Minimal Clinically Important Difference of the Standardized Cosmesis and Health Nasal Outcomes Survey

Crooked Nose: Aesthetic and Functional Outcomes

Purpose

To highlight a detailed analysis of aesthetic and functional rhinoplasty outcomes utilizing the most recent highly validated Standardized Cosmesis Health Nasal Outcomes Survey (SCHNOS) for Middle Eastern crooked nose patients.

Methods

A longitudinal cohort study scrutinizing preoperative rhinoplasty patients' satisfaction retrospectively and their postoperative outcomes prospectively. The patients fulfilled the Arabic SCHNOS during postoperative follow-up. Preoperative and postoperative responses were recorded and then reviewed and analyzed.

Results

This study included 41 patients with a mean age of 27.8 years. Females represented 41.5% of patients. About 73% of patients had a history of trauma. 90% of patients underwent primary procedures for crooked nose correction. Twelve patients (29.3%) underwent surgery for functional reasons, and twenty-six (63.4%) had it for both aesthetic and functional issues. There was a statistically significant difference regarding changes in SCHNOS regarding nasal obstruction scores (SCHNOS-O) and nasal cosmesis scores (SCHNOS-C) (p < 0.001). These findings coincided with a substantial reduction of all SCHNOS items postoperatively (p < 0.001). There was no statistically significant relationship between changes in (SCHNOS-O) or (SCHNOS-C) pre-and postoperatively and either age, sex, history of trauma, or type of surgery. However, a statistically significant difference was detected when assessing the relationship between changes in SCHNOS-O and the reason for surgery.

Conclusion

A thorough knowledge of three-dimensional pathology and time-associated changes is required to achieve optimal aesthetic and functional outcomes for crooked nose patients. The use of highly validated questionnaires like SCHNOS in clinical practice is highly encouraged to modify and trace surgical techniques to the most appropriate and successful ones for the patients.

Secondary Contouring for the Butterfly Graft: Improving Form and Preserving Function

OBJECTIVE

The butterfly graft (BFG) secondary contouring procedure addresses external nasal irregularities following the primary BFG surgery. We explore demographic factors associated with the desire for secondary contouring and assess patient-reported outcomes following the procedure.

METHODS

A retrospective analysis of 374 patients undergoing BFG between April 2020 and April 2023 identified 10 individuals electing for secondary contouring. Demographics, Nasal Obstruction Symptoms Evaluation (NOSE) scores, Rhinosinusitis Disability Index (RSDI), and decision regret scale (DRS) were collected and reported.

RESULTS

Secondary contouring rate was 2.7% of total cases. The majority of patients desiring BFG secondary contouring were white females (90%). NOSE scores significantly improved post-primary surgery (mean change: 51.7, SD: 14.01, p-value: <0.05). Although overall NOSE scores remained improved after secondary contouring (mean change: 47.2, SD: 18.84, p-value: <0.05) compared with their preoperative NOSE scores, one patient (10%) reported worse score after secondary contouring. Four patients (40%) reported worsening after secondary contouring compared with after initial BFG surgery. DRS indicated minimal regret from patients.

CONCLUSION

BFG secondary contouring is a valuable option for patients with external nasal complaints, providing improvements in nasal appearance and durable improvement in breathing outcomes. We emphasize the importance of patient counseling and appropriate patient selection. Our results suggest that patients should expect a slight worsening of NOSE scores following secondary contouring, but that significant worsening is a low risk.

LEVEL OF EVIDENCE

Level 4: Case series Laryngoscope, 2024.

Patient-Reported Outcome Measures in Nasal Valve Repair and Nasal Obstruction

Although no gold-standard test exists for measuring the success of surgery in functional rhinoplasty, the patient's own subjective experience of their nasal airway obstruction and its impact on quality of life is paramount in outcomes assessment. Patient-reported outcome measures (PROMs) are questionnaires designed to evaluate both disease-specific nasal functional and esthetic domains and global health-related quality of life domains. Ideal PROMs are derived from patient input, psychometrically validated, reliable, and responsive. Assessment at both preoperative and postoperative visits allows for quantitative analysis of surgical outcomes and helps promote communication between the patient and surgeon.

Evaluation and Management of Lateral Wall Insufficiency

Successful treatment of nasal airway obstruction depends on accurate diagnosis of the underlying etiology. Lateral wall insufficiency (LWI) is a common cause of obstructed nasal breathing and should be recognized and treated accordingly by the rhinoplasty surgeon. LWI refers to dynamic collapse of the lateral nasal sidewalls at the internal (zone 1) and external (zone 2) nasal valves. This article serves as an overview of the important aspects in evaluation and management of LWI.

Comparing Patient-Reported Outcomes with Computational Fluid Dynamics-Derived Nasal Airflow After Nasal Airway Surgery: Prioritizing the Patient's Perception of Nasal Obstruction

Background: Some patients report persistent nasal obstruction after surgical treatment despite objective improvement. Objective: To compare patients' perceptions of nasal obstruction after surgery with objective nasal airflow as determined by computational fluid dynamics (CFD) modeling: (1) Is perception driven by a more symptomatic side? (2) Can symptom improvement be predicted with CFD modeling? Methods: Pre/postoperative Nasal Obstruction Symptom Evaluation (NOSE) and visual analog scale (VAS) score were collected for patients undergoing nasal obstruction surgery. Pre/postoperative computed tomography was used to generate patient-specific airway models for CFD simulation at 15 L/min resting inspiration. Results: Ten patients (22-53 years, seven men and three women) underwent septoplasty, turbinate reduction, and/or rhinoplasty. Postoperative NOSE was most correlated with postoperative VAS score from the "affected" side (R2 = 0.59, p < 0.01), and postoperative NOSE was strongly predicted by a two-parameter model using parameters only from the "affected" side (R2 = 0.84, adjusted R2 = 0.80, p < 0.01). Conclusion: The postoperative state of the initially "affected" side drives outcomes after nasal obstruction surgery. Surgeries should prioritize improving the "affected" side. A two-parameter model using the VAS and nasal airflow from only the "affected" side strongly predicts NOSE and is promising for the future using virtual planning to individualize procedures to optimize outcome.

Boomerang Modification of the Septal Extension Graft: Graft Design and Functional Outcomes

Background: A "boomerang" graft is an end-to-end caudal septal extension graft (SEG) that conforms to the geometry of the anterior septal angle, and avoids septal overlap, unlike a side-to-side SEG. Objective: To compare breathing improvements in rhinoplasty patients receiving boomerang SEGs and patients receiving side-to-side SEGs. Methods: Retrospective cohort analysis of patients undergoing rhinoplasty with either end-to-end boomerang SEG or a side-to-side SEG. Functional outcomes were assessed through the Nasal Obstruction Symptom Evaluation (NOSE) survey. Results: The boomerang SEG cohort had a mean age of 34 years and were 68% female compared with 38 years and 67% female in the side-to-side SEG cohort (p > 0.05). The cohorts did not differ in the proportion of the lateral crural tensioning, spreader graft placement, or history of rhinoplasty. The boomerang cohort demonstrated a 67% reduction in NOSE scores compared with a 70% reduction among the side-to-side SEG cohort (p = 0.14). Men undergoing boomerang graft placement reported significantly less postoperative functional improvement than men undergoing placement of a side-to-side SEG (62% vs. 77%, p = 0.01). Conclusion: Use of a boomerang graft is not likely to negatively affect rhinoplasty functional outcomes when compared with a side-to-side SEG.

