BrazJOtorhinolaryngol.2020;86(3):343---350
www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Computed
tomography
evaluation
of
internal
nasal
valve
angle
and
area
and
its
correlation
with
NOSE
scale
for
symptomatic
improvement
in
rhinoplasty
夽
Amr
G.
Shafik
a,∗,1,
Hussam
Adel
Alkady
a,1,
Gehad
Mohamed
Tawfik
b,c,1,
Ahmed
Mostafa
Mohamed
d,
Tahany
Mohamed
Rabie
a,
Nguyen
Tien
Huy
e,∗ aAinShamsUniversity,FacultyofMedicine,DepartmentofOtorhinolaryngology,Cairo,EgyptbAinShamsUniversity,FacultyofMedicine,Cairo,Egypt
cOnlineResearchClub(http://www.onlineresearchclub.org/),Japan
dAinShamsUniversity,FacultyofMedicine,DepartmentofDiagnosticRadiology,Cairo,Egypt eDuyTanUniversity,InstituteofResearchandDevelopment,DaNang,Vietnam.
Received29March2019;accepted29August2019 Availableonline3October2019
KEYWORDS NOSEscores; Rhinoplasty; CT-scan; INV; Area; Angle; Postoperative Abstract
Introduction:Nasal obstructionisoneofthemostfrequent otolaryngologiccomplaints;and thecollapseoftheinternalnasalvalveisonethemaincausesofthenasalairflowobstruction.
Objective: WeaimedtoevaluateinternalnasalvalvebyusingreformattedCT-scanspre-and post-rhinoplastyat3monthsandtoassessitscorrelationtosymptomaticimprovementofnasal obstructionusingtheNOSEscale.
Methods:AprospectiveobservationalstudywasconductedbetweenMarch2017---May2018ina tertiarycareotorhinolaryngologycenter.Weincludedpatientssufferingfromnasalobstruction secondarytointernalnasalanglecollapseandnasaldeformity.Patientswithsinusitis,nasal polyposis,andnasalmasseswereexcluded.
Results:Twentyconsecutivepatientsunderwentrhinoplasty,withameanage(22.2±2.8),with majorityofmales(n=14;70%).Therewasnosignificantcorrelationbetweenpre-andpost- CT-scansoftheinternalnasalvalveangle/areaandNOSEscores.Ahighsignificantdifferencewas detectedbetweenmeanpre-andpost-NOSEscores(p<0.0001),whichwasabsentinCT-scan results.
夽 Pleasecitethisarticleas:ShafikAG,Alkady HA,TawfikGM,MohamedAM,RabieTM,HuyNT.Computedtomographyevaluationof
internalnasalvalveangleandareaanditscorrelationwithNOSEscaleforsymptomaticimprovementinrhinoplasty.BrazJOtorhinolaryngol. 2020;86;343---50.
∗Correspondingauthors.
E-mails:amrgouda@hotmail.com(A.G.Shafik),nguyentienhuy4@duytan.edu.vn(N.T.Huy).
1 Authorsequallycontributedthework.
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2019.08.009
1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion:ReformattedCT-scansmeasurementsofinternalnasalvalveareaandanglewere notofvalue.NOSEscorespre-andpost-rhinoplastyhadasignificantvaluetodeterminedegree ofobstructivesymptomimprovement.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE EscoreNOSE; Rinoplastia; Tomografia computadorizada; VNI; Área; Ângulo; Pós-operatório
Avaliac¸ãodoânguloedaáreadaválvulanasalinternaportomografia
computadorizadaesuacorrelac¸ãocomaescalaNOSEnamelhorasintomáticapós rinoplastia
Resumo
Introduc¸ão:A obstruc¸ão nasal é uma das queixas otorrinolaringológicas mais comuns, e o colapsoouobstruc¸ãodaválvulanasalinternaéaprincipalcausadaobstruc¸ãodasviasaéreas nasais.
Objetivo:Objetivamosavaliaraválvulanasalinternapré,e3mesespós-rinoplastiautilizando tomografiascomputadorizadasreformatadaseavaliarsuacorrelac¸ãocomamelhoradosintoma obstrutivoutilizandoaescalaNOSE,doInglêsNasalObstructionSymptomEvaluation. Método: Umestudoobservacionalprospectivofoirealizado entremarc¸ode2017emaiode 2018emumcentrodeotorrinolaringologiadeatenc¸ãoterciária.Foramincluídospacientesque apresentavamobstruc¸ãonasalsecundárioacolapsodavalvanasalinternaedeformidadenasal. Pacientescomsinusite,poliposenasaletumoresnasaisforamexcluídos.
