ABSTRACT
Objective
Functional rhinoplasty can improve disease‐specific quality of life (QoL) domains. However, less is understood about its association with global health‐related QoL outcomes. The goal of this study is to evaluate the relationship between disease‐specific and long‐term global QoL outcomes following functional rhinoplasty.
Methods
Prospective cohort study at a tertiary medical center of patients undergoing functional rhinoplasty for nasal airway obstruction.
Results
Fifty patients (58% female, 42% male), with a mean age of 38.5 (StD 14.7), were surveyed. Baseline and long term (> 6 months) follow up Euroqol‐5D (EQ‐5D) and Standard Cosmesis and Health Nasal Outcomes Survey (SCHNOS) questionnaires were collected. Mean baseline SCHNOS‐Obstructive (SCHNOS‐O) score improved from 77.5 (95% CI: 71.5–83.5) to 22.7 (95% CI: 14.4–31.1) at follow up. Mean SCHNOS‐Cosmesis (SCHNOS‐C) score improved from 44.9 (95% CI: 33.9–56.0) to 13.9 (95% CI: 8.9–21.1). A higher SCHNOS‐O is a significant predictor for expressing pain/discomfort at follow up (p = 0.011). A higher SCHNOS‐C is a significant predictor for expressing anxiety/depression at follow up (p = 0.019). There is no relationship between SCHNOS‐O/SCHNOS‐C and mobility, self‐care, or activity. A greater improvement in SCHNOS‐O is associated with less anxiety/depression (p = 0.03) and pain/discomfort (p = 0.02) at follow up. However, a greater improvement in SCHNOS‐C is not significantly associated with anxiety/depression (p = 0.678) or pain/discomfort (p = 0.558) at follow up. Patients who expressed anxiety/depression at baseline are more likely to express anxiety/depression at follow up.
Conclusion
Patients with long‐term improvements in nasal obstruction, but not cosmesis, are less likely to report long‐term anxiety/depression and pain/discomfort following functional rhinoplasty.
Level of Evidence
4.
Keywords: functional rhinoplasty, quality of life, rhinoplasty
1. Introduction
Nasal obstruction is a commonly encountered problem for facial plastic surgeons. Nasal obstruction may occur due to nasal valve insufficiency, trauma, iatrogenic causes, or senescence [1]. Functional rhinoplasty can reduce nasal airway obstruction by addressing specific structural abnormalities of the nasal airway, including the ala, tip, septum, and bony sidewall, all of which can contribute to nasal valve collapse [1, 2].
Assessing outcomes of rhinoplasty is important to the practice of evidence‐based medicine. Studies have measured the efficacy of rhinoplasty using quantitative techniques, such as rhinomanometry [3, 4, 5, 6]. However, the importance of patient reported outcome measures (PROMs) is invaluable, as there is no universally agreed upon objective benchmark for functional rhinoplasty. Ultimately, a patient's experience of nasal obstruction is the most important outcome. A widely used assessment of patient‐reported outcomes in functional rhinoplasty is the nasal obstruction symptom evaluation (NOSE) scale. This is a disease‐specific questionnaire that evaluates the impact of nasal obstruction on a patient's QoL. The tool has demonstrated that functional rhinoplasty leads to significant improvements in nasal obstruction symptoms postoperatively [7, 8, 9, 10]. Other validated tools, such as the standardized cosmesis and health nasal outcomes survey (SCHNOS), assess both patient‐reported nasal obstruction and cosmetic outcomes [11, 12, 13, 14, 15, 16].
The NOSE and SCHNOS are limited in that they are disease‐specific instruments and do not capture the impact of functional rhinoplasty on general QoL outcomes. These factors are referred to as global health‐related QoL (HRQoL) measures, one of which is the EQUATION 5D. Initially developed for healthcare economics research, the tool sought to measure health status to inform the cost‐effectiveness of healthcare interventions [13]. Today, it is widely used in clinical research, randomized control trials, and population health surveys. The instrument has a low user burden and takes approximately 2 min to complete. It consists of five questions assessing the domains of mobility, self‐care, usual activities, pain/discomfort, and anxiety/depression, and incorporates a visual analog scale, on a scale from 1 to 100. When applied to nasal obstruction, the EQUATION 5D demonstrates clinically significant improvements in overall QoL, which are correlated with disease‐specific changes in NOSE score following functional rhinoplasty [15, 16]. Yet, the relationship between EQUATION 5D and SCHNOS has not been explored.
