The Effect of Septoplasty and Inferior Turbinate Reduction on Measures of Exercise Capacity

ABSTRACT

Objectives

We seek to examine the effects of septoplasty with inferior turbinate reduction (ITR) on objective measurements of exercise physiology and how they may correlate with subjective measures such as patient‐perceived improvement and disease‐specific quality of life (DSQOL).

Methods

Thirteen subjects with deviated nasal septum and inferior turbinate hypertrophy limiting exercise tolerance underwent pre and 3‐month postoperative exercise testing. Measurements included heart rate (HR), tidal volume (V _t), maximum oxygen consumption relative to body weight (VO₂), lactate, and rating of perceived exertion (RPE), and peak nasal inspiratory flow (PNIF) testing, in addition to two validated surveys including the NOSE instrument and SNOT‐22 questionnaire.

Results

The population included 54% women with an average age of 33.8 years. Postoperative improvement was shown in PNIF (99.6 vs. 146.7 L/min, p = 0.002) NOSE scale (13.2 vs. 2.1, p < 0.001), total SNOT‐22 score (29.1 vs. 11.4, p = 0.003), and subjective improvement at Stages 3, 4, and 6 of exercise testing. There was improvement at Stage 6 in HR (177.3 vs. 171.7 bpm, p = 0.046) and lactate (lactate 5.84 vs. 4.71 mmol/L, p = 0.004). There was no change in relative VO₂ or V _t.

Conclusion

This is the first study to directly assess the role of septoplasty/ITR in relation to exercise performance. Participants did not show improvement in cardiovascular fitness but did have subjective improvements in performance and DSQOL. These findings support the effectiveness of septoplasty/ITR in improving tolerance to exercise independent of cardiovascular fitness level.

Level of Evidence

3.

Herein we examine the effects of septoplasty and inferior turbinate reduction on objective measurements of exercise physiology and subjective measures of patient perceived improvement. Comparison of preoperative and 3‐month postoperative testing on 13 participants showed significant improvement in peak nasal inspiratory flow, disease‐specific quality of life metrics, and self‐rated exercise performance. However, there was no significant difference in maximum oxygen consumption as a measure of cardiovascular fitness.

1. Introduction

Otolaryngologists perform a range of airway enhancing procedures to improve breathing and exercise tolerance. These interventions have the potential to benefit a diverse patient population, from elite athletes seeking performance optimization to amateurs striving to increase physical activity for overall health improvement. Nasal obstruction due to septal deviation and inferior turbinate hypertrophy (ITH) is a common barrier to optimal exercise capacity and septoplasty with inferior turbinate reduction (ITR) remains one of the most frequently performed otolaryngologic procedures in adults [1, 2]. These procedures are well established in improving nasal airflow and quality of life. Prior studies have focused primarily on subjective symptom relief with some evidence to suggest improvement in physiologic lower airway function as evaluated by pulmonary function testing, but their direct impact on exercise physiology has limited evaluation in the literature [3, 4, 5].

This study aims to evaluate the effects of septoplasty and ITR on objective exercise physiology parameters and their correlation with patient‐reported outcome measures (PROMs) and disease‐specific quality of life (DSQOL) assessments. To achieve this, we analyzed pre and postoperative data from patients undergoing septoplasty with ITR, incorporating formal exercise testing utilizing key subjective and physiologic markers. By investigating the relationship between nasal airflow and exercise performance, this study provides new insights into the physiologic impact of nasal surgery and its potential role in optimizing physical function.

2. Methods

This prospective study was funded by the American Rhinologic Society CORE Grant (2019). Institutional Review Board (IRB, 1801018875) approval was obtained.

2.1. Inclusion and Exclusion Criteria

Adult patients were recruited from the senior author's (A.N.P.) outpatient practice. Eligible participants presented with nasal obstruction limiting exercise capacity and were found to have a deviated nasal septum with ITH on examination with failure to improve subjective symptoms of nasal obstruction with medical management. All participants underwent risk stratification according to American College of Sports Medicine guidelines, which are standard for assessing cardiovascular risk prior to exercise testing. Only those deemed low risk for adverse cardiovascular events were included [6].

