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Sept/Oct 2018

Diagnostic and Therapeutic Management of Nasal Airway Obstruction: Advances in Diagnosis and Treatment

Author Affiliations
  • 1Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
JAMA Facial Plast Surg. 2018;20(5):409-418. doi:10.1001/jamafacial.2018.0279
Key Points

Question  What advances in the diagnosis and treatment of nasal obstruction have been introduced in the past 5 years?

Findings  In this review, nasal airway obstruction is presented as a complex condition with many synergistic causes, complicated by subjective complaints that do not necessarily correlate with objective findings. A combination of patient-reported, physician-derived, and objective testing may be complementary in effective nasal airway obstruction management.

Meaning  Increasing use of validated questionnaires, such as the Nasal Obstruction Symptom Evaluation, and improved objective measures, such as 4-phase rhinomanometry, computational fluid dynamics, and mucosal cooling, have advanced nasal airway obstruction care, but a criterion standard objective measure remains elusive.


Importance  Nasal airway obstruction (NAO) is a common complaint in the otolaryngologist’s office and can have a negative influence on quality of life (QOL). Existing diagnostic methods have improved, but little consensus exists on optimal tools. Furthermore, although surgical techniques for nasal obstruction continue to be developed, effective outcome measurement is lacking. An update of recent advances in diagnostic and therapeutic management of NAO is warranted.

Objective  To review advances in diagnosis and treatment of NAO from the last 5 years.

Evidence Review  PubMed, Embase, CINAHL, the Cochrane Library, LILACS, Web of Science, and Guideline.gov were searched with the terms nasal obstruction and nasal blockage and their permutations from July 26, 2012, through October 23, 2017. Studies were included if they evaluated NAO using a subjective and an objective technique, and in the case of intervention-based studies, the Nasal Obstruction Symptom Evaluation (NOSE) scale and an objective technique. Exclusion criteria consisted of animal studies; patients younger than 14 years; nasal foreign bodies; nasal masses including polyps; choanal atresia; sinus disease; obstructive sleep apnea or sleep-disordered breathing; allergic rhinitis; and studies not specific to nasal obstruction.

Findings  The initial search resulted in 942 articles. After independent screening by 2 investigators, 46 unique articles remained, including 2 randomized clinical trials, 3 systematic reviews, 3 meta-analyses, and 39 nonrandomized cohort studies (including a combined systematic review and meta-analysis). An aggregate of approximately 32 000 patients were reviewed (including meta-analyses). Of the subjective measures available for NAO, the NOSE scale is outstanding with regard to disease-specific validation and correlation with symptoms. No currently available objective measure can be considered a criterion standard. Structural measures of flow, pressure, and volume appear to be necessary but insufficient to assess NAO. Therefore, novel variables and techniques must continue to be explored in search of an ideal instrument to aid in assessment of surgical outcomes.

Conclusions and Relevance  Nasal airway obstruction is a clinical diagnosis with considerable effects on QOL. An adequate diagnosis begins with a focused history and physical examination and requires a patient QOL measure such as the NOSE scale. Objective measures should be adjunctive and require further validation for widespread adoption. These results are limited by minimal high-quality evidence among studies and the risk of bias in observational studies.

Level of Evidence  NA