Septoplasty

What repeats

Five findings that hold across the literature.

Surgery beats sprays in both randomised trials

NAIROS randomised 378 adults across 17 UK clinics to septoplasty or six months of nasal steroid and saline spray. At six months the mean SNOT-22 score was 19.9 in the surgical arm and 39.5 in the medical arm, an estimated 20.0 points better for surgery. The Dutch trial randomised 203 adults and measured quality of life at 12 months on the Glasgow Health Status Inventory: 72·2 after surgery against 63·9 without, a mean difference of 8·3, and the effect held to 24 months.

Rests on: Carrie et al., NAIROS · van Egmond et al., Lancet trial · and nasal airway obstruction.

The worse the blockage at the start, the larger the gain

NAIROS found that greater improvement in SNOT-22 was predicted by higher baseline symptom severity. Both trials required moderate or worse symptoms to enter: a score above 30 on the NOSE scale. The meta-analysis of the randomised evidence found no difference from sprays at three months and a difference at six and twelve, so the benefit takes time to appear.

Rests on: Carrie et al. · Rennie et al., trial protocol · Taha et al., meta-analysis.

Complications are uncommon, and bleeding is the common one

In NAIROS, seven of the 174 patients who had surgery were readmitted with bleeding, 4%, and a further 20 patients, 12%, needed antibiotics for infection. In the Dutch trial one surgical patient had a septal abscess and two had a septal perforation. Pooled across the randomised evidence, rates ran from 0.31% for revision surgery to 4.12% for bleeding and infection.

Rests on: Carrie et al. · van Egmond et al. · Taha et al..

Smell improves after the airway opens

A meta-analysis pooled 996 patients tested before and after septoplasty. Scores rose on every test used. The pre-operative to post-operative differences in means were 0.63 for the Brief Smell Identification Test, 0.80 for the Connecticut test, 1.16 for odour threshold, 1.43 for odour discrimination and 1.18 for odour identification. The authors call the effect discrete and unequal between patients.

Rests on: Grabosky et al., olfactory meta-analysis.

It is not a treatment for sleep apnoea

Forty-nine patients with obstructive sleep apnoea and a fixed blockage from a deviated septum were randomised to septoplasty or sham surgery. Every patient in the sham group was a non-responder, and in the surgical group four of 27, 14.8%, responded. Nasal surgery rarely treats obstructive sleep apnoea effectively.

Rests on: Koutsourelakis et al., sham-controlled trial.

By how the operation is done

The choices a surgeon makes inside one operation.

Endoscope or headlight

A meta-analysis of 38 articles covering 2733 people found endoscopic septoplasty gave a larger change in NOSE score and less mucosal tearing, and fewer cases of epistaxis, haematoma, residual deviation, perforation, spur and synechia. A separate meta-analysis of 13 randomised trials with 735 patients found endoscopic surgery better for obstruction relief, with a risk ratio of 1.20. A single randomised trial of 63 patients found the same NOSE improvement in both arms, with operative time and intraoperative complications favouring the endoscope.

Rests on: Kim et al., endoscopic meta-analysis · Besharah et al., randomised-trial meta-analysis · Paradis and Rotenberg, randomised trial.

With or without turbinate reduction

Twelve randomised trials enrolling 775 participants compared septoplasty alone with septoplasty plus reduction of the inferior turbinate. Reducing the enlarged turbinate on the wider side gave better NOSE scores. The rate of adverse events was significantly higher with the added procedure.

Rests on: Bin Lajdam et al., turbinate meta-analysis · and turbinate surgery.

Packing, splints or stitches

Nineteen randomised trials with 1845 subjects compared a stitch through the septum against packing the nose. Pain, headache and adhesions were lower with the stitch. Bleeding, haematoma, perforation, infection and residual deviation were the same. A systematic review of 17 studies reached the same point on pain: quilting sutures hurt less than either packing or splints.

Rests on: Wang and Dong, suturing versus packing · Quinn et al., postoperative management.

When the splints come out

Six studies with 516 patients grouped removal into days 1 to 3, days 4 to 7 and after day 7. Pain was lower with late removal than with intermediate removal. NOSE scores favoured early and intermediate removal over late. Smell testing was worse after early removal than after either later timing.

Rests on: Alansari et al., splint timing.

Antibiotics or none

Fifteen studies covering 2225 patients, 1274 given prophylactic antibiotics and 951 not, produced an odds ratio of 0.65 with a confidence interval of 0.23 to 1.89. No significant protective effect against post-operative infection.