Literature regarding how disease‐specific outcomes relate to global HRQoL outcomes in functional rhinoplasty is sparse. We present the first study to evaluate the relationship between EQUATION 5D and SCHNOS in functional rhinoplasty. The purpose of this study was to investigate the relationship between disease‐specific QoL improvements and global HRQoL improvements following functional rhinoplasty using the SCHNOS and EQUATION 5D.
2. Materials and Methods
This study was performed at a single tertiary care medical center between August 2019 and July 2022 with institutional review board approval (IRB 5230340). Patients presenting to the principal investigator's clinic being evaluated for functional rhinoplasty were administered both the EQ‐5D and SCHNOS questionnaires. Surveys were collected at the initial consultation and subsequent postoperative follow‐up visits at the 6‐month and 12‐month intervals. All adult patients who underwent functional rhinoplasty for nasal airway obstruction and who had completed both the EQ‐5D and SCHNOS questionnaires preoperatively and postoperatively at greater than 6 months were included.
The EQUATION 5D domains of mobility, self‐care, usual activities, pain/discomfort, and anxiety/depression were reported using an ordinal scale of either report or did not report. A visual analogue scale (VAS) where the patient indicated their overall health from 0 (worst health imaginable) to 100 (best health imaginable) was also recorded. The SCHNOS questionnaire comprises four main concepts: nasal obstruction, overall nasal cosmesis, specific nasal cosmesis, and social perception of nasal appearance using a 10‐question survey. Each item was ranked using a Likert scale from 0 (no problem) to 5 (extreme problem). Four of the SCHNOS questions regarding nasal obstruction were calculated as an obstructive score (SCHNOS‐O) and the remaining six questions were calculated as a cosmesis (SCHNOS‐C) score. Preoperative and postoperative EQUATION 5D, SCHNOS‐O, and SCHNOS‐C scores were analyzed.
Data were analyzed using IBM SPSS Statistics Version 27. Descriptive statistics were calculated. EQUATION 5D domains were converted from a three‐point ordinal scale to dichotomous values (problem vs. no problem) which is recommended by the EuroQol group when few patients report problems in each domain. The normality of continuous variables was evaluated using the Shapiro‐Wilk test. Scores at baseline and follow up were compared using Fisher's exact test for categorical variables and Wilcoxon matched‐pair signed‐rank test for continuous variables. Counts, including missing counts, with % of total and means with 95% confidence intervals, are reported. A multivariate generalized linear regression model was used to evaluate the relationship between EQUATION 5D VAS and SCHNOS scores at long term follow up. Standardized β coefficients, 95% confidence intervals, and p‐values for Type III Wald tests are reported. A similar analysis for EQUATION 5D domain scores at long term follow up was performed using multivariate binary logistic regression. Odds ratios with 95% confidence intervals and Wald p‐values are reported for each domain. Due to the small number of cases for self‐care, odds ratios and confidence intervals were either unable to be calculated or too impractical to report. These cases are noted in the results section. Two‐tailed p‐values < 0.05 were considered statistically significant for all tests.
3. Results
A total of 183 patients underwent functional rhinoplasty for nasal airway obstruction and were followed for 6–12 months post‐operatively (Table 1). The cohort had a mean age of 41.7 years and was 54.1% female. 46 (25.1%) patients had prior nasal surgery, and 116 (63.4%) patients reported a history of nasal trauma. 83 (45.4%) and 39 (21.3%) patients reported a history of allergies and obstructive sleep apnea, respectively.
TABLE 1.
Patient characteristics.
| Variable | Mean (95% CI) or count (% of total) |
|---|---|
| Age, years | 41.65 (39.28, 44.02) |
| Gender | |
| Male | 84 (45.9%) |
| Female | 99 (54.1%) |
| History of nasal surgery | 46 (25.1%) |
| History of nasal trauma | 116 (63.4%) |
| Allergy rhinitis | 83 (45.4%) |
| Obstructive sleep apnea | 39 (21.3%) |
| Expressed interest in changing the shape of the nose | |
| Cosmetic rhinoplasty | |
Patients were asked to complete the EQUATION 5D and SCHNOS questionnaires at baseline and long term follow up. Counts of each domain score are reported (Table 2). Patients were less likely to report issues with mobility (12.6% vs. 3.8%; p < 0.001), pain/discomfort (47% vs. 15.3%; p = 0.005), and anxiety/depression (38.3% vs. 27.9%; p = 0.001) at long term follow up when compared to baseline. There was no difference in self‐care (5.5% vs. 1.1%; p = 1.00) or activities (21.9% vs. 6.0%; p = 0.221). There was no significant change in EQUATION 5D VAS (73.8 vs. 76.2; p = 0.099). SCHNOS‐O (79.4 vs. 23.0; p < 0.001), and SCHNOS‐C (48.9 vs. 15.5; p < 0.001) scores decreased significantly at long term follow up.
