The efficiency of Nose Obstruction Symptom Evaluation (NOSE) scale on patients with nasal septal deviation

The efficiency of Nose Obstruction Symptom Evaluation (NOSE) scale on patients with nasal septal deviation

Auris Nasus Larynx 39 (2012) 275–279 Contents lists available at SciVerse ScienceDirect Auris Nasus Larynx journal homepage:

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Auris Nasus Larynx 39 (2012) 275–279

Contents lists available at SciVerse ScienceDirect

Auris Nasus Larynx journal homepage:

The efficiency of Nose Obstruction Symptom Evaluation (NOSE) scale on patients with nasal septal deviation Orhan Kemal Kahveci a,*, Murat Cem Miman a, Aylin Yucel b, Fatih Yucedag a, Erdog˘an Okur a, Ali Altuntas a a b

Department of Otolaryngology, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar, Turkey Department of Radiology, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar, Turkey



Article history: Received 30 April 2011 Accepted 5 August 2011 Available online 31 August 2011

Objective: The aim in this study was to evaluate the efficiency of Nasal Obstruction Symptom Evaluation (NOSE) scale for septoplasty (without turbinate reduction) in comparison with other examination methods. Methods: Prospective observational study was undertaken in otolaryngology department of university hospital. NOSE scale for quality of life assessment, visual analog scale for examination findings, acoustic rhinometry and coronal computed tomography were performed before and after septoplasty. The efficiency of NOSE scale to assess for septoplasty results and the correlation between NOSE scores and other techniques was analyzed. Results: Twenty-seven patients underwent septoplasty; there was a very significant improvement in mean NOSE scores of patients (60.2 versus 11.28, p < 0.01). There was no correlation between NOSE scores and acoustic rhinometry. Correlation was found between NOSE scores and examination and computed tomography findings (p < 0.05). Conclusion: NOSE scale that is well correlated with examination findings and computed tomography, is very useful tool to evaluate the effectiveness of pure septoplasty. ß 2011 Elsevier Ireland Ltd. All rights reserved.

Keywords: NOSE scale Septum deviation Septoplasty Quality of life Visual analog scale Acoustic rhinometry Computed tomography

1. Introduction Nasal obstruction is a very common complaint of the patients in otolaryngology practice. Many methods such as rhinomanometry, acoustic rhinometry, computed tomography, and quality of life (QOL) questionnaires have been used to evaluate indication and outcomes of surgeries for nasal obstruction. Stewart et al. developed and validated Nose Obstruction Symptom Evaluation (NOSE) scale as a disease-specific quality of life instrument for use in nasal obstruction [1]. NOSE scale was used in few studies and seeming as a useful tool for evaluating nasal obstruction surgeries [2–4]. Septoplasty is the main surgical procedure to overcome nasal obstruction caused by septal deviation. It is not only most common sinonasal operation, but also third most commonly surgical procedure in otolaryngology practice in United States [2,5]. Therefore, in this study, we have tried to assess the efficiency of NOSE scale by comparing it with physical examination findings, acoustic rhinometry and computed tomography (CT). This study is

* Corresponding author at: AKU Arastirma Hast, KBB AD, Izmir yolu, 03200 Afyonkarahisar, Turkey. Tel.: +90 505 2184236; fax: +90 272 2133066. E-mail address: [email protected] (O.K. Kahveci). 0385-8146/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2011.08.006

unique evaluating the efficiency of NOSE scale compared with other tools for assessing nasal obstruction symptom on the patients, before and after septoplasty.

2. Materials and methods A prospective observational study was performed. Institutional review board approval was received from Afyon Kocatepe University Medical Ethics Committee. Twenty-seven patients with nasal septal deviations who complained of nasal obstruction were included in the study. All patients signed informed consent and they were informed about study. All the patients but four did accept to have paranasal sinus tomography before and after the septoplasty. The senior surgeons decided for indication of septoplasty operation with patients by doing a complete ENT examination. Inclusion criteria were as follows: at least 18 years old, septal deviation consistent with nasal obstruction at least for 3 months, persistent symptoms after a 4-week trial of medical management. Nasal steroid, antihistaminic and/or oral decongestants were used for trial of medical management. Exclusion criteria were as follows: sinonasal malignancy, being in need of nasal surgery other than septoplasty (such as endoscopic sinus

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276 Table 1 Questionnaire of NOSE scale.

Over the past 1 month how much of a problem were the following conditions for you? Please mark the most correct response

1. 2. 3. 4. 5.

