Keywords
olfactory dysfunction - septoplasty - anxiety - emotional status - quality of life
- olfaction test
Introduction
Olfactory dysfunction due to decreased nasal airflow is a common symptom among patients
with nasal obstruction related to nasal septal deviation.[1] Olfactory disorders may have a significant negative impact on different areas of
daily life, including food appreciation, safety (detection of environmental hazards,
such as smoke, fire, gas, and spoiled food), personal hygiene, and social communication.
Especially in the case of individuals whose professions depend on a well-functioning
sense of smell, such as cooks, wine tasters, perfumers, or firemen, olfactory deficits
can be catastrophic.[2] Therefore, olfactory impairment due to septal deviation, although underestimated
by patients and overlooked by doctors,[3] may substantially affect the quality of life (QoL) of patients and potentially be
associated to mental health.[2]
[4]
[5]
[6] Nasal septoplasty is the standard treatment of nasal septal deviation because it
usually produces an improvement of nasal airflow and resolution of nasal obstruction
symptoms.[7]
[8]
[9]
[10] To date, there are a few studies evaluating the effects of septal surgery on olfactory
function.[1]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18] However, the impact of olfactory impairment due to septal deviation on the nasal-symptom
related and general QoL of the patients has not been adequately addressed in the literature.
In addition, although there are studies investigating predictive factors for QoL outcomes
after septoplasty,[19]
[20]
[21]
[22]
[23]
[24]
[25] there is no data available to the relevance of the olfactory function specifically
to patients' psychological status (anxiety and depression symptoms) and its effect
on their satisfaction with the surgical procedure and postoperative QoL recovery.
The use of standardized olfactory tests, validated olfaction-specific questionnaires,
and mental health psychometric instruments allows a clearer delineation of the psychological
profile and evaluation of olfaction of the patients as a co-determinant for QoL and
emotional status after septoplasty. The clinical importance is that these data may
enable otorhinolaryngologists to better assess their patients and inform them about
the anticipated benefit for their QoL after septoplasty.
The aim of the present prospective study was to assess the emotional status and QoL
outcomes of patients with olfactory dysfunction and nasal obstruction symptoms who
undergo septoplasty. Additionally, the study explored differences in QoL and psychological
status between normosmic patients and those with olfactory deficits and investigated
the prognostic value of demographic and clinical characteristics for clinically significant
improvement of QoL, anxiety symptoms, and emotional status of patients with olfactory
dysfunction.
Materials and Methods
This was a prospective observational study. Sixty adult patients with nasal obstruction
due to nasal septal deviation were studied. The diagnosis of septal deviation was
established based on clinical examination and nasal endoscopy. Twenty-five healthy
individuals, who had neither nasal obstruction nor septal deviation, were recruited
as controls. All the enrolled participants signed the informed consent. The study
protocol was performed according to the Declaration of Helsinki and was approved by
the local institutional review board (decision no 3525/10.02.2016).
Adult patients younger than 65 years with nasal septal deviation, diagnosed by means
of clinical examination and presence of symptoms of nasal obstruction for at least
6 months, were included in the study. Patients were excluded if they met any of the
exclusion criteria, such as chronic rhinosinusitis, with or without nasal polyposis;
allergic rhinitis; previous nasal surgical procedure; sinonasal malignancy; perforation
of the nasal septum; nasal valve collapse; craniofacial syndrome; fracture or trauma
of the nose during the last 3 months; pregnancy or cognitive impairment. Patients
with a recent infection of the upper respiratory tract, a known hyposmia, patients
exposed to chemicals or those suffering from any neurological or systematic diseases
with potential impact on the olfactory function were not included in the study. Additionally,
patients who underwent any other nasal surgical procedure, particularly rhinoplasty
and sinus surgery concomitant to septoplasty, were also excluded.
All participants filled in a detailed health form, which included demographic information
and presence of medical comorbidities, and focused on factors that might affect olfactory
function, such as smoking habits, profession, medical treatment, and recreational
activities. For recruitment to the study, in addition to anterior rhinoscopy and nasal
endoscopy, participants underwent skin prick testing for atopy and sinus computed
tomography scanning (when medically justified) for the identification of those who
met the exclusion criteria.
The ‘‘Sniffin’ sticks'' test package (Burghart Messtechnik GmbH, Wedel, Germany),
which includes specific tests for odor threshold (OT), odor discrimination (OD), and
odor identification (OI)[26]
[27]
[28] was used for quantitative evaluation of the olfactory function of all participants.
The results of each test were combined with an overall ‘‘Threshold Discrimination
Identification (TDI) score’'[28]
[29]. The TDI score ranges from 0 to 48. Values of 16 or less represent anosmia; values
between 16.25 and 30.5 represent hyposmia; and values over 30.75 represent normosmia.[28] A six-point difference in the TDI score was considered a clinically significant
change of olfactory function after surgery.[30]
The olfactory tests were performed preoperatively and 6 months after septoplasty.