Patients with a history of sinonasal malignancy, head and neck radiation, septal perforation, acute nasal trauma, nasal valve collapse, adenoid hypertrophy, sarcoidosis, granulomatosis with polyangiitis, uncontrolled asthma, pregnancy, prior sinonasal surgery, coexisting allergies, or any other sinonasal disease were excluded from the study. Eligible subjects provided full informed consent for both the study protocol and septoplasty/ITR. Power analysis was performed indicating a goal recruitment of 30 participants to detect improvement in 1 metabolic equivalent (MET), which is associated with a 15% reduction in all‐cause mortality [7]. With the above population and standard of care intervention, we conducted a prospective single‐arm pre‐post interventional cohort study.

2.2. Data Collection

Preoperatively, subjects completed four surveys. The first collected demographic information, medical and surgical history, social history, medication use, and details of exercise and sports participation. The second was the Nasal Obstruction and Septoplasty Effectiveness (NOSE) instrument, a validated five‐item questionnaire assessing nasal congestion, obstruction, breathing difficulty, sleep impact, and airflow impairment during exertion [8, 9]. The third was the Sinonasal Outcome Test (SNOT‐22), a 22‐item instrument evaluating sinonasal, facial, and otologic symptoms along with DSQOL measures [10]. The fourth was a brief questionnaire evaluating subjects' perceived exercise vigor level as well as exercise capacity on a Likert scale of 1–5 (with 1 indicating not at all strenuous and very poor exercise capacity, respectively, and 5 indicating very strenuous and very good exercise capacity, respectively).

All surveys, except for the demographic and medical history questionnaire, were repeated at 3 months postoperatively. Peak nasal inspiratory flow (PNIF) was measured preoperatively and 3 months postoperatively using a standard device that directly measures nasal airflow during maximal inspiration in L/min [11]. Subjects were instructed to exhale fully before the application of an airtight nasal mask, after which they performed a short, forceful nasal inhalation lasting 1–2 s. PNIF values were recorded at both time points.

2.3. Energy Expenditure Testing

Enrolled subjects underwent exercise physiology testing preoperatively and at least 3 months postoperatively. All exercise tests were overseen by a single exercise physiologist (P.d.M.). Subjects were instructed to refrain from vigorous exercise and alcohol for 24 h prior to testing and to avoid consumption of caffeine, nicotine, or calories for 4 h prior to testing.

Testing was conducted on either a Woodway Pro motorized treadmill (Woodway USA, Waukesha, WI) or a Lode Excalibur cycle ergometer (Lode Inc., Groningen, The Netherlands). For all tests, subjects were fitted with a two‐way oro‐nasal breathing mask (7450 series, Hans Rudolph Inc., Shawnee KS) connected to a laboratory metabolic measurement system (Parvo Medics' TrueOne 2400, Sandy, UT). In accordance with manufacturer instructions, the metabolic system was warmed up for over 60 min before testing with a minimum of two flowmeter and gas analyzer calibrations each.

Heart rate (HR) was continuously monitored using a wireless Polar chest strap (H10, Polar Inc., Lake Success, NY). Blood lactate measurements were obtained via fingerstick at each stage of each test using the Lactate Plus meter (Nova Biomedical, Waltham, MA). The Modified Borg scale (1–10) was reviewed prior to testing and used to obtain rating of perceived exertion (RPE) measures at each stage of each test. Subjects demonstrated an understanding of the Borg scale by describing the level of exertion assigned to each number to the examiner prior to testing [12]. During the warm‐up, subjects were asked to identify the workload that corresponded to an RPE of “4” on the Modified Borg scale. This workload was used as the first stage for the test and subsequently increased by approximately 1.5 METs every 4 min until the subject requested to stop or could no longer maintain the workload. Four‐minute stages were used to allow adequate time for the subject to reach a steady state of HR (±5 beats/min) and oxygen consumption (±150 mL/min) for three consecutive minutes. The test ends when the patient is no longer able to keep up with the pace, thereby reaching his or her maximum exercise capacity over 20–30 min. Parameters collected included HRHR, respiratory rate (RR), relative maximum oxygen consumption (VO₂), point‐of‐care (POC) lactate measured in the final 30 s of each stage, and tidal volume (V _t).

2.4. Analysis

Descriptive statistics were calculated for exercise physiology metrics, as well as to evaluate changes in PNIF, NOSE score, SNOT‐22 score, and Likert score before and after surgery. The paired t‐test and Wilcoxon signed rank test were used, as appropriate, to assess the change in these variables pre and postoperatively. SPSS version 22 (IBM, Armonk, NY) was used for all statistical analyses, with threshold for significance set at p < 0.05.

