Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review

Abstract

Clin. Otolaryngol. 2011, 36, 106–113

Background:  Nasal septal surgery is a common procedure, but there are concerns that the benefits of this surgery are mainly cosmetic.

Objective of review:  The primary aim is to identify any functional benefits of septal surgery and provide any evidence of a change in patency of the nasal airway, as assessed by objective methods such as rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow.

Type of review:  Systematic review.

Search strategy:  A systematic search of the available literature was performed, using Pubmed, Medline (1950–November 2010), Embase (1947–November 2010) and the Cochrane Controlled Trials Register. Papers written in English that objectively compared pre- and post-surgical treatment of nasal obstruction in adults because of septal deviation were reviewed. Objective measurements of rhinomanometry, acoustic rhinometry and nasal peak inspiratory flow were specified within the search. Searches were restricted to surgery on the nasal septum, which included septoplasty, submucous resection and septal (deviation) corrective surgery.

Results:  Seven studies (460 participants) involving rhinomanometry, six studies (182 participants) with acoustic rhinometry and one study (22 participants) using nasal peak inspiratory flow were included in the review. All the studies reported an objective improvement in nasal patency after septal surgery. Mean unilateral nasal resistance (data from six studies) decreased from preoperative 1.19 Pa/cm³/s to postoperative 0.39 Pa/cm³/s, mean minimum cross-sectional area (data from five studies) increased from preoperative 0.45 cm² to postoperative 0.61 cm², median peak nasal inspiratory flow (data from one study) increased by 35 L/min after surgery.

Conclusions:  There is sufficient evidence in the literature to conclude that septal surgery improves objective measures of nasal patency and that improved nasal airflow may have beneficial effects for the patient.

Nasal obstruction is one of the most common reasons for nasal surgery, and a deviated nasal septum is the most common cause of nasal obstruction.¹ In England and Wales, over 23 500 people were diagnosed with a deviated nasal septum in 2008–2009.^2,3 Septal surgery is one of the most common procedures in ENT practice, with more than 20 000 submucous resections (SMRs) and septoplasty performed in England and Wales in 2008–2009,^4,5 but the benefits of this form of surgery have been questioned.⁶ A recent position paper, published by the professional association of UK ENT surgeons, expresses concern that some hospital administrations are considering abolishing or severely restricting septal surgery, because of doubts over the benefits of the operation.⁷ One of the main concerns put forward about septal surgery is that the benefits are subjective and that the operation is often performed for cosmetic reasons, rather than for any functional improvement in the patency of the nasal airway. As Roblin & Eccles⁶ in 2002 found:

‘There is little hard evidence that this procedure provides any benefit to the patient unless the problem is cosmetic, in which case septal surgery may be of value.⁶’

However, there is a body of evidence in the clinical literature demonstrating that septal surgery does provide an objective and functional benefit to the patient, by increasing the patency of the nasal airway. The main aim of this review is to identify any functional benefits of septal surgery, by providing evidence of a change in patency of the nasal airway as assessed by the objective methods of rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow.

Methods

The literature was searched for papers that objectively compared pre- and post-surgical treatment of nasal obstruction because of septal deviation. Different forms of objective measurements were specified within the search. These were rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow. The searches were restricted to surgery on the nasal septum, which included septoplasty, submucous resection and septal (deviation) corrective surgery.

Search strategy

A systematic search of the available literature was performed, using Pubmed, Medline (1950–November 2010), Embase (1947–November 2010) and the Cochrane Controlled Trials Register. Key words were searched for within the paper’s title or abstract.

The specific terms searched for were ‘rhinomanometry’, ‘rhinomanometer’, ‘rhinomanometric’, ‘acoustic rhinometry’, ‘acoustic rhinometer’, ‘peak flow nasal patency’, ‘nasal inspiratory flow’, ‘peak inspiratory flow’, ‘peak nasal inspiratory flow’, ‘nasal peak flow’, ‘peak flow’, ‘nasal forced inspiratory’, ‘objective’, ‘operation’, ‘surgery’, ‘septal’, ‘septum’, ‘septoplasty’, ‘submucous’, ‘SMR’, ‘nasal’, ‘septal deviation’ and ‘nasal patency’.

