Introduction
Nasal obstruction ranks among the most common symptoms reported in the general population, with nasal septal deviation (NSD) recognised as its predominant cause.Reference Alessandri-Bonetti, Costantino, Cottone, Carbonaro, Cardone and Amendola1 The prevalence of NSD in the general population has been reported to range widely between 26 and 97 per cent.Reference Alessandri-Bonetti, Costantino, Cottone, Carbonaro, Cardone and Amendola1, Reference Alghamdi, Albogami, Alsurayhi, Alshibely, Alkaabi and Alqurashi2 It has been demonstrated that nasal septal deviation may lead to obstructive sleep apnea, sleep disorders, chronic upper airway obstruction with consequent chronic alveolar hypoventilation, pulmonary hypertension and cor pulmonale.Reference Alghamdi, Albogami, Alsurayhi, Alshibely, Alkaabi and Alqurashi2–Reference Sahin, Ozmen and Yalcin5
Carotid intima–media thickness (IMT) measurement is used as a non-invasive marker of subclinical atherosclerosis.Reference Tschiderer, Seekircher, Izzo, Mancusi, Manzi and Baldassarre6, Reference Fernández-Alvarez, Linares Sánchez, López Alvarez, Suárez Nieto, Makitie and Olsen7 Carotid IMT has been identified as a powerful predictor of future vascular events and is significantly associated with cardiac and cerebrovascular diseases.Reference Tschiderer, Seekircher, Izzo, Mancusi, Manzi and Baldassarre6, Reference Lorenz, Markus, Bots, Rosvall and Sitzer8, Reference Liu, Du, Shao and Ma9 Carotid IMT can be assessed using a rapid, non-invasive and reproducible technique, with ultrasound measurements demonstrating strong concordance with histopathological validation.Reference Lorenz, Markus, Bots, Rosvall and Sitzer8–Reference Willeit, Tschiderer, Allara, Reuber, Seekircher and Gao10
The primary aim of this study was to investigate the relationship between subjective nasal obstruction symptoms and carotid IMT values in individuals scheduled for septoplasty, thereby exploring the potential vascular system effects of chronic nasal obstruction.
Materials and methods
This prospective study enrolled 60 patients scheduled for surgery due to NSD as a patient group. Ten participants did not complete the study for various reasons, and their data were excluded from the final analysis. Fifty healthy individuals without any complaints of nasal obstruction, matched with the patient group in terms of age, gender and body mass index (BMI), were enrolled as the control group. Ethical approval was obtained from the Ethics Committee of Selçuk University Hospital (Approval No: 2018/252). Written informed consent was obtained from all participants. The study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000347167).
Individuals with the following conditions were excluded from the study: smoking and alcohol use, diabetes mellitus, hypertension, hypercholesterolemia, cardiovascular disease, active infection, asthma, allergic rhinitis, history of cerebrovascular disease, chronic sinusitis, chronic obstructive pulmonary disease (COPD), immune-related disorders, age under 18 or over 65, current use of medications such as angiotensin-converting enzyme (ACE) inhibitors, diuretics, angiotensin II receptor blockers, beta-blockers, BMI > 35, hyperthyroidism, pregnancy, lactation and poor general health status.
The participants were evaluated using the Visual Analogue Scale (VAS; 0 = completely patent nose, 10 = completely obstructed nose) and the Turkish version of the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire.Reference Karahatay, Taşlı, Karakoç, Aydın and Türker11 All NOSE scores were converted to percentage values by multiplying the raw scores by five. Symptom duration was determined based on patient self-report during clinical evaluation, and the duration of nasal obstruction symptoms was recorded in years. Symptom duration ranged from 1 to 10 years. Electrocardiographic (ECG) assessment and ultrasonographic measurement of common carotid IMT were performed in all participants.
Common carotid IMT measurements
Carotid artery imaging protocol
An experienced cardiologist performed ultrasonographic evaluation of the carotid arteries. During the assessment of both common carotid arteries (CCAs), participants were instructed to slightly extend the neck and turn the head away from the side being examined. The carotid bifurcation was used as an anatomical landmark for imaging. In the longitudinal plane, two-dimensional, real-time gray-scale images were captured at frame rates of 20–50 frames per second, using optimised focus and gain settings to enhance the visibility of both the near and far arterial walls.Reference Efremov, Yang, Jacobs, Thijs, Kuznetsova and Struijker-Boudier12 In this study, a total of 200 images were analysed (100 participants, two arteries and one scanning plane) (Fig. 1).
