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Mohan S, Fuller JC, Ford SF, Lindsay RW. Diagnostic and Therapeutic Management of Nasal Airway Obstruction: Advances in Diagnosis and Treatment. JAMA FACIAL PLAST SU 2019; 20:409-418. [PMID: 29801120 DOI: 10.1001/jamafacial.2018.0279] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Nasal airway obstruction (NAO) is a common complaint in the otolaryngologist's office and can have a negative influence on quality of life (QOL). Existing diagnostic methods have improved, but little consensus exists on optimal tools. Furthermore, although surgical techniques for nasal obstruction continue to be developed, effective outcome measurement is lacking. An update of recent advances in diagnostic and therapeutic management of NAO is warranted. Objective To review advances in diagnosis and treatment of NAO from the last 5 years. Evidence Review PubMed, Embase, CINAHL, the Cochrane Library, LILACS, Web of Science, and Guideline.gov were searched with the terms nasal obstruction and nasal blockage and their permutations from July 26, 2012, through October 23, 2017. Studies were included if they evaluated NAO using a subjective and an objective technique, and in the case of intervention-based studies, the Nasal Obstruction Symptom Evaluation (NOSE) scale and an objective technique. Exclusion criteria consisted of animal studies; patients younger than 14 years; nasal foreign bodies; nasal masses including polyps; choanal atresia; sinus disease; obstructive sleep apnea or sleep-disordered breathing; allergic rhinitis; and studies not specific to nasal obstruction. Findings The initial search resulted in 942 articles. After independent screening by 2 investigators, 46 unique articles remained, including 2 randomized clinical trials, 3 systematic reviews, 3 meta-analyses, and 39 nonrandomized cohort studies (including a combined systematic review and meta-analysis). An aggregate of approximately 32 000 patients were reviewed (including meta-analyses). Of the subjective measures available for NAO, the NOSE scale is outstanding with regard to disease-specific validation and correlation with symptoms. No currently available objective measure can be considered a criterion standard. Structural measures of flow, pressure, and volume appear to be necessary but insufficient to assess NAO. Therefore, novel variables and techniques must continue to be explored in search of an ideal instrument to aid in assessment of surgical outcomes. Conclusions and Relevance Nasal airway obstruction is a clinical diagnosis with considerable effects on QOL. An adequate diagnosis begins with a focused history and physical examination and requires a patient QOL measure such as the NOSE scale. Objective measures should be adjunctive and require further validation for widespread adoption. These results are limited by minimal high-quality evidence among studies and the risk of bias in observational studies. Level of Evidence NA.
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Affiliation(s)
- Suresh Mohan
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
| | - Jennifer C Fuller
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
| | - Stephanie Friree Ford
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
| | - Robin W Lindsay
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
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Bonaparte JP, Campbell R. A prospective cohort study assessing the clinical utility of the Cottle maneuver in nasal septal surgery. J Otolaryngol Head Neck Surg 2018; 47:45. [PMID: 29996920 PMCID: PMC6042367 DOI: 10.1186/s40463-018-0292-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A nasal septal deviation can have a significant detrimental effect on a patient's quality of life. Nasal valve collapse (NVC) often co-exists with a septal deviation. The Cottle maneuver is one of the most common methods to diagnose NVC; however, no study has assessed the efficacy of this physical exam finding. This study tests the hypothesis that patients with nasal obstruction due to a septal deviation with a negative pre-operative Cottle maneuver will demonstrate a greater improvement in their Nasal Obstruction Symptom Evaluation (NOSE) score, compared to patients who demonstrate a positive pre-operative Cottle maneuver, when assessed at 12 months following a septoplasty with turbinate diathermy. METHODS This was a prospective Cohort Study. The population was 141 patients with nasal obstruction due to a septal deviation with or without nasal valve collapse, excluding patients with bilateral complete nasal valve collapse. Patients were placed in cohorts according to the results of the Cottle maneuver (positive or negative). A NOSE questionnaire was administered at baseline and 12-months after a septoplasty with turbinate diathermy. Non-adjusted NOSE scores were used (score out of 20). An ANOVA was used to compare if there was a difference in outcomes between patient cohorts. RESULTS One hundred and forty-one patients completed 12-month follow-up with 71.5% of patients demonstrating a positive Cottle maneuver at baseline. The mean (95% C.I.) difference in NOSE score at 12 months between patients with a positive Cottle versus a negative Cottle was 0.18 (- 1.6 to 1.92; p = 0.38). CONCLUSION In a univariate, single surgeon study, a positive Cottle Maneuver does not appear to influence outcomes in the described patient population compared to those with a negative Cottle Maneuver when undergoing a septoplasty.
