2017-18 HSC Section 4 Green Book

Reprinted by permission of Otolaryngol Head Neck Surg. 2017; 156(5):809-815.

Systematic Review/Meta-analysis

Otolaryngology– Head and Neck Surgery 2017, Vol. 156(5) 809–815 American Academy of Otolaryngology—Head and Neck

Systematic Review and Meta-analysis of Studies Evaluating Functional Rhinoplasty Outcomes with the NOSE Score

Surgery Foundation 2017 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599817691272 http://otojournal.org

Elizabeth Mia Floyd, MD 1 , Sandra Ho, MD 1 , Prayag Patel, MD 1 , Richard M. Rosenfeld, MD, MPH 1 , and Eli Gordin, MD 1

N asal obstruction may have a dramatic impact on a patient’s quality of life (QOL), and it is one of the most common complaints presenting to the otolar- yngologist. The differential diagnosis of nasal obstruction includes a range of etiologies, such as nasal septal deviation, inferior turbinate hypertrophy, intranasal masses, and rhini- tis, as well as compromise of the internal or external nasal valve. Often, multiple concomitant pathologies contribute to the patient’s symptoms. Septoplasty and inferior turbinate reduction are the most common procedures targeted toward improving the nasal airway; however, these techniques will not address structural abnormalities involving tissues of the external nose, such as the ala, tip, and bony sidewall, which may contribute to nasal valve collapse. While procedures aimed to correct the nasal valve are quite varied, the umbrella term ‘‘functional rhinoplasty’’ is commonly used to encompass these techniques that alter the external nasal structure with the goal of improving nasal breathing. 1,2 In 2004, Stewart et al developed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, which was the first validated, disease-specific QOL instrument for use in measuring nasal obstruction. 2 Using the NOSE scale, the group went on to show that performing septoplasty in patients with septal deformity resulted in an improvement in patient satisfaction and QOL. 1 In 2008, a systematic review of functional rhinoplasty by Rhee et al 3 demonstrated evi- dence of the beneficial effect of functional rhinoplasty on nasal valve collapse, but it did not provide any pooled out- come data due to the heterogeneity in outcome measures, which included nonvalidated instruments. The aim of this study is to evaluate the change in NOSE scores for patients 15 years of age who underwent rhino- plasty for nasal obstruction, with or without a cosmetic component. This was completed by performing a systematic review (eg, as done by Rhee et al) and meta-analysis to

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective. To provide aggregate data regarding the ability of functional rhinoplasty to improve nasal obstruction as mea- sured by the Nasal Obstruction Symptom Evaluation (NOSE) score. Review Methods. A search was performed with the terms ‘‘nasal obstruction’’ and ‘‘rhinoplasty.’’ Studies were included if they eval- uated the effect of functional rhinoplasty on nasal obstruction with the NOSE score. Case reports, narratives, and articles that did not use the NOSE score were excluded. Functional rhino- plasty was defined as surgery on the nasal valve. This search resulted in 665 articles. After dual-investigator independent screening, 16 articles remained. Study results were pooled with a random effects model of meta-analysis. Change in NOSE score after surgery was assessed via the mean difference between baseline and postoperative results and the standardized mean difference. Heterogeneity was assessed and reported through the I 2 statistic. Results. Patients in the included studies had moderate to severe nasal obstructive symptoms at baseline. The NOSE scores were substantially improved at 3-6, 6-12, and 12 months, with absolute reductions of 50 points (95% CI, 45- 54), 43 points (95% CI, 36-51), and 49 points (95% CI, 39-58), respectively. All of these analyses showed high heterogeneity. Conclusions. Nasal obstruction as measured by the NOSE survey is reduced by 43 to 50 points (out of 100 points) for 12 months after rhinoplasty. Our confidence in these results is limited by heterogeneity among studies, large variability in outcomes beyond 12 months, and the inherent potential for bias in observational studies. Data Sources. PubMed, EMBASE, Cochrane databases.

1 State University of New York, Brooklyn, New York, USA

Keywords functional rhinoplasty, NOSE score, nasal obstruction, nasal valve surgery

This article was presented at the 2016 AAO-HNSF Annual Meeting & OTO EXPO; September 18-21, 2016; San Diego, California. Corresponding Author: Elizabeth Mia Floyd, MD, State University of New York, 450 Clarkson

Received August 29, 2016; revised December 29, 2016; accepted January 10, 2017.

Avenue, Brooklyn, NY 11203, USA. Email: Elizabeth.floyd@downstate.edu

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