Effect of Turbinate Surgery in Rhinoseptoplasty on Qualityoflife

The Laryngoscope VC 2012 The American Laryngological, Rhinological and Otological Society, Inc.

Effect of Turbinate Surgery in Rhinoseptoplasty on Quality-of-Life and Acoustic Rhinometry Outcomes: A Randomized Clinical Trial

Michelle Lavinsky-Wolff, MD, MSc, PhD; Humberto Lopes Camargo, Jr., MD, MSc; Carolina Rocha Barone, MS; Luisi Rabaioli, MS; Fernando Herz Wolff, MD, PhD; Jose Eduardo Lutaif Dolci, MD, PhD; Carisi Anne Polanczyk, MD, ScD

Objectives/Hypothesis: To evaluate the role of inferior turbinate reduction during rhinoseptoplasty in quality-of-life outcomes and nasal airway cross-sectional area. Study Design: Randomized clinical trial. Methods: Individuals over 16 years with nasal obstruction, candidates to functional and aesthetics primary rhinoseptoplasty, were evaluated from December 2010 though January 2012 at a tertiary University Hospital, Brazil. Eligible participants were randomly allocated to rhinoseptoplasty with or inferior turbinate reduction through submucosal diathermy. Outcomes: Relative changes ([postop–preop]/preop score) in specific (Nasal Obstruction Symptom Evaluation; NOSE) and general quality-of-life instruments (WHOQOL-bref), nasal obstruction visual analogue scale (NO-VAS) and nasal area measurements in acoustic rhinometry. Outcomes were blindly assessed 3 months postoperatively. Protocol was registered at ClinicalTrials.gov (NCT01457638). Results: 50 patients were included, mainly Caucasians with moderate/severe allergic rhinitis symptoms. Mean age was 32 6 12 yr and 58% were female. Rhinoseptoplasty improved specific and general quality-of-life scores irrespective of turbinate intervention (P < 0.001).There was no difference between subjects submitted or not to inferior turbinate reduction in NOSE score (75% vs. 73%; P ¼ 0.893); all WHOQOL-bref score domains (P > 0.05), NO-VAS (88% vs. 81%; P ¼ 0.89) and acoustic rhinometry recordings (P > 0.05).During follow-up less patients in the rhinoplasty with inferior turbinate reduction group were using topical corticosteroids (6[24%] vs. 13[54%]; P ¼ 0.03). Multivariable analyses, adjusting for postoperative topical corticosteroid use and previous nasal fracture, had no effect on these results. Conclusions: Turbinate reduction through submucosal diathermy during primary rhinoseptoplasty did not improve short-term general and specific quality-of-life outcomes and acoustic rhinometry recordings. The role of turbinate reduction in sparing chronic corticosteroid use should be confirmed in long-term follow-up studies. Key Words: Rhinoplasty, turbinate surgery, quality of life, acoustic rhinometry, randomized clinical trial. Level of Evidence: 1b. Laryngoscope, 123:82–89, 2013

INTRODUCTION Inferior turbinates are the main regulator of nasal Rhinoplasty remains one of the most commonly per- airflow, playing an important role in normal respiratory formed aesthetic surgical procedures in plastic surgery.1 function.3 They are also part of nasal valve area, fre- Interest in functional and quality-of-life outcomes has quently reduced in rhinoplasty surgeries.4 It seems increased as a method of validation of surgery results, reasonable to consider that turbinate reduction during rhi- and is a growing focus among otolaryngologists and noseptoplasty would improve postoperative nasal airflow facial plastic surgeons.2 and, consequently, quality-of-life outcomes. However, no randomized clinical trial has evaluated whether turbinate