Nose obstruction and stuffiness Nose obstruction Trouble breathing through my nose Trouble sleeping Unable to get enough air through my nose during exercise or exertion

surgery, nasal valve surgery, turbinate surgery, etc.), sinonasal infections, sinonasal inflammatory disease, prior nasal surgery, septal perforation, craniofacial syndrome, nasal trauma, or fracture, adenoid hypertrophy, pregnancy, cardiac and lung disease. The main outcome measure used in the study was NOSE scale (Table 1). All the patients were asked to complete NOSE scale 1 week before the surgery. Sums of the answers were multiplied by five to base the scale out of a possible score of a 100 for analysis. Then the patient was examined by a physician who was blinded to patient’s NOSE score to asses the severity of nasal deviation and complete a 10-cm visual scale (VAS). Nasal cavities were cleaned by suction and prepared for acoustic rhinometry. Acoustic rhinometry (Rhinometrics, Denmark) measurements were performed after applying nasal decongestant (xylometazolin 0.01%) in a relatively quiet room at normal temperature and humidity (40  15.3%). Minimal cross section area at the first 2 cm (MCA1) and between 2nd and 5th cm of nasal cavity (MCA2), and nasal cavity volume at the first 2 cm (Vol1) and between 2nd and 5th cm (Vol2) were recorded for deviated side of nose (DN) and for non-deviated side of the nose (NDN) separately. The sum of Vol1 and Vol2 was accepted as total volume (TVol) of associated side of the nasal cavity. Twenty-three patients underwent paranasal sinus computed tomography (CT) (120 kV, 215 mA s, 3 mm slice thickness, 1.5 mm increment, 200 mm field of view, with bone filter, display matrix 512  512 pixels). The most deviated part of the septum was marked among these slices in coronal plane. The degree of deviation angle and areas of deviated side and non-deviated side of the nasal cavity were measured at that part by a radiologist (AY) using View forum program (version R5.1V1L2, 2007, Philips Medical Systems, Nederland B.V.). Deviation angle was constituted by delineating a line from most deviated point of septum to crista galli and drawing another line to horizontal plate of the maxillary or palatine bone (Fig. 1). Most of the septoplasties were done by senior surgeons and some of them were done by ENT residents under the supervision of senior surgeons. The operation technique was hemi-transfixion incision followed by mucoperichondrium elevation, addressing all areas of deviation with reshaping and/or removal of the deviated portion. Internal nasal splint or nasal packing was inserted at the end of the operation and removed 2 or 3 days after septoplasty. Ringer lactate irrigation four times a day was used for 2 weeks for softening crusts and cleaning nose. The patients were called for control and undergone the same procedures (NOSE scale, ENT examination, acoustic rhinometry, and paranasal sinus tomography) after septoplasty. The examination was done by same physician who completed their preoperative VAS scale and paranasal tomography was evaluated by same radiology specialist (Fig. 2). Statistical analyses were performed using SPSS for Windows (9.05, SPSS Inc., Chicago, IL). The equality of variances was assessed by Levene test and distribution by Kolmogorov–Smirnov test. If two groups were compared, paired or unpaired t test with equal and unequal variances was used. Pearson’s correlation coefficient was used to reveal correlations between data. p < 0.05 was accepted as the statistical significance level.

Not a problem

Very mild problem

Moderate problem

Fairly bad problem

Severe problem

0 0 0 0 0

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

3. Results Twenty-seven patients met eligibility criteria and underwent surgery. There were 5 females and 22 males in the study. The mean age was 34.9 years ranging from 18 to 69 years. The mean body mass index (BMI) of the patients was 25.4 (range 18.4–38.4). Mean postoperative control time was 6.2 months (range 3–16 months). The patients had significant improvement in nasal obstruction symptoms after septoplasty operation (p < 0.01). The mean


Fig. 1. Preoperative paranasal sinus CT image in the coronal plane (a), angle and area measurements are shown in the same section (b).


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Acoustic rhinometry results were evaluated in two subcategories as the deviated side and the non-deviated side. Table 2 shows mean values and standard deviations of acoustic rhinometry results. The increase was significant in both preoperative and postoperative MCA1 and MCA2 values of the deviated side. But no correlation was found between the iNOSE scores and improvement in MCA1 or MCA2 values (p > 0.05). Also, the gain in deviated side’s total volume (iTVol) was calculated and no statistical significant correlation was found with iNOSE scores (p > 0.05). CT examination revealed there is a significant change between preoperative and postoperative angles of most deviated part of the septum (p < 0.05). More angle value means a straighter septum and the value of 1808 means entirely straight septum. It was 146.748 (SD, 11.94) preoperatively and it was 155.718 (SD, 15.09) postoperatively. There was a modest negative correlation between the increase in angle degree and iNOSE scores (p < 0.05, r = 0.45). Also, there was a modest negative correlation between the increase in angle degree and iVAS scores (p < 0.05, r = 0.42). There was no significant change in the CT area measurements of deviated and non-deviated sides postoperatively (p > 0.05). The preoperative area of the deviated side was 207.76 mm2 (SD, 66.32) and it was 226.90 mm2 (SD, 65.98) postoperatively. The preoperative area of non-deviated side was 275.96 mm2 (SD, 73.97) and it was 275.69 mm2 (SD, 72.0) postoperatively.

