Purpose Nasal obstruction is a highly subjective and commonly reported symptom. The internal nasal valve (INV) is the rate limiting step to nasal airflow. A static INV grading score was devised with regard to visibility of the middle turbinate. Methods A prospective study of all patients who underwent primary external functional septorhinoplasty in 2017 for nasal obstruction. All patients’ INV score was assessed pre- and postoperatively in a blinded and independent fashion by surgeons of varying seniority. Results Twenty-eight patients were studied, with mean age 30.9 years and follow-up 18.8 weeks. Inter-rater and test–retest reliability of INV grading were excellent, with Cronbach’s alpha 0.936 and 0.920, respectively. There was also statistically significant improvement in both subjective and objective postoperative outcome measures including nasal inspiratory peak flows. Conclusions We demonstrate a novel, easy to interpret, clinically valuable grading system of the static internal nasal valve that is reliable and reproducible. Keywords Nasal obstruction · Septoplasty · Septorhinoplasty · Nasal inspiratory peak flow · Valve Introduction systems are in place for a DNS and ENV collapse but not INV obstruction . Internal nasal valve obstruction can be Nasal obstruction is a common and highly subjective com- caused by a static structural abnormality (high septal devi- plaint, but examination findings do not always correlate with ation or an enlarged turbinate) or by a dynamic collapse patients’ symptoms . There have been numerous attempts abnormality of the upper lateral cartilage/lateral nasal wall to validate clinical, instrumental and qualitative question- on inspiration secondary to a weakness in the integrity of the naires to quantify degrees of nasal obstruction with varying upper lateral cartilage/nasal side wall. Static and dynamic successes [2–5]. INV collapses are distinct entities but can also coexist. The American Academy of Otolaryngology clinical con- The internal nasal valve (INV) is located approximately sensus statement stated that the internal nasal valve plays a 1.3 cm from the nares and is typically the narrowest portion distinct role in nasal obstruction separate from other ana- of the nasal cavity. It is a cross-sectional area bounded medi- tomical pathologies, such as allergy. Furthermore, there was ally by the dorsal septum, laterally by the caudal portion of agreement that surgery is an effective treatment option for the upper lateral cartilage and inferiorly by the head of the such cases . inferior turbinate . The average angle of the INV in a Cau- Structural nasal obstruction can be caused by a deviated casian ranges from 9° to 15° and inter-racial variance is well nasal septum (DNS), internal nasal valve (INV) obstruc- recognised, in part due to the size of the inferior turbinate. tion or external nasal valve (ENV) obstruction. Grading Collapse of the valve is thought to obey Bernoulli’s principle and as such, is a common cause for nasal obstruction . We have devised a method of analysing the static compo- * B. Patel nent of the internal nasal valve by measuring the degree of firstname.lastname@example.org middle turbinate visualisation, which can serve as a marker Rhinology Department, Royal National, Throat, Nose of internal nasal valve obstruction. The primary objective and Ear Hospital, Gray’s Inn Road, London WC1X 8DA, of this study is to investigate and assess the validity of our UK Vol.:(0123456789) 1 3 2740 European Archives of Oto-Rhino-Laryngology (2018) 275:2739–2744 grading system and secondary endpoints are to evaluate its correlation with objective and subjective rhinological out- come measures both pre- and postoperatively. Materials and methods Patients A prospective study of all patients who underwent primary external functional septorhinoplasty under the care of both senior authors at the Royal National Throat Nose and Ear Hospital in 2017 for nasal obstruction. Exclusion criteria were patients under 16 years old, inability to give informed consent, incomplete data and those undergoing concomitant procedures. Fig. 1 INV grading system. MT Middle turbinate, IT inferior turbi- Questionnaires, INV grading and NIPF nate, S septum, LW lateral wall. Measurement is made using a Thudi- measurements cum’s speculum on anterior rhinoscopy or, ideally, a 0° Hopkins rod placed at