Inclusion and exclusion criteria

Abstracts were reviewed if the paper title was pertaining to nasal septal surgery for nasal obstruction. If the abstract suggested any form of objective measurement, then the full paper was retrieved and read.

Inclusion criteria included the following: English language, adult patients, objective measurement before and after surgery, surgery performed for nasal obstruction, attempts made to ensure obstruction was not suitable for medical management, and surgery performed only on the nasal septum (such as septoplasty or submucous resection). Where more than one surgical technique was used within the study, the data for septal surgery alone were extracted for comparison. Studies were excluded if: the study was not available in English, the participants were children, data for septal surgery alone were not available or measurements of pre- and post-surgery were not available.

From our original searches, we identified 20 articles written in a language other than English. Twelve abstracts (nine performing rhinomanometry and three performing acoustic rhinometry) were available in English, which were all read, but we were unable to include any data from these in the review.

Results

The nose is an airway, and objective measures of the patency of that airway may be made in several different ways. This review provides information on studies that have used the three most commonly used methods of assessing nasal patency: rhinomanometry, acoustic rhinometry and nasal peak inspiratory flow. Rhinomanometry provides a physiological measure of nasal patency, as it involves measurement of nasal airflow and the pressure gradient that moves the airflow during normal breathing. Acoustic rhinometry provides an anatomical measure of nasal patency, as it involves measurement of the narrowest point of the nasal airway as a minimum cross-sectional area (MCA) during a breath-hold. Nasal peak inspiratory flow provides a physiological measure of maximal nasal airflow at maximum effort.

In assessing the efficacy of any surgical procedure for the treatment of nasal obstruction, it is important to describe the procedure clearly and to restrict the assessment to one procedure, so that the effects of this procedure can be assessed in isolation. One of the problems encountered in this review was that in many studies, septal surgery was accompanied by turbinate surgery, and therefore, these studies could not be included in this review. Another issue was that the surgical procedure was not always described in detail, but whatever details were provided are given below for each study.

Rhinomanometry

Assessing data from studies using rhinomanometry were often difficult because of the different units that were used for nasal airway resistance (NAR) and the different formula that were used to calculate resistance. It is beyond the remit of this review to discuss the validity and calculations of the different units used in rhinomanometry, and the reader is directed to the methods of the different studies for more information about the units and the equipment used to measure nasal patency. The units used in the studies included in this review are defined below.

Units that describe the resistance to airflow in terms of the pressure gradient and nasal airflow:

• Pascals per cubic centimetre per second (Pa/cm³/s)

• centimetres of water per litre per second (cm H₂O/L/s)

• Pascals per litre per second (Pa/L/s)

• millilitres per second (mL/s)

• V₂ describes NAR as the angle (V₂) on the flow-pressure curve where it intersects a circle of 200 radius units, for use in statistical analysis.⁸

The results of seven studies that assess the efficacy of septoplasty by using rhinomanometry to measure nasal patency are shown in Table 1. All the studies provided objective data for the decongested nose. Decongestion of the nose with a topical nasal decongestant or by exercise eliminates any vascular component of nasal obstruction caused by swelling of the turbinates, and it allows assessment of the anatomical or hard tissue component of the nasal obstruction. Personal communication with Pirilä⁹ confirmed that the units of airflow quoted in Table 1 of his study¹⁰ were mL/s (not mL/min). No units of resistance were specified by Wang et al.¹¹ We have assumed them to be Pa/cm³/s.

Table 1.   Pre- and postoperative results for septoplasty as measured by rhinomanometry

