The statement says that a trial of medical therapy of more than four weeks is unnecessary to establish candidacy for surgery. In some cases, such as severe caudal septal deviation with complete obstruction, there’s no way that a nasal spray could get into the cavity, Dr. Lian said. In those cases, it seems unreasonable to have a month’s trial of medical management. But, some carriers ask for that. “If there are other elements in the history, such as allergic rhinitis, that are suggestive that they may respond to steroid nasal spray, and if it appears it’s able to be delivered, then a month is a reasonable time,” said Dr. Lian.
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November 2015Perioperative Antibiotics and Turbinoplasty with Septoplasty
The statement says there is no benefit to administering antibiotics perioperatively unless nasal packing or a splint is placed during the procedure. Dr. Stringer noted that the literature suggests that antibiotics provide no benefit, even in cases with packing or splints, but the experts chose to make an exception in packing or splint cases. “There is a lot of belief in our specialty that splints and nasal packing are different,” said Dr. Stringer. Both he and Dr. Lian added that they very rarely use packing or splints anyway.
Dr. Stringer also advised that, even though insurers sometimes are hesitant to approve coverage for turbinoplasty in addition to septoplasty, the panelists “came to a consensus fairly rapidly” that the turbinates need to be addressed as well. “I think it’s important that we have that in there,” he said. “We’re not really treating the septum alone. We’re treating an airflow issue.”
Septoplasty and OSA
The statement says that septoplasty can improve continuous positive airway pressure (CPAP) tolerance for patients with obstructive sleep apnea (OSA) and a deviated septum, but does not say that septoplasty alone directly improves OSA.
The panel also emphasized the improved sensation of nasal airflow. “The perception is that when a patient lies down to sleep that they can then breathe unobstructed through their nose,” he said. “While it may not change their polysomnography, the patient’s happiness is improved.”
Thomas Collins is a freelance medical writer based in Florida.
Take-Home Points
- Nasal endoscopy can provide useful information prior to septoplasty, such as other causes of nasal obstruction, even when anterior rhinoscopy documents septal deviation.
- A CT scan of the paranasal sinuses is unnecessary to document the septal deviation prior to septoplasty but may be useful in diagnosing other sinonasal pathology in patients with symptoms that cannot be explained by septal deviation.
- A trial of medical therapy for more than four weeks is unnecessary to assess surgical candidacy for septoplasty.
- There is no benefit to routine peri-operative antibiotics during septoplasty unless nasal packing or a splint is placed during the procedure.
Consensus Statement vs. Guidelines
As defined by the Institute of Medicine, consensus statements are different from guidelines in that they’re essentially opinions on topics that are considered important and controversial but for which there is not enough high-level evidence for a clinical practice guideline. “There are a lot of questions that come up that we grapple with as clinicians, and there aren’t any randomized trials to help us out,” said Richard Rosenfeld, MD, MPH, senior advisor for guidelines and quality at the AAO-HNS. “The purpose of this [statement] was to get a meeting of the minds and, using a fairly systematic rigorous process, to try to identify important areas of consensus that could reduce uncertainty and improve the quality of patient care.”