From the Graduate Program in Epidemiology (M.L. W., F.E.L.), reduction during rhinoseptoplasty impacts on clinical out- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; the comes. Considering the paucity of evidence on inferior Otolaryngology and Head and Neck Surgery Department (M.L.-W.) of turbinate surgery efficacy, recent systematic reviews3,5 re- Hospital de Clıńicas de Porto Alegre (HCPA), Porto Alegre, Brazil; The Otolaryngology and Head and Neck Surgery Department (H.L.C.) of inforced the need of prospective controlled studies with Complexo Hospitalar Santa Casa de Porto Alegre; Porto Alegre, Brazil, both objective and subjective validated outcomes measures. The Otolaryngology Department (J.E.L.D.) of Faculdade de Medicina da The aim of this trial was to evaluate the clinical Santa Casa de Saõ Paulo; Saõ Paulo, Brazil, and Medical students (C.R.B., L.R.) from Universidade Federal do Rio Grande do Sul and Universidade effect of turbinate reduction during primary rhinosepto- Federal de Cieˆncias da Saude de Porto Alegre; Porto Alegre, Brazil. plasty upon quality-of-life outcomes and nasal airway Editor’s Note: This Manuscript was accepted for publication July cross-sectional area among patients with functional and 9, 2012. aesthetic nasal complaints. This work was supported by Fundo de Incentivo a Pesquisa e Eventos–FIPE/HCPA. The authors have no other funding, financial relationships, or conflicts of interest to disclose. MATERIALS AND METHODS Send correspondence to Michelle Lavinsky-Wolff, MD, Rua 0 Quintino Bocaiuva, 673 4 andar. Porto Alegre, Brazil, 90440-003. Trial Design E-mail: [email protected] This was a pragmatic double-blind, single-center, random- DOI: 10.1002/lary.23628 ized [1:1] and parallel-group clinical trial comparing quality-of

Laryngoscope 123: January 2013 Lavinsky-Wolff et al.: Turbinate Surgery in Rhinoplasty 82 life outcomes (general and specific to nasal obstruction) and tion mode at 30 Watts. Intervention was carried out by the acoustic rhinometry recordings of primary rhinoseptoplasty same surgeon (MLW) in all cases. with versus without inferior turbinate reduction.