Patient-Reported Outcome Measures Including Nasal Breathing Improvement After Functional Rhinoplasty Using Endonasal Septal Extension Grafting

Objective: To measure the change perceived by patients after endonasal rhinoplasty using a, septal extension graft (SEG), as measured by patient-reported outcome measures (PROMs). Methods: A retrospective review of patients with nasal obstruction underwent septoplasty, turbinoplasty, and SEG. PROMs were assessed to compare operative outcomes for breathing (Nose Obstruction Symptom Evaluation [NOSE], Sinonasal Outcome Test [SNOT]-22, Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]), and sleep quality (Epworth Sleepiness Scale [ESS]) Results: Of the 34 patients undergoing rhinoplasty with Endonasal SEG, the median patient age was 38.3 years (range 17-58) and mostly male (n = 18, 52.9%). Additional procedures performed on the patients included septoplasty (n = 34, 100%) and turbinate reduction (n = 34, 100%). Average follow-up was 126.6 days (range 28-573) for a majority of PROMs. There were no complications. The average change in NOSE score was 71.5 and -49.4 (standard deviation [SD] = 19.0, p < 0.001). SNOT-22 change was 35.4 and -24.2 (SD = 14.5, p < 0.001), and ESS scores averaged 6.7 and -3.4 (SD = 4.3, p < 0.001). The average SCHNOS total, functional, and cosmetic scores were 40.6, 67.9, and 22.4, respectively, and -28.0 (SD = 19.8), -44.5 (SD = 22.9), and 17.1 (SD = 24.6) (p < 0.001). Conclusion: In this pilot study, patients reported improvement in nasal breathing after correcting a deviated caudal septum and applying an Endonasal SEG.

Quantifying the Subjective Experience of Nasal Obstruction: A Review

Nasal obstruction is an exceedingly common problem and challenging to treat due to its multifactorial etiology. Therefore, measuring treatment outcomes of nasal obstruction can be equally complex yet vital to appropriately assessing symptom improvement or resolution. Both physiologic and anatomic assessments of the nasal airway exist in addition to validated patient-reported outcome measures (PROMs), which objectify subjective nasal obstruction and sinonasal symptoms. Correlation between objective and subjective treatment outcome measures is controversial with clinical guidelines favoring the use of PROMs for surgical treatment of nasal obstruction. In this review, the anatomic and physiologic measurements of the nasal airway and validated PROMs will be discussed, as well as the rationale for implementing PROMs into the rhinoplasty surgeon's practice.

Effectiveness of Radiofrequency Device Treatment for Nasal Valve Collapse in Patients With Nasal Obstruction

OBJECTIVE

Internal nasal valve dysfunction is a prevalent cause of nasal obstruction. This systematic review, along with a Meta-analysis, evaluated the efficacy of temperature-controlled radiofrequency device (RFD) treatment in alleviating nasal obstruction by rectifying nasal valve collapse.

DATA SOURCES

A comprehensive review of studies retrieved from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases (up to December 2022) was conducted.

REVIEW METHODS

We included studies that evaluated the quality of life and nasal obstruction scores before and after RFD treatment. In addition, sham-controlled studies were analyzed.

RESULTS

In total, 451 patients across 8 studies were included in the analysis. Patients who underwent RFD treatment reported a significantly enhanced quality of life 24 months after treatment compared to pretreatment scores. The rates of clinically improved states and positive responses regarding quality of life after treatment were 82% and 91%, respectively. Moreover, the disease-specific quality of life, as assessed by the Nasal Obstruction Symptom Evaluation score, significantly improved.

CONCLUSION

RFD may help improve nasal obstruction symptoms. Further randomized clinical studies on larger cohorts are essential to substantiate its efficacy in enhancing nasal valve function.

Patient Outcomes in Lateral Crural Repositioning and Reconstruction in Revision Rhinoplasty

Background: In revision rhinoplasty, lateral crural repositioning/reconstruction is considered a complex maneuver. The aim of this study is to measure patient outcomes after lateral crural repositioning/reconstruction in revision rhinoplasty. Methods: In this retrospective case series, patients who underwent revision rhinoplasty with lateral crural repositioning/reconstruction for functional, cosmetic, or combined purposes were reviewed. Preoperative Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) scores, functional and cosmetic visual analog scales (VAS-functional [F] and VAS-cosmetic [C]), and lateral wall insufficiency (LWI) grades were compared with their respective postoperative scores. Results: Forty-two patients were identified who underwent lateral crural repositioning. The mean postoperative follow-up for ≤6 months (PO1) and >6 months (PO2) was 3.1 (standard deviation [SD] 1.7) and 11.5 (SD 5.3) months, respectively. At both postoperative periods, significant improvement (p < 0.05) in patient-reported outcomes was observed in mean SCHNOS-Obstruction, SCHNOS-Cosmesis, VAS-F, and VAS-C scores. The postoperative changes in LWI scores (Δ) were significant on both sides at zone 1 at PO1 (p < 0.05) and PO2 (p < 0.05), and at PO2 on the left side (p < 0.05) only, for zone 2. Conclusion: Lateral crural repositioning with reconstruction is an effective maneuver in revision rhinoplasty in a subset of patients and specifically helps to improve nasal tip aesthetics while preserving function.

Prevalence and Characteristics Associated with Positive Body Dysmorphic Disorder Screening Among Patients Presenting for Cosmetic Facial Plastic Surgery

Background: Many patients with body dysmorphic disorder (BDD) seek out cosmetic surgery to alleviate their symptoms of distress related to a perceived defect in their appearance; however, the prevalence and risk factors for BDD among patients with cosmetic concerns have not been well characterized. Methods: We screened adult patients presenting to the clinic from June 2021 through September 2022 for BDD using the BDD Questionnaire-Aesthetic Surgery (BDDQ-AS) who were seen in consultation for rhinoplasty, aging face, and injectables. Results: Among 488 patients, the prevalence of screening positive for BDD was 41.0%. The prevalence of a positive BDD screen was highest among patients who were younger (p = 0.02), and those who had a positive self-reported psychiatric history (p = 0.02). Among rhinoplasty patients, those with aesthetic/cosmetic motivations, and those seeking revision rhinoplasty had higher rates of positive BDD screen. Higher scores on the Standardized Cosmesis and Health Nasal Outcomes Survey-Nasal Obstruction Score (SCHNOS-O) (p = 0.01) and Standardized Cosmesis and Health Nasal Outcomes Survey-Nasal Obstruction Score-Nasal Cosmesis Score (SCHNOS-C) (p < 0.0001) were predictive of a positive BDD screen, while question 5 of the SCHNOS was highly predictive of positive BDD screening (p < 0.0001). Conclusions: Our study characterizes relationships between positive BDD screening and age, gender, self-reported psychiatric history, and motivations for consultation, among patients seen for cosmetic surgery evaluation in a facial plastic and reconstructive surgery setting.

