European Journal of Cardiovascular Medicine

Allergic rhinitis is an IgE mediated type 1 hypersensitivity reaction which produces by exposure to certain allergens to which the patients are sensitize. It is characterized by the symptoms like nasal obstruction, rhinorrhea, sneezing and itching. Symptoms purely develop after sensitization from the antigens. There are two types of allergic rhinitis; the one with frequency of episodes of < 4 days per week or < 4 consecutive weeks per year is considered as intermittent and opposite to that when it is more than that it is persistent. It is         further divided into Mild and Moderate – severe depending upon whether it affects your day to day activity, sleep etc or not. Around 75% of the patients fall under persistent type.

Due to the global prevalence of septal deviation and the increasing level of air pollution, the prevalence of allergic rhinitis increases affecting millons of people globally, disrupting their daily lives, work performance and productivity. The coexistence of septal deviation and allergic rhinitis often leads to headache. Septoplasty the main treatment for allergic rhinitis shown improvement in allergic rhinitis symptoms. 1 type of tool for assessment of the severity of the symptoms in allergic rhinitis with DNS (Deviated nasal septum). 2 Outcomes of nasal septal surgery are often rated using subjective scales of nasal obstruction such as the Nasal Obstruction Evaluation ( NOSE) score, the sino-nasal outcome score (SNOT-22) and visual analogue scales (VASs).The outcomes are often regarded as successful if the difference between pre- and post- operative ratings is found to be statistically significant.3

The aim of this study is to assess the effect of septoplasty on the clinical course of allergic rhinitis with DNS and improvement in quality of life by ARCT questionnaire (Allergic rhinitis control test) which was developed by ARIA (Allergic Rhinitis and its Impact on Asthma) 2007 guidelines. 4 Nasal septoplasty is the third most common surgery performed in the ear nose and throat (ENT) specialty and can be done under local or general anesthesia. Some patients of allergic rhinitis with deviated nasal septum need surgery to relieve symptoms. 1 Nevertheless, the gain of this surgery has been questioned. Some studies have showed moderate to excellent results but a new study from Sweden suggests that the results are unsatisfactory. 5 Difficulty in nasal breathing is probably the most common complaint in rhinological practice. Among the major causes are Deviated nasal septum (DNS) and Allergic rhinitis (AR). Treatment of symptomatic DNS is surgical with success rate, in terms of patient satisfaction, particularly if the deformity is localized in the caudal septal end or the valve area. Treatment of AR is a much complex issue, including medications, avoidance of causative allergen, densensitisation and the use of a variety of surgical techniques, which mainly aim at the reduction of the size of the inferior turbinates .

When allergic rhinitis and nasal septum deviation coexist, the patient may undergo septoplasty combined with some form of volume reduction of the inferior turbinates. 6 When deciding on the best therapeutic strategy for patients with nasal pathology one must have a tool for the assessment of subjective symptoms. The Nasal Obstruction Symptom Evaluation (NOSE) Scale is a disease – specific quality of life instrument for use in nasal obstruction (LundbackBet al., 1998). 7 Nasal blockage is a common complaint. In the adult population chronic diseases such as Chronic rhinosinusitis and allergic rhinitis are two of the main causes for nasal Congestion. In Europe, Chronic rhinosinusitis has a prevalence of 10.9% and allergic rhinitis a prevalence of 17-29%

Septal deviation and turbinate hypertrophy are among the most common structural causes of symptomatic nasal obstruction in adult patients. Septoplasty is one of the most frequently performed procedures by otolaryngologists annually. Correction of the nasal deformity has been shown to have significant benefit on disease – specific (nasal obstruction) quality of life.

There is little research into the outcomes of septal surgery on patients with co-morbid allergic rhinitis. It has been suggested that surgeons “proceed with for caution “in patients with concomitant allergic rhinitis and nasal septal deviation as the allergic rhinitis patients are more likely to be less satisfied after Septoplasty as compared to the non- allergic patients.

This prospective observational study was conducted in the Department of ENT & Head and Neck Surgery, SMGS GMC Jammu for a period of one year w.e.f. 1^st August 2023- 31^st July 2024. Study was conducted after approval from Institutional Ethical Committee, Govt Medical College, Jammu. The study included all the patients of allergic rhinitis with deviated nasal septum who required septoplasty. .

Inclusion criteria

• Allergic rhinitis patients with symptomatic DNS who underwent Septoplasty and was willing to take part in the study.
• Patient aged 18 years to 60 years.
• Patients were included regardless of recent local medication use such as steroid nasal spray for control of nasal allergy.

Exclusion criteria;

• Revision cases were excluded
• Patients with co-existing sinus pathology such as sinusitis or polyp.
• Patients with Co- morbid illness (uncontrolled DM, uncontrolled HTN, CHF)

Work Up Of Patients

After explaining about the surgical procedure, informed consent was obtained from all the patients. They were assessed according to the methodology given in the proforma;

History; Detailed history was taken with special emphasis on complains of nasal obstruction in allergic rhinitis patients.

