The Laryngoscope

© 2019 The American Laryngological,

Rhinological and Otological Society, Inc.

Preoperative Characteristics of Over 1,300 Functional

Septorhinoplasty Patients

Natalie Justicz, MD ; Shekhar K. Gadkaree, MD ; Jennifer C. Fuller, MD ;

Joseph J. Locascio, PhD; Robin W. Lindsay, MD

Objective: To identify characteristics of patients presenting preoperatively for functional septorhinoplasty associated
with increased Nasal Obstruction Symptom Evaluation (NOSE) scores.
Study Design: Retrospective analysis of a prospective cohort at a tertiary medical center. Only baseline assessments were
analyzed in this cross-sectional study.
Methods: 1,338 patients completed baseline nasal evaluation, resulting in 1,034 NOSE scores. Demographics, medical his-
tory, surgical history, and physical exam findings were recorded.
Results: The average preoperative NOSE score was 59.8 out of 100 (standard deviation: 24.9). Fifty-four percent
(578 per 1,074) of respondents were female, although sex did not affect baseline NOSE score (P = 0.7). Forty-five percent
(404 per 896) reported prior nasal surgery. History of rhinoplasty was not associated with a difference in baseline NOSE score
(P = 0.1924); however, history of septoplasty (P = 0.0390) was associated with an increased baseline NOSE score. Snoring was
also both associated with higher baseline NOSE score (P = 0.0003). All 12 septal/nasal valve measurements were associated
with higher preoperative NOSE score, whereas the internal nasal valve narrowing variables retained significance in multivari-
ate analysis (left: P = .0490; right: P = .0077).
Conclusion: Patients presenting for nasal airway obstruction were evaluated. Sex was not associated with difference in
NOSE score. History of septoplasty was associated with higher baseline NOSE score, as were snoring and internal nasal valve
narrowing at rest.
Key Words: Septorhinoplasty, nasal valve, NOSE, nasal airway obstruction.
Level of Evidence: 2C
Laryngoscope, 00:1–7, 2019

INTRODUCTION Anecdotally, many patients report symptomatic NAO asso-

Nasal airway obstruction (NAO) is one of the most
common presenting complaints of patients seen in otolaryn-
gology and specialized facial plastic surgery clinics. Medical
management options for NAO include topical decongestant
and steroid nasal sprays, oral allergy medications, and
nasal strips to physically alleviate obstruction. Surgical
options are variable and tailored specifically to the patient;
they may include septoplasty, turbinoplasty, nasal valve
correction, or functional septorhinoplasty (FSRP). Patients
with refractory NAO secondary to nasal valve compromise
often seek surgical consultation after failed medical
management.
During the initial surgical consultation, FSRP for cor-
rection of symptomatic nasal obstruction is often discussed.
From the Department of Otolaryngology, Harvard Medical School
(A.N.J., S.K.G., R.W.L.); the Department of Neurology, Massachusetts General
Hospital/Harvard Medical School (J.J.L.); the Department of Otolaryngology,
Massachusetts Eye and Ear Infirmary (A.N.J., S.K.G., R.W.L.), Boston,
Massachusetts; and the Department of Otolaryngology, University of
Minnesota (J.C.F.), Minneapolis, Minnesota, U.S.A.
Editor’s Note: This Manuscript was accepted for publication on
March 11, 2019.
Presented at the Triological Society Combined Sections Meeting,
Coronado, California, U.S.A., January 24–26, 2019.
The authors have no funding, financial relationships, or conflicts of
interest to disclose.
Send correspondence to Natalie Justicz, MD, 243 Charles Street,
Boston, MA 02114. E-mail: natalie_justicz@meei.harvard.edu
DOI: 10.1002/lary.27955
ciated with allergies or previous trauma. Some report a his-
tory of nasal surgery such as turbinoplasty, septoplasty, or
previous functional rhinoplasty in a prior attempt to correct
symptomatic NAO. Other patients may have undergone
previous cosmetic rhinoplasty with the development of
nasal obstruction over time. However, there is little consen-
sus on what patient characteristics create and inform NAO
and lead them to seek care.
Fortunately, valid and reliable patient-reported out-
comes measures assessing overall health status provide a
means to evaluate the impact of chronic conditions,
including nasal obstruction.1 The use of a validated global
quality-of-life (QOL) measure allows for the calculation of
Healthy Utility Values1 for specific chronic diseases in
relation to each other. Disease-specific measures of QOL
have also been used to measure nasal obstructive symp-
toms, such as the Nasal Obstruction Symptom Evaluation
(NOSE) scale,2 a validated functional outcome measure of
nasal symptomatology via five questions. The NOSE scale
was validated by Stewart et al. in 2004 to show QOL
improvement after septoplasty.2 Since that time, Rhee et al.
have studied the efficacy of functional rhinoplasty techniques
using the NOSE instrument,3 and Most performed a pro-
spective examination of 41 patients to further delineate the
efficacy of specific functional rhinoplasty techniques using
the NOSE instrument.4 In 2012, Lindsay reported signifi-
cant improvements in NOSE score following functional

