5.2.2. Surgery
Nasal surgery can be a treatment option for medically resistant nasal
obstruction due to structural pathology at the level of the nasal bones
or cartilage.
Septoplasty is the most commonly performed surgical ENT intervention in
adults; however, due to a lack of controlled trials, clear evidence on
its effectiveness is currently lacking 83. One of the
possible reasons for septoplasty failure could be an unaddressed nasal
valve insufficiency. In this case, septorhinoplasty could bring a
solution, although also for this type of intervention, evidence on
functional benefit is mostly lacking. Endoscopic sinus surgery is
indicated in CRS patients who fail to respond to maximal medical therapy21.
To our knowledge, a part from one study showing a benefit of early
reduction of sports-induced nasal fracture 84, no
studies are available on the benefit of nasal surgery in athletes. As is
the case for the general population, the key factor is to make the
correct surgical indication and mucosal pathology should be excluded
and/or treated before deciding on surgical intervention.
6. Recommendations and unmet needs for the application
of personalized medicine.
Due to a lack of knowledge and attention for the impact of nasal
symptoms on athletic performances, several unmet needs persist for
treating athletes 56, 85. It is clear that more
well-designed studies are needed that target this specific patient
population in order to gain more insights in disease mechanistic as well
as in specific diagnostic and treatment options for their nasal
pathology.
To optimize their current management, we suggest to follow the concept
of precision-based medicine, which is based on the 4 P’s: prediction,
prevention, personalization and participation 86.
Prediction: Sports-specific factors may predispose athletes to
develop nasal disease and when dealing with (ultra-)endurance athletes
and outdoor or aquatic athletes and awareness for nasal symptoms should
be increased. Some athletes will be bothered more by nasal symptoms than
others and questionnaires such as NOSE and RQLQ (rhinitis) or SNOT-22
(rhinosinusitis) can be helpful tools in assessing QOL impact.
Predicting and identifying these athletes can lead to early intervention
and possible improvement of their accomplishments.
For outdoor athletes diagnosed with a seasonal AR, symptomatology can be
predicted according to the respective pollen seasons and should be
anticipated with appropriated preventive measurements and if indicated,
pharmacological therapy or ideally, AIT.
Because both rhinitis and rhinosinusitis are risks factors for
developing asthma 87, symptomatic athletes should
always be questioned for lower airway symptoms. In case of positive
history, spirometry and/or bronchial provocation testing are indicated.
Prevention: Because of the potential negative impact of
environmental irritants on nasal function, limiting these exposures to a
minimum may prevent symptom development. For aquatic athletes this means
monitoring and, if necessary, adapting the levels of chlorination
products in the training pool. Ideally, training occurs in swimming
pools that use alternative methods of disinfection such as ozone or
cupper-silver ionization. The use of a nose clip in this matter can be
debated and will depend largely on the preference of the swimmer. For
non-aquatic sports, training in a polluted environment should be avoided
at all cost.
Warm-up exercises have shown to decrease symptoms in EIB patients88 and might be useful for patients suffering from
exercise-induced rhinitis. However, this has not been investigated and
should be a topic of future studies, as is the possible therapeutic
option of pre-exercise nasal douching in order to prevent possible
mucosal dehydration by hyperventilation.
Personalization: The most important topic within the concept of
precision-based medicine is the attempt to deliver personalized care to
the patient. Therefore, a correct diagnosis of the nasal dysfunction is
essential and the patient should be treated according to the respective
guidelines. For athletes suffering from mucosal disease, the
sport-specific environment should be maximally optimized and if
necessary, pharmacological therapy administered. If the athlete suffers
from AR and fits the criteria for AIT, this is the preferred therapy16. For those presenting with a structural pathology,
nasal surgery might be the treatment of choice and nasal valve surgery
might be preserved for those with a subjective effect of an external or
internal nasal dilator during a sport-specific test.
Participation: Athletes are a challenging patient population with
regards to therapeutic adherence; in a recent German study, only less
than half of athletes suffering from AR used a treatment for this
condition. This percentage was even lower in the elite and semi-elite
athletes (34.8% and 30.2% respectively) 16. Also,
the majority of subjects had concerns about pharmacological treatment
options and feared side effects, negative impact on sports performance
and lack of long-term effects 16. These findings
emphasize the need of patient education about their disease, the
potential impact on his/her performance, possible preventive
measurements and especially the available pharmacological therapies
including side-effects and how they fit within the WADA regulations.
Disease-specific smartphone applications delivering patient education
and following symptoms might be useful within this regard89. Not only athletes, but also their health care
providers should be informed about anti-doping regulations and the fact
that prohibited drugs are published annually by WADA.