Resultados: Vintepacientesconsecutivos,amaioriadosexomasculino(n=14;70%)commédia deidadede22,2±2,8anos,foramsubmetidosarinoplastiaeincluídosnoestudo.Nãohouve correlac¸ãosignificanteentreasavaliac¸ões tomográficaspré/póscirúrgicasdoângulo/área davalvanasalinternaeosescoresNOSE.Foidetectadaumadiferenc¸aaltamentesignificante entreosescoresmédiosdaescalaNOSEentreopréepós-operatório(p<0,0001),masnãonos resultadosdaavaliac¸ãoportomografiacomputadorizada.
Conclusão:Asmedidas reformatadasde tomografiascomputadorizadas daárea eângulo da valvanasalinternapréepóscirúrgicasnãotiveramvalor.Entretanto,osescoresdaescalaNOSE préepós-rinoplastiamostraramumadiferenc¸asignificanteaodeterminarograudemelhora dosintomaobstrutivo.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Nasal obstruction is one of the most common complaints of patients in Otorhinolaryngology (ORL) medicine.1
Col-lapse or obstruction of the Internal Nasal Valve (INV) is mostly the cause of nasal airway obstruction.2,3 Airflow
resistanceis veryessential duringbreathingfor good pul-monaryfunction.TheINVisconsideredthenarrowestpart of nasalairway, hence, has the greatestresistance flow.2
Fiftypercent of total airwayresistance is fromnasal air-way resistance, which mostly occursin the anterior part ofnosewhichcalledINV.4Anatomically,theINVislocated
roughly1.3cmfromnaresandisborderedbyseptum medi-ally,byupperlateralcartilageslaterally,andbyanteriorend ofinferior turbinate inferiorlyandnose floor.5 Itis a
slit-likeopening;itscross-sectionalareaisabout55---65mm.6---8
In asymptomatic people, The INV angle is about 10◦---15◦ betweenupperlateralcartilageandseptum.3,9,10
TheINVisaremarkablysignificantareaforORLsurgeons tocorrectlyevaluatebeforerhinoplastyand/orseptoplasty surgeryfor patients withnasal obstruction. Different sur-gical techniques are used to correct INV collapse during
functional rhinoplasty, which may include partial infe-riorturbinectomy,septoplasty,andplacementofspreader grafts,whichisoneofthemosteffectivemethods of cor-rectingnasalobstruction.11Despitemanystudieswhichhave
evaluatedthe functional andanatomical analysisof nasal cavity, a standard accurate measure of nasal obstruction hasnotyetbeenverified.4,12 Nogoldstandardtestisbeing
usednowadaystodiagnoseINVobstruction.5Manytoolshave
beenusedinevaluationofnasalresistanceandINV, includ-ingrhinomanometryandacousticrhinometry,however,they possessthelimitations, oflacking reliabilityandrequiring expensive equipment.6,7,13 To overcome these limitations,
ComputedTomography(CT)scansandQualityOfLife(QOL) questionnaireshavebeenusedtoassessimplicationand out-comesofORLsurgeriesfornasalvalvecollapse.CT-scanhas beensuggestedasanobjectivetooltomeasureINVanatomy pre- and post-operatively.14,15 However,it was found that
usingtheconventionalcoronalimagingplanedoesnotresult insufficientevaluationofINV.Cakmaketal.16andPoetker
etal.,17suggestthatINVanglemaybebetterassessedwhen
CT-scans arereformatted toaplane perpendicular tothe estimatedacousticaxis.16,17These studiesconfirmthatCT
CT-scanevaluationofINVanditscorrelationwithNOSEscale 345 maybeaworthytoolinobjectivelyevaluatingoutcomesof
functionalnasalsurgeries..
Stewartetal.developedandvalidatedtheNose Obstruc-tion Symptom Evaluation (NOSE) scale as a symptomatic improvement quality of life scale, to be used in evalua-tion of INV obstruction.1 The NOSE scale was reportedin
studies as a useful tool for assessing INV pre- and post-surgeries.18---20 Proper preoperative evaluation of the INV
is criticaltotheworkup decisionsdevelopedfor repairof this area’s problems. Asking a patient to do a CT scan for INV angle/areapreoperative can provide theORL sur-geon with upgraded anatomical information to evaluate the INV.21 To fill this void for knowing which is the best
evaluation tool to be used before and after rhinoplasty, we uniquelyevaluatedtheINV areaand angle using refor-matted CT-scans, and thencompared its results to NOSE scores scale for assessing symptomatic improvement of patients undergoingrhinoplasty for nasal obstruction plus nasal deformity pre- and post- rhinoplasty. Targeting the detectionofthemosteffectivetoolsfor evaluationofINV before rhinoplasty and for followup after surgery can be instructive.