Rhinoseptoplasty without Inferior Settings and Participants Turbinate Reduction (ITR) The study was undertaken at the Facial Plastic Surgery Patients in this group underwent primary rhinosepto- Clinic of Otolaryngology Department of the Hospital de Clinicas plasty as described above, without any intervention in inferior de Porto Alegre, a tertiary care, university hospital in southern turbinates. Brazil. Eligible participants were adults aged 16 years old with symptoms of nasal obstruction, and candidates to functional Primary Outcome and aesthetic primary rhinoseptoplasty. Besides nasal obstruc- Primary outcome was the relative change in a disease-spe- tion complaints, eligible individuals should present an anatomic cific quality-of-life questionnaire for assessing outcomes in abnormality, such as septal deviation, insufficient nasal tip sup- nasal obstruction in trials, the Nasal Obstruction Symptom port or rotation, nasal valve collapse, or crooked nose. Evaluation in the Portuguese language (NOSE-p), published Exclusion criteria were: 1) previous nasal surgery; 2) tur- elsewhere.7,8 A score of ‘‘ 0’’ means no problems with nasal binate hypertrophy as the unique reason to explain nasal obstruction, and a score of ‘‘ 100’’ means the most severe prob- obstruction; and/or 3) additional concomitant procedures, as lem possible with nasal obstruction. functional endoscopic sinus surgery, adenoidectomy, blepharo- plasty or otoplasty. Written informed consent was obtained from each patient Secondary Outcomes before study enrollment. The protocol was registered at Clinical- WHOQOL-bref. WHOQOL-bref is a generic quality-of-life Trials.gov (http: //clinicaltrials.gov) as NCT01457638. The instrument, a cross-culturally and valid assessment of well-being research protocol was approved by the Ethics and Research developed by the World Health Organization.9–11 It is composed Committee of Hospital de Clinicas de Porto Alegre (registered of 26 questions, two of them measuring overall and general #10-420). health. The other 24 questions are divided into four domains: physical, psychological, social relationships, and environment. The scores varies between 0 and 100, with 0 being the least Randomization favorable quality of life and 100 being the most favorable one. Randomization sequence was created using Randomiza- Rhinoplasty Outcome Evaluation (ROE). The Rhino- tion.com statistical software with a 1:1 allocation and random plasty Outcome Evaluation (ROE)12,13 scale is a quality-of-life block sizes of 4 and 6. The computer-generated random number questionnaire validated for rhinoplasty patients. It is composed list was prepared by an investigator not related to this trial. of six questions that capture three quality-of-life domains: physi- The allocation sequence was concealed from those involved in cal, mental/emotional, and social. According to this scale, highest enrolling and assessing participants. level means ‘‘total satisfaction’’ and 0 ‘‘major dissatisfaction. ’’ Nasal Obstruction Visual Analogue Scales (NO-VAS). Subjects were asked to grade their present nasal obstruction Data Collection and annoyance with the symptom on a scale with anchor 0 indi- At study enrollment, each subject completed a brief ques- cating no symptoms (‘‘fully open’’ and ‘‘not annoyed at all’’) and tionnaire to provide demographic and baseline characteristics. anchor 100 indicating maximum symptoms (‘‘totally obstructe- d’’and ‘‘severely annoyed’’). Acoustic Rhinometry (AR). AR noninvasively measures Interventions nasal airway cross-sectional area as a function of longitudinal All patients underwent primary rhinoseptoplasty. During distance along the nasal passageway following the path of an anesthetic induction, patients were randomly allocated to rhino- acoustic pulse.14 An impulse acoustic rhinometer (RhinoMetrics septoplasty with or without inferior turbinate reduction. SRE2100, Rhinoscan version 2.5, built 3.2.5.0; Interacoustics, Surgeries were performed by a single surgeon (MLW) with the Minneapolis, MN) was handled by the same experienced physi- assistance of medical residents. All procedures were performed cian blinded to intervention throughout the study (HLC). using an endonasal rhinoplasty technique. Septoplasty, nasal Recordings were performed in accordance to published proto- tip refinement, appropriate dorsal profile alignment, and lateral cols.15 The following measures were recorded: minimum cross- and medial osteotomies were performed in all procedures. No sectional area (MCA) in cm2 between 0 to 2.2 cm (MCA1) and other techniques which would affect nasal airway, such as between 2.2 to 5.4 cm (MCA2); and, nasal cavity volumes (NCV) spreader grafts, batten grafts or flaring sutures, were in cm3 between 0 to 2.2 cm (NCV1) and between 2.2 to 5.4 cm performed. (NCV2). To account for variations of nasal cavities dimensions due to the nasal cycle, an average value from the left and right side were calculated.15 Rhinoseptoplasty with Inferior Turbinate Reduction (ITR) Patients allocated to this group had turbinate reduction Follow-Up through submucosal diathermy. The procedure was done by Outcomes were blindly assessed, preoperatively and at 3 inserting a 22-Gauge spinal anesthesia needle into the anterior months postoperatively, by trained investigators. Patients were end of the inferior turbinate and advancing it until the poste- clinically evaluated weekly in the first month and then monthly. rior end was reached.6 This procedure was performed at least In all medical appointments patients were asked about allergic twice on each inferior turbinate, until maximal coagulation and rhinitis symptoms and were classified as presenting 1) intermit- shrinkage of mucosal and submucosal structures was achieved tent or persistent and 2) mild or moderate/severe allergic without charring. The electrosurgical unit was set in coagula- rhinitis symptoms, according to Allergic Rhinitis and its Impact