At these time points, the participants also filled in six widely used questionnaires,
translated, and validated into the Greek language: the Nasal Obstruction Symptom Evaluation
(NOSE) questionnaire, assessing the severity of nasal obstruction symptoms;[31]
[32] the SinoNasal Outcome Test-22 (SNOT-22), assessing nasal symptom-related QoL;[33]
[34] the Questionnaire of Olfactory Deficits (QOD), assessing olfaction-associated QoL;[35]
[36] the Short Anxiety Screening Test (SAST), evaluating anxiety symptoms;[37]
[38] the Beck Depression Inventory (BDI), evaluating the emotional status of the patients;[39]
[40] and the Short Form 36 (SF-36), assessing general QoL.[41]
[42] A postoperative general-health survey specific for patients' satisfaction with the
surgical procedure, the Glasgow Benefit Inventory (GBI),[43]
[44] was completed at 6 months after septoplasty. The NOSE is a questionnaire for the
evaluation of nasal obstruction. It consists of five questions that are scored on
a five-point Likert scale from zero to four. The final score ranges between 0 (no
symptoms) and 100 (severe nasal obstruction). The SNOT-22 is a health-related questionnaire,
in which patients grade 22 different symptoms related to both nasal and general health,
physical and emotional status on a scale from 0 (no symptoms) to 5 (symptoms as severe
as can be). The QOD is an olfaction-specific QoL questionnaire, which evaluates the
effect of olfactory dysfunction on several areas of daily life. Patients answer to
25 4-point scale statements (17 ‘‘negative’', 2 ‘‘positive’', 6 ‘‘socially desired’').
The maximum total score is 57, and high scores represent a high negative impact of
olfactory disorders on QoL. The SAST consists of 10 questions related to somatic symptoms
manifestations of anxiety. Each item is self-rated from 1 to 4, and the total score
ranges between 10 and 40, with higher scores indicating a higher degree of anxiety.
The BDI is a screening instrument for the evaluation of the psychological profile.
It is a 21-item self-reporting questionnaire, and each item is graded from 0 to 3.
A higher score is associated with higher levels of depressive mood. The SF-36 is an
overall-health related survey assessing QoL in eight domains covering aspects from
both physical and mental health from the perspective of patients suffering from chronic
diseases. Scores range from 0 to 100, with a higher score indicating better general
QoL. Finally, the GBI is a validated 18-item postintervention questionnaire measuring
the patient's benefit, developed especially for surgical interventions. The total
score ranges from +100 (maximum positive change) to -100 (maximum negative change).
All patients underwent surgery under general anesthesia. The same consultant surgeon
performed all the operations and did not participate in the questionnaires' collection
and analysis of data. The standardized surgical procedure included partial resections
and reshaping of the deviated areas of the septum and submucosal radiofrequency tissue
ablation for volume reduction of the inferior nasal turbinates. The anterior nasal
packings were removed 48 hours after surgery, and the silicone septal splints were
removed on the 4th postoperative day. No major complication was encountered postoperatively.
Statistical Analysis
The data were analyzed with IBM SPSS Statistics for Windows version 25.0 (IBM Corp.,
Armonk, NY, USA). Descriptive statistics were obtained; quantitative variables are
expressed as means with standard deviation (SD) while qualitative variables are presented
as frequencies (percentages). The normality of the variables was ascertained with
the Kolmogorov-Smirnov test. Differences between not normally distributed data were
assessed with the use of the Mann-Whitney U test and Wilcoxon signed-rank test for independent and related samples respectively.
For differences in qualitative parameters between groups, the Chi-square test was
applied. Univariate linear regression analysis was used for the evaluation of any
potential association between the likelihood of clinically significant improvement
for each QoL questionnaire and patients' demographic and clinical characteristics.
Clinically significant improvement for each QoL questionnaire was defined as a change
of ≥ 1/2 SD of the preoperative score.[45] Multivariate stepwise logistic regression analysis was performed to explore which
of the studied patients' characteristics were independently associated with clinically
significant improvement of each QoL questionnaire. Only variables with statistical
significance during the univariate regression analysis were incorporated into the
multiple regression analysis. Odds ratios (ORs) and 95% confidence intervals (CIs)
were estimated as the measure of association between clinically significant improvement
for each QoL questionnaire and all potential predictive factors. A p-value of less than 0.05 was considered as the statistical significance level.
Results
The study cohort consisted of 60 patients (34 [56%] males - 26 [44%] females, mean
age: 32.98 ± 11.98years) and 25 healthy control subjects (13 [52%] males - 12 [48%]
females, mean age: 29 ± 8.87 years). In the patients' subgroup, 20 participants were
smokers (33.33%). Regarding the socioeconomic status, 14 (23%) had low, 24 (40%) had
medium, and 22 (37%) had high socioeconomic status. In the controls' subgroup, 10
participants were smokers (40%). Regarding the socioeconomic status, 6 (25%) had low,
9 (35%) had medium, and 10 (40%) had high socioeconomic status. There were no statistically
significant differences related to age (p = 0.151 - Mann-Whitney U test), gender (p = 0.176), smoking habits (p = 0.143), or socio-economic status (p = 0.942 - Chi-squared test for the 3 qualitative parameters) between the 2 groups.
