Limitations of this study
nasal valve dysfunction, rhinitis, Nasal obstruction, nasal obstruction
CHRONIC RHINOSINUSITIS, SECONDARY, RHINITIS, ALLERGIC RHINITIS
The study has several limitations. At baseline, more than 80% of patients had NOSE scores in the severe or extreme category. This may reflect the population currently referred to secondary care. However, the conclusions for these two subgroups were strong. The benefits for those participants with moderate baseline symptoms was less clear, whereas those with moderate NOSE scores at baseline did not report an improvement that reached the minimal clinically important difference of 9 points on SNOT-22—only 18 participants were included in this subgroup of the STEPP analysis.Nasal obstruction is a non-specific symptom with many underlying possible causes (chronic rhinosinusitis, allergic rhinitis, non-allergic rhinitis, nasal valve dysfunction). As a pragmatic trial, the current study did not seek to diagnose or treat these conditions before randomisation. Also, surgical interventions were performed by experienced surgeons. In NHS practice, septoplasty is often performed by junior trainee surgeons, albeit many are supervised by more senior colleagues. The evidence is limited for septoplasty outcomes and surgeon experience. However, previous studies have found no association between grade of surgeon and septoplasty outcomes when assessing the need for revision surgeryThe current trial did not assess, and therefore cannot define, what should constitute an appropriate trial of medical management for patients and clinicians to consider before septal surgery is discussed. Participants in the medical management group reported an improvement in symptoms with mometasone nasal steroid and saline sprays. Participants with an element of underlying rhinitis contributing to the nasal obstruction in addition to the septal deviation may have responded to this treatment. Consensus opinion from the US recommends a course of medical management for four weeks before septoplasty is considered.