Abstract
The complaint of nasal obstruction or difficulty in nasal breathing is highly subjective. The benefits of surgery vary depending upon patient perception and satisfaction. Along with objective methods like nasal endoscopy improvement in subjective score of patients symptoms is definitely an important outcome parameter of management. Assessing the disease specific quality of life outcomes of patients undergoing septoplasty by means of a questionnaire using nose scale and correlating it with diagnostic nasal endoscopic findings and clinical examination thirty patients above 17 years of age, with anatomical deviation of the nasal septum as the sole cause of obstruction and symptoms persisting for more than 3 months, underwent septoplasty. Degree of septal deviation was classified as per Mladina classification. Patients Nasal Obstruction & Symptom Evaluation (NOSE) score were documented preoperatively and postoperatively and analysed. In our study it was found that there was significant improvement in nose scores which correlated with the improvement in nasal endoscopic findings. Use of NOSE score will help in letting the patient know his expected outcome following septoplasty and can be used as a predictor of successful surgery/an adjunct to clinical examination and nasal endoscopy in patients undergoing septoplasty. Disease specific health status instruments like Nose scale are needed along with objective outcome measures to compare disease-specific health status and symptom severity in patients before and after treatment. Similarly it could be used to assess differences in outcome when different surgical techniques are used. These subjective scales like nose scale can be used as along with to clinical examination and nasal endoscopy in the management of patients undergoing septoplasty.
Keywords: Nasal obstruction, Nasal septum, Quality of life
Introduction
Nasal obstruction is a common presenting complaint in otolaryngology OPD. Septal deviation is the leading cause of chronic nasal obstruction and can only be corrected surgically. Procedure of choice for treating these patients is septoplasty.
Patients perspective of nasal obstruction depends on many psychological and physiological factors. Operative techniques and expectations of the patient may play a major role in the assessment of satisfaction level postseptoplasty [1]. Postoperative physical examination and objective tools have been used in previous studies to assess the effectiveness of septoplasty [2]. However, these have drawbacks. Physical examination is subjective and depends on the examiners perspective, whereas objective tools have limited role in clinical setting [3, 4].
Outcomes after nasal surgery can be assessed subjectively or objectively. There is no agreement on the tool for objective assessment of nasal obstruction. At present in agreement with the guidelines of the Oxford centre for evidenced based medicine there is no basis to attribute more importance to the value of objective outcomes over subjective patency symptoms either in routine rhinologic practice or for evaluation of therapeutic intervention. Hence there is only limited justification for use of rhinomanometry or acoustic rhinometry [5].
The nose scale is a symptom assessment score for assessment of treatment outcome of septoplasty was developed by Stewart et al. [6]. This study will compare the outcome of nasal septal surgery with preoperative symptoms using nose scale and correlating them with the preoperative and postoperative diagnostic nasal endoscopy findings and assess the applicability of use of this scale in the medical evaluation of serving personnel who are undergoing septoplasty.
Aims and Objectives of the Study
Assessing the disease specific quality of life outcomes of patients undergoing septoplasty by means of a questionnaire using nose scale and correlating it with diagnostic nasal endoscopic findings and clinical examination.
Materials and Methods
A prospective study was conducted at Command Hospital Air Force Bangalore in the department of ENT for period of 1 year from 2018 to 2019 in 30 patients who underwent conventional septoplasty. Informed written consent was be obtained from the patients.
Inclusion Criteria
Age at least 17 years.
Septal deviation causing chronic nasal obstruction.
Symptoms lasting at least 3 months.
Exclusion Criteria
Septoplasty performed 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.
Clinical examination including anterior rhinoscopy and preoperative and postoperative diagnostic nasal endoscopy will be done as a protocol and degree of deviated nasal septum will be graded as per Mladina classification [7]. The findings will be correlated with the outcome nasal scale questionnaire preoperatively and postoperatively after 3 months follow up.
