Versão em português do "The Utrecht questionnaire for outcome assessment in aesthetic rhinoplasty": validação e aplicação clínica

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

The

Portuguese

version

of

‘‘The

Utrecht

questionnaire

for

outcome

assessment

in

aesthetic

rhinoplasty’’:

validation

and

clinical

application

夽

Francisco

Rosa

_,

_Peter

_J.F.M.

_Lohuis

_,

_João

_Almeida

_,

_Mariline

_Santos

_,

Jorge

Oliveira

_,

_Cecília

_Almeida

_e

_Sousa

_,

_Miguel

_Ferreira

a_{CentroHospitalardoPorto,DepartamentodeOtorrinolaringologiaeCirurgiadeCabec¸aePescoc¸o,Porto,Portugal} b_{DiakonessenHospital,CenterforFacialPlasticandReconstructiveSurgery,DepartmentofOtolaryngology/HeadandNeck} Surgery,Utrecht,TheNetherlands

Received15September2017;accepted30November2017 Availableonline26December2017

KEYWORDS Surveysand questionnaires; Rhinoplasty; Qualityoflife; Plasticsurgery; Patientsatisfaction Abstract

Introduction:Theevaluationofsurgicaloutcomesmeasuredbypatientsatisfactionorqualityof lifeisveryimportant,especiallyinplasticsurgery.Thereisincreasinginterestinself-reporting outcomesevaluationinplasticsurgery.

Objective:Theaimofthisstudywastoperformthetranslation,cross-culturaladaptationand validation of‘‘TheUtrechtquestionnairefor outcome assessmentinaestheticrhinoplasty’’ fromEnglishtoPortuguese.

Methods:Retrospectivestudyinvolving50patients undergoingtorhinoplastycomparingthe preoperativeperiodwiththecurrentpostoperativesituation(minimum6monthsandmaximum 24monthspostoperatively).Statisticalanalysiswasperformedtoassessinternalconsistency, test---retestreliability,validityandresponsiveness.

Results:Nopatientsreceivedanegativescoreonthevisualanaloguescalecomparing preop-erativeandpostoperativeappearance.Thepostoperativeimprovementonthevisualanalogue scalerevealedaGaussiancurveofnormaldistributionwithameanimprovementof4.44points. Thetest---retestreliabilityshowedapositivecorrelationbetweenthepostoperativeresponse andthesamequestionnairerepeatedninety-sixhourslater.Theinternalconsistencywashigh (Cronbach’salphavalue:Preoperative=0.88;Postoperative=0.86).Theauthorsobserveda sig-nificantimprovement inresponsefor all individualquestionsinthe postoperative phaseas comparedwithpreoperativesituation(t-studenttest---p<0.05).

夽 _{Pleasecitethisarticleas:RosaF,LohuisPJ,AlmeidaJ,SantosM,OliveiraJ,SousaCA.,etal.ThePortugueseversionof‘‘TheUtrecht}

questionnaireforoutcomeassessmentinaestheticrhinoplasty’’:validationandclinicalapplication.BrazJOtorhinolaryngol.2019;85:170---5.

∗_{Correspondingauthor.}

E-mail:franciscorosa97@gmail.com(F.Rosa).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.11.007

1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Conclusion: ThePortugueseversionof‘‘TheUtrechtquestionnaireforoutcomeassessmentin aestheticrhinoplasty’’isavalidinstrumenttoassesspatients’outcomesfollowingrhinoplasty surgery.

© 2017 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 Pesquisase questionários; Rinoplastia; Qualidadedevida; Cirurgiaplástica; Satisfac¸ãodo paciente

Versãoemportuguêsdo‘‘TheUtrechtquestionnaireforoutcomeassessmentin aestheticrhinoplasty’’:validac¸ãoeaplicac¸ãoclínica

Resumo

Introduc¸ão: Aavaliac¸ãodoresultadocirúrgicomedidopelasatisfac¸ãodopacienteouqualidade devidaémuitoimportante,especialmentenacirurgiaplástica,umaespecialidadenaqualhá umcrescenteinteressenaavaliac¸ãoderesultadosporauto-relato.

