The dots indicate each patient response. The dotted line indicates the trend line for the patient responses (r = −0.22; P = .01).
Mean NOSE and PNIF values with 95% CIs at each time point. Dashed lines represent the minimal clinically important differences (MCIDs) from baseline. One-way analysis of variance with post hoc Tukey test finds significant differences between preoperative and postoperative scores and no difference between postoperative time points.
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Fuller JC, Bernstein CH, Levesque PA, Lindsay RW. Peak Nasal Inspiratory Flow as an Objective Measure of Nasal Obstruction and Functional Septorhinoplasty Outcomes. JAMA Facial Plast Surg. 2018;20(2):175–176. doi:10.1001/jamafacial.2017.1775
Nasal airway obstruction is a leading complaint among patients presenting to facial plastic surgeons. When medical treatment does not provide symptom relief, functional septorhinoplasty (FSRP) is often indicated. Understanding the efficacy of these surgical interventions is critical; however, there is currently no universally accepted objective measure of nasal obstruction that correlates with symptoms that can be used for both diagnosis and outcome assessment.
Peak nasal inspiratory flow (PNIF) is an inexpensive, rapid, easy-to-use objective measure that directly measures nasal airflow during maximal inspiration.1,2 Recent studies have found a correlation between PNIF and patient reported outcome measures when the validated Nasal Obstruction Symptom Evaluation (NOSE) scale is used.3,4 The current study assesses the utility of PNIF as an objective diagnostic and outcome measure for FSRP in combination with the NOSE scale.
This study was performed from February 27, 2015, to December 15, 2016, with institutional review board approval from the human subjects research committee at Massachusetts Eye and Ear Infirmary. Patients provided written informed consent and were not compensated for participation. Patients undergoing FSRP by the senior author (R.W.L.) for treatment of nasal obstruction were administered the NOSE scale and underwent PNIF testing using the In-Check portable inspiratory flow meter (Clement Clarke International Ltd) preoperatively and postoperatively. No patients in the study population had chronic obstructive pulmonary disease or lung disease. Patients were instructed to inhale as hard and fast as possible through the mask while keeping their mouth closed. Three trials at maximal effort were performed and the highest flow (in liters per minute) of these was used for analysis.
Statistical analyses were conducted using Microsoft Excel and GraphPad. The minimal clinically important difference (MCID) for NOSE scores was set at 30 points, and the MCID for PNIF values was set at 20 L/min as previously described.5,6 Preoperative and postoperative NOSE and PNIF scores were compared using paired and unpaired t tests as appropriate. Correlations were calculated using Pearson correlation coefficients, and the N1 two-proportion test was used to determine significance between binary variables.
A total of 136 patients (74 [54%] were women) with a mean (SD) age of 37.3 (14.5) years underwent FSRP for nasal airway obstruction and completed both the NOSE questionnaire and PNIF testing preoperatively. The correlation between preoperative NOSE and PNIF scores among all patients was −0.22 (P = .01), a statistically significant but weak correlation (Figure 1).
A total of 123 patients (66 [54%] were women) with a mean (SD) age of 36.3 (14.0) years had preoperative and postoperative follow-up at 2 months. At 2 months postoperatively, mean NOSE scores decreased by 43.3 (95% CI, 39.2-47.4) points from 62.5 (95% CI, 58.7-66.3) to 19.2 (95% CI, 16.1-22.3), a statistically (P < .001) and clinically significant change. Similarly, PNIF values increased by 26.1 L/min (95% CI, 19.3-32.9) from 82.3 (95% CI, 76.4-88.2) to 108.4 (95% CI, 100.3-116.1), which was also both statistically (P < .001) and clinically significant (Figure 2). Furthermore, the improvements in both PNIF and NOSE scores remained clinically significant over time (Figure 2).
Peak nasal inspiratory flow is a rapid, inexpensive, and easily performed test that measures airflow through the nose. We determined that PNIF can detect clinically significant objective improvements in nasal airflow following FSRP. We found only a weak correlation between PNIF and NOSE scores (−0.22), indicating a lack of usefulness for personalized evaluation of nasal airway obstruction. Therefore, we disagree with the conclusions of a previous report by Tsounis et al.4 The lack of a strong correlation between PNIF valves and NOSE score limits PNIF’s utility as a diagnostic tool for nasal airway obstruction. However, PNIF may prove a more useful tool to measure an individual’s objective nasal airway obstruction changes following surgery. We encourage surgeons to incorporate PNIF into their clinic practice as the best currently available objective outcomes assessment.
Corresponding Author: Jennifer C. Fuller, MD, Massachusetts Eye and Ear Infirmary, Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, 243 Charles St, Boston, MA 02114 (email@example.com).
Accepted for Publication: September 1, 2017.
Published Online: November 30, 2017. doi:10.1001/jamafacial.2017.1775
Author Contributions: Dr Fuller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Fuller, Bernstein, Lindsay.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Fuller, Lindsay.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Fuller, Levesque.
Administrative, technical, or material support: Bernstein, Levesque, Lindsay.
Study supervision: Lindsay.
Conflict of Interest Disclosures: None reported.
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