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JAMA Facial Plastic Surgery Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

JAMA Facial Plast Surg. 2018 Jul-Aug; 20(4): 307–313. Published online 2018 Mar 15. doi: 10.1001/jamafacial.2018.0036: 10.1001/jamafacial.2018.0036

PMCID: PMC5876913 PMID: 29543934

Repair of the Lateral Nasal Wall in Nasal Airway Obstruction A Systematic Review and Meta-analysis Cherian K. Kandathil, MD, Emily A. Spataro, MD, Katri Laimi, MD, PhD, Sami P. Moubayed, MD, Sam P. Most, MD, and Mikhail Saltychev, MD, PhD Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, Stanford University School of Medicine, Stanford, California Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Université de Montréal, Montréal, Québec, Canada Corresponding author. Article Information 1 1 2 3 1 2 1 2 3

Accepted for Publication: January 21, 2018.

Corresponding Author: Sam P. Most, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Stanford, CA 94305 (smost@stanford.edu).

Published Online: March 15, 2018. doi:10.1001/jamafacial.2018.0036

Author Contributions: Drs Most and Saltychev had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kandathil, Spataro, Laimi, Most, Saltychev.

Acquisition, analysis, or interpretation of data: Kandathil, Spataro, Laimi, Most, Saltychev.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Saltychev.

Administrative, technical, or material support: Kandathil, Spataro, Laimi, Most, Saltychev.

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Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

Study supervision: All authors.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We would like to acknowledge Christopher D. Stave, MLS, Instructional Program Coordinator, Lane Medical Library, Stanford School of Medicine, for his help with the initial search formulation for the study. Mr Stave was not compensated for his contributions.

Received 2017 Nov 22; Accepted 2018 Jan 21.

Copyright 2018 American Medical Association. All Rights Reserved. Key Points Question Is repair of the lateral nasal wall effective in adults with nasal airway obstruction? Finding Ipna nt ht si s, tshyes tpeomoal et idc reef fvei ce tws iazne do mf feutna c- at ino anlay ls irsh oi nf o1p0l assttuydoi ens ,t hweh Ni c ahs ianl cOl ubds et rdu ac tsi oa nm Spyl emopft o3 m2 4 p a r t i c i ‐ Eovbaslturuatcitoionns.cale supported the effectiveness of functional rhinoplasty for nasal airway Meaning Feruanlcntiaosnaal lwrahlilnionpsulafsfitcyiemnacyy. be an effective treatment for nasal airway obstruction caused by lat‐ Ttihenistssywsittehmnaatsicalreaviriwewayaonbdsmtreutcat-iaonna. lysis examines the effectiveness of lateral wall repair in pa‐ Abstract Importance Wa nhdi lme ef ut an-catni oanlyasli sr hoifn loaptel arsatlywhaal ls rbeepeani rbhraosa dbleyesnt uddoineed ,ptroeov iuoruksnlyo. wl e d g e n o s y s te m a t i c r e v i e w Objective

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Toobsetvraulcutaioten.the effectiveness of repair of the lateral nasal wall in adult patients with nasal airway Data Sources Mseeadrclihneed, Efmorbcalsinei,cCailnaanhdl, oCbensetrravla, tSioconpaul sst,uadnidesW. eb of Science databases and reference lists were Study Selection Ta nh de so eul teccot mi o en ) cfrri at emr ei awwo er kr e. Tdheef i rneelde vaacnc to sr tdui nd gi e tsowt he re ePsI eClOe c(tpe od pbuyl a2t i ionnd, ei np teenr dv ee nn tt i roenv, i ce owme rpsa rbi as so end, on the studies’ abstracts and full texts. Data Extraction and Synthesis DC oa ltlaa bwoerraet ieoxnt rgaucitdeedl iun seisn. gT hs tea ne fdf ae rc dt isziez ed sl iws tesrcehfoi rssetnc ablyc ut hl aet eadu tfho or resa ac chc sotruddi ny ga nt od Ct ho ec hn rpaonoe l e d t o ‐ gether using random effects synthesis. Heterogeneity was assessed using the I statistic, and publi‐ cation bias was evaluated by the Egger test. Main Outcomes and Measures To hp ee rraetsi vuel t Ns awsearl eOrbespt rour ct et ido na sS yp mo oplteodmr oEwv a ml u ea at ino nd isf fceorreenscaets di ni f fcehr ae nn gt et ismf re os mo f pf roel loopwe-ruapt i v( ≤e 3t o p o s t ‐ months, >3 to 6 months, and >6 months). Results Op of o1 l5e2d2s it nu idt iya ls ar emc po lred isn, c1l 0u dset ud d3i e2s4 wp ea rr et i cc iopna sni tdse. rWe dh er ne l ec ov amnbt —i n ianlgl oa fl l t thheemr eopbes ae trevda tmi oenaaslu. Tr ehse t o ‐ go ent ht heer , Nt haes apl oOobl es dt r ue fcftei oc tn sSi zyemfpo tro fmu nEcvt ai ol un aa tl i or hni ns coapl lea swt yi t hwha si g −h 4h7e. 7t e (r9o 5g %e n eC iIt, y− o5 f3 7. 42 t%o . 4T2h. 1e )ppoooilnetds e( −f f4e8c t. 4s ipzoe i no tust c[ o9 m5 %e s CwI , e−r 5e 2s. i5mtiol a −r 4i n4 . s4hpoor itn- t(s−]4) ,5a. 0n dp ol oi nntgs- t[e9r5m%( −C 4I , 9−. 04 7p. 8o i tnot s−[4925. 2%pCoIi,n−t s6]2) ., 1mt iod - −35.8 points]) follow-ups. Conclusions and Relevance Tp hl aes tpyofoolre dt heef fter ec ta tsmi z ee notf o1f 0n oa sbaslear ivrawt iaoyn oa lbssttur ud ci et iso snucpapuosretde db yt hlea teefrf ae lc tni va es anle ws sa ol l fi nf us nu cf ftiicoi ne na lc yr .hTi no o ‐ improve the level of evidence, randomized clinical trials are needed. 2 Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

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Level of Evidence NA. Introduction

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Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