Paper	n		Rhinomanometry measurement values			P-values		Follow-up duration
			Preoperative	Postoperative
Statistical significance is given where provided (‘na’ indicates that no statistical data were given). Unilateral measurements are for the most obstructed side of the nose, on the side of the septal deviation. Total measures are for the two nasal passages combined. *indicates that we have assumed units to be Pa/cm^3/s.
Broms et al.^12	100	Unilateral Total	13.8 cm H2O/L/s 2.1 cm H2O/L/s	4.2 cm H2O/L/s 1.5 cm H2O/L/s		≤0.001 ≤0.05		≥6 months
Jessen & Malm^15	100	Unilateral Total	1.38 Pa/cm^3/s 0.25 Pa/cm^3/s	0.47 Pa/cm^3/s 0.16 Pa/cm^3/s		≤0.001 na		6–12 months
Jessen et al.^16	35	Unilateral Total	1.25 Pa/cm^3/s 0.23 Pa/cm^3/s	0.39 Pa/cm^3/s 0.18 Pa/cm^3/s	0.34 Pa/cm^3/s 0.14 Pa/cm^3/s	≤0.001 0.01 ≥ P > 0.001	≤0.001 ≤0.001	9 months	9 years
Sipilä et al.^17	62	Unilateral	1067 Pa/L/s	188 Pa/L/s		na		6 months
Bohlin & Dahlqvist^8	35	Unilateral	V2 = 51.2 ± 21.5	V2 = 23 ± 14.3	V2 = 18.2 ± 9.0	≤0.001	≤0.001	3 months	10 years
Pirilä & Tikanto^10	110	Unilateral	180 mL/s (see Ref. 9)	322 mL/s (see Ref. 9)		<0.001		12 months
Wang et al.^11	18	Unilateral Total	8.95 ± 11.27* 0.46 ± 0.32*	0.53 ± 0.32* 0.18 ± 0.08*		0.015 0.003		6–12 months

Studies using rhinomanometry.

Broms et al.¹² used exercise to decongest the nose and measured nasal patency by anterior rhinomanometry. The study involved 100 consecutive patients (aged 17–65). The patients were selected from 370 patients with persistent unilateral or bilateral nasal obstruction, and who also had a nasal resistance to airflow that exceeded the 95% confidence limit for healthy subjects, in one or both nasal cavities, as determined in a previous study.¹³ The investigators described the surgery as functional septoplasty, performed according to the principles given by Masing¹⁴ (in Theisssing’s ‘Kurze HNO-Operationslehre’).

Jessen and Malm¹⁵ used exercise to decongest the nose and measured nasal patency by anterior rhinomanometry. This study involved 200 patients presenting for nasal stuffiness, where a non-mucosal obstruction was suspected. The group of 200 (aged 15–61) were split into two groups. One group of 100 patients had high NAR (according to Broms¹³) and were subsequently listed for operation. The remaining group with normal NAR were designated the control group. The operation was described as a functional septoplasty, according to the principles by Masing¹⁴ (in Theissings ‘Kurze HNO Operationslehre’).

Jessen et al.¹⁶ used exercise to decongest the nose and measured nasal patency by anterior rhinomanometry. Thirty-five patients (aged 23–76) who underwent surgery during a 2-year period were selected, if they complained of nasal obstruction and could be demonstrated to have pathological NAR after decongestion. The authors described the operation as a functional septoplasty, according to the principles by Masing¹⁴ (in Theissings ‘Kurze HNO Operationslehre’).

Sipiläet al.¹⁷ used oxymetazoline nose drops to decongest the nose and measured nasal patency using anterior rhinomanometry. This study involved 62 patients, whose main symptom was that of nasal obstruction. These were taken from a total of 102 patients (aged 17–59), who presented with a variety of symptoms and were found to have a septal deviation following an ENT examination. The septoplasty was described as a modified Cottle technique.¹⁸

Bohlin and Dahlqvist⁸ used a topical spray of oxymetazoline hydrochloride to decongest the nose and measured nasal patency with anterior rhinomanometry. The study involved all patients (aged 17–56) who underwent functional septoplasty during a 1-year period; however, the final number of 35 patients comprised all those who returned to the 10-year follow-up examination, and who were able to complete the rhinomanometry. The functional septoplasty was described as ‘according to current operative principles’.⁸

Pirilä and Tikanto¹⁰ used a mixture of 1 : 1000 epinephrine and 4% lidocaine to decongest the nose. Nasal patency was measured using anterior rhinomanometry and acoustic rhinometry of the deviated side. The study involved 157 consecutive patients who presented for septal surgery, once clinical examination confirmed their obstruction to be as a result of a septal deviation. One hundred and ten patients (aged 19–69) received solely a septoplasty. The investigators described the operation as a septoplasty performed through a hemi-transfixion incision.

