Clinical Utility and Necessity of Preoperative CT Imaging in Functional and Aesthetic Nasal Surgery: A Systematic Review

Overview and rationale Rhinoplasty, septoplasty and septorhinoplasty are among the most frequently performed operations worldwide. With a wide variety of indications like external deformities and internal dysfunctions, preoperative evaluations are necessary to inform sound, patient oriented surgical decisions. As such a wide variety of preoperative assessment methods are used, most common of which are physical examination, rhinoscopy, nasal endoscopy and CT imaging. These operations are costly, and most insurance companies require patients to have CT-documentation for clinical justification to proceed with payment. While CT scans provide ample insight into anatomical structures of the sinonasal region to help make informed decisions, they could also harm patients if used frequently due to their utilization of ionizing radiation. And since they are costly procedures, frequent use would also force significant financial burden on healthcare systems. Consequently, some recent studies have advocated for its limited use in complicated cases to ensure patient safety and cost-effectiveness. This PRISMA-2020-conformant systematic review was designed to respond to these controversies and assess CT scans overall utility and necessity in comparison to other preoperative assessment methods. Objective The main objective of this study was to compare various preoperative assessment methods in patients undergoing rhinoplasty, septoplasty or septorhinoplasty, with a specific focus on the utilization of CT imaging. Methods Eligibility: studies with patients undergoing rhinoplasty, septoplasty and septorhinoplasty (any age/indication) that utilized preoperative assessment with direct comparisons (CT vs other modalities). Included studies where Randomized trials, cohort studies, case-control studies, case series or cross-sectional studies reporting comparative outcomes. case reports, animal/in vitro studies, reviews, editorials, conference abstracts without full data, or studies lacking direct comparison between CT and alternative methods where excluded. Search and databases: an initial search was performed on April 14th,2025 in PubMed, Embase, Scopus, Web of Science and Cochrane library using MeSH terms and keywords. An updated search was performed on November 8th,2025 with same queries to cover the time gap. Language and publication date were not restricted. Also, reference list of relevant articles and systematic reviews were hand-searched to limit potential article-misses. Study selection and data extraction: two independent reviewers screened and data extracted articles with a third reviewer to resolve any disagreements. extracted domains included author(s), country, year of publication, sample size, study design, objective, patient characteristics, preoperative assessment methods (including computed tomography (CT) and alternative assessment methods as comparators), surgery type, surgery indication, relevant outcomes (diagnostic or clinical) and limitations. Risk of bias: MMAT 2018 was implemented to do study appraisal and risk of bias assessment. Studies where qualitatively categorized (low, medium, high) and no numerical scoring was applied, per MMAT guidance. Synthesis and certainty: although meta-analysis was considered initially, narrative synthesis was done due to significant heterogeneity. Certainty was graded using GRADE. Transparency: complete search strategies, PRISMA flow, extractions, risk-of-bias justifications and summary will be provided on OSF project page. AI assistance (ChatGPT) was only used for translation of non-English articles for screening and data extraction, with translations manually checked by reviewers. AI was not used to generate scientific content, analysis or conclusion. Current status and preliminary evidence map: From 2,334 records, 29 studies were included. The evidence base comprised two parallel-group randomized controlled trials (RCTs); 23 cohort or cross-sectional clinical studies; one technical study; and three laboratory or cadaveric studies. Population included both adult and pediatric; with three studies addressing adult nasal fracture; one pediatric series addressing congenital nasal dermoids; one small prospective case series focusing on adults undergoing secondary rhinoseptoplasty, comparing 3D volume-rendered CT with standard clinical examination; and three cadaveric investigations simulating functional rhinoplasty interventions. most common included preoperative modalities were nasal endoscopy, anterior rhinoscopy, or plain radiography; outcome domains included diagnostic agreement/accuracy, detection of specific anatomic or pathologic findings, changes in surgical planning, and patient-reported outcomes (NOSE, ROE, VAS, SNOT-22). Expected outcomes and contributions: Deliverables: PRISMA-2020 flow diagrams; study characteristics, surgery types, comparator modalities (CT vs alternative preoperative assessment methods), outcomes measured tables; risk of bias summary; GRADE-style summary of findings; SWiM compliant narrative synthesis Knowledge gains: the study will lead to a clean and complete map of human studies involving comparison of preoperative assessment methods in nasal surgeries, with emphasis on preoperative CT imaging and how it measures up in comparison to other preoperative modalities. This will highlight CT imaging areas of necessity and areas of redundancy, providing a clear map guiding physicians on how and where to use it in their assessments to ensure patients safety. Impact: this will help committees to come up with necessary guidelines and protocols for CT usage, inform future study designs to derive deeper paradigms, guide relative regulatory bodies such as ethics committees and insurance companies on appropriate comparators and their use, and help guide physicians for possibly more appropriate choices of preoperative modalities to ensure patient safety Limitations and Risk Management: possible anticipated limitations in studies are small sample size, unclear randomization and blinding methods, heterogenous study designs, inconsistent outcome definitions, limited objective statistical analysis. To address these, appropriate risk of bias tools, transparent use of GRADE for certainty evaluation and SWiM for narrative synthesis are utilized. Ethics, Roles, Dissemination: due to utilization of previously published human studies in this study, ethics approval was non-applicable. The study received no external funding. Team roles covered otolaryngologist, sinus and nasal surgery fellow, and biostatistician/methodologists. Corresponding author is Dr. Mehdi Bakhshaee (BakhshaeeM@mums.ac.ir; https://orcid.org/0000-0001-9590-4798) Study findings will be shared through an open OSF repository (protocol, material, extracted datasets, risk of bias justifications where permissible) and submission to a peer-reviewed journal, summarizing what is known, what is uncertain and what would be the next helpful steps.