adjusted for some clinical and demographic
variables. Additionally, the Spearman correlation coefficient was calculated to check
the correlation between the GBI and the pre- and postsurgical scores from the NOSE
and VAS scales. A statistical significance of p < 0.05 was defined a priori.
Results
The present study enrolled 115 patients, 82 (71%) males and 33 females (29%). The
mean age was 42 ± 14 years old. The demographic data of the patients are shown in
[Table 1]. Ninety-four patients completed the 6-to-26 month follow up surveys (VAS and NOSE),
and they were included in the pre- and postoperative analysis. Postoperative surveys
were completed in a mean of 9.46 months (6 to 26), as shown in [Table 1].
Table 1
Baseline demographic and clinical characteristics of the participants
|
Characteristic (n = 115)
|
n
|
%
|
|
Gender, f/m
|
33/82
|
28.7/71.3
|
|
Age (years old)[a]
|
41.94 (14.44)
|
41.83 (30.17–52.27)
|
|
Age group (years old)
|
|
|
|
< 20
|
12
|
10.43
|
|
20–40
|
43
|
37.39
|
|
40–60
|
48
|
41.74
|
|
> 60
|
12
|
10.43
|
|
Follow-up time (months)[a]
|
9.46 (3.50)
|
9.06 (6.94–10.87)
|
|
History and comorbidities
|
|
|
|
Smoking
|
13
|
11.30
|
|
Allergic Rhinitis
|
49
|
42.61
|
|
Height (meters)[a]
|
1.69 (0.09)
|
1.68 (1.62–1.75)
|
|
Weight (kilograms)[a]
|
75.56 (12.7)
|
75 (67–84)
|
|
BMI (kg/m2)[a]
|
26.77 (4.13)
|
26.22 (23.81–29.41)
|
|
BMI categories
|
|
|
|
Underweight
|
1
|
0.87
|
|
Normal (healthy weight)
|
45
|
39.13
|
|
Overweight
|
41
|
35.65
|
|
Obese
|
26
|
22.61
|
|
No data
|
2
|
1.74
|
Abbreviations: BMI, body mass index; F, female; M, male
a Values are expressed in Mean (standard deviation) and Median (Interquartile Range)
After surgery, in the NOSE scale, 70% and 50% of the patients had scores less than
40 and 17 respectively. Regarding the VAS scale, 50% of the patients had scores less
than 2, and 75% scored less than 5. A general decrease of the median NOSE and VAS
scores was observed in patients who had undergone a septoplasty along with a turbinoplasty
(48 points and 5 points, respectively) (p < 0.001) ([Table 2]).
Table 2
Pre- and postoperative NOSE and VAS scores
|
Surveys (n = 94)
|
Median preoperative (IQR)
|
Median postoperative (IQR)
|
p-value
[a]
|
|
NOSE
|
65 (50–80)
|
17 (5–40)
|
< 0.001
|
|
VAS
|
7 (6–8)
|
2 (1–5)
|
< 0.001
|
Abbreviations: NOSE, nasal obstruction symptom evaluation; IQR, interquartile range
(p25-p75); VAS, visual analogue scale.
a
p-value based in a paired sample Wilcoxon test
The box and whisker plot offers a detailed overview of the pre-post NOSE and VAS by
age groups and BMI. The box represents the 25th and 75th percentiles and the whiskers are the upper and lower ranges of pre-post NOSE and
pre-post VAS by age groups and BMI ([Fig. 1]). A general decrease in the NOSE and VAS scores in all age ranges and BMI categories
after surgery is graphically evidenced. There is a slight increase in the difference
between the pre- and post-NOSE medians in the age group under 20 years old, suggesting
that this age group would have a better outcome after surgery (55 points versus 45,
47, and 52 points for the groups between 21 and 40 years old, between 41 and 60 years
old, older than 60 years, respectively).
Fig. 1 Box and whisker plot of the pre-post NOSE and pre-post VAS by age groups and BMI
On the other hand, patients aged up to 60 years old had a greater reduction in nasal
obstruction after surgery according to the VAS scale. In this group, the VAS median
decreased 6.5 points compared with the preoperative VAS median. Regarding the BMI,
a decrease is observed in both: NOSE and VAS postoperative scores in a similar amount
among all the BMI groups.
To assess the QoL, the GBI test was administered to 109 patients; 91% of the patients
reported improvement in the total GBI score (including the 3 domains); 91% reported
improvement in the General Benefit domain, 73% reported improvement in Social Support
and 60% stated experiencing an improvement in Physical Health ([Table 3]).