Patient-Reported Outcomes Measures in Rhinoplasty: Need for Use and Implementation

Patient-reported outcome metrics (PROMs) are increasingly utilized to capture data about patients' quality of life. PROMs play an important role in the value-based health care movement by providing a patient-centered metric of quality. There are many barriers to the implementation of PROMs, and widespread adoption requires buy-in from numerous stakeholders including patients, clinicians, institutions, and payers. Several validated PROMs have been utilized by facial plastic surgeons to measure both functional and aesthetic outcomes among rhinoplasty patients. These PROMs can help clinicians and rhinoplasty patients participate in shared decision making (SDM), a process via which clinicians and patients arrive at treatment decisions together through a patient-centered approach. However, widespread adoption of PROMs and SDM has not yet been achieved. Further work should focus on overcoming barriers to implementation and engaging key stakeholders to increase the utilization of PROMs in rhinoplasty.

Temperature-controlled radiofrequency device treatment of septal swell bodies for nasal airway obstruction: An open-label, single arm multicenter study

BACKGROUND

Nasal airway obstruction (NAO) is a highly prevalent disorder. Septal swell body (SSB) hypertrophy is an often overlooked contributor to NAO. SSB treatment may relieve symptoms of NAO. The objective of this study was to assess the clinical use of a temperature-controlled radiofrequency (TCRF) device to treat SSBs to improve symptoms in adults with NAO.

METHODS

In this prospective, multicenter, open-label, single arm study, patients with severe or extreme NAO related to SSB hypertrophy received bilateral TCRF treatment in the SSB area. The primary endpoint was improvement in Nasal Obstruction Symptom Evaluation (NOSE) Scale scores from baseline to 3 months postprocedure. A subset of study patients underwent computed tomography (CT) imaging to evaluate posttreatment changes in SSB size.

RESULTS

Mean NOSE Scale scores significantly improved from 73.5 (SD 14.2) at baseline to 27.9 (SD 17.2) at 3 months postprocedure, a reduction of -45.3 (SD 21.4, 95% confidence interval [CI]: -50.4 to -40.1; p < 0.0001); the responder rate was 95.7% (95% CI: 0.88 to 0.99; p < 0.0001). CT evaluation at 3 months showed statistically significant reductions in the SSB with the greatest reduction in the middle thickness (mean change -3.4 [SD 1.8] mL, 95% CI: -4.0 to -2.8; p < 0.0001). Minimal adverse events with any relationship to the device or procedure were reported; none were serious in nature and no septal perforations occurred.

CONCLUSIONS

This study demonstrates that TCRF treatment of SSB hypertrophy is well tolerated and effective at reducing both SSB size and symptoms of NAO at 3 months posttreatment.

Functional and Aesthetic Outcomes of No-Dissection Nasal Dorsum Using Subdorsal Septal Excision in Preservation Rhinoplasty

BACKGROUND

Dorsal preservation (DP) caused privilege change in the concept of rhinoplasty and a promising superior functional and aesthetic transformation in rhinoplasty surgery. Avoiding dissection of the dorsal nasal bone and cartilage will leave the soft-tissue envelope intact, leading to a fine and smooth appearance, faster operation with less subsequent edema, and overall preservation of the dorsal aesthetic line.

METHODS

This prospective study included 113 patients who underwent DP rhinoplasty for nasal hump treatment with minimum dissection of nasal dorsum soft-tissue envelope. Results were evaluated using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).

RESULTS

The mean preoperative SCHNOS score was 7.21; the mean obstructive score was 2.95 ± 1.068 and the mean aesthetic score was 4.27 ± 0.771. The average lowering of the dorsal hump was 4.4 mm. Approximately 96% of patients showed improvement in the SCHNOS score after surgery, 86.7% (98 patients) showed improvement in the obstructive symptoms and 95.6% (108 patients) showed improvement in the aesthetic score. Complications were seen in 22.11% (most commonly residual hump in 13.27% of cases and dorsal indentation in 5.31%), bleeding was seen in 2.65%, and granuloma formation at the dorsal osteotomy site was seen in 0.88%. There was a very significant improvement in the aesthetic, obstructive, and overall SCHNOS score ( P = 0.000) for each parameter.

CONCLUSIONS

DP rhinoplasty is a safe and very effective procedure, with very low risk of complications. Most of the treated patients have improvement of the obstructive and aesthetic outcome after surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Patient's Perception of Nasal Function and Cosmesis After Maxillomandibular Advancement for Obstructive Sleep Apnea

Background: Maxillomandibular advancement (MMA) remains one of the most effective surgeries for the treatment of obstructive sleep apnea (OSA), but it can be difficult to manage nasal and midfacial esthetics for patients requiring significant maxillary advancement. Objective: To evaluate changes in the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) after the modified MMA approach. Methods: This prospective study was conducted on subjects undergoing MMA at a tertiary referral center from September 2020 to August 2021. Nasal function, cosmesis, and sleepiness were assessed perioperatively with the SCHNOS, visual analog scale for nasal function and cosmesis, and Epworth sleepiness scale (ESS). Objective polysomnography data were also investigated. Results: Thirty-one subjects met inclusion criteria. After MMA, SCHNOS-O (obstruction domain) improved from 44.38 ± 26.21 to 19.03 ± -4.75 (p < 0.001). The SCHNOS-C (cosmesis domain) improved significantly from 13.95 ± 19.32 to 5.27 ± 8.93 (p = 0.029). Specific items evaluating self-esteem, nasal straightness, and symmetry showed significant improvement (p = 0.006, 0.025, 0.044). The ESS also improved from 9.41 ± 6.11 to 3.26 ± 3.03 (p < 0.001), and it correlated with nasal obstruction scores. Conclusion: In this study, patients' perception of nasal obstruction and appearance improved after applying the nasal modifications to MMA described for OSA.

Most-Cited Patient-Reported Outcome Measures Within Otolaryngology-Revisiting the Minimal Clinically Important Difference: A Review

Importance

Patient-reported outcome measures (PROMs) allow clinicians and researchers to assess health-related information from a patient's perspective. These measures have been used more frequently over the last several decades, but an associated minimal clinically important difference (MCID) is needed to optimize their utility. This narrative review identified the top 100 most-cited otolaryngology-related PROM development and validation publications and assessed the presence and characteristics of the PROMs' associated MCID.

Observations

In this narrative review, a literature search in Scopus and Web of Science was conducted on June 29, 2022, using keywords related to PROM development and validation studies in otolaryngology and reference lists. Studies that met the definition of a PROM and assessed an otolaryngologic disorder or study population were included for full-text review. After full-text review of 188 articles, the top 100 most-cited PROM development and validation publications, resulting in 106 total PROMs, were chosen for review. A total of 39 (37%) of the identified PROMs had an associated MCID. Of those reporting an MCID, 14 (35.9%) used an anchor-based method, 12 (30.8%) used a distribution-based method, 10 (25.6%) used both, and 3 (7.7%) did not specify or used neither method. Rhinology had the greatest number of PROMs with an associated MCID (16 of 24, 66%), and pediatrics had the fewest (1 of 13, 7.7%). The median number of citations of PROMs with an MCID was higher than those without an MCID.

Conclusions and Relevance

The majority of the most-cited PROMs in otolaryngology lack an associated MCID. These data indicated that there are a multitude of PROMs that have been cited hundreds of times and used for decades without the ability to identify whether a particular change in score on the instrument is clinically meaningful. There is a need to determine and validate MCIDs for commonly used PROMs to aid clinical research and trial interpretation.

