www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Disease-specific
quality
of
life
after
septoplasty
and
bilateral
inferior
turbinate
outfracture
in
patients
with
nasal
obstruction
夽
Lucas
Resende
∗,
Carolina
do
Carmo,
Leão
Mocellin,
Rogério
Pasinato,
Marcos
Mocellin
UniversidadeFederaldoParaná(UFPR),HospitaldeClínicas,Servic¸odeOtorrinolaringologia,Curitiba,PR,Brazil
Received28March2017;accepted12July2017 Availableonline29July2017
KEYWORDS Nasalsurgical procedures; Turbinates; Qualityoflife; Nasalseptum; Nasalobstruction Abstract
Introduction:Septaldeviationsmightcausenasalobstructionandnegativeimpactonthe qual-ityoflifeofindividuals.Theefficacyofseptoplastyfortreatmentofseptaldeviationandthe predictorsofsatisfactorysurgicaloutcomesremaincontroversial.Technicalvariability, hetero-geneityofresearchsamplesandabsenceofasolidtoolfor clinicalevaluationarethemain hindrancestotheestablishmentofreliablestatisticaldataregardingtheprocedure.
Objective: Toevaluatetheclinicalimprovementsinthedisease-specificquality-of-lifebetween patientssubmittedtoseptoplastywithbilateraloutfractureoftheinferiorturbinateunder seda-tionandlocalanesthesiainatertiaryhospitalandtoassesspossibleclinical---epidemiological variablesassociatedwithfunctionaloutcome.
Methods:Fifty-twopatientsconsecutivelysubmittedtoseptoplastywithbilateraloutfracture oftheinferiorturbinatefortreatmentofnasalobstructionfilledinformsregardingclinicaland epidemiologicalinformationduringenrollmentandhadtheirsymptom objectivelyquantified usingtheNoseObstructionSymptomEvaluation(NOSE)scalepreoperativelyandoneandthree monthsaftertheprocedure.Statisticalanalysisaimedtodetermineoverallandstratified sur-gicaloutcomesandtoinvestigatecorrelationsbetweentheclinical---epidemiologicalvariables withthescoresobtained.
夽 Pleasecitethisarticleas:ResendeL,CarmoC,MocellinL,PasinatoR,MocellinM.Disease-specificqualityoflifeafterseptoplastyand bilateralinferiorturbinateoutfractureinpatientswithnasalobstruction.BrazJOtorhinolaryngol.2018;84:591---98.
∗Correspondingauthor.
E-mail:lucasresendelucinda@gmail.com(L.Resende).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.07.001
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Results:StatisticallysignificantimprovementinthepreoperativeNOSEquestionnairecompared tothescoresobtainedthreemonthsaftersurgerywasdemonstrated(p<0.001,T-Wilcoxon),
withstrongcorrelationbetweenthepreoperativescore andthepostoperativeimprovement during this period (r=−0.614, p<0.001, Spearman). After onemonth, patients reachedin average87.15%oftheresultobtained atthestudy termination.Smokersandpatients with rhinitisand/orpulmonarycomorbidity showedincreasedaveragepreoperativeNOSEscores, althoughwithoutstatisticalsignificance(p>0.05).Gender,age,historyofrhinitisandpresence ofpulmonarycomorbiditydidnotinfluencesignificantlysurgicaloutcomes(p>0.05).Smokers presentedgreaterreductioninNOSEscoresduringthestudy(p=0.043,U-Mann---Whitney). Conclusion:Septoplastywithbilateraloutfractureoftheinferiorturbinatehasprovento sig-nificantlyimprovedisease-specificquality-of-lifeandthisfavorableoutcomeseemstooccur precociously.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Procedimentos cirúrgicosnasais; Cornetos; Qualidadedevida; Septonasal; Obstruc¸ãonasal
Qualidadedevidaespecíficadadoenc¸aapósseptoplastiaefraturabilateralde conchainferiorempacientescomobstruc¸ãonasal
Resumo
Introduc¸ão:Osdesviosseptaispodemcausarobstruc¸ãonasaleimpactonegativonaqualidade devidadosindivíduos.Aeficáciadaseptoplastiaparaotratamentododesvioseptaleos predi-toresderesultadoscirúrgicossatisfatórioscontinuamcontroversos.Avariabilidadetécnica,a heterogeneidadedasamostrasdeestudoeaausênciadeumaferramentasólidaparaavaliac¸ão clínicasãoosprincipaisobstáculosaoestabelecimentodedadosestatísticosconfiáveissobreo procedimento.