Objetivo: O objetivo deste estudo foi realizar a traduc¸ão, a adaptac¸ão transcultural e a validac¸ãodo questionário‘‘TheUtrechtquestionnairefor outcomeassessmentinaesthetic rhinoplasty’’,doinglêsparaportuguês.

Método: Estudoretrospectivoenvolvendo50pacientessubmetidosarinoplastiacomparandoo períodopré-operatóriocomasituac¸ãoatual(mínimode6mesesemáximode24mesesde pós-operatório).Aanáliseestatísticafoirealizadaparaavaliaraconsistênciainterna,confiabilidade teste-reteste,validadeecapacidadederesposta.

Resultados: Nenhumpacienterecebeupontuac¸ãonegativanaescalavisualanalógicaao com-pararaaparênciapré-epós-operatória.Amelhorapós-operatórianaescalavisualanalógica revelouumacurvagaussianadedistribuic¸ãonormal,commelhoramédiade4,44pontos.A con-fiabilidadeteste-retestemostrouumacorrelac¸ãopositivaentrearespostapós-operatóriaeo mesmoquestionáriorepetidonoventaeseishorasdepois.Aconsistênciainternafoialta(valor doalfadeCronbach:pré-operatório=0,88;pós-operatório=0,86).Osautoresobservaramuma melhorasignificantenasrespostasparatodasasquestõesindividuaisnafasepós-operatóriaem comparac¸ãocomasituac¸ãopré-operatória(testetdeStudent---p<0,05).

Conclusão:Aversãoemportuguêsdo‘‘TheUtrechtquestionnaireforoutcomeassessmentin aestheticrhinoplasty’’éuminstrumentoválidoparaavaliarosresultadosdopacienteapósa cirurgiaderinoplastia.

© 2017 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

Rhinoplastyhasbecomeoneofthemaincosmeticsurgeries performed by otorhinolaryngologists and plastic surgeons. The major indications for rhinoplasty are: aesthetic and aesthetic-functional.1

Mostofthestudiesthatdiscussaestheticsurgeryinvolve discussions about surgical techniques, access pathways, complications, sequelae and reoperation rates. The eval-uationofthefinaloutcomeofthewasnotevaluatedfrom thepatient’spoint ofview;thisanalysisis veryimportant becausepatientsatisfactionisthepredominantfactor for surgicalsuccess.2

In rhinoplasty, more than any other aspect of rhinol-ogy, patient satisfaction and quality of life should be measures againstwhich thesuccessfulprocedure must be judged. In this context, quality-of-life questionnaires are veryadequate toolsthatallowthequantitativeevaluation ofsubjectiveresults,suchaspatientsatisfactionand, con-sequently,thesuccessofthesurgery.3

Based on suchphilosophy, Peter Lohuis and colleagues designedashortquestionnaireonthebasisofapreviously

validated questionnaire by Alsarraf. ‘‘The Utrecht ques-tionnaireforoutcomeassessmentinaestheticrhinoplasty’’ containedavisualanaloguescaleandfivesimplequestions toevaluatesubjectivebodyimageandqualityoflifein rela-tiontonasalappearancethatinfluence thesatisfactionof thepatientundergoingrhinoplasty.4,5

The aim of this study was to perform the transla-tion, cross-cultural adaptation and validation of ‘‘The Utrechtquestionnaireforoutcomeassessmentinaesthetic rhinoplasty’’fromEnglishtoPortugueseofPortugal.

Methods

Initially,theapplicationforauthorizationwasmadetothe original author. ‘‘The Utrecht questionnaire for outcome assessment in aesthetic rhinoplasty’’ was translated and adaptedaccordingtocriteriafromGuilleminetal.6

The first part of the questionnaire consisted of five questions (E1 through E5) interviewing the patient about bodyimageandqualityoflifeinrelationtonasal appear-ance.Eachofthefivequestionswasscoredonafive-point Likert scale (1, not at all; 5, very much/often), so that

The Utrecht questionnaire for outcome assessment in aesthetic rhinoplasty I give the following score to the way I like the appearance of my nose:

E1. Are you concerned about the appearance of your nose?