Ts ihg en imf i cual tni ft al yc taof rf ei ac lt eptai ot ileongtys ’oqf unaalsi tayl oa fi rlwi f ea .y oI nb s2t0r u1 c0t itohne iAs mweerl li cdaonc Au mc aednetme dy, oa fn Od ttohl iasr cy on ng do il toi og yn–c a n Hmei saed aasnad dNi setci kn cStucrl gi neircya lreenl et ai tsyelde aadci nl i ng itcoa lncaosna sl eani rswu as ys toabt es mt r ue nc tti odne .s c Tr ihbei ncgl i nn iacsaal l cvoanl vs ee ncsoums psrt ao t‐e ‐ mc oemn pt raol smo i si deeannt idf i edde sl ca rt ei br ea dl nt ah seailmwpaol lr ct aonl lcaep soef sour rigniscua fl fci coi rerneccyt iaosn af odri sittisn tcrteeattimo leongty. oFf unnacstai ol nv aa llv e rhinoplasty is the treatment of choice for nasal valve compromise. The term functional rhinoplasty rneaflenr as staol av aclov lel es cot iro bnoot hf .v a r Ti ohues ps autrhgoi cpahl yt se icohl on gi qyuleesa dt oi ncgo tror eccotmo pb rs ot rmu icstei oonf obfotthhe t hi net ei nr nt earl noarl ea xntde r ‐ external nasal valves has been described extensively in the literature. The compromise of in‐ ttee rr nn aa ll aa nn dd ee xx ttee rr nn aa ll nn aa ss aa ll vv aa llvv ee ss cdaune btoe leaittehrearl sntaast iacl owradl lycnoal lma pi cs. eTihsetedrymn ae md i c c o l l a p s e o f b o t h i n ‐ lateral wall insufficiency . This validated grading system is based on the location and percentage of closure of tshc ea l lea ti se raa wl ni da es al yl wu sael ld t, opwa tai redn tt-hr ee ps oe rptteudmo. u Tt choemNeams ael aOs bu sr ter ut hcat itoenf fSeycmt i vpetloymq uEavna tl ui f ai et si onna (sNa lOoSbEs) t r u c ‐ ttoiomnssdymuepttoomnas.sal TvahleveNcOoSmEpsrcoamleiissea. reliable and valid method to assess nasal obstruction symp‐ Ds yesst pe mi t ea tgi rc orwe vi ni egwi ns the ar ev se t ei nv anl ua as tael dv aelvvied ec on mc epfroormt hi see eaf nf edc ti ti vs esnuersgsi coafl fcuonr cr tei oc tni oa nl r, ho innl yo p2l apsrteyv. Ri ohuese e t av al l v eh ac ov emfporuonmdi seev.i dTehna ct es tfuodr yt hdei de nf foe tc tiinvcelnuedses ao qf uf uannctti ti oa tni vael rshyinntohpeltai cs taynianl yt hs ies . tIrne at ut mr ne,nat soyf snt ea ms aal t i c re er va itei vwe ba ny dF lpooysdt oept earl a t i vi nec Nl uOdSeEd sac mo reetsa -i na nf aa lvyos ri s orfefpuonrcttiinogn as il grnhi if ni coapnlta ds ti yf f. eBr oe tnhc epsr ebveitowueserne vpireewo sp ‐ hn ai qvueeisn, cal un dd ecda uhsi gehs l yo fhneat es raol gv ea nl veeocuosms pa mr opml ei ss ec. oSmu cbhi nai nbgr od ai fdf ear pe np tr os taucdhyhdaes sliegfnt sm, rahniyn oqpuleassttiyo nt esc h ‐ ue vniadnesnwc ee rf eodr . tThhe ee of fbe jcet ci vt ievneeos sf tohfef up nr ec st ieonntasl yrsht ienmo ap tl iacs rt ye vwi ehwe na nl adt emr aelt aw- aa lnl ai nl yssui sf f iwc iaesn tcoy ewvaasl utahtee pt hr ie‐ mary cause of airway obstruction and lateral nasal wall repair the primary mode of treatment. Methods Ttihoen,ccroitmerpiaarfiosronco, annsdidoeruitncgomsteu)dfierasmfoerwtohriskraesvfieowllowwesr: e based on the PICO (population, interven‐ Tf uylpl -es sc aol ef sotruidg ii ensa:l Calri nt i iccl ae ls aonrdbor bi esferrevpaot irotns ai nl spt ue de ri e- rs ewv iiet hwaevdaai lcaabdl ee ma bi cs tj roaucrtns aalns dwpi tuhbnl ios h e d a s restriction on language or time of publication. Pilot reports, case reports, case series (<5 1 2 2 3,4 2,3,5,6 3 7 8,9 8 10 11

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pleattteiernst,sa)n, ddeesdcirtioprtiiavles pwuebrleiceaxticolunds eodn. surgical techniques, theses, conference proceedings, PInatretricviepnatniotsn::AFduunlctstio(≥n1a8l ryheinarosp)lawsittyh. nasal obstruction due to lateral nasal valve compromise. Cp or emoppaerriastoi vne: Na nodt rpeoasttmo pe ne rt ,aot itvhee mr teraesaut mr eesnwt , ipt hl ai nc etbh oe , ssahma me c, oo hr oc rotm. p a r i s o n b e t w e e n O sc u o t r c e o s m . e: Differences between groups in preoperative and postoperative change in NOSE total Data Sources and Searches Ts ehaer cMheeddl iinne J, uEl my 2b 0a s1e7, Swciot hpouus t, Cr eoscthr ri catni oenCoe nn ttrhael , tWi me eb ooff pS uc ibelni ccaet,i oa nn .dTChien as he al rdcaht acbl aaus es es wf oer r teh e M“ Rehdi nl i no ep lsaes at yr /c hm we tahso tdhse” [fMo lel os hw]i nAgN: D( “ N“ Ha us aml aOnbss”t[rMu cetsi ho ]n /NsOuTr g“eCrayd”a[ Mv eers” h[ M] Oe sRh ] N O T “ I n V i t r o Tl aepcshen” i q[ TuIeAsB” []MOeRs h“ s] )e pAtNu Dm (d“ ea vl ai ar tri oi mn ”” [[ TT II AA BB ]] OO RR ““ dl aetve iraatle nd asseapl twu aml l”” [[TTIIAABB]] OORR ““sneapstaall ddoe rvsi autmi o nc o” l ‐ [“ Tf uI An cBt]i oOnRa l“ ri nhfienroi op rl a tsut yr b” [i Tn IaAt eB”] [OTRI A“Bn]a Os aRl v“ wa livdee ccool ll aupmseel”l [aT” I[ATBI A] BO]RO“Rn a“ spat ol vt iacl vnea scaolmt ippr” o[mT IiAs eB”] ) O R [TTyIpAeB] ]NOORT ““nCaosma lmv ea nl vte” d[ Py us fbul inccattiioonn” [TTyIpAeB] ] NNOOTT“ RE ed vi tioe rwi a[ pl ” t y[ Ppu] bNl iOc Ta t “i Ao nd vTeyrpt ies ]e mN Oe nT t “s L” e[ tPt ue rb”l i c a t i o n [TPy up be l]i cNa Ot i To n“ATcyapdee]mNi cO DT i“sNs ee rwt as ”t i o[ Pnus b” l[i Pc autbi ol i nc aTt iyopne ]T yNpOeT] “NROeTt r “aAcbt isot nr aoc ft sP” u[ bP lui cbal ti ci oa nt i”o [nP Tu ybpl iec ]a tNi oOnT “c Ma seee*t[iTn Ig] ANbOsTt rgauc itds ”e l[iPn ue *b[l Ti cIa] t Ni oOnTTpy rpaec] t iNc eO*T[ TpIr]oNt oOcTo lc[hTiIl ]d *N[OTTI ] rNe Ov iTe wa d[ To Il ]e sNc Oe nT*p[ Tr eI ]l i mN Oi nTa rpye[dTi Ia]t rNi *O T [hTaIs]aNbOstTrapcot[lytepx*t[]TSI]tuNdOyTserlheicntiitoisn[.”TI] NOT sinusitis[TI] NOT radiofrequency[TI] AND Tl yoi nagv oi ni ds t emaids soi nngmpaont eunatl i as el l lye cr et iloenv .aSnitmsitlua dr icelsa, ut shees uws ee roef uostehde rwl ihme int esresaar cnhdi nf igl t et hr se wo tahserreds at rtiacbt eads e, rs e. ‐ The references of identified articles and reviews were also checked for relevant articles. A( Cf t. Ke r. Kt. haen ed xEc .lAu .sSi .o) nf i rosf t dausps el i sc sa et eds t, ht he erseel se,vcaonnc fee roef nt hc ee pr er omcaeiendi ni nggrse, ceot cr ,d2s ibnadseepde on nd et ni t tl erse av ni edwaebr ‐s sr et rsaocl tvse, da ni nd bt ho et hn pa hs saes sesse bdyf uc ol l -nt se ex nt saur st i col re sb fyo ar tehl iigr idb irl ei tvyi. eDwi sear .gAr es etmh eernet swbeer tewneoe nr erlee vv iaenwt errasn wd oe mr e‐ ized clinical studies, the methodological quality of the included trials was not rated. Data Extraction Dizaetdafnoermedbedasfeodr oanqureacnotmitamtiveendaantaiolynssisbwyethree extracted from the included trials using a standard‐ Cochrane Handbook for Systematic Reviews of Interventions , version 5.1.0, part 7.6. The protocol of the review was registered on the Prospero database (identifier CRD42017072072). 12 Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