Nasal Obstruction and Septoplasty Effectiveness Scale
| Not a problem | Very mild problem | Moderate problem | Fairly bad problem | Severe problem | |
|---|---|---|---|---|---|
| Nasal stuffiness/congestion | 0 | 1 | 2 | 3 | 4 |
| Nasal blockage/obstruction | 0 | 1 | 2 | 3 | 4 |
| Trouble breathing through nose | 0 | 1 | 2 | 3 | 4 |
| Trouble sleeping | 0 | 1 | 2 | 3 | 4 |
| Unable to get enough air through exertion | 0 | 1 | 2 | 3 | 4 |
The sum of the answers the patient circles will be multiplied by 20 to base the scale out of a possible score of 100 for analysis. A NOSE score of:
< 25 is suggestive of Mild obstruction
25–50, is suggestive of moderate obstruction
> 50 is suggestive of severe obstruction
Post-operative patient’s symptoms were again evaluated using Nasal Obstruction Symptom Evaluation Scale (NOSE) at 3 months. Nasal airway was evaluated at 3 months post surgery with nasal endoscope and compared with preoperative findings. Change in preoperative symptom score to post operative symptom score at 3 months is compared. The correlation of change in nose scale to the correction of DNS is done.
Statistical Methods
Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. Non normally distributed quantitative variables were summarized by median and interquartile range (IQR). The association between pre-operative and post-operative outcomes was assessed by cross tabulation. IBM SPSS version 22 was used for statistical analysis.
Results
Mean age of patients in the study group was 26 years (age range was 17–48 years). All patients were males (Table 1).
Table 1.
Comparison of pre and post-operative degree of nasal blockage or obstruction (N = 30)
| Preop nasal blockage or obstruction | Postop nasal blockage or obstruction | |
|---|---|---|
| Not a problem | Very mild problem | |
| Very mild problem (N = 1) | 1 (100%) | 0 (0%) |
| Moderate problem (N = 5) | 4 (80%) | 1 (20%) |
| Fairly bad problem (N = 22) | 11 (50%) | 11 (50%) |
| Severe problem (N = 2) | 2 (100%) | 0 (0%) |
No statistical test was applied-due to 0 subjects in the cells
One subject with very mild nasal obstruction pre operatively, had reported it as not a problem in the post-operative period. The proportion of subjects reporting complete relief of nasal obstruction among pre operatively reported moderate, fairly bad and severe problem categories was 80%, 50% and 100% respectively. Remaining proportion of people in moderate and fairly bad categories also reported improvement but persistence of it as a very mild problem post operatively (Tables 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14).
Table 2.
Comparison of pre and post-operative trouble breathing through my nose (N = 30)
| Preop trouble breathing through my nose | Post op trouble breathing through my nose | ||
|---|---|---|---|
| Not a problem | Very mild problem | Moderate problem | |
| Not a problem (N = 8) | 8 (100%) | 0 (0%) | 0 (0%) |
| Very mild problem (N = 7) | 6 (85.71%) | 1 (14.28%) | 0 (0%) |
| Moderate problem (N = 14) | 4 (28.57%) | 8 (57.14%) | 2 (14.28%) |
| Fairly bad problem (N = 1) | 0 (0%) | 1 (100%) | 0 (0%) |
No statistical test was applied-due to 0 subjects in the cells
Table 3.
Comparison of pre and post-operative degree of trouble sleeping (N = 30)
| Preop trouble sleeping | Postop trouble sleeping | ||
|---|---|---|---|
| Not a problem | Very mild problem | Moderate problem | |
| Not a problem (N = 4) | 4 (100%) | 0 (0%) | 0 (0%) |
| Very mild problem (N = 2) | 2 (100%) | 0 (0%) | 0 (0%) |
| Moderate problem (N = 14) | 9 (64.28%) | 3 (21.42%) | 2 (14.28%) |
| Fairly bad problem (N = 7) | 5 (71.42%) | 2 (28.57%) | 0 (0%) |
| Severe problem (N = 3) | 3 (100%) | 0 (0%) | 0 (0%) |
No statistical test was applied-due to 0 subjects in the cells
Table 4.
