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Editorials

Septoplasty for nasal obstruction

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2341 (Published 18 October 2023) Cite this as: BMJ 2023;383:p2341

Linked Research

Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction

  1. Annakan V Navaratnam, consultant rhinologist, facial plastic and ENT surgeon,
  2. Alfonso Luca Pendolino, senior clinical rhinology fellow
  1. Department of Ear, Nose and Throat, Royal National ENT and Eastman Dental Hospitals, London WC1E 6DG, UK
  1. Correspondence to: A V Navaratnam annakan.navaratnam{at}nhs.net

New trial paves the way for evidence based guidelines

Health resources everywhere are stretched in this post-pandemic era. The pursuit of effectiveness has led policy makers and health insurance companies to pay close attention to the value of common procedures, and otorhinolaryngology is not spared.12 In common with other surgical techniques developed before evidence based medicine, there is a paucity of high quality evidence evaluating septoplasty and therefore no clear guidelines for its use. Consequently, clinicians have varying opinions about when, or even if, septal surgery can benefit patients with nasal obstruction.

In the linked paper, Carrie and colleagues (doi:10.1136/bmj-2023-075445) enrolled 378 adults with septal deviation and at least moderate symptoms of nasal obstruction into a randomised controlled trial: the Nasal Airways Obstruction Study (NAIROS).3 Participants were randomised 1:1 to receive either septoplasty (with or without unilateral inferior turbinate surgery at the surgeon’s discretion) or defined medical management (nasal steroid and saline spray for six months). The authors observed a statistically significant improvement at both six and 12 months in reported sinonasal symptoms among participants randomised to receive septoplasty, and better scores in quality of life and nasal breathing at six months.

In the only other randomised controlled trial comparing septoplasty, with or without inferior turbinate surgery (unilateral or bilateral), and non-surgical management, van Egmond and colleagues also found better patient reported outcomes up to 24 months after septoplasty.4 Both studies used health related quality of life questionnaires as their primary outcome. Carrie and colleagues used the disease specific instrument (the Sino-Nasal Outcome Test-22), whereas van Egmond and colleagues used a general quality of life measure (Glasgow Health Status Inventory). This highlights the importance of this procedure in improving quality of life as its final goal.

Both randomised controlled trials showed that septoplasty offered substantial subjective and objective benefits over non-surgical management. One important difference between the studies was the management of the participants in the non-surgical arm. This was undefined in the study by van Egmond and colleagues, whereas patients had a specific medical treatment regimen in Carrie and colleagues’ study.

Carrie and colleagues’ findings are compelling and provide a strong evidence base supporting septoplasty for patients with reported nasal obstruction associated with septal deviation. This does not, however, mean that all patients with nasal blockage and septal deviation should be offered septoplasty over medical management.

Impaired nasal breathing can have a multitude of causes.5 Mucosal inflammatory disease processes such as allergic rhinitis can contribute substantially to obstructed nasal airflow and are predominantly managed with medical treatment.6 Furthermore, some anatomical nasal disorders such as dynamic nasal valve collapse are seldom corrected with septoplasty alone.7 In NAIROS, patients with causes of nasal obstruction other than septal deviation were not identified specifically and were included in the overall study cohort.

A major difficulty in evaluation of septoplasty outcomes is a lack of consensus on the classification of septal deformities.8 The extent and location of nasal septal deviation was not documented in NAIROS. The type of septal deviation present would potentially indicate which patients may benefit most from septoplasty and which surgical approach should be adopted. Advanced surgery in the form of a functional septorhinoplasty may be warranted in some patients with more complex conditions.910

The methods used in Carrie and colleagues’ trial allowed several possible confounding factors into the analysis. The surgical techniques used, although all endonasal (no external scars), were not standardised, and the use of additional interventions such as inferior turbinate surgery was uncontrolled. Arguably, however, it was the pragmatic design that allowed such an important trial to be conducted in the first place.

The Getting it Right First Time ENT report (a key national report on ear, nose, and throat surgery in England)11 published in 2019 highlighted variation in the rate of septoplasty operations in adults across otolaryngology departments in England.12 Comprehensive fact finding visits to all English ear, nose, and throat units revealed contrasting opinions over precise indications for septoplasty. As a result, septoplasty was often performed based on a clinician’s experience owing to a lack of robust evidence.

The results of Carrie and colleagues’ trial will provide a basis for guidance both for primary care clinicians and for ear, nose, and throat surgeons about the indications for septoplasty. An opportunity also exists for streamlining patient pathways, optimising referrals, and ensuring that all patients receive the same high level of care while tackling the substantial backlog in the National Health Service.13

At a time when the NHS and many other health systems are focused on tackling the backlog of patients awaiting operations, funding for surgical procedures is being closely examined to find cost savings, and clinicians have a responsibility to ensure the effectiveness of their treatments. Carrie and colleagues’ have produced a landmark study showing the efficacy of septoplasty over medical management in patients with nasal obstruction due to a deviated nasal septum. It is vital that these findings now translate into guidance to ensure all patients with suitable pathology are offered this effective intervention.

Footnotes

  • Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References