Wang et al.¹¹ used 1 : 1000 ephedrine to decongest the nose and measured nasal patency with both acoustic rhinometry and anterior rhinomanometry. This study involved 54 patients (aged 17–62), who were operated on over a 1-year period for nasal obstruction because of septal deviation. Eighteen of these patients received solely a septoplasty. The investigators described their operation as a novel modified septoplasty, exposing three high-tension lines.

Table 1 shows the seven studies identified that fulfilled our selection criteria. The table includes the values in the original units as provided by their papers. All of these studies used septoplasty, and all provide unilateral data. Four of these studies provided total nasal patency in addition to the unilateral values. The postoperative follow-up ranged from 3 months to 10 years.

It can be seen from Table 1 that all of the studies show an increase in patency following septoplasty. All reported a statistically significant increase in objective nasal patency following septoplasty. Sipiläet al.¹⁷ did not provide a P-value, despite their increase being statistically significant.

In Fig. 1, the values of the unilateral nasal patencies for anterior rhinomanometry from each study have been converted to the same SI units (Pa/cm³/s), to allow for easier comparison. Once again, all of the studies in this graph reported a statistically significant difference between pre- and postoperative measurements. By combining the results of these papers, a mean unilateral preoperative resistance of 1.19 ± 0.21 Pa/cm³/s decreases to a postoperative resistance of 0.39 ± 0.10 Pa/cm³/s, an improvement in patency of 67%. Wang et al.¹¹ are excluded from this graph, as we cannot confirm the units used within their study.

Figure 1.  Pre- and postoperative results for septoplasty as measured by rhinomanometry for unilateral (narrowed) side measurements only. All studies showed significant objective improvements in nasal patency after surgery. The duration of follow-up can be identified in Table 1.

Acoustic rhinometry

Data from studies using acoustic rhinometry were easier to assess than rhinomanometry, as all studies expressed results as the MCA in units of cm². The MCA measures the narrowest part of the nose, and there are conflicting opinions about the anatomical correlates of this measurement (Nigro et al.¹⁹). Two of the studies (Marais et al.²⁰, Skouras et al.²¹) did not mention whether any decongestion was used in the nose. When Pirilä & Tikanto¹⁰ decongested the nose, the site of the MCA moved anteriorly because of shrinkage of the inferior turbinate; this indicates that the measurement was at the level of the anterior end of the inferior turbinate. However, in other studies, the site of the MCA was not defined (Wang et al.¹¹, Marais et al.²⁰, Skouras et al.²¹ and Reber et al.²²).

Studies using acoustic rhinometry.

Marais et al.²⁰ did not mention whether they decongested the nose. They used acoustic rhinometry to measure the total MCA. This study involved 8 patients who underwent septoplasty alone, taken from a group of 16 consecutive patients (aged 14–70) and who were operated on for nasal obstruction. The authors provided no additional description of the septoplasty.

Reber et al.²² used a Novesin–adrenaline spray to decongest the nose and measured the nostril with the smaller preoperative (narrower) MCA and total MCA (sum of MCA for each side) using acoustic rhinometry. The study consisted of 27 consecutive patients (median age 32) who presented with nasal obstruction and were found to have an anterior septal deviation. Only 16 patients received solely a septoplasty. The remaining 11 underwent a septoplasty with another procedure (surgery to turbinates, soft palate or rhinoplasty).

Kemker et al.²³ used a 1% phenylephrine nasal spray to decongest the nose and measured the cross-sectional area of the first narrowing (nasal valve) of the side with the septal deviation by acoustic rhinometry. The study involved patients who had already been listed for surgery, of which 14 (aged 24–50) underwent septoplasty only. No further explanation of how patients were selected, or description as to the style of septoplasty used were provided by the authors.

Pirilä and Tikanto¹⁰ as described in the rhinomanometry section above.

Skouras et al.²¹ did not mention whether nasal decongestion was performed. The nasal patency was measured by acoustic rhinometry. This study included 16 patients (no ages provided) who were operated on for nasal obstruction. The investigators described the surgery as plastic surgery to the nasal septum.

Wang et al.¹¹ as described in the rhinomanometry section above.