Examination;

General physical Examination

Complete ENT Examination with special emphasis on;

• NOSE EXAMINATION
• Absolute Eosinophil Count
• Serum IgE
• NCCT nose/ PNS
• DNE
• SNOT-22

Statistical Analysis:

All of the collected data was entered in the proforma and entered in Microsoft excel spread sheet and compared using statistical package. Appropriate analytical tests was applied as per advice of the statistician.

In our study, maximum number of patients (71.7%) were in age group of 18-30 years. The youngest patient being 18 yrs old and oldest was 60 years of age.

In our study, maximum patients were males 42% (70.8%) and females were 18 (30%) with male: female ratio 2.3:1.

Table 1: Age and Gender Distribution among patients (n=60)

In our study, maximum male 31 [73.8%] patients were in age group 18-30 years whereas only 2 [4.8%] patients were in age groups of 51-60 years. Among females maximum 12 [66.7%] were in age group 18-30 years followed by 6 [33%] patients who were in age group of 31-40 years. In our study, no female patients were in age group of 41-60 years.

Table 2: Type of DNS

In our study, maximum patients having S shaped DNS were 19 [31.7%] patients followed by C shaped DNS in 13 [21.6%] patients and thickened septum was observed in 5(8.4%) patients.

Table 3: Prevalence of Symptoms among Patients

In our study, Sneezing and Rhinorrhoea were the most common presenting symptoms observed in 54 (90%) Patients each. The second most common presenting symptoms was nasal blockage in 52 (86.7%) patients followed by Itchy nose in 50 (83.3%) patients.

Table 4: Combined Symptoms among Patients

In our study, combined symptoms of (nasal blockage+ sneezing + rhinorrhea) were most commonly observed in 56 Patients (93.3%)  and the second most common combined symptoms (Nasal blockage+ sneezing+itching) were observed in 54 patients (90%).

Table 5: Comparison of Nose Score

The mean NOSE score of 60 patients during the study was found to be 13.20. After Septoplasty there was a decrease in the score found at the end of 6 months which was 5.90. In our study with the help of the NOSE questionnaire there was  a decrease in the NOSE score which shows improvement in the quality of life of the patient after septoplasty at a significant level ( p<0.001). 

Table 6: Comparison of ARCT Score

In our study, the mean ARCT score of 60 patients during the study was found to be 9.81. After Septoplasty there was an increase in the ARCT score to 19.41 at the end of 6 months which showed that there was improvement in the quality of life of the patient after septoplasty at a significant level ( p<0.001).

Table 7: Comparison based on SNOT Score before and after surgery

In our study, average preoperative SNOT-22 Score was 42.02. Postoperative mean SNOT-22 score at one month was 10.73, after 3 months was 7.48 and after 6 months was 5.28. The decrease in the average SNOT score after surgery was statistically significant (p value< 0.001).

Table 8:  Sino Nasal Outcome Test (SNOT-22)/ Questionnaire

Table 9: Clinical symptoms with reference to SNOT-22 test/ Questionnaire [preoperative]

The most important Complaint in rhinological practice is being nasal blockage and the most common for that is deviated nasal septum and allergic rhinitis, its co-existence makes it more difficult for the patients to breathe and to carry out day to day activities.

High number of deviated nasal septum patients have concurrent allergic rhinitis.Even though the conditions are not similar. For patients with allergies or a deviated septum, there are some similarities. For example, both diseases may lead to sinus infection, both minic the signs and symptoms of common cold. Allergic rhinitis by the way of triggering allergic response to airborne allergens while deviated septum can also have nasal swelling and increased mucus, leading the same. A significant deviated nasal septum deviation nasal septum causes blockage on one side of the nose and reduces airflow, causes difficulty breathing. On diagnosing nasal septum deviation, medical management using topical nasal steroids, antihistamines, and decongestants as applied for the nasal mucosa is typically attempted first. In case of failure, a surgical intervention to correct the underlying septal deformity is the second line.

In our study the most common symptom was nasal blockage (86.66%), followed by sneezing (90%) & rhinorrhea (90%) and Itching (83%).

In our study the males (71%) are more common than females (28%). The maximum 43 (71.6%) patients were in age groups 18-30 Years followed by 12(20%) in age groups 31-40 years ,3(5%) patients in age groups 41-50 years and 2 (3.3%) patients in age groups 51-60.

Preand Post-Operative Nose Score Before And After Septoplasty:

In our study we have used the NOSE scale for subjective assessment and ARCT score to assess the quality of life postoperatively. NOSE scale is a disease specific quality of life instrument for use in nasal obstruction, developed by Stewart MG et al., (2004). 2

The statistically significant decrease in NOSE score in the allergic rhinitis with symptomatic deviated nasal septum proves that septoplasty is benefited in these patients as shown in other study. 8 In our study the same result has been noted.

The mean NOSE score of 60 patients during the study was found to be 13.20 out of 60. After Septoplasty there is a decrease in the score found at the end of 6 months which was 5.90.In our study with the help of the NOSE questionnaire there is a decrease in the NOSE score which shows improvement in the quality of life of the patient after septoplasty at a significant level at p<0.001.

The findings in our study were in accordance with the above quoted studies.