Regarding the preoperative quantitative evaluation of the participants' olfactory
function with the use of Sniffin' Sticks test, patients presented statistically significant
lower olfactory scores (OT, OD, OI, TDI) compared with controls (Mann- Whitney U test, p < 0.001 for all the variables). The olfactory scores of patients and controls are
presented in [Table 1]. Six months after surgery, there was a statistically significant improvement in
all olfactory scores (Wilcoxon signed-rank test, p < 0.001 for OT, OI, TDI, and p = 0.008 for OD). However, the OT, OD, and TDI scores remained statistically significantly
lower compared with the scores of the control group (Mann-Whitney U test, p < 0.05 for all parameters). Patients, as expected, had preoperatively statistically
significant more severe nasal obstruction symptoms (NOSE scores). The patients' NOSE
scores were significantly improved postoperatively but remained lower than the controls'
scores.
Table 1
Olfactory function, questionnaires of quality of life and psychological status of
the controls and the patient group (preoperatively and 6 months after surgery)
|
Control
(n = 25)
|
Patient group
(n = 60)
|
p-value
|
|
|
preop
|
postop
|
|
|
Olfactory scores
|
|
|
|
|
|
OT
|
9.2 (2.19)
|
4.78 (2.88)
|
6.98 (3.03)
|
< 0.001
|
|
OD
|
13.12 (1.67)
|
9 (2.76)
|
11.35 (2.45)
|
0.008
|
|
OI
|
13.32 (2.18)
|
10.08 (1.69)
|
12.08 (1.97)
|
< 0.001
|
|
TDI
|
35.64 (2.62)
|
23.87 (4.28)
|
29.42 (4.72)
|
< 0.001
|
|
QoL tools
|
|
|
|
|
|
SF-36
|
83.48 (9.74)
|
80.20 (15.45)
|
|
|
|
SNOT 22
|
12.9 (8.86)
|
42.93 (19.57)
|
26.7 (18.9)
|
< 0.001
|
|
QOD
|
6.92 (2.08)
|
8.85 (5.11)
|
7.91 (3.42)
|
0.25
|
|
Psychological tools
|
|
|
|
|
|
SAST
|
11.7 (6.39)
|
22.63 (7.94)
|
17.5 (4.4)
|
0.05
|
|
BDI
|
6.85 (3.43)
|
7.53 (5.76)
|
7 (5.36)
|
0.08
|
Abbreviations: BDI, Beck depression inventory; OD, olfactory discrimination; OI, olfactory
identification; OT, olfactory threshold; QOD, questionnaire of olfactory disorders;
QoL, quality of life; SAST, short anxiety screening test; SF-36, short form – 36;
SNOT 22, SinoNasal outcome test 22; TDI, threshold discrimination identification.
Bold: Statistically significant difference compared with the control group, p-values: pre and posttreatment scores comparisons for the patient group—Wilcoxon Signed-Rank
test for paired samples.
Data are expressed as mean values (standard deviation), preop: preoperatively, postop:
postoperatively.
Regarding QoL and psychological status assessment, there were no statistically significant
differences both before and 6 months after surgery in olfaction-associated QoL (QOD
scores), emotional status (BDI scores,) and general health status (SF-36 scores—only
preoperative evaluation) between patients and controls (Mann-Whitney U test, p > 0.05 for all parameters). The mean values are presented in [Table 1]. Preoperatively, the differences in SF-36 scores between patients and controls were
minor; therefore, the questionnaire was not filled in by the participants 6 months
after surgery. Patients had preoperatively statistically significantly worse nasal
symptom-related QoL (SNOT-22 scores) and higher stress levels (SAST scores) than controls
(Mann-Whitney U test, p < 0.001 for all parameters). Although these parameters were significantly improved
postoperatively, they maintained their statistically significant difference between
the patients and control groups ([Table 1]).
We further investigated QoL and psychological implications in the subgroup of patients
with olfactory dysfunction (according to TDI scores). The preoperative results are
presented in [Table 2] and the postoperative ones in [Table 3]. Preoperatively, patients with decreased olfactory function had worse nasal-symptom
related and olfaction-associated QoL, higher stress levels, more depressive mood,
and reduced general QoL than normosmic patients. However, only the differences in
SNOT-22 and BDI scores reached statistical significance (p < 0.05 for both). Six months after surgery, normosmic patients had statistically
significantly better nasal-symptom related QoL, lower stress levels, better emotional
status and more personal benefit from the surgical procedure (GBI scores) than patients
who reported olfactory deficits (p < 0.05 for all parameters). Except for general QoL (SF-36 scores), both patients'
groups (normosmics and patients with decreased olfactory status) had worse scores
in all the above parameters preoperatively compared with controls. These differences
were statistically significant for all scores between the patients with olfactory
impairment and healthy controls. For normosmic patients, only differences in SNOT-22
and SAST scores reached statistical significance (Mann-Whitney U test, p < 0.001 for both). Postoperatively, patients with decreased olfactory function had
statistically significantly worse SNOT-22, SAST, and BDI scores than controls (Mann-Whitney
U test, p < 0.05 for all). Normosmic patients showed, postoperatively, statistically significant
differences from controls only in SNOT-22 scores (Mann-Whitney U test, p < 0.05).