Laryngoscope 123: January 2013 Lavinsky-Wolff et al.: Turbinate Surgery in Rhinoplasty 83 on Asthma (ARIA) guidelines.16 Patients with mild intermittent Previous self-reported nasal trauma, postoperative symptoms were advised to use oral H1-antihistamines as use of topical corticosteroids, and the composite variable needed. From the 30th day postoperative visit on, topical corti- (postoperative corticosteroid use *intervention group) costeroids (Budesonide 100 mcg, twice a day) were prescribed to were not independently associated to general and dis- patients presenting mild persistent or moderate/severe intermit- ease-specific quality-of-life scores, but were maintained tent or persistent symptoms, according to ARIA guidelines.16 If in the multivariate model for clinical reasons. patients were still presenting mild persistent, or moderate/ severe intermittent or persistent symptoms, on day 60 reevalua- There was a negative and regular correlation tion visit, high-dose topical corticosteroids were prescribed between the 3-months postoperative psychological and (Budesonide 200 mcg, twice a day). All patients were oriented environment WHOQOL-bref domains with NOSE-p to use oral H1-antihistamines as needed. In each medical visit scores. Postoperative NO-VAS was strongly correlated patients answered a standardized questionnaire about medica- with NOSE-p scores, and inversely correlated with physi- tions used for allergic rhinitis. cal and psychological WHOQOL-bref domains (Table II). At the third month follow-up visit (mean 99 6 12 Sample Size days), fewer patients in the ‘‘rhinoseptoplasty with ITR’’ Sample size was calculated to detect a reduction of 20 points group were using topical corticosteroids (6[24%] vs. in NOSE-p score, using the results reported by Stewart et al.17 as 13[54%], P ¼ 0.03). reference. A two-sided 5% significance level and a power of 80% were used to calculate a total sample size of 42 patients divided in two groups. In order to account for a dropout rate of 10% and NOSE–p score to apply multivariate analysis, 50 patients were recruited. NOSE-p mean scores were significantly lower postoperatively in both groups (71 6 23 vs. 24 6 24 in ITR group [P < 0.001]; 76 6 19 vs. 25 6 20 in control group Statistical Methods [P < 0.001]), but no difference was observed in postoper- Statistical analyses were carried out using the SPSS ver- ative NOSE-p and D relative change of NOSE-p scores sion 18.0. Data were reported as mean 6 standard deviation or median, 25th and 75th percentiles, or percent, as appropriate. between intervention groups (Table III). The analyses adhered to the intention-to-treat principle and a 2- tailed P value of less than 0.05 indicates statistical significance. For intragroup comparisons of pre- and postoperative data, WHOQOL-bref a paired 2-tailed t test for normally distributed variables and Both groups presented higher postoperative WHO- Mann-Whitney U test for of asymmetric variables were used. QOL-bref scores when compared to preoperative scores Outcomes were described as delta relative change ([postop- in all domains (P < 0.05). However, no difference was erative score–preoperative score]/preoperative score) in percent. observed in all WHOQOL-bref domains scores between Interaction of postoperative corticosteroid use and intervention intervention groups (Table III). group was tested, and a composite variable (postoperative topical corticosteroid use *intervention group) was created and included into the multivariable model. Rhinoplasty Outcome Evaluation (ROE) scale Analysis of variance was conducted to compare differences ROE scale scores were significantly higher postop- in outcomes across intervention groups, controlling for baseline eratively in both groups (27.5 vs. 78.1 in ITR group [P < history of nasal fracture, postoperative corticosteroids use, and 0.001] and 31.8 vs. 74.3 in control group [P < 0.001]). No the composite interaction variable. Spearman coefficient was used to assess the WHOQOL-bref domains, NOSE-p, and NO- significant difference was observed in D relative change VAS scores correlation. score between patients allocated to rhinoseptoplasty with or without ITR (200% vs. 175%, respectively; P ¼ 0.111) (Table III). RESULTS From December 2010 through October 2011, poten- tially eligible patients were screened. The first 50 Nasal Obstruction Visual Analogue subjects who fulfilled the entry criteria and consented to Scales (NO-VAS) participate in the protocol were included (Fig. 1). Previ- Degree of nasal obstruction (61.8 vs. 19.6 in ITR ous nasal surgery and aesthetic complaints only group [P < 0.001], and 63.6 vs. 22.3 in control group [P (without nasal obstruction symptoms), were the main < 0.001]) and annoyance with nasal obstruction (58.4 vs. reasons for noneligibility. After randomization, one 18.6 in ITR group [P < 0.001], and 71.7 vs. 23.2 in con- patient did not complete the 90-day follow-up visit and trol group [P < 0.001]) were significantly lower in 3 one other patient did not perform the acoustic rhinome- months postoperative evaluation in both groups. No try follow-up. Both patients had been randomized were significant difference was observed between groups assigned to ‘‘rhinoseptoplasty without ITR’’ group. (Table III). The study population included predominantly Cau- casian subjects with moderate/severe allergic rhinitis symptoms. Mean age was 32 6 12 years and 58% were Acoustic Rhinometry (AR) female. Except for previous nasal trauma, more preva- Minimal cross-sectional area and volume of the nasal lent in the ‘‘rhinoseptoplasty without ITR’’ group, all cavity anterior segment (MCA1 and NCV1) recordings other baseline clinical characteristics were similar were reduced after rhinoseptoplasty with and without between groups (Table I). ITR (Table IV). The same did not occur in other posterior

Laryngoscope 123: January 2013 Lavinsky-Wolff et al.: Turbinate Surgery in Rhinoplasty 84 Fig. 1. Study Flow Diagram. [Color fig- ure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]