Pre and Post Operative Arct Score Before and After Septoplasty:

Inourstudy we have used the ARCT (allergicrhinitis Control test) questionnaire developed by DemolyPetal., (2011) for evaluation of control of allergic rhinitis following septoplasty. 4 Some investigators believe that, regardless of the magnitude of the septal deviation, surgical correction eliminates a possible contributing factor of rhinitis because after septoplasty surface area of the septum is markedly reduced as we remove the deviated septal part hence allergens get less attached to the mucosa and allergic reaction will decrease. Another theory is post operative fibrosis in the nasal mucosa leads to loss of allergic response to the allergens and exposure, thus decrease in the frequency and severity of the episodes, supported by other study.  9

In our study, the mean ARCT score of 60 patients during the study was found to b 9.81 out of 60. After Septoplasty there is a increase in the score found at the end of 6 months which was 19.41. In our study with the help of ARCT questionnaire there is a increase in the ARCT score which shows improvement in the quality of life of the patient after septoplasty at a significant level at p< 0.001.

Our study also clearly brings out the fact that Septoplasty when performed in allergic rhinitis patients with deviated nasal septum improves the allergic rhinitis status as similar study done by KimYHetal.,(2011). 10 High number of deviated nasal septum patients have concurrent allergic rhinitis. Some conditions are similar for both allergic rhinitis and deviated nasal septum.For example, both diseases may lead to sinus infection, both mimic the signs and symptoms of common cold. Allergic rhinitis by the way of triggering allergic response to airborne allergens while deviated septum can also have nasal swelling and increased mucus, leading to same as similar study done by KeratzanisADet al.,(2009). 6

In our study of 60 patients, who underwant septoplasty, majority of them were in 2nd and 3rd decade. Nasal obstruction was the most common symptoms followed by headache, bleeding, nasal discharge and hyposmia.

Diagnostic Nasal Endoscopy:

On diagnostic nasal endoscopy, anterior deviation was the most common symptom followed by headache, bleeding, nasal discharge and hyposmia. On diagnostic nasal endoscopy, anterior deviation was the most common abnormality followed by posterior deviation, septal spur, HIT and high DNS. Post-operative follow up visits showed lesser residual deformity.Postoperatively and during subsequent visits, there was a significant statistical improvement in NOSE scoring.

Septoplasty is an effective treatment for nasal obstruction in patients with symptomatic deviated nasal septum and NOSE scoring is a useful parameter for assessing the improvement in quality of life among symptomatic DNS patients.

Pre- Operativencct Nose & Endoscopic Findings:

NCCT findings of noserevealedthat the types of DNS. In our study groups C shaped DNS was seen in (17%) patients, S shaped DNS was seen in (21%) patients, Dislocated of caudal septum was seen in (8%)patients, Septal spur formation was seen in ( 9%)patients and thickening of nasal septum was seen in (5%) patients.

Nasal Endoscopic: findings of NOSE and PNS revealed that C shaped DNS was observed in 20% patients, S Shaped DNS was observed in 18% patients, purulent nasal discharge was seen in 70%, congested nasal mucosa was seen in 75%, Osteomeatal complex was blocked in 30% and hypertrophied inferior turbinate was present in 16%.In our study there was excellent correlation between the CT SCAN findings and endoscopic sinus surgery findings in accordance with the above quoted studied.

Pre& Post Operative Clinical Profileofpatients As Per Snot-22 Questionarrebefore and After Septoplasty:

In this study average preoperative SNOT-22 score was 42.02. Postoperative average SNOT-22 score at 1 month after surgery was 10.73, average SNOT-22 score at 3 months after surgery was 7.48 and the average SNOT-22 Score at 6 months after surgery was 5.28.The average pre-operative SNOT-22 Score was 42.02 which decreased to an average score of 10.73 at one month. The scores further decreased to an average score of 10.73 at one month. The scores further decreased to an average of 7.48 at 3 months and 5.28 at 6 months. The score decreased by 34.77 % at one month, 81.9% at 3 months and 86.25% at 6 months. The decrease in the average SNOT score after surgery was statistically significant as the scores were less than 0.001. in a similar study found that one month after surgery, nasal obstruction became a no problem in 100 % patients, hyposmia became a no problem in 63% patients, post nasal discharge became a no problem in 96% patients and facial pain became a no problem in 84.4%.

Although the results match to a good extent but the variation might be because of the ambiguity of the questionnaire, things like no problem and very mild problem can be taken differently by two examiners and the results of questionnaire are patient dependent.

The result of this study suggest that Septoplasty alone seems to be a good management choice for allergic rhinitis patients when they have deviated septum. These findings open the gate for more understanding of anatomical factors role in induction of allergic rhinitis patients or initiating them. The study shows that most common symptoms are nasal blockage, rhinorrhea and sneezing more affecting the age group of 18-30 years. Males with deviated nasal septum seen more commonly. It improves symptoms like nasal obstruction, sneezing and rhinorrhea etc. Improves the quality of life by decrease in the severity of allergic rhinitis. Thus there is a subjective improvement seen in these patients which is benefited for them to carry out day to day activity as was difficult preoperatively.

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