Laryngoscope 00: 2019 Justicz et al.: Medical History Predicts NOSE Scores
1
rhinoplasty.5 In a subsequent study, Chambers et al. demon-
strated that patients with nasal obstruction refractory to
septoplasty who underwent FSRP had statistically signifi-
cant improvement in NOSE scores at 2 months, 4 months,
and 6 months postoperatively and the most common preop-
erative physical exam finding was internal nasal valve
narrowing.6 Since that time, Fuller et al. have demonstrated
improvement in NOSE scales with the use of PDS plates in
FSRP.7
In this study, we expand on this foundation by
assessing characteristics associated with an increase in
NOSE scale in patients presenting for the consideration of
FSRP. To accomplish this, we compare patient demo-
graphic information, health information, and preoperative
characteristics with NOSE scores. This is the largest cross-
sectional evaluation of a preoperative cohort yet described.
By studying baseline trends, we can better understand the
clinical and anatomic factors that influence quantitative
subjective measures of nasal obstruction and identify
patients who will benefit from specific surgical techniques
based on clinical and anatomic factors, increasing our
awareness of specific patient populations that report higher
severity of nasal obstruction symptoms. In addition, this
data will provide clinical researchers with baseline ranges
of NOSE scores for patients with varying demographics.
MATERIALS AND METHODS
Patient Selection
This is a single-center, prospective observational study con-
ducted at a tertiary care medical center under an approved pro-
tocol by the institutional review board human subjects research
committee. The study period spanned 5 years (2013–2018). Eligi-
ble subjects consisted of adult and pediatric (less than 18 years
old) patients who presented to the Massachusetts Eye and Ear
Infirmary Facial Plastic and Reconstructive Surgery (Boston,
MA) clinic for assessment and treatment of nasal obstruction by
the senior author (R.W.L.). Eligible participants had a concern for
NAO. Some were referred for surgical intervention, whereas
others wanted to discuss medical and surgical options. The sub-
jects completed a preoperative NOSE questionnaire in the clinic
on paper or electronically and underwent a standardized nasal
history and physical exam.8 All data were collected utilizing
REDCap (Research Electronic Data CaptureJ) (Vanderbilt Uni-
versity, Nashville, TN), an electronic data-capture platform
designed for academic clinical and translational database devel-
opment.9 Patient demographic characteristics, nasal history,
nasal exam, and preoperative NOSE scores were recorded
through REDCap (Vanderbilt University) in a Health Insurance
Portability and Accountability Act-compliant manner.
Outcome Measures
The NOSE scale was used as the primary outcome measure.
The NOSE scale is a standardized and validated, patient-reported,
disease-specific QOL assessment instrument that contains five
questions related to nasal obstruction rated along a five-point
Likert scale.2–4,10 Patients are queried: “Over the past ONE
month, how much of a problem were the following conditions for
you?” and asked to circle the most correct response on a scale of
0 to 4. These include five areas: 1) nasal congestion or stuffiness,
2) nasal blockage or obstruction, 3) trouble breathing through my
nose, 4) trouble sleeping, and 5) unable to get enough air through
Laryngoscope 00: 2019
2
my nose during exercise or exertion. Question response scores are
summed and converted to a total score from 0 (no nasal obstruc-
tion) to 100 (severe nasal obstruction).
Physical Exam
Physical exam findings were documented on a nasal exam