TABLE 2.
EQUATION 5D and SCHNOS outcomes at baseline and follow up.
| Baseline | Follow up | p | |||||
|---|---|---|---|---|---|---|---|
| Yes | No | Missing | Yes | No | Missing | ||
| EQ‐5D | |||||||
| Mobility | 23 (12.6%) | 137 (74.9%) | 23 (12.6%) | 7 (3.8%) | 75 (41.0%) | 101 (55.2%) | < 0.001* |
| Self‐care | 10 (5.5%) | 150 (82.0%) | 23 (12.6%) | 2 (1.1%) | 80 (43.7%) | 101 (55.2%) | 1.00 |
| Activities | 40 (21.9%) | 120 (65.6%) | 23 (12.6%) | 11 (6.0%) | 71 (38.8%) | 101 (55.2%) | 0.221 |
| Pain/discomfort | 86 (47.0%) | 74 (40.4%) | 23 (12.6%) | 28 (15.3%) | 54 (29.5%) | 101 (55.2%) | 0.005* |
| Anxiety/depression | 70 (38.3%) | 86 (47.0%) | 27 (14.8%) | 51 (27.9%) | 30 (16.4%) | 102 (55.7%) | 0.001* |
| Mean (95% CI) | Missing | Mean (95% CI) | Missing | p | |
|---|---|---|---|---|---|
| EQ‐5D VAS | 73.8 (70.5, 77.2) | 35 (19.1%) | 76.2 (71.6, 80.9) | 111 (60.7%) | 0.099 |
| SCHNOS‐O | 79.4 (76.3, 82.6) | 29 (15.8%) | 23.0 (17.0, 29.0) | 100 (54.6%) | < 0.001* |
| SCHNOS‐C | 48.9 (43.1, 54.7) | 30 (16.4%) | 15.5 (9.9, 21.2) | 101 (55.2%) | < 0.001* |
Note: Data are presented as counts (% of total) for binary variables or mean (95% CI) for continuous variables. Missing data are presented as counts (% of total).
p < 0.05 for Fisher's exact test for binary variables and Wilcoxon matched‐pair signed‐rank test.
Next, to assess the effect of SCHNOS‐O and SCHNOS‐C scores on VAS scores at long term follow up, we performed a multivariate linear regression to predict long term VAS scores (Table 3). Patients with a history of nasal surgery had higher VAS scores by 15.45 points (p = 0.002). Conversely, patients with a history of nasal trauma had lower VAS scores by 12.41 points (p = 0.011). SCHNOS‐O score was an independent predictor of EQUATION 5D VAS (p = 0.047). Every point increase in SCHNOS‐O score was associated with a 0.20‐point decrease in VAS. There was no association between SCHNOS‐C scores and VAS (p = 0.461). There was also no association between age, gender, allergies, OSA, and VAS.
TABLE 3.
Multivariate linear regression of VAS and SCHNOS scores.
