Question1. How do we know that undertaking an operation will benefit a patient?
Question 2. How do policy makers / health systems know an operation is effective and ‘good value for money’?
As trained professionals, we spend our careers seeking to learn the answer to question 1, which is often not a binary answer. We rely on the learning we have gained as trainees as well as the ongoing education we undertake throughout our working lives. This is clearly hand in hand with the experience of seeing countless patients. All of this, in combination with assessing any given patient, results in a full discussion of all options, of which an operation may be one course of action. Ultimately, if we offer an operation to a patient, we believe it is likely to benefit them.The answer to question 2 is often at loggerheads with question 1. This can be due to the fact that policy is made by people without specific insight and experience of a given specialty and the operations that are undertaken by them. One hopes the ‘decision makers’ would be reliant on gaining advice from experts within that field as well as good quality evidence but, in reality, either of these may not be used or in fact available. There is also the eternal question of money in a resource-limited healthcare system and cost improvement programmes hanging above our collective heads like the sword of Damocles.This month’s Editors’ Choice is a NICE commissioned multicentre randomised controlled trial assessing septoplasty versus medical management for patients with nasal obstruction associated with septal deviation. The results show that in this group of patients, septoplasty was a clinically effective treatment with superior outcomes for nasal symptoms and quality of life measures when compared with defined medical management alone. This study helps guide both patients and us to answering question 1 and, just as importantly, question 2. The editors would, as always, like to thank all of our reviewers for their valued contributions. Happy New Year!
Nazia Munir and Hannah Cooper
This article presents the results of a new multicentre randomised controlled trial comparing septoplasty and a defined medical management for nasal obstruction associated with septal deviation, which paves the way for evidence-based guidelines. Septoplasty is a common operation, with approximately 16,700 operations performed in England in 2019/2020. However, there is a lack of high-quality evidence to support the clinical effectiveness of septoplasty and, as a result, there are no clear set guidelines for its use in the UK. The Nasal Airways Obstruction Study (NAIROS) was commissioned to offer conclusive evidence and recommendations regarding the clinical effectiveness of septoplasty. In this study, 378 adults with at least moderate symptoms of nasal obstruction were randomised to receive septoplasty or a defined regimen of nasal steroid and saline spray. The results prove that septoplasty is clinically more effective, with a mean SNOT-22 score at six months of 19.9, when compared with a defined medical treatment, with a mean SNOT-22 score at six months of 39.5; an estimated 20.0 points lower (better) for patients receiving septoplasty. Objectively, patients who had septoplasty demonstrated greater improvement in nasal obstruction and quality of life, as assessed through the SNOT-22 questionnaire. Nevertheless, individuals with deviated septum and at least moderate symptoms of nasal obstruction typically exhibit improvement over time with medical management. This study highlights the superior outcome of septoplasty for nasal obstruction associated with septal deviation, when compared with a defined medical management. It is crucial that these discoveries are translated into guidelines, to ensure that individuals with appropriate pathology are offered septoplasty.