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trivial effect (SMD, 0.11-0.81). The broad CI for the out- comes at 12 months suggests considerable uncertainty regarding the effect size at this time and is largely caused by having only 4 studies that reported results for data pool- ing. Therefore, it is difficult to draw conclusions regarding the change in NOSE scores beyond 1 year. The primary limitation of this systematic review stems from the implicit weakness of the studies included in this analysis, which are mostly case series. The lack of an untreated control group creates uncertainty about the true effect size of treatment, because some spontaneous improve- ment may also occur from natural history or regression to a mean symptom state. Another important limitation is the inability to exclude the effect of septoplasty on NOSE score. Septoplasty in an integral part of functional rhino- plasty for the purpose of cartilage harvest; thus, data regard- ing the effect of functional rhinoplasty without septoplasty are not possible. More formal comparisons between func- tional rhinoplasty and septoplasty alone and their effects on NOSE score would be a valuable adjunct to the literature and could help further elucidate this effect. Additionally, our confidence in these results is tempered by the heteroge- neity among the studies, the large variability in outcomes beyond 12 months, and the potential for bias inherent in observational studies. Generally speaking, the main difficulty and confounding factor in measuring the effect of ‘‘functional rhinoplasty’’ on nasal obstruction is the wide range of techniques that are employed in the surgical correction of nasal valve compro- mise. Pathology may occur in the region of the internal or external nasal valve. It may be static or dynamic in nature. While an analysis including different techniques of nasal valve repair would be of strong interest to many surgeons, the umbrella term of ‘‘functional rhinoplasty’’ was used for the purposes of this study, as obtaining enough data to compare specific procedures measured by a validated system is not cur- rently possible. Our goal, rather, was to provide insight into the effects of the overall concepts and strategies employed in functional rhinoplasty on the patient’s experience of nasal obstruction, as assessed by a validated instrument. While this broad evaluation of functional rhinoplasty is by no means exact, nasal obstruction is ultimately a subjective complaint, and surgeons will base treatment on subjective evaluation of the patient’s anatomic pathology by employing whatever techniques with which they are comfortable, in an attempt to address deficiencies of the nasal valve and vesti- bule. There will always be some degree of heterogeneity when examining the topic of functional rhinoplasty, unless specific components are taken in isolation, which is not necessarily a faithful model of realistic practice. Nevertheless, this systematic review provides useful insight into the effects of functional rhinoplasty on the nasal airway, and it should strengthen the clinician’s recommen- dation for functional rhinoplasty to the patient with nasal valve compromise, with the expectation that it will exert a significant clinical effect on symptoms of nasal obstruction.

Last, the NOSE score appears to be a helpful tool in the assessment of these patients. As a validated metric of nasal obstruction, it provides a simple means for compiling data for analysis and for documenting an individual patient’s baseline symptoms and results. More extensive, prospective studies based on the NOSE questionnaire or another vali- dated scale are needed for the purposes of comparing the array of available rhinoplasty techniques so that we may draw more precise conclusions and further improve the sur- gical management of nasal valve compromise. Conclusion Nasal obstruction as measured by the NOSE survey is sub- stantially improved for up to 12 months after functional rhi- noplasty and may persist beyond 12 months. Our confidence in these results is limited by the heterogeneity among stud- ies, the large variability in outcomes beyond 12 months, and the inherent potential for bias in observational studies. Author Contributions Elizabeth Mia Floyd , lead author, data collection, data interpreta- tion, final approval; Sandra Ho , data collection, contributing author, final approval; Prayag Patel , contributing author, data col- lection, data analysis, final approval; Richard M. Rosenfeld , study design, contributing author, data analysis and interpretation, manuscript editor, final approval; Eli Gordin , study design and conception, contributing author, manuscript editor, final approval, principal investigator. 1. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg . 2004;130:283-290. 2. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg . 2004;130:157-163. 3. Rhee J, Arganbright J, Mcmullin B, Hannley M. Evidence sup- porting functional rhinoplasty or nasal valve repair: a 25-year sys- tematic review. Otolaryngol Head Neck Surg . 2008;139:10-20. 4. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological Index for Non-randomized Studies (MINORS): development and validation of a new instrument. ANZ J Surg . 2003;73:712-716. 5. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Comprehensive Meta-analysis: A Computer Program for Research Synthesis [computer software]. Version 3.3. Englewood, NJ: Biostat; 2014. 6. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to Meta-analysis . West Sussex, UK: Wiley; 2009. Disclosures Competing interests: None. Sponsorships: None. Funding source: None References

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