Fig. 2. Postoperative paranasal sinus CT image in the coronal plane.


4. Discussion Patients’ perception of nasal obstruction is complex and may be effected from multiple physiologic and psychological factors. Operative technique, condition of vascular and nerve supplies and expectations of patients from surgery may effect perception of nasal obstruction and outcomes of surgery [6]. The coexistence of allergy or sinonasal disease with septal deviation is also statistically associated with higher rates of dissatisfaction after surgery [7]. Inappropriate indication for septal surgery was also found as a major factor for patients’ dissatisfaction [8]. This is a critical comment on success of septal surgery from a scientific and legal point. Surgeons need a reliable method to prove their indication for septal surgery is appropriate. Although no objective method has been validated yet, NOSE scale is a promising and reliable method to evaluate septal surgery. Acoustic rhinometry (AR) and rhinomanometry were not found as valuable methods for indication and evaluation of surgery for nasal obstruction. This study is the first effort to compare acoustic rhinometry with disease specific question of life scale (NOSE scale). In a prospective study, AR was used for measuring childhood septoplasty outcomes and concluded it as an objective tool for evaluation surgical success [9]. However, this conclusion was also done depending on parents’ evaluation of the outcomes after septoplasty. Mamikoglu et al. compared physician rated clinical findings with AR and found a poor correlation between them [10]. In our study, significant changes in MCA1, MCA2 and Vol2 were found in deviated side of the nasal cavity. But, these findings were not correlated with NOSE scores. AR could be assessed as an important method according to

Fig. 3. Improvements in iNOSE and iVAS scores of the septoplasty patients.

preoperative NOSE score was 60.2 (SD, 17.45) and mean postoperative score was 11.28 (SD, 10.45). Minimum iNOSE (improved NOSE) score was 20 and maximum iNOSE score was 80. Pre- and postoperative VAS scales were used to assess degree of septal deviation according to examination findings. Preoperative mean VAS score was 7.26 (SD, 1.07) and postoperative mean VAS score was 1.32 (SD, 0.87). It was significant that there was improvement in examination findings of the deviation after septoplasty (p < 0.01). Also, it was found that there was a positive and modest correlation between iNOSE scores, and improvement in VAS (iVAS) scores (p < 0.05, r = 0.48) (Fig. 3).

Table 2 The mean values and standard deviations of acoustic rhinometry results. Deviated side

MCA1 (cm2) MCA2 (cm2) Vol1 (cm3) Vol2 (cm3)