E2. Does this concern bother you often?

E4. Does this concern affect your relationships with others?

E5. Do you fell stressed by the appearance of your nose? E3. Does this concern affect your daily life (e.g., your work)? Not at all Not at all Not at all Not at all A little A little A little A little A little Moderate Moderate Moderate Moderate Moderate Much or often Very nice Very ugly Much or often Much or often Much or often Much or often

Very much or often

Very much or often

Very much or often

Very much or often Very much or often Not at all I 1 0 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 7 6 8 9 10 I I I I I I I I I I

Figure1 TheUtrechtquestionnaireforoutcomeassessmentinaestheticrhinoplasty.

in total a minimum of five points and a maximum of 25 pointscould be gathered.The third and fourth questions (E3and E4)were considered ‘‘trick’’questionsthatwere included withthe ideathat theyprovide insight of a dis-turbanceinbodyperception or bodydysmorphicdisorder. Thesecond partofthequestionnaireconsisted ofavisual analoguescaleonwhichpatientscouldratetheappearance of their nose on a 10 point scale (0, very ugly; 10, very nice).4

The original Englishversion (Fig.1)wasdeliveredto3 translatorswithfluencyinEnglishbuthavingPortugueseas theirnativelanguage.

In a second phase,a panel of expertscompared the3 translationsandcreatedaconsensualtranslation.Thislast translation was deliveredto 3 translators with English as anative languageandwithhighfluencyinPortuguese lan-guage,creatingretroversionfromPortuguesetoEnglish.A secondpanelofexpertscomparedtheoriginalversionofthe questionnairewiththeretroversion,andfinallyan interme-diateversionwascreated.

This intermediateversion wasdeliveredto15 patients previouslyundergoingrhinoplasty.Inthisway,itwaspossible totestthecomprehensionofeachitem.Thisphaseallowed theculturaladaptationoftheversion,resultinginthefinal Portugueseversion.

Toassess thechangesinsubjective perceptionofnasal appearanceaftersurgery,thequestionnairewassentto vol-unteerpatients by e-mail toretrospectively compare the preoperative period with the current situation. Informed

consent was obtained from all individual participants includedinthestudy.Theinclusioncriteriawere:patients undergoingprimaryrhinoseptoplastyin2015and2016,older than18yearsandunder65 years,minimumpostoperative periodof6monthsandamaximumof2years.Theexclusion criteriawere: patientswithcongenital facialdeformities, who did not speak Portuguese from Portugal and did not intendtoparticipateinthestudy.

To assess reliability, validity, and internal consistency of our questionnaire, we statistically analyzed preopera-tive and postoperative questionnaire data. We evaluated test---retest reliability by determining for each question the Pearson correlation coefficient between the postop-erativeresponse andthe same questionnairerepeated 96 hourslater.Weusedat-testtoevaluatethesecorrelation coefficients.The internalconsistencyof thequestionnaire wasmeasured withCronbach’salpha. The validity of this shortquestionnairewasassessedbymeasuringthe respon-sivenesstochange.Therefore,weperformedapairedt-test

bycomparingpreoperativeandpostoperativeresponses.For the statisticaltests, resultswithp<0.05 wereconsidered significant.

Results

The final version of the questionnaire translated and adapted from English to Portuguese, according to the Guillemincriteria,ispresentedinFig.2.

Questionário de Utrecht para avaliação dos resultados de uma rinoplastia estética

É a seguinte a classificação que atribuo á minha satisfação com o aspeto do meu nariz:

E1. Está preocupado(a) com o aspeto do seu nariz?

E2. Esta preocupação incomoda-o(a) frequentemente?

E3. Esta preocupação afeta a sua vida quotidiana (por exemplo, o seu trabalho)?

E4. Esta preocupação afeta o seu relacionamento com outras pessoas?