Six studies fulfilled our criteria using acoustic rhinometry. These are shown in Table 2. All but one performed septoplasty. Skouras et al.²¹ did not specify which kind of septal surgery they used. Marais et al.²⁰ were the only group not to provide unilateral acoustic rhinometry measurements, and along with Reber et al.²² gave values for total cross-sectional area. Skouras et al.²¹ did not mention their follow-up duration, but the follow-up period of the remaining studies ranged from 1 month to 18 months. Two of these studies did not mention the use of nasal decongestion prior to objective assessment (Marais et al.²⁰, Skouras et al.²¹).

Table 2.   Pre- and postoperative results for septal surgery as measured by acoustic rhinometry

Paper	n	Surgical procedure		Acoustic rhinometry measurement (cm^2)		Follow-up duration	P-value
				Preoperative	Postoperative
Statistical significance is given where provided. Unilateral measurements are for the most obstructed side of the nose, on the side of the septal deviation. Total measures are for the two nasal passages combined.
Marais et al.^20	8	Septoplasty	Total	2.05	2.26	2 months	na
Reber et al.^22	16	Septoplasty	Unilateral Total	0.49 1.10	0.58 1.17	2–6 months	na na
Kemker et al.^23	14	Septoplasty	Unilateral	0.58 ± 0.21	0.65 ± 0.14	1–18 months	na
Pirila & Tikanto^10	110	Septoplasty	Unilateral	0.35	0.49	12 months	<0.001
Skouras et al.^21	16	Septal surgery	Unilateral	0.43 ± 0.19	0.70 ± 0.23	na	0.0007
Wang et al.^11	18	Septoplasty	Unilateral	0.38 ± 0.21	0.63 ± 0.14	6–12 months	0.000

Table 2 shows that all six studies demonstrated an increase in minimal cross-sectional area following septal surgery. Three of these showed a statistically significant increase from pre- to post-surgery.^10,11,21 The unilateral MCAs can be more easily compared in Fig. 2 (where * signifies statistical significance). As Marais et al.²⁰ have not used unilateral measurements in their study, it has been excluded from this graph. By combining the results of these papers, a mean MCA of 0.45 ± 0.09 cm² improves to a postoperative MCA of 0.61 ± 0.08 cm², an increase in MCA of 36%.

Figure 2.  Pre- and postoperative results for septal surgery as measured by acoustic rhinometry for unilateral (narrowed) side measurements only. Four studies showed significant objective improvements in nasal patency after surgery, identified with *. The duration of follow-up can be identified in Table 2.

Peak nasal inspiratory flow

Only one study (Low²⁴) provided results of peak nasal inspiratory flow following septal surgery alone. This is shown in Table 3. All other papers provided data with combinations of septal surgery and turbinate surgery. Low²⁴ does not mention the use of nasal decongestion. The study involved 22 patients (aged 18–55) of 30, with symptomatic nasal obstruction (for at least 6 months) secondary to septal deviation and with associated snoring. He did not specify the type of septal surgery, but showed a postoperative difference (increase) of 35 L/min (median value) from a preoperative value of 80 L/min (median). No information was available regarding whether this was a statistically significant increase.

Table 3.   Pre- and postoperative results for septal surgery as measured by peak nasal inspiratory flow

Paper	n	Surgical procedure	Peak nasal inspiratory flow measurement (L/min)		Follow-up duration	P-value
			Preoperative	Postoperative
‘na’ indicates that no statistical data were given for this increase.
Low^24	22	Septal surgery	80 (median)	Increase of 35 (median difference)	4–12 months	na

Discussion

This review demonstrates that objective evidence exists that nasal obstruction because of septal deviation can be significantly improved by septal surgery. Objective improvement in nasal patency is a clinically significant change, as the primary function of the nose is an airway. Singh et al.²⁵ have previously attempted to demonstrate by a meta-analysis of three studies (Bohlin & Dahlqvist⁸ Jessen et al.¹⁶ and Nofal & Thomas²⁶) that septal surgery improves nasal airflow. Two of these studies Bohlin & Dahlqvist⁸ and Jessen et al.¹⁶ are included in the present review, but the study by Nofal & Thomas²⁶ is excluded from this review, as the study included some cases that had out-fracture of the inferior turbinates, and therefore it is not possible to determine the effects of septal surgery alone.