Objetivo:Avaliaramelhoraclínicanaqualidadedevidaespecíficadadoenc¸aentrepacientes submetidosaseptoplastiaefraturabilateraldaconchainferiorsobsedac¸ãoeanestesialocal emumhospitalterciárioepossíveisvariáveisclínico-epidemiológicasassociadasaodesfecho funcional.
Método: Cinquentae dois pacientesconsecutivamente submetidos aseptoplastia e fratura bilateral daconchainferiorparaotratamentodaobstruc¸ãonasal preencheramformulários cominformac¸õesclínicaseepidemiológicasduranteainclusãonoestudoetiveramseus sin-tomasquantificadosobjetivamenteutilizandoaescaladeAvaliac¸ãodeSintomasdeObstruc¸ão Nasal (NoseObstruction SymptomEvaluation-NOSE) nopré-operatório eum e trêsmeses apósoprocedimento.Aanáliseestatísticaobjetivoudeterminarresultadoscirúrgicosglobais eestratificadoseinvestigarcorrelac¸õesentreasvariáveisclínico-epidemiológicaseosescores obtidos.
Resultados: Foidemonstradaumamelhoraestatisticamentesignificativanosescoresobtidosno questionárioNOSEtrêsmesesapósacirurgia(p<0,001,T-Wilcoxon),quandocomparadocom osescoresobtidosnopré-operatório,comumafortecorrelac¸ãoentreoescorepré-operatório eamelhorapós-operatória duranteesse período (r=-0,614,p<0,001,Spearman). Apósum mês, os pacientesatingiram em média 87,15% do resultado obtido ao término do estudo. Fumantesepacientescomrinite e/oucomorbidadepulmonarapresentaram valores médios pré-operatóriosdoescoreNOSEaumentados,emborasemsignificânciaestatística(p>0,05). Sexo,idade,históriaderiniteepresenc¸adecomorbidadepulmonarnãoinfluenciaram signi-ficativamenteosresultadoscirúrgicos(p>0,05).Osfumantesapresentarammaiorreduc¸ãonos escoresdeNOSE(p=0,043,U-Mann-Whitney).
Conclusão:Aseptoplastiaefraturabilateraldaconchainferiordemonstrarammelhorar sig-nificativamenteaqualidadedevidaespecíficadadoenc¸aeeste resultadofavorávelparece ocorrerdeformaprecoce.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Thenasalseptumisamidlinestructureresponsiblefor giv-ingthenoseitscentralposition.Fromanteriortoposterior it could be divided into threedifferent portions, accord-ingtoitscomposition:amembranous,acartilaginousanda bonyportion.Whensignificantlydeviated,itmightresultin importantfunctionalandestheticproblems.Nasal obstruc-tionisthemostcommoncomplaintinrhinologicalpractice andseptaldeviationisconsidereditsmaincause.Ithasbeen estimated that up toone third of the general population presentswith somedegree of nasal obstruction, ofwhich upto25%areeligibleforsurgicalproceduresaspartofthe treatment.1
Indication for septoplasty is usually made on clinical grounds, although it might be supported by complemen-taryevaluation.2Ingeneral,thesurgicalapproachiselected
afterfailureofclinicaltreatmentofnasalobstructionwith medicationssuchastopicalcorticosteroids,antihystaminics anddescongestionants.1
Theefficacyofseptoplastyfortreatmentofseptal devi-ationandthepresenceofpredictorsofsatisfactorysurgical response remaincontroversial in the literature.Technical variability,the heterogeneityof researchsamplesand the absenceofasolidtoolforclinicalevaluationofthepatients are the main hindrances tothe establishment of reliable statisticaldata.Asaresult,clinicaloutcomefollowing sep-toplastyisstillratherunpredictable.
