JAMA Facial Plastic Surgery Journal Club Slides: Patient-Reported Nasal Obstruction Scores

1. JAMA Facial Plastic SurgeryJournal Club Slides:Patient-Reported Nasal Obstruction Scores Rhee JS, Sullivan CD, Frank DO, Kimbell JS, Garcia GJM. A systematic review of patient-reported nasal obstruction scores: defining normative and symptomatic ranges in surgical patients. JAMA Facial Plast Surg. Published online March 6, 2014. doi:10.1001/jamafacial.2013.2473.

2. Introduction • A gold standard objective measure of nasal airway obstruction (NAO) does not currently exist. • Treatment is focused on the anatomic source of obstruction as determined by the surgeon, but the ultimate test of a successful treatment is the patient’s reported relief from the sense of obstruction. • Two validated and commonly used instruments for measuring individual NAO are the Nasal Obstruction Symptom Evaluation (NOSE) scale and the visual analog scale (VAS).

3. Purpose • The goals of this study are to systematically review studies on NOSE and VAS scores in surgically treated patients with NAO and to compile and standardize the data to (1) define symptomatic and normative values for presurgical and postsurgical patients with NAO, asymptomatic individuals, and the general population; (2) determine if postsurgical scores are comparable with asymptomatic scores; and (3) determine if there is a clinically useful difference between preoperative and postoperative score change.

4. Relevance to Clinical Practice • Surgery for NAO is among the most commonly performed in the field of otolaryngology, yet reported failure rates can vary from 20% to 50%. • Patient-reported, disease-specific measures such as NOSE and VAS scores are the most clinically meaningful assessment tools to quantify treatment success. • Establishing normative and symptomatic ranges and defining meaningful clinical numerical changes to these scores are important for measuring the success of an intervention and deciding whether a surgical intervention is appropriate.

5. Description of Evidence • A systematic review of the literature was performed through PubMed for studies assessing NOSE and VAS scores in patients with chronic NAO. • Strict inclusion criteria were applied to focus on anatomic obstruction only. Studies of patients with nasal congestion due to other illnesses (eg, common cold, flu, allergies, recent trauma, or facial nerve paralysis) were excluded. Similarly, studies on nonsurgical treatments for nasal obstruction (ie, pharmacological intervention) were not included. • Articles were further excluded when there was not enough information given to perform statistical analysis. • For statistical analysis, the patients were classified as asymptomatic, presurgical and postsurgical with NAO, and the general population.

6. Description of Evidence Mean NOSE and VAS Scoresa • The NOSE and VAS scores for NAO in the included studies showed a surprising amount of consistency among the studies despite the diversity of patient populations, interventions, and surgical techniques. • There was no score overlap between study populations with NAO and those without NAO, showing a clear demarcation based on patient-reported measures.

7. Controversies and Consensus • The consistency of NOSE and VAS mean scores for NAO in both obstructed and nonobstructed patients lends credibility to the category means listed in the previous table as a categorization for normative and symptomatic values for NAO. • Patients who sought surgery for NAO had mean NOSE and VAS scores higher than the means of the general population. • People who reported no NAO had mean NOSE and VAS scores lower than the means for the general population. • The NOSE and VAS mean scores of the general population reflected a range of symptoms and fell between reportedly symptomatic and asymptomatic means.

8. Controversies and Consensus • Regardless of the type of surgery or combination of procedures used for NAO, most studies report significant postsurgical decreases in both NOSE and VAS mean scores. • Mean NOSE scores consistently decreased by >30 points. • Mean VAS scores consistently decreased by >3 points. • Postsurgical patient mean scores are consistently below those of the general population and are most comparable to the scores of people who report no NAO.

9. Comment • Normative and symptomatic values may help stratify the severity of NAO (eg, normal, mild, moderate, and severe). • This information can also be used to educate patients and give realistic expectations for improvement of NAO symptoms following procedures. • These values may also help guide treatment. • For example, a patient with a NOSE score of 60, with enlarged inferior turbinates and a deviated septum, could reasonably be expected to have a score improvement of more than 30 points with surgery. • This numerical expectation of improvement can be compared with alternatives to surgery, such as a nasal steroid treatment, as a means to justify surgery if medical therapy does not have an equal effect.

10. Conclusions • NOSE and VAS scores are consistent and reliable patient-reported scales for evaluation of NAO. • Normative and symptomatic value ranges based on these scales can be established for meaningful clinical use. • Physicians, researchers, and other stakeholders may consider using these patient-reported measures as reliable and clinically meaningful measures of successful surgical outcomes.

11. Contact Information • If you have questions, please contact the corresponding author: • Corbin D. Sullivan, MD, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 3746 N 98th St, Milwaukee, WI 53222 (csulliva@mcw.edu). Funding/Support • This study was funded by grant R01EB009557 from the National Institute of Biomedical Imaging and Bioengineering to the Medical College of Wisconsin (MCW) and by subcontract from MCW to the University of North Carolina at Chapel Hill. Conflict of Interest Disclosures • None reported.