Assessment of olfactory function after septoplasty: a longitudinal study

AIM: Aim of the study was to evaluate septoplasty-related changes of lateralised olfactory function during both early and late postoperative periods in comparison to the preoperative situation. MATERIAL/METHODS: Lateralised olfactory function was assessed in 30 patients using the "Sniffin' Sticks" test battery. Measurements were performed preoperatively, and 4 and 9 months postoperatively. RESULTS: Prior to septal surgery measurements revealed significantly higher odor thresholds for the obstructed nostril compared to contralateral thresholds. No such observations were made for suprathreshold measures. Postoperatively, a significant decline of odor discrimination was found in comparison to the preoperative situation. However, there was no significant change of odor thresholds and odor identification function during the 9-month postoperative follow up. On an individual basis, one of the initially normosmic patients became hyposmic following surgery. CONCLUSIONS: The present data indicate that odor thresholds, but not suprathreshold olfactory function, are related to nasal obstruction resulting from septal deviation. In contrast, postoperative changes were only seen for odor discrimination. Apart from psychological explanations of this finding, it may be hypothesized that these observations result from changes in intranasal airflow following surgery.     

Assessment of symptom improvement following nasal septoplasty with or without turbinectomy

Most studies show that objective measures to quantify and determine surgical success in the treatment of nasal obstruction do not correlate with subjective improvement as reported by patients.AimTo evaluate the subjective improvement of nasal symptoms in patients undergoing septoplasty with or without turbinectomy.Materials and methodsA prospective study. We evaluated 72 septoplasty patients with or without partial inferior turbinectomy; the patients answered a questionnaire preoperatively and on the 60th day after surgery.ResultsSeptoplasty was done associated with bilateral partial inferior turbinectomy in 83.3% of patients; it was unilateral in 9.7%; there was no need for turbinate reduction in 6.9%. An improvement of all symptoms was observed after surgery. Nasal obstruction had improved in 68 patients (94.4%) by the 60th postoperative day. The average nasal obstruction score in patients with and without allergic symptoms was similar before surgery and on the 60th postoperative day. Older patients had milder preoperative allergic symptoms.ConclusionsNasal symptoms in patients undergoing septoplasty, with or without turbinectomy, improved. Patients with and without allergic symptoms showed a similar improvement of nasal obstruction on the 60th postoperative day.     

Numerical study of the aerodynamic effects of septoplasty and partial lateral turbinectomy

OBJECTIVES: To investigate, first, the effects of septal deviation and concha bullosa on nasal airflow, and second, the aerodynamic changes induced by septoplasty and partial lateral turbinectomy, using computational fluid dynamics (CFD). METHODS: A three-dimensional model of a nasal cavity was generated using paranasal sinus computed tomography images of a cadaver with concha bullosa and septal deviation. Virtual septoplasty and partial lateral turbinectomy were performed on this model to generate a second model representing the postoperative anatomy. Aerodynamics of the nasal cavity in the presence of concha bullosa and septal deviation as well as postoperative changes due to the virtual surgery were analyzed by performing CFD simulations on both models. Inspiratory airflow with a constant flow rate of 500 mL/second was used throughout the analyses. RESULTS: In the preoperative model, the airflow mostly pass through a narrow area close to the base of the nasal cavity. Following the virtual operation, a general drop in the maximum intranasal air speed is observed with a significant increase of the airflow through right middle meatus. While in the preoperative model the greatest reduction in pressure is found to be in the localization of anterior septal deviation on the right side and confined to a very short segment, for the postoperative model, it is observed to be in the nasal valve region in both nasal cavities. Following septoplasty and partial lateral turbinectomy, total nasal resistance is reduced significantly. CONCLUSIONS: CFD simulations promise to make great contributions to understand the airflow characteristics of healthy and pathologic noses. Before surgery, planning for any specific intervention using CFD techniques on the nasal cavity model of the patient may help foreseeing the aerodynamic effects of the operation and might increase the success rate of the surgical treatment.     