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NOSE Scale Tg oe sdt si f fuesrienng t ai a st ec opraet ioe fn 3t s0woirt hh oi grhwe ri.t h oAuct cnoarsdai nl og bt os t rt huicst isocna,l ea, st he ve esryi tmy ps tcoaml esf oo rf pt haet i eNnOt sS Er espc oo rr tei ns gu g ‐ n(8a0sa-1l0o0b)s.truction are categorized as mild (5-25), moderate (30-50), severe (55-75), and extreme NOSE Scale Minimal Clinically Important Difference Tc lhi nei cma il ncihmaanl gcel i nd iectaelcl yt aibml ep ob ryt aa npt adt ii ef fne tr. ePnrceev (i oMuCs Il yD, )t hi se aMsCc IoDr ef ocrh at hneg eN aOsSsEo cwi aa tse cda wl c iut hl a tt ehde bs ma sael dl e sotn (a1n)da(n2)anacshtoatris(tcihcaalndgiestirnibburteioatnhoinfgscsotarteuss. perceived by patients who have had an operation) In this study, the distribution-based MCID of NOSE scores was used, setting the cutoff at 19.4 points. Statistical Analysis Tt ahl eNeOf Sf eEc ts csoi zreess obfetthwee iennc lgurdoeudp tsr. iAa lss twh ee rset acnadl caurlda tde edvai as t iao rnoowf md i ef faenr edni cf fee ri ne nmc ee ai nn st hwea cs hraenpgoer toefdt o ‐ bs iyt i voint yl yt ea sftewwasst ur udni e ws , iwt hh tehne pcoooelfifni cgi,etnhtespe rt ea-tp0o. s8t. cTohrer ee lfaf et icot ns iczoees f wf i ceireen ta cwcaosmspe at na ite0d. 6b ya nt hd etihr e9s5e%n ‐ ct ho ensf ii sd ewnacse ui ns et edr rv ea gl sa. rAdsl ews se ohfa tdh ee xppaerct ti ec ud l av ra rl ei avbeill iot yf hi ne tset ruodgyesneet itti yn. gTsh, ea sr ya nn tdhoems i-se (f f1e)c ct so mm be ti na -esdy nt h‐ e NN OO SS EE ss cc oo rr ee ss ra ec pr oo srst e3d dai tf faelrl et ni mt ep opsot ionpt se r(as tei ve ek i fnogl l foowr -cuhpa pn eg re i of rdosm( ≤b3a sme ol i nn teh) sa, n> d3 (t 2o )6c ommo bn itnh es d, atnhde >m6etma-osnytnhtsh)e.sWise. also performed a sensitivity test excluding the study by Egan and Kim from the The test for heterogeneity was conducted using the I statistic describing the percentage of varia‐ tt ii oo nn ab ci ar so swsasst ue dv ai el us aotreidg ibnya tai nngEmg goerre tfersotmf ohr eatseyr mo gme ne teriyt yotfhtahne ffruonmn eclhpalnocte(. tTe shtef op ro ttehnet i a l p u b l i c a ‐ y- intercept =a n0df-rf iol lmmtehteh ol idn ewaar sr eugs reeds tsoi oinmopfunt eo rs mt uadliiezse di net of f et hc te efsutni mn ea lt ep laogtation sctopr rr ee cc itsai os ny m) , mw he terrye. At hl let ht rei m - analyses were made using Comprehensive Meta-Analysis, version 3.3 (Biostat). Results Ti ehs e, csoenafrecrhe ny ci eel dper do c1e5e2d2i nrgesc, ol er tdt es r(sF, i eg du irt eo r1i a) . l sA, fat enrd etxhcel suedsi ,n3g 1d0u rpel iccoart de sr ewceorred ss c, rr ee ev ni eewd s b, cy a2s ei nsdt ue d‐ ‐ pb ea ns edde notnr tehvei ei rwfeurl ls tbe ax st se. dE ol env et int l es tsuadni eds awb es trrea cc ot sn. sTihd ee rreedmraeilneivnagn8t 3f orretchoer df isn wa l e r e f u r t h e r a s s e s s e d analyses. All 11 studies had nasal valve dysfunction as the primary cause oo fr nbaostahl aasi rawsaeyc oo bn sdtar ruyc tci ao uns. eF iov fe aoi rf w1 a1ys ot ubdsitersu ci nt icol un d. Ae df t ear deexvcilautde idn gs etph teu smt u, tduyr bb yi n Sa ut ef yhaynp ee tr tarlo p h y, 13 9,14 9,15 9 16 2 4,16,17,18,19,20,21,22,23,24,25 Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