3. Results

3.1. Patient Characteristics

Thirteen patients were recruited and passed preoperative physical testing for inclusion in the study. The mean age was 33.8 years old and the gender distribution was seven (54%) women and six (46%) men. The most frequently reported forms of exercise were running, weight training, and cycling. The mean time to postoperative office evaluation was 129.6 days and mean time of postoperative exercise testing was 147.8 days (Table 1). One patient was lost to follow up after moving out of state in the postoperative period.

TABLE 1.

Patient demographics and exercise habits.

Patient characteristics
Mean age (years)	33.8 ± 7.43
Female	7 (54%)
Men	6 (46%)
Exercise class
Running	69%
Weight training	54%
Cycling	38%
Organized sports	23%
Yoga	15%
Swimming	8%
Rowing	8%
Mean time to follow up (days)	129.6 ± 59.2
Mean time to postoperative exercise testing (days)	147.8 ± 58.9

3.2. Patient Reported Outcomes Measures

Following septoplasty and ITR, 12 of 13 patients presented for postoperative clinic visits with postoperative PROM and DSQOL completion. Patients had improved PNIF (99.6 vs. 146.7 L/min, p = 0.002), improvement in NOSE score (13.2 vs. 2.1, p < 0.001), and total SNOT‐22 score (29.1 vs. 11.4, p = 0.003). Additionally, all subgroups of the SNOT‐22 including rhinologic symptoms, extra‐nasal symptoms, ear and facial symptoms, psychological dysfunction, and sleep dysfunction were significantly improved after surgery (Table 2).

TABLE 2.

Nasal patency and DSQOL assessment pre and postoperatively.

	Preoperative mean (SD)	Postoperative mean (SD)	p
PNIF (L/min)	99.58 ± 29.27	146.67 ± 42.28	0.002
SNOT‐22
Rhinologic	9.54 ± 5.64	3.46 ± 4.35	0.004
Extra‐nasal	4.54 ± 3.67	1.08 ± 1.71	0.007
Ear/facial	6.77 ± 3.98	1.23 ± 1.69	< 0.001
Psychological	14.38 ± 9.24	4.69 ± 7.95	0.004
Sleep dysfunction	5.77 ± 4.42	2.38 ± 4.75	0.023
Total	29.08 ± 15.26	11.42 ± 15.94	0.003
NOSE	13.23 ± 2.68	2.08 ± 2.99	< 0.001
Likert performance	3.5 ± 1.19	4.17 ± 0.80	< 0.05

3.3. Energy Expenditure Testing

Preoperative and postoperative exercise physiology testing was completed in 12 of 13 patients. Obtaining maximum exercise testing was based on subjective tolerance of increasing METs as described above. In order to include the majority of participants, analysis was limited to Stage 6 of testing (Figure 1).

FIGURE 1.

Comparison of exercise physiology parameters at preoperative baseline compared to postoperative performance. Point of care lactate (A), heart rate (B), relative perceived exertion (C), relative VO₂ (D), respiratory rate (E), and V _t (F). White bar represents preoperative testing, hash mark bar represents postoperative testing. Significan denoted by *p < 0.05 and **p < 0.01.

POC lactate testing showed no difference in pre and postoperative levels between Stage 1 to Stage 5, however, at Stage 6 postoperative mean POC lactate was significantly decreased compared to preoperative levels (5.84 vs. 4.71 mmol/L, p = 0.004). RPE was equivalent at Stage 1 and 2, and reached significance at Stage 3, 4, and 6, but reported RPE at Stage 5 was not different (7.36 vs. 7.01, p = 0.3874).

HR evaluation also showed no significant difference in Stages 1 through 5, but did have a significant difference at Stage 6 (177.3 vs. 171.7 bpm, p = 0.046). RR did not show any significant difference across all stages, but neared significance at Stage 6 (38.7 vs. 36.6 breaths/min, p = 0.057). Both V _t and VO₂ showed no difference in pre and postoperative comparison across all stages.

