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Narrowed Posterior Nasal Airway Limits Efficacy of Anterior Septoplasty.

ABSTRACT: Background: Predicting symptomatic relief after septoplasty has been difficult. Minimal cross-sectional area (mCSA) measured by acoustic rhinometry and airflow resistance (R) measured by rhinomanometry have been used to select surgical candidates with mixed success. An important assumption is that mCSA and resistance are tightly coupled, but studies have reported weak or no correlation. Recently, we proposed the Bernoulli Obstruction Theory as an explanation, where tight coupling between mCSA and R is only predicted below a critical mCSA (A_crit). Methods: The nasal airway and septum of 10 healthy subjects were reconstructed from computed tomography scans. Simulated anterior septal deviations of increasing severity were created. Computational fluid dynamics simulations were performed to quantify mCSA, resistance, and flow in the healthy septum model and four simulated septal deviation models for each subject (total of 50 models). Results: A tighter coupling between mCSA and resistance was found below A_crit, estimated to be 0.20 cm² (a very severe deviation). Above A_crit, enlarging the mCSA had a smaller effect in patients with narrower cross-sectional area in the postvalve region (CSA_PV). Conclusions: Two patterns of flow increase are expected with septoplasty. Below A_crit, enlarging mCSA predictably increases flow. Above A_crit, the effect size of increasing mCSA depends on CSA_PV. Unrecognized small CSA_PV may explain persistent sensation of nasal obstruction after septoplasty. Our data suggest that inferior turbinate reduction ipsilateral to a septal deviation may amplify airflow benefits after septoplasty in patients with a narrow CSA_PV.

SUBMITTER: Campbell DA

PROVIDER: S-EPMC7876352 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundSeptoplasty (surgery to straighten a deviation in the nasal septum) is a frequently performed operation worldwide, with approximately 250,000 performed annually in the US and 22,000 in the UK. Most septoplasties aim to improve diurnal and nocturnal nasal obstruction. The evidence base for septoplasty clinical effectiveness is hitherto very limited.AimsTo establish, and inform guidance for, the best management strategy for individuals with nasal obstruction associated with a deviated septum.Methods/designA multicentre, mixed-methods, open label, randomised controlled trial of septoplasty versus medical management for adults with a deviated septum and a reduced nasal airway. Eligible patients will have septal deflection visible at nasendoscopy and a nasal symptom score ≥ 30 on the NOSE questionnaire. Surgical treatment comprises septoplasty with or without reduction of the inferior nasal turbinate on the anatomically wider side of the nose. Medical management comprises a nasal saline spray followed by a fluorinated steroid spray daily for six months. The recruitment target is 378 patients, recruited from up to 17 sites across Scotland, England and Wales. Randomisation will be on a 1:1 basis, stratified by gender and severity (NOSE score). Participants will be followed up for 12 months post randomisation. The primary outcome measure is the total SNOT-22 score at 6 months. Clinical and economic outcomes will be modelled against baseline severity (NOSE scale) to inform clinical decision-making. The study includes a recruitment enhancement process, and an economic evaluation.DiscussionThe NAIROS trial will evaluate the clinical effectiveness and cost-effectiveness of septoplasty versus medical management for adults with a deviated septum and symptoms of nasal blockage. Identifying those individuals most likely to benefit from surgery should enable more efficient and effective clinical decision-making, and avoid unnecessary operations where there is low likelihood of patient benefit.Trial registrationEudraCT: 2017-000893-12, ISRCTN: 16168569. Registered on 24 March 2017.

Project description:ImportancePostoperative packing in nasal surgery often results in nasal obstruction and discomfort. Commercially available silicone intranasal airways (IAs) serve as dual-nasal airway tubes aimed at alleviating this process, but the safety and efficacy of these devices are unknown.ObjectiveTo evaluate the safety and efficacy of an intraoperatively placed IA device in rhinoplasty and nasal surgery.Design, setting, and participantsIn this retrospective record review, the medical records of patients undergoing nasal surgery with insertion of the IA at a single institution from 2012 to 2017 were reviewed. After review of over 200 patients, a questionnaire was developed to assess device efficacy.ExposuresUse of the IA device. The IA is 12 cm long, anchored across the columella, extends distally along the nasal floor, and has a proximal external portion used for cleaning and maintaining patency. Placed intraoperatively, the device aims to support air flow postoperatively in the face of edema, hemorrhage, and packing.ResultsA total of 302 operations in 300 patients were analyzed, including primary and revision septorhinoplasty. A total of 24 (7.9%) patients self-removed or inadvertently dislodged the IA. Minor acute postoperative complications not unique to airway insertion included cellulitis in 4 (1.3%) participants and epistaxis in 6 (2%). Postoperatively, 1 (0.3%) patient developed dehiscence along transcolumellar incisions. A total of 59 patients (100% compliance) completed the efficacy questionnaire. The mean breathing score was between good and average (2.9 of 5), comfort scores between comfortable and average (2.9 of 5), and mean ease of irrigation score was between very easy and easy (1.96 of 5). The device was irrigated on average 3.57 times per day. A total of 43 (76%) particpiants had full patency or only partial obstruction, compared with 13 (24%) patients with total obstruction. In all patients, with or without obstruction, the effect lasted an average of 4 days.Conclusions and relevanceThe device is safe and well-tolerated for maintaining patency of the nasal airway in patients undergoing rhinoplasty and nasal reconstruction without increased risk of incisional dehiscence.Level of evidence4.

Project description:ObjectiveTo assess the clinical effectiveness of septoplasty.DesignMulticentre, randomised controlled trial.Setting17 otolaryngology clinics in the UK's National Health Service.Participants378 adults (≥18 years, 67% men) newly referred with symptoms of nasal obstruction associated with septal deviation and at least moderate symptoms of nasal obstruction (score >30 on the Nasal Obstruction and Symptom Evaluation (NOSE) scale).InterventionsParticipants were randomised 1:1 to receive either septoplasty (n=188) or defined medical management (n=190, nasal steroid and saline spray for six months), stratified by baseline symptom severity and sex.Main outcome measuresThe primary outcome measure was patient reported score on the Sino-Nasal Outcome Test-22 (SNOT-22) at six months, with 9 points defined as the minimal clinically important difference. Secondary outcomes included quality of life and objective nasal airflow measures.ResultsMean SNOT-22 scores at six months were 19.9 (95% confidence interval 17.0 to 22.7) in the septoplasty arm (n=152, intention-to-treat population) and 39.5 (36.1 to 42.9) in the medical management arm (n=155); an estimated 20.0 points lower (better) for participants randomised to receive septoplasty (95% confidence interval 16.4 to 23.6, P<0.001, adjusted for baseline continuous SNOT-22 score and the stratification variables sex and baseline NOSE severity categories). Greater improvement in SNOT-22 scores was predicted by higher baseline symptom severity scores. Quality of life outcomes and nasal airflow measures (including peak nasal inspiratory flow and absolute inhalational nasal partitioning ratio) improved more in participants in the septoplasty group. Readmission to hospital with bleeding after septoplasty occurred in seven participants (4% of 174 who had septoplasty), and a further 20 participants (12%) required antibiotics for infections.ConclusionsSeptoplasty is a more effective intervention than a defined medical management regimen with a nasal steroid and saline spray in adults with nasal obstruction associated with a deviated nasal septum.Trial registrationISRCTN Registry ISRCTN16168569.

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Narrowed Posterior Nasal Airway Limits Efficacy of Anterior Septoplasty.

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