Anterior turbinectomy. A new surgical approach to turbinate hypertrophy: a review of 220 cases

Surgical correction of mechanical nasal airway obstruction is commonly treated by septoplasty. The nasal airflow, however, is often inadequate postoperatively. The inferior turbinates are responsible for nasal obstruction more often than is realized. Recent studies have confirmed that the main site of respiratory resistance is located at the level of the anterior ends of the inferior turbinates. A new turbinectomy approach in which the anterior end of the inferior turbinate is resected with a specially modified forceps is described. A large series of patients, along with their follow-up data, are described. The advantages of the anterior turbinectomy are discussed.     

Inferior turbinectomy: comparison of four techniques

As yet, there is not totally satisfactory means for treating hypertrophied turbinates and the proper management of turbinate dysfunction remains in question. In the present series, four of the widely practiced surgical procedures for the reduction of the size of the inferior turbinates were evaluated and compared. In all cases turbinectomy was performed as an isolated procedure. Eighty patients with chronic non-allergic rhinitis and hypertrophied inferior turbinates were selected, randomly divided into four groups, and followed up post-operatively for one year. Study of the results indicated that the beneficial effect of the operation is mainly mechanical by reduction of the resistance to nasal airflow. The post-operative improvement in smell acuity correlated positively with the increased patency of the nasal airway. None of the procedures had a deleterious effect on olfactory acuity. In contrast, the operation failed to enhance the mucociliary clearance rate or significantly decrease nasal drainage. Partial inferior turbinectomy and laser turbinectomy improved nasal breathing in 77 per cent of patients, and enhanced olfactory acuity in 78 per cent of patients who had pre-operative hyposmia. The results of turbinoplasty and cryoturbinectomy were less favourable. The surgical technique, advantages, and drawbacks of each of these procedures are discussed.     

Abhängigkeit des uni- und bilateralen Riechvermögens von der nasalen Strömung bei Patienten mit chronischer Rhinosinusitis

OBJECTIVE: Olfactory dysfunction is a common finding in patients with chronic rhinosinusitis (CRS). The aim of this study was to investigate the relationship between olfaction and nasal flow as determined by active anterior rhinomanometry (AAR). METHODS: Thirty patients with CRS were included in this series. Patients' histories and subjective assessments of olfaction were documented with questionnaires. Smell tests, assessments of olfaction, AAR, and results of rhinoscopy were recorded, including odor identification, discrimination and thresholds measured with the "Sniffin' Sticks"-test. RESULTS: CRS influenced olfactory performances variably in the different tests: 10% of the patients had pathologic rates of odor discrimination, compared with 34% in odor identification and 73% in thresholds. Statistical analyses (using Spearman's test) indicated a significant correlation between nasal airflow and odor identification screening (r29 = 0.56, P < 0.01) and n-butanol-threshold (r29 = 0.44, P < 0.05), respectively. CONCLUSION: Olfactory performance in CRS was correlated to several parameters of nasal airflow measured with AAR. The n-butanol threshold test revealed the most frequent pathological results and may best be used for detecting olfactory disorders. However, because a number of factors may influence olfactory dysfunction in CRS, our findings must be evaluated in a lager series.     

Intranasal trigeminal sensitivity: measurements before and after nasal surgery

Nasal surgeries constitute an extensive manipulation of the nasal mucosa and therefore of structures related to trigeminal and olfactory sensitivity. While olfactory changes due to nasal surgery are relatively well investigated, there are only very few studies regarding trigeminal sensitivity. Aim of the present study was to investigate sensory changes after nasal surgery with special regard to the trigeminal sensitivity. In 38 patients prior to and around 12 weeks after nasal surgery the following psychophysical measures were performed: odor identification, odor discrimination, phenyl ethyl alcohol odor threshold, sensitivity to trigeminal stimuli, trigeminal detection thresholds and trigeminal pain thresholds. These results were compared to those of a control group (43 healthy volunteers). Psychophysical olfactory and trigeminal testing showed no major changes in patients after surgery compared to the control group. Independent from the time of measurement higher trigeminal detection thresholds were found in patients compared to healthy subjects, meaning that trigeminal thresholds were already increased before surgery. The present study revealed a decreased trigeminal sensitivity in patients already before surgery. It may be hypothesized that patients also exhibit a decreased sensitivity for nasal airflow, which may also contribute to the patients’ impression of impaired nasal breathing.     