4. Discussion

Patient complaints of nasal obstruction, difficulty breathing, and exercise intolerance are extremely common in otolaryngology. These complaints are frequently secondary to nasal septal deviation which has an incidence of 37% in adults, and the otolaryngologist may offer a multitude of medical and surgical therapies to help improve these symptoms [13, 14]. Assessment of exercise physiology with nonsurgical management of nasal obstruction has provided mixed results. A study in 1992 demonstrated that oxymetazoline use did not affect athletic performance as measured by VO₂ max, oxygen saturation, blood pressure, HR, or RR [2]. In contrast, other studies showed that external nasal dilator strips significantly reduced HR, improved VO₂ max, and perceived exertion in athletes [15, 16]. Of the surgical airway‐enhancing techniques, septoplasty and ITR remain a highly utilized tool offered to patients; however, there is a paucity of literature that examines the effects of septoplasty/ITR on objective improvements in exercise tolerance. Both Arifa et al. and Tuzuner et al. provided some insight into this realm by demonstrating increased walking distance, decreased dyspnea rate, reduced fatigue scores, and improved pulmonary function tests after septoplasty [4, 17]. Here, we present a cohort of 13 patients who presented with nasal obstruction, secondary to septal deviation/ITH, limiting exercise tolerance. To expand on the existing literature, we analyzed amateur athletes within their preferred mode of exercise and normalized performance with RPE to enhance the reliability of their performance metrics.

During high intensity exercise, Type II‐Fast twitch muscle fibers are fully recruited and are highly glycolytic. Lactate is the byproduct of glucose utilization in these muscle cells. As exercise intensity increases, lactate production will inevitably reach a point that is greater than the body's capacity to metabolize it, defined as the lactate threshold (LT). Exercise physiology testing utilizes the LT with POC lactate measurements that correlate with the participant's maximum sustainable pace [18, 19]. Numerous studies have shown that athletes or individuals who have undergone endurance training have lower blood lactate concentrations compared to non‐athletes or untrained, otherwise healthy individuals [20, 21, 22, 23]. We postulated that by improving nasal obstruction participants would demonstrate improved LT and associated metrics of cardiovascular fitness.

Improvements in postoperative nasal airway dynamics were critical to the reliability of exercise physiology testing. At their postoperative visit, the participants demonstrated significant improvement in PNIF, by an average of 47% from their preoperative baseline. This correlates with prior publications that have shown that septoplasty physically improves nasal patency and airflow, objectively measured by rhinomanometry, acoustic rhinometry, and PNIF [24]. Now when assessing postoperative exercise physiology and LT thresholds, study participants showed a trend towards improvement in POC lactate levels after septoplasty/ITR, with a significant decrease at Stage 5, suggesting improvement in nasal airflow does correlate with measures of exercise endurance and potential improvement in performance compared to their preoperative baseline.

Within exercise physiology, the point at which LT is reached can be correlated with measurements of HR. As participants progressed through each stage of exercise testing, HR ultimately decreased significantly (177.3 vs. 171.7 bpm, p = 0.046) at Stage 6, the greatest exertional level. Evidence of decreased HR at equivalent stages of MET suggests improvements in nasal airway obstruction also correlate with improvement in cardiovascular fitness.

Recent literature has also made an effort to assess the influence of septoplasty on physical performance scores. A few studies demonstrated improvements in physical performance with the 6‐Minute Walk Test [17, 25]. However, use of this test is prone to test/re‐test error with improvements in performance after 1 day with no intervention suggesting risk for confounding with subjective improvements in pacing and test confidence after the first trial [26, 27].

Interestingly, despite significant improvement in nasal patency, lactate, and HR, direct measurements of pulmonary and maximal cardiovascular function did not show significant change postoperatively. VO₂ max represents the maximum amount of oxygen the body is capable of using during intense exercise. VO₂ max is a widely used indicator of one's potential as an endurance athlete and the gold standard for determining overall cardio‐respiratory fitness [28]. Here we used relative VO₂ max to normalize maximum oxygen consumption by participants' size. In contrast to prior studies that showed improvement in forced vital capacity and forced expiratory volume, there was no significant change in the maximum volume of air that can be inhaled or exhaled within the respiratory cycle, as assessed by V _t. Further assessment of VO₂ max also did not meet levels of statistical significance. Understanding that the amount of oxygen required at any given stage will be the same pre and postoperatively and the tidal volume will remain relatively unchanged at each workload, it is not surprising that the VO₂ max remained unchanged. This contrasts with prior evidence of improved pulmonary function at rest, which could be explained by measurement of both improved upper and lower airway patency, analogous to PNIF assessment. Melekoǧlu et al. assessed athletic performance in a small population of athletes after septoplasty and similarly found no difference in VO₂ max, but did identify improvement in running economy suggesting improvements in nasal airway resistance may improve respiratory muscle efficiency [29]. Taken together, the absence of change in VO₂ max may be limited by the present framework for exercise physiology testing which cannot exclude the possibility of oral breathing patterns, making improvements in the nasal airway nonsignificant during strenuous exercise.