Rests on: Benites et al., antibiotic meta-analysis.

What to ask about a septoplasty

Questions the evidence supports asking.

How blocked do I have to be for this to be worth it

The trials enrolled people scoring above 30 on the NOSE scale, and the size of the gain tracked the size of the starting symptom. Ask for your NOSE score before and after, and ask what the surgeon expects it to be at six months.

Rests on: Rennie et al. · Carrie et al..

Are the turbinates coming down at the same time

Adding turbinate reduction improved symptom scores in the pooled randomised evidence and raised the rate of adverse events. Ask which turbinate, how much, and by what method.

Rests on: Bin Lajdam et al. · and turbinate surgery.

What will be in my nose afterwards, and for how long

Packing, splints and septal stitches are the three options, and the stitch is the one associated with less pain and fewer adhesions. If splints go in, ask on which day they come out.

Rests on: Wang and Dong · Alansari et al. · and recovery.

What happens if the septum bends back

The pooled revision rate in the randomised evidence was 0.31%, and residual deviation is reported separately from revision. Ask how the surgeon handles the caudal end, which is the part that most often stays crooked.

Rests on: Taha et al. · and the caudal septum.

The terms, defined

The words used about this operation.

• Septum: the osseocartilaginous wall dividing the nose into two cavities. [36514566]
• Deviated septum: a septum bent far enough off the midline to obstruct airflow or impair smell; minor deviation is a normal developmental variation in most people. [36514566]
• Septoplasty: surgery to straighten the deviation. [32054508]
• NOSE scale: Nasal Obstruction Symptom Evaluation, the patient-completed questionnaire used as the entry criterion and outcome in most of these trials. [32054508]
• SNOT-22: Sino-Nasal Outcome Test, 22 items, the primary outcome in NAIROS, where 9 points was set as the minimal clinically important difference. [37852641]
• Peak nasal inspiratory flow: an objective measure of how much air the nose moves on breathing in. [39230606]
• Turbinate reduction: shrinking the enlarged inferior turbinate, often on the wider side. [36150153]
• Nasal packing: absorbent material placed in the nose after surgery, the alternative to a through-and-through septal stitch. [28917002]
• Septal splint: a thin plate held against each side of the septum for days after surgery. [42046593]
• Synechia: a scar band joining the septum to the side wall of the nose. [37554910]
• Septal perforation: a hole through both sides of the septum. [31227374]
• Nasal cycle: the alternating congestion of the two sides of the nose through the day. [35286439]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess before operating and what belongs in the record afterwards, the airway included.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a Septal Surgery section. Four of its chapters cover this operation. They are written for surgeons and go further into technique than a patient page should.

• Septoplasty and Turbinate Surgery
• Powered Instrumentation for Rhinoplasty and Septoplasty
• Algorithm for treatment of anterior septal deviations
• Pediatric Septoplasty

The reference summary

Septoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications, the operative steps and the complication list in full text at no charge.

The societies

• ENT Health, the patient site of the American Academy of Otolaryngology, on the deviated septum.
• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

NAIROS is registered as ISRCTN16168569. Two further questions about this operation are under test.

• Evaluation of the Outcome of Septoplasty With or Without Inferior Turbinate Reduction, not yet recruiting, 40 participants.
• Does Batten Grafting Improve Nasal Outcomes in Septoplasty and Turbinate Reduction, recruiting, 96 participants.

What is not settled

• The whole randomised evidence base is three trials totalling 721 patients. [39230606]
• Whether trial results transfer to routine practice is questioned by rhinologists who accept the results themselves. [38416120]
• Symptom scores improved, and peak nasal inspiratory flow showed no significant difference between surgery and sprays. [39230606]
• Cost-effectiveness depends on how the operation is costed. The incremental cost per quality adjusted life year was £27 114 in the base case and £16 682 using micro-costing, with a 15% and 78% probability of being cost-effective at a £20 000 threshold. Extended to 24 months in a model, the probability was 99%. [42409405]
• Every splint-timing study came from one country, which limits how far the timing advice carries. [42046593]
• Turbinate reduction improves symptom scores and raises adverse events, and the trials are few enough that the authors of the pooled analysis warn against reading it as settled. [36150153]
• Septoplasty evens out the nasal cycle across the two sides, and inspiratory resistance did not change significantly in that study. [35286439]