Septal Perforation Repair Using a Temporoparietal Fascia and Polydioxanone Plate Construct: A Multi-Institutional Analysis

Background: Nasal septal perforations (NSPs) are notoriously difficult to fix and closure can paradoxically lead to worsening of symptoms, prompting numerous techniques for repair including temporoparietal fascia (TPF)-polydioxanone (PDS) plate interposition grafting. Objectives: To compare rates of NSP closure with TPF-PDS interposition grafting among a variety of institutions with diverse environmental influences and patient-specific factors. Methods: Retrospective review of patients undergoing TPF-PDS interposition grafting at seven different U.S. institutions over 5 years. Outcomes include closure rate, self-reported symptom improvement, change in Nasal Obstruction Symptomatic Evaluation (NOSE) score, and postoperative complications. Results: Sixty-two patients (39 female) with a mean age of 41.5 years were included. Most common perforation location was anterior (53%), and average size was 1.70 cm². NSP closure with symptomatic improvement was achieved in 95% of participants. Postoperative NOSE scores decreased on average by 42 points. Residual crusting occurred in 29% of patients, independent of external factors. Conclusions: TPF-PDS interposition grafting is highly effective for NSP repair in a wide variety of settings, and NOSE scores correspond well with patient-reported outcomes.

Outcomes 12 Months After Temperature-Controlled Radiofrequency Device Treatment of the Nasal Valve for Patients With Nasal Airway Obstruction

Question

Is temperature-controlled radiofrequency device treatment of the nasal valve safe and associated with improvement in symptoms of nasal airway obstruction through 12 months postprocedure?

Findings

At 12-month follow-up of 108 patients treated in a randomized clinical trial with 3-month crossover available to patients in the index sham control arm, patients in the combined active treatment group exhibited a sustained improvement in symptoms over baseline, measured by the Nasal Obstruction Symptom Evaluation Scale.

Meaning

Temperature-controlled radiofrequency device treatment of the nasal valve was associated with a sustained improvement in symptoms of nasal airway obstruction through 12 months.

Importance

Nasal valve collapse is a primary cause of nasal airway obstruction (NAO). Patients with NAO and nasal valve collapse experience a variety of symptoms that lower their quality of life, such as nasal congestion, headache, sleep disturbance, daytime sleepiness, and snoring.

Objective

To determine if active treatment of the nasal valve with a temperature-controlled radiofrequency (TCRF) device, previously demonstrated superior to a sham procedure at 3 months, was safe and associated with sustained improvements in symptoms of NAO through 12 months.

Design, Setting, and Participants

In a prospective, multicenter, single-blinded, randomized clinical trial, patients in 16 centers in the US with index procedures between August and December 2020 were assigned to TCRF device treatment of the nasal valve or a sham control procedure (no RF energy). Patients had a baseline Nasal Obstruction Symptom Evaluation (NOSE) Scale score of 55 or greater with nasal valve collapse as the primary or substantial contributor to NAO. After primary end point evaluation at 3 months, eligible patients in the sham control arm crossed over to active treatment. Data analysis was performed between April and May 2022.

Interventions

Patients were treated bilaterally with the TCRF device at 4 or fewer nonoverlapping areas on the nasal mucosa at the junction of the upper and lower lateral cartilage on the lateral nasal wall.

Main Outcomes and Measures

The primary end point measure was responder rate, defined as 20% or greater reduction in NOSE Scale score or 1 or greater reduction in NOSE Scale clinical severity category.

Results

A total of 108 patients received active treatment (77 as index active treatment, 31 after crossover). The mean (SD) age of patients was 48.5 (12.3) years; 66 (61.1%) were women. The combined group of patients receiving active treatment had a mean baseline NOSE Scale score of 76.3 (95% CI, 73.6-79.1). At 12 months (n = 88), the responder rate was 89.8% (95% CI, 81.7%-94.5%). The NOSE Scale score improved from baseline (mean change, −44.9 [95% CI, −52.1 to −37.7]). No device/procedure-related serious adverse events were reported.

Conclusions and Relevance

In this follow-up of a cohort from a randomized clinical trial, the minimally invasive TCRF device, previously demonstrated to be superior to a sham procedure, was safe and associated with improvement in symptoms of NAO through 12 months postprocedure.

Trial Registration

ClinicalTrials.gov Identifier: NCT04549545

Effect of alar nasal valve stent on nasal breathing

PURPOSE

Lateral nasal wall insufficiency has previously been a surgical challenge. In 2018, the Alar Nasal Valve Stent (Medtronic) was taken into use at Helsinki University Hospital. The alar cartilages are repositioned and locked into position with the Alar Nasal Valve Stent on the mucosa. The stent gives support and widens the alar valve while cartilages scar into their new position presumably facilitating breathing after removal of the stent. The aim of this prospective, observational study was to investigate whether the Alar Nasal Valve Stent has an effect on nasal breathing in patients with lateral nasal wall insufficiency.

MATERIALS AND METHODS

Symptom questionnaires (Sino-Nasal Outcome Test-22, Nasal Obstruction Symptom Evaluation, five-step symptom score) were analyzed preoperatively and at 3, 6, and 12 months postoperatively. Acoustic rhinometry, rhinomanometry, and peak nasal inspiratory flow were analyzed preoperatively and 3 months postoperatively. The patients performed a stress ergometry preoperatively and 3 months postoperatively, with their noses being photographed and filmed.

RESULTS

In a series of 18 patients, a significant positive difference was seen in subjective symptom scores preoperatively versus postoperatively. The difference remained stable throughout the follow-up. No difference in objective symptom measurements was observed.

CONCLUSIONS

Patients suffering from lateral nasal wall insufficiency experience a significant subjective improvement in nasal breathing after Alar Nasal Valve Stent surgery.

Multi-dimensionality of patient reported outcome measures in rhinoplasty satisfaction

Background The FACE-Q rhinoplasty module (nose and nostrils), Utrecht Questionnaire and NOSE-scale are validated Dutch patient-reported outcome measures (PROMs) to evaluate rhinoplasty satisfaction. The objective of this study was to analyze the dimensionality of the measured variables in these four existing questionnaires. Additionally, we investigated the ability of the PROMS to measure change. Methods A prospective single center study was performed in a consecutive cohort of 106 Dutch-speaking patients. Patients were invited to fill in four PROMs: FACE-Q rhinoplasty module (nose and nostrils), Utrecht Questionnaire and NOSE-scale, preoperatively and 3 months postoperatively. Item quality was calculated in all four questionnaires. The ability of the questionnaires to differentiate between pre-and postoperative patients was determined with a binary logistic regression. Exploratory factor analysis was performed to determine the latent dimensions. Results Item quality was confirmed in all questionnaires. Backward binary logistic regression revealed that NOSE and FACE-Q nose module were the best discriminant factors pre- and postoperatively. Combination of these two questionnaires gave a specificity of 97,33% and a sensitivity of 94.52% to discriminate between pre-and post-operative cases. Exploratory factor analysis identified the presence of 4 dimensions: 1) cosmesis of the nose 2) cosmesis of the nostrils 3) nasal function and 4) psychosocial well-being in rhinoplasty patients. Lack of factorial invariance in the pre- as compared to the postoperative phase was detected, especially with the FACE-Q nose and to a lesser extent with the Utrecht questionnaire.