Methods
Patientsanddatacollection
Weperformed aprospectiveobservationalcohortstudyof twentyconsecutivepatientsfromMarch2017tillMay2018, who underwent rhinoplasty surgery at the Otorhinolaryn-gologydepartmentinAinShamsUniversityHospital,Cairo, Egypt. Institutional Review Board approval was received from Vice Dean of Medical Ethics Committee of Faculty ofMedicineAinShamsUniversityforGraduateStudiesand Research.Allpatientssignedinformedwrittenconsent with-out receivingany stipend, and theywere informedabout studyrequirementsaccordingtoWorldMedicalAssociation Declaration ofHelsinki (version2002). Allpatientsagreed toundergoaCT-scanofthenosepre-rhinoplastyandthree months post-rhinoplasty. Complete ORL examination and endoscopic assessment of the nose was completed in all patientspriortosurgery.Inclusioncriteriawereasfollows: maleandfemalepatientswithrange20---50yearsold,nasal obstructionsecondarytointernalnasalvalvecollapse,nasal deformity, and/or inferior turbinate hypertrophy, and/or deviated nasalseptum.Exclusioncriteriawereasfollows: sinusitis,nasalpolyposis,andnasalmasses.
Measuringtools
Reformatted coronal CT-scans of INV area/angle were requestedat aplaneperpendiculartotheanterioraspect ofacousticaxis. Acoustic axisis determined onasagittal reformattedimagebasedonresultsofCakmakstudy,16who
revealedthataxispassesthroughthecenterofnasalpassage inanarc(Fig.1).Functionalseptorhinoplastywasdonewith spreadergraftinsertioninmostofthepatients.
WemeasuredtheINVcross-sectionalareaandvalveangle through a standardized section (1mm cut, immediately anteriortohead ofinferior turbinate)22 fromreformatted
scansasshowninonecaseofourpatients(Fig.2A---D).All patientswereaskedtocompleteNOSEscalequestionnaire beforeand3monthsaftersurgery.Sumsoftheanswerswere multipliedbyfiveoutofatotalscoreofa100.1,19
Statisticalanalysis
The statistician who performed statistical analysis was blinded and uninvolved with clinical record or radiologic analysis.Alldatawerecollected,coded,tabulatedand ana-lyzedusingSPSSversion24.0software(IBMCorp.Released 2016. IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp).
Samplecharacteristics
Data were normally distributed, therefore, mean and Standard Deviation (SD) were calculated for parametric numericaldata, while frequency and percentagefor non-numericaldata.AShapiro---Wilk’stest(p-value>0.05)23and
visual inspection of their normal Q-Q plots and box plots showedthatthepostnasalscoreswereapproximately nor-mally distributed for both males and females,24 with a
skewnessof0.591(StandardError ---SE=0.597)anda kur-tosisof−0.108(SE=1.154)forthemalesandaskewnessof 0.857(SE=0.845)andakurtosisof−0.300(SE=1.741)for thefemales(SupplementaryFig.S1).25
Pearson correlation coefficient (r) was used to assess strengthof association betweenINV angle andarea mea-suresfromeachnaresandaverageofbothsideswithNOSE scoresmeasurementstodefine thestrength anddirection ofthelinearrelationshipbetweenthem.Studentttestwas usedtoassessstatisticalsignificanceofdifferencebetween two study group means. All reported p-values originated fromtwo-sidedtestswithstatisticalsignificancedefinedas
Figure1 Sagittalreformattedcomputedtomographicviewofnasalcavity.Theyellowlineindicatestheestimatedacousticaxis andphysiologicnasalairflow.
Shafik
AG
et
al.
