Is a systematic review comparing conventional extracorporeal septoplasty with modified extracorporeal septoplasty (L-strut-preserving or L-strut-reconstruction) in terms of functional and structural outcomes necessary and would it address a gap in the literature?

Comparing Conventional vs Modified Extracorporeal Septoplasty: A Systematic Review of Functional and Structural Outcomes

A systematic review comparing conventional extracorporeal septoplasty with modified extracorporeal septoplasty (L-strut-preserving or L-strut-reconstruction) would address a significant gap in the literature, as there is currently no comprehensive analysis comparing these techniques with standardized outcome measures.

Background on Septoplasty Approaches

• The nasal septum is off-center in approximately 80% of the general population, but only about 26% have clinically significant deviation causing symptoms 1, 2
• Conventional septoplasty reshapes, repositions, or recontours the cartilage with up to 77% of patients achieving subjective improvement, but may be inadequate for severe deviations 1, 2
• Extracorporeal septoplasty (ECS) involves complete removal of the septal cartilage, external reconstruction, and reimplantation, which is useful for severe deviations but carries higher risks 1, 2
• Modified ECS techniques preserve part of the L-strut (typically 0.5 cm in height) to maintain structural support while addressing severe deviations 3, 4

Current Evidence Gap

• While individual studies on conventional and modified ECS exist, there is significant heterogeneity in outcome measures and reporting of complications 4
• A 2019 systematic review found that less than half of the 31 studies on ECS were of good methodology, with high heterogeneity regarding outcome measures 4
• No systematic review has specifically compared conventional ECS with L-strut-preserving or L-strut-reconstruction techniques using standardized functional and structural outcomes 4

Importance of L-Strut Preservation

• Complete septal resection with extracorporeal correction may lead to a high percentage of aesthetic profile deformities even in experienced hands 1, 2
• L-strut preservation provides structural support without destabilizing the keystone area, potentially reducing complications 3
• Modified ECS with L-strut preservation has shown long-term functional effectiveness (4-6 years) for moderate to severe septal deviations 3

Functional Outcomes Worth Comparing

• Nasal Obstruction Symptom Evaluation (NOSE) scores have shown significant improvements after both conventional and modified ECS techniques 5, 4
• A meta-analysis of 5 studies reporting NOSE score changes after ECS showed a pooled effect of -60.0 points (95% CI, -67.8 to -52.2), but with high heterogeneity (I² = 96%) 4
• Objective measures like rhinomanometry have demonstrated significant improvements in inspiratory flow in patients with moderate to severe deviations after modified ECS 3

Structural Outcomes and Complications

• When comparing modified vs conventional ECS, the relative risk for nasal dorsal irregularities was 0.29 (95% CI, 0.16-0.53), suggesting fewer aesthetic complications with modified techniques 4
• Secure fixation of the reimplanted septum is critical for successful long-term aesthetic and functional outcomes following ECS 6
• Batten-type grafts from cartilage or bone are often used to reorient and straighten remaining dorsal and caudal septal struts in reconstruction 1, 2

Clinical Relevance

• The choice between conventional and modified ECS techniques should be based on the severity of septal deviation and the need for structural support 2, 3
• Modified ECS may offer advantages for patients with severe deviations who require both functional improvement and maintenance of structural support 3, 5
• A systematic review would help establish evidence-based guidelines for selecting the appropriate surgical approach based on patient-specific factors 4

Methodological Considerations for the Proposed Review

• The review should use standardized outcome measures including both objective (rhinomanometry) and subjective (NOSE scores) assessments 3, 5
• Long-term follow-up (minimum 1 year) should be included to assess durability of results 3
• Complication rates should be systematically reported, particularly focusing on structural issues like dorsal irregularities and need for revision surgery 4
• Quality assessment of included studies using tools like Cochrane risk of bias tool (RoB2) and Newcastle Ottawa Scale (NOS) would strengthen the review 7

Potential Pitfalls to Address

• High heterogeneity in surgical techniques and outcome measures may limit direct comparisons 4
• Many existing studies have moderate to high risk of bias, which should be acknowledged in the review 7
• The distinction between conventional and modified ECS techniques is not always clearly defined in the literature 4
• Patient selection criteria vary widely across studies, potentially confounding outcomes 4

A systematic review on this topic would provide valuable guidance for surgeons in selecting the most appropriate technique for patients with severe septal deviations, potentially improving both functional and aesthetic outcomes while minimizing complications.