Effects of nasal septum deviation and concha bullosa surgery on the frequency and financial burden of acute rhinosinusitis.

BACKGROUND: Nasal septum deviation/concha bullosa (DNS)/(CB) are known to be predisposing factors in the pathophysiology of acute rhinosinusitis (ARS). However, the effects of surgical treatment of these pathologies on ARS have not been adequately investigated. AIMS: To reveal the effects of the surgical treatment of DNS and CB on the frequency of the ARS, the use of antibiotics (ABs), and the direct cost incurred. METHODS: Medical records of the patients who had undergone successful surgery for DNS/CB and were diagnosed with ARS in the preoperative and postoperative 3-year period were retrospectively analyzed. The average annual number of ARS examinations of the patients, the number of ABs prescribed, and prescription, examination, and total health system costs were compared. RESULTS: Fifty-three patients (33 men (62%) and 20 women (38%)) were included in the study. There was a statistically significant decrease in the mean annual number of examinations for ARS, the number of ABs prescribed, prescription, examination, and total health system costs (p < 0.05) in the postoperative period compared with the preoperative period. CONCLUSIONS: The present study determined that successful surgeries performed in patients with DNS/CB resulted in a significant decrease in the average annual number of examinations performed for ARS, number of AB prescriptions, and prescription, examination, and total health system costs. With these results, it seems beneficial to direct patients to surgery within the framework of the health policies of countries to reduce the frequency and financial burden of ARS in DNS/CB patients.

Evaluation of Cost-effectiveness and Clinical Value of Routine Histopathologic Examination of Septoplasty Specimens.

OBJECTIVES: During septoplasty, normal cartilage and bone are often sent for pathologic examination despite benign appearance. We explored pathology results following septoplasty from April 2016 to April 2018, examining clinical value and relevance, implications, and cost analysis. STUDY DESIGN: Retrospective chart review. SETTING: Single-institution academic medical center. METHODS: A retrospective chart review was compiled by using Current Procedural Terminology code 30520 for septoplasty for indication of nasal obstruction, deviated septum, and nasal deformity. RESULTS: A total of 236 consecutive cases were identified spanning a 2-year period. Septoplasty specimens were sent for pathology evaluation in 76 (31%). The decision to send a specimen for histopathology was largely physician dependent. No cases yielded unexpected or significant pathology that changed management. The average total charges for septoplasty were $10,200 at our institution, with 2.2% of procedural charges accounting for pathology preparation and review, averaging $225. Nationally, this results in an estimated charged cost of $58.5 million. The Centers for Medicare and Medicaid Services (CMS) reimbursement for septoplasty pathology charges was $46 in 2018, accounting for 1.3% of hospital-based reimbursements and 2.2% of ambulatory center reimbursements. With CMS as a national model for reimbursement, $11.8 million is spent yearly for septoplasty histopathology. Given that CMS reimbursement is significantly lower than private insurers, national total reimbursement is likely considerably higher. CONCLUSION: Routine pathology review of routine septoplasty specimens is unnecessary, unremarkable, and wasteful. Correlation of the patient's presentation and intraoperative findings should justify the need for pathology evaluation. This value-based approach can offer significant direct and indirect cost savings. LEVEL OF EVIDENCE: 4.

Is septal deviation associated with headache?: A nationwide 10-year follow-up cohort study.

To investigate the potential relationship between septal deviation (SD) and headache using nationwide representative cohort sample data.This study used a nationwide cohort sample from the Korean National Health Insurance Service database. The cohort sample was composed of 1 million patients, which is obtained by propensity score matching from 2002 to 2013. There were 9171 individuals in the SD group and 28243 in the control or no SD group. The Kaplan-Meier survival analysis, the log-rank test, and Cox proportional hazard regression analysis were used to calculate the incidence, survival curve, and hazard ratio of headache for each group.There were no statistically significant differences in sex (P = .7708), age (P = .991), residential area (P = .9626), or socioeconomic status (P = .9982) between the 2 groups. The survival curve between SD and control or no SD showed a statistically significant difference. The adjusted hazard ratio for headache incidence during the 10-year follow-up period of the SD group was 1.37 (95% CI: 1.31-1.43).This cohort study suggests that SD is associated with headache. Therefore, these findings suggest that septoplasty can be considered as 1 of the treatment option in SD patients with headache.

Good correlation between visual analogue scale and numerical rating scale in the assessment of nasal obstruction.