Experiences in middle turbinectomy

Rhinologists have long cautioned about removal of the middle turbinate, though exenteration of the ethmoid labyrinth including the middle turbinate has shown the structure can be sacrificed. The middle turbinate can be removed in the crowded nose often with septoplasty and partial inferior turbinectomy, to improve the nasal airway. A vasoactive middle turbinate which engorges and compresses against an often deviated nasal septum gives rise to the “four finger headache” patient for whom middle turbinectomy, often with septoplasty, is helpful. Point cocainization of the compressed site helps prognosticate the good candidate for surgical relief. Patients with purulent sinusitis have been excluded from the study. Results have been good to excellent with no long-term adverse sequelae. There has been no crusting, drying, or infection as a result of our middle turbinectomies. Careful patient selection is critical.     

Rehabilitation of olfaction after laryngectomy by means of a nasal airflow-inducing maneuver: the "polite yawning" technique

OBJECTIVE: To develop a nasal airflow-inducing maneuver and apply it in the olfactory rehabilitation of patients who have undergone laryngectomy. DESIGN: Intervention study; before-and-after trial. SETTING: National cancer center. PATIENTS: Forty-four patients who underwent laryngectomy; 34 men and 10 women; mean age, 64 years (range, 42-80 years); mean time since surgery, 6 years (range, 8 months to 18 years). INTERVENTION: In a prospective clinical intervention study, we assessed the effectiveness of a nasal airflow-inducing maneuver ("polite yawning," ie, yawning with closed lips). Speech therapists trained the patients in the maneuver, and its effectiveness in inducing nasal airflow was checked with digital and water manometers. MAIN OUTCOME MEASURES: Olfactory acuity was assessed before and after the intervention by means of an odor detection test and a structured questionnaire concerning olfaction, taste, and appetite. Patients were categorized as "smellers" and "nonsmellers" on the basis of the results of the odor detection test and the present odor perception scale derived from the questionnaire. RESULTS: The nasal airflow-inducing maneuver could be taught to all patients, mostly in only one 30-minute therapy session. Fifteen of the 33 patients in the pretreatment nonsmeller category converted to smellers, for a success rate of 46% (P<.001). CONCLUSION: The nasal airflow-inducing maneuver (the "polite yawning" technique) allowed almost half of the patients to recover their sense of smell.     

Sense of smell before and after functional esthetic rhinoplasty

Background. The aim of the present study was to determine possible changes in olfactory threshold after functional and esthetic nasal operations and to evaluate whether these changes were recognized by the patients. Methods. The study included 41 patients before and after nasal surgery (septoplasty, septorhinoplasty). Nasal airway resistance, olfactory thresholds, and subjective symptom scores were evaluated and compared pre- and postoperatively. The mean follow-up was 5.4 months. Olfactory performance was assessed using the Sniffin' Sticks. Results and conclusions. The postoperative values in the screening test for olfactory sensitivity were not significantly different from those before nasal surgery. Nasal ventilation was improved postoperatively in all patients, assessed by determination of nasal airway resistance and subjective symptom scores. Besides an increase in nasal ventilation, functional and esthetic nasal operations can lead to improvement of olfactory function. The rarely seen postoperative increase in olfactory threshold does not seem to be subjectively recognizable by the patients.     

Comparison of the effects of radiofrequency tissue ablation,CO2 laser ablation,and partial turbinectomy applications on nasal mucociliary functions