Duetothegreatamountofindividualswithsymptomatic septaldeviation,itisessentialtocontinuouslyevaluatethe efficacyofthe differenttechniques ofseptoplasty.3
Previ-ousstudieshavesuggestedobjectivebenefitsofoutfracture inthetreatmentofnasalobstruction,withorwithout con-comitantseptoplasty.4,5However,dataregardingsubjective
improvementsaftertheprocedureorpreoperative predic-tivefactorsofbettersurgicaloutcomesremainscarce.
Many diagnostic tools, such as computed tomography, rhinomanometry,rhynometry andquality of life question-naires, have been investigated to predict subgroups of patientswithgreaterprobabilityofhavingsatisfactory out-comes after septoplasty. Stewart et al.6 developed and
validatedtheNoseObstructionSymptomEvaluation(NOSE) scale asa disease-specific quality-of-life questionnaire in nasalobstruction. It consistsofa five-item questionnaire. Foreachitemthepatientscorefromzerotofour.Thesum ofthe itemsisthen multipliedbyfive,resultinginafinal scoreoftheclinicalburdenassociatedwithnasal obstruc-tionwhichrangesfromzerotoahundred.Table1showsthe originalversionofthisresearchtool.6,7
This is a prospective study, whose included patients agreed with the informed consent form, which was authorized by the Ethics Committee of The Hospital (n◦ 51009815.0.0000.0096).Theprimarygoalofthisstudyisto evaluatepatientswhoweresubmittedtoseptoplastywith bilateraloutfractureof theinferiorturbinatein atertiary Brazilianhospitalinordertotreatsymptomaticseptal devi-ationwithorwithouthypertrophyoftheinferiorconchae, astoimprovementsinthedisease-specificQL,measuredby theNOSEquestionnaire.Secondarygoalsincluded:toassess thecorrelationbetweenthepre-operativeNOSEscoresand thescorevariationafterthreemonthsofthestudyandto
determinepossibleclinical---epidemiologicalvariables asso-ciatedwithfunctionaloutcomeoftheprocedure.
Methods
ThepatientswereconsecutivelyrecruitedbetweenMayof 2015 and January of 2016. Inclusion criteria were: indi-viduals with chronic nasal obstruction caused by septal deviation;persistentsymptomsforovertwelveweeks; fail-ureofclinicaltreatmentofeventuallyconcomitantrhinitis; surgicalindicationofseptoplastyandageabove18years.
Weexcludedpregnantwomen,patientsundergoing sep-toplasty as a surgical access to other sites or along withrhinoplasty and patients withhistory or diagnosis of otherrhinologicalcomorbiditiessuchasseptalperforation, craniofacialmalformations,adenoidhypertrophy, granulo-matosis and chronic rhinosinusitis (according to the EPOS 20078 criteria). We also excluded patients with inferior
conchaehypertrophyrefractorytotheuseoftopical vaso-constrictorsandthereforewithformalindicationofsurgical techniquesincludingresectionofredundanttissue.
Septoplastywasdefinedasanopensurgerywhichaimed tostraightenthenasalseptumandasubmucosalapproach was preferred. In our study, this procedure was carried out under sedation (an initial 1mcg/kg loading dose of midazolam in 10min followed by continuous infusion of dexmedetomidine 0.2---0.7mcg/kg/h) and local anesthesia withlydocainewithvasoconstrictor(1:100,000).Theseptum wastherefore straightenedafterelevationof a mucoperi-chondrialandmucoperiostealflap.Thisflapwasraisedafter aseptocolumellaror transfixating incisionontheconcave sideofthedeflection.Afteraninitialchondrotomyadjacent tothedeviated portion,acontralateralflapwasalso ele-vated.Theremovalofthebonyandcartilaginousdeviated areaswasthenperformed,alongwithexcisionofanyspurs andridges.Acarefulapproachwasadoptedinorderto pre-servethestructureofthekeystonearea,whichisparamount tothe maintenanceof the nose structure. Ifthere wasa caudalseptaldeflection,itwasrepositionedinmidlineand thenanchoredwithU-suturesusingtheMetzembaum tech-nique,originallydescribedin1990.9Adrainageincisionand
atransseptalsuturealongtheareawherethedeviationhad beenremovedweremadetopreventhematomaformation. The bilateral turbinectomy was routinely performed as a simple,quicklyandrathertolerableprocedure.This proce-durebeganwithinfiltrationofbothinferiorturbinateswith thesame1:100,000lydocaine/epinephrine solution.Then, usingafreerelevator,theentireturbinatewasfirstmoved mediallyandsuperiorlyuntilacrunchingsoundwasheard. Usingthesame elevator,thewhole inferiorturbinate was then movedinferiorly andlaterally. By holding a large or mediumKillian’snasalspeculumvertically,eachofitsblades wasinserted ineach nostril,andthespeculumwas force-fullyopenedtoachieveeffectiveandfulllateralizationof both of the inferior turbinates. The use of postoperative splints or nasal packing wasnot necessary. The surgeries wereperformedbyresidentENTphysiciansfromour depart-ment,accordingtotheevaluationandtechnicalsupervision from an attending physician. During the study, the patientswerenotusinganymedications,besidesopportune
Table1 NasalObstructionSymptomEvaluation(NOSE)questionnaire.