the level of the head of the inferior turbinate. Grade 0 the Pre- and postoperatively all patients completed the Nasal middle turbinate is easily visible including the head. Grade 1 the mid- dle turbinate is partially obscured and in Grade 2 the middle turbinate Obstruction Symptom Evaluation (NOSE) score and Sino- is not visible nasal Outcome Tool (SNOT-23) questionnaires alongside a Visual Analogue Scale (VAS) comprising a 10-cm linear scale in which patients rated their nasal obstruction (unilat- the patient’s nose and mouth. For bilateral measurements, eral and bilateral). The SNOT-23 and NOSE scores were the patient was asked to breathe in through the nose as hard chosen as both are established scoring systems in pre- and and as fast as possible. For unilateral measurements, one post-operative evaluation of surgical patients . nostril was closed off with tape and the same instructions The internal nasal valve (INV) is graded according to were followed. the degree of middle turbinate visualisation. On endoscopic imaging, this is assessed in each nostril at rest, at the level Operative technique of the head of the inferior turbinate. On anterior rhinoscopy INV is graded based on a horizontal line at the level of the All patients underwent surgery under the care of two senior head of the inferior turbinate. Grade 0 signifies that the head authors (PSR, PA). Endoscopic assessment of the INV was of the middle turbinate is easily visible. Grade 1 signifies performed preoperatively as outlined above. As septoplasty that the middle turbinate is partially obscured. Grade 2 sig- alone around the INV area carries a significant risk of sad- nifies that the middle turbinate is not visible. A maximum dle collapse with subsequent reduction in nasal airway, all grade 2 is given for each nostril (Fig. 1). INV grading was patients underwent septorhinoplasty via external approach documented on the day of surgery and at the patient’s second with corrective surgery guided by INV grade. All patients postoperative visit. Endoscopic images were taken and this underwent septal corrective surgery with columellar struts grading was compared between three authors independently placed to reinforce tip support. In the majority of patients, and repeated at 3-month post-surgery by these three authors. the INV was not adequately corrected with septoplasty and The assessments were blinded and independent, with each columellar struts alone, therefore spreader grafts were also of the authors of differing experience (non-specialist junior inserted with cartilage harvested from the septum. doctor, otolaryngology trainee and rhinology consultant). All subjects were decongested pre and post measurements Statistical analysis with phenylephrine (5% lignocaine, 0.5% phenylephrine) to exclude significant mucosal disease and the variability GraphPad Prism (La Jolla, CA, USA) with paired t tests incurred secondary to the nasal cycle. Unilateral and bilat- and rank correlation coefficients. Internal consistency eral nasal inspiratory peak flows (NIPF) were taken on the was measured with Cronbach’s alpha. A P value less than same days as the grading of the INV, with the best result 0.05 was considered statistically significant. Correlation of three attempts used for analysis . This was performed coefficient, r, is considered strongly positive if above 0.5, with a peak flow meter attached to a face mask secured over moderate if above 0.3 and weakly associated if above 0.2. 1 3 European Archives of Oto-Rhino-Laryngology (2018) 275:2739–2744 2741 Cronbach’s alpha is considered excellent if more than or Table 1 Pre- and postoperative outcome measures equal to 0.9, good if between 0.8 and 0.9 and acceptable if Preoperative mean Postoperative p value between 0.7 and 0.8. mean SNOT 23 55.3 (44.6–66.1) 39.6 (29.4–49.8) 0.0012* Ethical consideration NOSE 14.0 (12.2–15.6) 7.5 (5.9–9.0) < 0.0001* Right NIPF 63.9 (55.5–72.3) 78.2 (70.0–86.4) < 0.0001* There was no deviation in our standard of care for any of the Left NIPF 58.4 (50.2–66.6) 76.3 (69.6–83.0) < 0.0001* patients included in the study and so ethical approval from Bilateral NIPF 79.8 (69.9–89.8) 101.4 (92.1–110.8) < 0.0001* the hospital board was not required. Informed consent was Right VAS 6.8 (5.8–7.7) 3.9 (3.2–4.6) < 0.0001* taken from all patients and data anonymised. Left VAS 7.1 (6.1–8.1) 3.6 (2.9–4.4) < 