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 2

Author: Sarmed Finjan Supervisor: Åke Davidsson MD. Ph.D.

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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

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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

differences in airflow and pressure to calculate nasal airway resistance [3]. These methods can help

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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].

The procedure is commonly performed under general anesthesia. Topical decongestant is applied to

the nose, followed by injections of local anesthetic.

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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.

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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.

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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

complication; one patient experienced bleeding and infection and one patient had a hematoma and

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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 1. Preoperative self-assessed grade of nasal obstruction (n=78)

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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 3. Preoperative self-assessed impact of nasal obstruction on daily activities and/or sleep (n=78)

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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

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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

increased markedly in teenagers [48].

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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 A

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19

B

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21

C

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D