Table 2
Nasal symptom related quality of life (QoL), olfaction related QoL, stress levels,
depressive mood and general health status of controls, patients with olfactory deficits
and normosmic patients, preoperatively
|
Controls (n = 25)
|
Patients with olfactory deficits (n = 50)
|
Normosmic Patients (n = 10)
|
p-value
|
|
SNOT 22
|
12.9 (8.86)
|
57.7 (14.75)
|
38.8 (9.16)
|
0.019
|
|
QOD
|
6.92 (2.08)
|
10.94 (2.85)
|
8.9 (2.75)
|
0.109
|
|
SAST
|
11.7 (6.39)
|
23.62 (7.91)
|
20.4 (7.86)
|
0.222
|
|
BDI
|
4.65 (2.08)
|
8.26 (2.72)
|
4.7 (2.7)
|
0.029
|
|
SF 36
|
83.48 (9.74)
|
77.65 (13.34)
|
81.2 (10.98)
|
0.086
|
Abbreviations: BDI, Beck depression inventory; QOD, questionnaire of olfactory disorders;
QoL, Quality of life; SAST, short anxiety screening test; SF-36, Short Form – 36;
SNOT 22, SinoNasal outcome test 22.
Bold: Statistically significant difference compared with control group, p value: comparisons
between normosmics and patients with olfactory dysfunction, all groups comparisons:
Mann-Whitney U test for independent samples.
Data are expressed as mean values (standard deviation). n: number of patients.
Table 3
Nasal symptom-related quality of life (QoL), olfaction-related QoL, stress levels,
depressive mood and patient's satisfaction with the surgical procedure of patients
with olfactory deficits and normosmic patients, 6 months after surgery
|
Controls (n = 25)
|
Patients with olfactory deficits (n = 41)
|
Normosmic patients (n = 19)
|
p-value
|
|
SNOT 22
|
12.9 (8.86)
|
30.97 (12.11)
|
22 (8.74)
|
0.014
|
|
QOD
|
6.92 (2.08)
|
8.27 (4.33)
|
7.02 (3.4)
|
0.14
|
|
SAST
|
11.7 (6.39)
|
20.58 (5.61)
|
15.57 (5.76)
|
0.045
|
|
BDI
|
4.65 (2.08)
|
8.09 (2.49)
|
4.63 (0.61)
|
0.028
|
|
GBI
|
|
5.35 (2.18)
|
18.05 (3.51)
|
0.002
|
Abbreviations: BDI, Beck depression inventory; GBI, Glasgow benefit inventory; QOD,
questionnaire of olfactory disorders; QoL, quality of life; SAST, short anxiety screening
test; SNOT 22: SinoNasal outcome test 22.
Bold: Statistically significant difference compared with control group, p-value: comparisons between normosmic patients and patients with olfactory dysfunction,
all groups comparisons: Mann-Whitney U test for independent samples.
Data are expressed as mean values (standard deviation). n: number of patients.
Among the patients' cohort, clinically significant improvement was observed in 22
patients (36.67%) for olfaction-associated QoL (QOD score), 32 (53.3%) for stress
levels (SAST scores) and 18 (30%) for emotional health (BDI scores), while 32 patients
(53.3%) reported a positive change of their general health status (GBI scores) after
surgical procedure ([Tables 4] and [5]). The incidence of clinically significant improvement of the QOD, SAST, BDI scores,
and positive change of GBI scores in relation to the patients' demographics and disease
characteristics was further analyzed ([Tables 4] and [5]). In the univariate linear regression analysis ([Table 4]), it was found that the likelihood of clinically significant improvement of the
QOD score was higher for patients with clinically significant improvement of the NOSE
and SNOT-22 scores and postoperative normal olfactory function (p < 0.05 for all parameters). The incidence of positive change of GBI score was higher
for patients with clinically significant improvement of the NOSE and SNOT-22 scores
6 months after surgery (p ≤ 0.001—[Table 4]). The likelihood of clinically significant improvement of the SAST score was higher
for those patients who had clinically significant improvement of the NOSE and SNOT-22
scores (p < 0.05 and p < 0.001, respectively—[Table 5]). The likelihood of clinically significant improvement of the BDI score was higher
for patients with clinically significant improvement of the NOSE and SNOT-22 scores
and postoperative normal olfactory function (p < 0.05 for all parameters—[Table 5]).
