An Evaluation of the Caudal End Deviation of the Nasal Septum Using the Quantitative Analysis of Computed Tomography
Round 1
Reviewer 1 Report
This is very interesting manuscript, and I think it would be of the grrat interests to readers.
But, I have some doubts. Please, include the power analysis.
It is not clear how the authors choose this sample size.
I detect only minor English style mistakes.
It would be great that the authors send the manuscript to final check to the professionals
Author Response
Of the 117 patients who underwent caudal end reconstruction, VAS was compared between pre-operatively and 3-months postoperatively in 97 cases, and N/W ratio was compared between them in 64 patients (those who agreed to undergo a sinus CT scan postoperatively).Reviewer 2 Report
The introduction is too long. It can be made concise while conveying the key information. Remove unnecessary details and be more focused.
The methods section needs more details. Elaborate on how exactly the CT analysis was done, how the ratios were calculated. Explain the surgical procedures in more depth. Mention the tools and techniques used.
The number of patients, 300, seems less for the study duration of 3 years. Mention why only 64 patients were included for subjective and objective evaluation. Provide more details on patient selection and follow up.
Chi-square test may not be the most appropriate statistical test here. Mention why it was chosen and its limitations. Discuss the results of the statistical analysis in depth.
The discussion section is missing. Analyze your results, compare with other similar studies. Discuss limitations and future directions. Provide a conclusion highlighting key findings and their implications.
The language needs improvement for better readability. Use shorter sentences, transition words and headings. Remove repetition and reword where needed.
Figures need to be inserted consecutively according to their mention in text. Figure legends need to be made more descriptive for the reader to understand them without referring to the main text.
References are not formatted properly. Cross check and edit according to the journal style. Remove references not being cited. Add more recent relevant references.
The abstract needs to structured with headings for objectives, methods, results and conclusions. Make it concise by including key details about study design, main outcomes and key conclusions.
The flow chart in Fig. 5 is confusing. Make it simpler with clear legends to depict patient selection and categorization. Clearly define the groups L(+) and L(-) for the reader.
Mention how CT analysis and ratio calculation were done for the cases. Explain what N/W ratio refers to and the cut off of 0.8, 0.6 in more depth.
Discuss why only 117 out of 130 cases recognized caudal end deviation intraoperatively. Mention why different surgical techniques were used for different cases.
The chi-square test result is mentioned but not interpreted. Discuss the result in terms of whether there is an association between AR findings and N/W ratio. Mention strengths and limitations of the statistical analysis.
Fig. 6 needs to be made simple with clear legends. Mention what the x and y axes represent, use larger font. Explain in text what the figure depicts and discuss the results shown in it.
-The results seem to be a mix of subjective and objective findings. Separate them under different subheadings for better organization and understanding. Discuss each result set separately.
- Compare your results with findings from other similar studies. Discuss how your results support or contradict them. Analyze possible reasons for differences.
- Nasal septal deviation can lead to rhinogenic cephalea by obstructing nasal airflow and drainage. Septoplasty to correct the deviated septum helps relieve this type of headache by re-establishing nasal patency. Patients with persistent rhinogenic cephalea may require more extensive sinus surgery to address associated chronic sinonasal disease, please discuss and cite doi:10.1007/s00405-021-06724-6
Discuss limitations of your results in depth. Mention issues of small sample size, short follow up, inter-observer variability, choice of statistical test, etc. Suggest ways to improve upon these limitations.
Turbinate surgery is a procedure aimed at reducing the size of the nasal turbinates, bony structures lined with soft tissue that can cause airway obstruction if enlarged. Headaches, or cephalgia, can be associated with nasal issues such as a deviated nasal septum and enlarged turbinates, which can affect the ventilation and drainage of the paranasal sinuses. Septoplasty is a surgical procedure that corrects the deviation of the nasal septum, improving respiratory function and potentially reducing the frequency of headaches associated with nasal issues, and increasing nasal volume to facilitate airflow., please discuss and cite doi: 10.23812/19-522-L-4
Highlight most significant findings and their implications in a concluding paragraph. Restate the importance of objective tools for diagnosis and their role in optimizing surgical outcomes.
Minor editing of English language required.
Author Response
The introduction is too long. It can be made concise while conveying the key information. Remove unnecessary details and be more focused.
: The introduction was shortened by removing unnecessary details.
The methods section needs more details. Elaborate on how exactly the CT analysis was done, how the ratios were calculated. Explain the surgical procedures in more depth. Mention the tools and techniques used.