| Absolute score at follow up | ∆SCHNOS score at follow up | |||
|---|---|---|---|---|
| ꞵ (95% CI) | p | ꞵ (95% CI) | p | |
| Age | −0.06 (−0.38, 0.26) | 0.694 | −0.26 (0.10, 1.95) | 0.163 |
| Gender | ||||
| Female | −4.97 (−15.03, 5.08) | 0.332 | −4.85 (−16.04, 6.34) | 0.395 |
| Male (ref) | — | — | ||
| Nasal surgery | ||||
| Yes | 15.45 (5.59, 25.23) | 0.002* | 20.87 (9.64, 32.09) | < 0.001* |
| No (ref) | — | — | ||
| Nasal trauma | ||||
| Yes | −12.41 (−21.93, −2.88) | 0.011* | −18.82 (−29.30, −8.34) | < 0.001* |
| No (ref) | — | — | ||
| Allergies | ||||
| Yes | −3.56 (−12.35, 5.22) | 0.427 | −0.44 (−10.12, 9.23) | 0.928 |
| No (ref) | — | — | ||
| OSA | ||||
| Yes | −3.88 (−13.53, 5.76) | 0.430 | −0.40 (−10.87, 10.06) | 0.940 |
| No (ref) | — | — | ||
| SCHNOS‐O | −0.20 (−0.39, −0.003) | 0.047* | 0.09 (−0.08, 0.26) | 0.305 |
| SCHNOS‐C | 0.10 (−0.17, 0.38) | 0.461 | 0.04 (−0.12, 0.22) | 0.594 |
Note: Multivariate linear regression predicting EQUATION 5D VAS and SCHNOS‐O score using both absolute and ∆SCHNOS scores at long term follow up in a generalized linear model. Standardized beta coefficients with 95% confidence intervals and p‐values are displayed.
Abbreviations: CI, confidence interval; OSA, obstructive sleep apnea; ref, reference category.
p < 0.05.
We then performed a similar analysis for each EQUATION 5D domain using multivariate logistic regression (Tables 4 and 5). Older patients were more likely to have issues with mobility (OR = 1.09, p = 0.046). Higher SCHNOS‐O scores were associated with reporting difficulty with activities (OR = 1.03, p = 0.037) and pain/discomfort (OR = 1.04, p = 0.002). Patients with a history of nasal trauma had six times greater odds of reporting issues with daily activities (OR = 6.01, p = 0.06), though this only approached statistical significance. There was no association between SCHNOS‐O and anxiety/depression domain scores (OR = 1.01, p = 0.622). SCHNOS‐C was not associated with any EQUATION 5D domain.
TABLE 4.
Multivariate binary logistic regression of EQUATION 5D and absolute SCHNOS scores.
| Mobility | Self‐care | Activities | Pain/discomfort | Anxiety/depression | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | |
| Age | 1.09 (1.00, 1.18) | 0.046* | 459.44 (— a ) | 0.991 | 1.03 (0.97, 1.09) | 0.401 | 1.00 (0.96, 1.04) | 0.995 | 1.01 (0.97, 1.05) | 0.774 |
| Gender | ||||||||||
| Female | 3.23 (0.20, 52.24) | 0.410 | — a | 0.985 | 4.65 (0.64, 33.76) | 0.129 | 0.81 (0.22, 3.03) | 0.752 | 1.38 (0.40, 4.82) | 0.610 |
| Nasal surgery | ||||||||||
| Yes | — a | 0.998 | — a | 0.996 | 0.60 (0.12, 3.41) | 0.598 | 0.86 (0.24, 3.11) | 0.814 | 0.99 (0.30, 3.22) | 0.980 |
| Nasal trauma | ||||||||||
| Yes | 10.29 (0.65, 162.28) | 0.098 | — a | 0.990 | 6.01 (0.93, 38.94) | 0.060 | 0.66 (0.19, 2.30) | 0.513 | 1.13 (0.37, 3.48) | 0.829 |
| Allergies | ||||||||||
| Yes | 0.72 (0.078, 6.64) | 0.770 | — a | 0.992 | 0.53 (0.11, 2.53) | 0.425 | 0.55 (0.18, 1.73) | 0.307 | 0.92 (0.32, 2.64) | 0.871 |
| OSA | ||||||||||
| Yes | 1.03 (0.13, 8.22) | 0.977 | — a | 0.982 | 1.43 (0.26, 7.88) | 0.683 | 1.72 (0.48, 6.17) | 0.405 | 1.14 (0.36, 3.69) | 0.822 |
| SCHNOS‐O | 1.01 (0.97, 1.04) | 0.688 | 4.31 (— a ) | 0.998 | 1.03 (1.002, 1.06) | 0.037* | 1.04 (1.01, 1.06) | 0.002* | 1.01 (0.98, 1.03) | 0.622 |
| SCHNOS‐C | 0.99 (0.95, 1.04) | 0.746 | 0.09 (— a ) | 0.992 | 0.98 (0.95, 1.02) | 0.297 | 1.01 (0.98, 1.04) | 0.578 | 1.02 (1.00, 1.05) | 0.101 |
Note: Multivariate binary logistic regression predicting issues with EQUATION 5D domains at long term follow up using absolute SCHNOS scores. Reference categories are identical to those reported in Table 3 and are not shown.
