SOHAG MEDICAL JOURNAL
Vol. 21 No.3 october 2017
Nasal septal deviation: Associated anatomical variations and
outcome of surgery
Presented by
Ahmed Mohamed Ahmed Haridy
Abstract
Objective: Sino Nasal Outcome Test – 22 (SNOT-22) Questionnaire study was done to
analyse the effectiveness of septoplasty surgery by noting the improvement of nasal
symptoms & general quality of life(QOL) by means of SNOT-22 questionnaire given to
patients before the surgery and 3 monthes after the surgery. Analysis of effectiveness of
septoplasty is usually done by noting pre and post operative symptoms.
Study Design: This is a prospective study and our data analysis consisted originally of 40
patients all of them answered the SNOT-22 questions both preoperatively and
postoperatively. The age group of the patients was between 18 to 47 years.
Results: In the post operative SNOT- 22, the need to blow nose, sneezing, running nose,
nasal obstruction, loss of smell or taste, post nasal discharge, facial pain/pressure,
difficulty in falling asleep, waking up at night lack of good night's sleep, wake up tired,
reduced productivity and embarrassed improved significantly.
Conclusion: Evaluation of symptoms & findings in the patient is essential in deciding
whether surgery or other treatment can be done in individual patient having nasal
blockage symptoms. The results are encouraging us to use the systematic questionnaire
(SNOT -22) to estimate the severity of symptoms in daily clinical practice.
Key Words: Health related quality of life, septum, SNOT -22.
Introduction
Several studies have addressed outcomes
after septoplasty using subjective or
objective
criteria,
most
being
retrospective.[3,4]
There have been only a few studies that
assesssd the impact of nasal septal
surgery (septoplasty, SMR, caudal
dislocation
with
or
with
out
turbinectomy). on the patient’s quality of
life (QOL) and subjective relief of
symptoms.[5]
The SNOT score was originally
developed as a rhinosinusitis specific,
health-related
questionnaire
that
combines symptoms related to the nose
and general health. It has been validated
in this respect in 1999.[6]
Deviated nasal septum (DNS) may be
asymptomatic in an individual or may
cause nasal obstruction and symptoms of
rhinosinusitis like nasal discharge, facial
pain, epistaxis, disturbance of smell. The
pathology in sinonasal cavity can also
affect the function of throat and ear and
surgery of septum and sinuses is
indicated in such a situation.[1]
The definitive treatment for septal
deviation is nasal septoplasty, performed
to improve nasal airways by correcting
deviations in the nasal septum. Patients
suffering from nasal obstruction are
perhaps the least controversial indication
for septoplasty, but it has been suggested
that the evidence base for this procedure
in such patients is lacking.[2]
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SOHAG MEDICAL JOURNAL
Vol. 21 No.3 october 2017
Nasal septal deviation: Associated anatomical variations
Ahmed Mohamed Ahmed Haridy
A pre- assessment was made using the
Sino-nasal Outcome Test. This is a
single questionnaire that can quickly be
completed in an out-patient setting by
the patient and can be used on a regular
basis. In what is effectively a quality-oflife operation, the figures generated are
useful when assessing outcome. [7]
The SNOT-22 questionnaire, validated
by Hopkins et al in 2009 is the most
effective tool currently available for
grading the severity and impact of
clinical symptoms of CRS. It has already
been adopted by many clinicians both
for the assessment of CRS, but also for
evaluating the outcome of treatment of
nasal polyposis and in nasal septal
surgery.[7,8,9]
The SNOT- 22 Questionnaire study has
been used in studies on chronic
Rhinosinusitis & is also a useful tool in
nasal septal surgery(7, 8). The SNOT 22 has 22 items and was recently
reported to be valid & easy to use. In the
Questionnaire, patients rate each item
from 0 (no problem) to 5 (problem as
bad as it can be). The total maximum
number of points in the SNOT-22 is thus
22x5 = 110 points. The patient is also
asked to mark at maximum the five most
important items. The scoring of SNOT22 points is as mentioned below: (0= no
problem, 1= very mild problem, 2= mild
or slight problem, 3= moderate problem,
4= severe problem, 5= problem as bad as
it can be.)