Carotid intima–media thickness measurement.
Offline image analysis
According to the Mannheim consensus document, carotid IMT is defined as the tissue extending from the luminal edge of the artery to the boundary between the media and adventitia.Reference Touboul, Hennerici, Meairs, Adams, Amarenco and Bornstein13 For CCA–IMT measurements over two cardiac cycles, a vendor-customised software package with a semi-automated edge-detection technique was used (EchoPAC, version 113; GE Vingmed, Horten, Norway). Measurements were performed by selecting the region of interest during the cardiac cycle in which both interfaces were optimally visualised. At end-diastole, a rectangular box was positioned around the far wall of the carotid artery within a plaque-free segment, 5–10 mm proximal to the carotid bifurcation. This region corresponded to an approximately 10-mm carotid segment and contained more than 200 recorded points. The presence of atherosclerotic plaque was defined according to the Mannheim consensus report. Accordingly, a focal structure encroaching into the arterial lumen by at least 0.5 mm, or by 50 per cent of the surrounding IMT value, or demonstrating a thickness >1.5 mm when measured from the intima–lumen interface to the media–adventitia interface, was considered a plaque.Reference Efremov, Yang, Jacobs, Thijs, Kuznetsova and Struijker-Boudier12, Reference Touboul, Hennerici, Meairs, Adams, Amarenco and Bornstein13 Both scanning planes were examined to assess the presence of plaques in three carotid segments (proximal and distal CCA and the carotid bulb). Maximum plaque thickness was measured in millimeters within the frame that provided the best visualisation of the plaque.
Statistical analysis
All statistical analyses were performed with R Version 3.6.0 (www.r-project.org). Shapiro–Wilk normality test and Q-Q plots were used to check the normality of the data, and Levene’s test was used to examine the homogeneity of variance. Numerical variables were expressed as mean ± standard deviation and were compared with independent samples t test or Welch’s t test according to groups. Categorical variables were described as counts (n) and percentages (%) and compared with Yates continuity correction chi-squared test according to groups. Pearson and Spearman’s rho correlation analyses were used to determine the relationship among VAS, NOSE, time and right carotid IMT (RC-IMT) and left carotid IMT (LC-IMT). A p-value less than less than 0.05 was considered as statistically significant. Generalised linear model with normal distribution and identity link-function was used to assess the effect of nasal obstruction on carotid IMT. The results were reported as odds ratio (OR) with corresponding 95 per cent confidence interval (CI) and p-values. To assess the magnitude of between-group differences, Cohen’s d effect sizes were calculated.
Results
The control group consisted of 50 healthy participants, comprising 30 males (60 per cent) and 20 females (40 per cent), whereas the patient group consisted of 31 males (62 per cent) and 19 females (38 per cent). The average age was 30.20 ± 7.74 years (range: 19–50) in the control group and 30.44 ± 10.51 years (range: 18–60) in the patient group. No significant differences were observed between the groups with respect to sex and age (p = 0.999 and p = 0.897, respectively). The mean BMI was 23.32 ± 1.62 (range: 19.90–27.40) in the control group and 23.47 ± 2.45 (range: 18–30) in the patient group. There was no significant difference in BMI between the groups (p = 0.708). Electrocardiographic evaluation revealed a normal sinus rhythm in all participants.
The results of the between-group comparisons for VAS nasal obstruction score, NOSE score, RC-IMT and LC-IMT are presented in Table 1 and Figure 2.