0.0001* Bilateral VAS 8.4 (7.8–8.9) 3.8 (3.1–4.5) < 0.0001* Right INV grade 1.11 (0.84–1.37) 0.36 (0.12–0.60) 0.0003* Results Left INV grade 1.11 (0.80–1.41) 0.32 (0.14–0.51) 0.0001* Patient demographics Parentheses demonstrate 95% CI confidence interval. NIPF measured in l/min *Significant p value Twenty-eight patients were followed up with 18 male (64.3%), 10 female (35.7%) and a mean age of 30.9 years (95% CI 27.0–34.8). All patients underwent primary exter- and unilateral NIPFs with unilateral VAS. Finally, the INV nal functional septorhinoplasty under the care of the senior authors (PA, PSR). Mean follow-up was 18.8 weeks (95% grading system showed moderate correlation with bilateral VAS scores, NOSE scores, unilateral NIPFs and weak cor- CI 14.8–22.7). A large proportion of patients (75) were excluded due to incomplete datasets and loss to follow-up. relation with SNOT-23. Inter‑rater reliability and test–retest reliability Discussion of static INV grading Synopsis Inter-rater reliability (n = 112, 3 raters) was excellent, with Cronbach’s alpha 0.936 (95% CI 0.913–0.954). Grading systems to clinically evaluate nasal obstruction Test–retest reliability (n = 336, over 3 months time period) was excellent, with Cronbach’s alpha 0.920 (95% are myriad but lack any consensus or standardisation. In addition, some of these demonstrate no correlation to nasal CI 0.901–0.935). airflow as demonstrated by Camacho et al. who compared NOSE, VAS and inferior turbinate size . Visualisation of Pre‑ and postoperative outcome measures the anatomical INV boundaries remains the key to evaluate these patients. Table 1 summarises pre- and postoperative outcome measures. Our internal nasal valve grading system is a simple and reproducible grading system to objectively assess nasal This demonstrates statistically significant reductions in subjective scores (SNOT, NOSE, VAS) postoperatively. obstruction. This study demonstrates excellent inter-rater and test–retest reliability (across a large number of obser- There was statistically significant improvement in unilateral and bilateral NIPFs postoperatively. In addition, the inter- vations), which is fundamental to the use of any grading system. This scoring tool is of value for the static com- nal valve grading was significantly reduced postoperatively (Figs. 2, 3). ponent of INV dysfunction. These grades can therefore be affected by a multitude of pathologies such as septal Comparative analysis deviation, turbinate hypertrophy, inferior displacement of the upper lateral cartilages or a narrowed pyriform To explore the relationship between these subjective and aperture. Clinical acumen is still required to decide how best to achieve expansion of the nasal airway to improve objective scoring systems, correlation analysis was per- formed. This is summarised in Table 2. The main findings the patient’s symptoms. In addition, the dynamic com- ponent of the INV must also be assessed preoperatively. include strong positive correlation between NOSE and bilateral VAS scores, moderate positive correlation between In this study, we selected only primary surgical candi- dates with no evidence of dynamic collapse. We also SNOT and NOSE scores alongside with a moderate nega- tive correlation between bilateral VAS and bilateral NIPFs ensured that there was little reversibility in nasal airflows 1 3 2742 European Archives of Oto-Rhino-Laryngology (2018) 275:2739–2744 Fig. 2 Pre- and postoperative outcome measures Fig. 3 Pre- and postoperative changes in unilateral and bilat- eral nasal inspiratory peak flow (NIPF, l/min) post-decongestion to exclude or minimise the impact of This study also demonstrates significant improvements in mucosal disease. This grading system also serves as an INV grading postoperatively alongside with other subjective operative guide, in that, we aim for a grade 0 view at the and objective outcome measures. These data will be useful end of the surgery, and thus, for example, in addition to to highlight the efficacy of septorhinoplasty surgery, par - realigning the septum, spreader graft insertion may be nec- ticularly in view of increasing commissioning restrictions. essary to ensure an optimal view of middle turbinate and In this series, visual analogue scores appear to correlate hence optimise nasal airflow. with unilateral NIPFs. Visual analogue score is often thought to