Overthepastonemonth,howmuchofaproblemwerethefollowingconditionsforyou? Notaproblem Verymild
problem
Moderate problem
Fairlybadproblem Severeproblem
Nasalcongestionandstuffiness 0 1 2 3 4
Nasalblockageorobstruction 0 1 2 3 4
Troublebreathingthroughnose 0 1 2 3 4
Troublesleeping 0 1 2 3 4
Unabletogetairthroughnose duringexercise
0 1 2 3 4
treatmentforrhinitisifnecessaryandtailoredtothedisease severity,accordingtoARIA(AllergicRhinitisanditsImpact onAsthma)10 guidelines.
Theprimaryoutcomewasthedisease-specificQLscore, measured by the NOSE questionnaire validated for the Portuguese language,appliedbeforesurgery and oneand threemonthsafter the procedure.Data analysiswas car-riedout usingthe SPSS10.0 (SPSS Inc.,Chicago, IL). The non-parametric Wilcoxon T test was performed in order tocomparethepre-andpostoperativeNOSEquestionnaire scoresobtainedduringthefollowup.TheSpearman’s corre-lationcoefficientwasusedtoassessthecorrelationbetween thepreoperativescoreandthepostoperativeimprovement, calculatedbythedifferencebetweenpostoperative(three monthsaftersurgery)andpreoperativescores.Comparative analysisbetweensubgroupsaccordingtotheirbaseline char-acteristicswasevaluatedusingtheMann---WhitneyUtest.A p-valuelowerthan5%wasdeemedsignificant.
Results
Fifty-six patients met the inclusion criteria. From these, threelostfollow-up andhadtobe excluded.One patient hadanacuteepisodeof rhinosinusitispostoperativelyand
wasalsoexcluded fromthestudy.As aresult,52 patients completedthestudy protocolandhadtheirdataincluded instatisticalanalysis(Fig.1).
Clinicalandepidemiologicalbaselinecharacteristicsand theaveragepreoperativeNOSEscoreforeachsubgroupare presentedinTable2.Descriptivestatisticalanalysisofthese datashowedanegativeimpactofthefollowingfactorson preoperativeNOSEscores:smoking,historyofrhinitis, pul-monarycomorbidity,bilateralsymptomsandpreviousnasal trauma.However,noneofthesevariablesreachedstatistical significance(p>0.05,UMann---Whitney).