The Safety and Efficacy of Spreader Grafts and Autospreaders in Rhinoplasty: A Systematic Review and Meta-analysis

BACKGROUND

The aim of this study was to systematically evaluate the evidence of surgical outcomes and complications of spreader grafts and autospreader flaps in the context of middle vault reconstruction after dorsal hump removal.

MATERIAL AND METHODS

A systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion and exclusion criteria were based on the population, intervention, comparison, and outcome (PICO) framework. Medline (via PubMed), EMBASE, Cinahl, Scopus, and Web of Science were searched for Clinical and observational studies published in peer-reviewed academic journals with abstracts available that reported rhinoplasty employing either spreader graft or autospreader flap techniques and were published prior to March, 2021.

RESULTS

Fifty-two of 1129 relevant studies were included in the qualitative analysis. Thirty-four studies (65.4%) were related to spreader graft (SG), 10 (21.1%) studies of autospreader flap (AF) alone and 8 (13.5%) studies involving both grafts. Meta-analysis was performed on 17 studies reporting change in NOSE scores, with pooled effect of - 23.9 (95% CI, - 26.7 to - 21.1) points. High heterogeneity with I² = 99%. Summary data showed no differences between groups, AF group versus no graft (p = 0.7578), AF versus SF group (p = 0.9948), and SG group versus no graft (p = 0.6608).

CONCLUSION

Based on available data, change in NOSE scores after rhinoplasty was similar in procedures that used spreader graft only or autospreader flap only.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Comprehensive Strategy for Improving Nasal Outcomes After Large Maxillomandibular Advancement for Obstructive Sleep Apnea

Background: Rate of corrective nasal surgery after maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) has been reported to be 18.7% for functional and aesthetic indications. Objective: Describe a comprehensive strategy to optimize nasal outcomes with MMA for OSA. Methods: A retrospective review of patients undergoing MMA for OSA in a tertiary referral center was performed, with a comprehensive perioperative intervention to optimize nasal outcomes from January 2014 to February 2018. Outcomes included the Apnea-Hypopnea Index (AHI), oxygen saturation (SpO₂) nadir, corrective nasal surgery needed after MMA, and Nasal Obstruction Symptom Evaluation (NOSE) scores. Results: AHI after MMA showed significant reduction (-34.65, p < 0.001), SpO₂ nadir increased (+6.08, p < 0.001), and NOSE scores decreased (-5.96, p < 0.001). Corrective nasal surgery needed after MMA was reported in 6.5% (8 of 122) subjects at a mean of 8.5 months, ranging from 1 to 24.7 months. Six subjects underwent either septoplasty and/or valve stenosis repair, and two subjects underwent functional and aesthetic rhinoplasty. Conclusion: A perioperative strategy was applied since 2014 that showed effectiveness in reducing post-MMA corrective nasal surgery to 6.5%.

Temperature-controlled radiofrequency device treatment of the nasal valve for nasal airway obstruction: A randomized controlled trial

Background

Nasal valve collapse is one of several causes of nasal obstruction. The safety and efficacy of a temperature‐controlled radiofrequency (RF) device for the treatment of the nasal valve for nasal airway obstruction (NAO) has been established in single‐arm studies. The objective of this trial was to compare active device treatment against a sham procedure (control).

Methods

In a prospective, multicenter, single‐blinded, randomized controlled trial (RCT), patients were assigned to bilateral temperature‐controlled RF treatment of the nasal valve (n = 77) or a sham procedure (n = 41), in which no RF energy was transferred to the device/treatment area. The device was applied to the mucosa over the lower lateral cartilage on the lateral nasal wall. The primary endpoint was responder rate at 3 months, defined as a ≥20% reduction in Nasal Obstruction Symptom Evaluation (NOSE)‐scale score or ≥1 reduction in clinical severity category.

Results

At baseline, patients had a mean NOSE‐scale score of 76.7 (95% confidence interval [CI], 73.8 to 79.5) and 78.8 (95% CI, 74.2 to 83.3) (p = 0.424) in the active treatment and sham‐control arms, respectively. At 3 months, the responder rate was significantly higher in the active treatment arm (88.3% [95% CI, 79.2%‐93.7%] vs 42.5% [95% CI, 28.5%‐57.8%]; p < 0.001). The active treatment arm had a significantly greater decrease in NOSE‐scale score (mean, −42.3 [95% CI, −47.6 to −37.1] vs −16.8 [95% CI, −26.3 to −7.2]; p < 0.001). Three adverse events at least possibly related to the device and/or procedure were reported, and all resolved.

Conclusion

This RCT shows temperature‐controlled RF treatment of the nasal valve is safe and effective in reducing symptoms of NAO in short‐term follow‐up.

Comparison of the Distribution of Standardized Cosmesis and Health Nasal Outcomes Survey Scores Between Symptomatic and Asymptomatic Patients

Background: The Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) is a validated patient-reported outcome measure that evaluates subjective cosmetic and functional complaints. The goal of this study was to compare scores between patients with and without nasal complaints. Methods: This is a retrospective review of SCHNOS-O (obstructive) and SCHNOS-C (cosmetic) scores in patients presenting for functional or cosmetic concerns between 2019 and 2020. Receiver operating characteristic curve analysis was used to determine the score that best separated symptomatic from asymptomatic patients. SCHNOS scores were also subdivided to define severity of presenting complaints. Results: In total, 414 patients were included. A SCHNOS-O score of 40 differentiated patients with and without nasal obstruction. Patients may be categorized as having mild (<40), moderate (45-70), and severe (75-100) nasal obstruction based on the SCHNOS-O score. A score of 30 on the SCHNOS-C differentiated patients with and without aesthetic concerns. Patients may be categorized as having mild (<33.3), moderate (33.3-66.6), and severe (>66.6) aesthetic distress based on the SCHNOS-C. Conclusion: An understanding of SCHNOS scores that differentiate symptomatic for asymptomatic patients can aid in the preoperative evaluation of rhinoplasty patients.

Using Nasal Self-Esteem to Predict Revision in Cosmetic Rhinoplasty

BACKGROUND

It would be useful if existing tools or outcomes measures could predict which patients are at greater risk of revision surgery following rhinoplasty.

OBJECTIVES

The authors sought to determine if a single question assessing nasal self-esteem could be utilized to predict which patients are at greatest risk of revision surgery following rhinoplasty.

METHODS

The authors conducted a retrospective chart review of 148 patients who underwent cosmetic rhinoplasty. Results of pre- and postoperative Standardized Cosmesis and Health Nasal Outcomes Survey questionnaires and rates of revision or patient-initiated revision discussions (RD) were collected. Patients were stratified based on answers to Standardized Cosmesis and Health Nasal Outcomes Survey question 5 (SQ5), "Decreased mood and self-esteem due to my nose."

