Abstract
To find out the improvement in cosmetic and functional aspects as measured using Rhinoplasty outcome evaluation questionnaire following Septorhinoplasty. To measure the increase in nasal airflow as measured using “Peak Nasal Inspiratory Flow meter” in patients undergoing Septorhinoplasty. Design: prospective cohort study. Settings: patients with complaints of nasal obstruction and external deformity who are undergoing Septorhinoplasty after evaluation. Subjects: patients undergoing Septorhinoplasty at Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla during a period of 1½ years, starting from 01/01/2017. Methods: non-random, consecutive sampling. The mean age in this study is 26.10 years. The most common age group of patients who were included in the study was 11–20 years. We had 11 females and 8 males. Female to male ratio was 1.375. The mean duration of symptom was 6.33 years. Most of the patients in our study were students. The mean pre-op ROE score was 29.79 ± 15.28 and post-op score was 87.32 ± 8.75. There was significant improvement in ROE scores following Septorhinoplasty (p < 0.0001). The mean pre-op PNIF score was 76.58 ± 41.37 and post-op score was 125 ± 50.22. There was significant improvement in PNIF scores following surgery (p < 0.0001). There is significant improvement in cosmetic and functional aspects in patients undergoing Septorhinoplasty. There is significant improvement in external appearance and nasal obstruction following Septorhinoplasty. The patient satisfaction following Septorhinoplasty can be measured with ease with the help of Rhinoplasty outcome evaluation questionnaire and Peak nasal inspiratory flow meter.
Keywords: Septorhinoplasty, Rhinoplasty outcome evaluation questionnaire, Peak nasal inspiratory flow, Cosmetic aspect, Functional aspect
Introduction
The nose and the sinus cavities associated with it at the beginning of upper airway forms a complex unit, both in the anatomical aspect and in their physiology, the basic functions being air conditioning, filtering and humidification of inspired air and protection of lower airway forming an immunological response for allergens, pollutants and other particles [1]. Nose plays an important part in one’s appearance and also the expression [2].
Septorhinoplasty is a surgical procedure performed to improve the functional aspect and also the cosmetic appearance of nose [2]. Septorhinoplasty have been performed from the earliest times. The first mentioned plastic repair of nose is seen in Edwin Smith Papyrus, a transcription of an Ancient Egyptian medical text, the oldest known surgical treatise dated to the Old Kingdom from 3000 to 2500 BC. Rhinoplasty techniques were carried out in ancient India by the Ayurvedic Physician Sushruta (c. 800 BC) who described Sushruta Samhita, where he mentioned the reconstruction of the nose. Sushruta’s development of the technique of rhinoplasty involved the procurement of skin from the forehead with its blood supply from the angular artery [3–6].
Later in Gaspare Tagliacozzi successfully applied the arm flap procedure for nasal reconstruction on some patients [3, 5, 6]. Jacques Joseph was a pioneer in the field of rhinoplasty surgeries, especially in reduction rhinoplasty. Carl Ferdinand von Gräfe (1787–1840), Professor of Surgery at Berlin University was considered the founder of modern plastic surgery in Germany. Von Gräfe favoured the upper arm-flap procedure, for he was unhappy about the donor site scar morbidity, produced by the forehead rhinoplasty [6]. Goodman initiated the shift from the closed technique of rhinoplasty to an open technique, and this was refined and popularized by Anderson et al. [7–9].
The surgical goal is to improve the appearance of the patient by giving a natural look to the nose in harmony with the surrounding facial features and an unobstructed airway [10]. All surgeons are interested in patient outcomes. Outcome research is the field of study that focuses on these results in terms of patient-related measures such as satisfaction, functionality, and quality of life, rather than solely traditional clinical measures of treatment efficacy [11]. As in any cosmetic surgery, patient satisfaction and an improvement in the quality of life are considered as the success of Septorhinoplasty [12].