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Affiliation(s)
- James P Bonaparte
- Department of Otolaryngology - Head and Neck Surgery Senior Clinical Investigator, The Ottawa Hospital Research Institute, University of Ottawa, 1919 Riverside Drive, Suite 308, Ottawa, Ontario, K1H 7W9, Canada.
| | - Ross Campbell
- Department of Otolaryngology - Head and Neck Surgery, The University of Ottawa, Ottawa, Canada
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Valsamidis K, Titelis K, Rachovitsas D, Konstantinidis I, Markou K, Triaridis S. Long-Term Evaluation of Nasal Septoplasty Followed by Inferior Turbinate Cauterization for the Treatment of Nasal Obstruction using Objective and Subjective Methods. Int Arch Otorhinolaryngol 2018; 22:284-290. [PMID: 29983770 PMCID: PMC6033599 DOI: 10.1055/s-0037-1613688] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/30/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction
Nasal septoplasty is considered the treatment of choice for nasal obstruction due to septal deviation. An ongoing discussion among rhinologists is whether it is reasonable to perform objective measurements of nasal patency pre or postoperatively routinely.
Objective
The primary aim of this study was to identify the short- and long-term functional benefits for patients undergoing septal surgery, as assessed by acoustic rhinometry (AR). The secondary goal was to evaluate the short- and long-term perception of symptom relief and disease-specific quality of life (QoL) outcomes on the part of the patients.
Methods
This was a prospective observational study in which AR was utilized for the assessment of nasal patency preoperatively and 1, 6 and 36 months after septoplasty. Total 40 patients who underwent septoplasty filled out the Nasal Obstruction Septoplasty Effectiveness (NOSE) questionnaire and the Glasgow Benefit Inventory (GBI) to assess their subjective improvement in nasal obstruction symptoms and the changes in their QoL.
Results
There were statistically significant improvements in nasal patency, mean postoperative NOSE and GBI scores postoperatively. However, there was no correlation between the mean NOSE and GBI scores and the AR measurements. Furthermore, the GBI scores tended to decrease as the postoperative period increased.
Conclusion
The present study confirms that septoplasty significantly increases nasal patency and causes a significant subjective improvement in nasal obstruction symptoms. The absence of a statistically significant correlation among the objective measurements, the symptom scores, and the patients' low GBI scores indicates that factors other than the anatomical findings may also contribute to the patients' perception of QoL.
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Affiliation(s)
- Konstantinos Valsamidis
- Department of Otorhinolaryngology, Georgios Gennimatas General Hospital, Thessaloniki, Greece
| | - Konstantinos Titelis
- Department of Otorhinolaryngology, Georgios Gennimatas General Hospital, Thessaloniki, Greece
| | - Dimitrios Rachovitsas
- 1st University Department of Otorhinolaryngology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Iordanis Konstantinidis
- 2nd University Department of Otorhinolaryngology, Geniko Nosokomeio Thessalonikis Papageorgiou, Thessaloniki, Greece
| | - Konstantinos Markou
- 2nd University Department of Otorhinolaryngology, Geniko Nosokomeio Thessalonikis Papageorgiou, Thessaloniki, Greece
| | - Stefanos Triaridis
- 1st University Department of Otorhinolaryngology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ziai H, Bonaparte JP. Determining a Successful Nasal Airway Surgery: Calculation of the Patient-Centered Minimum Important Difference. Otolaryngol Head Neck Surg 2017; 157:325-330. [PMID: 28418779 DOI: 10.1177/0194599817701719] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Determine whether the patient-identified minimum important difference (MID) in Nasal Obstruction Symptom Evaluation (NOSE) score differs from a statistically calculated estimate of MID in patients with septal deviation undergoing nasal airway surgery. Study Design Prospective cohort. Setting Tertiary academic referral center. Subjects Patients with nasal obstruction due to septal deviation. Methods Patients completed the NOSE questionnaire preoperatively and indicated the change from their baseline score that they would consider the minimum improvement required to define the septoplasty with turbinate reduction as successful. A previously published distribution-based approach was used to estimate the MID based on baseline NOSE scores. Scores were reported both as a raw score and as a percentage of patients' baseline scores. One-sample t test was used to compare the statistically estimated MID to the patient-reported MID. Results Seventy-six patients were included. The mean (SD) baseline NOSE score was 12.9 (4.03). The mean (SD) patient-identified MID was 5.3 (2.1), corresponding to a 41.1% change (95% confidence interval, 37.2-41.3) from baseline. The statistically estimated MID was 5.2 points (40.3% reduction from baseline scores). The estimated MID was not significantly different from the patient-identified MID ( P = .4). Conclusion In patients with septal deviation, an improvement of approximately 40% in their nasal obstructive symptoms as assessed by the NOSE questionnaire is required to define a nasal airway surgery as successful. The patient-identified and the statistically calculated MIDs were similar. Furthermore, this MID can be used to guide research, improving the ability to use the NOSE score as a dichotomous scoring measure (treatment success/failure) and estimating sample size.
