My Surgical Results

I see and treat Patients with the whole range of ENT conditions, but functional and cosmetic surgery to the nose and sinuses forms 90% of my surgical workload in both my Private and NHS Practice.

The vast majority of these operations are for conditions that are not life-threatening, but significantly affect Patient’s quality of life and self-esteem.

Unlike my Surgical colleagues who operate on Patients who DO have life –threatening issues I thankfully am therefore unable to measure the results of my Surgery in terms of ‘survival rates’ or ‘disease free interval’.

It is, however, very important to measure and audit the results of any surgical treatment, and this is a process I completely endorse and wholeheartedly embrace.

In the NHS, where resources are so limited, the effectiveness and suitability of particular treatments are monitored very closely for their value for money before GP Clinical Commissioning Groups (CCGs) will agree to fund these treatments for their Patients.

Measuring the effect of nose and sinus surgery lends itself nicely to validated questionnaires which have been designed and tested to take into account the measurement of all the symptoms that Patients find most troublesome prior to undertaking such surgery.

These are termed “Patient Related Outcome Measures’ (or PROMs for short.)

I use 3 of these PROMs for measuring the results of my surgery to the nose and sinuses by measuring the total score before and then 3 months after surgery.

The advantage of using these standard questionnaires is that one receives consistent and relevant information, which one can compare both with one’s own previous figures, and with one’s Surgical peers both in the UK and around the World.

– For surgery to the sinuses (Functional Endoscopic Sinus Surgery or F.E.S.S), I use the Sino-Nasal Outcome Test 22 (SNOT-22) which asks Patients to rate the severity of 22 highly relevant nasal and general quality of life symptoms.

– For Functional and Cosmetic Rhinoplasty, I use both the Sino-Nasal Outcome Test 23 (SNOT-23) and the Rhinoplasty Outcome Evaluation (ROE).

The SNOT-23 is identical to the SNOT-22, with the addition of a single extra question referring to how much the patient likes the shape of their nose.

The most important aspect of these measurements is thus the CHANGE in score from before to after the surgery. It has previously been shown that for a Patient to notice an improvement after surgery the SNOT-22 score has to improve by on average 8.9 points after the FESS surgery. This is termed the Mean Clinical Improvement Difference (or MCID), and the percentage of patients that achieve this improvement in their SNOT-22 score is something I have also measured for my Patients undergoing FESS.

For both SNOT-22 and SNOT-23, a high score indicates worse symptoms, so what you like to see is a significant REDUCTION in score after sinus or Rhinoplasty surgery respectively.

The ROE is a percentage satisfaction score, so what one likes to see is a relatively low satisfaction score before Rhinoplasty, which INCREASES significantly after surgery.

Measuring the score prior to surgery is also important to decide whether surgery is likely to be worthwhile – patients with a relatively low SNOT-22 score prior to surgery are unlikely to benefit, as they have less margin to improve!

The questionnaires I use are attached at the bottom of this document for your interest. Try filling it in, as if you sinus problems and have a high SNOT-22 score, or have issues with the breathing or shape of your nose and a high SNOT-23 and/or low ROE score, you may benefit from coming to talk to me about it!

Below are my personal results of the nose and sinus surgery that I have performed over the past 2 years.

For the patient group undergoing FESS, I have reported the results for all my Patients, and then secondly sub-divided them into Patients WITH and those WITHOUT nasal polyps.

Patients with nasal polyps often have worse and more debilitating symptoms prior to surgery, but (as the results show) often have even better relief from their symptoms after surgery, so if you do have nasal polyps do not despair!

Group	Average pre-op SNOT 22 score	Average SNOT 22 score 3 months post op	Improvement in SNOT 22 Score (% improvement)
*All Patients*	*52.85*	*15.12*	*37.23* *(71%)*

Patients with polyps	53.1	14.5	38.6 (73%)
Patients without polyps	52.1	16.2	35.9 (69%)

As you can see, there is on average a 70% improvement in Patient symptoms according to the SNOT-22 score in my Patient group over the 3 month period after surgery.

In 2015, an eminent group of Nasal and Sinus Surgeons in London analysed the SNOT-22 results obtained from a group of 2263 patients from 87 UK Hospitals undergoing FESS in exactly the same way as I have done (reference 1.)

I have compared my own improvement results to this National UK survey below, as well as comparing my own figures for the percentage of Patients that have achieved an improvement in their SNOT-22 score after surgery of more than the MCID.

	*My Series*	UK Series (ref 1)
% improvement in SNOT 22	71 %	40%
% Patients achieving MCID	88.3%	66%

For the patient group undergoing Rhinoplasty or Septo-Rhinoplasty, I have measured both the SNOT-23 and ROE scores after surgery.

Average SNOT-23 score prior to Rhinoplasty

Average SNOT-23 score 3 months after Rhinoplasty

(% improvement)

13 (65%)

It is interesting to note that as one would expect, Patients undergoing Rhinoplasty have less severe general nasal and quality of life symptoms before their operation than those undergoing sinus surgery (as measured by the almost identical SNOT-22 questionnaire), but the degree of improvement after surgery is almost the same at 65%.

By way of comparison with other Surgeons, I can only compare my Patient series ROE scores to another single UK reported series of Patients (reference 2) as comparable numerical results of Rhinoplasty such as SNOT-23 have rarely been published as things stand at present.

The series I have compared my own ROE results to is, however, a combined series of 141 Patients from several very reputable UK ENT Departments. These Patients had an average follow up period of 36 months (as opposed to 3 months for my series), but gives a reasonable estimation of comparability. They did not, however, quote the pre-operative ROE scores for comparison with my Patients as I have done below.

The Surgeons in the other series have also sensibly added 2 questions to the end of the ROE questionnaire, asking 1) ‘Overall, are you happy with the procedure outcome’ and 2) ‘Knowing what you do now, would you undergo the procedure again’, which I have copied, and these results are also shown below.

	*My Series*	UK Series (ref 2)
Happy with procedure overall?	Yes – 96%	Yes – 75%
Would you undergo procedure again?	Yes – 92%	Yes – 83%
Average pre-op ROE Score	32%
Average post-op ROE Score	79.15 (47% improvement)	73.3%

It is gratifying to see that my results compare very favourably with comparative series in the UK from centres of excellence in this type of surgery.

In demonstrating this, I hope I can offer you the benefit of my ongoing interest and focus on functional and cosmetic nasal surgery.

Auditing my results is an ongoing process, and I will continue to update this section of my website to keep it entirely up to date as time passes.

References

1. The predictive value of the preoperative Sinonasal Outcome Test-22 score in Patients undergoing Endoscopic Sinus Surgery for Chronic Rhinosinusitis.

Hopkins C, Rudmik L and Lund V.J

Laryngoscope 2015 (125), 1779-1784

2. Patient reported outcome measures in Septorhinoplasty surgery.

Biggs T.C, Fraser L.R, Ward M.J, Sankaraneni V.S, Harries P.G and Salib R.J

Ann R Coll Surg Eng 2015 (97) 63-65.

Downloads

SNOT 22

SNOT 23

ROE PREOP

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