There was a statistically significant improvement assessed by theWilcoxon test on theoverall NOSE scores after three months of surgery, when compared to base-linedata(p<0.001).The reductiononthescoreswasalso significant when comparing preoperative and one-month follow-up values (p<0.001) and likewise when evaluating the scores after one and three months of the procedure (p=0.0096).Fig.2depictstheprogressionofaverageNOSE scoresduringthestudy.ConsideringthemeanNOSEvalue, it might be observed that 87.15% of the overall surgical outcome couldalready benoted at one-month follow-up. Spearman’s correlation coefficient showed strong corre-lation between preoperative NOSE questionnaire and the subjective improvement reported (NOSE score reduction,
56 patients were prospectively enrolled in the study
53 patients completed the questionnaires of interest
correctly
52 patients had their data analyzed 01 patient developed postoperative acute
rhinosinusitis
03 patients lost to follow up during data collection
Table2 AverageNOSEscoreaccordingtoclinicalanddemographicvariables,accordingtotimeofevaluation. AverageNOSEscore
Variable n(%) Preoperative After1month After3months Total
Gender Women 32(61.54) 75.16 30.94 21.09 42.39 Men 20(38.46) 74.75 27.00 24.25 42.00 Age(years) <30 17(32.69) 74.11 22.65 15.59 37.45 30---54 28(53.85) 74.82 31.07 27.14 44.34 >55 07(13.46) 77.86 39.28 19.28 45.48 Smoking Yes 05(9.62) 82.00 15.00 06.00 34.33 No 47(90.38) 74.26 30.96 24.04 43.08 Nasaltrauma Yes 05(9.62) 85.00 30.00 27.00 47.33 No 36(69.23) 75.97 28.88 22.08 42.31
Couldnotrecall 01(1.92) 70 45 55 56.66
Notinvestigated 10(19.23) 67 29.5 17.5 38 Pulmonarydisease Yes 08(15.38) 83.13 40.00 24.37 49.17 No 44(84.62) 73.52 27.50 21.93 40.98 Allergicrhinitis Yes 34(65.38) 77.06 31.32 23.68 44.02 No 18(34.52) 71.11 25.83 19.72 38.88 Obstruction Unilateral 29(55.76) 72.24 --- --- 29(55.76) Bilateral 23(44.23) 78.47 --- --- 23(44.23) Total 52 74.81 28.33 21.48 –20 0 20 40 60 80 100 120
AVERAGE NOSE SCORE
PREOPERATIVE AFTER SURGERY ONE MONTH AFTER SURGERY THREE MONTHS (p < 0.001)
(p < 0.001)
(p < 0.05)
Figure 2 Preoperative and postoperative (one and three months)averageNOSEscores(p<0.05).
i.e. the difference between the values of baseline NOSE scoreand ofthe samevariableafter threemonthsof the surgery)(r=−0.614,p<0.001)Ascatterplotclearlydepicts thiscorrelationbetweenpreoperativeNOSEscoresandthe magnitudeoftheimprovementobservedatthestudy end-point(Fig.3). 0 10 20 30 40 50 60 70 80 90 100 –100 –80 –60 –40 –20 0 20 P reoper a ti v e N O SE s c o re
Absolute improvement in the NOSE score during the study Figure3 Scatterplotshowingcorrelationbetween preoper-ative NOSEscores andtheimprovementin thescore after 3 monthsofthesurgery,calculated bythe differencebetween preoperativeNOSEvaluesandthescoresobtainedatthestudy endpoint(r=−0.614,p<0.001).
Mann---WhitneyU-testdidnotshowanystatistically sig-nificantdifferenceintheoverallmagnitudeofreductionof initialNOSEscoresatthestudyendpointwhenthepatients were grouped according to gender, age, associated rhini-tis,typeofsymptom(ifunilateralorbilateral),presenceof pulmonarycomorbidityorhistoryofnasaltrauma(p>0.05)
Table3 p-Value obtaineduponanalysisoftheimpactof differentclinicalandepidemiologicalfactorsonthe reduc-tionofpreoperativeNOSEscoreafterthreemonthsofthe procedure.
Variable p-Value
Gender 0.862
Agegroup
Betweentheyoungestandtheintermediary groups
0.307 Betweentheintermediaryandtheoldest
groups
0.472 Betweentheyoungestandtheoldestgroups 0.844
Smoking 0.043
Nasaltrauma 0.691
Pulmonarydisease 0.213
Typeofobstruction(unilateralorbilateral) 0.183
Reportofrhinitis 0.763
Mann---WhitneyU-test.Significancelevel<0.05.
(Table3).Inthissample,patientswhosmokedshowed
sig-nificantlygreaterimprovementintheirbaselinescoreswhen comparedtonon-smokingpatients(p=0.043)(Table3).
Theestimatedtimeofthewholeprocedurerangedfrom 15 to 45min, with an average duration of about 25min. Although not systematically counted and registered, the meantimeoftheturbinectomyalonewasunlikelytoexceed 5min.