: We described how exactly the CT analysis was done, how the ratios were calculated, and explain the surgical procedures in more depth and mentioned the tools and techniques used.
The number of patients, 300, seems less for the study duration of 3 years. Mention why only 64 patients were included for subjective and objective evaluation. Provide more details on patient selection and follow up.
：Of the 117 patients who underwent caudal end reconstruction, VAS was compared between pre-operatively and 3-months postoperatively in 97 cases, and N/W ratio was compared between them in 64 patients (those who agreed to undergo a sinus CT scan postoperatively). More details on patient selection and follow up was provided.
Chi-square test may not be the most appropriate statistical test here. Mention why it was chosen and its limitations. Discuss the results of the statistical analysis in depth.
: Fisher’s exact test was performed instead of Chi-square test. We discussed the results of the statistical analysis in depth.
The discussion section is missing. Analyze your results, compare with other similar studies. Discuss limitations and future directions. Provide a conclusion highlighting key findings and their implications.
: We mentioned discussion section. We analyzed our results, compare with other similar studies, discussed limitations and future directions, and provide a conclusion highlighting key findings and their implications.
The language needs improvement for better readability. Use shorter sentences, transition words and headings. Remove repetition and reword where needed.
: We used shorter sentences, transition words and headings and removed repetition and reword where needed.
Figures need to be inserted consecutively according to their mention in text. Figure legends need to be made more descriptive for the reader to understand them without referring to the main text.
: We inserted figures according to their mention in text. Figure legends were made more descriptive.
References are not formatted properly. Cross check and edit according to the journal style. Remove references not being cited. Add more recent relevant references.
: We formatted references properly cross checked and edited according to the journal style, remove references not being cited, and added more recent relevant references.
The abstract needs to structure with headings for objectives, methods, results and conclusions. Make it concise by including key details about study design, main outcomes and key conclusions.
: We structured the abstract with headings for objectives, methods, results and conclusions, and concised by including key details about study design, main outcomes and key conclusions.
The flow chart in Fig. 5 is confusing. Make it simpler with clear legends to depict patient selection and categorization. Clearly define the groups L(+) and L(-) for the reader.
: We changed the contents of Fig. 5 (Fig.6) and explained the groups L(+) and L(-) in figure leｇends.
Mention how CT analysis and ratio calculation were done for the cases. Explain what N/W ratio refers to and the cut off of 0.8, 0.6 in more depth.
: We mentioned how CT analysis and ratio calculation were done for the cases and explain ed what N/W ratio refers to and the cut off of 0.8 in more depth. The setting of 0.6 as the cutoff value has been removed.
Discuss why only 117 out of 130 cases recognized caudal end deviation intraoperatively. Mention why different surgical techniques were used for different cases.
: We discuss the reason why 13 out of 130 cases were not recognized caudal end deviation intraoperatively.
The chi-square test result is mentioned but not interpreted. Discuss the result in terms of whether there is an association between AR findings and N/W ratio. Mention strengths and limitations of the statistical analysis.
: Fisher’s exact test was performed with B instead of A Chi-square test. We discussed the result in terms of whether there is an association between AR findings and N/W ratio and mentioned strengths and limitations of the statistical analysis.
Fig. 6 needs to be made simple with clear legends. Mention what the x and y axes represent, use larger font. Explain in text what the figure depicts and discuss the results shown in it.
: We removed Fig.6.
The results seem to be a mix of subjective and objective findings. Separate them under different subheadings for better organization and understanding. Discuss each result set separately.
: We separated subjective and objective findings under different subheadings and discussed each result set separately.
Compare your results with findings from other similar studies. Discuss how your results support or contradict them. Analyze possible reasons for differences.
: We compared our results with findings from other similar studies and discussed how our results support or contradict them and analyzed possible reasons for differences.
Nasal septal deviation can lead to rhinogenic cephalea by obstructing nasal airflow and drainage. Septoplasty to correct the deviated septum helps relieve this type of headache by re-establishing nasal patency. Patients with persistent rhinogenic cephalea may require more extensive sinus surgery to address associated chronic sinonasal disease, please discuss and cite doi:10.1007/s00405-021-06724-6
: We cited doi:10.1007/s00405-021-06724-6 and discussed the above content in introduction section.
Discuss limitations of your results in depth. Mention issues of small sample size, short follow up, inter-observer variability, choice of statistical test, etc. Suggest ways to improve upon these limitations.