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wt i vi tehainnas luyfsf iisc .i eAnl tthi on uf ogrhmtahtei osnt uodny lba yt e Er ag la nn aasna dl wKai ml l r e pi naci rl u, 1d0e ds t1u dpiaetsi ewn et rwe i ti nh ccl uo dmepdo isni t tehger qa fut arnetpi taai‐r fnoars aulnvi laal tveer ai nl snuaf sf iacli es nt ecnyoasni sd, idt yanl saomi inc c sl uu dp er da - 6a l apra tl iaet ne trsa lwwi tahl l ncaosl al al pvsael vwe hc oo l ul anpds ee r dwueen tt of ui nn tcet ri onna al l rc ho imn op pu ltai ns gt yt hwei tehf fpelcatc se imz ee. nAt sosf haol awr nb iant tTeanbgl er a1f ,t so. f Ht he en c1e0, iitnwc lausd ceodnsstiudde ireesd, 7r ewl eevraenct oanndduicnt celdu di ne dt hien Us tnuidt ei eds Swt aetrees ,p2r oi ns pAeucst itvr ea l ai an, da n2dw1e irne Cr ea tnraodsap. eAc ltli vt eh .eSianmc lpu ldeesdi zsetsu dr ai ensg we de rf er oomb s6e rt ov a7t i9o np aa lt.i eEni gt sh. tS i x studies included revision surgery. Six of 10 studies reported baseline NOSE scores rsaanmgpinlegifnrcolumd5ed5.032to4 8p6ar.5ticpiopianntsts, iinndtiocatatiln. g severe or extreme nasal obstruction. The pooled study Ti nh Teamb laei n2 .r Te hs ue l tssa mr eep oi nrftoe rdmbayt itohne iisn cplruedseedn tsetdu di ni e gs rwa pe hr ei ccaol nf ovremr t ei nd Fi ni guunr ief i 2e d. Tfho er me f faencdt spi rzee ss evnatreide d f( rBoamr h−a 2m1 et to a−l ,6 0 Ppaol ei nstys eotna tl ,h e aNnOdS EYesucna gl e eat nadl w)e. rWe hs et ant ics ot imc abl liyn isni gg ntihf iec adnatt ai na ac lrlobsus ta3l l s1t0u ds iteusd i e s a(Fnidgufrroem3)a, lwl aitvhahilaigbhlehteimteeropgoeinnetsit,yth(e pooled effect size was −47.7 (95% CI, −53.4 to −42.1) points I = 72%) and no need for trim-and-fill correction with an Egger coefficient of 0.67 (95% CI, −1.81 to 3.18; P = .54). The sensitivity test was conducted exclud‐ i(n−g4 7t h. 7e ps toui nd tys b[ y9 5E%g a Cn I a, −n 5d 4K. 0i mt o. − 4I n1 .t4h aptoci na st se], )t hwehpe on ocloe md be si nt iimn ga tael l rtehme arienpeeda et esds emn teiaa sl luy rtehse. s a m e CCoI, m−4b7in.8intgo t−h4e2s.h2oprot-itnetrsm]) fbiguut rweisth(≤lo3wmhoenttehrso)g, ethneeiptyoo( led effect was similar (−45.0 points [95% I = 0%) (eFigure 1 in the Supplement). For mpoidin-ttes)rmwiftohlllooww-uhpet(e>r3ogteon6eimtyo(nths), the pooled effect was −48.4 points (95% CI, −52.5 to −44.4 I = 0%) (eFigure 2 in the Supplement). The pooled effect ob‐ sweirthvehdiginh ahelotenrgo-gteernmeitfyol(low-up (>6 months) was −49.0 points (95% CI, −62.1 to −35.8 points) I = 93%) (eFigure 3 in the Supplement). The lower limit of all the calcu‐ lma tael dd pe toeoc lteadb leef fcehcat nsgi zee, s aenx dc egerdesa 1t e9r. 4t hpaoni nt wt s i, cae pt hr eevMi oCuIsDl y f os ur gNg Oe sStEe ds cNo Or eSsE i ns cdoi cr ae t li en vg eal fsourc ca ems si fnui ‐l sfourrgaictrailmo-uatncodm-fiell. coTrrheectriiosnk.of publication bias was insignificant for all 4 analyses, with no need Discussion Ipna ttiheins tss y, st ht eemNaOt iScEr es cvoi erwe sasnhdo mw ee dt a s- ai gnnailfyi cs ai sn ot fo 1v e0r oa lbl si me rpv raot ivoenma le snttuadfiteesr al antde rpaol onlaesda ls awma lpl lreeopfa 3i r2. 4 Tu hr ees r. eTshuel tcsawl ceurl ae t seidmpi loa or lwe dh eenf f epcot osliiznegs esfuf egcgtessitzeeds tfhoart sfha ov or tr-a, bml ei dr-e, as un ldt sl oonf gt h- tee rrme pfaoi lrl oawr e- uapl sfoi gs‐e e n mreopraeirthwainthhoaulftcaoymeeasr blaatseer.dTohnisNmOeStEa-sacnoarleyscishainncgleusd. ed o nly studies evaluating lateral nasal wall Limitations 16 4,16,18,21,22,24 17 20 25 2 16 2 2 2 15 9 Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

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Ts thued ii ne sc l ou nd et dh eo tbospeircvfaut li foi lnl ea dl stthued ii ne sc l wu sei roen mc roi tset lryi ac. oAnl tdhuocut egdh ot hni ss mmaeltl as- aa mn apl yl essi s, af na vdonr oe dr at hn ed oe mf f ei zc e‐ d tl oi vwe n- qeus as l oi t fy soubr sgei cr av la ltai ot enraal l snt ua sdai el sw, ar el l t rr eo ps pa ierc, tt ihvee ms t au idni el ism, ai tna dt i os nt u od fi et sh iws irt ehvoiue twc ownatsr ot hl se. Ti nhcel uestiho inc aol f isstsuudei es sr eo lna ttehde ttoo pc oi cnodfuicnttienrge rsat .n d oBme ci zaeuds et roi af ltshien l souwr gneurmy bmearyoef xspt ul adi ni e tshien aeba scehnsceepoa fr ar at en fdool lmo wi z e- udp ac anna lay fsfies c, tr et hs ue l rt se smu ul tss t obf et hi net emr eptrae-taenda cl yasui st i. oRuhsel ye, ae st as lm a lal ns dt uFdlioe ys da reet aplr o naet ttroi bruatne dtoh me i en rarboi lri ttyh taot svtarluv ec tcuor me op pr ot immiaslesat unddyvda er isai gbnl es sfuo rr ghi ci gahl et erclhenvieql su eosf ne ve icdeesns ac er yt of otrh ei t smcuolrt irfeaccttioorni a. l n a t u r e o f n a s a l Pe vr ei dvei onuc es soyf sttheemuattiilci t yr eovfi ef wu ns cot ifofnuanl crthi oi nn oa lp rl ahsi nt yo ipnl at sr et ya thi na vg epba et ieenn tus swe fi ut hl innaps ar ol vo ibdsi nt rgu hc tiigohne rd-ul eevteol valve narrowing. However, both of these terms are somewhat loosely defined to include multi‐ pt i loentsr ef aact me de nb yt s 2a np dr i od ri asgynsot es me sa, tri ec srpeevci et iwv esl yo. fTfhuen cc tui or rneanl tr shtiundo yp lwa satsy dbeys icgonnecdo mt o i toavnetrl yc osmp eec li if my i int ag ‐ d i s ‐ et iaosne i snt at ht ee, st rt ue adti me sewn ta tsynpaer, raonwd eoduttoc oi nmcel umd ee aosnulryel. aTt ehrea pl rwi ma l la irnys eutfifoi cl oi egnyc yo, f eni tahsearl abiyr wi t saeyl fo ob rs tirnu c ‐ ct eocmh nb ii qn ua tei ownaws ittoh i annc l ui ndt ee ronnallynl aa st earl avlanl vaes.aFl owl laol wl rienpg awi ri twh i tt hh eo sr ewl eict ht eodu et tcioo nl ocguyr, rtehnet psreipmt oa rpyl assut yr,g i c a l tFui nr ba il nl yo, tphl ae sot yu, toc or mb oe t mh et oa saudrdersetsos bt hees st upde icei fdi cwseerceo nbda as er yd coanu tshees No fOnSaEs sacl aalier,waavyaol ibd sattreudc at inodn .w i d e l y uf osre da pp aa rt itei cnut -l ar er peot irot el odg oy uutscionmg ea ms i ne ag sl eu roeu. t cBo ymde ems iegansi nu gr eo, uwre sht ua dv ey ab tat seemdpot endat os pme coi rf iec si np teecri vf iec na ltliyo n determine the efficacy of lateral wall stabilization in the face of lateral wall insufficiency. Irne pt ho er t ceudr troe nhta svteu sdeyv, ebraes eodr oe xn t rr ee mp oer nt eads ablaos be sl itnreu cNt iOoSnE. Ts hc oe rs ee ss, caol lr iensc al urde eidn sl itnued wi e ist he xt cheepst t 1u dwyebr ye Fv el or ye dn ea ts aa ll , o b isnt rwu chtiicohn tahcec roer pd oi nrgt etdo aevset ar ab gl ies hperde os pe ve er ar ittiyv ec lNa sOsSi fEi csactoi or ne . o f T6 h7 e. 4 mweoaunl di mi npdr iocvaet emae ns et ‐i n Nb yO FS El o sycdoer te sa la t tfhoer 3t h- itso p6e-rmi oodn. tThhpe os es t roepseurlat st i vs eu gpgeersi ot dt h wa tatshael scoo hc oo rmt poaf rpaabtliee nt ot s t ihnec loubdseedr vi na toi ounr s sf ut undc yt i oc no aull dr hbi en oapsl ua sbtsye at so fa nt hien tpeor pv eu nl at ti oi onn i ni n gc leundeerda li. nHtehree isnt u, hdoy wb eyvFe lro, ywde eht aavl e, p rwohviicdhe dd ema ol t rwe ist hp e ‐ cdiifsiceadsaetaprroegceasrsditnhganlastetartailcwaairlwl satyaboiblisztartuiocnti,ownh. ich one may argue treats a fundamentally different Fv aultiudraet erde speaatri ecnht -srheopuolrdt ef advoour tccoonmt reoml l eeda s(uprreesf esruacbhlyarsatnhdeoNmOi zSeEds)ctorri ael. s w i t h o u t c o m e s b a s e d o n Conclusions Tp hl aes tpyowo hl eedn etfrfee ac tt i ns igz en ao sf a1l 0a ior bwsaeyr voabtsi ot rnuacl t si ot undci ae us sseudp pb oy rl taet de rtahl en ea fsfaelc wt i vael lniensssu of ffi cfiuenncctyi.oTnoa li mr h‐ i n o ‐ prove the level of evidence, randomized controlled trials on the subject are needed. 26 10 11 10,11 8 11 13 11 11 27 Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

