2017-18 HSC Section 4 Green Book

Original Investigation Research

Nasal Valve Obstruction After Rhinoplasty

Table 2. Multiple Linear Regression Analysis for Postoperative NOSE Scale Score at 3 Months a Variable β Value (95% CI)

Figure 3. Postoperative Change in Nasal Obstruction Symptom Evaluation (NOSE) Scale Score by Patient Group

P Value

Mean NOSE scale scores A

Spreader graft use

−6.17 (−18.32 to 5.98) −1.25 (−12.92 to 10.42) 4.36 (−5.97 to 14.69) −5.77 (−16.28 to 4.74) 24.99 (9.51 to 40.48)

.31 .83 .84 .28

80

Functional group Aesthetic-functional group

Alar graft use

Aesthetic tip intervention Aesthetic vault intervention

60

Intercept

.002

40

eral single-surgeon or single-center studies 12,13 demon- strated that functional rhinoplasty provides significant improvement in nasal breathing, with or without aesthetic in- terventions. However, the single-surgeon or single-center de- sign raises concerns about the generalizability (external va- lidity) of the findings. Also, in the absence of a suitable study to allowdirect comparison, whether patients undergoing aes- thetic-functional rhinoplasty benefit similarly comparedwith those undergoing functional rhinoplasty alone remains un- certain. Our results showed improvement in nasal obstruc- tion after surgery. Overall, themean improvement in theNOSE scale score was 48.6 points at the 3-month assessment com- pared with the preoperative baseline score. This improve- ment corresponds to a 65% reduction in baseline score. Rhee et al 23 performed a systematic review evaluating the norma- tive and symptomatic NOSE scale score in patients undergo- ing surgery. Lipan andMost 24 further provided a severity clas- sification systemfor nasal obstructionbasedon theNOSE scale score. Our study showed substantial change from severe ob- struction (NOSE scale score range, 55-75) at baseline to nor- mal ormild symptoms postoperatively (NOSEscale score range, 5-25). Themagnitude of postoperative improvement was con- sistentwith findingspresentedby single-center cohorts. In their reports of patients undergoing functional rhinoplasty for na- sal obstruction, Rhee et al, 25 Most, 19 andLindsay 20 foundmean improvements in the NOSE scale score of 48.4, 44.6, and 42.7 points, respectively. In their systematic review, Rhee at al 25 similarly showed a mean improvement of 42 points after a variety of surgical procedures to treat nasal obstruction. Patients undergoing functional rhinoplasty commonly have aesthetic goals and desires. Aesthetic interventionsmay not contribute favorably to the nasal airflow. A few published studies 26,27 showed a rhinometric decrease in nasal patency after aesthetic rhinoplasty, although the impact did not seem to be of clinical significance. Furthermore, the aesthetic in- terventionsmay competewith the spreader and alar grafts for the available cartilagematerial. The novel contribution of our study is our ability to compare the functional and aesthetic- functional subgroups in a prospective cohort study. Both groups had similar nasal breathing outcomes (mean [95% CI] unchanged with an insignificant effect for the methods of reconstruction and aesthetic interventions. Analysis of variance showed no significant difference in NOSE scale outcome between centers ( P = .23). Methods of reconstruction (spreader and alar grafts) and aesthetic interventions (tip and vault) were used as predictors. The model produced R 2 = 0.04 and P = .63. Abbreviation: NOSE, Nasal Obstruction Symptom Evaluation. a The regression model was repeated using 2-level regression (patients nested within centers) and allowed random intercept and random coefficients to accommodate for possible center differences. The results remained

20

NOSE Scale Score

0

Baseline

Postoperative Assessment, mo 3 6

12

Mean change in NOSE scale scores B

80

60

40

20

NOSE Scale Score

0 Postoperative Improvement in

Postoperative Assessment, mo 3 6

12

nitude of improvement in nasal breathing, with a mean (95% CI) improvement in theNOSE scale score of 51.4 (42.1-60.7) and 46.6 (37.1-56.1), respectively ( P = .49). The results fromthe sec- ondary regressionmodel were consistent with those of the pri- mary analysis ( Table 2 ). No significant association was found between the NOSE scale score outcome at 3 months and the use of aesthetic interventions (tip or vault) or the reconstruc- tionmethods (spreader and alar grafts). The results remained unchanged when the regression was repeated using a multi- level model allowing for possible center effect; the analysis of variance showed no significant difference in NOSE scale out- come between centers ( P = .23). We also performed subgroup analysis in 8 patients who did not undergo septoplasty as part of their rhinoplasty (alternative cartilage source). The NOSE scale outcome was similar for those who received and did not receive septoplasty ( P = .18). For the6patients identifiedashav- ing a surgical failure (≤10% improvement), no correlationwas found with the reconstruction methods (Fisher exact test, P = .61 and P = .33 for spreader and alar grafts, respectively) or the aesthetic interventions (Fisher exact test, P = .61 and P = .33 for tip and vault interventions, respectively). The NOSE scale score ranges from 0 to 100, with a higher score indicating greater severity of obstruction. Data markers indicate mean NOSE scale score; error bars, 95% CI.

Discussion The surgical treatment of NVI has received increasing atten- tion among otolaryngologist and rhinoplasty surgeons. Sev-

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