Table1 Demographic,symptomatic,andclinicalfeaturesofincluded20patients. Patient
code
Age (years)
Sex Indicationforrhinoplasty Preoperative Postoperative
Post-traumatic (Yes/No) Revision (Yes/No) NOSE score
INVarea(mm2) INVangle(degree) NOSE score
INVarea(mm2) INVangle(degree) Lt.side Rt.side Lt.side Rt.side Lt.side Rt.side Lt.side Rt.side
P1 23 F No Yes 55 170.1 140.4 11.7 9.1 35 132.2 133.0 12.1 15.0 P2 20 M Yes No 75 73.7 230.5 8.7 9.1 45 79.1 101.7 7.0 9.4 P3 24 M Yes No 70 108.5 138.2 5.6 7.7 40 118.3 176.6 5.1 10.4 P4 23 M Yes No 80 161.5 93.8 13.1 0 40 131.3 178.2 10.0 14.5 P5 21 F Yes No 60 72.7 98.2 8.2 12.9 35 150.2 114.5 18.4 16.0 P6 22 M Yes No 80 133.2 74.6 12.0 0 45 145.8 131.2 9.5 6.1 P7 21 F Yes No 55 159.4 115.3 10.7 6.0 40 179.3 99.1 12.5 5.3 P8 20 M Yes No 60 111.5 181.3 20.1 8.9 50 86.2 108.7 11.8 9.4 P9 20 M Yes No 65 198.4 127.4 9.3 8.3 40 110.0 184.7 5.9 14.7 P10 23 M Yes No 65 251.7 99.7 17.1 5.4 35 129.0 149.9 11.3 11.5 P11 21 F Yes No 60 150.9 89.8 13.9 6.4 40 148.2 150.3 5.2 8.3 P12 20 M Yes No 70 121.6 302.1 6.0 20.1 35 191.0 158.2 13.6 18.9 P13 20 F Yes No 70 107.8 110.9 7.4 8.4 35 143.0 163.6 10.7 12.1 P14 26 M Yes No 60 109.9 99.9 9.1 8.0 30 118.7 100.0 10.0 7.4 P15 27 M Yes No 65 112.0 174.7 3.7 11.7 30 139.9 106.2 6.9 8.6 P16 21 M No Yes 80 100.3 229.3 0 19.5 30 113.9 143.9 12.4 13.9 P17 20 M Yes No 75 140.7 154.4 6.5 12.1 55 95.8 111.1 7.8 11.1 P18 20 M Yes No 70 80.9 66.9 5.8 8.8 35 108.5 117.4 10.0 7.0 P19 30 F Yes No 65 82.3 84.4 9.1 5.4 45 74.1 77.4 8.9 8.6 P20 22 M Yes No 70 158.9 161.5 9.0 15.3 40 109.5 114.0 8.0 6.8
INV,internalnasalvalve;NOSE,NoseObstructionSymptomEvaluation;M,male;F,female;P,patient;Lt.,left;Rt.,right.
CT-scanevaluationofINVanditscorrelationwithNOSEscale 347
Figure2 Internalnasalvalveangle/areapreandpostoperativebyreformattedcoronalCT-scans.A,anglepre-operative;B;angle post-operative;C,areapre-operative,D,areapost-operative.
p<0.05.Linearregressionwasdonetotestandestimatethe dependenceofaquantitativevariablebasedonits relation-shipwithasetofindependentvariables.
Stewartetal developedand validatedNOSE scale asa disease-specificQOLinstrumenttobeusedinnasal obstruc-tionproblems(SupplementaryTableS1).1,19
Results
Table 1shows patients’ characteristics (n=20).A totalof 20patientsmetoureligibilitycriteriaandunderwent rhino-plastysurgery.Ofthe20patientsexamined,14weremale (70%)and6werefemale(30%)withagesrangingfrom20to 50yearsoldandagemean±SD(22.2±2.8).Twopatients (10%)hadahistoryofpreviousrhinoplastyand18(90%)had ahistoryofnasaltrauma.Allpatients(100%)initially com-plainedofnasalobstructioninatleastonenares.Follow-up forpatientswasforthreemonths.
Comparing between males and female postoperative nasal scores showed no significant difference between them,where the mean±SDwas39.3±7.6and 38.3±4.1 (p=0.78),respectively.
Patient’ssymptomaticimprovementfromnasal obstruc-tion was evaluated using (NOSE) scale and showed that the mean preoperative (NOSE) score was 67.5±7.9 and meanpostoperative(NOSE)scorewas39±6.6withamean changeof(NOSE)score28.5±9.3,indicatingahighly statis-ticallysignificantdifferencebetweenpreandpostoperative NOSEscores(p<0.0001),withthemostdifferencebetween pre- and post-operative NOSE scores was 50 (80 vs. 30) (Table2).
Radiographicallymeasurementsofcoronal CT-scansofINVcross-sectionalarea
The INV cross-sectionalareashowedthat mean preopera-tiveINVareaontheleftside,rightside,andaverageofboth
were130.3±44.9,138.6±60.6,and134.5±52.8, respec-tively.Aswell,itshowedthatthemeanpostoperativeINV areaontheleftside,rightsideandaverage ofbothwere 125.2±30.4, 130.9±30.7 and 128.1±30.5, respectively. Therewas nostatistically radiologically significant differ-encebetweeneithermeansofpre-andpost-operativeINV areaonleft,right,ortheiraverage(Table2).