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Notes Supplement.

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Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

eFigure 1. Analysis of short-term follow-up (up to 3 months) on 206 participants eFigure 2. The pooled effect at 3 to 6 months postoperatively on 128 participants eFigure 3. The pooled effect over 6 months postoperatively of 110 participants References 1s i. gFnui lf li ec ra nJ Ct ,gLl oebv ae ls qh ue ae l Pt hA-,r Le li antdesdaqy uRaWl i t. yA- os sf -el si fsemi me npt roofv tehme eEnutrfooQl loolw5i-ndgi mf uenncstii oo nn aql useespt it oo rnhniani or ep lf aosrt dy .e t e c t i o n o f c l i n i c a l l y JAMA Facial Plast Surg . 2017;19(2):95-100. [PubMed: 27893020] 2. Rhee JS, Weaver EM, Park SS, et al.. Clinical consensus statement: diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg . 2010;143(1):48-59. [PMCID: PMC5943059] [PubMed: 20620619] 3. Most SP. Trends in functional rhinoplasty. Arch Facial Plast Surg . 2008;10(6):410-413. [PubMed: 19018063] 4. Lindsay RW. Disease-specific quality of life outcomes in functional rhinoplasty. Laryngoscope . 2012;122(7):1480-1488. [PubMed: 22549339] 5. Lee J, Constantinides M. Trends in functional rhinoplasty 2008. Curr Opin Otolaryngol Head Neck Surg . 2009;17(4):295- 301. [PubMed: 19502981] 6. Cannon DE, Rhee JS. Evidence-based practice: functional rhinoplasty. Otolaryngol Clin North Am . 2012;45(5):1033-1043. [PubMed: 22980683] 7. Tsao GJ, Fijalkowski N, Most SP. Validation of a grading system for lateral nasal wall insufficiency. Allergy Rhinol (Providence) . 2013;4(2):e66-e68. [PMCID: PMC3793115] [PubMed: 24124639] 8Sy. mStepwtoamrt EMvGal,uWatiitosnel(lNDOLS, ESm) sicthalTe.L, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Otolaryngol Head Neck Surg . 2004;130(2):157-163. [PubMed: 14990910] 9Se. pStteowplaarsttMy EGf,fSemctiivthenTeLs,sW(NeaOvSeEr)EsMtu, deyt.al.. Outcomes after nasal septoplasty: results from the Nasal Obstruction Otolaryngol Head Neck Surg . 2004;130(3):283-290. [PubMed: 15054368] 1205.-yRehaeresJySs,tAemrgaatnibcrriegvhiteJwM. , McMullin BT, Hannley M. Evidence supporting functional rhinoplasty or nasal valve repair: a Otolaryngol Head Neck Surg . 2008;139(1):10-20. [PubMed: 18585555] 1rh1i.nFolpolyadstEyMo,uHtcooSm, ePsatwelitPh, RthoeseNnOfeSlEdsRcMor,eG. ordin E. Systematic review and meta-analysis of studies evaluating functional Otolaryngol Head Neck Surg . 2017;156(5):809-815. [PubMed: 28168892] 12. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 London, UK: Cochrane Collaboration; 2011. http://handbook.cochrane.org. 13. Lipan MJ, Most SP. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg . 2013;15(5):358-361. [PubMed: 23846399]