and nasal anatomic worksheet in REDCap (Vanderbilt Univer-
sity). The nasal exam worksheet focused on external nasal anat-
omy and the nasal anatomic worksheet (NAW) on intranasal
anatomy.8 On the NAW, deviation of the septum and nasal valve
narrowing and collapse were analyzed by unique categories: left
superior septal deviation (rated 0 if not present, 1 for mild, 2 for
moderate, 3 for severe), right superior septal deviation (0–3), left
inferior septal deviation (0–3), right inferior septal deviation (0–3),
left internal valve narrowing at rest (rated 1 for absent/mild, 2 for
moderate, 3 for severe), right internal valve narrowing at rest
(1–3), left external valve narrowing at rest (1–3), right external
valve narrowing at rest (1–3), left internal valve collapse with
inspiration (1–3), right internal valve collapse with inspiration
(1–3), left external valve collapse with inspiration (1–3), and right
external valve collapse with inspiration (1–3). Each item was
scored individually. The individual scores were combined to create
the total NAW score.
Statistical Analysis
Unless otherwise stated, means and standard deviations
for numeric variables are reported, as are frequencies for cate-
gorical variables. Cross-sectional analyses were performed. A
P value of <0.05 was considered statistically significant. SAS sta-
tistical software version 9.4 (SAS Institute Inc., Cary, NC) was
used for analyses.
Given that there were many predictor variables whose rela-
tions to preoperative NOSE scores we wished to examine, we
reduced the data to four subsets of variables related to: 1) medi-
cal history; 2) surgical history; 3) physical examination; and 4)
septum and nasal valve assessments, respectively. Table I lists
the variables in the respective categories and indicates whether
each was categorical (binary) or numeric. For each of these sets
separately, we analyzed relations of the variables to NOSE
scores first by assessing the univariate relation of each predictor
to NOSE, followed by a multivariate assessment in which all pre-
dictors within a set were simultaneously related to NOSE,
adjusting each predictor for all others in the set. For the univari-
ate analyses, if the predictor was binary, we employed an inde-
pendent group t test, using the Satterthwaite approximation
version if a pretest indicated significantly different variances
between the groups, contrary to the assumption of a conventional
t test. The t test result was confirmed with a Mann-Whitney non-
parametric test if the distribution of NOSE scores did not strictly
conform to the assumption of normality. Multivariate analysis
permitted both categorical and numeric predictors to be in the
same model as needed. Residuals from the multivariate regres-
sion were examined for conformance to assumptions of normal-
ity. The multivariate regression additionally included the
covariates of gender and age of the participant at time of assess-
ment. The univariate analyses allowed us to descriptively assess
the marginal relations of each predictor to NOSE scores primar-
ily for purposes of clinical utility, whereas the multivariate tests
in which all predictors were statistically adjusted for each other
allowed for a more mechanistic interpretation of predictors that
were most operative in their relation to NOSE as opposed to only
indirectly or spuriously related.
Justicz et al.: Medical History Predicts NOSE Scores
 TABLE I.
Preoperative Characteristics.
General Linear Model
Significance Re: NOSE
Correlation
Univariate vs. NOSE Partial Adjusted
Significance (for Numeric Regression Means
N Mean SD Re: NOSE (P) Predictors) P Value Coefficient (NOSE)

