A comprehensive study on haematological and platelet related changes following septoplasty

INTRODUCTION

Septoplasty is an elective surgical procedure indicated for the improvement of anatomic nasal airway obstruction. It usually involves a judicious excision/realignment of a portion of the bone and/or cartilage in the nasal cavity.¹ It is one of the most commonly performed surgeries with an estimated 260,000 septoplasties performed per year. The nasal obstruction symptom evaluation (NOSE) scale is composed of five questions concerning the severity of nasal obstruction.² It is a reliable and valid tool to identify restrictions of quality of life in patients with nasal problems. Nasal obstruction is a common presenting symptom in our day to day practice. Nasal deformity (septal deviation), turbinate hypertrophy, adenoid hypertrophy, nasal polyposis, are the few causes of nasal obstruction and nasal septal deviation (NSD) is the most common etiology.³ 80% of the general population is estimated to have some type of nasal deformity. Marked NSD causes chronic upper airway obstruction (UAO). UAO causes alveolar hypoventilation leading to chronic hypoxia and hypercarbia.⁴ Chronic hypoxia and hypercarbia show a tendency for hypercoagulopathy. hypoxia leads to chronic inflammation, oxidative stress, and endothelial dysfunction.⁵ Platelets have an important role in endothelium damage repair and regulating hemostasis. Platelets produce pro-inflammatory mediators such as cytokines and chemokines during vascular inflammation.⁶ Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are new markers for inflammation. PLR, NLR, and platelet distribution width (PDW) values are inflammatory markers that can detect platelet activation and inflammation.⁷ Similarly hypoxia causes certain changes in the RBCs and WBCs by altering cellular metabolism leading to an increase in the production of erythrocytes and leucocytes. An acute decrease in plasma volume is observed in hypoxic situations causing a rapid increase in hemoglobin concentration.⁸

METHODS

The study was conducted between January 2019 – June 2020 on 50 patients attending ENT OPD in Vinayaka Mission’s Kirupanandha Variyar Medical College and Hospital, Salem. 50 patients fulfilling inclusion/ exclusion criteria who give Informed Consent were included in the study.

Inclusion criteria

Inclusion criteria were subjects who are symptomatic case of deviated nasal septum, subjects who are undergoing septoplasty and able to comply with study procedures.

Exclusion criteria

Exclusion criteria were subjects with a previous history of any blood and platelet related disorders, subjects with nasal polyposis, chronic rhinosinusitis, and adenoid hypertrophy.

An evaluation was performed to assess the septal deformity either anterior, posterior, or septal spur. Also, to detect if there is a contact point between the nasal septum and the lateral nasal wall as well as endoscopy was done to exclude any other sinonasal pathology. CT scan paranasal sinuses was done for every patient preoperatively to confirm findings of clinical examinations and also to exclude any hidden sinonasal pathology. Requisite blood investigations were then done and patient was treated surgically with septoplasty. Patient was followed up regularly and requisite blood investigations done 60 days after surgery. Blood investigations were studied and compared. Patient was also assessed improvement with respect to NOSE scoring.

Statistical analysis

The data are reported as the mean±SD or the median, depending on their distribution. The differences in quantitative variables between groups were assessed using the unpaired T test. A comparison between groups was made by the nonparametric mann-whitney test. The chi-square test was used to assess differences in categoric variables between groups. A p value<0.05 using a two-tailed test was taken as being of significance for all statistical tests. All data were analyzed with a statistical software package. (SPSS, version 16.0 for windows).

RESULTS

In this study, 2 patients were among the age group 11-20 years, 22 patients were among the age group 21-30 years, 18 patients were among the age group 31-40 years and 8 patients were among the age group 41-50 years. In the present study, 28 patients were male and 22 patients were female (Table 1).

Here, in (Table 2) neutrophil counts in DLC of patients before surgery was found to be 54% and 62% after surgery. MPV, before surgery, was found to be around 9.75 fL and around 8.45 fL after surgery. The average MCH values of patients before surgery was 31.9 pg and after surgery was 29 pg. Before surgery, average PLR values were 124.38 and 131.07 after the procedure. NLR was found to be around 1.53 before surgery and 1.68 after surgery. According to the analysis, MPV, PLR, and NLR parameters before and after surgery were found to be statistically significant. The parameters with no significant differences were found in RBC, WBC, Platelet count, ESR, Hb, Htc, MCV, MCHC, and PDW values.

There was a statistically significant improvement in nasal symptoms, 60 days after surgery according to NOSE scoring (Figure 1).

DISCUSSION

Nasal obstruction is one of the most common symptoms in nasal septal deviation. Due to nasal obstruction, patients are exposed to intermittent hypoxia leading to an alteration in platelet function. MPV is the marker for platelet reactivation potential. PDW, PLR, and NLR are the inflammatory markers that can show platelet activation and inflammation.⁹ Prolonged nasal obstruction period may also increase the risk of cardiopulmonary complications. In our present study, the patients with deviated nasal septum causing upper airway obstruction (UAO) are subjected to blood investigations which shows significant changes before and 60 days after surgery.¹⁰ A resultant compromise in quality of life due to interfering with social and business activities can occur in Chronic nasal obstruction. It is well known that long-lasting hypoxia can affect coagulation and platelet function.¹¹ In this study, we investigated the hematological changes before and after septoplasty in patients with nasal septal deviation.¹² In a study conducted by Maran AG et al patients with NSD and healthy subjects were compared in terms of MPV and it was found to be statistically significantly higher compared with healthy subjects.¹³ Our present study before surgery, the average MPV value was 9.75 fL and after surgery it was 8.45 fL.¹⁴ In a study conducted by Nayak DR et al pre- and post-operative 3rd month mean Hb levels were analyzed and no statistically significant difference was found (p =0 .68).¹⁵ Hb values in our study were 14.8 gm/dL and 14.5 gm/dL respectively. In a study conducted by Gupta N et al PLR and NLR parameters between the patients and control groups were found to be statistically significant (p=0.039, p=0.017). Average PLR values in our study were 124.38 before and 131.07 after surgery and average NLR values were 1.53 before and 1.68 after surgery respectively. This decrease in MPV increase in PLR and NLR values after surgically correcting the deviated nasal septum shows that these hematological parameters and the general condition of the patients are improved after septoplasty.¹⁶ Further, the NOSE scale is a valid and specific tool in the evaluation of the quality of life of patients with nasal obstruction before and after septal surgery.¹⁷ In this present study, there was a statistically significant improvement in symptoms of nasal obstruction 60 days after septoplasty.

CONCLUSION

Chronic nasal obstruction caused by NSD causes significant changes not only in the quality of life but also in several blood and platelet related profiles. MPV is an important marker and determinant of platelet function. Also, PLR and NLR are new markers for inflammation. Septoplasty is the treatment option of choice for symptomatic NSD patients. In our study, MPV value is decreased, and PLR and NLR values are increased significantly after septoplasty. Also, the decrease in NOSE score after surgery is the confirmatory parameter proving that septoplasty not only improves the quality of life but also significantly corrects the altered blood and platelet related parameters in NSD patients.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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