E5. Sente-se mal com a aparência do seu nariz? De modo nenhum 5 5 5 5 5 4 4 4 4 4 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1 De modo nenhum De modo nenhum De modo nenhum De modo nenhum Um pouco Um pouco Um pouco Um pouco Um pouco Moderadamente Moderadamente Moderadamente Moderadamente Moderadamente Muito ou frequentemente Muito ou frequentemente Muito ou frequentemente Muito ou frequentemente Muito ou frequentemente Muitíssimo Muitíssimo Muitíssimo Muitíssimo Muitíssimo I 1 0 2 3 4 5 6 7 8 9 10 I I I I I I I I I I

Muito feio Muito bonito

Figure2 Portuguesefinalversionof‘‘TheUtrechtquestionnaireforoutcomeassessmentinaestheticrhinoplasty’’.

Weincluded 50patientswhounderwentrhinoplastyfor aestheticoraesthetic-functionalreasons.Theaverageage was 37.34 years (Standard Deviation --- SD±9.96) with a rangefrom22to63years,26(52%)weremalesand24(48%) werefemales.

No patients had negative variation in the score on the Visual Analogue Scale (VAS) comparing preoperative and postoperativeappearance (6 months to2 years after surgery).Thepostoperativeimprovementonthevisual ana-loguescalerevealedaGaussiancurveofnormaldistribution with a mean improvement of 4.44 (SD±1.8) points. The majorityofpatients(80%)consideredthatthenose appear-anceimprovedbetween3and6points(Fig.3).

Test---retestreliabilitymeasuredthestabilityofan instru-ment over time after repeated testing. The test---retest reliability showed a positive correlation between the

postoperative response and the same questionnaire repeated ninety six hours later (Table 1). The t-test

evaluation of these correlation coefficients did not show statisticallysignificantdifferences(p<0.05).

Internalconsistencyreferredtothewayindividualitems relatetoeachother,inordertoprovidehomogeneityamong them,andwasmeasuredusingCronbach’salpha.The min-imum acceptable score for Cronbach’s alpha is 0.7. The internalconsistencyofthequestionnairewasadequate.The alphavaluewas0.88forpreoperativeresponsesand0.86for postoperativeresponses.

The validity of the questionnaire was assessed by measuringtheresponsivenesstochange.Weobserveda sig-nificantimprovement(p<0.05)inresponseforallindividual questionsinthepostoperativephaseascomparedwith pre-operativesituation(Table2).

0 2 4 6 8 10 12 14 16 0 1 2 3 4 5 6 7 8 9 10 Nu m b e r o f p a ti e n ts

Improvement VAS after rhinoplasty

Figure3 PostoperativeimprovementontheVisualAnalogue

Scale(VAS) revealed aGaussian curve ofnormaldistribution withameanimprovementof4.44points.

Table 1 Test---retest reliability: the Pearson correlation coefficient between the postoperative response and the samequestionnairerepeated96hourslater.

Question(1---5) Pearson correlation coefficient p E1 0.89 0.209121 E2 0.87 0.209867 E3 0.91 0.284477 E4 0.86 0.091176 E5 0.87 0.091176 SUM(E1-E5)---(5---25) 0.96 0.098301 VAS 0.89 0.349522 t-studenttest(p<0.05).

Table2 Validityofthequestionnaire:comparisonof pre-operativeandpostoperativescores.

Question (1---5) Preoperative score Postoperative score p E1 3.52 1.68 1.43×10−13 E2 3.4 1.54 2.23_×10−13 E3 2.08 1.3 4.73×10−13 E4 2 1.22 7.47×10−13 E5 3.06 1.38 4.76×10−13 SUM (E1-E5)---(5---25) 14.06 7.12 1.24×10−12 VAS 3.82 8.26 1.94×10−12 t-studenttest(p<0.05).

Discussion

Some factors may influence patient satisfaction, such as culture,lifeexperience,andespeciallythepatient’s expec-tationsaboutthefinaloutcome,whichmayormaynotbe realistic.Althoughtheprocedurecanoftenbeconsidereda successbythe surgeon,the patientmaynotfeelsatisfied withit,andtheoppositeisalsotrue.7,8

Rhinoplasty, altering the patient’s image and conse-quentlyhis/her self-esteem,increasingly suggests theuse ofsatisfactionquestionnaireswiththeprocedure.9

Theeasyadministrationofthequestionnairewasoneof theconcernsthatLohuisandcolleagueshadindoingit.4_We

noticedthat,afteritstranslationandcross-cultural adapta-tion,thischaracteristicwasnotlost.