represent the best outcome measure for identifying nasal 1 3 European Archives of Oto-Rhino-Laryngology (2018) 275:2739–2744 2743 Table 2 Selected correlative statistics obstruction. We have also shown that the INV can be surgi- cally improved with resultant improvements in both subjec- Correlation r p tive and objective outcome measures. NOSE score vs bilateral VAS 0.54 0.00002* An additional strength of this grading system is its ability SNOT vs bilateral VAS 0.21 0.129 to augment the training of septorhinoplasty surgery amongst SNOT vs NOSE 0.40 0.003* our juniors. It came to light that by instilling the concept of SNOT vs bilateral NIPFs − 0.17 0.087 being able to visualise the middle turbinate bilaterally as an NOSE vs bilateral NIPFs − 0.23 0.217 end marker of operative success, juniors found this grading VAS bilateral vs bilateral NIPFs − 0.38 0.004* system very valuable, although it is important to be aware of Unilateral NIPFs vs unilateral VAS − 0.45 < 0.0001* and assess for the role of mucosal disease in these patients Unilateral NIPFs vs unilateral INV grade 0.30 0.0014* alongside with the dynamic aspect of INV dysfunction. INV grading vs NOSE 0.32 0.0006* The main limitation of this study is the reduced number INV grade vs bilateral VAS 0.41 < 0.0001* of participants due to incomplete datasets and the subse- INV grade vs SNOT 0.21 0.0259* quent limited power of the study. However, within our NHS limitations and given that, at least 112 INV gradings were *Significant p value made by three different observers of varying grades; there were sufficient data to ascertain our primary endpoint, the obstruction . This aids in the validation of unilateral reliability and reproducibility of the grading system. NIPF as an essential routine measure and may represent the A further limitation of this study was that we did not best objective marker of nasal obstruction. The moderate incorporate an additional dynamic component to the grading correlation between the INV grading system and unilateral system which would have evaluated internal valve collapse NIPF demonstrates the benefits of the grading system and on deep inspiration. We decided against this as it proved justifies its use as a standard of care. challenging to measure with regards to explaining to the A previous study in our centre demonstrated postop- patient the force of deep inspiration required and also we erative improvement in NIPFs following septorhinoplasty were very conscious to keep this simple and easy to use although there was no significant correlation with SNOT in our busy clinical setting. In addition, controversy exists scores . In this study, we have shown that unilateral NIPFs regarding the dynamic evaluation of nasal obstruction [3–5]. do correspond with subjective unilateral and bilateral block- While acoustic rhinometry may provide a static measure of age. This study suggests that VAS, NIPFs and INV grading the cross-sectional area across the INV, the placement of the are the most useful markers. Unsurprisingly, there was good probe itself splints the nasal airway and therefore invalidates correlation between NOSE and VAS scores. There was no measurement of the INV through this modality. By contrast, significant correlation with SNOT-23, most likely in view a recent study by Pendolino et al., has demonstrated rea- of its wider range of questions rather than focusing on nasal sonable correlation between unilateral NIPF and unilateral blockage symptoms. AAR—the gold standard in the measurement of nasal airway Prospective data collection in the form of questionnaires, resistance . We therefore feel that unilateral NIPF repre- grading scales and objective data in the form of NIPFs are sents a good measurement of nasal airflow. valuable at monitoring both medical and surgical interven- Furthermore, recent publications question the concept of tions and serve as useful tools to monitor outcomes and the INV angle and computational dynamics indicate that the identify trends. Interestingly, our study found that follow- shape of this region is variable, suggesting that assessment ing surgery there was an improvement in all of the outcomes with anterior rhinoscopy or endoscopes is not sufficient [2 ]. recorded. It is also beneficial for patients to see how their scores have improved following intervention. Ideally a con- sensus should be reached for