It was found that there is no statistically significant correlation between preoperative NOSE scores and pre-operative INV cross-sectional areas either on left side, right side, or average of both with correlation coeffi-cient(r)(r=−0.16;p=0.5),(r=0.207;p=0.381),(r=0.077; p=0.746),respectively.Therewasastatisticallysignificant negative correlation between postoperative NOSE scores and postoperative INV cross-sectional area on left side (r=−0.444;p=0.05)(Table3andSupplementaryFig.S2).
Otherwise, no statistically significant correlation was detectedonrightside(r=−0.197;p=0.405)oraverageof bothsides(r=−0.394;p=0.085)(Table3).
Radiographicallymeasurementsofcoronal CT-scansofINVangle
TheINVangleshowedthatmeanpreoperativeINVangleon theleftside,rightside,andaverageofbothwere9.4±4.6, 9.15±5.2 and 9.3±4.9, respectively. As well, it showed that the mean postoperative INV angle on the left side, right side and average of both were 9.9±3.2, 10.8±3.7 and10.3±3.5,respectively.Resultsrevealedthattherewas nostatisticallyradiologicallysignificantdifferencebetween eithermeans of pre-and post-operativeINVarea onleft, right,ortheiraverage(Table2).
Preoperatively, there was no statistically significant correlationbetweenpreoperativeNOSEscoresand preoper-ativeINVangleseitheronleftside,rightside,oraverageof both(r=−0.367;p=0.111),(r=0.021;p=0.93),(r=−0.347; p=0.133),respectively.Postoperativelytherewasno statis-ticallysignificant correlation between postoperativeNOSE
Table2 RadiographicallymeasurementsofleftandrightreformattedcoronalCT-scansofINVangleandcross-sectionalarea.
Preoperative Postoperative p-Value
Mean±SD Minimum Maximum Mean±SD Minimum Maximum
INVareaLt.Side 130.3±44.9 72.7 251.7 125.2±30.4 74.1 191.0 0.642 INVareaRt.Side 138.7±60.7 66.9 302.1 130.9±30.7 77.4 184.7 0.613
AverageINVarea 134.5±52.8 73.9 211.9 128.1±30.5 75.8 174.6 0.431
INVangleLt.Side 9.4±4.6 0 20.1 9.9±3.2 5.1 18.4 0.683
INVangleRt.Side 9.2±5.2 0 20.1 10.8±3.7 5.3 18.9 0.170
AverageINVangle 9.3±4.9 6.0 14.5 10.3±3.5 6.75 17.2 0.121
NOSEscore 67.5±7.9 55.0 80.0 39.0±6.6 30.0 55.0 0.0001a
INV,internalnasalvalve;NOSE,NoseObstructionSymptomEvaluation;SD,standarddeviation;Lt.,left;Rt.,right.
ap-valueissignificant,p<0.05.
Table3 PearsoncorrelationforassociationofINVangle/areameasurementswithpostoperativeNOSEscores.
Preoperative Postoperative
Correlationcoefficient p-Value Correlationcoefficient p-Value
INVareaLt.Side −0.160 0.500 −0.444 0.050a
INVareaRt.Side 0.207 0.381 −0.197 0.405
AverageINVarea 0.077 0.746 −0.394 0.085
INVangleLt.Side −0.367 0.111 −0.282 0.228
INVangleRt.Side 0.021 0.930 −0.225 0.341
AverageINVangle −0.347 0.133 −0.298 0.201
INV,internalnasalvalve;NOSE,NoseObstructionSymptomEvaluation;Lt.,left;Rt.,right.
ap-valueissignificant,p<0.05.
Table4 Multipleregressionstostudyindependentfactors affectingpostoperativeNOSEscores.
Factors Regression coefficient
p-Value 95%CI
Age −1.035 0.081 0.146,-0.215
Sex 0.760 0.810 −5.750,7.270
PostINVarea −0.120 0.079 −0.250,0.015 PostINVangle −0.556 0.312 −1.690,0.576 INV,internalnasalvalve.
scores and postoperative INV angles either on left side, right side, or an average of both (r=−0.282; p=0.228), (r=−0.225;p=0.341),(r=−0.298;p=0.201),respectively (Table3).
IncorrelationbetweencasesageandpostoperativeNOSE scores, there was no statistically significant correlation detected(r=−0.206;p=0.384).
Afteradjustmenttoallfactors,age,sex,postoperative INVareaandangle,multipleregressionrevealedthatnone ofthefactorswasstatisticallyaffectingpostoperativeNOSE scoreswithregressioncoefficient(−1.035,p=0.081),(0.76, p=0.81), (−0.12, p=0.079), (−0.556, p=0.312), respec-tively(Table4).