All patients had CT scan coronal cuts to
identify the association of concha
bullosa and the type of concha bullosa if
present.
The angle of septal deviation in relation
to the medline (as indicated by the crista
galli) was estimated and categorized
cases into three groups according to
degree of septal deflection:
Group I-mild angle ( ≤ 20°).
Group II-moderate angle (21°-30°).
Group III-marked angle (>30°).
and the level of deviation in the vertical
plane in relation to the nasal turbinates
was identified and calssified in three
categories:
Category A: angle of deviation against
inferior turbinate.
Category B: angle of deviation between
middle and inferior turbinate.
Category C: angle of deviation against
middle turbinate.
Surgical intervention:
All cases underwent
septoplasty
operation for correction of
their
deviated septum and cases with concha
bullosa underwent middle turbinoplasty.
Statistics:
Methodology
This study included 40 patients with
nasal semptoms due to deviated nasal
septum who were admitted for surgical
managment in ENT department, Sohag
University Hospital in the period from
june 2016 to may 2017.
The study was approved by the scientific
and ethical committee of our institution.
Study Population: 40 patients were
included in this study.
Inclusion criteria:All cases of nasal
septal deviation undergoing septoplasty
operation including post traumatic septal
deviation.
Exclusion criteria:Cases with deviated
nasal septum associated with other
sinonasal pathology such as chronic
sinusitis, nasal polyps, nasal allergy,
tumours or granulomas.
All patients were subjected to the
following:
I-Full history taking and pre operative
SNOT-22.
II-ENT examination.
III-CT Nose & PNS.
IV-Septoplasty operation.
V-Post operative SNOT-22.
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Nasal septal deviation: Associated anatomical variations
Ahmed Mohamed Ahmed Haridy
SOHAG MEDICAL JOURNAL
Vol. 21 No.3 october 2017
association between two variables and
applying Wilcoxon Signed-Rank Test,
Mann-Whitney test and Kruskal-Wallis
test for nonparametric data.
Data were analysed using the Statistical
Package for the Social Sciences software
(version 14; SPPS, Chicago, Illinois,
USA),phi coefficient test to measure the
Results:
This study included 40 patients with nasal septal deviation. They were 32.5% females
and 67.5% males. Patients ranged in age between 18 to 47 years.[the mean age=26.52].
Comparison between pre and post operative SNOT-22 score acorrding to all cases,
development of concha, level of deviation and angle of deviation:
Pre
op
SNOT22 Mean
Pre
op
SNOT22
Median
Post
SNOT22
Mean
All cases
34.875
36
Without concha
33.04
With concha
Post op
SNOT22
Median
p-value
8.75
8
.000
33
8.4
7
.000
37.93333
39
9.333333
8
.001
Level of deviation cat A
33.14286
35
7.142857
6
.018
Level of deviation cat B
33.66667
34
9.259259
9
.000
Level of deviation cat C
42.33333
44
8.333333
7.5
.027
Mild Deviation
32.76471
33
8
.000
7
.000
8
.027
op
8.882353
Moderate deviation
Marked deviation
35.17647
40
38
42
8.764706
8.333333
pre and post SNOT-22 score.
The mean preoperative SNOT-22 score points were 34.875 (range 14 to 50).
Postoperative SNOT-22 score points was 8.75 (range 2 to 25) and the difference was
26.125, (n= 40).
The table shows the mean values of pre and post SNOT- 22 items, and probability values.
By comparing the means values of preoperative SNOT-22 scores and postoperative
SNOT-22 scores using Wilcoxon signed rank test we found asignificant improvement in
SNOT-22 score (p-value =.0001)
Preoperative SNOT-22 score mean is higher when concha bullosa were present,the angle
of deviation against middle turbinate(level C) and when the angle of deviation >30
(marked deviation).