AR recordings. No difference was observed in AR record- The only difference detected between groups was ings between both groups (Table IV). the postoperative need of topical corticosteroid. In the 3-month follow-up visit, significantly more patients from the control group were using topical corticosteroid. In DISCUSSION multivariable analysis, the effect of turbinate surgery The theory that turbinate reduction could be partic- over the studied outcomes was controlled for that poten- ularly effective in rhinoseptoplasty patients as an tial confounding factor, but no relevant differences were adjunctive maneuver to avoid postoperative nasal valve seen between crude and adjusted analysis (data not area narrowing is advocated by some authors,18–20 but shown). However, avoidance of chronic topical corticoste- this intervention is based on case reports and expert roid use may be advocated as a justification for surgical opinion. This was the first randomized clinical trial inferior turbinate reduction in rhinoseptoplasty patients designed to evaluate the role of turbinate reduction in with preoperative nasal obstruction symptoms, particu- rhinoseptoplasty. larly if this finding persists in longer follow-up. Our results did not demonstrate short-term benefit Nasal obstruction is a subjective complaint involv- associated to turbinate reduction in primary rhinosepto- ing mucosal, structural, and even psychological plasty upon general and specific quality-of-life outcomes factors.21 It is a symptom with great variability during as well as in acoustic rhinometry recordings. the day, and can present differently during the same

Laryngoscope 123: January 2013 Lavinsky-Wolff et al.: Turbinate Surgery in Rhinoplasty 85 TABLE I. interest, and when it is applied flexibly as it would be in Baseline Characteristics. daily practice?’’ This is the reason why the study protocol, including the submucosal diathermy method and RhinoseptoplastyRhinoseptoplasty with Inferior without Inferior postoperative indication of topical corticosteroids use, Turbinate Turbinate were adopted, following the principles of daily clinical Reduction Reduction practice and evidence-based medicine.16,23 Characteristics (n ¼ 25) (n ¼ 25) The choice of including postoperative topical cortico- Age, mean (SD), years 32 (12.3) 32 (15.1) steroid prescription into the study protocol, even Female sex 17 (68) 12 (48) considering this effect in nasal airway, was done for ethi- Caucasian 23 (92) 25 (100) cal reasons. As described in Table I, 98% (49/50) of the Years of study included patients were individuals with moderate/severe Up to 8 years 3 (12) 6 (24) allergic rhinitis symptoms, and 42% (21/50) of them 9 to 11 years 13 (52) 14 (56) were in use of nasal corticosteroids preoperatively. It did 12 years 9 (36) 5 (20) not seem ethical to deny our patients this treatment, since many of them also had other nasal symptoms as Previous nasal trauma 5 (20) 12 (48) rhinorrea, nasal sneezing, and itching (Table I). Nasal symptoms Although in an ideal scenario it would be better not to Rhinorrhoea 10 (40) 10 (40) have this potential confounding factor, we could not Nasal sneezing 10 (40) 11 (44) withdraw from our patients a standard of care treatment Nasal itching 13 (52) 9 (36) only because they were taking part in a trial. Even so, Seasonal nasal symptoms 18/24 (75) 15/21 (71) one could suppose that primary outcome could be differ- Symptoms of AR* intermittent ent if postoperative nasal corticosteroids were avoided in persistent 14 (56) 15 (60) all patients. In an attempt to control this potential con- 11 (44) 10 (40) founding bias, nasal corticosteroids were prescribed in a AR symptoms severity* 24 (96) 25 (100) standardized protocol, equal in both groups; also, infor- moderate/severe mation about its use was collected and included into the Current use of topical corticosteroid 9 (36) 12 (48) multivariable model. Self-reported chronic disease 12 (48) 11 (44) Quality-of-life measurement has been increasingly used as an outcome measure in clinical trials.9 The Number as expressed as n (%), unless otherwise specified. *According to ARIA guidelines; # Pearson chi-square for categorical Nasal Obstruction Symptom Evaluation (NOSE) is a variables; t test for independent samples for continuous variables. AR ¼ Al- brief, valid, reliable and responsive disease-specific qual- lergic Rhinitis. ity of life instrument for use in nasal obstruction outcomes assessments.7,8 Stewart at al 17 conducted a week or month. Also, seasonality, rhinitis, use of topical multicenter non randomized study comparing septo- corticosteroids, and even other still unknown mecha- plasty with and without partial turbinectomy outcomes nisms can interfere in nasal obstruction intensity, and, using NOSE questionnaire. Although their sample did consequently, in outcomes measures. Those are our real not undergo rhinoplasty, their 3-month follow-up find- life patients, and these difficulties contribute for the ings were similar to ours, showing a great postoperative daily challenge of assessing and managing them. This improvement in NOSE scores (66.6 vs. 20.3 in ITR group was a pragmatic trial,22 which means that we aimed to and 69.7 vs. 31.2 in control group), but no additional evaluate the effectiveness of turbinate reduction in rhi- benefit associated to turbinate surgery. noseptoplasty rather than its efficacy. The question to be The World Health Organization defines quality-of- answered in this trial was: ‘‘Does the intervention work life as ‘‘ an individual’s perception of their position in life when used in normal practice setting, with little or no in the context of the culture and value systems in which selection of participants beyond the clinical indication of they live, and in relation to their goals, expectations,