OBJECTIVES: One of the major causes of chronic nasal airway obstruction is disease of the inferior turbinate. However, there is no agreement on how to deal with this problem. Comparison was made of the nasal functions after treatment by radiofrequency tissue ablation, laser ablation, and partial turbinectomy using subjective symptom scores and objective tests. STUDY DESIGN: Prospective, randomized clinical trial. METHODS: The study was conducted on three groups of 45 adult volunteer patients with symptoms and signs of nasal obstruction and stuffiness related to enlarged turbinates. In group A, laser ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group B, radiofrequency tissue ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group C, patients who were not treated by any surgical techniques were the control subjects. Clinical examinations, visual analogue scales, rhinomanometry, and isotopic study of nasal mucociliary transport time were used to assess treatment outcomes. RESULTS: At 12 weeks after surgery, the nasal mucociliary transport time results were compared in the same patients. The average time was 25.60 minutes on the side where laser ablation was applied and 11.40 minutes on the side where partial turbinectomy (PT) was applied. In the patients on whom radiofrequency tissue ablation and partial turbinectomy were applied, the average nasal mucociliary transport time was 10.33 minutes on the radiofrequency tissue ablation side, whereas it was 11.33 minutes on the partial turbinectomy side. Rhinomanometric measurements demonstrated a significant decrease in nasal resistances at 12 weeks in both sides in groups A and B. CONCLUSIONS: In the study it was demonstrated that radiofrequency tissue ablation to the turbinate is effective in improving nasal obstruction objectively and in preserving nasal mucociliary function. Laser ablation of the turbinate is effective in improving the nasal obstruction; however, it disturbs the mucociliary function significantly. With the partial turbinectomy technique, results obtained were similar to the results with the radiofrequency tissue ablation technique.     

Clinical significance of results from olfactory testing

BACKGROUND: Although widely used in healthy subjects and patients with olfactory loss, the significance of changes of scores from validated olfactory tests is unknown. AIM AND METHODS: The aim of the present study was to relate the self-assigned changes of olfactory function in terms of "better," "unchanged," and "worse" in patients with smell disorders with the results from olfactory testing by means of a validated test set. Olfactory function of 83 anosmic or hyposmic patients (40 women, 43 men; age 12-84 yr) was tested on two occasions (mean interval 136 days, minimum 7 days, maximum 6.7 yr). Olfactory function was assessed using a validated technique ("Sniffin' Sticks"). This test consists of three subtests, one for odor threshold (T), odor discrimination (D), and odor identification (I), with possible results ranging up to 16 points each. From the sum of the results from the three subtests a composite "TDI" score was obtained. RESULTS: Forty-four patients indicated an improvement of olfactory function, whereas 39 patients reported no change. No subject reported deterioration of olfactory sensitivity. Subjects assigned to group BETTER had higher TDI scores in the second olfactory tests than subjects assigned to the group UNCHANGED, both in absolute terms and as compared with the first olfactory test (effect "test occasion" by "self-assessed improvement," P < .001). There was no significant difference between groups with respect to age and sex (P = .99 and .84, respectively). Logistic regression showed that more than 60% of the subjects reported an improvement of olfactory sensitivity when the TDI score increased by 5.5 points. CONCLUSION: We show that there is a statistically significant relation between measured and perceived improvement of olfactory function in patients who first presented with the diagnosis of anosmia or hyposmia. The results indicate that improved olfactory function in patients with olfactory deficiency is perceived as such in everyday life and is quantitatively related to an improvement in the composite TDI score of the "Sniffin' Sticks" olfactory test battery. This is the basis for the application of a specific therapy for olfactory loss because of a possible gain in quality of life for the patients.     

鼻内窥镜手术的中鼻甲处理

探讨鼻内窥镜手术中鼻甲部分切除和保留中鼻甲与预后的关系。方法４０例双侧慢性窦炎鼻息肉患者,在鼻内窥镜手术中１侧切除术中鼻甲,另侧保留中鼻甲,观察术后鼻腔清理时间,粘连情况和手术前后觉变化。     