Age 1,056 38.3 16.6 <0.05* 0.15*

Under 18 75 (7.10%) 15.8 2.0 0.0705 0.05692 54.3
18–65 900 (85.23%) 37.3 13.4 60.9
65 and older 81 (7.67%) 71.3 5.5 57.4
Gender 1,334 .7315 0.4227*
Female 721 (54.05%) Female 60.5*
Male 613 (45.95%) Male 59.0
NOSE score 1,074 59.8 24.9
Female 578 (53.82%) 60.1 25.8
Male 492 (45.81%) 59.5 24.1
Medical history
Sinus disease 1,016 0.002 0.8722
No 812 (79.92%)
Yes 204 (20.08%)
Seasonal allergies 1,012 0.0007 0.4845
No 472 (46.64%)
Yes 540 (53.36%)
Nasal steroid usage 993 0.0003 0.0664
No 887 (89.33%) 64.8
Yes 106 (10.67%) 70.2
Snoring 1,000 <0.0001 0.0003
No 491 (49.10%) 63.6
Yes 509 (50.90%) 71.4
OSA 933 0.0011 0.2850
No 812 (87.03%)
Yes 121 (12.97%)
Smoking 668 0.0281 0.0476
No 638 (95.51%) 62.7
Yes 30 (4.49%) 72.2
Nasal fracture 1,016 0.3301 0.8303
No 528
Yes 488
Surgical history
History of nasal surgery 896 0.0732 0.8799
No 616 (68.75%)
Yes 404 (45.09%)
History of nasal 1,338 0.3018 0.0453
reduction
No 1,256 (93.8%) 63.5
Yes 82 (6.13%) 56.6
History of rhinoplasty 1,338 0.1477 0.1924
No 1,190 (88.94%)
Yes 148 (11.06%)
History of septoplasty 1,338 <0.0001 0.0390
No 1,051 (78.55%) 56.8
Yes 287 (21.45%) 63.2

(Continues)

Laryngoscope 00: 2019 Justicz et al.: Medical History Predicts NOSE Scores
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 TABLE I.
Continued
General Linear Model
Significance Re: NOSE
Correlation
Univariate vs. NOSE Partial Adjusted
Significance (for Numeric Regression Means
N Mean SD Re: NOSE (P) Predictors) P Value Coefficient (NOSE)

History of sinus surgery 1,338 0.1060 .8626

No 1,292 (96.56%)
Yes 46 (3.43%)
History of turbinoplasty 1,338 0.0006 .6585
No 1,270 (94.92%) 59.3
Yes 68 (5.08%) 60.8
Physical exam findings
Deviation of the bony dorsum 1,338 0.0211 0.1676
No 1,132 (84.60%)
Yes 206 (15.40%)
Deviation of the 1,338 0.0244 0.4775
cartilaginous dorsum
No 964 (72.05%)
Yes 374 (27.95%)
Narrowing of the middle vault 1,338 0.365 0.482 0.0008 0.5369
No 849 (63.45%)
Yes 489 (36.55%)
Septal deviation and nasal valve narrowing/collapse
NAW (all 12 combined) 1,338 16.78 6.127 <0.0001 0.24981 <0.0001 1.1650
Left superior septal deviation 1,338 1.271 1.279 <0.0001 0.12857 0.4669 0.711
Right superior septal deviation 1,338 1.088 1.231 <0.0001 0.15286 0.1084 1.7324
Left inferior septal deviation 1,338 1.148 1.233 <0.0001 0.14797 0.0672 1.6491
Right inferior septal deviation 1,338 0.865 1.116 <0.0001 0.12353 0.4035 −0.9266
Left internal valve 1,338 2.116 0.834 <0.0001 0.18307 0.0490 2.566
narrowing at rest
Right internal valve 1,338 2.042 0.818 <0.0001 0.20105 0.0077 3.4706
narrowing at rest
Left external valve narrowing 1,338 1.481 0.682 0.0061 0.08368 0.2178 −1.8397
at rest
Right external valve 1,338 1.410 0.631 <0.0001 0.12321 0.2848 1.7674
narrowing at rest
Left internal valve collapse 1,338 1.357 0.568 <0.0001 0.14272 0.8735 0.4618
with respiration
Right internal valve collapse 1,338 1.360 0.578 <0.0001 0.15707 0.2247 3.4897
with respiration
Left external valve collapse 1,338 1.324 0.558 <0.0001 0.13647 0.4080 2.4877
with respiration
Right external valve collapse 1,338 1.316 0.561 <0.0001 0.13283 0.9422 −0.2248
with respiration

*Values vary slightly depending on other predictors/covariates in model.