OBJECTIVE: Results from telephone interviews may be needed to supplement those from mailed questionnaires when response rates are inadequate. This study assessed the correlation between visual analogue scale ratings used in mailed questionnaires and numerical rating scale scores used in telephone interviews. METHODS: Patients scheduled for nasal septal surgery routinely respond to a visual analogue scale of obstruction during the day and at night. In this study, they were also asked to verbally rate their sense of obstruction using whole numbers. RESULTS: There was no significant difference between visual analogue scale and numerical rating scale obstruction scores. CONCLUSION: Ratings of nasal obstruction obtained with a numerical rating scale in telephone interviews are comparable to visual analogue scale scores in mailed questionnaires.

Effect of non-surgical maxillary expansion on the nasal septum deviation: a systematic review.

Nasal breathing is a requirement for proper growth and development of the craniofacial complex. Inadequacy of the nasal airway from obstruction such as from nasal septal deviation (NSD) can affect craniofacial development. Further investigation of the possibility of rapid maxillary expansion (RME) correcting NSD would be valuable, considering the undesirable sequelae of NSD on nasal breathing, which can consequently affect craniofacial development. A systematic review of the effect of RME treatment on NSD was conducted. Electronic database searches were conducted until April 2015 using MEDLINE, EMBASE, Web of Science, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CCTR), Cochrane Methodology Register (CMR), Database of Abstracts of Reviews of Effects (DARE), American College of Physicians Journal Club (ACP Journal Club), Health Technology Assessments (HTA), and NHS Economic Evaluation Database (NHSEED). MeSH terms used in database searches were 'nasal septum,' 'palatal expansion,' and 'maxillary expansion,' 'orthodontic device,' and 'palatal expansion technique.' The methodological quality of studies was reviewed using methodological index for non-randomized studies (MINORS). Only two studies were finally selected and reviewed. Both studies had significant methodological limitations. One study reported a significant straightening of the nasal septum in the middle and the inferior third of nasal cavity from RME in children aged 5 to 9 years. The other study reported no positional change in the nasal septum from RME in adolescent orthodontic patients. Thus far, the limited available (moderate risk of bias) evidence suggests a potentially positive effect on the nasal septum asymmetry during childhood, but no significant change in adolescence from RME in patients with NSD. The clinical significance of reported changes could be considered questionable.

Assessment of the correlation between nasal septal deviation and compensatory hypertrophy of the middle turbinate.

The aim of the study was to investigate the relationship between nasal septal deviation and the middle turbinate hypertrophy using computed tomography. In this retrospective analysis, we examined 77 patients with nasal septal deviation. The mucosal and bone structures of the middle turbinate and the angle of the septum were measured using radiological analysis. Measurements of the middle turbinate on the convex side were compared to those on the concave side. Measurements of the bony and mucosal structure area of the middle turbinate were significantly greater than those on the concave side. The dimensions of medial mucosa thickness and bone thickness were not significantly different between the convex and concave sides. No significant correlation was found between the angle of deviation and other parameters. The present findings suggest that compensatory middle turbinate hypertrophy was caused both by conchal bone growth and mucosal hypertrophy in patients with nasal septal deviation.

Pathological review of turbinate tissue from functional nasal surgery: incurring costs without adding quality.

OBJECTIVE: Inferior turbinate surgery for nasal obstruction can be performed in a variety of ways. Only a few of these methods produce tissue that can be sent for pathologic analysis. According to the College of American Pathologists, turbinate tissues are not exempt from requisite pathologic evaluation. Our objectives were to evaluate the clinical value and cost implications of routine pathological examination of turbinate specimens. STUDY DESIGN: Case series with chart review. SETTING: Academic tertiary care medical center. SUBJECTS AND METHODS: Charts of patients who underwent an inferior turbinate procedure for nasal obstruction between January 2008 and August 2011 were reviewed. RESULTS: Thirteen hundred consecutive cases from 17 surgeons were identified. Among these patients, 223 (17%) underwent an isolated turbinate reduction procedure and 779 (59%) underwent a reduction procedure in conjunction with a septoplasty. The remaining patients had a turbinate procedure in addition to another head and neck procedure. Only 591 (45%) turbinate reduction procedures were performed by methods that were tissue producing, and of these, 137 (23%) were sent for pathologic analysis. All submitted specimens received a gross examination and 123 (90%) also underwent histologic analysis. No abnormalities were reported. CONCLUSION: At our institution, most surgeons did not submit turbinate tissues for pathologic examination even when a specimen was produced. Of the specimens sent, no abnormal pathologic results were identified. Our results suggest that routine pathologic evaluation of inferior turbinate specimens may not contribute to patient care and perhaps represents an unnecessary cost.