: We discuss limitations of our results in depth and mentioned issues of small sample size, short follow up, inter-observer variability.
Turbinate surgery is a procedure aimed at reducing the size of the nasal turbinates, bony structures lined with soft tissue that can cause airway obstruction if enlarged. Headaches, or cephalgia, can be associated with nasal issues such as a deviated nasal septum and enlarged turbinates, which can affect the ventilation and drainage of the paranasal sinuses. Septoplasty is a surgical procedure that corrects the deviation of the nasal septum, improving respiratory function and potentially reducing the frequency of headaches associated with nasal issues, and increasing nasal volume to facilitate airflow., please discuss and cite doi: 10.23812/19-522-L-4
: We cited doi: 10.23812/19-522-L-4 and discussed the above contens.
Highlight most significant findings and their implications in a concluding paragraph. Restate the importance of objective tools for diagnosis and their role in optimizing surgical outcomes.
: We highlightend most significant findings and their implications in a concluding paragraph and reestated the importance of objective tools for diagnosis and their role in optimizing surgical outcomes.
Reviewer 3 Report
Dear authors
Thank you for the opportunity to get acquainted with your interesting work.
The work requires corrections:
The introduction should include information that nasal septum deviation does not only affect adults but also children. Deviation of the septum of the nose causes ailments that reduce the quality of life, which should also be included and supported by literature, e.g
DOI: 10.3390/children9111714 .
The authors should supplement it in the material methodology with clear inclusion and exclusion criteria in the study and control group.
The degree and type of nasal septum deviation should be assessed using the appropriate classification, e.g. Mladina doi: 10.5152/balkanmedj.2015.159957.
The assessment of nasal septum deviation in computed tomography should be performed in three planes [sagittal, frontal and horizontal], and not, as shown in the paper, only in two.
Include limitations of the work in the discussion.
In the conclusions, attach practical conclusions resulting from the work
There are many spelling and language mistakes and the manuscript needs to be corrected by a native English speaker.
Author Response
The introduction should include information that nasal septum deviation does not only affect adults but also children. Deviation of the septum of the nose causes ailments that reduce the quality of life, which should also be included and supported by literature, e.g
DOI: 10.3390/children9111714 .
: We cited DOI: 10.3390/children9111714 and discussed the above contents.
The authors should supplement it in the material methodology with clear inclusion and exclusion criteria in the study and control group.
：We supplemented it in the material methodology with clear inclusion and exclusion criteria in the study and control group.
The degree and type of nasal septum deviation should be assessed using the appropriate classification, e.g. Mladina doi: 10.5152/balkanmedj.2015.159957.
The assessment of nasal septum deviation in computed tomography should be performed in three planes [sagittal, frontal and horizontal], and not, as shown in the paper, only in two.
Include limitations of the work in the discussion.
: We cited doi: 10.5152/balkanmedj.2015.159957 and discussed the above the contents.
In the conclusions, attach practical conclusions resulting from the work
: We attached practical conclusions resulting from the work in the conclusions.
Reviewer 4 Report
The study has tried to objectively define surgical indications for caudal end septoplasty for nasal septum. There is need to address this issue and authors need to be complimented for filling this gap in knowledge.
Fig 3 is taken from the article by Nigro et al. Although authors have acknowledged it but permission may be obtained to publish it.
I have no other suggestions to improve it.
Author Response
The Fig 3 has been changed to own version.
Round 2
Reviewer 3 Report
Thanks to the authors for posting changes to the work. Unfortunately, the article still raises doubts and needs to be changed.
In the literature, it is reported that about 40% of people have nasal septum deviation, which takes various forms (they are described in the available classifications of nasal septum deviation). Of course, we operate on people with clinical symptoms of nasal septum deviation.
My questions and suggested changes are:
Were the criteria for exclusion of patients from the study group patients with allergies and asthma, patients with acute sinusitis, chronic sinusitis without polyps?
Computed tomography is an additional examination, so it may be helpful in making a therapeutic decision.
Unfortunately, in the version of the manuscript sent to me, I did not find "We cited doi: 10.5152/balkanmedj.2015.159957 and discussed the above content".
The study group should be divided according to one of the better clinical divisions of nasal septum deviations according to Mladina doi: 10.5152/balkanmedj.2015.159957.
Does the presented test method apply to only one type of nasal septal deviation or to others?