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Affiliation(s)
- Hedyeh Ziai
- 1 Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James P Bonaparte
- 2 Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
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Urbančič J, Soklič Košak T, Jenko K, Božanić Urbančič N, Hudoklin P, Delakorda M, Juvanec A, Zupančič Urbančič K, Vadnjal J, Gluvajić D. Cross-cultural adaptation and validation of nasal obstruction symptom evaluation questionnaire in Slovenian language. Zdr Varst 2017; 56:18-23. [PMID: 28289459 PMCID: PMC5329781 DOI: 10.1515/sjph-2017-0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/26/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Nasal obstruction is highly subjective perception with numerous efforts being made towards objective measuring. Many instruments in quality of life studies encompass subjective symptom of nasal obstruction, but only NOSE has been properly validated and is easy to use in every day practice. METHODS Multicenter prospective instrument validation and cross-cultural adaptation cohort study was conducted on patients with deviated nasal septum, with or without inferior turbinate hypertrophy, to develop the Slovenian version of NOSE questionnaire. A cross-cultural adaptation of the original questionnaire was done in five steps, producing Slovenian NOSE-si, used on a pilot group to confirm the quality of adapted tools and, afterwards, on the main study and control group. Symptoms were lasting for more than 12 months and all had an indication for septal surgery. A control group was selected from a pool of healthy subjects, self-assessed as having no rhinological complaints. RESULTS NOSE-si was used on 116 patients (58 from the study group vs. 58 from the control group). High degree of internal consistency - Cronbach's a 0.971 and reliability after retesting - Goodman-Kruskal gamma coefficient 0.984 was proven. Responsiveness was confirmed in the surgery subgroup with standardized response mean (SRM) 2.76 (p<0.001). CONCLUSIONS The study produced a valid Slovenian version of NOSE questionnaire through rigorous and well defined five-phase effort to maintain scientifically comparable QoL instrument, and may be used by clinicians and researchers.
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Affiliation(s)
- Jure Urbančič
- University Medical Centre Ljubljana, Department of Otorhinolaryngology and Cervicofacial Surgery, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Tanja Soklič Košak
- University Medical Centre Ljubljana, Department of Otorhinolaryngology and Cervicofacial Surgery, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Klemen Jenko
- University Medical Centre Ljubljana, Department of Otorhinolaryngology and Cervicofacial Surgery, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Nina Božanić Urbančič
- University Medical Centre Ljubljana, Department of Otorhinolaryngology and Cervicofacial Surgery, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Peter Hudoklin
- Novo mesto General Hospital, Department of Otorhinolaryngology, Šmihelska cesta 1, 8000 Novo mesto, Slovenia
| | - Matej Delakorda
- Celje General Hospital, Department of Otorhinolaryngology, Oblakova 5, 3000 Celje, Slovenia
| | - Ajda Juvanec
- Community Health Centre dr. Adolfa Drolca Maribor, Ulica talcev 9, 2000 Maribor, Slovenia
| | | | - Jana Vadnjal
- Zavod Zdravje d.o.o, Ulica padlih borcev 22, 6258 Prestranek, Slovenia
| | - Daša Gluvajić
- University Medical Centre Ljubljana, Department of Otorhinolaryngology and Cervicofacial Surgery, Zaloška 2, 1000 Ljubljana, Slovenia
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van Egmond MMHT, Rovers MM, Hendriks CTM, van Heerbeek N. Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial. Trials 2015; 16:500. [PMID: 26537948 PMCID: PMC4634847 DOI: 10.1186/s13063-015-1031-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/23/2015] [Indexed: 11/25/2022] Open
Abstract
Background Septoplasty, i.e., surgical correction of the deviated nasal septum, is the most common ear, nose and throat (ENT) operation in adults. Currently the main indication to perform septoplasty is nasal obstruction. However, the effectiveness of septoplasty for nasal obstruction in adults with a deviated nasal septum remains uncertain. Scientific evidence is scarce and inconclusive, and internationally accepted guidelines are lacking. Moreover, there is no consensus on whether or not septoplasty should be combined with concurrent turbinate surgery. The objective of the current ongoing trial is to study the effectiveness of septoplasty (with or without concurrent turbinate surgery) as compared to non-surgical management for nasal obstruction in adults with a deviated nasal septum, both in terms of subjective (health-related