Örebro University School of Medicine Degree project, 15 ECTS May 2016
Septoplasty for nasal obstruction in Region
Örebro County – A retrospective study
evaluating postoperative complications and
quality of life
version 2Author: Sarmed Finjan
Table of contents
Abstract 3
Introduction and background 3
Nasal obstruction 3 Septal deviation 4 Septoplasty 4 Objective 5 Methods 5 Ethics 7 Statistics 7 Results 7 Discussion 10 Conclusions 12 References 13 Appendix 17 A 17 B 18 C 20 D 22
Abstract
Background
The nasal septum is a key element in the nasal construct. By separating the two nasal cavities it contributes to ensuring optimal airflow in and out of the nose. The nasal septum can become deviated from trauma, congenital abnormalities and iatrogenic or other causes. The deviation constricts airflow and leads to nasal obstruction. It is possible to correct this deviation with nasal septoplasty, one of the most commonly performed procedures involving the nose.
Objective
We wanted to evaluate the quality of septoplasty in Region Örebro County by studying postoperative complications and quality of life in patients that underwent septoplasty.
Methods
In this retrospective study 140 patients who underwent septoplasty in Region Örebro County were evaluated for postoperative complications (bleeding, infection, hematoma, synechiae or septal perforation). 85 of those patients were also evaluated regarding quality of life. Data was gathered from patient journals and the Swedish National Quality Registry for Septoplasty.
Results
We found that postoperative complications as defined were seen in 12,8% of patients. We observed a statistically significant improvement in self-assessed degree of nasal obstruction (p<0.01) and self-assessed impact on daily activities and/or sleep (p<0.01). 61% of patients reported symptomatic improvement after surgery, however only 21% answered they experienced no symptoms.
Conclusions
We concluded that the observed complication and improvement rates are in line with those observed in other studies and that further long-term evaluation of our patients is required.
Introduction and background
Nasal obstruction
Nasal obstruction can stem from a deviated nasal septum, nasal polyposis and hypertrophy of the turbinates or adenoid. Different forms of rhinitis, drugs or other etiologies can cause congestion which in turn leads to nasal obstruction [1]. When assessing nasal obstruction, a need arises to objectively quantify the subjective perception of nasal obstruction. Acoustic rhinometry and rhinomanometry can be used for this purpose. Acoustic rhinometry utilizes reflecting sound waves (sent into the nostrils) to confirm and locate the site of nasal obstruction [2]. Cross-sectional area (CSA) values are obtained for different parts of the nasal cavity. Rhinomanometry utilizes
the physician ascertain the nature and grade of nasal obstruction. Here we choose to focus on the deviated nasal septum as a cause of nasal obstruction.
Septal deviation
The nasal septum is the midline structure of the nose separating the nasal cavities. It is comprised of quadrangular cartilage, the perpendicular plate of ethmoid bone, vomer and the crests of the nasal, frontal, maxilla and palatine bones [4].
Several studies have made efforts to determine the prevalence of nasal septal deviation. In newborns, studies have shown a prevalence as high as 22% [5]. Mladina et al., using a a strict classification system, showed in a large international study that the prevalence in the adult population is 89% [6].
Septal deviations have a wide range of etiologies, including but not limited to trauma, infections and polyps [7].
The nasal septum can become deviated as early as during intrauterine life or birth [5]. Constant compression of the nose or developmental abnormalities that occur in the uterus can cause a septal deviation. During normal birth, the fetal head rotates within the birth canal. Depending on the position of the fetus, it may acquire a septal deviation corresponding to the direction of the rotation. This occurs because the cartilage becomes displaced during the rotation.
If sustained by an early age, even microfractures and the subsequent asymmetrical healing and growth of the entire nose and face may lead to a deviated nasal septum later in life [8-10].
As previously mentioned, trauma is a common cause of nasal septal deviation. Assault, accidents and sports are the most common etiologies of nasal bone fractures [11,12] and it has been observed that over 90% of nasal bone fractures are associated with a corresponding septal fracture [13]. Septal fractures may in turn lead to hematoma, infection and subsequent septal abscesses and necrosis [14]. Deformities in the septal cartilage and bone give rise to a septal deviation, which can cause nasal obstruction [15].