Comparison of VAS score, NOSE score, RC-IMT and LC-IMT values between groups
Table 1 Long description
Variables include VAS, NOSE percent, RC-IMT in millimeters, and LC-IMT in millimeters, each reported for control and disease groups with p-Value1 and Cohens d. For VAS, overall values were 1.98 plus or minus 0.68 in control and 8.12 plus or minus 1.02 in disease, p-Value1 less than 0.001, Cohens d 7.05; male values were 2 plus or minus 0.59 and 8 plus or minus 0.97, p-Value1 less than 0.001, d 7.51; female values were 1.95 plus or minus 0.83 and 8.32 plus or minus 1.11, p-Value1 less than 0.001, d 6.54. For VAS, the row labeled, p-Value2 lists 0.816 under control and 0.294 under disease. For NOSE percent, overall values were 17.30 plus or minus 5.46 in control and 82.60 plus or minus 10.51 in disease, p-Value1 less than 0.001, d 7.80; male values were 17.67 plus or minus 5.83 and 81.29 plus or minus 10.24, p-Value1 less than 0.001, d 7.60; female values were 16.75 plus or minus 4.94 and 84.74 plus or minus 10.86, p-Value1 less than 0.001, d 8.13. For NOSE percent, the row labeled, p-Value2 lists 0.566 under control and 0.265 under disease. For RC-IMT, overall values were 0.51 plus or minus 0.09 in control and 0.62 plus or minus 0.12 in disease, p-Value1 less than 0.001, d 1.08; male values were 0.52 plus or minus 0.09 and 0.60 plus or minus 0.12, p-Value1 0.007, d 0.71; female values were 0.48 plus or minus 0.07 and 0.66 plus or minus 0.12, p-Value1 less than 0.001, d 1.74, with p-Value2 of 0.101 for control and 0.099 for disease. For LC-IMT, overall values were 0.51 plus or minus 0.07 in control and 0.63 plus or minus 0.12 in disease, p-Value1 less than 0.001, d 1.11; male values were 0.51 plus or minus 0.07 and 0.59 plus or minus 0.11, p-Value1 0.002, d 0.83; female values were 0.50 plus or minus 0.06 and 0.66 plus or minus 0.13, p-Value1 less than 0.001, d 1.60, with p-Value2 of 0.542 for control and 0.046 for disease. Control and disease columns each list n as 50, while the male and female rows list n as 61 and 39.
LC-IMT = left carotid intima–media thickness; RC-IMT = right carotid intima media thickness.
Note: Data were presented as mean ± standard deviation, 95% CI: 95% confidence interval, Cohen’s d: effect size. Bold values indicate statistical significance (p < 0.05). p-Values were calculated using Student’s t-test or Welch’s t-test.
1 p-Value indicates comparison between groups (control vs. disease).
2 p-Value indicates comparison within groups (male vs. female) in each study groups (both control and disease).
Comparison of right (RCCA) and left (LCCA) common carotid artery intima–media thickness values between groups.
Figure 2 Long description
Panel A shows box plots for RCCA values. The vertical axis represents intima-media thickness from 0.4 to 0.8 millimeters. For males, the control group has a lower median than the disease group. For females, the disease group shows a higher median and wider interquartile range than the control group. Panel B shows box plots for LCCA values. The vertical axis represents intima-media thickness from 0.4 to 0.8 millimeters. For males, the disease group has a higher median than the control group. For females, the disease group also shows a higher median and wider interquartile range. Outliers are present as individual points. Significance is indicated by asterisks above the plots.
RC-IMT values were significantly higher in patients (0.62 ± 0.12 mm) compared with the control group (0.51 ± 0.09 mm) (p < 0.001; Cohen’s d = 1.08). The mean RC-IMT value was approximately 12 per cent higher in individuals with nasal obstruction compared to those without obstruction (OR:1.121; 95 per cent CI: 1.075–1.168; p < 0.001). In both males and females, patients demonstrated significantly elevated RC-IMT values compared with the control group (Table 1).
The LC-IMT value was also significantly higher in the patient group (0.63 ± 0.12 mm) compared with healthy individuals (0.51 ± 0.07 mm) (p < 0.001, Cohen’s d = 1.11). Individuals with nasal obstruction demonstrated approximately 11 per cent higher LC-IMT values than those observed in participants without obstruction (OR:1.114; 95 per cent CI: 1.072–1.157; p < 0.001). Patients exhibited higher LC-IMT values than controls in both male and female subgroups (Table 1).
The correlations of carotid IMT with VAS score, NOSE score and duration of complaints in the patient group are shown in Table 2. Analysis revealed a significant direct correlation between VAS and NOSE scores and the examined parameters (p < 0.001). No significant correlation was observed between disease duration and RC-IMT; however, a negative correlation was present between disease duration and LC-IMT (Spearman’s rho = -0.289; p = 0.041).