Discussion
Therewasahighlysignificantdifferencebetweenthemean ofpre-andpos-toperativeNOSEscores. Thehighestmean changeof NOSEscores was50, whilelowest meanchange
was10postoperatively.Nosignificantdifferencewasfound between themeanofpre-andpost-operative radiological measurementsofcross-sectional areaandangle ofINV. In addition,nocorrelationwasfoundbetweenradiological CT-scansofarea/angleandNOSEscoremeasurements.
Many physiologic and psychological factors can affect patients’perception ofnasalobstruction andoutcomesof surgeries. Those factors include: expectations of patients fromsurgeryoutcomes,differentsurgicaltechniques, and statusofvascularandnervesupplies.26 Thecoincidenceof
sinusitisoranynasalor sinusesmasseswithnasal obstruc-tionisstatisticallylinkedtohigherratesof dissatisfaction aftersurgery,whichmaygivewrongimpressionson effec-tivenessofmeasurablemethodused.Forthatourexclusion criteria were:sinusitis, nasal polyposis,and nasal masses that affect airwayresistance and give the wrong impres-sion that surgery does not give good results quickly as expected,asthoseexclusionsneedadditionaltimefor feel-ingimprovementwithamandatorycontinuationonmedical treatment.27 Thisisadecisivejudgmentonthesuccess of
rhinoplastysurgeryfromascientificandlegalview.Surgeons inORLneedareliablemethodtoprovetheirindicationsfor surgery are proper, or for followup of patients by assess-ing degree of obstruction pre-and post-surgery. Although noaccuratemethodhasbeenvalidatedyet,theNOSEscale wasfoundtobeapromisingandreliablemethodtoassess symptomaticimprovementofnasalobstructionproblems.A studyhasbeenproposedfortheefficacyofCT-scanforINV assessment.17 Previously theyrecommendedusingCT-scan
planes to be in perpendicular line toacoustic axis, how-ever,mostinstitutionsdonothaveavailabilityforemploying complex reformatting planes. Moreover, most radiologists usestandardimagesasbeingmorefamiliarforthem.When
CT-scanevaluationofINVanditscorrelationwithNOSEscale 349 theyappliedaxialplanescorrectly,amoreadequate
visu-alization of INV ensued, incorporatingall three bordering structures.17Kahvecietal.28reportedthatmean
preopera-tiveNOSEscoreswere60.2±17.5andmeanpostoperative scorewas11.3±10.5, withminimumandmaximum NOSE scores at 20 and 80. In our study, we found that there wasnostatisticallysignificantdifferencebetweenpre-and postoperativeINVcross-sectionalareas,eitheronleftside, right side orthe average ofboth sides. Forthese results, CTscanradiologicalmeasurementsmustnotgiveaccurate an impression of patient symptomatic improvement after surgery.Asregardspre-andpostoperativeINVangle/area, there was no statistically significant differenceeither on the left side, right side or the average of both sides. In accordancewithour findings,Veron etal. confirmed that CTscananalysisofINVdoesnotproduceanobjective eval-uation ofthe degree of nasalo bstruction; it isbetter to be correlatedwithseptal morphology asa possible cause ofnasalobstructionsymptoms.29Inaddition,Bloometal.,
confirmedtheimportanceoftakinginconsiderationthe pre-operative physical examination, and not just CT imaging inthedecision forwhichpatients arecandidates forsurgi-calintervention.22Incontrast,Mocheetal.30reportedthat
radiographicimagingofINVareaproducedgoodsensitivity andspecificityvalues,makingitagoodmeasurementtool forINVassessment.
On the other hand, after evaluation of symptomatic improvementaccording toNOSE scoresscale, therewasa highlystatisticallysignificantdifferencebetweenpre-and postoperativeNOSEscores,withsignificantimprovementin the scores aftersurgery, which agrees withthe resultsof many studies.19,28,31---35 A collective systematic review was
conductedcollectingallincludedNOSEpapersscores pub-lished until2014, revealing thatNOSE scores can beused as a clinically significant measure of successful surgical outcomes.36EvenIshiietal.detectedthatNOSEscorescould
beusedasascreeningtoolinsteadof theEpworth sleepi-nessscale for patients at risk of undiagnosed obstructive sleepapnea.37
Aswell,therewasnosignificantcorrelationbetweenCT scanspostoperativeINVanglesandareaswithpostoperative (NOSE) score.Thus,therewasnocorrelation between CT scansanalysisoftheINVandthe(NOSE)scale,whichagrees withVeronetal.29 Kahvecietal.,28 whodetecteda
signif-icant negativecorrelation between angle degree increase and NOSE scores. Our results beg a question of whether physical examinationfindings byNOSE scores scale should beindicatedasamandatorymeasurementtoolover post-operativeradiologicassessmentsforfollow-up,tobeusedin concordancewithCT-scanspreoperativeformoreaccurate surgicaloutcomeplans.