Nasal soft tissue obstruction improvement after septoplasty without turbinectomy

The objective of the study was to evaluate the outcome of septoplasty without inferior turbinectomy in patients with septum deviation and nasal obstruction. After exclusion of allergic rhinitis, this study included 30 patients with deviated nasal septum and hypertrophied inferior nasal turbinate who were prepared for septoplasty without turbinectomy. After full history taking and complete otorhinological examination, all patients graded their extent of obstruction using the Nasal Obstruction Symptoms Evaluation scale and underwent CT scans to evaluate the side and shape of deviation, thickness of the medial and lateral mucosa and inferior conchal bone on both the concave and convex sides. Postoperative (PO) follow-up consisted of evaluation of surgical outcome, nasal obstruction grading and patient’s satisfaction. CT imaging was repeated for evaluation of the previous items and to compare with preoperative data. All surgeries were conducted smoothly without intraoperative complications and all were managed as day surgery. The mean duration of follow-up was 20.1 ± 4.4 months. All patients showed progressive significant decline of nasal obstruction symptoms and only eight patients still had mild symptoms. Patients’ satisfaction scores showed significant progressive increase reaching a peak at the 12th month. Preoperative CT confirmed the presence of hypertrophied mucosa on the concave septal side with significantly thicker medial and non-significantly thicker lateral mucosa on the concave side compared to the convex side. At the 12th month PO, mean medial mucosal thickness significantly decreased on the concave side with significant increase on the convex side, but the effect was significantly pronounced on the concave side. Mean lateral mucosal thickness was significantly decreased on the concave and non-significantly increased on the convex side. Conchal bone thickness showed non-significant change despite the diminution on both sides In the absence of allergic rhinitis, septoplasty without turbinectomy significantly improves nasal obstruction-related manifestations and approaches high patient satisfaction with associated reduction of hypertrophied mucosa and spares turbinectomy-related complications.     

Revision septoplasty: review of sources of persistent nasal obstruction

BACKGROUND: Patients with nasal obstruction from septal deviation commonly undergo septoplasty to improve nasal airflow. Some patients suffer from persistent obstruction after their primary septoplasty and may undergo a revision septoplasty to improve their nasal passageway. Our objective was to identify patients who underwent revision septoplasty and to identify their sources of persistent nasal obstruction. METHODS: Patients who underwent septoplasty at our institution between 1995 and 2005 were reviewed. Data is collected on demographics, comorbidities, age at septoplasty, associated and concomitant procedures, surgical approach, and anatomic site of obstruction. RESULTS: Five hundred forty-seven patients met inclusion criteria including 477 who underwent primary septoplasty and 70 who underwent revision surgery. Nineteen percent of nonrevision patients underwent nasal valve surgery along with their primary septoplasty versus 4% of patients in the revision group. Fifty-one percent of revision patients had nasal valve surgery at revision surgery. Patients who underwent sinus surgery along with primary septoplasty were less likely to undergo revision septoplasty. History of facial trauma, obstructive sleep apnea, site of deviation, and performance of inferior turbinate surgery did not affect the likelihood of revision septoplasty. CONCLUSION: A significant number of patients who undergo revision septoplasty also have nasal valve collapse. We recommend that in addition to septal deviation and inferior turbinate hypertrophy, nasal valve function be fully evaluated before performing septoplasty. This will help to ensure a complete understanding of a patient's nasal airway obstruction and, consequently, appropriate and effective surgical intervention.     

鼻内镜下下鼻甲骨部分切除术治疗下鼻道出血

目的:探讨鼻内镜下下鼻甲骨部分切除术治疗下鼻道出血的有效性。方法:对21例下鼻道出血患者行鼻内镜下下鼻甲黏骨膜分离、下鼻甲骨骨折后部分切除,局部填塞。术后鼻腔粘连者,分离后放置薄荷石蜡油浸后的明胶海绵,观察疗效。结果:全部患者经过手术填塞后止血满意,3~7 d治愈出院,随访2个月~3年,无复发。结论:鼻内镜下黏骨膜分离及下鼻甲骨部分切除术治疗下鼻道鼻出血是一种有效、可靠的方法。用薄荷石蜡油浸润后的明胶海绵放置隔离预防粘连,简单易耐受,效果好。     

下鼻甲手术方式的选择

目的 :探讨下鼻甲手术的最佳方式 ,进一步明确常用术式的适应证。方法 :采用 5种下鼻甲术式对97例慢性肥厚性鼻炎或下鼻甲代偿肥大的患者行手术治疗 ;检测手术前后的鼻阻力的变化。结果 :5种术式中 ,下鼻甲部分切除术疗效好 ,但术后反应大 ,易并发出血及术后鼻腔干燥感 ;功能性下鼻甲手术疗效较好 ,术后反应轻、恢复快。结论 :5种下鼻甲术式均有明确的适应证 ,但功能性下鼻甲手术适应证较广 ,疗效确切     

Topical ephedrine administration and nasal chemosensory function in healthy human subjects.