Relationship of RC-IMT and LC-IMT values with VAS score, NOSE score and symptom duration
Table 2 Long description
Parameters are rc imt in millimeters and lc imt in millimeters, each paired with values for vas, nose percent, and time, reported as Spearman rho with p values. For rc imt, vas is 0.526 with p less than 0.001, nose is 0.531 with p less than 0.001, and time is minus 0.065 with p 0.654. For lc imt, vas is 0.479 with p less than 0.001, nose is 0.461 with p less than 0.001, and time is minus 0.289 with p 0.041. Rc imt is slightly higher than lc imt for both vas and nose. Time differs by parameter, with a small negative value for rc imt and a larger negative value for lc imt.
LC-IMT = left carotid intima–media thickness; RC-IMT = right carotid intima media thickness.
Note: Values were expressed as Spearman’s rho (ρ) with p-values. Bold values indicate statistical significance (p < 0.05).
The correlations of carotid IMT values with VAS and NOSE scores are summarised in Table 3. Carotid IMT was found to be significantly increased in patients whose VAS score exceeded 5 and NOSE score exceeded 50, compared with those scoring below 5 on the VAS and 50 below on the NOSE questionnaire (Table 3).
Analysis of RC-IMT and LC-IMT values based on VAS and NOSE score categories
Table 3 Long description
RC-IMT and LC-IMT are reported in millimeters as mean plus or minus standard deviation for groups defined by VAS and NOSE categories. For VAS, the group at or below 5 with 52 participants has RC-IMT 0.51 plus or minus 0.09 and LC-IMT 0.51 plus or minus 0.07. For VAS, the group above 5 with 48 participants has RC-IMT 0.62 plus or minus 0.12 and LC-IMT 0.62 plus or minus 0.12. The VAS p-value is less than 0.001 for RC-IMT and less than 0.001 for LC-IMT. For NOSE, the group at or below 50 with 51 participants has RC-IMT 0.51 plus or minus 0.09 and LC-IMT 0.51 plus or minus 0.07. For NOSE, the group above 50 with 49 participants has RC-IMT 0.62 plus or minus 0.12 and LC-IMT 0.61 plus or minus 0.12. The NOSE p-value is less than 0.001 for RC-IMT and less than 0.001 for LC-IMT.
LC-IMT = left carotid intima media thickness; RC-IMT = right carotid intima–media thickness.
Note: Data were presented as mean ± standard deviation. Bold values indicate statistical significance (p < 0.05). p-Values were calculated using Student’s t-test or Welch’s t-test.
The VAS nasal obstruction score (area under the curve [AUC]: 0.814; 95 per cent CI: 0.706–0.921; p < .001) and the NOSE score (AUC: 0.792; 95 per cent CI: 0.697–0.886; p < 0.001) were able to discriminate RC-IMT values greater than 0.7 mm significantly. The optimal cutoff value for the VAS score was 7.5, at which sensitivity was 85.7 per cent, specificity 67.4 per cent, positive predictive value (PPV) 30 per cent and negative predictive value (NPV) 96.7 per cent. The NOSE score showed an optimal cutoff point of 72.5, yielding 92.9 per cent sensitivity, 65.1 per cent specificity, a PPV of 30.2 per cent and an NPV of 98.2 per cent (Table 4 and Fig. 3).
Potential of VAS and NOSE score cutoffs to estimate right and left carotid artery IMT measurements
Table 4 Long description
Parameters are reported for right carotid IMT and left carotid IMT, each with rows for VAS score and NOSE percent. Columns list AUC with 95 percent confidence interval, DeLongs Z with p value, optimal cutoff point, sensitivity, specificity, PPV, and NPV. For right carotid IMT, VAS score has AUC 0.814 with 95 percent confidence interval 0.706 to 0.921, DeLongs Z 5.713 with p less than 0.001, cutoff 7.5, sensitivity 85.7 percent, specificity 67.4 percent, PPV 30 percent, and NPV 96.7 percent. For right carotid IMT, NOSE percent has AUC 0.792 with 95 percent confidence interval 0.697 to 0.886, DeLongs Z 6.042 with p less than 0.001, cutoff 72.5, sensitivity 92.9 percent, specificity 65.1 percent, PPV 30.2 percent, and NPV 98.2 percent. For left carotid IMT, VAS score has DeLongs Z 7.346 with p less than 0.001, cutoff 6, specificity 60.5 percent, PPV 27.5 percent, and NPV 95 percent. For left carotid IMT, NOSE percent has DeLongs Z 8.602 with p less than 0.001, cutoff 77.5, specificity 69.8 percent, PPV 35 percent, and NPV 100 percent.