Table 3
Description of results regarding quality of life as measured by the Glasgow Benefit
Inventory
|
GBI Subscales[a]
|
Median (IQR)[b]
|
n
[c]
|
%[c]
|
|
General benefit
|
25 (16.66–45.83)
|
99
|
90.83
|
|
Social support
|
33.33 (0–50)
|
80
|
73.39
|
|
Physical health
|
16.66 (0–33.33)
|
65
|
59.63
|
|
Total GBI
|
25 (13.88–44.44)
|
99
|
90.83
|
Abbreviation: GBI, Glasgow Benefit Inventory.
a
n = 109 participants without missing data
b Summary measures of the scores for each of the domains and the total of the scale,
interquartile range: (p25-p75)
c Absolute and relative frequencies of participants who showed improvement in the domains
of the scale
Patients under 20 years old and over 60 years old had a score ≥ 0 in all the GBI domains.
On the other hand, some of the patients between 21 to 60 years old had a negative
benefit in all the domains, especially in the Social Support and Physical Health domains
([Annex 1 online]). Regarding the BMI, normal weight patients had the highest scores or greater benefit
in all the GBI domains. In contrast, even though most obese and overweight patients
had a positive benefit, they reached the lowest scores (negative benefit) in the General
Benefit and Physical Health domains ([Annex 1 online]).
Bivariate and multivariate quantile regression analyses were performed. A decrease
of 45 points was observed (coefficient of - 45 points; 95% confidence interval [CI]:
- 53.53–-35.46; p < 0.001) in the postoperative NOSE score (after septoplasty and turbinoplasty) in
comparison with the preoperative score after adjusting for possible confounders, as
seen in [Table 4]. Obesity was associated with the worst results in the postoperative bivariate NOSE
score and was still found to be significant after adjusting for other variables (coefficient
of 15 points; 95%CI: 2.04–28.2; p = 0.02).
Table 4
Associations between sociodemographic and clinical variables with NOSE scores after
surgery according to bivariate and multivariate quantile regression
|
Variable
|
Bivariate model[b]
|
Multivariate model[b]
|
|
β[a]
|
95%CI
|
β[a]
|
95%CI
|
|
Time
|
|
|
|
|
|
Post-NOSE score (versus pre-NOSE score)
|
- 45
|
(- 53.44–-36.55)
|
- 45
|
(- 53.53–-35.46)
|
|
Age
|
0.22
|
(- 0.25–0.69)
|
-0.20
|
(- 0.61–0.21)
|
|
Gender
|
|
|
|
|
|
Female (versus male)
|
10
|
(- 4.34–24.34)
|
-2.76
|
(- 15.39–9.87)
|
|
BMI
|
|
|
|
|
|
Overweight (versuss normal weight)
|
10
|
(- 6.91–26.91)
|
5.30
|
(- 7.19–17.81)
|
|
Obese (versuss normal weight)
|
10
|
(- 8.27–28.27)
|
15.14
|
(2.04–28.23)
|
|
Allergic rhinitis
|
|
|
|
|
|
Yes (versus not)
|
10
|
(- 2.81–22.81)
|
6.60
|
(- 5.34–18.55)
|
|
Smoking
|
|
|
|
|
|
Yes (versus not)
|
- 5
|
(- 25.54–15.54)
|
0.80
|
(- 13.67–15.27)
|
|
Follow- up time
|
0.001
|
(- 2.02–2.02)
|
0.79
|
(- 0.66–2.25)
|
Abbreviations: BMI, body mass index; CI, confidence interval.
a
β: Quantile coefficient regression
b Log-likelihood Model: - 790.907; AIC: 1601.815; n = 175
[Fig. 2] shows the calculated correlations in the correlation matrix. Numerical correlations
were observed in the lower left area; there is a strong correlation between preoperative
NOSE and preoperative VAS scores (rho = 0.67; 95%CI: 0.55–0.77; p < 0.001) and between postoperative NOSE and postoperative VAS results (rho =0.75;
95%CI: 0.65–0.82; p < 0.001). Moreover, there is a strong negative correlation between postoperative
NOSE results and total GBI score (rho = - 0.43; 95%CI - 0.571–- 0.26; p < 0.001), as well as between postoperative VAS results and total GBI score (rho = -
0.58; 95%CI: - 0.69–- 0.44; p < 0.001). This means that the less nasal obstruction, the better the QoL. However,
there is no correlation between GBI domains and total GBI scores with preoperative
NOSE and VAS scales.