Table 4
Clinically significant improvement of questionnaire of olfactory disorders and positive
change of Glasgow benefit inventory in relation to the demographic and clinical characteristics
of the patients
|
Clinically improved QOD (n, %)
|
OR (95% CI)
|
p-value
|
Positive change GBI (n, %)
|
OR (95% CI)
|
p-value
|
|
Age
|
|
|
0.39
|
|
|
0.55
|
|
≤ 30 years
|
9 (30%)
|
Ref.
|
|
15 (50%)
|
Ref.
|
|
|
> 30 years
|
13 (43.3%)
|
1.02 (0.97–1.06)
|
|
17 (56.7%)
|
1.01 (0.97–1.05)
|
|
|
Sex
|
|
|
0.429
|
|
|
0.944
|
|
Males
|
12 (35.2%)
|
Ref.
|
|
18 (52.9%)
|
Ref.
|
|
|
Females
|
10 (38.4%)
|
1.53 (0.53–4.42)
|
|
14 (53.8%)
|
1.03 (0.37–2.88)
|
|
|
Smoking
|
|
|
0.85
|
|
|
0.855
|
|
No
|
15(37.5%)
|
Ref.
|
|
22 (55%)
|
Ref.
|
|
|
Yes
|
7 (35%)
|
0.46 (0.36–1.21)
|
|
10 (50%)
|
0.9 (0.3–2.65)
|
|
|
Socio-economic status
|
|
|
0.285
|
|
|
0.804
|
|
Low
|
4 (28.5%)
|
Ref.
|
|
7 (50%)
|
Ref.
|
|
|
Medium
|
8 (33.3%)
|
1.26 (0.56–2.07)
|
|
13 (54.1%)
|
1.02 (0.66–2.25)
|
|
|
High
|
10 (45.4%)
|
1.47 (0.72–2.98)
|
|
12 (54.5%)
|
1.08 (0.56–2.11)
|
|
|
Clinically improved NOSE
|
|
|
0.009
|
|
|
< 0.001
|
|
No
|
9 (20%)
|
Ref.
|
|
4 (9%)
|
Ref.
|
|
|
Yes
|
13 (63.3%)
|
4.57 (1.45–14.38)
|
|
28 (88%)
|
11 (3.29–36.75)
|
|
|
Clinically improved SNOT-22
|
|
|
0.022
|
|
|
0.001
|
|
No
|
7 (22.5%)
|
Ref.
|
|
10 (26.2%)
|
Ref.
|
|
|
Yes
|
15 (51.7%)
|
3.67 (1.2–11.18)
|
|
22 (81.3%)
|
6.6 (2.12–20.55)
|
|
|
Olfactory dysfunction postoperatively[a]
|
|
|
0.024
|
|
|
0.302
|
|
No
|
17 (46.3%)
|
Ref.
|
|
22 (53.6%)
|
Ref.
|
|
|
Yes
|
5 (26.3%)
|
0.27 (0.18–0.96)
|
|
10 (52.6%)
|
0.97 (0.6–2.29)
|
|
Abbreviations: CI, confidence intervals; GBI, Glasgow benefit inventory; NOSE, nasal
obstruction symptom evaluation; OR, odds ratio; p-values, univariate linear regression; QOD, questionnaire of olfactory disorders;
SNOT 22, SinoNasal outcome test 22.
Data are expressed as number of patients (n) and percentages (%).
a Based on TDI score.
Table 5
Clinically significant improvement of short anxiety screening test and Beck depression
inventory in relation to the demographic and clinical characteristics of the patients
|
Clinically improved SAST (n, %)
|
OR (95% CI)
|
p-value
|
Clinically improved BDI (n, %)
|
OR (95% CI)
|
p-value
|
|
Age
|
|
|
0.143
|
|
|
0.114
|
|
≤ 30 years
|
17 (56.7%)
|
Ref.
|
|
10 (33.3%)
|
Ref.
|
|
|
> 30 years
|
15 (50%)
|
0.33 (0.18–1.08)
|
|
8 (26.7%)
|
0.87 (0.69–1.08)
|
|
|
Gender
|
|
|
0.944
|
|
|
0.309
|
|
Male
|
17 (50%)
|
Ref.
|
|
11 (32.3%)
|
Ref.
|
|
|
Female
|
15 (58%)
|
1.76 (0.34–2.68)
|
|
7 (27%)
|
0.55 (0.17–1.74)
|
|
|
Smoking
|
|
|
0.204
|
|
|
0.238
|
|
No
|
20 (50%)
|
Ref.
|
|
7 (35%)
|
Ref.
|
|
|
Yes
|
12 (45%)
|
0.25 (0.17–2.32)
|
|
11 (27.5%)
|
0.24 (0.17–4.7)
|
|
|
Socioeconomic status
|
|
|
0.443
|
|
|
0.825
|
|
Low
|
7 (50%)
|
Ref.