The present review did not attempt a meta-analysis of the 14 studies that were included, as they were deemed to be too different in patient selection, and methods of objective measurement, for any grouping for meta-analysis. However, the 14 studies as a group do provide important evidence that septal surgery improves nasal patency, with data obtained by the use of three different objective methods of assessing nasal patency.

Why unilateral nasal measurements are informative

The changes in nasal patency because of surgery are clinically significant as they return the patency of the obstructed nasal passage back towards a normal range. Most of the studies focus on changes in unilateral resistance of the obstructed side of the nose, on the side of the deviation, but the surgery also has effects on the contralateral nasal passage²⁷ and the nasal valve region.²⁸ Correction of a septal deviation may decrease the patency of the nasal passage opposite to the deviation, but in general this does not cause any symptom of obstruction as the sensation of nasal obstruction is correlated with the patency of the deviated side and not with total nasal patency.²⁷ A reduction of the inferior turbinate on the side opposite to the deviation is commonly performed to correct for any decrease in patency on correction of the deviation, but there is little evidence to support any benefit of this procedure.²⁷ Normal data for unilateral nasal patency after decongestion are described by Broms,¹³ and he reports that unilateral patency varies between 0.14 and 0.23 Pa/cm³/s according to patient height. Figure 1 illustrates pre- and postoperative values of nasal patency, demonstrating that septal surgery returns unilateral patency towards the normal range, from preoperative resistance values that are well above this normal range. The change in mean unilateral NAR (data from six studies) from a preoperative 1.19 Pa/cm³/s to a postoperative 0.39 Pa/cm³/s illustrates the magnitude of the change in nasal patency as NAR is reduced by 67%.

Relevance to clinical practice

This review concurs with other reviews and studies that have examined the anatomical causes of nasal obstruction. Unfortunately, there were some studies where data for septal surgery alone were not available, resulting in fewer studies (and participants) for comparison. The strength of this review is its extensive search of studies on septal surgery and the removal of all data where septal surgery could not be identified as the only altering factor. A systematic review by Andréet al.²⁹ in 2009 looked at the correlation between objective and subjective changes in nasal obstruction following septal surgery. It was noted that in patients with obstructive symptoms, a correlation is more likely to be found with rhinomanometry or acoustic rhinometry. They suggested that objective measurements could be used as part of an overall evaluation of the patient, but questioned whether any ‘…meaningful contribution to the diagnostic and therapeutic process…’²⁹ would be achieved by objective measurements, if correlation was highest when subjective symptoms were present. We agree that objective measurements should be in addition to an overall evaluation, but further believe that they are useful in the identification of patients which might benefit from septal surgery (by comparing with normal ranges), as well as providing evidence of a benefit to nasal patency, and therefore justification for the procedure.

Benefit to patients

Quality of life questionnaires suggest that following septal surgery, patients need to visit their doctor less and require less medication for nasal obstruction.³⁰ This has potential cost saving implications. The cost of medications prescribed for nasal obstruction in Primary Care within England and Wales for 2008–2009 was £59 million (net ingredient cost).^31,32 Septal surgery, either alone or as part of a combined procedure, may be indicated for other conditions other than the sensation of nasal obstruction; however, the aim of this review was not to establish such associations.

Conclusion

This review includes 14 studies (536 participants) on the objective effects of septal surgery on nasal patency. All of these studies provide objective evidence that septal surgery improves nasal patency. The improvements in nasal patency for the majority of these studies have been shown to be statistically significant. In no study was it found that septal surgery did not provide objective benefit. This review demonstrates that septal surgery is a valid and beneficial treatment for patients complaining of nasal obstruction from an anatomical cause.

Keypoints

• • 
  Surgical management of septal deviation has been criticised as providing only cosmetic benefits. This review provides evidence of functional benefits to the patient.
• • 
  Surgical management of septal deviation provides an objective increase in nasal patency that can be demonstrated by rhinomanometry, acoustic rhinometry and nasal peak inspiratory flow.

Conflict of interest

None to declare.