Association of Septoplasty With Sinonasal and Related Outcomes in Adults With Nasal Septal Deviation

Nasal septal deviation (NSD) is a common structural finding and indication for septoplasty [1, 2]. While NSD is typically managed for symptomatic nasal obstruction, its contribution to upper airway disease remains uncertain. Computational modeling has demonstrated altered airflow near the osteomeatal complex in septal deviation, suggesting impaired mucociliary clearance and sinus ventilation [3]. However, the correlation between NSD and downstream disease such as chronic rhinosinusitis (CRS) is inconsistent. While one review concluded that septal deviation could not be definitively established as a pathogenic factor in CRS development [4], subsequent radiographic and anatomic studies have demonstrated associations between NSD and CRS distribution or recurrence [5-7]. If NSD contributes to upper airway disease development, surgical correction may influence long-term outcomes. However, existing septoplasty literature has primarily focused on symptomatic improvement in patients with established disease, such as improved quality of life in allergic rhinitis (AR) patients and CPAP tolerance in obstructive sleep apnea (OSA) patients [8-12]. Importantly, these studies evaluated symptom response in patients with established disease rather than disease development. Given the healthcare burden associated with upper airway disease [13, 14], the association of septoplasty with long-term disease incidence and healthcare utilization warrants investigation. We sought to evaluate longitudinal airway diagnoses and healthcare utilization following septoplasty compared with nonsurgical management, hypothesizing that septoplasty is associated with lower disease incidence and healthcare utilization. In this retrospective cohort study, adults ≥ 18 years with NSD recorded over a 20-year period were identified in the TriNetX Global Collaborative Network, a federated database of de-identified electronic health records from 170 healthcare organizations globally. Patients undergoing septoplasty comprised the exposure cohort and were indexed at the date of first surgery. Nonoperative NSD controls were indexed at first NSD diagnosis. Patients with prior sinonasal surgery, cystic fibrosis, immunodeficiency, sinonasal malignancy, or pre-existing CRS, AR, or OSA prior to index were excluded. To isolate the effect of septoplasty for NSD, patients undergoing concurrent sinonasal procedures (e.g., endoscopic sinus surgery) at index were excluded. Propensity score matching (1:1) was performed on age, sex, race, ethnicity, asthma, and smoking. Outcome-naive analyses assessed incidence of CRS, CRS with nasal polyps (CRSwNP), AR, and OSA at 1-, 3-, and 5-year intervals. Secondary outcomes included acute sinusitis episodes, medication utilization, and emergency department (ED) or inpatient encounters. Within-cohort analysis of the septoplasty group compared secondary outcome prevalence 1 year pre- and post-operatively. Categorical outcomes were compared using risk ratios (RR) with 95% confidence intervals (CI), while count outcomes were compared using two-sample t-testing. All tests were two-sided, with α ≤ 0.05 considered statistically significant. The use of de-identified data qualified for exemption from IRB review. After matching, 65,802 patients remained in each cohort. Incidence of upper airway diagnoses was lower for the septoplasty cohort across all time points, with lower risks of CRS (RR 0.730, 95% CI 0.677–0.748), CRSwNP (RR 0.532, 95% CI 0.476–0.594), AR (RR 0.885, 95% CI 0.851–0.921), and OSA (RR 0.903, 95% CI 0.863–0.946) at 5 years. Acute sinusitis episodes were lower in the surgical group at 3 years (1.692 vs. 1.777, p = 0.009) and 5 years (1.843 vs. 1.950, p < 0.001). Within the septoplasty cohort, acute sinusitis prevalence decreased from 7.0% preoperatively to 4.4% postoperatively (p < 0.001). Antibiotics, decongestants, and allergy medications increased postoperatively despite a decrease in acute sinusitis prevalence (Table 1). However, this pattern varied across medication classes, with similar heterogeneity observed between operative and nonoperative cohorts. Emergency department or inpatient visits were lower for septoplasty patients across all follow-up intervals (p < 0.001), but did not differ significantly upon within-cohort comparisons. Prior literature has largely focused on symptomatic improvement in patients with established disease, consistently demonstrating improved subjective metrics following septoplasty [8-12]. By incorporating outcome-naive patients and a matched nonsurgical comparator, the present analysis examined differences in diagnostic and utilization patterns rather than symptom response alone. These findings do not establish a causal role of septoplasty in preventing airway disease, but rather suggest that patients undergoing septoplasty demonstrate distinct longitudinal patterns of diagnosis and healthcare utilization compared to patients managed nonoperatively. Several limitations warrant consideration, including reliance on administrative coding, absence of anatomic and symptom severity, and potential systematic differences related to residual confounding following propensity matching. Indications for surgical procedures and healthcare utilization could not be directly ascertained. Disease incidence may also reflect differences in care-seeking behaviors or diagnostic intensity. Therefore, differences may reflect selection effects rather than direct disease modification. However, these findings underscore how structural correction of NSD may be associated with longitudinal differences in airway disease development and healthcare utilization on the basis of surgical selection. Prospective studies are necessary to clarify whether septoplasty directly alters disease trajectory or reflects underlying patient selection. Septoplasty in adults with NSD was associated with decreased airway disease incidence and reduced healthcare utilization over 5 years. Prospective evaluation is needed to clarify whether these associations reflect disease modification or surgical selection. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from TrinetX. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of TrinetX.