Inspiteofourattemptstodiscoveranobjective measure-ment,thestudyof20patientsasasamplesizemaynotserve asatruenormalpopulation.However,patientswhohadany significantnasalandsinusdisordersthatcouldaffectnasal obstructionaverageimprovementtimewereexcluded.
Conclusion
Radiologicalmeasurementsofcross-sectionalareaandangle ofINVbyreformattedCTscanswerenotofvaluein evalua-tionofINVpreandpost-rhinoplasty.Onthecontrary,there was a highly significant difference between NOSE scores pre and post-rhinoplasty, in which it wasfound to be of significant value todetermine thedegree ofsymptomatic improvement preand post rhinoplasty.Therefore for bet-terclinicalsymptomaticevaluationpre-andpost-operative
in rhinoplasty; using NOSE scale assessment is preferable tousingroutineCTscancommonlyrequested byORL sur-geonsforsomedecisionmakingafterphysicalexamination. Besides,NOSEscale wouldbeausefulfollow-up measure-ment tool for assessment of the degree of symptomatic improvement.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Appendix
A.
Supplementary
data
Supplementarymaterialrelatedtothisarticlecanbefound, in the online version, at doi:https://doi.org/10.1016/j. bjorl.2019.08.009.
References
1.StewartMG,WitsellDL,SmithTL,WeaverEM,YuehB, Hann-leyMT.DevelopmentandvalidationoftheNasalObstruction SymptomEvaluation(NOSE)scale.OtolaryngolHeadNeckSurg. 2004;130:157---63.
2.FattahiT.Internalnasalvalve:significanceinnasalairflow.J OralMaxillofacSurg.2008;66:1921---6.
3.TeichgraeberJF,WainwrightDJ.Thetreatmentofnasalvalve obstruction.PlastReconstrSurg.1994;93:1174---82,discussion 1183-4.
4.BaileyB.Nasalfunctionandevaluation,nasalobstruction.Head NeckSurg-Otolaryngol.1998.
5.RheeJS,Weaver EM,ParkSS,Baker SR,HilgerPA,Kriet JD, et al. Clinical consensus statement: diagnosis and manage-mentofnasalvalvecompromise.OtolaryngolHeadNeckSurg. 2010;143:48---59.
6.GrymerLF.Reduction rhinoplasty and nasal patency:change inthecross-sectionalareaofthenoseevaluatedbyacoustic rhinometry.Laryngoscope.1995;105:429---31.
7.RoithmannR,ColeP,ChapnikJ,ShpirerI,HoffsteinV,Zamel N.Acousticrhinometryintheevaluationofnasalobstruction. Laryngoscope.1995;105:275---81.
8.ShaidaA,KenyonG.Thenasalvalves:changesinanatomyand physiologyinnormalsubjects.Rhinology.2000;38:7---12.
9.KasperbauerJ,KernE.Nasalvalvephysiology.Implicationsin nasalsurgery.OtolaryngolClinNorthAm.1987;20:699---719.
10.Murakami C. Nasal valve collapse. Ear Nose Throat J. 2004;83:163---4.
11.Rhee JS, Arganbright JM, McMullin BT, Hannley M. Evi-dencesupportingfunctionalrhinoplastyornasalvalverepair: a 25-year systematic review. Otolaryngol Head Neck Surg. 2008;139:10---20.
12.Nigro CEN, de Aguiar Nigro JF, Mion O, Mello JF Jr. Nasal valve: anatomy and physiology. Braz J Otorhinolaryngol. 2009;75:305---10.
13.AdamsonP,SmithO,ColeP.Theeffectofcosmeticrhinoplasty onnasalpatency.Laryngoscope.1990;100:357---9.
14.Montgomery WM, Vig PS, Staab EV, MattesonSR. Computed tomography:athree-dimensionalstudyofthenasalairway.Am JOrthod.1979;76:363---75.
15.KasselE,CooperP,KasselR.CTofthenasalcavity.J Otolaryn-gol.1983;12:16---36.
16.C¸akmakÖ,Cos¸kunM,C¸elikH,BüyüklüF,Özlüo˘gluLN.Valueof acousticrhinometryformeasuringnasalvalvearea. Laryngo-scope.2003;113:295---302.