|
|
5 (21.7%)
|
Ref.
|
|
|
Medium
|
13 (54.1%)
|
1.02 (0.43–2.12)
|
|
7 (25.1%)
|
1.03 (0.24–1.98)
|
|
|
High
|
12 (54.5%)
|
1.3 (0.66–2.54)
|
|
6 (29.2%)
|
1.08 (0.52–2.24)
|
|
|
Clinically improved NOSE
|
|
|
0.011
|
|
|
0.029
|
|
No
|
7 (23.3%)
|
Ref.
|
|
6 (24%)
|
Ref.
|
|
|
Yes
|
25 (83.3%)
|
4.03 (1.37–11.83)
|
|
12 (68%)
|
3.82 (1.15–12.71)
|
|
|
Clinically improved SNOT-22
|
|
|
0.001
|
|
|
0.019
|
|
No
|
9 (15%)
|
Ref.
|
|
5 (21.3%)
|
Ref.
|
|
|
Yes
|
23 (79.3%)
|
6.39 (2.07–19.68)
|
|
13 (72.4%)
|
4.22 (1.26–14.09)
|
|
|
Olfactory dysfunction postoperatively[a]
|
|
|
0.941
|
|
|
0.012
|
|
No
|
22 (53.6%)
|
Ref.
|
|
12 (65.7%)
|
Ref.
|
|
|
Yes
|
10 (52.6%)
|
0.94 (0.35–3.1)
|
|
6 (17.2%)
|
0.28 (0.14–0.68)
|
|
Abbreviations: BDI, Beck depression inventory; CI, confidence intervals; NOSE, nasal
obstruction symptom evaluation; OR, odds ratio; p-values, univariate linear regression; SAST, short anxiety screening test; SNOT 22,
SinoNasal outcome test 22.
Data are expressed as number of patients (n) and percentages (%).
a Based on TDI score.
The multivariate logistic regression analysis ([Table 6]) revealed that the clinically significant improvement of the SNOT-22 score was an
independent predictive factor significantly associated with higher likelihood of clinically
significant improvement of all parameters (QOD score—OR: 3.79, 95%CI: 1.11–12.88,
p < 0.05; SAST score - OR: 6.14, 95%CI: 1.87–20.07, p < 0.05; BDI score—OR: 5.61, 95%CI: 1.35- 23.15, p < 0.05) and higher incidence of positive GBI score (OR: 8.75, 95%CI: 2.07–36.93,
p < 0.05). Additionally, the clinically significant improvement of the NOSE score was
statistically significantly associated with a higher likelihood of clinically significant
improvement of the QOD (OR: 3.51, 95%CI: 1.02–12.04, p < 0.05) and SAST scores (OR: 3.82, 95%CI: 1.16–12.51, p < 0.05) and higher incidence of positive GBI score (OR: 14, 95%CI: 3.32–58.95, p < 0.001—[Table 6]). Furthermore, the presence of olfactory dysfunction was an independent predictive
factor significantly associated with a lower likelihood of clinically significant
improvement BDI score (OR: 0.56, 95%CI: 0.13–0.76, p < 0.05).
Table 6
Multivariate logistic regression analysis between predictor variables and clinically
significant improvement of QOD, SAST and BDI scores and positive change of GBI scores
|
OR (95% CI)
|
p-value
|
|
QOD
|
|
|
|
Clinically improved NOSE
|
3.51 (1.02–12.04)
|
0.046
|
|
Clinically improved SNOT-22
|
3.79 (1.11–12.88)
|
0.033
|
|
Olfactory Dysfunction postoperatively
|
0.23 (0.16–1.8)
|
0.204
|
|
SAST
|
|
|
|
Clinically improved NOSE
|
3.82 (1.16–12.51)
|
0.027
|
|
Clinically improved SNOT-22
|
6.14 (1.87–20.07)
|
0.003
|
|
BDI
|
|
|
|
Clinically improved NOSE
|
2.67 (0.69–10.39)
|
0.154
|
|
Clinically improved SNOT 22
|
5.61 (1.35–23.15)
|
0.017
|
|
Olfactory Dysfunction postoperatively
|
0.56 (0.13–0.76)
|
0.021
|
|
GBI
|
|
|
|
Clinically improved NOSE
|
14 (3.32–58.95)
|
< 0.001
|
|
Clinically improved SNOT-22
|
8.75 (2.07–36.93)
|
0.003
|
Abbreviations: BDI, Beck depression inventory; GBI, Glasgow benefit inventory; NOSE,
nasal obstruction symptom evaluation; QOD, questionnaire of olfactory disorders; SAST,
short anxiety screening test; SNOT-22, SinoNasal outcome test-22.
Data are expressed as odds ratios (OR) with their 95% confidence intervals (CI). Only
variables with statistical significance during univariate linear regression analysis
are included. pvalues: Multivariate logistic regression analysis.