TABLE II. Correlations Between 3-months Postoperative WHOQOL-bref Domains, NOSE-p scores and NO-VAS (Spearman coefficient) in 49 Patients.

NOSE-p WHOQOL-bref domains NO-VAS NOSE-p 1 Physical Psychological Social Environment Physical 0.232 1 Psychological 0.313* 0.725† 1 Social 0.133 0.523† 0.818† 1 Environment 0.355* 0.543† 0.691† 0.616† 1 NO-VAS 0.789† 0.291* 0.478† 0.259 0.419 1

NOSE-p ¼ Nasal Obstruction Symptom Evaluation in the Portuguese language; NO-VAS ¼ Nasal obstruction visual analogue scale (degree of nasal obstruction). *Correlation is significant at 0.05 level (2-tailed). †Correlation is significant at the 0.01 level (2-tailed).

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TABLE III. Quality-of-Life Outcomes and Visual Analogue Scales Scores Between Individuals Who Underwent Rhinoseptoplasty with and without Inferior Turbinate Reduction.

Rhinoseptoplasty with Inferior Rhinoseptoplasty without Inferior Turbinate Reduction (n ¼ 25) Turbinate Reduction (n ¼ 24) Preop 3 mo Postop D Relative Change Preop 3 mo Postop D Relative Change Mean Median Mean (SD) Median (P25;P75) (SD) (P25;P75) P value* NOSE-p 70.8 24.2 75.0% 77.2 25.2 72.7% 0.89 (23.2) (24.4) (93;-47%) (18.9) (19.7) (84;-54%) ROE 27.5 78.2 200% 31.8 74.3 157.1% 0.11 (16.0) (17.3) (126;400%) (17.3) (15.8) (100;245%) NO-VAS degree of nasal obstruction 61.7 19.7 88.0% 63.6 22.4 80.8% 0.89 (27.7) (26.9) (95;-46%) (28.0) (24.9) (95;-29%) NO-VAS annoyance with nasal obstruction 58.5 18.6 82.5% 71.8 23.2 86.6% 0.77 (28.8) (26.7) (97;-44%) (22.2) (27.9) (96;-41%)

Rhinoseptoplasty with Inferior Rhinoseptoplasty without Inferior Turbinate Reduction (n ¼ 25) Turbinate Reduction (n ¼ 24) Preop 3 month Postop D Relative Change Preop 3 mo Postop D Relative Change P value* WHOQOL-bref domains Median (P25;P75) Median (P25;P75) Physical 53.6 60.7 7.2% 53.6 57.1 6.5% 0.10 (50.0;60.7) (54.4;66.9) (0.0;19.9%) (50.0;60.7) (50.0;67.8) (7.0;18.2%) Psychological 58.4 66.6 6.1% 62.5 66.7 6.9% 0.16 (45.8;70.8) (55.2;75.0) (0.0;21.8%) (56.2;70.8) (58.4;77.0) (4.9;15.8%) Social 75.0 75.0 0.0% 75.0 75.0 0.0% 0.99 (52.0;83.3) (66.6;89.5) (7.5;24.3%) (66.7;83.4) (75.0;97.9) (0.0;20.0%) Environment 60.9 67.2 7.3% 65.6 68.7 5.5% 0.77 (50.0;68.7) (53.9;74.2) (0.0;24.3%) (54.6;70.3) (59.3;77.3) (1.0;2.4%)