Discussion
Thesurgicalmanipulationofthenasalseptumfortreatment of airflow obstruction has long been performed. The first report of a septoplasty dates back to 3500 b.c. in Egypt anditisdocumentedintheEbersPapyru.Therearemany describedtechniquesandincisionsforseptalsurgery,each onewithitsownadvantagesanddrawbacks.11Traditionally,
septaldeviationissurgicallytreatedasanopenprocedure, withhemitransfixationoftheanteriornasalmucosaand ele-vationofbilateralmucoperichondrialflaps.Thebonyand/or cartilaginouspart of theseptum implicatedonthe devia-tionisthenselectivelyremoved.Maximumtissueresection has been historically advocated in order to assure septal realignment.However, more aggressiveapproaches might impair future procedures and increase the risk of post-operative esthetical complications. Hence, avant-guarde techniques,suchastheuseofscarifications,haveemerged withtheintentiontopreservetheseptalstructureasmuch aspossible.3
Duringthepastfifteenyears,alargenumberofstudies aiming toevaluate the success rates of septoplastywere published.Theresultshavebeenmixed,withpositiverates rangingfrom27%to84%atafollow-upfrom6monthsto11 yearsaftersurgery.Thesestudiesshowdifferent methodol-ogyforassessingclinicalresponse,aswellasdiversesample sizes anddropout rates. As aresult,their findingscannot becompared.Someresearchhasalsobeenmadeon predic-torsofsatisfactorypost-septoplastyoutcomes.Nonetheless,
standardized guidelinesforselectingpatientswithgreater probabilityofsurgicalsuccessarestilllacking.12
SeveralrecentpapershaveusedNOSEquestionnaireto investigate nasal surgery overall success.7,13,14 This
ques-tionnaire has been proved suitable for evaluating French andEnglish-speakingpopulations.9Asforthefactors
affect-ingpostoperative outcomes,one studyhassuggested that agemighthaveanimpactonclinicalresponse.15Inanother
study,allergicrhinitishasalsobeenfoundtopredictworse outcomes.14
NOSE questionnaire has recently been validated for Portuguese-speaking patients.16 Preliminary studies have
used this tool in order to corroborate subjective clinical improvement after septoplasty and to assess the success rates of specific surgical techniques.17,18 Bezerra et al.
have shown significativeNOSE scorereductionafterthree months of septoplasty withor without turbinectomy. The authorsalsodemonstratedastrongcorrelationbetween pre-operative scores and the magnitude of surgical response. In this study,gender did not interfere withpostoperative outcomes.18
Thepresentstudyconfirmedthehypothesisthat septo-plastywithbilateral outfractureof theinferiorturbinates improvesdisease-specificqualityoflife,measuredbyNOSE questionnaireafter3monthsoftheprocedure.Therewas astatisticallysignificanteffectonNOSEaveragescore dur-ingthestudy follow-upperiod(p<0.001)(Fig.2)andalso astatisticalcorrelationbetweentheimprovementin post-operative score and the preoperative score in the NOSE questionnaire(r=−0.614,p<0.001)(Fig.3).
It was also detected a significant improvement on NOSE scoresalsowhencomparingthepreoperative values withthose obtained duringthe one month follow-up visit (p<0.001)andbetweenthescores obtainedafteroneand three months of the surgery (p<0.05) (Fig. 2). It should be highlighted that in this sample the major improve-ment on average NOSE scores during the follow-up was observed after one month of the surgery (87.15% of the reductionofthescore)(Table2).Thesedataindicatethat thepostoperativeimpactonqualityoflifemightbefound at least up to 3 months after surgery, although the sub-stantial benefitofseptoplastywithoutfractureof inferior turbinatescould bealreadydetermined 30daysafter the procedure.
Thesubgroupsofsmokerpatientsandofthosewith his-tory of previous nasal trauma, comorbid lung illnesses or concomitant rhinitis showedcomparatively worseaverage preoperative NOSE scores, although these results did not reachstatisticalsignificance(p>0.05).