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1q4u.eMstioonndnianiareMs., Marro M, Maurice S, Stoll D, de Gabory L. Assessment of nasal septoplasty using NOSE and RhinoQoL Eur Arch Otorhinolaryngol . 2012;269(10):2189-2195. [PubMed: 22231798] 1o5b.sLtroudcdtieornW? L, Leong SC. What are the clinically important outcome measures in the surgical management of nasal Clin Otolaryngol . 2017;00:1-5. [PubMed: 29078021] 16. Egan KK, Kim DW. A novel intranasal stent for functional rhinoplasty and nostril stenosis. Laryngoscope . 2005;115(5):903-909. [PubMed: 15867663] 1ce7p. hBaalrihcacmruHraPl, tKunrnis-einlyfoAr, cCohrrriesctetinosnenofJ,eSxatecrknsaRl ,vMalvarecdeyl lssfuGnNc,tHioanr.vey RJ. Cos tal cartil age l ateral crural s trut graft vs JAMA Facial Plast Surg . 2015;17(5):340-345. [PubMed: 26247619] 1va8l.vCehcaomrrbeecrtsioKnJ,iHn oprasttikenottstewKiAth, SahhainslteoyryKo, Lf ifnaidlseadysRepWto. Epvlaasltuya.tion of improvement in nasal obstruction following nasal JAMA Facial Plast Surg . 2015;17(5):347-350. [PubMed: 26291169] 19. Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope . 2011;121(3):474-479. [PubMed: 21344421] 2co0r. rPeaclteisoyn To,fPerxattetrEn,aMl nraasdaNl v, aMlvaercdeyllssfuGnNc,tiHoanr.vey RJ. Airflow and patient-perceived improvement following rhinoplastic JAMA Facial Plast Surg . 2015;17(2):131-136. [PubMed: 25675172] 2q1u.aRlihtyeeofJSl,ifPeo. etker DM, Smith TL, Bustillo A, Burzynski M, Davis RE. Nasal valve surgery improves disease-specific Laryngoscope . 2005;115(3):437-440. [PubMed: 15744153] 22. Roofe SB, Most SP. Placement of a lateral nasal suspension suture via an external rhinoplasty approach. Arch Facial Plast Surg . 2007;9(3):214-216. [PubMed: 17515499] 23. Sufyan A, Ziebarth M, Crousore N, Berguson T, Kokoska MS. Nasal batten grafts: are patients satisfied? Arch Facial Plast Surg . 2012;14(1):14-19. [PubMed: 22250264] 24. Tan S, Rotenberg B. Functional outcomes after lateral crural J-flap repair of external nasal valve collapse. Ann Otol Rhinol Laryngol . 2012;121(1):16-20. [PubMed: 22312923] 2rh5i.nYoepulnagstAy,. Hassouneh B, Kim DW. Outcome of nasal valve obstruction after functional and aesthetic-functional JAMA Facial Plast Surg . 2016;18(2):128-134. [PubMed: 26660141] 26. McDonald PJ, Kulkarni AV, Farrokhyar F, Bhandari M. Ethical issues in surgical research. Can J Surg . 2010;53(2):133- 136. [PMCID: PMC2845955] [PubMed: 20334746] 27. Vaezeafshar R, Moubayed SP, Most SP. Repair of lateral wall insufficiency. JAMA Facial Plast Surg . 2018;20(2):111-115. d 1 o 0 i .1 : 1 0 0 0 . 1 1 / 0 ja 0 m 1/ a j f a a m ci a a f l a .2 ci 0 a 1 l. 7 2 . 0 0 1 7 7 1 . 8 0 ] 718 [PMCID: PMC5885964] [PubMed: 28837711] [CrossRef: Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

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Figures and Tables Figure 1.

PRISMA Flow Diagram

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Dc oamt aeb)a sf reasmweewr oe rske. aAr cf theerde xf oa rmrienl ei nvga nr et csot ur dd si easnuds ei nx cg l curdi it ne rgi ad uf rpol mi c atthees Pa InCdOa(rpt ioc pl eusl at ht i aotnd, ii dn tneor vt emn et ieot ns, t cuodmy cprairtiesroi an, , 8a3n df uol lu-t ‐ tmexint eadrtitcolebse daepspcrroipbriinagteclfionricinacl launsdioonbisnertvhaetmioentaal-asntuadlyiessisw. ere assessed for eligibility. Of these, 10 studies were deter‐ 7/1/24, 9:49 AM Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

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Table 1. Basic Characteristics of the Included Studies

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Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

Source (Location)

Design

Nasal Valve Disfunction

Intervention or Comparison

Groups Total

Age of Total Patients, Mean, y (Age of Patients in Subgroups, Mean, y)

Women in Total Patient Population, % (Women in Study Subgroups, %)

Patients, No. (Patients in Subgroups, No.)

Ba la, rh a2m0 1e5t, (Australia) Ca lh, a m2b0e1r5s , e t (US) Dale, ro2ee01e1t (US) EKgiman, an2d005 (US) 17 18 19 16

Po rbos sepr ve ac tt ii vo en a l comparative

External Gt urronu- pi n 1m: caenpehuavl ei cr ; gc ra or tui pl a 2g e: cgor as ft tasl

41 (25/16) 35 (32/41) 61 (76/38)

Po rbos sepr ve ac tt ii vo en a l E in x t t e e r r n n a a l l and Open functional r g h ra in ft o s plasty with 40 39

43 NR

a

Ro be tsreorsvpa et icot invael External Gt ercohunpi q1u: es ; t ag br o u p 2 in : c m is a i r o g n inal technique Rcaestreossepreiecstive Internal and e n x o t s e t r r n il al or stenosis Or hpi ne no pf ul anscttyi own iatlh eg ir tahf te rp laal ca er mb aetnt et n og rracf to rme pp aoisri t e

35 (15/20) NR

7

NR

NR

L2 i0n1d2s a( Uy , S ) Po rbos sepr ve ac tt ii vo en a l comparative 4

E in x t t e e r r n n a a l l and Group 1: internal n2 a: se xa tl evranlavlen; agsr oa lu p vb aoltvhen; agsroa lu vpa3l v: e s ;

6(104/16/30) 40

28

m tec i x h e n d i q s u u e r s gery ifnucnlcutdioinngalopen

Abbreviation: NR, not reported. (Gnr=a6ft)s, uanseddawlaerrreimspgreraafdtser(ngr=af5ts). (n = 39), columellar strut grafts (n = 23), lateral crural strut grafts (n = 20), flaring sutures a

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Table 2. Nasal Obstruction Symptom Evaluation Scores of Studies Analyzed BCharahnagme ientsaclo, re2f0o1r 5entire sample −30.25 (25.33) 41 CChhaannggee iinn ssccoorree ffoorr cceopshtaalliccartutirlnag-iengmraaftnseuver −29.73 (23.05) 25 −31.25 (25.33) 16 CB ha as me l ibneer ss ceot rael , 2 0 1 5 75.7 (20.1) 40 Score at 2 mo 31.4 (27.2) 40 Score at 4 mo 34.0 (19.8) 40 Score at 6 mo 22.1 (18.8) 40 DChearonegee eint aslc,ore2011 −40.4 (7.9) 12 EBgaasnelai nned sKciomre, 2005 67.1 (10.4) 6 Postoperative score 18.6 (14.6 6 Score at 3 mo 21.4 (15.2) 6 17 a 18 19 16 Source Mean (SD)

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Cohort Size, No.

LE innt di rseasya, m2p0l1e2 Baseline score Score at 1-3 mo Score at 6-12 mo IBnatseer nl i anlensacsoarl ev a l v e Score at 1-3 mo Score at 6-12 mo EBxatseerlni na le nsacsoarle v a l v e Score 1-3 mo Score 6-12 mo 4

66.42 (20.25) 60 21.85 (20.68) 54 22.33 (23.05) 45 61.79 (23.34) 14 13.46 (19.19) 13 4.09 (7.35) 11 59.69 (20.69) 16 22.69 (15.22) 13 18.85 (17.34) 13

S B S t t s v v ii aattii oo nn sa dwoeprteecdaflrcouml a treedp of rrot emd rpeopsotrotpeedr9a t5i %v e cs ot annf di daerndcdeeivnitaetri voanl s( .c o s t a l c a r t i l a g e g r a f t s g r o u p ) . NTohedNataasnael eOdbesdtrfuocrteioffnecStysmizpetocamlcEuvlaatliuoantiroenpsocroterde.s are reported on a 20-point scale; thus, the scores were multiplied by 5. o a a t n n h d d v a a r a r d d lv d d e e e

a b c d

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Repair of the Lateral Nasal Wall in Nasal Airway Obstruction - PMC

Change in Effect Sizes (Nasal Obstruction Symptom Evaluation Score Change) Across the 10 Analyzed Studies TS yhme pe ftfoemc t Es vi zael su aotfi ot hnes icnocrleusd be de t twr ieael ns gwreoruepcsa. lTc uh leaet ef fde cats sai zreoswwme reea na cdciof fme rpeannciee di nbtyh et hcehi ar n9g5e%o fc toont af ildNe na sc ae l i On tbesr tvraul cs t. i o n Figure 3.

