Introduction
Septoplasty and submucous resection of the septum are common ENT surgical procedures. In Scotland, a total of 2202 septoplasties or submucous resections was performed in 2003.1 Septal surgery is performed to improve nasal airways by correcting deviations in the nasal septum. Submucous diathermy to the inferior turbinates, or other turbinate surgery, is occasionally performed as part of the procedure.
There are many articles in the medical literature on the outcomes of septal surgery, using a variety of patient-based outcome measures. These can be divided into: disease- or condition-specific outcome measures, which assess nasal symptoms; and general health status outcome measures (such as the Glasgow benefit inventory), which are generic and assess a broad range of health status indicators and effects of illness.
Disease-specific outcome measures which have been used previously include the nasal obstruction septoplasty effectiveness study,Reference Stewart, Smith, Weaver, Witsell, Yueh and Hannley2 the sino-nasal outcome test,Reference Buckland, Thomas and Harries3 the Fairley nasal symptom scoreReference Arunachalam, Kitcher, Gray and Wilson4 and the nasal health survey.Reference Siegel, Gliklich, Taghizadeh and Chang5 The nasal obstruction septoplasty effectiveness study was a multicentre study using a validated questionnaire; it showed a significant improvement in scores three and six months after septal surgery.Reference Stewart, Smith, Weaver, Witsell, Yueh and Hannley2 The sino-nasal outcome test was originally designed as a rhinosinusitis questionnaire; however, Buckland et al. used it as an outcome measure for septal surgery, and showed an improvement in nasal obstruction scores at three months.Reference Buckland, Thomas and Harries3 Arunachalam et al. measured the Fairley nasal symptom score and showed a post-operative improvement after septoplasty.Reference Arunachalam, Kitcher, Gray and Wilson4 Seigel et al. also measured nasal specific outcomes (using the nasal health survey) and found an improvement in scores after septoplasty.Reference Siegel, Gliklich, Taghizadeh and Chang5 Tools such as acoustic rhinometry, rhinomanometry and nasal peak flow have also been used. Improvement in these scores correlates weakly with improved patient symptom scores.Reference Pirila and Tikanto6 The major disadvantage of disease-specific instruments is that they do not allow comparison with other patient groups suffering other diseases or conditions.
General health status questionnaires which have been used previously in the literature include the Nottingham health profile (assessing general health status), the Nottingham general health questionnaire (GHQ-28) (assessing occult psychological distress in patients with physical symptoms)Reference Arunachalam, Kitcher, Gray and Wilson4 and the short form 12.Reference Siegel, Gliklich, Taghizadeh and Chang5 None of these questionnaires show any significant benefit arising from septal surgery. As generic questionnaires cover a broad range of health status indicators, many items may be irrelevant to a particular condition. These items result in a wide range of scores which are not relevant to the condition being studied. As there are few questions relevant to a specific condition, the instrument may be insensitive to changes that might occur as a result of treatment for that condition.
The Glasgow benefit inventory is a validated quality of life measurement which was developed at the Medical Research Council Institute of Hearing Research in Glasgow. It has been widely used in otolaryngology to measure benefit following interventions.Reference Robinson, Gatehouse and Browning7 It is not disease-specific but measures change in health status following interventions. It allows comparison between different interventions. The Glasgow benefit inventory is a post-intervention questionnaire containing 18 questions which can be completed by the patient or an interviewer. The scores range from +100 (maximum positive change) to −100 (maximum negative change).8
Materials and methods
The aim of this study was to measure the change in patients' overall health status following septal surgery with or without turbinate surgery.
Glasgow benefit inventory questionnaires were sent to patients throughout Scotland as part of the Scottish ENT outcomes study. This was a multicentre trial aiming to assess health-related quality of life in otorhinolaryngology patients. The patients in the Scottish ENT outcomes study were recruited as follows: 82 patients (82.8 per cent) from Aberdeen Royal Infirmary; 15 patients (15.2 per cent) from the North Glasgow National Health Service (NHS) Trust (i.e. Glasgow Royal Infirmary and Gartnavel General and Stobhill Hospitals); and two patients (2 per cent) from Crosshouse Hospital, Kilmarnock.
Patients undergoing septal surgery in the North Glasgow NHS Trust (i.e. Glasgow Royal Infirmary and Gartnavel General and Stobhill Hospitals) between 1 September 2003 and 29 February 2005 were identified from theatre books and the discharge coding system. Any of these patients who had not completed a Glasgow benefit inventory as part of the Scottish ENT outcomes study were sent a copy of the inventory to complete, so no patient would be included twice. Questionnaires were sent out six to 12 months after surgery.
The inclusion criteria were all adult elective patients undergoing septoplasty or submucous resection with or without turbinate surgery (including revision surgery). The exclusion criteria were: age under 16 years, emergency surgery (e.g. for epistaxis or trauma) and additional surgery (e.g. functional endoscopic sinus surgery or rhinoplasty). The inclusion and exclusion criteria are the same for both groups of patients.
The outcome measure was the Glasgow Benefit Inventory Score.
The Glasgow benefit inventory score was recorded, giving a measure of change in health status. Statistical analysis was performed using the StatistXL for Microsoft Excel software.