RESULTS

Of the 148 patients included in the analysis, 72.9% were women, and the mean age was 30.9 (15-59, standard deviation = 10.3) years. Those patients who selected 4 or 5 on SQ5 had an overall revision rate of 16.7% and 18.8%, respectively, and a RD rate of 27.8% and 31.25%, respectively. Those patients who selected 0 through 3 on SQ5 had an overall revision rate of 0% and an overall RD rate of 10.4%. Only SQ5 was predictive of revision and RD on logistic regression analysis (P = 0.0484 and P = 0.0257) after Bonferroni correction.

CONCLUSIONS

SQ5 appears to offer a useful adjunct to guide surgical management of the cosmetic rhinoplasty patient. Those patients who reported worse nasal self-esteem and associated mood preoperatively were more likely to request and undergo revision.

LEVEL OF EVIDENCE: 4

Impact of intraoperative Cone-Beam Computed Tomography use on patient satisfaction after closed nasal reduction

Background: The aim of the study was to assess, whether there is a difference in aesthetic and functional patient satisfaction between closed nasal reductions with intraoperative Cone-Beam Computed Tomography (CBCT) and without using intraoperative medical imaging. Methods: A monocentric, retrospective cohort study of 43 patients (20 patients treated with intraoperative CBCT and 23 patients treated without intraoperative imaging) was conducted. Subjective postoperative aesthetic and functional aspects of the nose were assessed. Additionally, questions comparing the aesthetics and function of the nose before and after the accident and on the desire of revision surgery were asked. Results: Both the SCHNOS-C and total SCHNOS score in the non-CBCT group were higher than the respective scores of the CBCT-group. The comparison of SCHNOS-C between male subjects of the two groups showed no statistical significance. The comparison of SCHNOS-C between male and female subjects over both groups showed significantly higher scores for female subjects. Conclusions: Patients undergoing surgery with intraoperative CBCT imaging showed better aesthetical outcomes than patients, treated without intraoperative imaging. However, the difference showed no clinical importance, so that both strategies appear to have comparable outcomes regarding postoperative aesthetics and function of the nose. Gender instead of the different strategies could contribute to the demonstrated differences. Female subjects seem to be less satisfied with the aesthetics of their nose postoperatively, potentially being more sensitive to remaining nasal deformities after surgery.

Application of Conchal Cartilage Grafts in Nasal Tip Plasty: Comparison and Experience of 3 Methods

INTRODUCTION

The autologous conchal cartilage of good elasticity is easy to harvest, thus is often used in nasal tip plasty of East Asians. However, the operation techniques vary a lot among different surgeons. This article aims to introduce 3 techniques commonly used in clinical practice.

METHODS

One hundred three patients were included in this study and divided into 3 groups according to the shape of the nasal tip during 2017 to 2019. The patients were followed up for at least 6 months. All patients were measured with Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). ImageJ software was used to measure and calculate the projection ratio for lateral position standard image, and columella-labial angle (CLA) was measured.

RESULTS

In group 1, SCHNOS for nasal obstruction (SCHNOS-O) score were 13.23 ± 7.61 and 14.49 ± 10.55 (P > 0.05); SCHNOS for nasal cosmesis (SCHNOS-C) score were 66.55 ± 31.23 and 21.73 ± 18.91 (P < 0.001); projection ratio were 0.51 ± 0.04 and 0.57 ± 0.05 (P < 0.001); CLA were 91.02° ± 5.67° and 93.55° ± 4.64° (P > 0.05), preoperative and postoperative, respectively. In group 2, SCHNOS-O score were 16.76 ± 13.44 and 15.44 ± 9.26 (P > 0.05); SCHNOS-C score were 61.87 ± 44.14 and 19.16 ± 29.37 (P < 0.001); projection ratio were 0.50 ± 0.05 and 0.58 ± 0.03 (P < 0.001); CLA were 92.32° ± 6.39° and 94.86° ± 5.96°(P > 0.05), preoperative and postoperative, respectively. In group 3, SCHNOS-O score were 15.25 ± 7.83 and 17.73 ± 11.66 (P > 0.05); SCHNOS-C score were 52.03 ± 33.38 and 17.73 ± 11.66 (P < 0.001); projection ratio were 0.53 ± 0.05 and 0.57 ± 0.02 (P < 0.001); CLA were 91.65° ± 5.75° and 93.21° ± 5.38° (P > 0.05), preoperational and postoperational, respectively.

CONCLUSIONS

None of these 3 techniques cause or aggravate nasal obstruction, and all of them can achieve high cosmetic satisfaction. Technique 1 and technique 2 are suitable for the patients with moderate and moderate to severe short nose that is common in East Asia, which can better increase the protrusion of the tip and length of the nose. Technique 3 is suitable for the patients with better shape of the nose, who need to slightly increase the protrusion of the nasal tip and increase the upward rotation.

Effect of Lateral Crural Procedures on Nasal Wall Stability and Tip Aesthetics in Rhinoplasty

OBJECTIVES/HYPOTHESIS

To evaluate the lateral nasal wall stability, nasal function, and cosmesis when creating an aesthetically pleasing nasal tip subunit utilizing lateral crus (LC) altering procedures.

STUDY DESIGN

Retrospective cohort.

METHODS

In this retrospective cohort study, cosmetic rhinoplasty patients undergoing LC procedures with available lateral wall insufficiency (LWI) scores were included. An LWI grading system was used to evaluate internal (zone 1) and external (zone 2) nasal valves objectively. Secondarily, Nasal Obstruction Symptom Evaluation (NOSE) Score, Visual Analog Scale (VAS) and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) results were evaluated. Based on the LC intervention, the cohort was divided into six groups: lateral cural strut graft (LCSG), mini-LCSG, lateral crural overlay (LCO) with and without additional support, cephalic trimming, and cephalic turn-in flaps.

RESULTS

Subjects undergoing LCO with and without support, LCSG, and mini-LCSG showed significant improvement in zone 1 LWI (P = .042, P = .041, P < .001, and P < .001, respectively), while cephalic trimming and turn-in/hinged flaps had no effect. Subjects undergoing LCO with support and LCSG showed significant improvement in zone 2 LWI (P = .022, P = .004), while LCO without support, mini-LCSG, cephalic trimming, and turn-in flaps showed no effect on LWI. The SCHNOS-C and VAS-C showed significant improvement in all subgroups (P < .05) when comparing pre- to postoperative values. Alar-spanning sutures did not significantly change zone 1 scores but did conceal zone 2 improvements in LCSG and LCO with support groups.

CONCLUSIONS

Selected LC procedures are robust techniques for improving tip cosmesis independently without compromising nasal lateral wall stability. Some LC procedures can improve nasal valves patency in tip surgery. Laryngoscope, 131:E1830-E1837, 2021.