Pooled Effect Size in the Pooled Study Population of 324 Participants Wvohraebnlceormesbuilntsinogftthheedraetpaaaircraoressalaslol 1s0eesntumdioerseathnadnfrhoamlf aalyl eaavraillaatberl.e time points, the pooled effect size suggested that fa‐

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The Laryngoscope © 2023 The American Laryngological, Rhinological and Otological Society, Inc.

Ef fi cacy of Septoplasty in Patients with Nasal Obstruction: A Systematic Review and Meta-analysis

Mario Alessandri-Bonetti, MD; Andrea Costantino, MD ; Giuseppe Cottone, MD; Riccardo Carbonaro, MD; Federica Cardone, MD; Francesco Amendola, MD; Armando De Virgilio, MD, PhD ; Enrico Robotti, MD; Paolo Persichetti, MD; Luca Vaienti, MD

Objective: Septoplasty is the most frequently performed ENT surgery to correct nasal septal deviation (NSD). The present study aimed to quantify the effectiveness of septoplasty with or without turbinate surgery according to NOSE questionnaire scores, with the hypothesis that it is able to clinically improve patient-reported nasal obstructive symptoms in the post operative follow-up. Methods: An electronic search was performed on PubMed/MEDLINE, Embase, and Cochrane Library. The primary out come was the change in NOSE score at 6 months after surgery. It was assessed with the mean difference (MD) between base line and postoperative results. Results: A total of 2577 patients (males: 65.1%, 95% CI: 59.9 – 70.2) with a mean age of 33.3 years ( n = 1456, 95% CI: 30.4 – 36.2) were included in this meta-analysis. The pooled baseline NOSE mean score was 68.1 ( n = 2577, 95% CI: 64.3 – 71.9). The pooled MD in NOSE score at 6-months follow-up compared to baseline was 48.8 ( n = 1730, 95% CI: 54.6 to 42.9). Conclusions: Functional septoplasty with or without turbinate surgery shows a critical improvement of obstructive symptoms and quality of life according to the validated NOSE score. KeyWords: nasal obstruction, NOSE, quality of life, septal deviation, septoplasty. Level of Evidence: NA Laryngoscope , 133:3237 – 3246, 2023

obstruction 5 with a negative impact in patients ’ quality of life (QOL) and mood. 6 – 8 In this context, nasal septal devi ation (NSD) is one of the most prevalent upper airway diseases causing airway obstruction, 9 – 11 with some authors reporting prevalence up to 70% – 80% in the gen eral population. 6,12 NSD impairs the air fl ow and prevents from breathing comfortably through the nose. As a conse quence, it can cause crusting and bleeding, mucosal dam age, compensatory turbinate hypertrophy, and altered olfactory function. 13 Septoplasty is the most frequently performed ENT surgery to correct NSD in adults. 14 However, debate has grown regarding the poor existing evidence about the ef fi cacy of septoplasty in the treatment of NSD-related obstructive symptoms, and a need for randomized con trolled trials (RCT), and high level of evidence studies has been voiced in recent years. 15,16 A previous system atic review conducted in 2017 tried to de fi ne the effective ness of septoplasty in improving nasal obstruction due to NSD. 6 However, a proper meta-analysis was not per formed, and the authors concluded that literature evi dence did not support fi rm conclusions on its effectiveness. One of the most used instruments in evaluating patient-reported obstructive symptoms is the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. The NOSE questionnaire was developed in 2004 by Stew art et al, and it was the fi rst validated, disease-speci fi c QOL instrument to measure nasal obstruction. 17 It

INTRODUCTION Nasal airway obstruction is de fi ned as the subjective sensation of insuf fi cient air fl ow or impaired breathing through the nose. 1 Nasal obstruction is amongst the most common complaints in the general population, and it is frequently encountered by various specialists including otolaryngologists, facial plastic surgeons, and allergists. 2,3 Symptoms of nasal obstruction are subjective and can therefore be misleading. Moreover, the fi ndings of nasal examination and endoscopic evaluation may not always correlate with the patient complaints. 4 In fact, minimal nasal pathologies can cause a feeling of serious nasal From the Department of Reconstructive and Aesthetic Plastic Surgery, I.R.C.C.S. Istituto Galeazzi ( M . A .- B ., G . C ., R . C ., F . C ., F . A ., L . V .), University of Milan, Via Riccardo Galeazzi 4, 20161, Milan, Italy; Department of Biomedical Sciences ( A . C ., A . D . V .), Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele – Milan, Italy; Otorhinolaryngology Unit ( A . C ., A . D . V .), IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano – Milan, Italy; Private Practice ( E . R .), Clinica Sant ’ Apollonia, Via Giovanni Motta, 37 – 24123, Bergamo, Italy; and the Department of Reconstructive and Aesthetic Plastic Surgery ( P . P .), Campus Bio-Medico University of Rome, Via Alvaro Del Portillo, 200, Rome, Italy. Editor ’ s Note: This Manuscript was accepted for publication on March 21, 2023. The authors have no other funding, fi nancial relationships, or con fl icts of interest to disclose. Send correspondence to Andrea Costantino, MD, Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele – Milan, Italy. Email: andrea.costantino94@gmail.com

DOI: 10.1002/lary.30684

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15314995, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/lary.30684 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

consists of fi ve questions evaluating the severity of fi ve different symptoms related to nasal obstruction, rated on a 5- point Likert scale. The total score ranges between 0 and 100, and a higher score implies a more severe nasal obstruction. 17 The present study is a systematic review and meta analysis aiming to quantify the effectiveness of septoplasty with or without turbinate surgery according to NOSE questionnaire scores. The hypothesis was that septoplasty with or without turbinate surgery is able to clinically improve patient-reported nasal obstructive symptoms in the post-operative follow-up. METHODS This systematic review was reported according to the Pre ferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines. 18 Institutional review board approval and informed consents were not required for this study, since all the reported data were obtained from the available pub lished literature. The review protocol was registered on PROS PERO database (CRD42022325219). ture search strategy: population (P), adults affected by NSD; intervention (I), septoplasty with or without turbinate surgery; comparator (C), none; outcome (O), change in NOSE scale score at 6 months (primary outcome), and at 3,12 months (secondary outcomes); study type (S), case series, cohort studies, and RCT. Studies were excluded if: (a) they were not in English, (b) they were not available in full text form, (c) they include pediatric patients, (d) they were subgroup analysis of patients from a larger study, (e) aesthetic rhinoplasty was also performed, (f) procedures other than septoplasty with or without turbinoplasty were performed, (g) reported insuf fi cient data or data were not extractable, (h) follow-up time <3 months, (i) outcomes were not evaluated using the NOSE scale, (l) the article type was a confer ence abstract, a review, a case report, a book chapter or a letter to the editor. No publication date was imposed, but articles had to be published in a peer-reviewed journal. Data source and Study Searching An electronic search was performed on PubMed/MEDLINE, Embase, and Cochrane Library using relevant keywords, phrases and medical subject headings (MeSH) terms. The search strategy applied for PubMed/MEDLINE was: ( “ Health-Related Quality Of Life ” OR “ HRQOL ” OR “ quality of life ” OR “ lifestyle ” OR “ well being ” OR “ QOL ” OR “ NOSE score ” OR “ NOSE questionnaire ” OR “ nasal obstruction symptom evaluation ” ) AND ( “ nasal septal deviation ” OR “ septum deviation ” OR “ septoplasty ” OR “ septal surgery ” OR “ functional nasal surgery ” OR “ nasal obstruction surgery ” ). The reference list of each selected articles was checked to screen for additionally potentially relevant studies (i.e., snowballing method). The last search was carried out on March, 2nd 2022. Eligibility Criteria The PICOS framework 19 was used in developing the litera