Discussion
Nasal septal deviation is a common nasal disease causing nasal obstruction symptoms
and decreased olfactory function, which, in turn, affect the QoL of the patients.[15]
[46] Although there are previous reports on patients' satisfaction and the impact of
septoplasty on the QoL of th epatients,[23]
[47]
[48]
[49]
[50]
[51] there are no studies analyzing the impact of olfactory dysfunction on the emotional
status and QoL in patients who had septoplasty. The present study assessed olfactory
function as a potential predictor of patients' QoL and psychological status improvement,
analyzing the correlations of demographic and clinical characteristics of the patients
who experience a clinically significant improvement on the emotional status and QoL.
The clinical importance of investigating the emotional status and QoL in this group
of patients is related to the fact that nasal septal deviation is a common cause of
olfactory impairment and nasal obstruction. Psychological status and QoL are likely
to be affected due to the chronicity of symptoms, and it is a surgically treatable
condition whose outcome measurement is essential to plan personalized patient care.
Interesting findings regarding the correlations between patients' demographic and
clinical characteristics and QoL, stress levels, depressive mood, and personal benefit
from septoplasty were noted.
In the present study as well as in previous researches,[52] it was observed that patients with septal deviation had impaired olfactory function
(lower OT, OD, OI and TDI scores), more severe nasal obstruction symptoms and reduced
nasal-symptom related QoL than healthy controls. Furthermore, patients with olfactory
deficits due to septal deviation had reduced nasal-symptom related and olfaction-associated
QoL compared with normosmic patients and healthy controls. Normosmic patients had
less impact on olfaction-associated QoL than patients with impaired olfactory function
compared with healthy controls. Six months after septoplasty, probably due to increased
intranasal airflow, an improvement of olfactory function was observed and this was
expressed by a significant improvement of TDI scores and all separate olfactory (OT,
OD, OI) scores. Previous reports demonstrated similar results.[1]
[11]
[13]
[14]
[15]
[46]
[53] Postoperatively, olfaction-associated QoL did not differ significantly between the
three groups. Olfaction-related QoL was improved for both normosmic patients and those
with olfactory dysfunction. Specifically, the mean value of the QOD score for the
group of patients with olfactory deficits postoperatively reached the preoperative
mean value of the normosmic patients. The QOD is a symptom-specific (olfaction) QoL
measure but is possibly also affected by other nasal symptoms. The effects of other
nasal symptoms might have a more prominent negative impact on QoL of patients with
olfactory dysfunction because nasal symptoms coexist with impairment in areas such
as food enjoyment, harm avoidance, and socializing.[2] According to the results of the present study, septoplasty leads to olfaction recovery
and increase in the number of patients with normal olfactory function. Additionally,
it contributes to nasal-symptom related and olfaction-associated QoL improvement in
patients with olfactory dysfunction and septal deviation, through nasal symptoms resolution
and improvement of olfactory status.
Another important finding of the present study was that although in univariate analysis,
the presence of postoperative olfactory dysfunction was significantly negatively correlated
with clinically significant improvement of QOD, this association became non-significant
in multivariate analysis. After screening of all potential demographic and clinical
predictors, it was found that clinically significant improvement of nasal obstruction
symptom severity (NOSE scores) and nasal-symptom related QoL (SNOT-22 scores) were
the only parameters highly associated with an increased likelihood of clinically significant
improvement of olfaction-associated QoL (QOD scores). These results support the opinion
that there seems to be a disconnection between quantitative assessment of olfactory
function and subjective experience of olfactory impairment and that olfactory-specific
QoL is affected by additional factors beyond olfactory status.
In the present study, it was found that the whole patient group had higher stress
levels (SAST values) than healthy individuals. Patients with olfactory deficits had
more anxiety symptoms than patients with normal smell and healthy controls. Stress
levels were reduced for the whole patient group after nasal septoplasty, in accordance
with the results reported by Hong et al.[24] However, 6 months after surgery, only patients with normal olfactory function had
stress levels that presented no significant differences from healthy controls. Furthermore,
clinically significant improvement of nasal obstruction symptom severity (NOSE scores)
and nasal-symptom related QoL (SNOT-22 scores), but not the presence of normal olfaction,
were highly associated with an increased likelihood of clinically significant improvement
of anxiety symptoms (SAST scores). Specifically, patients with clinically significant
improvement of nasal obstruction symptom severity and nasal-symptom related QoL were
3.82 and 6.14 times more likely to experience clinically significant improvement of
anxiety symptoms (SAST scores), respectively. These results suggest that the levels
of stress in patients treated for septal deviation are less affected by olfactory
impairment than what has been reported for patients with other sinonasal diseases,
such as chronic rhinosinusitis with or without nasal polyposis.[54]
[55]
[56] Although patients with olfactory deficits present higher stress levels than normosmic
patients, nasal obstruction symptoms appear to be the main factor inducing anxiety
symptoms in patients with septal deviation. This finding seems reasonable because
nasal obstruction can be connected with symptoms such as insomnia/sleep disturbances
and headaches, which are assessed with the use of the SAST questionnaire.