While direct measure of cardiopulmonary function fell short of significance, there was an overwhelming subjective improvement in participant performance. Specifically, the improved self‐assessment of fitness, NOSE, SNOT‐22, and the improvement in RPE exemplify that perceived exertion has dropped significantly independent of cardiovascular fitness. Additionally, the DSQOL measures are taken at a resting state, but the RPE is performed during exertion, showing improved subjective change after surgery at higher ventilatory rates. We believe that this may be directly related to the surgical changes of the airway improving the perceived ease with which they breathe at higher ventilatory rates. Previously, the clinical significance of measures such as PNIF has been largely unknown, as they have not been found to correlate with postoperative patient reported outcomes or DSQOL measures [8, 30, 31, 32, 33]. These metrics had not been valid for predicting surgical efficacy of nasal surgery, but in the present study, participants noted significant improvement in NOSE and SNOT‐22 scores across all domains postoperatively. This correlated with significant improvements in RPE during exercise testing, which held across Stage 3 through Stage 6 of testing. Our findings may provide useful information for surgeons when counseling patients preoperatively about their expected postoperative outcomes regarding exercise tolerance and function after septoplasty/ITR.

There are several inherent limitations to this study. Firstly, there is likely a selection bias, as individuals who volunteer for exercise testing are more likely to be athletic and cardiovascularly fit. This subgroup may not proportionately represent the general population of patients undergoing septoplasty/ITR. The participants selected also may demonstrate a ceiling effect, where they do not have sufficient freedom to improve their performance metrics. However, our patient population fell between the 14th and 90th percentiles for age and gender adjusted VO₂ max suggesting the risk of a ceiling effect was low in the present study [34]. There is also opportunity for confirmation bias, where the subjective sensation of surgical success, potential for variability in post‐surgical exercise regimen, and perceived decreased exertion could lead participants to withhold maximal effort at each stage to align themselves with their perceived state of improved nasal competency. However, we specifically sought to prevent this by advising subjects to remain as unchanged as possible with any athletic training in between their pre and postoperative exercise testing. This study does not include a non‐operative control group; however, it would be unethical to withhold indicated surgical treatment for individuals who were deemed appropriate candidates. We also acknowledge that this is an underpowered study, so its application to a broader audience must be taken cautiously. It is important to note that any statistically significant finding is also to be interpreted as more of a potential trend, given the small sample size of the study. Finally, there were several variables that were compared between the pre and postoperative groups, increasing the likelihood of encountering Type I (false‐positive) errors.

Despite its limitations, the results of this study suggest septoplasty/ITR may provide both subjective and objective enhancement of athletic performance in patients with deviated septum/ITH. This information can be impactful for patients seeking to improve their overall health, as it is very well‐known that any physical activity improves health, prevents several chronic and costly diseases, and reduces all‐cause mortality across multiple populations, with an inverse dose‐relationship between vigorousness of exercise and mortality [35, 36, 37, 38]. Furthermore, results from this study may also greatly benefit professional and elite athletes with nasal obstruction limiting exercise tolerance. Even small improvements in exercise physiology may render substantial gains in competition in this population. Lastly, this study is the first to utilize paradigms within exercise physiology to examine surgical efficacy of combined septoplasty and ITR. Potentially, other airway‐enhancing surgeries can be evaluated in a similar way in the future to further validate their uses.

5. Conclusion

Septoplasty with ITR is a common surgical procedure to improve symptoms of nasal obstruction and difficulty breathing during exercise. This study suggests that patients do experience improved nasal patency, which correlates to subjective improvements in perceived athletic performance at rest and with exertion, as well as decreased lactate production and reduced HR. Furthermore, some of these objective metrics correlate with subjective DSQOL measures. These findings will help surgeons better counsel patients preoperatively about expected postoperative outcomes regarding exercise tolerance and function. Lastly, these same paradigms within exercise physiology may potentially be applied to examining other airway‐enhancing surgeries in the future to further validate their uses.

Funding

This study was supported by the American Rhinologic Society CORE Grant (2019).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.