Examining Preoperative Expectations and Postoperative Satisfaction in Rhinoplasty Patients: A Single-Center Study

Background: In Rhinoplasty, understanding patient expectations are pivotal in achieving an optimal surgical outcome. Objective: To understand preoperative expectations and postoperative satisfaction in patients undergoing rhinoplasty for functional, aesthetic, or both. Method: Adult patients undergoing functional, aesthetic, or combined rhinoplasty from March 2017 to June 2019 were prospectively enrolled. Only patients with complete preoperative functional and cosmetic expectation visual analog scales (VAS) and at least one postoperative functional and cosmetic satisfaction VAS were included. Nasal Obstruction and Symptom Evaluation Scale score and Standardized Cosmesis and Health Nasal Outcomes Survey score were also collected. Results: In the functional subgroup (mean preoperative functional expectation VAS score [17.98 (22.49)] higher mean (standard deviation) postoperative functional satisfaction VAS score were observed at postoperative time interval <2 months [29.59 (27.08), p = 0.008] and 8-12 months [31.43 (28.25), p = 0.035]. In the aesthetic subgroup mean preoperative cosmetic expectation VAS score [89.69 (17.74)], lower mean postoperative aesthetic satisfaction VAS scores were observed at <2 months [79.09 (20.01), p = 0.0001], 2-5 months [79.79 (20.79), p = 0.032], 5-8 months [72 (18.27), p < 0.0001], 8-12 months [78.15 (24.50), p = 0.021], and >12 months [75 (20.64), p = 0.00020]. In the combined subgroup (mean preoperative aesthetic expectation VAS score [85.85 (18.19)]), lower mean postoperative aesthetic satisfaction VAS scores were observed at 2-5 months [78.94 (20.88), p = 0.01] and at >12 months [75.86 (25.57), p = 0.01]. Conclusion: Although rhinoplasty patients tend to be less satisfied with aesthetic than the functional outcome of surgery, preoperative aesthetic expectations are higher in cosmetic rhinoplasty and functional and cosmetic rhinoplasty patients.

Correlation of the Standardized Cosmesis and Health Nasal Outcomes Survey With Psychiatric Screening Tools

BACKGROUND

Identifying mental health disorders, including body dysmorphic disorder (BDD), is important prior to rhinoplasty surgery; however, these disorders are underdiagnosed, and screening tools are underutilized in clinical settings.

OBJECTIVES

The authors sought to evaluate the correlation of a rhinoplasty outcomes tool (Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]) with psychiatric screening tools.

METHODS

Patients presenting for rhinoplasty consultation were prospectively enrolled and administered mental health instruments to assess depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and BDD (BDD Questionnaire-Aesthetic Surgery [BDDQ-AS]) as well as the SCHNOS rhinoplasty outcomes scale. Convergent validity of SCHNOS scores with these mental health instruments was assessed as well as calculation of an optimal SCHNOS-C score to screen for BDD.

RESULTS

A total 76 patients were enrolled in the study. The average SCHNOS-O score (standard deviation) was 46.1 (34.0) and the average SCHNOS-C score was 61.1 (27.0). Five (7%) patients screened positive for depression, and 24 (32%) patients screened positive for mild, 5 (7%) for moderate, and 4 (5%) for severe anxiety. Twenty-four (32%) patients screened positive for BDD by BDDQ-AS scores. SCHNOS-O and SCHNOS-C did not correlate with Patient Health Questionnaire-9 or Generalized Anxiety Disorder-7 scores; SCHNOS-C did correlate with BDDQ-AS. A score of 73 or greater on SCHNOS-C maximized the sensitivity and specificity of also screening positive for BDD with BDDQ-AS. This score correlated with a sensitivity of 62.5%, specificity of 80.8%, and number needed to diagnose of 2.3, meaning for every 2 patients with a score of ≥73 on SCHNOS-C, 1 will have a positive BDDQ-AS score.

CONCLUSIONS

SCHNOS-C correlates with BDDQ-AS and may help screen rhinoplasty patients at higher risk for BDD.

LEVEL OF EVIDENCE: 2

Functional Outcomes of Septal Extension Grafting in Aesthetic Rhinoplasty: A Cohort Analysis

Background: Septal extension grafts (SEGs) are used widely in rhinoplasty as a means of controlling tip position. Grafts positioned in a side-to-side configuration may cause nasal airway obstruction. Methods: Retrospective cohort analysis of patients undergoing cosmetic rhinoplasty. Patients undergoing SEG placement were grouped according to completion of the Nasal Obstruction Symptom Evaluation (NOSE) or Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). The latter has a cosmetic (C) and functional (O) domain. Each group was matched to a cohort that did not undergo SEG placement using criteria: preoperative NOSE or SCHNOS-O score, age, and gender. Patient demographics and outcomes, including NOSE, SCHNOS, and visual analog scale (VAS) scores, were compared between SEG and no-SEG groups using univariate and multivariate analyses. If patients underwent placement of an SEG and complained of obstruction, the laterality of the graft in relation to the complaint was examined. Results: SEGs were placed in 79 patients, of whom 77 completed the NOSE survey and 37 completed the SCHNOS-O both pre- and postoperatively. These patients were matched to patients without SEGs. For both the SCHNOS and NOSE-matched cohorts, functional outcomes (NOSE, SCHNOS-O, and VAS-F) did not significantly differ between SEG and no-SEG groups. These findings were also observed when patients were stratified by cosmetic surgery alone versus combined functional and cosmetic surgery. On multivariate linear regression analysis, when accounting for intraoperative techniques, there was no difference in postoperative NOSE or SCHNOS-O outcomes between the SEG and no-SEG cohorts. Side of postoperative nasal obstruction did not correlate with side of SEG placement. Conclusion: SEGs, when used in a unilateral side-to-side configuration, yield excellent aesthetic results without compromising functional outcomes.

Natural History of the Standardized Cosmesis and Health Nasal Outcomes Survey After Rhinoplasty

OBJECTIVES/HYPOTHESIS

To explore the natural history of nasal obstruction and cosmesis following rhinoplasty by utilizing the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).

STUDY DESIGN

Retrospective chart study.

METHODS

This study was carried out at a tertiary referral center, preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE), SCHNOS-Obstruction (SCHNOS-O), and SCHNOS-Cosmesis (SCHNOS-C) scores in patients who underwent rhinoplasty for functional, cosmetic, or both reasons from June 2017 to May 2019 were reviewed and analyzed. Postoperative intervals were defined as <2 months, 2 to 5 months, 5 to 8 months, 8 to 12 months, and >12 months.

RESULTS

A total of 302 patients (67% women), with a mean age (standard deviation [SD]) of 35 (13) years, who underwent rhinoplasty for functional (90, 30%), cosmetic (124, 41%), and combined functional and cosmetic (88, 29%) reasons, met inclusion criteria. The mean follow-up period (SD, range) was 5 months (4.2 months, 13 days-1.8 years). Compared to the preoperative mean NOSE score, SCHNOS- O, and SCHNOS-C scores, postoperative mean scores for the functional and combined subgroup were significantly lower (P < .05) across all five postoperative intervals. In the cosmetic subgroup, postoperative mean SCHNOS-C scores were significantly lower (P < .05) across all postoperative intervals compared to the mean preoperative scores.

CONCLUSIONS

The natural history of the SCHNOS-O and SCHNOS-C score in patients who underwent rhinoplasty demonstrates 1) after functional rhinoplasty, an improvement in nasal breathing symptoms is attained as early as <2 months postoperatively; and 2) after cosmetic rhinoplasty, an improvement in nasal cosmesis is seen as early as <2 months postoperatively. These improvements in nasal breathing and cosmesis are sustained through a follow-up interval >12 months.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E116-E123, 2021.

Impact of Dorsal Preservation Rhinoplasty Versus Dorsal Hump Resection on the Internal Nasal Valve: a Quantitative Radiological Study

BACKGROUND

This study evaluates the impact of different hump takedown techniques, namely the conventional hump resection with midvault reconstruction, the push-down (PD) and the let-down (LD) procedures, on the INV dimensions.