AUC = area under the curve; CI = confidence interval; LC-IMT = left carotid intima–media thickness; NPV = negative predictive value; PPV = positive predictive value; RC-IMT = right carotid intima–media thickness.
Note: Bold values indicate statistical significance (p < 0.05).
(A) ROC curves of VAS score and NOSE (%) for predicting right carotid intima–media thickness values. (B) ROC curves of VAS score and NOSE (%) for predicting left carotid intima–media thickness values. LCCA = left common carotid artery; NOSE = Nasal Obstruction Symptom Evaluation; RCCA = right; ROC = receiver operating characteristics; VAS = Visual Analogue Scale.
Figure 3 Long description
ROC curves of VAS score and NOSE percent in predicting RCCA. Two solid curves are shown, one for VAS score and one for NOSE. A dashed diagonal reference line runs from (1.00, 0.00) to (0.00, 1.00). The horizontal axis label is Specificity (FPR), range 1.00 to 0.00. The vertical axis label is Sensitivity (TPR), range 0.00 to 1.00. Legend text: VAS score, AUC: 0.814, 95 percent CI: 0.706 to 0.921; Sens: 85.7 percent, Spec: 67.4 percent; Cut-off: 7.5. NOSE, AUC: 0.814, 95 percent CI: 0.706 to 0.921; Sens: 85.7 percent, Spec: 67.4 percent; Cut-off: 7.5. ROC curves of VAS score and NOSE percent in predicting LCCA. Two solid curves are shown, one for VAS score and one for NOSE. A dashed diagonal reference line runs from (1.00, 0.00) to (0.00, 1.00). The horizontal axis label is Specificity (FPR), range 1.00 to 0.00. The vertical axis label is Sensitivity (TPR), range 0.00 to 1.00. Legend text: VAS score, AUC: 0.826, 95 percent CI: 0.739 to 0.913; Sens: 100 percent, Spec: 60.5 percent; Cut-off: 6. NOSE, AUC: 0.837, 95 percent CI: 0.760 to 0.914; Sens: 100 percent, Spec: 69.8 percent; Cut-off: 77.5.
The VAS (AUC: 0.826; 95 per cent CI: 0.739–0.913; p < 0.001) and NOSE (AUC: 0.837; 95 per cent CI: 0.760–0.914; p < 0.001) scores demonstrated significant discriminatory power for detecting LC-IMT values above 0.7 mm. The VAS score demonstrated an optimal cutoff point of 6, corresponding to 100 per cent sensitivity, 60.5 per cent specificity, a PPV of 27.5 per cent and an NPV of 95 per cent. For the NOSE score, the optimal threshold was determined as 77.5, yielding a sensitivity of 100 per cent, specificity of 69.8 per cent, a PPV of 35 per cent and an NPV of 100 per cent (Table 4 and Fig. 3).
Discussion
The principal finding of this study was that NSD, a leading cause of nasal obstruction, is associated with a significantly greater carotid IMT than that observed in healthy controls. These results suggest that NSD leading to nasal obstruction is not solely a localised disorder but may also exert systemic effects on the vascular system.