17.PoetkerDM,RheeJS,MocanBO,MichelMA.Computed tomog-raphytechniqueforevaluationofthenasalvalve.ArchFacial PlastSurg.2004;6:240---3.
18.Gandomi B,Bayat A,Kazemei T.Outcomes ofseptoplastyin youngadults:theNasalObstructionSeptoplastyEffectiveness study.AmJOtolaryngol.2010;31:189---92.
19.StewartMG,SmithTL,WeaverEM,WitsellDL,YuehB, Hann-leyMT,etal.Outcomesafternasal septoplasty:resultsfrom theNasalObstructionSeptoplastyEffectiveness(NOSE)study. OtolaryngolHeadNeckSurg.2004;130:283---90.
20.Rhee JS, Book DT, Burzynski M, Smith TL. Quality of life assessment in nasal airway obstruction. Laryngoscope. 2003;113:1118---22.
21.CemMimanM,Deliktas¸H,ÖzturanO,TopluY,Akarc¸ayM. Inter-nalnasalvalve:revisitedwithobjectivefacts.OtolaryngolHead NeckSurg.2006;134:41---7.
22.BloomJD,SridharanS,HagiwaraM,BabbJS,WhiteWM, Con-stantinidesM.Reformattedcomputedtomographytoassessthe internalnasalvalveandassociationwithphysicalexamination. ArchFacialPlastSurg.2012;14:331---5.
23.Razali NM, Wah YB. Power comparisons of shapiro-wilk, kolmogorov-smirnov,lillieforsandanderson-darlingtests.JStat ModelAnal.2011;2:21---33.
24.GhasemiA,ZahediaslS.Normalitytestsforstatisticalanalysis:a guidefornon-statisticians.IntJEndocrinolMetab.2012;10:486.
25.DoaneDP,SewardLE.Measuringskewness:aforgottenstatistic? JStatEdu.2011;19:2.
26.KonstantinidisI,TriaridisS,TriaridisA,KaragiannidisK, Kont-zoglouG.Longtermresultsfollowingnasalseptalsurgery:focus onpatients’satisfaction.AurisNasusLarynx.2005;32:369---74.
27.JessenM,IvarssonA,MalmL.Nasalairwayresistanceand symp-tomsafterfunctionalseptoplasty:comparisonoffindingsat9 monthsand9years.ClinOtolaryngolAlliedSci.1989;14:231---4.
28.KahveciOK,MimanMC,YucelA,YucedagF,OkurE,AltuntasA. TheefficiencyofNoseObstructionSymptomEvaluation(NOSE) scaleonpatientswithnasalseptaldeviation.AurisNasus Lar-ynx.2012;39:275---9.
29.VeronA.ValueofCTscanmeasuresofthenasalvalvefor pre-dictingclinicalnasalobstruction;2011.
30.MocheJA,CohenJC,PearlmanSJ.Axialcomputedtomography evaluationoftheinternalnasalvalvecorrelateswithclinical valvenarrowingandpatientcomplaint.In:Paperpresentedat: internationalforumofallergy&rhinology;2013.
31.YooS,MostSP.Nasalairwaypreservationusingtheautospreader technique:analysisofoutcomesusingadisease-specific quality-of-lifeinstrument.ArchFacialPlasticSurg.2011;13:231---3.
32.RheeJS,PoetkerDM,SmithTL,BustilloA,BurzynskiM,Davis RE.Nasalvalvesurgeryimprovesdisease-specificqualityoflife. Laryngoscope.2005;115:437---40.
33.MostSP.Analysisofoutcomesafterfunctionalrhinoplastyusing adisease-specificquality-of-lifeinstrument.ArchFacialPlastic Surg.2006;8:306---9.
34.Dolan RW. Minimally invasive nasal valve repair:an evalua-tionusingtheNOSEscale.ArchOtolaryngol---HeadNeckSurg. 2010;136:292---5.
35.MondinaM,MarroM,MauriceS,StollD,deGaboryL.Assessment ofnasalseptoplastyusingNOSEandRhinoQoLquestionnaires. EurArchOto-Rhino-Laryngol.2012;269:2189---95.
36.RheeJS,SullivanCD,FrankDO,KimbellJS,GarciaGJ.A sys-tematicreviewofpatient-reported nasal obstructionscores: definingnormativeandsymptomaticrangesinsurgicalpatients. JAMAFacialPlastSurg.2014;16:219---25.
37.Ishii L, Godoy A, Ishman SL, Gourin CG, Ishii M. The nasal obstructionsymptomevaluationsurveyasascreeningtoolfor obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2011;137:119---23.