*P value ¼ Analysis of variance adjusted for postoperative corticosteroid use, group * postoperative topical corticosteroid use and previous nasal fracture; Dependent variables ¼ D Relative Change score ¼ ([postop – preop] / preop score); #P> 0.05 for preoperative characteristics among both groups: Independent Samples T-Test for normal distributed variables; Independent Samples Mann-Whitney U Test for non-normally distributed variables (WHOQOL-bref domains). P25 ¼ 25th Percentile; P75 ¼ 75th Percentile; NO-VAS ¼ Nasal Obstruction Visual Analogue Scale; NO¼ Nasal Obstruction. 87 TABLE IV. Acoustic Rhinometry Results Among Turbinate Surgery and No Turbinate Surgery Patients.

Turbinate surgery (n ¼ 25) No turbinate surgery (n ¼ 23)

Preop Postop D Relative Change Preop Postop D Relative Change Mean (6 SD) Median Mean (6 SD) Median P Value* MCA1 (cm2) 1.01 (0.26) 0.87 (0.24) 11.3% (33.5; 7.2%) 1.02 (0.26) 0.90 (0.27) 10.5% (17.9; 1.0%) 0.57 MCA2 (cm2) 1.16 (0.41) 1.22 (0.39) 5.9% (19.6; 36.0%) 1.07 (0.32) 1.03 (0.29) 5.3% (23.6; 24.0%) 0.33 NCV1 (cm3) 3.76 (0.71) 3.04 (0.46) 18.8% (28.7; 8.0%) 3.84 (0.77) 3.19 (0.59) 14.4% (23.6; 6.6%) 0.26 NCV2 (cm3) 10.11 (4.49) 12.08 (3.46) 25.6% (8.3; 0.7) 9.41 (3.13) 12.50 (5.9) 28.6% (4.0; 48.7%) 0.58

** Univariate analysis of variance adjusted for postoperative topical corticosteroid use, previous nasal fracture, composite variable (group*postoperative topical corticosteroid use); dependent variables ¼ D Relative Change ([postop – preop] / preop recording); Recordings obtained before nasal vasoconstriction and presented as average values from the left and right side; MCA1: minimum cross-sectional area in cm2 between 0 and 2.20 cm behind the nostril; MCA2: minimum cross-sectional area in cm2 between 2.20 to 5.4 cm behind the nostril; NCV1: nasal cavity volumes in cm3 between 0 and 2.20 cm behind the nostril; NCV2: nasal cavity volumes in cm3 between 2.2 to 5.4 cm behind the nostril; D ¼ Delta; Preop ¼ preoperative; Postop ¼ postoperative; SD ¼ Standard Deviation. standards and concerns.’’24,25 In measuring quality-of- Concerning the sample size, the study was not pow- life therefore, the World Health Organization Quality of ered to detect small differences in secondary outcomes, Life Assessment Group (WHOQOL Group) takes the leading to a potential beta error. However, the results view that it is important to know how satisfied or both- were very similar between groups, and even though ered people are by important aspects of their life, and larger samples may detect statistically significant differ- this interpretation.25 WHOQOL-bref questionnaire, a ences, they would be doubtfully of clinical relevance. For cross-culturally valid assessment of well-being, was the primary outcome, the sample size calculation previ- applied in rhinoseptoplasty patients for the first time in ous assumed was achieved. our study. Baseline scores found in our sample were worse than those from general Brazilian population nor- CONCLUSION mative data,9 and comparable to scores of patients with 26 Our study demonstrated that inferior turbinate coronary artery disease. These findings reinforce the reduction through submucousal diathermy during pri- idea that dissatisfaction with nasal appearance associ- mary rhinoseptoplasty did not improve short-term ated to nasal obstruction symptoms can impact general and specific quality-of-life outcomes and acoustic negatively general health quality-of-life outcomes. Sig- rhinometry recordings. The role of turbinate reduction nificant correlation between postoperative psychological in sparing chronic corticosteroid use should be confirmed and environment WHOQOL-bref domains and NOSE-p in long-term follow-up studies. scores suggests that both instruments are able to that capture postoperative quality of life. The use of the acoustic reflection technique in the BIBLIOGRAPHY nasal cavity was first described in 1989.27 Since then, it is 1. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg 2011;128:49e–73e. 2. Lee J, Constantinides M. Trends in functional rhinoplasty 2008. 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