Regarding the emotional status, patients with olfactory deficits had more depressive
mood (BDI scores) compared with patients with normal olfactory function and healthy
controls, both before and 6 months after surgery. Previous studies evaluating the
impact of olfactory disorders, due to various causes, on the QoL of patients[2]
[4]
[5]
[6] demonstrated that individuals with olfactory dysfunction experience reduced food
enjoyment, problems related to personal hygiene (insecurity about personal body odor),
reduced participation in social life and limitations with sensing warning signals
(gas/smoke). It can be assumed that the aforementioned daily life restrictions may
impair QoL and impact the emotional status of patients with olfactory deficits related
to septal deviation. The negative impact of olfactory dysfunction on patients' emotional
status could also be related to the connection between olfactory system and structures
of the limbic system like the amygdala and orbitofrontal cortex,[57] which mainly contribute to the development of depressive symptoms.[58] It is noteworthy that, clinically significant improvement of nasal-symptom related
QoL (SNOT-22 scores) was associated with an increased likelihood of clinically significant
improvement of depressive mood (BDI scores). Patients with clinically significantly
improved SNOT-22 scores were 5.61 times more likely to experience clinically significant
improvement in levels of depression. In contrast, impaired olfaction postoperatively
was correlated with reduced incidence of improved BDI scores. Normosmic patients were
4.37 times more likely to experience clinically significant improvement of depressive
mood (BDI scores) than patients with olfactory deficits. These findings indicate that
olfactory impairment due to septal deviation appears to have a negative effect on
patients' emotional profile.
According to the results of the present study, olfactory impairment had a negative
impact on patient-reported benefit from surgery, as patients with impaired smell appeared
less satisfied than normosmic patients. However, olfactory status was not found to
have a significant impact on the likelihood of personal benefit from septoplasty.
Similarly, none of the patients' demographics affected the subjective evaluation of
surgical outcome, in agreement with previous studies which examined age, gender, smoking[19]
[21]
[24]
[25]
[48] and socio-economic status.[19] Clinically significant improvement of nasal obstruction and nasal-symptom related
QoL were the only predictive factors significantly associated with subjective surgical
outcome. Specifically, patients with clinically significant nasal obstruction symptom
resolution and nasal-symptom related QoL improvement were 14 and 8.75 times more likely
to experience higher personal benefit from surgery, respectively. This finding is
in accordance with other reports, which demonstrated that patients with more severe
nasal symptoms preoperatively had more potential of improvement of their health status
after septoplasty and were more satisfied with surgical outcome.[19]
[21]
[23]
[24]
[49] Thus, it seems that personal benefit from septoplasty is mainly affected by nasal
symptom resolution rather than improvement of olfactory function.
An interesting finding of the present study was that there were no significant differences
between general QoL (SF-36 scores) of healthy controls and patients with septal deviation,
either with olfactory deficits or normosmics. Probably, nasal obstruction and olfactory
impairment related to septal deviation do not cause a deterioration of health status
significant enough to be depicted in this general-health status questionnaire.[50]
[51] In contrast, the SNOT-22 is a specific nasal-symptom related QoL questionnaire,
and it covers the effects of physical health, functional limitations, and emotional
aspects of QoL related to the nasal functions, including olfaction. That explains
why, according to the results of the present study, clinically significant improvement
of the SNOT-22 score was an independent predictor highly associated with clinically
significant of olfaction-associated QoL, psychological status (anxiety symptoms and
depressive mood), and a higher likelihood of patients-reported benefit from the surgical
procedure.
To the best of our knowledge, this is the first study to address the association of
olfactory function with clinically significant improvement of QoL and psychological
outcomes of patients who undergo septoplasty. In the present study, validated tools
were used to measure general, disease-specific and olfaction-specific QoL, emotional
status, and patient outcome satisfaction and comparisons with healthy controls were
performed. Additionally, quantitative smell tests for the measurement of olfactory
performance were utilized, providing clinically important data for the olfactory function
in patients treated with septoplasty. Future studies may provide useful knowledge
on the clinical importance of olfactory testing prior to surgery for appropriate consultation
of patients.
Conclusion
Nasal septoplasty leads to better olfactory function along with nasal obstruction
resolution and improvement of nasal symptom-related QOL. Olfactory impairment related
to septal deviation has a negative impact on psychological status and disease-specific
QoL. Although improvement of nasal obstruction and nasal-symptom related QoL were
the only factors significantly associated with patients' evaluation of surgical outcome,
patients with olfactory deficits were less satisfied with the surgical procedure than
normosmics and experienced greater stress and depressive mood. Quantitative evaluation
of the olfactory status of patients treated for septal deviation is important for
optimal assessment of the patients and consultation regarding the anticipated septoplasty
outcomes.