Thequestionnairewasself-administeredbye-mail,and just a few minutes are enough to fill out the questions, thuscausingtheleastdiscomfortfortheresponder. Proba-bly,thisadministrationofthequestionnairetopatientsdid notalteritspurpose,becauseevenifitwereadministered throughinterview,thereadingwouldbeperformedipsis ver-bis,withoutanyexplanationofthequestions.Inaddition, inourclinicalpracticepatientstendtopreferthe question-nairetobeadministeredbye-mail.Thismethodhassome advantages, suchasfastercompletiontime,lowerrateof missingdataandthenon-interferenceoftheinterviewer’s motivationintheresponses.10

The method usedin this study, aretrospective assess-mentofpatientpreoperativesatisfaction,andprospective evaluationof thepatient’spostoperativesatisfaction,was similartotheonepublishedbyotherauthors.1,7

ThePortugueseversionofthequestionnaireshowedhigh internal consistencyliketheoriginalone,withCronbach’s alphacoefficienthigherthan0.8.

Thetest---retestreproducibilitywasassessedindifferent ways.Intheoriginalstudy,patientsfilledoutthe question-naire(self-administration)twotimes:1year aftersurgery (postoperative response) and 2 to 4 years after surgery (repost operative response). In our study, we evaluated test---retestreliabilityby computingfor each question the Pearsoncorrelation coefficientbetween thepostoperative response and the same questionnaire repeated 96 hours later.Despitedifferencesintheadministrationof question-naire,highcorrelation coefficientshavebeen achievedby bothforms.

Regarding the validity of the questionnaire, the Por-tuguese version revealed an optimum performance and a statistically significant difference in scores was noted whencomparingpreoperativeandpostoperativeresponses. The significant improvement in questionsE1 to E5 and in the sum of the questions strongly suggests a postopera-tive improvement in the subjective perception of nasal appearanceandqualityoflifeafterrhinoplastyinthestudy population.

Thepostoperative improvementonthevisual analogue scalerevealedaGaussiancurveofnormaldistributionwith ameanimprovementof4.44points.Withthissimpletool, suchasthevisualanaloguescale,theanalysisofthe oper-ated patients can givethe surgeonan evaluation of their performance,beingthisinformationusefulforthesurgeon andthepatient.

Forsurgeonswhoselectpatient-reportedoutcome meas-urestobeusedinclinicalpractice,thequalityandcontent of available questionnaires must be considered carefully. These can be divided into three categories: (1) Func-tionalself-assessment;(2)Aestheticself-assessment(e.g., Utrecht questionnaire); and (3) Aesthetic and functional self-assessment (e.g., Rhinoplasty Outcomes Evaluation). This short and practical questionnaire focuses specifically onaestheticrhinoplasty.Preoperatively,thequestionnaire informs the surgeonabout body image andquality of life regardingnasalappearance.Postoperatively,the question-naire measures the aestheticresult, which, for example,

maybeusefulindecidingwhetherminoradditional correc-tionsarenecessaryorcanbeavoided.

The authors concluded that a surgeon performing rhinoplasty can benefit from using this questionnaire in Portuguese. It is simple, quicklycompleted, and provides important subjective information about the preoperative nasalappearanceofthepatientandthepostoperative sur-gicaloutcome.

Conclusion

The Portugueseversionof ‘‘The Utrechtquestionnairefor outcome assessment in aesthetic rhinoplasty’’ is a valid instrumenttoassessresultsinrhinoplastypatients,resulting goodinternalconsistency,reproducibilityandvalidity.

Ethical

approval

Allproceduresperformedinstudiesinvolvinghuman partic-ipantswereinaccordancewiththeethicalstandardsofthe institution.

This article does not contain any studies with animals performedbyanyoftheauthors.

Previous

presentation

Thispaperwaspresentedasanoral communicationinthe ENTWorldCongressIFOSParis2017.

Informed

consent

Informed consent was obtained from all individual participantsincludedinthestudy.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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