NAW = nasal anatomic worksheet; NOSE = Nasal Obstruction Symptom Evaluation; OSA = obstructive sleep apnea; SD = standard deviation.

RESULTS Medical History

We summarize the below results for the four catego-
ries of predictors separately (see Table I). In all cases,
residuals from model distributions were normally distrib-
uted, except for a slight ceiling effect in some cases; how-
ever, the results of the nonparametric test counterpart to
the t tests always confirmed or nearly confirmed that of
the t test in terms of statistical significance.
In the univariate tests, the variables of sinus disease
(P = 0.002), seasonal allergies (P = 0.0007), snoring
(P < 0.0001), obstructive sleep apnea (OSA) (P = 0.001),
smoking (P = 0.028), and nasal steroid usage (P = 0.0003)
were each significantly related to NOSE scores, for which
in each case a “Yes” was associated with a higher mean
on NOSE than was a “No.”

Laryngoscope 00: 2019 Justicz et al.: Medical History Predicts NOSE Scores
4
 A multivariate analysis was also performed to estimate
a single regression model; NOSE scores were the main out-
come variable. In the multivariate analysis, only the predic-
tors snoring (P = 0.0003) and smoking (P = 0.0476) had
significant relations with NOSE (“Yes” always associated
with a higher NOSE mean than “No”). Nasal steroid usage
was only marginally significant (P = 0.0664). The covariate
age also had a significant (P = 0.0359) relation to NOSE
(older higher; partial regression coefficient = B = 0.15). The
overall model was significant (P = 0.0001, i.e., the optimal
linear combination of all predictors was significantly related
to NOSE), although the model only accounted for 6.3% of the
variance in NOSE scores. In these analyses and those below,
variables that predicted NOSE in the univariate tests but
not in the multivariate analysis presumably were primarily
related to NOSE indirectly via their connections with other
predictors or covariates; however, when they were adjusted
for the latter, their univariate relations with NOSE were
weakened or eliminated.
Surgical History
In the univariate tests, the variables for any history
of nasal surgery (P = 0.0732), history of closed nasal re-
duction (P = .3018), history of rhinoplasty (P = 0.1477),
and history of sinus surgery (P = .1060) were not signifi-
cantly related to NOSE scores. However, history of
septoplasty (P < 0.0001) and history of turbinoplasty
(P = 0.0006) were each significantly related to NOSE
scores, for which in each case a “Yes” was associated with
a higher mean on NOSE than was a “No.”
In the multivariate analysis, only the predictor of
history of septoplasty (P = 0.0390) retained significance
(“Yes” higher). History of closed nasal reduction gained
significance (P = .0453), whereas history of turbinoplasty
lost significance (P = .6585). The covariate age also had a
significant (P = 0.0051) relation to NOSE (older higher;
partial regression coefficient = 0.14). The overall multi-
variate regression was significant (P = 0.0004), although it
only accounted for 3.3% of the variance in NOSE scores.
Physical Exam
In the univariate tests, the variables for deviation of
the bony dorsum (P = .0211), deviation of the cartilagi-
nous dorsum (P = .0244), and narrowing of the middle
vault (P = .0008) were significantly correlated with NOSE
scores, for which in each case a “Yes” was associated with
a higher mean on NOSE than was a “No.”
In the multivariate analysis, deviation of the bony dor-
sum, deviation of the cartilaginous dorsum, and narrowing
of the cartilaginous dorsum did not retain significance
(P = .1676; P = .4775; P = .5369, respectively). The covariate
age, as before, had a significant (P = 0.0051) relation to
NOSE (older higher; partial regression coefficient = 0.16);
however, the overall multivariate regression model was not
significant (P = 0.3115) and accounted for only 2% of the var-
iance in NOSE.
All 12 variables individually demonstrated signifi-
cant correlations with NOSE due to our high sample
size, but the effect sizes were weak. The multivariate
Laryngoscope 00: 2019
regression model was significant for both left and right
internal valve narrowing at rest (P = .0490; P = .0077,
respectively). Our summative NAW variable of all 12 cat-
egories was also significant in the multivariate regres-
sion model (P < 0.0001).
DISCUSSION
We performed an in-depth analysis of a large cohort
of patients presenting to a facial plastic and reconstruc-