Comparison of pre and post-operative degree of unable to get enough air through my nose during exertion (N = 30)
| Preop unable to get enough air through my nose during exertion | Postop unable to get enough air through my nose during exertion | ||
|---|---|---|---|
| Not a problem | Very mild problem | Moderate problem | |
| Not a problem (N = 1) | 1 (100%) | 0 (0%) | 0 (0%) |
| Very mild problem (N = 4) | 4 (100%) | 0 (0%) | 0 (0%) |
| Moderate problem (N = 13) | 7 (53.84%) | 4 (30.76%) | 2 (15.38%) |
| Fairly bad problem (N = 10) | 4 (40%) | 4 (40%) | 2 (20%) |
| Severe problem (N = 2) | 2 (100%) | 0 (0%) | 0 (0%) |
No statistical test was applied-due to 0 subjects in the cells
Table 5.
Comparison of pre and post-operative degree of nasal stuffiness (N = 30)
| Preop nasal stuffiness | Postop nasal stuffiness | ||
|---|---|---|---|
| Not a problem | Very mild problem | Moderate problem | |
| Not a problem (N = 6) | 6 (100%) | 0 (0%) | 0 (0%) |
| Very mild problem (N = 6) | 1 (16.7%) | 5 (83.3%) | 0 (0%) |
| Moderate problem (N = 9) | 3 (33.3%) | 6 (66.7%) | 0 (0%) |
| Fairly bad problem (N = 6) | 0 (0%) | 6 (100%) | 0 (0%) |
| Severe problem (N = 3) | 2 (66.7%) | 0 (0%) | 1 (33.3%) |
No statistical test was applied- due to 0 subjects in the cells
Table 6.
Descriptive analysis of preoperative total score categories in the study population (N = 30)
| Prop total score categories | Frequency | Percentages |
|---|---|---|
| Mild (5–25) | 4 | 13.33 |
| Moderate (26–50) | 11 | 36.67 |
| Severe (> 50) | 15 | 50.00 |
Table 7.
Descriptive analysis of postoperative total score categories in the study population (N = 30)
| Postop total score categories | Frequency | Percentages |
|---|---|---|
| Mild (5–25) | 30 | 100.00 |
Table 8.
Comparison of mean nasal blockage or obstruction in pre-operative and post op operative (N = 30)
| Nasal blockage or obstruction | (Mean ± STD) | Mean difference | 95% CI of mean difference | P value | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Pre operative | 14.17 ± 2.96 | ||||
| Post operative | 2 ± 2.49 | 12.17 | 10.81 | 13.53 | <0.001 |
Table 9.
Comparison of mean trouble breathing through my nose in pre-operative and post operative (N = 30)
| Trouble breathing through my nose | (Mean ± SD) | Mean difference | 95% CI of mean difference | P value | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Pre op | 6.33 ± 4.54 | ||||
| Post op | 2.33 ± 3.14 | 4.00 | 2.67 | 5.33 | < 0.001 |
Table 10.
Comparison of mean Trouble sleeping in pre-operative and post op operative (N = 30)
| Trouble sleeping | (Mean ± SD) | Mean difference | 95% CI of mean difference | P value | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Pre op | 10.5 ± 5.62 | ||||
| Post op | 1.5 ± 2.98 | 9.00 | 6.68 | 11.32 | <0.001 |
Table 11.
Comparison of mean unable to get enough air through my nose during exercise or exertion in pre-operative and post op operative (N = 30)
| Unable to get enough air through my nose during exercise or exertion | (Mean ± SD) | Mean difference | 95% CI of mean difference | P value | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Pre op | 11.33 ± 4.54 | ||||
| Post op | 2.67 ± 3.65 | 8.67 | 6.71 | 10.62 | <0.001 |
Table 12.
Comparison of mean nasal stuffiness in pre-operative and post op operative (N = 30)
| Nasal stuffiness | (Mean ± SD) | Mean difference | 95% CI of mean difference | P value | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Pre op | 9 ± 6.35 | ||||
| Post op | 3.17 ± 2.78 | 5.83 | 3.69 | 7.98 | <0.001 |
Table 13.
Mladina’s classification of DNS
| Type I—Mild deviation in vertical plane |
| Type II—Moderate anterior vertical deviation of cartilaginous septum in full length |
| Type III—Posterior vertical deviation at level of Osteomeatal Complex and middle turbinate |
| Type IV—‘S’-shaped, posterior to one side and anterior to other |
| Type V—Horizontal septal crest touching or not touching the lateral nasal wall |
| Type VI—Prominent maxillary crest contralateral to the deviation with a septal crest on the deviated side |
| Type VII—Combination of previously described septal deformity types |
Table 14.