Non-deviated side







0.38  0.18 0.28  0.2 1.53  0.38 3.0  1.92

0.48  0.15 0.52  0.2 1.65  0.42 5.13  1.03

<0.01 <0.01 >0.05 <0.01

0.54  0.2 0.69  0.3 1.73  0.50 4.94  1.99

0.56  0.2 0.63  0.29 1.71  0.45 5.26  1.50

>0.05 >0.05 >0.05 >0.05


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its own standards, but its clinical use is limited, because of the uncorrelated with patients’ symptoms. Rhinometry can show only volume and area changes inside of the nose. However nasal breathing mechanism is more complex and may be affected from diverse parameters. Therefore rhinometry can be used in clinical researches or as a complementary examination to the examination findings and patient’s symptom scores. Many studies about outcomes of septoplasty have been done and most of them reported high patient satisfaction [6,11]. Most of the studies were retrospective and used questionnaires nonspecific for nasal obstruction symptoms [6,8,12–14]. Rhee et al. pointed out the importance of disease specific quality of life instrument for nasal obstruction [4]. A prospective study including 42 septoplasty with turbinate reduction (SWTR) and 16 septoplasty alone used the NOSE scale and showed that SWTR group had better improvement than septoplasty alone group [3]. More recent prospective trial using NOSE scale was studied on 62 SWTR patients and 22 septoplasty alone patients [2]. Since septoplasty is often accompanied by inferior turbinate reduction or lateralization the number of septoplasty alone patients was always lower than SWTR patients in most of the studies. Generally, turbinate surgery was not accepted as an exclusion criterion when the functional outcomes of septoplasty were evaluated [2,3,13]. But, if the aim is evaluating the efficiency of septoplasty, only septoplasty patients should be chosen as a main study group. The effects on nasal volume and area of turbinate hypertrophy and surgical reduction of turbinate may interfere with the results of NOSE scores, examination findings, AR and CT. In this study, acoustic rhinometry measurement values obtained after decongestion were used. Very significant improvement was found in NOSE scores after septoplasty. This reflects that septoplasty alone is very efficient technique to overcome nasal obstruction symptoms in carefully selected patients. Nasal breathing is a complex function of the nose that may be affected by various conditions such as humidity, nasal resistance and contact of inspiration air with nasal surfaces. Even the total nasal volume inside the nose is not changed in pure septoplasty; the patients’ subjective complaints about nasal obstruction are reduced. The main important benefit in septoplasty is correction of key areas which cause nasal resistance and to achieve better turbulent airflow. Examination findings are very subjective and degree of deviation can be underestimated by operating surgeon postoperatively. So in our study we used physician, who is blinded to preoperative and postoperative NOSE scores and surgical procedure of patient, to examine septal deviation and complete VAS. A significant improvement in VAS scores was found in postoperative assessments. NOSE scores were found correlated with these physician rated severity of septal deviation. Although examination findings are subjective and vulnerable to examination bias, it is an important finding to show how close NOSE scale to diagnose nasal obstruction is. Despite the small need for the patients having septal deviation as their main medical problem, CT was also used to evaluate nasal obstruction in many studies [10,15,16]. By using different techniques such as Nasal Base View, subjective grading of nasal deviation and nasal area measurements, several investigators sought to assess the best and objective method to measure nasal obstruction. Mamikoglu et al. compared subjective septum deviation grading findings in CT with examination findings and found a limited correlation between them [10]. CT is single method to show deviation objectively, however its routine use is not necessary for this kind of patients. Preoperative endoscopy recordings might be also thought as an objective evidence of deviation. But, it may also be affected by the angle of endoscope’s view. Computed Tomography is an expensive method and will expose patients to unnecessary radiation. Only CT scans which

were obtained formerly to evaluate paranasal sinuses can be used as a diagnostic tool for septal deviation. In this study, in order to compare NOSE scale’s efficiency in nasal obstruction, it was decided to use CT examination. The most deviated part of septum was found and the angle of this part was measured in CT cross sections. Two lines from most deviated part were drawn to crista galli and palatine or maxillary bone to constitute a standard angle. NOSE scale was found correlated with objective CT findings. This result once more proved NOSE scale is a powerful tool to evaluate outcomes of septoplasty. In CT examination, the cross sectional areas of deviated and non-deviated sides at most curved part were also measured and found no correlation with NOSE scores. Moreover, some areas in corrected sides found decreased after surgery. This may be resulted from the congested status of the nasal cavities since decongestant was not used before CT. The weaknesses of this study are the lack of control and low number of patients. As mentioned in former studies there is no alternative surgical or medical option for septum deviation, so it is difficult to form a control group [2,3]. Because of the advanced techniques in septorhinoplasty it is also difficult to find septoplasty only patients. Most of the patients with septum deviation deserve turbinate manipulation and/or nasal valve surgery with open septoplasty. This may be the cause of reduced number of patients included in the study. 5. Conclusion Nasal obstruction is one of the symptoms which is hard to evaluate. NOSE scale could be used for the evaluation of this symptom. The improvement of NOSE scale after septoplasty was found correlated with nasal examination VAS score and measurement of the corrected deviated part of the septum by CT scan. Acoustic rhinometry is not found correlated with NOSE scores. NOSE scale is found very efficient tool to evaluate outcomes of septoplasty. Conflict of interest The authors have no actual or potential conflict of interest in relation to this paper. Acknowledgements This study was financially supported by Afyon Kocatepe University Scientific Research Projects Commission. Acoustic rhinometry equipment was paid by Commission. References [1] Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004;130:157–63. [2] Gandomi B, Bayat A, Kazemei T. Outcomes of septoplasty in young adults: the Nasal Obstruction Septoplasty Effectiveness study. Am J Otolaryngol 2010; 31:189–92. [3] Stewart MG, Smith TL, Weaver EM, Witsell DL, Yueh B, Hannley MT, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg 2004;130: 283–90. [4] Rhee JS, Book DT, Burzynski M, Smith TL. Quality of life assessment in nasal airway obstruction. Laryngoscope 2003;113:1118–22. [5] Bhattacharyya N. Ambulatory sinus and nasal surgery in the United States: demographics and perioperative outcomes. Laryngoscope 2010;120:635–8. [6] Konstantinidis I, Triaridis S, Triaridis A, Karagiannidis K, Kontzoglou G. Long term results following nasal septal surgery. Focus on patients’ satisfaction. Auris Nasus Larynx 2005;32:369–74. [7] Jessen M, Ivarsson A, Malm L. Nasal airway resistance and symptoms after functional septoplasty: comparison of findings at 9 months and 9 years. Clin Otolaryngol Allied Sci 1989;14:231–4. [8] Dinis PB, Haider H. Septoplasty: long-term evaluation of results. Am J Otolaryngol 2002;23:85–90.

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