METHODS

In this cadaveric study, six heads were divided randomly into either the conventional hump resection technique (Group A; n = 6 sides) or DPR techniques (n = 6 sides). This latter group was subdivided such that initially a PD procedure was performed (Group B; n = 6 sides), followed by a LD procedure on the same heads (Group C; n = 6 sides). A validated radiological method was used to measure the INV angle and cross-sectional area (CSA) in a modified coronal plane both pre- and post-procedurally.

RESULTS

Group A did not show significant reduction in the INV angle nor in CSA (p = 0.068 and p = 0.156, respectively). In the push-down group (B), we observed a mean change of 2.05° in the angles and 0.3 cm² in the CSA (p = 0.0163 and p < 0.001, respectively). The LD group (C) did not show significant reduction in the INV angle nor in CSA (p = 0.437 and p = 0.331, respectively).

CONCLUSION

Neither the conventional hump resection nor the LD DPR technique reduced the INV dimensions. However, the PD preservation technique significantly reduced the INV dimensions.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A novel device combining acoustic vibration with oscillating expiratory pressure for the treatment of nasal congestion

BACKGROUND

Chronic nasal congestion affects 20% of the population with significant impact on quality of life. This study investigated the simultaneous administration of nasal acoustic vibration and oscillating expiratory pressure for the treatment of nasal congestion.

METHODS

Patients with chronic nasal congestion but without fixed anatomic obstruction participated in a prospective clinical study applying simultaneous acoustic vibrations and positive expiratory pressure to the nasal cavity twice daily over 5 weeks. Safety was assessed by rhinoscopy and patient questionnaires. Efficacy was assessed using peak nasal inspiratory flow (PNIF), visual analogue scale (VAS) of nasal symptoms, Total Nasal Symptom Score (TNSS), Nasal Obstruction and Septoplasty Effectiveness (NOSE) score, and the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

Forty patients (mean age 39 years, 65% female) completed the study with no adverse effects. At the 2 week follow-up, PNIF improved by 25.0 L/min (31% increase from baseline, p < 0.001). At the 5 week follow-up, nasal congestion VAS improved from mean ± SD of 5.8 ± 2.4 to 2.6 ± 2.3, TNSS improved from 7.2 ± 3.5 to 3.5 ± 3.1, NOSE improved from 50.4 ± 19.9 to 23.3 ± 17.2, and SNOT-22 improved from 31.7 ± 20.3 to 14.2 ± 12.7, all p < 0.001. Eighty percent of patients would use the device again and 87.5% would recommend to others.

CONCLUSION

Simultaneous administration of acoustic vibration and oscillating expiratory pressure appears to be a safe treatment for chronic nasal congestion. Results from this initial study are promising with regard to efficacy but will require further study.

Outcomes of Extracorporeal Septoplasty and Its Modifications in Treatment of Severe L-Strut Septal Deviation: A Systematic Review and Meta-analysis

Importance

While extracorporeal septoplasty (ECS) and its modifications have been previously studied, to our knowledge, no systematic review of surgical outcomes and complications of this technique has been performed.

Objective

To evaluate the evidence of surgical outcomes and complications of ECS (including modified techniques) to treat severe L-strut septal deviation defined as deviation within 1.0 cm of the caudal or dorsal septum.

Data Sources

MEDLINE, Embase, CINAHL, CENTRAL, Scopus, and Web of Science databases and reference lists were searched from inception to April 2018 for clinical and observational studies. Search terms included extracorporeal, septoplasty, and septum.

Study Selection

Selection criteria were defined according to the population, intervention, comparison, and outcome framework. Relevant studies were selected by 2 independent reviewers based on abstracts and full texts.

Data Extraction and Synthesis

Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. Data were collected and synthesized with ranges reported, as well as assessment of bias and heterogeneity when applicable. Analysis started in February 2019.

Main Outcomes and Measures

Outcomes assessed included functional nasal airway improvement by objective measurements and subjective measurements (Nasal Obstruction Symptom Evaluation [NOSE] and visual analog scale scores); complications including bleeding, infection, dorsal irregularities, and other functional or cosmetic deficits; and as revision surgery rates.

Results

Of 291 records initially obtained, 31 were considered relevant after review according to PRISMA guidelines. All studies except 1 randomized clinical trial (3.2%) were observational in nature, with 21 retrospective studies (67.7%) and 9 prospective studies (29.0%). Conventional ECS was performed in 16 studies (51.6%), and modified ECS was performed in 15 studies (48.4%). The sample size varied from 10 to 567, and the mean age varied from 22.5 to 46 years. Of 31 studies, 14 (45%) were of good methodology. Meta-analysis was performed on 5 studies reporting change in NOSE scores, with pooled effect of -60.0 (95% CI, -67.8 to -52.2) points, but heterogeneity was high, with I2 = 96%. When comparing complications between modified and conventional ECS, the relative risk for infections was 0.95 (95% CI, 0.34-2.7); for bleeding, 0; for nasal dorsal irregularities, 0.29 (95% CI, 0.16-0.53); for other cosmetic complications, 4.3 (95% CI, 0.87-21.1); for other functional complications, 0.47 (95% CI, 0.20-1.1); and for revision operations, 1.4 (95% CI, 0.83-2.3).

Conclusions and Relevance

Of the 31 studies included in this systematic review, less than half were of good methodology, and a significant level of heterogeneity was found regarding type of outcome measure used and reporting of complications. To improve the level of evidence, better study methodology, standardization of surgical outcomes measures, and reporting of complications are needed.

The miniature lateral crural strut graft: Efficacy of a novel technique in tip plasty

OBJECTIVES/HYPOTHESIS

To describe a novel technique for tip plasty and determine its efficacy using validated patient-reported outcome measures and objective measures.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study was carried out at a tertiary center. Patients undergoing tip plasty using the miniature lateral crural strut grafts (mini-LCSG) in cosmetic/combined rhinoplasty between January 2016 and August 2019 with available outcome measures were included. We used the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), Nasal Obstruction Symptom Evaluation (NOSE) scores, visual analog scale: functional and cosmetic, and lateral wall insufficiency (LWI) grades.

RESULTS

Among 52 patients, 33 were included; 26 had cosmetic whereas seven had combined functional and cosmetic rhinoplasty, with a follow-up up to 3 years. Both cosmetic and combined subjects showed significant improvement in SCHNOS-Cosmesis (C) scores (-57.31 ± 1.79, P < .001 and - 53.57 ± 8.39, P < .001, respectively) and zone 1 LWI (P < .05, both sides). SCHNOS-Obstruction (O) and NOSE scores showed significant decrease among subjects undergoing combined rhinoplasty only (-55.36 ± 18.58, P < .004, and - 53.93 ± 15.99, P < .003, respectively). With specific regard to tip cosmesis, the mean SCHNOS-6 (item 6 of the SCHNOS questionnaire for tip cosmesis) showed significant improvement (-2.61, P < .001).

CONCLUSIONS

The mini-LCSG is a novel modification for tip plasty that improves tip cosmesis and symmetry, both subjectively and objectively without compromising nasal function.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2581-2588, 2020.