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Kandathil CK, Rudy SF, Moubayed SP, Most SP. Lateral Wall Insufficiency Severity and Patient-Reported Nasal Obstruction Measures. JAMA Facial Plast Surg. 2018;20(5):427–428. doi:10.1001/jamafacial.2018.0216
Lateral wall insufficiency (LWI) as an etiology of nasal obstruction was originally described by the senior author (S.P.M) as dynamic collapse of the lateral nasal wall with inspiration.1 It is divided into 2 zones, with zone 1 corresponding to the sidewall and zone 2 corresponding to the ala.1 This study sought to explore differences in LWI severity2 in patients seen in consultation for functional, cosmetic, and combined rhinoplasty, and to determine if a correlation exists between physician-determined LWI severity2 and patient-reported nasal obstruction measures, including the nasal obstruction symptom evaluation (NOSE) scores and a visual analog scale (VAS).
A retrospective study of all patients seen by the senior author for rhinoplasty consultation between January 1, 2014, to December 31, 2016, were identified. Patients were divided into functional, cosmetic, and combination subgroups. For a given zone, LWI scores from both sides were averaged. One-way analysis of variance (ANOVA) was used to compare LWI scores between groups. Pearson correlation coefficients were calculated between LWI grades, NOSE, and VAS scores. Significance level was P < .05. The study was approved by the Stanford University institutional review board and written informed consent was waived owing to the retrospective nature of the study.
A total of 469 patients (203 men, 266 women) were included in analysis (Table 1). Of the 469 patients, 213 (45%) underwent surgery by the senior author (S.P.M). One-way ANOVA revealed a statistically significant difference in the preoperative LWI scores between the 3 subgroups (F2,466 = 14.65, P < .001; zone 1 only) (Table 1 and Table 2). A significant but weak correlation was found between LWI severity in both zones and NOSE scores (zone 1: r = 0.2; 95% CI, 0.11-0.28; P < .001; zone 2: r = 0.1; 95% CI, 0.02-0.19; P = .02) and VAS scores (zone 1: r = 0.2; 95% CI, 0.12-0.29; P < .001; zone 2: r = 0.1; 95% CI, 0.02-0.2; P = .01). Subgroup analysis revealed significant but weak correlations between VAS score and LWI severity in only zone 1 for the cosmetic subgroup (r = 0.2; 95% CI, 0.01-0.35; P = .04). Significant correlations between NOSE and VAS were found for the functional (r = 0.7; 95% CI, 0.66-0.79; P < .001), cosmetic (r = 0.9; 95% CI, 0.85-0.93; P < .001), and the combined subgroup (r = 0.8; 95% CI, 0.73-0.85; P < .001).
Prior work has highlighted the poor correlation between objective and subjective measures of the nasal airway.1,3 Our findings corroborate these data. Whereas physician-derived LWI scores were noted to be highest in patients with combined functional and cosmetic complaints, and higher still in patients with purely functional complaints, only weak correlations were found compared with patient-reported outcome measures for nasal obstruction. For example, we found a weak correlation between LWI scores and either NOSE or VAS scores in patients undergoing cosmetic, functional, or combined rhinoplasty, which is in accordance with prior similar studies.1,3 When patients were stratified by those with a positive modified cottle maneuver (MCM), no correlation was found between LWI scores and either NOSE and VAS scores. However, NOSE and VAS scores were highly correlated with each other for all the 3 subgroups.
Prior studies have used both NOSE and LWI scores to examine interventions for LWI.4,5 Furthermore, a recent systematic review demonstrated functional rhinoplasty as an effective treatment for nasal airway obstruction associated with LWI.6 The senior author prefers lateral crural strut grafts for zone 1 and rim grafts for zone 2.4 However, these data suggest that although the validated LWI scale may be useful to the clinician in the classification of severity of LWI, correlation to patient complaints must be made in the decision to perform a surgical repair. The most commonly used method for this is the MCM, which the senior author also advocates. The assessment of LWI according to Tsao et al2 is a physician-derived rating of collapse from observation of the lateral wall during inspiration. The MCM can be used to determine whether the lateral wall motion itself is causing significant obstruction, but the binary output of this observation does not help rate severity of lateral wall motion. A high LWI score indicates considerable wall motion alone and does not necessarily mean the patient feels subjective obstruction, much as the degree of septal deviation does not necessarily correlate with subjective obstruction. A positive MCM reveals that stabilizing wall motion improves symptoms, and the LWI score can be tracked preoperatvely and postoperatively to determine the amount of stiffening of the lateral wall that has occurred.
We suggest that the LWI scale is a useful adjunct in clinical decision making for patients with nasal obstruction and LWI, and that only patients with a positive MCM should be considered for repair of the nasal wall.
Accepted for Publication: February 13, 2018.
Corresponding Author: Sam P. Most, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Stanford, CA 94305 (firstname.lastname@example.org).
Published Online: April 19, 2018. doi:10.1001/jamafacial.2018.0216
Author Contributions: Dr Most 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: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Kandathil, Moubayed.
Administrative, technical, or material support: All authors.
Study supervision: Kandathil, Most.
Conflict of Interest Disclosures: None reported.
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