Fig. 2 Nasal obstructive subjective scales (NOSE and VAS) and the Glasgow Benefit Inventory
(GBI) correlation matrix
Additionally, there is a negative correlation between postoperative NOSE and VAS scales
and GBI domains: General Benefit and postoperative VAS (rho = - 0.60; 95%CI: - 0.70–-
0.46; p < 0.001), General Benefit and postoperative NOSE (rho = - 0.45; 95%CI: - 0.58–- 0.28;
p < 0.001), Social Support and postoperative VAS (rho = - 0.44; 95%CI: - 0.57–- 0.27;
p = 0.0018), Social Support and postoperative NOSE (rho = - 0.29; 95%CI: - 0.44–- 0.10;
p < 0.001), Physical Health and postoperative VAS (rho = -0.39; 95%CI: - 0.54–- 0.22;
p < 0.001), and Physical Health and postoperative NOSE (rho = - 0.32; 95%CI: - 0.48–-0.141;
p = 0.0009) ([Fig. 2]).
The upper area, in [Fig. 2], correlations are shown graphically; the size of the spheres represents the correlation
strength between scales, while the blue and red colors represent positive and negative
correlations, respectively. There is a strong negative correlation between the postoperative
VAS scale and Total GBI and its General Benefit domain. There is no significant correlation
between preoperative NOSE and VAS scales and the Total GBI or its domains. Moreover,
there is a strong, positive correlation between preoperative and postoperative NOSE
and VAS scales.
Discussion
Septoplasty and turbinoplasty are procedures frequently performed by an otorhinolaryngologist
to correct nasal obstruction in patients with septum deviation and inferior turbinate
hypertrophy.[1] Nowadays, the objective methods to evaluate nasal obstruction, such as rhinomanometry,
are not fully consistent with the patient's perception of nasal obstruction given
the complexity of its pathophysiology. This makes it difficult to identify patients
who benefit from surgery, and this results in unsatisfactory postsurgical outcomes.
Our study focuses exclusively on subjective measurement scales, which we consider
to be easier to use during ENT daily clinical practice. These scales should be considered
to choose a better target population and to improve counseling regarding expectations
after surgery.
Current studies show that septoplasty paired with turbinoplasty improves nasal obstructive
symptoms in the short-medium term, independent of the age and weight of the patient.
All our patients met the inclusion criterion (septal deviation), which was the reason
for performing septoplasty on them; however, all of them needed the turbinoplasty
to be performed due to some degree of hypertrophy of the turbinate. Consequently,
it was difficult to measure the impact of solely septoplasty or turbinoplasty in the
nasal obstruction improvement.
There was a statistically significant difference between pre- and postoperative values
of the NOSE and the VAS (p < 0.001) scales in the bivariate analysis and in the multivariate analysis, with
a difference of 45 points less in the postsurgical NOSE score (p < 0.001). This correlates with previously published studies.[18]
[19]
[20] Dinesh Kumar et al. used the NOSE score for subjective evaluation, and they reported
a 70-point NOSE score reduction after septoplasty and turbinoplasty in comparison
with preoperative NOSE scores.[21] A pilot study was performed by Corredor-Rojas et al. in 2017 in one of the institutions
included in the present study. Similarly, in that study, nasal obstruction was measured
through the NOSE and VAS scales and QoL through the GBI test, but just during a postoperative
midterm period. Corredor-Rojas et al. reported that 75% of the patients in their study
scored below 50 in the postsurgical NOSE and below 6 on the VAS score; both results
are consistent with postoperatory nasal obstruction relief. Moreover, confounding
factors were suggested, and that is why variables like allergic rhinitis and BMI are
considered now.[22]
Regarding the GBI scale, 90% of the patients reported an improvement in QoL, mainly
in the General Health domain. However, the P75 of the total GBI was 44, indicating
that only 25% of the patients managed to reach a benefit score that exceeded 45 points
out of 100 points, which is the maximum score. While it should be noted that it is
a score that indicates improvement, it is not substantially positive. As previously
stated, Corredor-Rojas et al. used the GBI scale in a similar context; they found
the percentage of the population with an improvement in the total GBI to be 76.79%,
with the General Health domain also showing the most improvement (78.57%). Compared
with our results, we observed a greater global postoperatory benefit, which could
be explained by the difference in sample size.
This may lead us to think that nasal permeability does impact QoL. However, septum
deviation may not be the main cause of patient discontent in our population, and other
factors influence this perception, such as the emotional state of the patient. This
is described by Valsamidis et al., who established that there is an association between
high rates of presurgical stress and low scores on the postsurgical GBI.[19] For this reason, it is worth highlighting the importance of explaining to patients
the complexity of their condition and the surgical procedure to reduce their anxiety
levels as much as possible and clarify the expected results after the medical and
surgical treatment is performed.