quality of life) as well as objective (nasal patency) outcome measures. Methods/Design The study is designed as a pragmatic, multicenter, parallel-group, randomized controlled trial. A total of 200 adults will be enrolled with nasal obstruction based on a deviated nasal septum and an indication for septoplasty according to current medical practice in the Netherlands. Participants will be randomized to either septoplasty (with or without concurrent turbinate surgery as originally indicated by the otorhinolaryngologist) or a non-surgical watchful waiting strategy. Follow-up visits will be scheduled at 0, 3, 6, 12, and 24 months. During each follow-up visit, health-related quality of life questionnaires will be administered and measurements of four-phase rhinomanometry and peak nasal inspiratory flow will be performed. Costs will be studied using a patient-based diary. Effects of septoplasty on health-related quality of life (primary outcome) and nasal patency will be calculated as mean differences with 95 % confidence intervals. Subgroup analyses according to gender, age, and severity of the septal deviation will be performed. All analyses will be performed on an intention-to-treat basis. Discussion With the results of this study we aim to contribute to the development of evidence-based guidelines regarding indications for septoplasty. Trial registration Nederlands Trial Register/Dutch Trial Registry (www.trialregister.nl), trial identifying number: NTR3868. Registered on 21 February 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1031-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M M H T van Egmond
- Department of Otorhinolaryngology, Radboud university medical center, Radboud Institute for Health Sciences, route 377, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - M M Rovers
- Department of Operating Rooms, Radboud university medical center, Radboud Institute for Health Sciences, route 715, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - C T M Hendriks
- Department of Otorhinolaryngology, Radboud university medical center, Radboud Institute for Health Sciences, route 377, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - N van Heerbeek
- Department of Otorhinolaryngology, Radboud university medical center, Radboud Institute for Health Sciences, route 377, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
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Menger DJ, Richard W, Swart KMA, Grolman W. Does Functional Septorhinoplasty Provide Improvement of the Nasal Passage in Validated Patient-Reported Outcome Measures? ORL J Otorhinolaryngol Relat Spec 2015; 77:123-31. [PMID: 25926049 DOI: 10.1159/000381025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/16/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether functional septorhinoplasty provides improvement of the nasal passage in validated patient-reported outcome measures (PROMs) for adults with an anatomical obstruction of the nasal valve. All patients with an anatomical obstruction of the nasal valve area due to nasal valve pathology and/or septal deviations in this area were included. METHODS A systematic PubMed, Embase and Cochrane Library search was performed to identify relevant articles. The articles were critically appraised and ranked according to validity and relevance. RESULTS Sixteen articles met our inclusion criteria, and after critical appraisal, 10 were eligible for further analysis. In 9 studies, the Nose Obstruction Symptom Evaluation (NOSE) score improved from 35 to 60 points. In 1 study, the Sino-Nasal Outcome Test (SNOT-22) improved 3.5 points. CONCLUSION The results suggest that there is a significant improvement of the validated PROMs after functional septorhinoplasty in the first postoperative year. We recommend that adults with nasal breathing problems due to an anatomical problem of the nasal valve area should consider undergoing functional septorhinoplasty.
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Affiliation(s)
- Dirk Jan Menger
- Department of Otorhinolaryngology/Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery, University Medical Center, Utrecht, The Netherlands
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Joseph J. Re: the effects of disclosure of sequential rhinomanometry scores on post-septoplasty subject scores of nasal obstruction: a randomised controlled trial. Clin Otolaryngol 2013; 37:422; author reply 422-3. [PMID: 23164272 DOI: 10.1111/coa.12013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2012] [Indexed: 11/27/2022]
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Manestar D. Response to Dr Joseph. Clin Otolaryngol 2012. [DOI: 10.1111/coa.12012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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