Changes in Subjective Outcomes during the Early Period after Septoturbinoplasty

Nasal obstruction is a common symptom that causes considerable discomfort and is closely related to quality of life.1 Reversible factors, such as edema of the nasal mucosa, fixed factors, such as septal deformity, or both can cause nasal obstruction, and it can be difficult to assess the effect of each factor individually on nasal obstruction. Therefore, surgical treatment is generally performed in patients who do not respond to medical treatment.

Septal deviation is a common nasal finding, and the prevalence of a deviated nasal septum is up to 42.94% in South Korea.2 Septoplasty involves the surgical correction of a deviated septum and is one of the most frequently performed otorhinolaryngology surgeries in adults.3 Several studies have demonstrated the effectiveness of septoplasty for relieving symptoms of nasal obstruction, crusting, rhinorrhea, and postnasal drip.4 Recently, an open, multicenter, pragmatic, randomized controlled trial showed that septoturbinoplasty is more effective than non-surgical management for nasal obstruction in adults with a deviated septum.5 Also, recent studies have shown that correcting septal deviation by performing septal correction along with turbinoplasty is significantly helpful in improving the symptoms of nasal congestion.6

Until recently, evaluation of symptom improvement is generally evaluated at 6 months after surgery because the improvement of symptoms may not be sufficient due to edema or crusting in the early stages of surgery.7, 8, 9 Moreover, there is still a lack of research on changes in nasal and nose-related symptoms during the early period after septoplasty with or without turbinoplasty,9, 10, 11 which makes it difficult to determine a follow-up plan and to offer counselling. Therefore, we aimed to investigate changes in subjective outcomes within 6 months after septoturbinoplasty.

Septoplasty is a commonly performed surgery in otorhinolaryngology and can improve nasal obstruction by correcting a deviated nasal septum. Many studies have reported that improvement in the nasal symptoms following septoplasty can improve a patient’s quality of life.5, 10 Additional research has also indicated that septal deviation is not only related to quality of life but also to various diseases, such as cardiovascular diseases.11, 13 Thus, we thought that the SNOT-22 questionnaire could be better at evaluating improvement in nasal symptoms and nose-related symptoms after septoplasty over obstruction score.

Within 2–3 weeks after septoturbinoplasty, symptoms often do not improve satisfactorily for various reasons, such as crust formation, edema, and secretion. Until now, there has been a lack of studies on the duration required for these symptoms to stabilize, and few studies have compared the early postoperative symptoms with those at long-term follow-up. Thus, we set the first follow-up for this study at 1 month after surgery.14

It is important to be aware of the correlation between an improvement in symptoms and long-term results of septoturbinoplasty for counseling patients. In this study, we investigated whether the final prognosis could be predicted within a relatively short period of observation after septoturbinoplasty. We found that SNOT-22 scores in the first month after surgery were significantly lower than preoperative scores. As reflected in SNOT-22 scores, symptoms continued to improve until the 3rd month after surgery and then got a little worse at 6 months. However, there was no statistically significant difference among SNOT-22 scores at 1, 3, and 6 months after surgery. VAS-NO scores also decreased significantly at 1 month after surgery, and there was no significant difference between VAS-NO scores at 1 month after surgery and obstruction scores at 3 or 6 months after surgery. These results suggest that we can predict long-term results of septoturbinoplasty as early as postoperative 1 month. As to worsening of SNOT-22 scores as time progresses, Stewart, et al.15 showed significant symptom improvement at 3 months after septoturbinoplasty, but slightly worse symptoms at 6 months after surgery without statistical significance. We can postulate that the patients can experience an improvement in nasal obstruction in the early postoperative period with the correction of nasal structure, but they may feel uncomfortable again as the initial period after surgery passes and the patients become adapted to improved symptoms. However, some studies have reported that symptoms continue to improve for up to 12 months.16, 17, 18

Regarding factor analysis to predict improvement in symptoms after septoturbinoplasty, there was no significant correlation with sex, allergy, smoking history, and preoperative SNOT-22 score; however, the amount of improvement at the first month after septoturbinoplasty was significant in multivariate logistic regression analysis. Also, a larger difference in SNOT-22 scores between preoperative and 1 month after surgery was significantly associated with significant improvement of symptoms at 3 or 6 months after surgery; the cut-off value for this was 10.5 according to ROC curves. This result suggests that surgeons can explain the surgical results and prognosis to the patient using differences in SNOT-22 scores before and after surgery at 1 month. Meanwhile, some previous studies have also indicated that sex, allergy, and smoking history have no effect on improving symptoms after surgery.15, 19 Contrary to our results, worse preoperative symptoms were associated with better improvement of nasal symptoms in other studies.15, 19, 20

This study has several limitations. First, even though we set 1 month after septoturbinoplasty as the initial evaluation of surgery, we still do not exactly know when symptoms begin to stabilize. Thus, further studies on shorter time periods, such as 1, 2, and 4 weeks, may be required. Second, the number of patients who participated in the study was too small for a definitive conclusion. In addition, there were 97 patients who underwent septoturbinoplasty during the study period; however, follow-up was not completed in all patients. This may have affected the accuracy of our analysis. To reach a concrete conclusion, we need to study a larger number of subjects and complete follow-up in all of them. Third, we considered significant symptom improvement as a SNOT-22 score that improved 9 or more points based on the results of a previous study.12 However, this is not a standard criterion. Therefore, results may differ when the criteria for symptom improvement are varied. Fourth, we could not consider the effect of patient compliance with medicine and/or nasal irrigation due to the limitations of retrospective studies. Fifth, our results are limited to subjective symptoms of patients. If objective results, such as endoscopic findings, rhinomanometry, and acoustic rhinometry, are included in a further study, more precise results will be obtained. Finally, changes in the quality of life in early after septoturbinoplasty could be affected by differences in culture, medical environment, and medical insurance between countries. Therefore, the results should be interpreted with caution.

In this study, we found that subjective symptoms in the first month after septoturbinoplasty improve significantly over those before septoturbinoplasty and that the degree of improvement at 1 month after surgery is significantly associated with a significant improvement in symptoms at 3 or 6 months after surgery. In conclusion, these results imply that subjective outcomes and the degree of improvement in the first month can be used as a predictor of the results of septoturbinoplasty and for counseling patients about its progress.