a minimum dataset, much like Conclusion thyroid surgery, to be recorded by all surgeons to allow com- parison of outcomes. This concept was particularly borne We present an easy to use, reliable and reproducible internal out following a recent questionnaire evaluating current ENT nasal valve grading score that has been validated. We would practice in measuring nasal obstruction . advocate using this alongside with a combination of subjec- tive and objective measures for all patients undergoing nasal Strengths and limitations of the study surgery. We have validated an objective, reliable and reproducible Acknowledgements We would like to thank our medical and nursing grading system for the static internal nasal valve. This is of colleagues in the outpatient department at the Royal National Throat clinical value in assessing patients appropriately with nasal 1 3 2744 European Archives of Oto-Rhino-Laryngology (2018) 275:2739–2744 Nose and Ear Hospital that aided in data collation alongside with all 2. Tripathi PB, Elghobashi S, Wong BJF (2017) The myth of the theatre staff. internal nasal valve. JAMA Facial Plastic Surg 19(4):253–254 3. Poirrier AL, Ahluwalia S, Goodson A, Ellis M, Bentley M, Andrews P (2013) Is the Sino-Nasal Outcome Test-22 a suitable Author contributions JSV analysed and interpreted the data alongside evaluation for septorhinoplasty? Laryngoscope 123(1):76–81 with drafting the manuscript; BP was involved in analysing the data 4. Takhar AS, Stephens J, Randhawa PS, Poirrier AL, Andrews P and redrafting the paper; PSR and PJA designed the study and are the (2014) Validation of the sino-nasal outcome test-23 in septorhi- lead clinicians. noplasty surgery. Rhinology 52(4):320–326 5. Andrews PJ, Choudhury N, Takhar A, Poirrier AL, Jacques T, Funding This research received no specific grant from any funding Randhawa PS (2015) The need for an objective measure in sep- agency, commercial or not-for-profit sectors. torhinoplasty surgery: are we any closer to finding an answer? Clin Otolaryngol 40(6):698–703 Compliance with ethical standards 6. Rhee JS, Weaver EM, Park SS, Baker SR, Hilger PA, Kriet JD et al (2010) Clinical consensus statement: diagnosis and manage- ment of nasal valve compromise. Otolaryngol Head Neck Surg Conflict of interest All authors declare that they have no conflict of 143(1):48–59 interest. 7. Poirrier AL, Ahluwalia S, Kwame I, Chau H, Bentley M, Andrews P (2014) External nasal valve collapse: validation of novel out- Informed consent All study participants’ guardians provided informed come measurement tool. Rhinology 52(2):127–132 consent prior to study enrollment. 8. Rhee JS, Sullivan CD, Frank DO, Kimbell JS, Garcia GJM (2014) A systematic review of patient-reported nasal obstruction scores: Open Access This article is distributed under the terms of the Crea- Defining normative and symptomatic ranges in surgical patients. tive Commons Attribution 4.0 International License (http://creat iveco JAMA Facial Plastic Surg 16(3):219–225 mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- 9. Ottaviano G, Fokkens WJ (2016) Measurements of nasal airflow tion, and reproduction in any medium, provided you give appropriate and patency: a critical review with emphasis on the use of peak credit to the original author(s) and the source, provide a link to the nasal inspiratory flow in daily practice. Allergy 71(2):162–174 Creative Commons license, and indicate if changes were made. 10. Ciprandi G, Mora F, Cassano M, Gallina AM, Mora R (2009) Visual analog scale (VAS) and nasal obstruction in persistent allergic rhinitis. Otolaryngol 141(4):527–529 11. Andrews P, Joseph J, Li CH, Nip L, Jacques T, Leung T (2017) References A UK survey of current ENT practice in the assessment of nasal patency. J Laryngol Otol 131(8):702–706 1. Camacho M, Zaghi S, Certal V, Abdullatif J, Modi R, Sridhara S, 12. Ottaviano G, Lund VJ, Nardello E, Scarpa B, Frasson G, Staffieri Tolisano AM, Chang ET, Cable BB, Capasso R (2016) Predictors A et al (2014) Comparison between unilateral PNIF and rhinoma- of nasal obstruction: quantification and assessment using multiple nometry in healthy and obstructed noses. Rhinology 52(1):25–30 grading scales. Plast Surg Int 2016:6945297 1 3
European Archives of Oto-Rhino-Laryngology – Springer Journals
Published: Oct 6, 2018
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