The dominance of men (74%) in the study group is puzzling
Have patients after nasal septum surgery had a computed tomography done, if they had symptoms - ailments related to the nose. If they had a CT scan with no clinical signs, then why were these people exposed to X-rays without a medical indication?
as previously
Author Response
Were the criteria for exclusion of patients from the study group patients with allergies and asthma, patients with acute sinusitis, chronic sinusitis without polyps?
: The criteria of in this study, patients with allergies and asthma, patients with acute sinusitis, chronic sinusitis without polyps were also included. This is because they thought that it would not affect the consideration of the N/W ratio. On the other hand, in cases underwent endoscopic sinus surgery (ESS) at the same time as septoplasty, when evaluating the nasal obstruction improving effect using VAS scale, it was necessary to consider the influence of ESS. Therefore, such cases were excluded from the examination of the change of nasal obstruction using VAS scale.
The study group should be divided according to one of the better clinical divisions of nasal septum deviations according to Mladina doi: 10.5152/balkanmedj.2015.159957.Does the presented test method apply to only one type of nasal septal deviation or to others?
：In this report, the cases judged as “L (+)” include the cases of Type 1, Type 2, Type 4, Type 6 and Type 7. We mentioned the details of Mladina’s classification in the section of discussion.
The dominance of men (74%) in the study group is puzzling.
At our facility, the proportion of cases undergoing septoplasty tends to be higher in men. Specifically, between April 2020 and July 2023,424 cases underwent septoplasty, of which 309 (72.9%) were men. Of those 424 cases, 183 cases underwent correcting the deviation of the caudal end. Furthermore, of those 183 cases, 157 (85.6%) were men.　Some researchers have similarly reported that there are more men in the population who underwent septoplasty, e.g., Choi reported that the proportion of men was 85.2%, Karamese ; 71.3%, Celiker; 70.4%, Velasco; 58.3%, Law; 57.1% ,Dizdar;57.0%, Shah; 56.9 %, and Serifoglu; 54.7%. In particular, the high proportion of men in cases underwent correcting caudal end deviation may related to the data that Mladina et al. suggest that Type 2 and Type 6, which are closely related to caudal end deviation, are more common in men.
Have patients after nasal septum surgery had a computed tomography done, if they had symptoms - ailments related to the nose. If they had a CT scan with no clinical signs, then why were these people exposed to X-rays without a medical indication?
: We asked patients whether they wish to have an objective assessment of their nasal septum correction by CT scan (we also explained that they will be exposed to X-rays), and we performed CT scans only for cases where they wished. We did not conduct examinations unilaterally without confirming the intentions of X-rays exposure. As a result, 64 out of 117 cases requested and were examined.
References
Choi et al. The Potential Esthetic Effect of Endonasal septoplasty on the cartilaginous dorsum in asian population. Facial Plast Surg Aesthet Med. 2021 Jan-Feb;23(1):42-48. doi: 10.1089/fpsam.2020.0039. Epub 2020 Jun 4.
Karamese et al. Our septoplasty results: Evaluation with the nose scale. J Craniofac Surg. 2022: 33:1775-1781. doi: 10.1097/SCS.0000000000008361. Epub 2021 Nov 5.
Celiker et al. Effect of septoplasty on the heart rate variability in patients with nasal septum deviation. J Craniofac Surg. 2018 Mar;29(2):445-448. doi: 10.1097/SCS.0000000000004149.
Velasco L et al.Assessment of symptom improvement following nasal septoplasty with or without turbinectomy. Braz J Otorhinolaryngol. 2011;77:577-83.
Law R et al. Predictors of long-term nasal obstruction symptom evaluation score stability following septoplasty with inferior turbinate reduction. Laryngoscope. 2021 131:E2105-E2110. doi: 10.1002/lary.29229. Epub 2020 Nov 3.
Dizdar et al. Evaluation of nasal symptoms in septoplasty patients using SNOT-22. ACTA Otorhinolaryngologica DOI: 10.14639/0392-100X-2061
Shah J et al.Septoplasty revision rates in pediatric vs adult populations. JAMA Otolaryngol Head Neck Surg. 202;148:1044-1050. doi: 10.1001/jamaoto.2022.3041.
Serifoglu et al. Relationship between the degree and direction of nasal septum deviation and nasal bone morphology. Head Face Med. 2017;13:3. doi: 10.1186/s13005-017-0136-2.
Author Response File: 
Author Response.docx
