Septoplasty is one of the most common surgical interventions performed to alleviate nasal obstruction caused by a deviated nasal septum. Often accompanied by inferior turbinate reduction, the procedure is designed to enhance airflow through the nasal cavities, improving both functional and quality-of-life outcomes. Despite its frequency, patient selection and the timing of surgery have often relied on clinical history and visual assessments rather than robust objective measures of nasal airflow.

In England alone, approximately 16,700 septoplasties were performed in the 2019/20 financial year, costing the National Health Service (NHS) an estimated £15.9 million. Meanwhile, in the United States, over 250,000 septoplasties are conducted annually, indicating the global prevalence of this procedure. Yet, until recently, a significant gap existed in the evidence base to determine which patients would benefit most from surgery, leading to variation in clinical practice and treatment outcomes.

The Case for Medical Management

Before considering septoplasty, many clinical guidelines recommend an initial trial of medical management to address nasal obstruction. This typically involves the use of intranasal steroid sprays, which can reduce inflammation and improve nasal airflow. However, recommendations on the optimal dose and duration of medical treatment vary, leaving room for inconsistency in practice.

In the UK, some NHS commissioning bodies have placed septoplasty on a list of restricted treatments. Funding is often contingent on patients demonstrating that nasal obstruction is causing documented medical problems, such as sleep disturbances or significant breathing difficulties. Additionally, patients must typically show that they have attempted and failed non-surgical treatments before surgery is approved.

While this approach emphasises cost-effectiveness, it raises important questions about how best to balance the use of medical management with timely surgical intervention. For patients with severe or persistent symptoms, prolonged reliance on medical treatment may delay the potential benefits of surgery, impacting their quality of life.

Evidence from the Nasal Airways Obstruction Study (NAIROS)

The NAIROS trial was designed to address the lack of high-quality evidence comparing septoplasty with medical management. By evaluating patient-reported outcomes and objective measures, the study sought to provide definitive guidance on the clinical effectiveness of septoplasty and establish criteria for patient selection.

The study found that patients undergoing septoplasty experienced significant improvements in their symptoms, as measured by the SNOT-22 (Sino-Nasal Outcome Test) score, compared with those receiving medical management. At six months, the surgical group demonstrated an improvement of 20 points on the SNOT-22 scale, compared with just 9.1 points in the medical management group. These benefits were sustained at 12 months, reinforcing the long-term efficacy of the procedure.

The study also introduced the concept of stratifying patients based on their baseline NOSE (Nasal Obstruction Symptom Evaluation) score. Adults with a baseline NOSE score greater than 30, in the absence of coexisting nasal or sinus disease, were identified as ideal candidates for surgery. This stratification allows clinicians to predict the degree of improvement that patients are likely to experience, facilitating shared decision-making.

Comparing NAIROS to Prior Research

NAIROS is not the only study to examine the effectiveness of septoplasty. In 2019, van Egmond et al published a randomised clinical trial conducted in the Netherlands, which also compared surgical and non-surgical management of nasal obstruction. Both studies reached similar conclusions, affirming that septoplasty offers significant benefits for selected patients.

However, key methodological differences between the two studies highlight the evolving approach to this research area. Van Egmond’s study did not define a standardised protocol for non-surgical management, which may have introduced variability in treatment outcomes. In contrast, NAIROS implemented a structured medical management arm, involving intranasal steroids and saline sprays, to ensure consistency.

Another distinction lies in the choice of outcome measures. While van Egmond’s trial used general quality-of-life assessments, NAIROS focused on disease-specific outcomes, providing a more nuanced understanding of the impact of surgery on nasal symptoms. Furthermore, van Egmond’s trial reported a crossover rate of 30% from the non-surgical to the surgical arm, complicating the interpretation of long-term results. To mitigate this issue, NAIROS selected a six-month primary endpoint, ensuring that the observed outcomes reflected the true differences between treatment arms.

The Role of Inferior Turbinate Reduction

An important consideration in septoplasty is whether combining it with inferior turbinate reduction enhances outcomes. Inferior turbinate’s, structures within the nasal cavity, can contribute to airflow obstruction when they become enlarged. While some surgeons routinely perform turbinate reduction alongside septoplasty, its clinical benefits remain a topic of debate.

The NAIROS study found no additional improvement in symptoms when turbinate reduction was performed alongside septoplasty. These findings align with van Egmond’s research, where turbinate reduction was left to the discretion of the surgeon and similarly showed no clear benefit.