Objective analysis of DNS
| Grades | Preop | Postop |
|---|---|---|
| Objective analysis | ||
| Mladina classification (total—30 cases) | ||
| I | 1 (3.3%) | Septum central |
| II | 11 (36.67%) | Septum central |
| III | 2 (6.67%) | Septum central |
| IV | 8 (26.67%) | Septum central |
| V | 0 | |
| VI | 2 (6.67%) | Septum central |
| VII | 6 (20.0%)) | Septum central |
Discussion
The perception of nasal obstruction by a patient depends on a variety of factors including psychological and pathological. Operative techniques and patient expectation play a major role in assessment of satisfaction level postseptoplasty [1].
Pre and post operative assessment of symptoms are necessary for outcome analysis. Post septoplasty assessment is generally done by clinical examination and nasal endoscopy. Mladina classifies septal deformity into seven types on the basis of their orientation in vertical and horizontal axes [7]. As per a recent study, almost 90% of the subjects showed one of the seven types of septal deformity [8]. It is possible to assess nasal obstruction objectively by Rhinomanometry and Acoustic Rhinometry [9]. However, most of the time it is found that pre and post operative symptoms of patients do not correlate with the physical finding and objective measurements [10]. As patient’s perception of nasal airflow is of primary concern, the improvement in subjective score of patient’s symptoms is definitely an important outcome parameter of management plan in order to address the complex problem.
The NOSE scale is a disease specific instrument which can be used to assess nasal obstruction in group of patients. It can be used to compare the effect of medical versus surgical therapy. The nose scale can be used to assess the outcome of different surgical procedures. The NOSE scale can compare symptoms severity between different groups of patients [6]. Various studies have been conducted to validate the utility of septoplasty in septal deviation. Philip et al. [11] reported significant improvement following septoplasty in septal deformity patients. A significant improvement was seen in all symptoms of modified NOSE questionnaire except for blocked sensation in the ear preoperatively in their study.
Kahveci et al. [12] studied the efficacy of NOSE scale to assess for septoplasty results and correlation between NOSE scores and visual analoge scale for examination findings, acoustic rhinometry and coronal computed tomography. They in their study found that rhinometry can only show volume and area changes inside the nose and found its clinical use to be limited. Correlation was found between NOSE scores and examination and computed tomography findings in their study.
There are other disease specific quality of life questionnaire available to assess nasal complaints but none of them is specific to assess the nasal obstruction only. “Sino-Nasal Outcome Test (SNOT-22)” [13], the “Chronic Sinusitis Survey (CSS)” [14], the “Rhinosinusitis Disability Index (RSDI)” [15], the “Rhino-conjunctivitis Quality of Life Questionnaire (RQLQ)” [16] and the “Allergic Outcome Survey (AOS)” [17]. In our study it was found that improvement in nose scores (mean 7.93) correlated with the improvement in nasal endoscopic findings. In our study there was statistically significant improvement in all 5 parameters of the symptom of nasal score at 3 months follow up.
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 [18]. This indicates that not every nasal obstruction coming along with septal deviation is due to deviation. Other factors like concha bullosa or protruding inferior concha can also act as breathing barriers [19]. Insufficient nasal valve functioning that is not diagnosed prior to surgery can also contribute to the persistence of nasal obstruction [20]. Grymer and Rosberg [21] in a retrospective study of 42 patients, noted that alar insufficiency accounted for 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 [22] play a pivotal role in assessment and evaluation of surgical outcomes. For an appropriate use in clinical practice the questionnaire’s should be clear and comprehensive for the patients and then the validity and reliability has to be proven. In assessment of surgical outcome 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 outcome 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 polyp. 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 septoplasty.
Conclusion
The definitive treatment of deviated nasal septum (DNS) is the universally accepted surgical correction or septoplasty. However the benefits of septoplasty, as perceived by the patient, widely vary over different grades of satisfaction, ranging from complete alleviation of symptoms to a total failure. Use of NOSE score will help in letting the patient know about his or her expected outcome following septoplasty.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Standard
Permission taken from institutional ethical committee for doing this study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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