Abbreviations: CI, confidence interval; OR, odds ratio; OSA, obstructive sleep apnea.
Unable to calculate meaningful and/or accurate values due to large standard error.
p < 0.05.
TABLE 5.
Multivariate binary logistic regression of EQUATION 5D and ∆SCHNOS scores.
| Mobility | Self‐care | Activities | Pain/discomfort | Anxiety/depression | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | |
| Age | 1.15 (0.98, 1.36) | 0.095 | 0.74 (— a ) | 1.000 | 1.05 (0.98, 1.13) | 0.187 | 1.05 (1.00, 1.10) | 0.068 | 1.01 (0.97, 1.06) | 0.564 |
| Gender | ||||||||||
| Female | 1.48 (0.07, 32.96) | 0.803 | — a | 0.999 | 2.20 (0.30, 16.12) | 0.436 | 1.01 (0.25, 4.05) | 0.986 | 2.66 (0.63, 11.18) | 0.182 |
| Nasal surgery | ||||||||||
| Yes | — a | 0.998 | — a | 1.000 | 0.34 (0.05, 2.64) | 0.304 | 0.70 (0.17, 2.87) | 0.624 | 0.97 (0.24, 3.90) | 0.969 |
| Nasal trauma | ||||||||||
| Yes | 19.35 (0.50, 746.66) | 0.112 | — a | 0.999 | 4.09 (0.56, 30.05) | 0.166 | 1.21 (0.34, 4.29) | 0.773 | 1.60 (0.45, 5.77) | 0.470 |
| Allergies | ||||||||||
| Yes | 0.30 (0.02, 5.28) | 0.411 | — a | 0.999 | 0.65 (0.12, 3.61) | 0.617 | 0.52 (0.15, 1.86) | 0.314 | 0.47 (0.13, 1.72) | 0.253 |
| OSA | ||||||||||
| Yes | 1.44 (0.15, 14.23) | 0.755 | — a | 0.999 | 0.73 (0.11, 4.75) | 0.738 | 1.22 (0.32, 4.74) | 0.771 | 2.14 (0.53, 8.62) | 0.284 |
| ∆SCHNOS‐O | 1.00 (0.97, 1.03) | 0.921 | 0.84 (— a ) | 1.000 | 1.01 (0.98, 1.03) | 0.623 | 1.02 (1.00, 1.04) | 0.120 | 1.01 (0.99, 1.03) | 0.635 |
| ∆SCHNOS‐C | 0.94 (0.89, 1.01) | 0.083 | 0.80 (— a ) | 0.999 | 0.98 (0.95, 1.01) | 0.199 | 0.98 (0.96, 1.00) | 0.118 | 0.99 (0.96, 1.01) | 0.173 |
Note: Multivariate binary logistic regression predicting issues with EQUATION 5D domains at long term follow up using ∆SCHNOS scores. Reference categories are identical to those reported in Table 3 and are not shown.
Abbreviations: CI, confidence interval; OR, odds ratio; OSA, obstructive sleep apnea.
Unable to calculate meaningful and/or accurate values due to large standard error.
p < 0.05.
4. Discussion
Patient reported outcomes play a central role in the evaluation of post‐intervention success. Functional rhinoplasty has consistently demonstrated significant improvement in nasal obstruction based on instruments measuring disease‐specific PROMs, such as the NOSE and SCHNOS [7, 8, 11, 12, 17].
Historically, the relief of nasal obstruction was considered to have likely diminutive impacts on global QoL and thus understudied [15]. Now, there is increasing evidence that functional rhinoplasty may also impact global HRQoL. Much of the previous literature investigating changes in global HRQoL has focused on the NOSE questionnaire [15, 16]. This is the first study investigating the relationship between disease‐specific and global HRQoL measures using the SCHNOS and EQUATION 5D questionnaires after functional rhinoplasty. We found that higher SCHNOS‐O scores predicted lower overall QoL based on EQUATION 5D VAS scores, as well as being associated with patients reporting more difficulty with performing daily activities and pain/discomfort.
