Discussion

Septoplasty is very successful for treating moderate or advanced nasal septal deviations, but great care should be taken when advising on septoplasty for mild deviations, to avoid unnecessary surgical intervention. Although, on average, the Nasal Obstruction Symptom Evaluation scale values for group 3 (mild deviation) indicated a statistically significant improvement in recovery after surgery, the 36-Item Short Form Health Survey physical function and general health perception values revealed no statistically significant differences, and there was a non-significant worsening in the post-operative period compared to the pre-operative period.

Paranasal sinus computed tomography, nasal endoscopy and nasopharyngoscopy performed pre-operatively are important for determining the most accurate approach. Sixty per cent of patients with septal deviation have compensatory conchal hypertrophy, but only 25 per cent complain of nasal congestion.^{Reference Gray9} In another study, 40 per cent of patients with high septal deviation also suffered from other nasal pathology, such as concha bullosa.^{Reference Baumann and Baumann10} Of patients with nasal obstruction, 70.5 per cent improved following septoplasty.^{Reference Samad, Stevens and Maloney11} An objective standard with which to evaluate success rates after septoplasty is currently lacking. In Sundh and Sunnergren's study,^{Reference Sundh and Sunnergren12} which evaluated the early and long-term success rates of septoplasty, the results indicated that surgery was successful in the short term, but this trend was reversed over the long-term. It is noteworthy that no pre-operative factors in that study (including age, gender, revision intervention, trauma, allergies or rhinometric obstruction) had any demonstrable effect on long-term satisfaction with septoplasty.^{Reference Sundh and Sunnergren12}

The Nasal Obstruction Symptom Evaluation scale, which can be used to evaluate septoplasty outcomes, alongside acoustic rhinometry and questionnaires, was originally developed by Stewart and colleagues.^{Reference Stewart, Witsell, Smith, Weaver, Yueh and Hannley8} This tool is valuable in determining the efficacy of septoplasty because it yields results consistent with physical examination and computed tomography findings.^{Reference Kahveci, Miman, Yucel, Yucedag, Okur and Altuntas13} Acoustic rhinometry and rhinomanometry studies have also been reported in several meta-analyses to give accurate and objective results when measuring the success of septoplasty.^{Reference Singh, Patel, Kenyon and Donaldson14}

Several studies in the literature have observed that the results of acoustic rhinometry on the side of the deviation in anterior septal deviations are consistent with survey findings.^{Reference Pirilä and Tikanto15,Reference Mamikoglu, Houser, Akbar, Ng and Corey16} In many studies, rhinomanometry values obtained in nasal obstruction cases are reported to closely match subjective evaluation findings, as revealed by surveys.^{Reference Kobayashi, Miyazaki, Karaki, Kobayashi, Karaki and Kosuke17,Reference Naito, Cole, Chaban and Oprysk18} It is therefore evident that many factors are of value in evaluating the success achieved by septoplasty. Considering that even post-operative time has a role in determining how successful septoplasty is perceived to be, it is reasonable to evaluate patients at the end of a six-month period, as in our study. Surveys such as the Nasal Obstruction Symptom Evaluation scale and 36-Item Short Form Health Survey are subjective measures, but patient satisfaction is, of course, also a subjective assessment.

We aim to obtain the best surgical outcome, and so it is important to use a suitable surgical approach, which can be an open or closed technique. In some patients with a severe anterior septal deviation, an open septoplasty technique similar to an open rhinoplasty approach was mandatory, as a closed septoplasty technique might have resulted in failure. It was difficult to declare that treatment for every patient with a severe anterior septal deviation resulted in a straight septum, even if an open septoplasty technique was used. This renders it impossible to create a pure population at the post-operative period. Nevertheless, it is clear that septoplasty was beneficial in this group, even if we did not have a homogeneous post-operative patient population. The other compromising issue might be the lacking of an objective assessment method for nasal patency, but, as mentioned before, as many objective measurements have been shown to correlate with the surveys, that issue might be ignored.

In our study, we took care to create as homogeneous a group of patients as possible. For example, patients with sleep apnoea, a condition which may also be related to weight, or patients with known allergies, were excluded from the study. The rationale for the exclusions is that other treatments, such as those for weight reduction or anti-allergic therapy, have a potential effect on nasal obstructive symptoms, which could confound the results if such individuals were included. In our study, the average Nasal Obstruction Symptom Evaluation scale scores were significantly improved in all three groups after surgery, but the improvement in group 3 (mild deviation) was less apparent than in the other groups. The mean values for physical function and general health perception (parameters of the 36-Item Short Form Health Survey) showed significant improvements after surgery in groups 1 and 2 (severe and moderate deviation), whereas there was no statistical difference after surgery in group 3. Moreover, these values appeared non-significantly worse in group 3 in the post-operative period.

Septoplasty is performed frequently by ENT specialists, but its indications are wide, in part because of unreliable objective tests. Although the physical examination as performed by the surgeon is important, symptomatic complaints and patient perception play a greater role in decision-making regarding treatment. Anterior septal deviations are more likely than posterior deviations to extend into the internal nasal valve area. Septoplasty is very successful for treating moderate or severe nasal septal deviations, but great care should be taken when considering employing septoplasty for mild deviations.