Results and analysis
A total of 149 Glasgow benefit inventories were returned: 99 from Scottish ENT outcomes study patients and 50 from North Glasgow NHS Trust patients. Thirteen inventories were incomplete and were thus excluded, leaving 136 to be analysed. The response rate of the Scottish ENT outcomes study patients was 55 per cent and that of the North Glasgow NHS Trust patients was 41 per cent, giving an overall response rate of 49 per cent.
The mean Glasgow benefit inventory score was 11.3 (standard deviation 20; 95 per cent confidence interval 7.8 to 14.7; range +64.7 to −55.6). The results of all the questionnaires are shown in Figure 1.
Fig. 1 Range of Glasgow benefit inventory (GBI) scores.
The Glasgow benefit inventory scores from the two groups were similar, with mean scores of 11.9 for the Scottish ENT outcomes study patients and 10.1 for the North Glasgow NHS Trust patients.
Discussion
The overall mean Glasgow benefit inventory score was 11.3. This is a positive score, which suggests that the patients perceived benefit from the procedure.
This study relied on patients completing and returning a questionnaire. This introduced a bias, as patients who did not respond may have perceived either a greater or lesser degree of benefit than those who did respond. In this study, only 49 per cent of questionnaires were returned. We have no record of the degree of success of the surgical procedure in the opinion of the surgeon.
The low mean Glasgow benefit inventory score obtained is similar to the findings of the other two studies to use the Glasgow benefit inventory as a measure of septal surgery outcome (i.e. Uppal et al. and Konstantinidis et al.).Reference Uppal, Mistry, Nadiq, Back and Coatesworth9, Reference Konstantinidis, Triaridis, Triaridis, Karagiannidis and Kontzoglou10 These authors found Glasgow benefit inventory scores of +5 and +15.5, respectively, with patient numbers of 75 and 51, respectively. Although no other authors have used the Glasgow benefit inventory as an outcome measure for septoplasty, some have used it as an outcome measure for rhinoplasty. McKeirnan et al. found a mean Glasgow benefit inventory score of +27.7 following ‘functional’ rhinoplasty.Reference McKiernan, Banfield, Kumar and Hinton11 The same study found a Glasgow benefit inventory score of +58.3 following ‘functional and cosmetic rhinoplasty’. This compares with a figure of +24 for septorhinoplasty in the original Glasgow benefit inventory paper (Table I).Reference Robinson, Gatehouse and Browning7
Table I Glasgow benefit inventory scores for otolaryngology interventions
* Present study. GBI = Glasgow benefit inventory; CI = confidence intervals; FESS = functional endoscopic sinus surgery; BAHA = bone-anchored hearing aid insertion; DCR = dacryocystorhinostomy
Other studies which used general quality of life measures, such as the Nottingham health profileReference Arunachalam, Kitcher, Gray and Wilson4 and the short form 12,Reference Siegel, Gliklich, Taghizadeh and Chang5 found no significant improvement following septal surgery.
The Glasgow benefit inventory has been used as an outcome measure for many other otolaryngology interventions. The published figures for mean Glasgow benefit inventory score include +23 for endoscopic sinus surgery,Reference Mehanna, Mills, Kelly and McGarry12 +31 for bone-anchored hearing aid implantation,Reference Arunachalam, Kilby, Meikle, Davidson and Johnson13 +27.5 for adult tonsillectomy,Reference Bhattacharya and Kepnes14 +13.3 for laser palatoplasty for snoring (after 12 months)Reference Banerjee and Dempster15 and +16.8 for endoscopic laser dacryocystorhinostomy (Table I).Reference Bakri, Carney, Robinson, Jones and Downes16
Negative Glasgow benefit inventory scores have been published, for example, following acoustic neuroma surgery.Reference Santarius, D'Sousa, Zeitoun, Cruickshank and Morgan17
• The Glasgow benefit inventory can be used to compare different ENT interventions
• Patients reported minimal improvement in overall health-related quality of life following septal surgery
• This large, multicentre study confirms that septal surgery has minimal effect on health-related quality of life
It has been shown that septal surgery leads to an improvement in nasal symptom scores. However, the present study found that septal surgery resulted in only a small change in general health status, as measured by the Glasgow benefit inventory. There are four possible explanations for this finding.
The first is that the indications for septal surgery were incorrect. Septal surgery is best performed for anterior septal deflections causing obstruction in the nasal valve area, and patients with coexisting rhinitis will not derive as much benefit from surgery.Reference Dinis and Haider18, Reference Samad, Stevens and Maloney19 In patients with incorrect indications, the outcomes of surgery will not be as good as those with the correct indications, even if the surgery is performed well.Reference Ridenour and Cummings20
The second possible explanation is the technical quality of the surgery. If septal deflections are over- or under-corrected, or if complications result, then general health status scores are unlikely to improve.
The third possible reason is that the Glasgow benefit inventory questions do not target those aspects of health-related quality of life affected by septal surgery.
The fourth and most likely explanation is that septal deviations cause minimal morbidity and that general health status questionnaires are therefore not the best tools with which to measure the morbidity caused. This would also explain why other general health status measures (such as the Nottingham health profile and the short form 12) have failed to show any significant health improvement after septal surgery.
Conclusion
Following septal surgery, patients reported minimal improvement in their overall health-related quality of life.