Globally, stroke ranks among the foremost causes of mortality and long-term disability. The Global Burden of Disease Stroke Statistics 2019 indicate that ischaemic stroke impacts nearly 77.2 million individuals per year and results in 2.7 million deaths.Reference Fernández-Alvarez, Linares Sánchez, López Alvarez, Suárez Nieto, Makitie and Olsen7 Carotid atherosclerosis is a major and potentially preventable cause of ischaemic stroke, accounting for 15–20 per cent of all ischaemic stroke cases.Reference Fernández-Alvarez, Linares Sánchez, López Alvarez, Suárez Nieto, Makitie and Olsen7 Identification of subclinical atherosclerosis is essential for providing aggressive vascular protection in the early period, thereby reducing future cardiovascular risk.Reference Fernández-Alvarez, Linares Sánchez, López Alvarez, Suárez Nieto, Makitie and Olsen7
Carotid IMT measurement has been reported to serve as a reliable marker for the detection of early atherosclerosis, particularly in young individuals without evidence of plaque formation or calcification.Reference Fernández-Alvarez, Linares Sánchez, López Alvarez, Suárez Nieto, Makitie and Olsen7, Reference Lorenz, Markus, Bots, Rosvall and Sitzer8 A recent meta-analysis demonstrated an approximately log-linear relationship between carotid artery IMT and the likelihood of carotid plaque development. Analyses corrected for age, gender and study arm revealed that each standard deviation increment in baseline carotid IMT increased the probability of carotid plaque formation by 40 per cent. Following additional adjustment for ethnicity, smoking, diabetes, BMI, systolic blood pressure, levels of low- and high-density lipoprotein cholesterol and treatment with lipid-lowering or antihypertensive agents, the risk was estimated at 34 per cent (95 per cent CI, 1.24–1.45; IReference Alghamdi, Albogami, Alsurayhi, Alshibely, Alkaabi and Alqurashi2 = 59.4 per cent; based on 14 studies, 16,297 participants and 6,381 carotid plaque cases). In summary, the study indicates that each standard deviation increment in carotid IMT increases the likelihood of carotid plaque formation by 34 per cent, independent of conventional cardiovascular risk factors.Reference Tschiderer, Seekircher, Izzo, Mancusi, Manzi and Baldassarre6 According to the meta-analysis conducted by Willeit et al., interventions that slow carotid IMT progression have been associated with a reduced probability of cardiovascular events.Reference Willeit, Tschiderer, Allara, Reuber, Seekircher and Gao10 Atherosclerosis typically progresses silently over many years without diagnosis or symptoms; therefore, early identification is crucial for preventing adverse clinical consequences.Reference Tschiderer, Seekircher, Izzo, Mancusi, Manzi and Baldassarre6 Current evidence indicates that increased carotid IMT is associated with the presence of atherosclerosis in the arterial system and with an elevated risk of future cardiovascular disease.Reference Tschiderer, Seekircher, Izzo, Mancusi, Manzi and Baldassarre6
Research on factors leading to upper airway obstruction indicates that such individuals tend to have higher carotid IMT values. Sagıt et al. demonstrated in their study of patients with nasal polyps that carotid IMT values were increased in the patient group. They also reported a significant positive association between carotid IMT and endoscopic polyp scores as well as paranasal sinus computed tomography (CT) scores.Reference Sagit, Sarli, Guler, Namuslu, Celik and Kurtul14 Another investigation demonstrated that carotid IMT was elevated in patients diagnosed with adenotonsillar hypertrophy.Reference Çiftel, Demir, Kozan, Yilmaz, Kahveci and Kiliç15 Several studies have likewise demonstrated increased carotid IMT in individuals with obstructive sleep apnoea (OSA).Reference Szabóová, Tomori, Donic, Petrovicová and Szabó16–Reference Nadeem, Harvey, Singh, Khan, Albustani and Baessler18 Patients with OSA have been shown to exhibit increased levels of systemic inflammatory markers, including tumor necrosis factor-alpha, interleukin-6, interleukin-8, C-reactive protein and adhesion molecules, all of which possess pro-atherogenic characteristics. Intermittent hypoxia has been shown to contribute to endothelial dysfunction and the development of atherosclerosis through multiple pathways.Reference Drager, Polotsky and Lorenzi-Filho19 It has been demonstrated that significant NSD leading to nasal obstruction may result in endothelial damage, which represents an early marker of atherosclerosis.Reference Dağıstan and Turan20 NSD represents one of the most common structural causes of chronic nasal obstruction in adults, although inflammatory conditions such as allergic rhinitis also contribute substantially to upper airway symptoms,Reference Öğreden, Tansuker, Cengiz, Tabaru, Özyilmaz and Ögur3, Reference Ozkececi, Akci, Bucak, Ulu, Yalim and Aycicek4, Reference Ulusoy, Tunçez, Gül, Tezcan, Erdur and Vatansev21 yet no studies examining its association with carotid IMT were found in the PubMed database. Our findings demonstrated significantly greater carotid IMT values in patients with NSD compared with healthy controls, supporting a potential association between chronic nasal obstruction and subclinical vascular alterations. In addition, we demonstrated that carotid IMT values increased with longer disease duration and greater severity of nasal obstruction. Earlier studies reported that a 0.1-mm rise in carotid IMT increases the likelihood of subsequent myocardial infarction by 10–15 per cent and stroke by 13–18 per cent.Reference Lorenz, Markus, Bots, Rosvall and Sitzer8 Our findings suggest an association between NSD-related nasal obstruction and increased carotid IMT, which may reflect subclinical vascular alterations, underscoring the importance of considering this factor in follow-up evaluations and therapeutic strategies.