tive surgery surgical practice for the evaluation of NAO
to determine historical and anatomic factors associated
with symptom severity. Currently, most operative decision
making primarily is determined through clinical expertise
uninformed by quantitative symptom assessment with vali-
dated patient-reported outcome measures (PROMs). Utiliza-
tion of PROMs has become the standard for evaluation of
patients with NAO for providers engaged in clinical research
and increasingly in clinical practice. Universal adoption of
routine PROM administration for all patients seeking evalu-
ation of NAO is supported by the Clinical Advisory Commit-
tee of the American Academy of Otolaryngology Head and
Neck Surgery as a metric to ensure high quality care. Clini-
cal practice guideline: improving nasal form and function
after rhinoplasty published in 2017 recommends that nasal
function should also be assessed by all clinicians after rhino-
plasty surgery using a patient-reported outcome measure.11
As the use of PROMs expands, it is important to understand
the clinical and anatomic factors that influence quantitative
subjective measures of nasal obstruction. In our analysis, we
found the following: gender did not influence baseline NOSE
scores; a medical history of snoring was associated with
higher baseline NOSE scores; surgical history of septoplasty
but not rhinoplasty had a significant negative impact on
NOSE scores; and a physical exam finding of internal nasal
valve narrowing was associated with a higher baseline
NOSE score.
All variables were initially tested with univariate
analysis to identify for associations, which were then rea-
nalyzed in multivariate analysis. Multivariate analysis
allowed us to control for confounding relationships and ana-
lyze for more accurate relationships between the demo-
graphic variables and NOSE scores. Univariate analysis has
the potential to show relationships between two variables
when a confounding variable is causing the observed effect.
Multivariate analysis demonstrated that men and women do
not differ on baseline NOSE scores. However, age was found
to significantly increase with NOSE scores on multivariate
analysis, suggesting that advanced age (65 or greater) should
be considered during data analysis of prospective outcomes
research using NOSE scores that have a high percentage of
older patients.
We found that a medical history of snoring is a predic-
tor of a significantly increased preoperative NOSE score in
both univariate and multivariate analysis (P < .0001;
P = .0003), whereas OSA was only significant in univariate
analysis alone (P = .0011). Associations between nasal anat-
omy and OSA severity have previously been studied,12,13
and NOSE scores have been suggested to be a possible
screening tool for OSA patients with nasal obstruction and
snoring.14 Snoring has been associated with lower sleep
Justicz et al.: Medical History Predicts NOSE Scores
5
quality.15 However, snoring alone has not previously been
demonstrated to be associated with higher NOSE score as
compared to patients who do not snore. One possible expla-
nation for this new finding is that patients who have symp-
toms of nasal obstruction and who also snore may also have
decreased sleep quality, influencing symptom severity.
Patients may therefore rate their symptoms of nasal obstruc-
tion higher, secondary to the impact on sleep quality,
because nasal obstruction is having a greater impact on
QOL as compared to patients who sleep well. Providers
should consider reporting of snoring as a marker for higher
symptom severity. Additional research is needed to deter-
mine if the relationship between higher NOSE scores and
snoring is secondary to decreased sleep quality or reduced
nasal airflow in this patient population.
Surgical history of septoplasty was significantly
associated with an increased NOSE score both in univari-
ate and multivariate analysis (P = < .0001; P = .0390).
Many patients undergo septoplasty for primary surgical
management of nasal obstruction; however, if nasal valve
compromise is not recognized prior to septal surgery or
unmasked by septoplasty, symptoms of nasal obstruction
will persist after surgery. Septoplasty alone cannot allevi-
ate nasal valve narrowing caused by dorsal or caudal
deviation of the septal L-strut. In patients with nasal
valve collapse, septoplasty will not correct underlying lat-
eral wall insufficiency (LWI).16,17 If not corrected at the