Additionally, other studies have suggested that turbinate reduction may provide a modest but statistically significant improvement in selected patients. For instance, a single-centre trial recently reported sustained benefits of turbinate reduction as measured by NOSE scores. These findings suggest that further multicentre trials are needed to determine the circumstances under which turbinate reduction may be warranted.

Limitations of Current Evidence

While the NAIROS study represents a significant step forward in evidence-based practice, several limitations should be acknowledged. One key limitation is the population studied. More than 80% of participants had severe or extreme baseline NOSE scores, meaning the findings are less generalisable to patients with moderate symptoms. Indeed, the study found that patients with moderate baseline NOSE scores did not experience improvements that reached the minimal clinically important difference of nine points on the SNOT-22 scale.

Another limitation is the potential impact of underlying nasal conditions that were not specifically diagnosed or treated before randomisation. Nasal obstruction is a non-specific symptom that can result from various causes, including chronic rhinosinusitis, allergic rhinitis, and nasal valve dysfunction. By focusing exclusively on septal deviation, the study may have overlooked these contributing factors.

The role of surgeon experience is another important consideration. While the NAIROS trial relied on experienced surgeons, septoplasty is often performed by junior trainees in NHS practice. Although previous studies suggest that surgeon grade does not significantly affect outcomes, further research is needed to confirm this in broader settings.

Finally, the Covid-19 pandemic disrupted certain aspects of the NAIROS trial, particularly clinical assessments of nasal airflow. While patient-reported outcomes were collected remotely, the suspension of objective airflow measurements may have influenced the precision of the findings.

Implications for Clinical Practice

The findings of the NAIROS study have important implications for the management of nasal obstruction. By establishing clear criteria for patient selection and demonstrating the superiority of surgery over medical management in severe cases, the study provides a framework for optimising treatment pathways.

One of the key contributions of NAIROS is its use of patient-reported outcome measures to guide clinical decisions. Tools such as the SNOT-22 and NOSE scores enable clinicians to quantify the expected benefits of surgery based on baseline symptom severity. This approach not only enhances the decision-making process but also helps manage patient expectations, fostering greater satisfaction with treatment outcomes.

At the same time, the study highlights the need for standardising medical management before surgery. Warranting that patients receive an adequate trial of intranasal steroids and saline sprays can help identify those who are most likely to benefit from surgical intervention. However, further research is needed to define what constitutes an optimal course of medical treatment.

Future Research 

While NAIROS has advanced our understanding of septoplasty, it also highlights areas where further research is needed. For example, multicentre trials could help clarify the role of turbinate reduction in combination with septoplasty, particularly in patients with severe nasal obstruction. Similarly, studies exploring the impact of surgeon experience on outcomes could inform training and practice guidelines.

Another priority is the development of updated clinical guidelines that reflect the latest evidence. By incorporating tools such as the SNOT-22 and NOSE scores, these guidelines could help standardise patient selection and improve outcomes across healthcare systems.

Finally, there is a need to explore the long-term effects of septoplasty, particularly in comparison with sustained medical management. While the NAIROS study provides valuable insights at six and 12 months, understanding outcomes over multiple years would provide a more comprehensive picture of the procedure’s effectiveness.

Conclusion

Septoplasty has long been a basis of treatment for nasal obstruction, but its clinical use has often been guided by tradition rather than evidence. The NAIROS study marks a turning point, offering robust data on the effectiveness of surgery and providing tools to improve patient selection and decision-making.

For patients with severe nasal obstruction who do not respond to medical management, septoplasty offers a reliable path to improved symptoms and quality of life. At the same time, the study highlights the need for continued research to refine surgical techniques, standardise treatment pathways, and ensure that the benefits of septoplasty are accessible to those who need it most.

By integrating the latest evidence into clinical practice, healthcare providers can enhance outcomes for patients and ensure that this common procedure is used to its full potential.

References

Carrie, S., O’Hara, J., Fouweather, T., Homer, T., Rousseau, N., Rooshenas, L., Bray, A., Stocken, D. D., Ternent, L., Rennie, K., Clark, E., Waugh, N., Steel, A. J., Dooley, J., Drinnan, M., Hamilton, D., Lloyd, K., Oluboyede, Y., Wilson, C., … Teare, M. D. (2023). Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction: multicentre, open label, randomised controlled trial. BMJ (Clinical Research Ed.), 383, e075445. https://doi.org/10.1136/bmj-2023-075445