The second major outcome of our research is the identification of a significant correlation between VAS nasal obstruction scoring, NOSE questionnaire results and carotid IMT. Patients scoring above 5 on the VAS or above 50 on the NOSE questionnaire exhibited increased carotid IMT values compared with those whose VAS was below 5 or NOSE score was below 50. Moreover, a VAS cutoff points of 7.5 yielded 85.7 per cent sensitivity and 67.4 per cent specificity in detecting right carotid artery IMT values above 0.7 mm. In this study, a carotid-IMT threshold of 0.7 mm was used as a pragmatic reference value for ROC curve analyses based on previous carotid ultrasound studies; however, this value should not be interpreted as a universally accepted diagnostic threshold for cardiovascular risk. For the NOSE score, the optimal cutoff was 72.5, at which sensitivity was 92.9 per cent and specificity was 65.1 per cent. For LC-IMT, the optimal cutoff value for the VAS score was 6, which yielded 100 per cent sensitivity and 60.5 per cent specificity. For the NOSE score, the optimal cutoff value was 77.5, at which sensitivity was 100 per cent and specificity was 69.8 per cent. Based on these findings, we suggest that, in patients with nasal obstruction due to septal deviation, the potential risk of cardiovascular pathology may be identified using the simple VAS scoring system or the NOSE questionnaire. We consider that patients with a VAS score exceeding 6 or a NOSE questionnaire score above 72 require closer surveillance for cardiovascular pathologies. However, our findings suggest that the VAS and NOSE questionnaires may help predict which individuals with NSD require further evaluation for subclinical cardiovascular disease. In this way, the use of these two questionnaires could contribute to the assessment of cardiovascular risk in patients, while minimising unnecessary healthcare costs, avoiding redundant diagnostic procedures and ensuring efficient utilisation of healthcare resources. These ROC-derived cutoff values should be interpreted cautiously, as they were derived from a relatively small single-centre cohort and require external validation in larger prospective studies before routine clinical application; moreover, whether carotid IMT changes associated with NSD-related nasal obstruction are reversible following septoplasty remains unclear and warrants further investigation in longitudinal studies incorporating postoperative follow-up.
• Nasal septal deviation is one of the most common causes of nasal obstruction
• Upper airway obstruction adversely affects the cardiovascular system
• Increased carotid intima–media thickness indicates subclinical atherosclerosis
• Our findings showed that nasal septal deviation significantly increased carotid intima–media thickness
• Visual Analogue Scale (VAS) and Nasal Obstruction Symptom Evaluation (NOSE) scores may help identify patients at increased subclinical cardiovascular risk
Conclusion
This study emphasises that nasal obstruction should not be regarded merely as a localised problem but rather as a condition with systemic cardiovascular implications. Incorporating symptom-based scoring systems such as VAS and NOSE into clinical practice could help stratify cardiovascular risk in patients with nasal septal deviation and facilitate closer cardiovascular surveillance and earlier intervention. Future large-scale, multicenter studies are warranted to validate these results and to further elucidate the underlying mechanisms linking chronic nasal obstruction to vascular pathology.
Conflicts of interest and source of funding
There is no conflict of interest between all authors.
Source of funding
Financial support was not taken.