time of the septoplasty, LWI can worsen after the septal
deviation is corrected, resulting in persistent symptoms
of NAO despite correction of the septal deviation. Thus,
we theorize that patients with history of septoplasty in our
study may have exacerbated underlying LWI or had under
treatment of their internal nasal valve a narrowing second-
ary to significant dorsal deviation of the L-strut, leading
them to seek additional surgical assessment and care.
Alternatively, there may be an adverse psychologic impact
of surgical failure that results in patients reporting higher
symptoms of nasal obstruction. Interestingly, a history of
previous rhinoplasty was not associated with an increase in
NOSE scores such as a surgical history of septoplasty. Addi-
tional research is needed to determine the specific cause of
this association.
Clinically, multiple physical exam findings are asso-
ciated with NAO. Multiple surgical techniques, including
septoplasty,18 extracorporeal septoplasty,19 spreader
grafts,5,20 and LCS grafts,5,21 have been demonstrated
to improve symptoms of NAO. However, an association
between specific physical exam findings and the severity of
NAO has not been previously reported. We identified 12 spe-
cific anatomic defects observed on anterior rhinometry that
have clinically been associated with NAO and scored
each anatomic area and combined the individual score to
create a summative NAW score. By assigning numerical
weighting to the relative deviation, narrowing, and collapse
of nasal physical characteristics, we are working to better
understand the gradation of deviation that leads to symp-
tomatic NAO. The NAW score, a combination of all 12 of
these parameters, was predictive of increased NOSE score
on multivariate analysis. However, the only individual exam
findings that retained significance were left and right inter-
nal valve narrowing (P = .0490; P = .0077, respectively),
Laryngoscope 00: 2019
6
demonstrating that they are the most important physical
exam predictors of NAO and a resultant increase in NOSE
scores. Patients with internal valve narrowing may be the
best candidates for relief via FSRP. These data may also sug-
gest that, in patients undergoing surgically intervention
with multiple anatomic defects, the treatment of internal
nasal valve narrowing should take priority if grafting mate-
rial is limited. Additional research will be needed to confirm
this finding.
This study has several limitations. Patients were
only included in the NOSE correlation portion of this
study if they were able to complete a preoperative NOSE
survey. Patents completed the baseline NOSE on the day
of initial clinic visit, which may have caused patients to
focus on their disease and rate their disease as having a
more negative impact on their QOL compared to their
average baseline. In statistical analyses, the P values
were not adjusted for multiple significance tests. Despite
these limitations, this study has a large sample size of
patients and provides a valuable baseline study for NOSE
scores prior to surgical intervention via FSRP.
CONCLUSION
The NOSE survey, a disease-specific QOL assessment
instrument, was administered to patients presenting preop-
eratively to FPRS clinic. NOSE scores of patients were mea-
sured and correlated with patient demographics, medical
and surgical history, and physical exam findings. NOSE
score increases with age. Medical history of snoring and
smoking are correlated with higher NOSE score, as is the
surgical history of septoplasty and physical exam findings
of internal valve narrowing. Future studies are required to
determine if patients with certain preoperative characteris-
tics and physical exam findings will benefit to a great extent
from surgical management (FSRP), as well as to determine
which specific surgical techniques are the most useful for
the treatment of NAO.
Acknowledgment
Study data were collected and managed using REDCap
electronic data capture tools hosted at Massachusetts Eye
and Ear Infirmary (MEEI).9 REDCap is a secure, web-based
application designed to support data capture for research
studies, providing 1) an intuitive interface for validated data
entry, 2) audit trails for tracking data manipulation and
export procedures, 3) automated export procedures for seam-
less data downloads to common statistical packages, and 4)
procedures for importing data from external sources.
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