Septoplasty
Septoplasty is one of the most commonly performed ENT (Ear, Nose and Throat) procedures. Approximately 3000 septoplasties were performed in Sweden in 2014 [16].
There are three main approaches to septoplasty: endonasal, endoscopic and extracorporeal.
Endonasal septoplasty is the most commonly performed form of septoplasty. It is therefore
described. A hemitransfixion incision is made along the leading edge to reach the subperichondrial plane. The mucoperichondrial flap is elevated and dissection is continued onto vomer and along the inferior border of the quadrilateral cartilage. The quadrilateral cartilage is mobilized and the
deformity corrected or excised. Maxillary crest spurs are removed. The quadrilateral cartilage is repositioned and fixed with bilateral sutures. The incision is closed with quilting sutures [17]. The nose is then packed with a nasal packing material.
Endoscopic septoplasty utilizes endoscopic visualization. Improved visualization, minimal mucosal elevation [18] and less postoperative complications [19] are advantages that the endoscopic
approach has over the endonasal. However, when the septal deviation is deflecting caudally or associated with an external nasal deformity, the endonasal or extracorporeal approach is preferred.
Extracorporeal septoplasty is used for correcting the most substantial septal deviations. In the procedure, the septum is extracted. It is then corrected and reinserted [20]. When the extent of the septal deformity is too great, autologous cartilage grafts (costal or conchal for instance) can be used to reconstruct the septum [21].
Objective
The objective of this report was to study the quality of septoplasty in Region Örebro County. Beyond two clinical visits after surgery, patients undergoing septoplasty are not followed up in any regard by our clinics. Therefore, a need exists to determine if the surgery results are satisfactory. This was accomplished by evaluating postoperative complications and quality of life in patients that had undergone septoplasty. Firstly, we wanted to determine the rate of postoperative complications. Secondly, we wanted to evaluate patient satisfaction and improvements in symptomatology after surgery.
Methods
We performed a retrospective review of all patients who underwent septoplasty with the indication nasal obstruction at Örebro University Hospital, Karlskoga Hospital and Lindesberg Hospital from March 2013 to March 2015. 170 patients were identified.
Patient data regarding age, gender, preoperative rhinomanometric measurements, postoperative complications and follow-up visit (defined as a visit to the clinic six months to one year after surgery) were collected. Postoperative complications were defined as following
1. Bleeding. Patient has postoperatively been admitted for overnight admission or been in contact with and examined by an ENT specialist for nasal bleeding. Trivial bleedings were excluded.
2. Infection. Patient has postoperatively visited and been examined by an ENT specialist for classical symptoms of infection (fever, swelling, etc) and was prescribed antibiotics. 3. Hematoma. Patient has postoperatively been examined by an ENT specialist and a
hematoma was discovered.
4. Synechiae. Patient has postoperatively been examined by an ENT specialist and synechiae were discovered.
5. Septal perforation. Patient had septal perforation at follow-up visit.
One week postoperatively patients are examined with nasal endoscopy. Six months to one year postoperatively patients are invited for a follow-up visit. No routine for postoperative
rhinomanometry exists at our clinics.
Patients who underwent surgery on other indications as acute trauma, tumor or cosmetic reasons were excluded. Patients who had surgery performed on their sinuses, adenoid, tonsils, nasal polyps or had rhinoplasty performed simultaneously were also excluded. 30 patients were excluded.