Methods
Type of study and source data A prospective cohort study was conducted for a period of one and a half years from January 2017 to June 2018 to find the improvements in cosmetic and functional aspects and to measure the increase in nasal airflow in ENT department of Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala.
Inclusion criteria
All patients > 18 years.
All primary cases.
Exclusion criteria
Patients with cleft lip and palate.
Patients with Lefort fractures.
Patients with pre-diagnosed psychiatric disorders.
Method of data collection
All patients coming to ENT OPD with nasal obstruction and external deformity were properly explained about the study. Diagnostic nasal endoscopy was performed. Written informed consent was taken from all patients participating in this study. Pre-operatively data were collected by Rhinoplasty outcome evaluation questionnaire and PNIF meter. Post operatively at the end of 3 months patients were re-assessed and data were collected by same scales. Comparison of data of both these settings were then done. Photographs were taken before surgery.
Pre-operatively a single dose of ceftriaxone injection was given for all the patients. Patient is placed in supine position with head up, to about 75° with the head raised on a head ring. Surgery was performed under general anaesthesia. Nose is infiltrated with 1% Lignocaine and 1:80,000 adrenaline. Patients had an external splint with plaster of Paris for adequate support with anterior nasal packing. Postoperatively, all patients were treated with intravenous antibiotics, pain medication (paracetamol). Anterior nasal pack was removed on post-operative day 1. Patients were discharged on post-op day 1. Plaster of Paris was removed at 1 week after surgery, on the 1st OPD visit. On the same setting the external sutures were removed.
Patients were followed up every 3 months. Photographs were taken at that time. Nasal air flow was assessed and ROE questionnaire data were collected.
Statistical analysis The results were compared with paired t test and the p-value was calculated. All p values < 0.05 were considered statistically significant.
Results
A total of 19 patients who met the inclusion criteria were enrolled in our study.
Age distribution
The mean age of patients included in this study was 26.10 years, with a SD of 8.93. The most common age group of patients who underwent Septorhinoplasty was 11–20 years. 8 patients were from this age group, which belonged to 42.1%. The youngest being 18 years and the oldest being a 49-year-old female (Table 1).
Table 1.
Age distribution of patients
| Age group | Frequency | Percentage (%) |
|---|---|---|
| 11–20 | 8 | 42.1 |
| 21–30 | 7 | 36.8 |
| 31–40 | 3 | 15.8 |
| 41–50 | 1 | 5.3 |
| Total | 19 | 100 |
Sex distribution
Female to male ration in our study is 1.375, with 11 females and 8 males. 58% patients were females and 42% were males.
Occupation
There were 16% professionals in the study group. 10% were skilled workers, 21% patients were home makers and majority were students which constituted 52.63% (Table 2).
Table 2.
Occupation of patients
| Occupation | Number of patients | Percentage (%) |
|---|---|---|
| Professional | 3 | 15.79 |
| Skilled worker | 2 | 10.52 |
| Home maker | 4 | 21.05 |
| Children/student | 10 | 52.63 |
| Total | 19 | 100 |
Duration of complaints
Mean duration of presenting complaints in this study was 6.33 years with a SD of 9.6.
Gender distribution and indication
Out of the 8 males, 1 patient was concerned only on the aesthetic aspect of nose while 7 patients had both aesthetic and functional concerns. We had 11 female patients who underwent Septorhinoplasty out of which 2 patients had external deformities alone, but 9 patients had both external deformities had nasal obstruction. A total of 3 patients (15.79%) had cosmetic concerns and 16 patients (84.21%) had both cosmetic and functional problems. There was no significant association of gender with indication for Septorhinoplasty (p = 0.623).