Library) were merged and the duplicates removed using the ref erence management software EndNote ® X9 (version X9.3.3). Titles and abstracts of unresolved papers were screened. When ever appropriate, full texts of relevant articles underwent subse quent evaluation for eligibility. In the presence of eventual discrepancies, a third reviewer (A.C.) was consulted to solve the conundrum. Data extracted from selected papers were archived in a cus tomized Excel ® (Microsoft Corp, Seattle, Washington, USA) spreadsheet with forced choice entry criteria. Risk of Bias and Study Quality Assessment Methodological quality of included studies was assessed independently by two separate authors (M.A.B. and F.C.). Meth odological Index for Non-randomized Studies (MINORS) criteria, 20 a validated instrument designed to assess the method ological quality of nonrandomized studies, were used to measure bias. A funnel plot was created using the effect size for NOSE scale score reduction at 6 months follow-up to examine a poten tial publication bias. Data Synthesis and Statistical Analysis Clinical measures were reported as provided by the individ ual studies. A single-arm meta-analysis of proportions was per formed to synthetize dichotomous variables using arcsine transformation of the data, while continuous variables were syn thetized through a meta-analysis of means using the generic inverse variance method. All data are reported with the corresponding 95% con fi dence intervals (CIs). A single-arm meta-analysis of means was used to calculate pooled NOSE score at baseline, while change in NOSE score after surgery was assessed with the mean difference (MD) between baseline and postoperative results after 3, 6, and 12 months. Raw effect size data were pooled using the “ metacont ” function in R software comparing between group mean differences. The MD and their 95% con fi dence intervals (CIs) were calculated for each study, and the pooled MD was measured for 3, 6, and 12 moths follow-up. Inverse variance method 21 was used to calculate the pooled effect estimate. Restricted maximum-likelihood estimator 22 was used to estimate the between-study variance ( τ 2 ). For the random effects model, Knapp-Hartung 23 adjustments were used to adjust test statistics and con fi dence intervals. Results are presented as pooled esti mates with 95% con fi dence intervals (CIs). A forest-plot graph was created for each outcome. Cochran ’ s Qmethod 24 was used to assess between studies heterogeneity, and I 2 was calculated as a measure of heterogene ity. 25 The I 2 value represents the percentage of total variation across studies caused by heterogeneity rather than by chance. Using a fi xed effects model, we assumed that all studies came from a common population and that the effect size is not signi fi cantly different among the different studies. If the heterogeneity test produced a low probability value (Q-statistic, p <0.05), meta-analysis was performed using a random effects model assuming both within-study and between-study variability for a more conservative estimate. In fl uence analysis 26 was performed to identify potential in fl uential studies. In particular, a leave one-out meta-analysis was performed to test the in fl uence of each included study on the overall effect and I 2 heterogeneity. More over, a subgroup analysis was performed to explore potential sources of heterogeneity for the primary outcome (e.g. level of evidence, MINORS score, septoplasty with or without inferior turbinate surgery). Scatter plots (Baujat plot) 27 were created for the 6 months follow-up. The horizontal axis ( x -axis) shows the

Data Extraction Two reviewers independently conducted the electronic liter ature search (M.A.B. and R.C.). The reference lists from three databases (i.e., PubMed/MEDLINE, Embase, and Cochrane

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3238

15314995, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/lary.30684 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

the NOSE score. 29 – 56 The reasons justifying the exclusion of 55 studies are reported in Figure 1. Study ’ s general characteristics are summarized in Table I. A total of 2577 patients (males: 65.1%, 95% CI: 59.9 – 70.2; females 34.9%, 95% CI: 29.8 – 40.1) with a mean age of 33.3 years ( n = 1456, 95% CI: 30.4 – 36.2) were included in this meta-analysis. All patients included in the analysis had a diagnosis of nasal septal deviation made with clinical examination along with endoscopy and/or rhinomanometry and/or Computed Tomography. Methodological Quality and Risk of Bias of Included Studies MINORS scores for the included studies are listed in Table II. MINORS criteria are based on a score of 16, with 16 being a perfect score for noncomparative studies. 20 The median score calculated in 28 included studies was 14 (range 8 – 15). The major de fi ciencies were the unbiased assessment of the study endpoint, the follow-up period appropriate for the aim of the study and the prospective calculation of the sample size. Most of the studies did not perform any blinding with regard to collection of NOSE score. Finally, few studies made mention of prospective calculation of sample size. All or nearly all studies had clearly stated aims and scarce loss to follow-up. Further more, given that only studies that used the NOSE score were included, nearly all the studies had endpoints that were appropriate to the study aim.

contribution of each study to the overall Q-test statistic for het erogeneity. The standardized difference of the overall treatment effect is plotted on the vertical axis, showing the in fl uence of each study on the pooled effect size. A meta-regression was per formed using a mixed-effects model to explore the relationship between the follow-up time and the change in NOSE score after surgery. The longest follow-up time was used for studies reporting the outcome at different time points. Analysis of publication bias was performed by visual inspection of the funnel plot and calculating the Egger ’ s regres sion intercept 28 for the 6 months follow-up analysis, which statis tically examines the asymmetry of the funnel plot. All the analyses were performed using the R software for statistical computing (R version 4.0.1; “ meta ” and “ dmetar ” pack ages). Statistical signi fi cance was de fi ned as p <0.05.

RESULTS Search Results and Studies Description

A fl ow chart of the study identi fi cation process is shown in Figure 1. A total of 1075 eligible papers was retrieved from the preliminary search on electronic data bases and from articles ’ references screening. After auto matic duplicates removal and both screening of titles and abstracts, 82 full-text manuscript were assessed for eligi bility. One article was identi fi ed from citation searching. Eventually, 28 articles were included in the qualitative analysis, as conformed to the aforementioned eligibility criteria, and all of them were used to calculate the best evidence regarding septoplasty outcomes evaluated using

Fig. 1. PRISMA 2020 fl ow diagram. [Color fi gure can be viewed in the online issue, which is available at www.laryngoscope.com.]

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