Anonymized data regarding patient-reported symptoms, quality on life, result and information of surgery was collected from the Swedish National Quality Registry for Septoplasty. The data
collected concerned the same three hospitals, however, data for the year of 2013 was not available. Patients fill out a questionnaire concerning the nature and grade of nasal obstruction. Patients grade their nasal obstruction accordingly “None”, “Mild”, “Moderate” or “Severe”. Impact on daily activities is ranked in the same manner. Smoking habits, length and weight preoperatively are also assessed (Appendix A). The preoperative questionnaire is complemented with diagnostic
information by an ENT specialist. A perioperative questionnaire (Appendix B) is filled out by the surgeon. One month postoperatively the patients receive a questionnaire by mail concerning postoperative complications (Appendix C). One year postoperatively the patients receive a questionnaire by mail with the same questions as the the preoperative questionnaire but with additional questions regarding lasting complications and expectations of surgery (Appendix D). 89 patients were included in the questionnaire. 4 patients were excluded for not completing the questionnaire correctly.
Ethics
Approvals to study patient journals were acquired from the operations managers at the ENT clinics at the corresponding hospital of Örebro, Karlskoga and Lindesberg. No registries containing
individual patient data were created. Ethics approval was deemed unnecessary since this is a quality project by a student.
Statistics
Conventional arithmetics were used for calculation of means, sums, percentages and standard deviations. Wilcoxon signed-rank test was used for paired categorical variables. Spearman’s rank correlation test was used for correlation. All tests were two-tailed and conducted at 5% significance. IBM® SPSS® Statistics version 23 was used for statistical analysis and figures. Microsoft Excel ® version 15.19.1 was used for tables.
Results
Of the 140 patients included in the study, 105 were males (75.0%) and 35 were females (25.0%). The mean patient age of surgery was 35.2±15.3 and ranged between 15 and 85 (Table 1).
Table 1. Age distribution of septoplasty patients
Age group Patients Percent
< 20 22 15.7
20 - 39 63 45.0
40 - 59 42 30.0
> 60 13 9.3
Total 140 100
All procedures were performed under general anesthesia and with the endonasal approach. Nasal packing in the form of Merocel© was used. 50 patients (35.7%) had surgery done on their turbinates at the same occasion. Preoperative rhinomanometry was performed in 107 patients (76.4%). 65 patients (46.4%) had a follow-up visit.
Postoperative complications (Table 2) were seen in 18 patients (12.8%). In our study, 7 patients experienced bleeding, 6 had an infection and 2 presented with hematoma. Synechiae were seen in 2 patients. Septal perforation was seen in 3 patients. 2 patients experienced more than one
infection. No correlation was found between postoperative complications and sex, age or turbinate surgery.
Table 2. Complications of septoplasty (n=20)
Complications Cases Percent of all septoplasties (n=140)
Bleeding 7 5.0
Hematoma 2 1.4
Infection 6 4.3
Synechiae 2 1.4
Septal perforation 3 2.1
Questionnaire data from 85 patients was analyzed. Response rate to the preoperative questionnaire was 91.8%. Response rate to the one-month postoperative questionnaire was 44.7%. Response rate to the one-year postoperative questionnaire was also 44.7%.
32 patients (84.2%) answered that they were adequately informed of the procedure. 8 patients (21.1%) reported they had sought medical attention because of postoperative complications. 21 patients (55.3%) answered that the result of the surgery was what they had expected. We observed a statistically significant improvement in self-assessed degree of nasal obstruction (p<0.01). Only 8 patients (21.1%) reported complete symptom relief after surgery, however 22 patients (62.8%) reported improvement (Figure 1-2).
Figure 2. Postoperative self-assessed grade of nasal obstruction (n=38)
No correlation was found between improvement in grade of nasal obstruction and Body Mass Index, smoking habits or simultanous turbinate surgery.
We also observed a statistically significant improvement in self-assessed degree of impact on daily life and/or sleep (p<0.01). Only 5 patients (16.7%) reported no impact on daily life and/or sleep after surgery, however 18 patients (64.3%) reported improvement (Figure 3-4).
Figure 4. Postoperative self-assessed impact of nasal obstruction on daily activities and/or sleep (n=30)
Discussion
Various numbers have been reported regarding the risk of postoperative complications after septoplasty. They range from 5% to 60% [15], depending on the what the authors have defined as complications.