Rhinoplasty outcome evaluation questionnaire (ROE)
ROE questionnaire was analysed for 19 patients aged 18 and above. Response rate for ROE questionnaire was 100%. The lowest value of ROE pre-op was 4, for a 40-year-old female with a saddle nose deformity (Figs. 1, 2). The highest value was 58, for 2 individuals. The lowest value of ROE post-op was 67, for an 18-year-old male with crooked nose. The highest value was 96, for 4 individuals. The mean pre-op ROE score in the study was 29.79 ± 15.28. The mean postop ROE score was 87 ± 8.45 (Fig. 3).
Fig. 1.
Saddle nose deformity
Fig. 2.
Bullous tip deformity
Fig. 3.
Crooked nose
Peak inspiratory nasal flow (PNIF)
PNIF scores were calculated in all patients undergoing Septorhinoplasty. Response rate to this method was 100%. Pre-operatively for 2 patients could not breath effectively through nose. Therefore, their PNIF scores were 0, which was the recorded lowest. The highest PNIF score was 180. The lowest score for PNIF post operatively was 55 for a 49-year-old female and the highest was 260 for a 22-year-old male. The mean pre-op PNIF score was 76.11 ± 41.34 and the mean post-op PNIF score was 87.00 ± 8.45.
Paired-T test results
The paired t test using the pre-op and post-op ROE score in our study population shows that the mean difference between 2 sets of values is statistically significant (p < 0.0001). The mean pre-op ROE score was 29.79 ± 15.28 and the mean post-op score was 87.32 ± 8.75. A post-op value > 85 is considered excellent which was obtained in 12 patients (63.16%). Out of which 5 were males and 7 were females (Table 3).
The paired t test using pre-op and post-op PNIF score in our study population shows that the mean difference between 2 sets of values is highly significant (p < 0.0001). The mean pre-op PNIF value was 76.58 ± 41.37 and mean post-op value was 125 ± 50.22 (Table 4).
Table 3.
Paired t test results of ROE before and after surgery
| Paired differences | t | df | Sig (2 tailed) | |||||
|---|---|---|---|---|---|---|---|---|
| Mean | SD | SE mean | 95% Confidence interval of the difference | |||||
| Lowest | Highest | |||||||
| ROE pre-op | 29.79 | 15.25 | 3.51 | − 65.51 | − 49.54 | 15.1381 | 18 | < 0.0001 |
| ROE post-op | 87.32 | 8.75 | 2.01 | |||||
Table 4.
Paired t test results of PNIF before and after surgery
| Paired differences | t | df | Sig (2 tailed) | |||||
|---|---|---|---|---|---|---|---|---|
| Mean | SD | SE mean | 95% Confidence interval of the difference | |||||
| Lowest | Highest | |||||||
| PNIF pre-op | 76.58 | 41.37 | 9.49 | − 62.99 | − 33.85 | 6.9812 | 18 | < 0.0001 |
| PNIF post-op | 125 | 50.22 | 11.52 | |||||
Since the sample size is small a non-parametric test, Wilcoxon signed rank test will be more appropriate for analysis, which showed high significance for both ROE (p = 0.00014) and PNIF (p = 0.00028).
Satisfaction following surgery
5 males and 7 females have excellent (> 85) improvement in ROE scores following surgery (63.16%). PNIF values > 120 L/min is considered normal, which was achieved in 11 individuals (57.89%) out of which 5 were males and 6 were females. A total of 8 patients have an excellent ROE score post-op and normal PNIF values, with 4 males and females each (Table 5).
Table 5.
Satisfaction following surgery
| ROE post-op | PNIF post-op | Both post-op ROE and PNIF | |
|---|---|---|---|
| Males | 5 | 5 | 4 |
| Females | 7 | 6 | 4 |
| Total | 12 (63.16%) | 11 (57.89%) | 8 (42.11%) |
Discussion
Septorhinoplasty aims in correcting the external deformity and nasal obstruction in a patient. In our study we included 19 patients who underwent Septorhinoplasty. 42.1% of patients belonged to the age group of 11–20 years. Only 5.3% patients were in the age group of 41–50 years. This may be due to the increased cosmetic concern in younger age group and also due to bad quality of life because of nasal obstruction in their growing age. There were 11 females and 8 males in the study population, which indicates the cosmetic and functional concerns prevailing among women. Similar sex distribution was seen in a study conducted by Strazdins et al. They had a total of 88 patients where 60.2% were females [13]. The mean patient age in that study was 37.6 years in comparison with 26.10 years in our study.