In this study, no significant difference was observed between the improvements on NOSE scores stratified by gender, age,concomitant rhinitis, comorbid lung disease, history of nasal trauma or qualityof nasal obstruction (if unilateral or bilateral) (p>0.05). In this sample, smok-ersshowedasignificantlygreaterimprovementonaverage NOSEscores(p=0.043)(Table3).
Thestudy had thefollowing limitations: lackof a con-trol group, non-randomized sample and the fact that it wasconducted ina tertiary referral center.Being held in a tertiary hospital might have given rise to a selection bias,butprovidedhomogeneityofinterventionintermsof operativeteaminvolved,surgicaltechniquesemployedand
postoperativefollow-up. The lack of analternative treat-mentwithprovenefficacyforrefractorynasalobstruction affectedthefeasibilityofusingacontrolgroup.
Thesizeofthesample,despiteitssuitabilityfor investi-gatingtheprimaryoutcomeofthestudy,mighthamperthe analysisof theresultsaccording tosubgroupsof patients. Hence, dataobtainedafterstratifyingthecohortmust be furtherconfirmedbylargerstudies.
Objective methods for assessment of nasalobstruction werenotusedinthisstudy.Areviewofthecurrentliterature revealsthatthereisapoorcorrelation betweenobjective anatomicaldata(gradesofseptaldeviationorhypertrophy ofinferiorturbinates)andthescoresobtainedon disease-specific qualityoflife questionnaires.Therefore,acoustic rhinometrymustprovideageometricrepresentationofthe nasalcavity,butwithpoorclinicalcorrelation.16,19,20
The effectiveness of septoplasty for refractory nasal obstructionhasbeenpreviouslydemonstratedusing differ-entresearchtools,bothqualitativeandquantitative.16,21---24
However, in Brazil, only Bezerra et al. had published theirdataonsurgical outcomesusingaspecific qualityof life questionnaire. Other Brazilian studies had evaluated different turbinectomy techniques.25,26 Nevertheless, this
study sought to assess a specific, standardized and com-bined technique, which was systematically employed to allincluded patientsundergoingseptoplasty,regardlessof the grade of inferior turbinates hypertrophy. However,it shouldbeoutlinedthatweexcluded patientswithinferior turbinateshypertrophyrefractorytotopicaldecongestants, as these individuals needed to undergo different proce-dures which would warrant excision of redundant tissue. Due tothe greatvariability of approaches to the inferior turbinates during septoplasty, studies focusingon investi-gation of standardized techniques can minimize a strong bias.We didnotassessthe gradeofthe septaldeviation. This fact does not have an impact on the main conclu-sions of the study, if we consider that they represent the overall results we would expect for a heterogeneous universe of patients, similar to that we routinely found in clinical practices and tertiary hospitals. However, we highlight that not evaluating the grade of septal devia-tion might have influenced the statistical data obtained when comparing the subgroups of the sample. It should also be emphasized that, even when carried out system-atically, bilateral inferior turbinate outfracture did not increase morbidity among these individuals, as the over-all complication rate in the study was low (one patient developed postoperative acute rhinosinusitis and there was no incidence of abnormal bleeding requiring nasal packing or revision surgery). The absence of increased morbidity was fortunately accompanied by maintenance of great subjective outcomes. However, as turbinectomy wasperformed along with correctionof the septal devia-tion,theconclusions ofthisstudy cannotbeextrapolated to evaluate outfracture of the inferior turbinates with-out septoplasty. Yet,there is still noconsensus regarding the long-term efficacy of inferior turbinates outfracture and our study wascapable of predicting the clinical out-come only up to three months after surgery. Longterm follow-upstudieswithlargercohortsmightovercomethese potential limitations and help confirm the results we obtained.
Conclusion
Patientsundergoingseptoplastywithbilateral outfracture oftheinferiorturbinateundersedationandlocalanesthesia significantlyimproveddisease-specificquality-of-life, mea-suredbyNOSEquestionnaire.Therewasastrongcorrelation betweenworse preoperative scores andthe magnitudeof reductionofNOSE scores at thetermination ofthe study. Moreover,thescorescontinuedtodiminishuptothethird month offollow-up, but a large part ofthe improvement achievedwasobservedwithinthefirstmonthaftersurgery. Apart from smoking, no other clinical or epidemiological characteristic seems to have an impact on postoperative outcomes.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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