OBJECTIVE: To investigate dose-related effects of ephedrine on olfactory function in healthy subjects. DESIGN: Placebo-controlled, randomized, double-blind study. METHODS: Drug effects were assessed using olfactory and trigeminal psychophysical measures (intensity ratings, odor discrimination, butanol and formic acid thresholds); nasal patency was assessed by means of anterior rhinoresistometry. The investigation was performed in 24 healthy volunteers; subjects were assigned to treatments A, B, or C (3 groups with 8 subjects each; 4 women and 4 men per group). All subjects received either placebo or ephedrine in both nostrils; group A subjects received placebo, and group B and C subjects received ephedrine in dosages of 0.12 and 0.24 mg, respectively. RESULTS: Treatment with ephedrine produced a tendency toward an increase of nasal airflow. However, during the time of observation there was no significant difference between effects produced by the 2 dosages. Ephedrine had no systematic effect on measures of olfactory function. The only significant correlation to the nasal airflow was found for perceived intensity of the trigeminal stimuli, which increased with increasing flow. CONCLUSIONS: Ephedrine appeared to have neither negative nor major positive effects on intranasal chemosensory function in healthy subjects. This indicates that ephedrine may be used as a decongestant in studies on olfaction.     

Histopathological verification of clinical indications to partial inferior turbinectomy.

Surgical treatment in cases where disturbances of the nasal patency causes changes in the nasal inferior turbinates is controversial. The authors performed light- and electron microscopy and morphometric examinations of the mucous membrane of the nasal inferior turbinates obtained after partial inferior turbinectomy in patients with vasomotor and perennial allergic rhinitis and compensation hypertrophy of the nasal inferior turbinate accompanied by nasal deviation of the septum. In specimens obtained from patients with vasomotor rhinitis, a small number of glands and fibrosis of the lamina propria was observed. In specimens obtained from perennial allergic rhinitis patients, plenty of glands and large oedema was observed. In the group with compensatory hypertrophy of the inferior turbinate, normal glands and fibred areas around the vessels were observed. The largest histopathological changes of degeneration and hypertrophy of the nasal mucosa were observed in vasomotor rhinitis patients. Histopathological examination of nasal mucosa slides confirmed the usefulness of a partial inferior turbinectomy, but only in vasomotor rhinitis patients.     

Partial inferior turbinectomy using the microdébrider

BACKGROUND: A microdébrider was selected to accomplish partial inferior turbinectomy, allowing for controlled and rapid removal of hypertrophic soft tissue while preserving the general turbinate form. OBJECTIVE: To assess the clinical outcome, healing, and any adverse consequences from the microdébrider partial turbinectomy procedure. SETTING: A public hospital in north-central Israel. DESIGN: A nonrandomized prospective study of 35 adults who were referred for nasal airway surgery, including turbinectomy. METHODS: All patients underwent bilateral inferior turbinate reduction with the microdébrider, with removal of mucosa from the medial and inferior portions of the inferior turbinates. Detailed follow-up was accomplished at 4 or more months postoperatively, including a visual analogue scale questionnaire and videoendoscopy. For seven patients, pre- and postoperative mucosal biopsies were available to evaluate healing and epithelial regeneration. RESULTS: Nasal endoscopy showed well-healed turbinate membranes and preservation of the turbinate form, with widening of the inferomedial nasal airway space. Subjective nasal patency improved after surgery, p < .01, and the subjective sense of smell was improved, p < .01, without associated crusting, pain, irritation, sneezing, or dryness. Postoperative biopsies showed subepithelial fibrosis and regenerated epithelium, generally of respiratory differentiation. CONCLUSION: Inferior turbinate reduction can be accomplished efficiently with the microdébrider device, without undue side effects. SIGNIFICANCE: Further experience and long-term follow-up with this technique are warranted.