The mean pre-op ROE score was 29.79 ± 15.28 and the mean post-op score was 87.32 ± 8.75. None of the patients in our study had a decrease in scores post-op. A post-op value > 85 is considered excellent which was obtained in 12 patients (63.16%). Out of which 5 were males and 7 were females. There is a significant improvement in ROE scores following Septorhinoplasty (p < 0.0001). This indicates that Septorhinoplasty improves the cosmetic concerns and nasal obstruction. ROE questionnaire is a fast, simple and effective subjective assessment tool in patients undergoing septoplasty.
Arima et al. [14] conducted a study with 19 patients in 2011had similar results with pre-op ROE score of 24.6 ± 11.3 which became 76.1 ± 19.5 post operatively. Wahmann et al. concluded that quality of life assessment after rhinoplasty with ROE questionnaire show a significant improvement [10]. A long term evaluation after Septorhinoplasty done by Faidiga et al. with 69 patients concluded that a mean value of 73.25% was obtained with ROE questionnaire [15]. Saleh et al. assessed the quality of life with regard to nasal function and appearance after rhinoplasty in 2011 and they found that there is improvement in ROE values post-operatively (p < 0.01) [16]. In a study conducted by Chavan et al. 87.5% patients who had undergone Septorhinoplasty had excellent results post-operatively as measured using ROE questionnaire [17]. There was a statistically significant (p < 0.01) improvement in ROE scores following Septorhinoplasty in a study conducted by Baser et al. where the average difference in pre-op and post-op ROE values was 54.26 ± 18.85 [2].
In our study we had an 18-year-old male with a post-op ROE score of 67. Even though his nose has significant good changes, it is not reflected in the scores. It is probably due to high expectation, may be influenced by the over emphasis of results by social media.
In our study the mean pre-op PNIF score was 76.58 ± 41.37 and the post op score was 125 ± 50.22. 11 patients have normal value (> 120 L/min) following surgery out of which 5 were males and 6 were females. Pre-operatively 2 patients couldn’t perform the test. It may be due to the technical difficulty in performing the test because of severe nasal obstruction. The highest pre-op PNIF value is 180, for a 22-year-old male. He had a post-op value of 260 which is the highest recording post op value. The lowest post-op PNIF value is 50, for a patient with pre-op value 0. On patient had post-op value of 55, but had a pre-op value of 80. The patient was having an upper respiratory tract infection during the follow-up period, which is the probable reason for a lower value post-op. There is statistically significant improvement in nasal airway following surgery as measured using PNIF meter (p < 0.0001).
The mean pre-op PNIF value in a study conducted by Xavier et al. was 86.5 L/min and mean post-op PNIF was 123 L/min which shows a significant improvement (p < 0.05). Pre-op mean PNIF was 101 ± 35 L/min which improved to 143 ± 44 L/min in a study conducted by Timperley et al. [18] An American study with 136 patients revealed statistical improvement of nasal airway after Septorhinoplasty with PNIF meter. Improvement from 82.3 to 108.4 L/min [19]. PNIF proved to be a reliable method to detect changes in nasal patency as it is easy to handle, inexpensive and reproducible as mentioned by Teixeria et al. in their study conducted in 78 individuals [20].
Limitations of study
We had a total of only 19 patients in our study which is very small. It is probably due to the lack of awareness in patients about the surgery and the results following it.
Funding
No funding was received by any of the authors for this study.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
This article does not contain any studies with animals performed by any of the authors.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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