xRead - Nasal Obstruction (September 2024) Full Articles

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measurements of obstructive symptoms, QOL or nasal patency. Therefore, in recent years there has been debate about the true value of septoplasty in improving subjec tive symptoms related to restrained nasal airway breathing. Research on this topic was prioritized by the British National Institute of Health and Research to overcome this gap of knowledge. 58 In response, van Egmond et al. recently published a RCT comparing septoplasty with nonsurgical management in adults with a deviated sep tum complaining of upper-airway obstructive symp toms. 58 Outcome measures were health-related QOL and objective nasal patency assessment. They concluded that septoplasty is more effective than non-surgical manage ment for nasal obstruction in adults with a deviated sep tum. 58 Moreover, in 2020, the same group published an economic evaluation showing that surgery would appear to be cost effective in the long term when compared to medical treatment. 59 The main strength of our study is that this is the fi rst meta-analysis to answer the call for further research in investigating the ef fi cacy of functional septoplasty, which has been voiced from clinical practice. However, this study is subjected to some limitations. First, no strat i fi cation of septal deviation severity was feasible and therefore subgroups analysis could not be performed. Sec ond, subdomains of the NOSE score could not be inves tigated because the raw data were missing for most of the included studies. Third, a wide range of surgical techniques are employed in the correction of nasal sep tal deviation and turbinates ’ hypertrophy, leading to a potential confounding bias. Regarding the impact of turbinate surgery on the NOSE score in the current lit erature, two previous systematic reviews showed a potential bene fi t of performing turbinoplasty in con junction with septoplasty. 6,60 In our study, we per formed a subgroup analysis distinguishing patients who underwent septoplasty with or without inferior turbinate surgery. Although the sample size of this analysis is relatively high, no signi fi cant difference was measured between subgroups. For this reason, the real bene fi t of concurrent turbinate surgery should be fur ther investigated, and the clinical bene fi t should be quanti fi ed in prospective comparative studies. Also, there is lack of a control group, creating uncertainty about the true effect size of treatment, because some spontaneous improvement or patient tolerance to a mean symptom state may also occur from natural his tory. Finally, our con fi dence in these results is tem pered by the high between-study heterogeneity measured in the single-arm meta-analysis, and the potential for bias inherent to observational studies. However, our in fl uence-subgroup analyses failed to fi nd potential sources of heterogeneity. As already written above, symptoms of nasal obstruction are subjective, and the fi ndings of nasal examination and endoscopic evaluation are not always balanced with the patient complaints. For this reason, the indication for septoplasty should be based on different factors. The wide range in baseline NOSE scores in the population of the included studies would suggest that varying

alone and studies including patients who underwent septoplasty with turbinate surgery. A non-signi fi cant dif ference was measured between the two subgroups (septoplasty alone: n = 962; pooled MD: 43.9, 95% CI: 55.0 to 32.9; septoplasty with turbinate surgery: n = 599; pooled MD: 52.9, 95% CI: 62.5 to 43.2). Meta-regression showed a nonsigni fi cant linear asso ciation between the pooled MD in NOSE score and the follow-up time ( p = 0.19). Accordingly, the residual between-study heterogeneity does not differ after the inclusion of the follow-up time in the model, con fi rming its limited impact on the change in NOSE score after sur gery ( I 2 = 97.5%; τ 2 = 158.2; Q = 1188.1, p <0.05). DISCUSSION This is the fi rst systematic review and meta-analysis providing aggregate and quantitative data regarding the change in patient-reported nasal obstructive symptoms measured according to NOSE questionnaire scores in adult patients who underwent septoplasty with or with out turbinate surgery for symptomatic nasal obstruction. The results obtained in this meta-analysis demonstrate a signi fi cant reduction in obstructive symptoms according to the NOSE questionnaire after septoplasty with a pooled mean difference of 48.8 points at 6 months follow up, when compared to baseline. A critical decrease in NOSE score was already observed at 3 months post-sur gery, and it is maintained at longer follow-up. Only 3threeof the included studies reported outcomes at follow-up longer than 6 months, however, the available data con fi rm the stability of the symptomatic improve ment obtained with septoplasty at 12-months post opera tion. Moreover, meta-regression analysis showed a limited impact of follow-up time on the change in NOSE score after surgery. The NOSE scale was developed to de fi ne the disease speci fi c QOL in individuals with nasal obstruction associated complaints, consisting of fi ve 5-point Likert Scale questions related to nasal obstruction. 17 Today, its widespread use and global popularity in outcome research and surgical evaluation are due to both its accu racy and ease in comprehension and ful fi lment. 56,57 Fur thermore, it comprised different parameters allowing a comprehensive analysis of patient ’ s discomfort, differ ently from objective measures that assess only one parameter. Therefore, the baseline NOSE score should always be gathered during preoperative visits to have a comprehensive quantitative and qualitative view of patient ’ s nasal breathing discomfort, and also to better predict the quantitative bene fi t after surgery. Septoplasty and inferior turbinate reduction are the most common procedures targeted toward improving the nasal airway obstruction. Many outcomes-based studies have examined the ef fi cacy of septoplasty on the relief of nasal obstructive symptoms, and they all agree in improvement of symptoms and quality of life after func tional septoplasty in adults with nasal septal deviation. However, most of the evidence for the effectiveness of septoplasty was based on prospective and retrospective cohort studies, comparing preoperative and postoperative

Laryngoscope 133: December 2023

Alessandri-Bonetti et al.: NOSE Score After Septoplasty

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