There are very few studies on the correlation between different subjective measures.[19] Our correlation analysis revealed that the postsurgical values in the NOSE and VAS
have a negative correlation with the GBI scale results with a rho = - 0.49 and - 0.58
(p < 0.001), respectively. These findings are similar to those reported by Uppal et
al.,[23] who found a correlation between the GBI and subjective nasal obstruction (rho =
0.61, p < 0.01). Additionally, in our results, the postsurgical VAS scores correlate more
strongly with the GBI and its subscales; moreover, the association between the VAS
and the NOSE results is also strong (rho = 0.7; p < 0.01). Lara-Sánchez et al. found a good correlation between NOSE and VAS results
(rho = 0.83327) from a cohort of 102 patients. This suggests that either scale can
be used to measure the degree of nasal obstruction.[24] We recommend the VAS as a useful tool because it is easy to administer and scores
can be obtained quickly; in addition, it correlates very well with the nasal symptoms
and with the satisfaction of the patient in terms of QoL.
Other authors have stated that the coexistence of allergic rhinitis with septal deviation
is associated with poor postsurgical results since these patients have more postsurgical
edema and discomfort.[25] It is also likely that, in some cases, nasal obstructive symptoms are caused mainly
by allergic rhinitis and not by septal deviation. Our findings differ somewhat regarding
this, given that despite having a high prevalence of allergic rhinitis based on symptoms
in our sample (42%), this is not a predictive factor of the short-medium term postsurgical
nasal obstruction outcomes. Neither smoking, gender, nor age were statistically significant
factors influencing postsurgical results.
On the other hand, in our sample, obese patients experienced less nasal obstruction
improvement after surgery compared with normal weight and overweight patients. Obesity
adds 15 points (95%CI: 2.04–28.23) to the postsurgical NOSE. However, this analysis
showed a wide CI, so further studies would be necessary to explore this association.
Additionally, obese and overweight patients had the lowest negative benefit in the
General Benefit and Physical Health domains.
Obesity is an energy-rich condition, and it activates inflammatory pathways in the
metabolically active organs such as the liver.[26] Therefore, it represents a hyperinflammatory state, and it can be linked to other
inflammatory conditions such as allergic rhinitis and chronic rhinosinusitis. Obesity
is also associated with a variety of comorbidities such as diabetes and cardiovascular
disease. This represents one of the most important factors that influence the decrease
in QOL of obese patients.[26]
[27]
Bearing this in mind, we expect more nasal edema and postoperative nasal obstruction
in these patients. This association was described by Steele et al., who reported less
improvement in their obese participants (29%) on the Sino-nasal Outcomes Test-22 (SNOT-22)
after sinus surgery compared with overweight and normal-weight participants (40% versus
48%, respectively).[28] Therefore, it is important to consider the expected outcomes in this population
when deciding on surgical management; this association will require future investigation.
The present study has the advantage of being a prospective study, where we use validated
scales to measure the parameters we wanted to analyze. In addition, the scales were
applied by well-trained otolaryngologists and ENT residents. Among the limitations,
it is worth mentioning the lack of a control group, the lack of allergy tests as part
of the diagnosis of allergic rhinitis, lack of objective measures, and incomplete
preoperative surveys of 22 patients that we could not include in the pre- and postanalysis.
We could not collect information on the topical corticosteroid nasal treatment status
nor the severity and location of the deviation.
Additionally, the time between the surgery and the post-operative follow- up lasted
longer than expected in a few participants, 75% of the patients had the postoperative
follow-up in<10 months, which represents a short-medium term follow-up. However, the
follow-up time did not influence the outcomes, as shown in the bivariate and multivariate
regression (95% CI: −0.66 −2.25; p. 0.28).
We believe that randomized controlled studies with a larger sample and longer follow-up
time are required to identify which factors influence patient satisfaction and postoperative
results and, thus, identify which patients benefit from surgical management.
Conclusions
The main benefit of septoplasty paired with turbinoplasty is the improvement of nasal
obstructions. Although these procedures improve the QoL of patients, there may be
other factors that influence and prevent the level of postsurgical satisfaction from
being higher. Obesity is the strongest predictor of suboptimal outcomes after septoplasty
and turbinoplasty in our patients. The decrease in nasal obstruction measured after
surgery with the NOSE and VAS scales has a good correlation with patient satisfaction
measured with the GBI, and our results recommend the VAS as a valuable and convenient
tool to use during the consultation to evaluate nasal obstruction and the level of
satisfaction of patients after surgery.