In this report we found that postoperative bleeding was seen in 5% of patients and infection in 4.3%. Previous studies have shown a postoperative bleeding rate of 6-13.4% and infection rate of 0.48%-12% [7,22-24]. We used a very strict definition of postoperative bleeding, which may explain our slightly lower rate of observed bleeding. The rate of infection was in line with what has been observed in other studies.
In a meta-analysis by Banglawala et al. it was observed that the frequency of hematoma after septoplasty was at most 6.9% [25,26]. This is in line with our observations (1.4%).
We observed a rate of synechiae formation of 1.4%, while recent studies have shown the rate to range between 5% to 36% [19,27-30].
The reasons for our lower rate of observed synechiae are several. Firstly, several of the studies mentioned have more follow-up visits than our clinics. Whether this is routine at the respective clinic or part of the study designs is not clear. Secondly, these studies have a notably lower
population of endonasal septoplasty patient involved. Thirdly, we observed that only 46.4% of our patients came for the second follow-up. With a lower rate of follow-up visits, and therefore a lower
probability to observe synechiae in patients combined with a larger study population we therefore see a lower rate of synechiae compared to other studies.
We suspect that the true rate of nasal septal perforations is actually higher than what we observed (2.1%). Not only because of the reasons mentioned above but also because it has been reported that several of patients with septal perforation are asymptomatic [24,31-34]. Nevertheless, our results are in line with the observations of Bloom et al; the incidence of septal perforation after septoplasty ranges between 1% and 6.7% [15].
It has been well established in numerous articles that septoplasty increases quality of life in patients with nasal obstruction [35-38]. Arunachalam et al. observed in their evaluation that 74% of patients reported improvement in grade of nasal obstruction after surgery [39]. Croy et al. observed
decreased symptom severity in 61.9% of patients [40]. These observations are in line with the ones in our study (62.8% reported improvement in degree of nasal obstruction). However, our results of only 21.1% of patients achieving symptom relief and 16.7% reporting no impact on daily activities one year after surgery are suboptimal. It is however important to note that only patients with remaining nasal obstruction answer the question regarding the impact of nasal obstruction on daily activities and/or sleep, therefore skewing results. Also, we observed that only 55.3% of patients answered that the procedure met their expectations. The causes of this dissatisfaction could be several. Firstly, the procedure might not have relieved the patients sufficiently of their symptoms. Secondly, the physician (or surgeon) may have conveyed an overestimated view of the patients’ chances for symptomatic improvement or the patients themselves for some reason have too grand expectations. Kuduban et al. recently studied patients who still experienced nasal obstruction after septoplasty and found that the leading causes were persistant obstructive septal deviation and inferior turbinate hypertrophy [41].
It has been shown in several published articles that symptom-relief and patient satisfaction in septoplasty patients are unsatisfactory when followed up long-term [42-44]. Since our study only concerns the short-term follow-up this area requires further investigation.
We observed an over-representation of men (75%), an observation that has been made in several other studies [6,19,45]. It has been postulated that a higher incidence of nasal trauma among men might be one of the reasons. We find this explanation probable, since it is well documented that the male sex dominates the nasal trauma cases [13,46,47]. This over-representation was observed by Ronis et al. to occur already in children attending preschool and primary school; it however
Journal data created before the year of 2013 were stored in paper format making information as previous history of nasal surgery difficult to obtain, and as such, were not included in the study. Furthermore, data from the Swedish National Quality Registry for Septoplasty was also only available from the end of the year of 2013.
Regarding patient-assessed quality of life and symptomatology, we experienced some difficulties in comparing our results to those of our international colleagues. Since our questionnaires neither utilize a scoring system nor go into great detail when assessing symptoms and quality of life, our ability to draw conclusions is limited to comparing broad patterns.
Conclusions
This study has attempted to review the quality of septoplasty in Region Örebro County. We conclude that our complication rates are in line with those observed in other articles. We also conclude that our results regarding quality of life in patients are difficult to interpret because of low response rate and difficulties in comparison. However, when comparing broad patterns such as subjective improvement in symptoms, our results reflect those of previous studies.
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Appendix
