The Effect of Septorhinoplasty on Allergic Nasal Symptoms in Asymptomatic Patients

Research Article

Austin J Otolaryngol. 2015; 2(8): 1061.

The Effect of Septorhinoplasty on Allergic Nasal Symptoms in Asymptomatic Patients

Saedi B*, Emami H, Safavi A and Hashemaghaee M

Department of Otolaryngology, Tehran University of Medical Sciences, Iran

*Corresponding author: Babak Saedi, Department of ENT, ENT Research Center, Tehran University of Medical Sciences, Otolaryngology Research Center, Imam Khomeini Medical Complex, Bagherkhan St., Chamran Highway, Tehran, Postal Code: 141973141, Iran

Received: June 10, 2015; Accepted: October 25, 2015; Published: October 27, 2015

Abstract

Objective: To investigate the impact of nasal plastic surgery on allergic rhinitis symptoms in patients with a personal history of allergic rhinitis.

Study Design: A prospective observational study, consecutive sampling of patients indicated for septorhinoplasty with concomitant positive personal history of allergic rhinitis over a 12-month period.

Setting: Academic tertiary otolaryngology clinic.

Subjects and Methods: Seventy-three patients with positive personal history of allergic rhinitis underwent septorhinoplasty for structural nasal deformities. No turbinate manipulation was performed. Symptoms associated with allergic rhinitis were quiescent in those with personal history. A visualanalogue- scale (VAS), a symptom scoring system (TSS), and also the degree of nasal deviation and turbinate hypertrophy were used to evaluate the patients preoperatively and six months postoperatively.

Results: The mean TSS score and the severity of septal deviation were significantly reduced after the surgery (P=0.009 and P<0.0001 respectively); while VAS scores, severity groups of TSS, and also severity of turbinate hypertrophy were not significantly changed (P=0.515, P=0.654 and P=0.146 respectively).

Conclusion: Surgical nasal intervention in patients with quiescent allergic rhinitis does not necessarily trigger the disease. Taken in combination with other studies, we suggest a more cautious approach must be taken in candidates for rhinoplasty with active allergic rhinitis.

Keywords: Allergic rhinitis; Nasal surgery; Rhinoplasty; Septoplasty; Nasal obstruction

Introduction

Allergic rhinitis is a mucosal inflammation of intranasal airways due hyper-responsiveness to certain allergens through an IgEmediated immunologic interaction [1-6]. The process starts when airborne allergens are first exposed to the immune system at the nasal mucosa. Thereafter, through a sensitization process, some allergen-specific IgE are generated which circulate in the peripheral blood and attach to the surface basophils and mast cells [5]. From the second exposure on, the allergens activate local immune cells and subsequently lead to the “allergic response” at the site of exposure. This, in the nose, is expressed as acute nasal symptoms and dominantly as nasal obstruction [5,7-11].

As one of the septorhinoplasty outcome, the surgery of deviated septum is effective in relieving nasal obstruction symptoms. However, given the high incidence of allergic rhinitis in the general population, a large subset of patients with either cosmetic nasal deformities or structural nasal obstruction requiring surgical intervention may be at risk for exacerbation of allergic rhinitis. The effect of nasal surgery on allergic rhinitis in this patient population has not been examined. The majority of studies have focused on the effect of active allergic rhinitis on surgical outcomes, such as the study by Karatzanis and Stoksted, which reported poorer outcomes of nasal surgery in patients with concomitant allergic rhinitis [12,13]. A study by Kim at Inha University in Korea, demonstrated less patient-satisfaction in those undertaking nasal surgery merely for their allergic rhinitis compared to those with concomitant nasal deformities and allergic rhinitis [10]. These studies provide evidence that the outcomes of nasal surgical interventions are poorer in patients with allergic nasal disease, or more specifically, that patients with allergic rhinitis do not necessarily get better results from their surgeries than normal patients [10,12- 17].

We sought to determine prospectively if surgical intervention in patients at-risk for allergic rhinitis symptoms (those with a personal history but currently quiescent) triggers an allergic-type mucosal response or aggravates the pre-existing condition and finally what is its effect on nasal airflow after surgery.

Subjects and Methods

A prospective observation study was conducted at a tertiary academic center (ENT- clinic of Imam Khomeini Hospital, an affiliate of Tehran University of Medical Sciences - TUMS) through March 2011 to March 2012.