Value-based analysis of routine pathologic septal and inferior turbinate specimens.

OBJECTIVE: To determine the frequency and clinical relevance of unanticipated histopathologic results in routine sinonasal surgery and evaluate the necessity for histologic processing of nasal septal cartilage, bone, and inferior turbinate specimens. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: A retrospective review of surgical pathology reports on adult patients undergoing sinonasal surgery during a 5-year period from 2005 to 2010 was performed. All cases with the preoperative diagnosis of sinonasal neoplasia, autoimmune disease, or directed septal biopsies were excluded from review. RESULTS: A total of 1194 pathology reports were reviewed from 1172 individual patients. This included histopathologic evaluation of 1194 septal cartilage and bone specimens and 714 inferior turbinate specimens. None of the patients had unanticipated histopathologic findings that were clinically significant. CONCLUSION: Many surgeons obtain histopathologic diagnoses on all tissue removed from a patient. Based on our institutional case series, histopathology of the septum and inferior turbinates in routine sinonasal cases may not be necessary. A value-based approach to processing grossly unremarkable septal and turbinate tissue by waiving histologic processing and subsequent microscopic evaluation could provide significant cost savings.

Exploring the clinical value and implications of routine pathological examination of septoplasty specimens.

OBJECTIVES/HYPOTHESIS: During septoplasty, otherwise normal cartilage and bone are removed and routinely submitted for pathologic examination. According to the College of American Pathologists, however, the examination of bone and cartilage from septoplasty and rhinoplasty may be left to the pathologist's discretion. We explored the processing of tissues removed during septoplasty, examining the clinical value and implications of current practices. STUDY DESIGN: Retrospective chart review. METHODS: Our database was searched for septoplasty (CPT code 30520) procedures performed specifically for the indication of nasal obstruction. RESULTS: Five hundred sixteen consecutive cases from 15 surgeons spanning a 2-year period were identified. In the majority of cases, septal tissues removed during surgery were submitted to pathology. The majority of cases (>90%) involved septoplasty performed in conjunction with another procedure, most commonly addressing the inferior turbinates. All septal specimens received gross examination by a pathologist, and a smaller fraction were also examined histologically. Gross findings included the qualitative appearance of the specimen and dimensional measurements of bone and cartilage fragments. No abnormalities were identified (by gross or histologic examination) in any of the specimens. Associated costs included specimen handling, storage, and pathology fees. CONCLUSIONS: In our health care system, it is common practice to submit tissues removed during septoplasty for pathologic examination. This study demonstrates that routine evaluation of septal tissues following surgery for obstruction has no clinical value whatsoever, and is associated with direct and indirect costs. Given the current health care climate, this practice should be further scrutinized and reconsidered.

Assessment of septal deviation effects on nasal air flow: a computational fluid dynamics model.

OBJECTIVES/HYPOTHESIS: The purpose of this article is to analyze the effects of septal deviation on the aerodynamic air flow pattern compared with that of a normal nose by computational fluid dynamics (CFD) tools. METHODS: Two 3-dimensional (3-D) models of nasal cavities were constructed from the magnetic resonance imaging and computed tomography scans of a healthy human nose and a nose with septal deviation, with the use of the software MIMICS 12.1 (The Materialise Group, Leuven, Belgium). Thereafter high-resolution 3-D volume meshes comprising boundary layer effect and computational domain exterior to the nose were constructed. Numerical simulations were carried out using FLUENT (ANSYS, Canonsburg, PA) for CFD simulations. The Reynolds-averaged Navier-Stokes equations were solved for the turbulence flow with the shear stress transport k - omega model. RESULTS: In the nose model with septal deviation, major changes in the pattern of inspiratory airflow (e.g., flow partitioning and nasal resistance, velocity and pressure distributions, intensity and location of turbulence), wall shear stress, and increasing of total negative pressure through the nasal cavity were demonstrated qualitatively and quantitatively. In the healthy nose, the area with the highest intensity of turbulent flow was found in the functional nasal valve region, but it became less apparent or even disappeared in the septal deviation one. CONCLUSIONS: This CFD study provides detailed information of the aerodynamic effects of nasal septal deviation on nasal airflow patterns and their associated physiological functions.