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SOHAG MEDICAL JOURNAL
Vol. 21 No.3 october 2017
Nasal septal deviation: Associated anatomical variations
Ahmed Mohamed Ahmed Haridy
Comparison between pre and post operative SNOT-22 score acorrding to all cases, development of
concha, level of deviation and angle of deviation:
Discussion
before doing the surgery & for better
outcome the severity of the symptoms
should be assessed and the patients
having only minor symptoms should not
be operated on or at least the indication
for septoplasty. should be very carefully
discussed with the patient. So the results
of this study encourage the use of a
systematic questionnaire such as the
SNOT- 22, for patients with nasal
symptoms in daily clinical practice to
estimate the severity of his symptoms.[8]
In the previous studies of septoplasty
chronic rhino sinusitis and nasal
polyposis, the decrease in symptom
score was 17.0, 12.6, and 17.7,
respectively. [7,8]
In this study, the mean total pre-SNOT22 score was 34.875 & the total post
SNOT score was 8.75 with a mean
difference of 26.125.
Using SNOT-22 Questionnaire we
were able to measure the effect of
septoplasty.
The
40
septoplasty
operations were performed in the period
from june 2016 to may 2017 in ENT
Department Sohag University Hospital.
After a 3 monthes follow up period post
operative SNOT-22 was filled by the
patients
and
compared
to
the
preoperative SNOT-22 score. The result
reviled of the questionnaire.
In healthy populations, the mean SNOT22 score is 9.3 and in patients, the
minimally important difference is 8.9
points. We were also able to recognise
that in the few items of SNOT-22
(reduced
concentration,
frustrated/restless, irritable, sad , fatigue,
ear pain and dizziness) the p values was
not significant, suggesting decreasing
Health-Related Quality of Life (HRQoL)
. It was also noted from the study that
the more nasal symptoms the lower was
the health related QoL but the disease
specific nasal symptoms has markedly
reduced after surgery. Thus careful
diagnostics & treatment of patients
having nasal symptoms are important. so
Conclusion
Analysing the outcome of surgery was
measure 3 monthes after septoplasty, the
total SNOT-22 score was reduced,
showing a significant improvement of
nasal symptoms
in SNOT-22 after
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SOHAG MEDICAL JOURNAL
Vol. 21 No.3 october 2017
Nasal septal deviation: Associated anatomical variations
Ahmed Mohamed Ahmed Haridy
septoplasty
and
a
significant
improvement in facial pain and post
nasal discharge after septoplasty.
SNOT-22 Questionnaire was very useful
in knowing the severity of patient’s nasal
problems and helped us in evaluating
and selecting the patients for surgery and
in evaluating the outcome and
effectiveness of surgery. It also helped
us in analysing the severity of symptoms
in daily clinical practice
5- Arunachalam PS, Kitcher E, Gray
J, Wilson JA (2001) Nasal septal
surgery: Evaluation of symptomatic
and general health outcomes. Clinical
Otolaryngology 26:367–370
6- Anderson FR, Murphy MP,
Weymuller ER (1999) Clinimetric
evaluation of the Sinonasal Outcome
Test 16. Otolaryngology Head and
Neck Surgery 14:702–707
7- Buckland JR, Thomas S, Harries
PG(2003) Can the Sinonasal outcome
test(SNOT-22) be used as a reliable
outcome measure for successful
septal surgery? Clinical Otolaryngol
Allied Sci 28(1):43-47.
8- Hopkins C, Gillett S, Slack R et al
(2009) Psychometric validity of the
22-item Sinonasal outcome Test.Clin
Otolaryngol 34(5):447-454
9- BROWNE, J. P., HOPKINS, C.,
SLACK,
R.,
TOPHAM,
J.,
REEVES, B., LUND, V., BROWN,
P., COPLEY, L. & VAN DER
MEULEN, J. 2006. Health-Related
Quality of Life after Polypectomy
with and without Additional Surgery.
The Laryngoscope, 116, 297-302.
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