Our disease‐specific outcomes align with those reported in the literature. Our mean preoperative SCHNOS‐O and SCHNOS‐C scores were 79.4 (±6.3) and 48.9 (±11.6), respectively. These results are similar to the mean preoperative SCHNOS‐O and SCHNOS‐C scores in functional rhinoplasty patients of 72.9 (±17.8) and 30.1 (±28.2) reported by Kandathil et al. [12] Our mean SCHNOS‐O score improved 54.8 points and mean SCHNOS‐C score improved 31 points, which is in accordance with the minimal clinically important difference (MCID) of 28 for SCHNOS‐O and 18 for SCHNOS‐C determined by Kandathil et al. [18].
The EQ‐5D has been widely established and accepted as a global HRQoL outcome assessment instrument [14, 19]. It has been used to compare medical treatments for multiple diseases by helping determine health utility values (HUV) for cost‐benefit analyses [16]. It has broad applicability and allows direct comparison between patients with different demographics, disease processes, and treatments. The HUV can also be translated to a Quality Adjusted Life Year (QALY) score which can then be used for cost‐benefit analyses. These values may aid in understanding health care resource utilization, allocation, and cost‐effectiveness. Thus, the use of the EQ‐5D in the assessment of this patient population may contribute to a broader understanding of the impact of functional rhinoplasty on the health care system.
Although disease‐specific outcomes in functional rhinoplasty have been previously established, few studies have investigated the relationship between disease‐specific and global HRQoL outcomes. A positive correlation between disease‐specific outcomes and global HRQoL can have important implications for patients and practitioners. Examining this relationship can assist in preoperative counseling for patients considering functional rhinoplasty. An understanding of the impact of functional rhinoplasty on a patient's overall health may assist in shared decision‐making for patients considering functional rhinoplasty.
We found that patients were less likely to report problems with mobility, pain/discomfort, and anxiety and depression at long‐term follow up after functional rhinoplasty. There was no significant improvement in reported problems with activities and self‐care. A patient's ability to breathe through their nose during exercise or exertion may impact their overall perception of mobility. Patients may avoid exercising if they feel that they are unable to adequately breathe during activity and thus may be more likely to note improved mobility following functional rhinoplasty. The feeling of a blocked nasal airway can be a significant source of stress, discomfort, and anxiety for patients. Patients undergoing functional rhinoplasty typically represent a relatively healthy population, given the elective nature of the surgery. Thus, they are less likely to be significantly limited in their self‐care abilities and usual activities, leaving less room for demonstrating significant improvements in these domains at follow up. Their ability to perform activities of daily living, which are lower exertion compared to aerobic activities like running or cycling, may not be significantly impacted by being able to breathe through their nose more easily. The findings in this cohort are similar to a prior study examining the relationship between the EQUATION 5D and NOSE in functional rhinoplasty, in which problems with pain/discomfort and usual activities decreased at long‐term follow‐up [15]. A prospective observational study in Colombia found that in patients who underwent closed septoplasty and turbinate reduction, as NOSE and VAS scores improved, their Glasgow Benefit Inventory scores, used to measure global quality of life, also improved [20]. The impact of functional rhinoplasty on a patient's overall well‐being is not fully understood, but more data suggests that improvement in nasal obstruction can improve patient quality of life far beyond disease‐specific nasal obstructive outcomes [20, 21]. Further prospective studies examining the long‐term impact of functional rhinoplasty on patient global HRQoL are needed.
Of note, SCHNOS‐C scores also improved at follow up despite this cohort undergoing functional rhinoplasty. Maneuvers aimed at addressing functional issues may have inherent secondary cosmetic benefits, such as improving nasal tip deviation when straightening the caudal septum or balancing the frontal proportions of the dorsum when placing spreader grafts in a narrow middle vault. Given the primarily functional nature of the surgery, larger improvements are seen in SCHNOS‐O compared to SCHNOS‐C scores. Furthermore, there was no correlation between improved SCHNOS‐C scores and EQUATION 5D subdomain anxiety scores. The smaller improvements in cosmetic domains may not be large enough to impact a patient's overall burden of anxiety and depression, which is driven by a multitude of psychosocial and neurocognitive factors. In addition, there is a higher incidence of anxiety/depression at long term follow‐up than baseline, possibly due to retention bias, in which extremely satisfied patients do not follow up as consistently. A subsequent analysis between improvements in SCHNOS scores and whether patients who reported anxiety/depression at baseline but no longer do at follow‐up could be a topic of future study.