Objective versus subjective outcomes assessment in rhinology.

BACKGROUND: Prior studies on the relationship between computed tomography scan findings and patient-based quality of life in chronic rhinosinusitis (CRS) have found very low correlations. Whereas surprising, similarfindings have been noted in other diseases. METHODS: We performed a cross-sectional analysis of the association between objective and subjective findings in nasal septal deformity and a systematic review and synthesis of the literature on CRS and other diseases. RESULTS: We found no association between objective anatomic findings and subjective symptoms in nasal obstruction (R = 0.03; Kruskal-Wallis test, p = 0.97). Multiple studies in CRS and other diseases-sleep apnea, hearing loss, asthma, etc.- have found similarly low correlations between objective and subjective testing. CONCLUSION: For nasal septal deviation and CRS, the patient's subjective perception of disease severity has, at best, a very weak association with objective assessment of severity. Patient-based outcomes assessment remains important; these instruments apparently quantify an aspect of disease not detected by objective testing.

Assessment of adenoid size in children by fibreoptic examination.

In order to investigate the relationship between the size of the adenoid and upper respiratory symptoms in children, fibreoptic examination of the nasal cavity and nasopharynx was performed in 817 children. The size of the adenoid was classified into three categories according to the distance between the vomer and the adenoid tissue. There was a significant relation between the size of the adenoid and the complaints of nasal obstruction (P < 0.001) and of snoring (P < 0.001), but not with the presence of purulent sinusitis. In the whole population, the size of the adenoid correlated well with the results of tympanometry (P < 0.001), but this does not hold in all age groups. This study has confirmed adenoid hypertrophy as a common aetiological factor in children with the complaints of nasal obstruction and snoring. The enlargement of the adenoid only partially explains the occurrence of otitis media with effusion. The introduction of the flexible fibrescope in the examination of the nasal cavity and nasopharynx in children is of great clinical value, especially in the selection of children for adenoidectomy. It is a minor invasive examination well tolerated by most children, giving more information than a lateral skull radiograph and avoiding unnecessary radiation.

Correlations between subjective sensation of nasal patency and rhinomanometry in both unilateral and total nasal assessment.

The correlation between rhinomanometry and subjective sensation of nasal obstruction was studied. Patients assessed their nasal airway patency using a visual analogue scale (VAS). The VAS results and rhinomanometry correlated better when unilateral nasal obstruction was evaluated compared to total nasal evaluation. When rhinomanometric data were divided into four clinically relevant grades of obstruction (very patent, normal, obstructed and very obstructed) and the quartiles of the VAS results were compared to these, the agreement was good or fairly good in 75-85% of cases. A similar result was also encountered when, in an experimental study, 30 individuals were asked to breathe through four artificial nose models with a varying inner diameter of 9-3 mm. Again, most subjects assessed these models logically, but in 11% of the cases the subject assessed the narrowest tube as patent or the widest tube as very obstructed. Our results prove the necessity of having some sort of objective method to evaluate nasal patency; if we rely only on the patient's sensation, we may get a misleading picture of his nasal function.

Clinical assessment of squamous cell carcinoma of the nasal cavity proper.

The subjects were 14 patients with squamous cell carcinoma or undifferentiated carcinoma of the nasal cavity treated at Nihon University Hospital between October 1984 and November 1991, who were followed for at least 3 years. The site of the tumor origin within the nasal cavity was the lateral wall in 8 patients, the nasal septum in three patients, and unknown in three patients. Histologically, there were 13 squamous cell carcinomas in (3 well differentiated, 7 moderately differentiated, and 3 poorly differentiated) and 1 undifferentiated carcinoma. Treatment was by a combination of radiotherapy, chemotherapy, and surgery in 8 cases, a combination of radiotherapy and surgery in 5 cases, and surgery alone in 1 case. The 3-year and 5-year Kaplan-Meier survival rates were 86 and 69%, respectively. A total of 6 patients suffered a recurrence, with local recurrence occurring in 4 patients and pulmonary metastasis in 2 patients. Tumor control was achieved in 3 of the 4 cases of local recurrence by reoperation, and by surgery in 1 of the 2 cases of pulmonary metastasis. The duration of the recurrence-free interval in the patients who developed local recurrences, 18 to 46 months after the completion of the initial course of therapy, was of considerable interest.