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.