Study subjects

Seventy three consecutive patients were chosen among septorhinoplasty candidates referred to our clinic (Cosmetic or Functional reason). The patients were all positive for personal history of allergic rhinitis. We used patients’ history to documentation allergic rhinitis. The purpose of the surgery was not to treat the allergic rhinitis but to correct anatomical deformities (cosmetic or functional) for which septorhinoplasty was indicated. Exclusion criteria included patients with inferior turbinate hypertrophy requiring turbinoplasty, patients with pronounced symptoms of allergic rhinitis (overlapped with other nasal symptoms due to anatomical problems), and those with concomitant sinusitis, nasal polyposis, cases of revisionsurgeries, as well as all patients with an underlying systemic disease other than atopia.

Ethical approval: The protocol of this study was approved by the Institutional Review Board of the Tehran University of Medical Science. Detailed information about the study was given to the participants and a written informed consent was obtained from each one. All aspects of the study were conducted according to the Declaration of Helsinki.

Type of procedures and medical treatment: We used the external rhinoplasty approach in all cases and controls. All procedures were performed under general anesthesia by one of the senior authors. Internal lateral osteotomy was performed in all procedures, and no packing was used. Antibiotic prophylaxis (Cephalexin 500 mg/QID for five days) was prescribed to all patients and the only prescribed analgesic was acetaminophen. Subsequently, their nasal splints were removed after 7 days but taping was continued for 4 weeks thereafter. There was no usage of corticosteroid or antihistamine drugs in perioperative or postoperative periods.

Variables

The diagnosis of allergic rhinitis in patients was according to patients’ history. The state of nasal symptoms and its intensity was evaluated once one month prior to the surgery and once six months after the surgery via a subjective visual analogue scale (VAS) and also an objective symptom scoring system (total nasal symptom score – TNSS). The states of septal deviation and turbinate hypertrophy were also evaluated at the same time.

Visual analogue scale (VAS): The patients used a visual analog scale (VAS) to subjectively determine the intensity of their nasal obstruction. These results were translated into a 0 to 10 numeric scale, with a value of “10” being the strongest symptoms.

Total nasal symptom score (TNSS): Seven symptoms, which were the most common areas of complaint by patients, were objectively addressed by one of authors. In this scale, the absence of a symptom scored 0 while the presence of a symptom was categorized either as mild (1 score), moderate (2 scores), or severe (3 scores); accordingly, with seven questioned items and by adding the scores, a scoring system with a total score ranging from 0 to 21, named as “Total Nasal Symptom Score or TNSS” [18], was formed that identified the clinical severity of the symptoms each patient had. Based on the final TNSS, the patients were categorized into four symptom severity groups: patients with no symptoms (scores of 0), mild symptoms (scores of 1-7), moderate symptoms (scores of 8-14), and severe symptoms (scores of 15 to 21) [18]. We asked the patients to answer the TNSS questions according to their previous six months symptoms. Changes in the “mean TNSS” and also “TNSS groups” were used to evaluate the changes in the pre- to post-operative symptoms.

Septal deviation

As a factor that the septorhinoplasty intends to correct surgically, septal deviation was defined as any significant deviation could be found in anterior rhinoscopy [16].

Turbinate hypertrophy: The inferior turbinates were not operated on, and thus changes in turbinate hypertrophy could reflect the effect of surgery on exacerbating or alleviating nasal mucosal swelling. The severity of turbinate hypertrophy was referred to as “mild” for those occupying 0 to 30% of nostril cavity, “moderate” for 31-60% occupation, and severe for 61-100% , which was evaluated by anterior rhinoscopy.

Statistical methods: The data were analyzed using SPSS version 15.0 for Windows (SPSS Inc., Chicago, IL). Comparative studies were performed by Chi-Square and Paired Sample T-Test. The values were evaluated using descriptive statistical methods (mean ±SD) and p value < 0.05 was significant.

Results

Seventy three patients who were candidate septorhinoplasty entered to the study. Twenty one patients (28.8%) were male and the rest 52 (71.2%) were female. The mean age was calculated as 26.63±4.62 years ranging from 18 to 45. Table 1 outlines the results comparing the pre- and post-op status of nasal symptoms and outcomes.

Citation: Saedi B, Emami H, Safavi A and Hashemaghaee M. The Effect of Septorhinoplasty on Allergic Nasal Symptoms in Asymptomatic Patients. Austin J Otolaryngol. 2015; 2(8): 1061. ISSN :2473-0645