A limitation of this study is that approximately less than half of our initial study population was included in the study. This includes patients who completed the surveys preoperatively and continued to follow up until their 6‐month post‐operative appointment. However, many patients were lost to follow‐up before the 6‐month mark or did not fill out the paper surveys completely and were subsequently excluded from the study. However, our results are consistent with the relevant literature and may have remained stable in the context of a larger study population. Based on the published estimates of minimal clinically important differences for SCHNOS‐O, SCHNOS‐C, and EQ‐5D, the follow up population remained sufficient to ensure an adequately powered study to detect clinically meaningful differences. Additionally, given this study is based on PROMs, there is a risk of reporting bias given the subjective nature of this measure. Further studies should be conducted with a larger cohort and multi‐institutional patient populations to corroborate the findings of this study. Moreover, the relationship of functional rhinoplasty to objective quality of life measures, such as socioeconomic factors, life expectancy, and cognitive function should be examined.
5. Conclusion
This study shows that improvements in nasal obstruction following functional rhinoplasty, as measured by SCHNOS‐C scores, correlate with improvements in HRQOL assessed by the EQUATION 5D, reflecting the impact of functional rhinoplasty on overall health.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data that supports the findings of this study are available in the supporting information of this article.
References
- 1. Kim D. W. and Rodriguez‐Bruno K., “Functional Rhinoplasty,” Facial Plastic Surgery Clinics of North America 17, no. 1 (2009): 115–131, 10.1016/j.fsc.2008.09.011. [DOI] [PubMed] [Google Scholar]
- 2. Rhee J. S., Arganbright J. M., McMullin B. T., and Hannley M., “Evidence Supporting Functional Rhinoplasty or Nasal Valve Repair: A 25‐Year Systematic Review,” Otolaryngology–Head and Neck Surgery 139, no. 1 (2008): 10–20, 10.1016/j.otohns.2008.02.007. [DOI] [PubMed] [Google Scholar]
- 3. Kahraman E., Cil Y., and Incesulu A., “The Effect of Nasal Obstruction After Different Nasal Surgeries Using Acoustic Rhinometry and Nasal Obstruction Symptom Evaluation Scale,” World Journal of Plastic Surgery 5, no. 3 (2016): 236–243. [PMC free article] [PubMed] [Google Scholar]
- 4. Jessen M., Jacobsson S., and Malm L., “On Rhinomanometry in Rhinoplasty,” Plastic and Reconstructive Surgery 81, no. 4 (1988): 506–510, 10.1097/00006534-198804000-00003. [DOI] [PubMed] [Google Scholar]
- 5. Courtiss E. H. and Goldwyn R. M., “The Effects of Nasal Surgery on Airflow,” Plastic and Reconstructive Surgery 72, no. 1 (1983): 9–19, 10.1097/00006534-198307000-00003. [DOI] [PubMed] [Google Scholar]
- 6. McKEE G. J., O'Neill G., Roberts C., and Lesser T. H. J., “Nasal Airflow After Septorhinoplasty,” Clinical Otolaryngology 19, no. 3 (1994): 254–257, 10.1111/j.1365-2273.1994.tb01226.x. [DOI] [PubMed] [Google Scholar]
- 7. Floyd E. M., Ho S., Patel P., Rosenfeld R. M., and Gordin E., “Systematic Review and Meta‐Analysis of Studies Evaluating Functional Rhinoplasty Outcomes With the NOSE Score,” Otolaryngology–Head and Neck Surgery 156, no. 5 (2017): 809–815, 10.1177/0194599817691272. [DOI] [PubMed] [Google Scholar]
- 8. Gerecci D., Casanueva F. J., Mace J. C., et al., “Nasal Obstruction Symptom Evaluation (NOSE) Score Outcomes After Septorhinoplasty,” Laryngoscope 129, no. 4 (2019): 841–846, 10.1002/lary.27578. [DOI] [PubMed] [Google Scholar]
- 9. Bezerra T. F. P., Padua F. G. M., Pilan R. R. M., Stewart M. G., and Voegels R. L., “Cross‐Cultural Adaptation and Validation of a Quality of Life Questionnaire: The Nasal Obstruction Symptom Evaluation Questionnaire,” Journal of Rhinology 49, no. 2 (2011): 227–231, 10.4193/Rhino10.019. [DOI] [PubMed] [Google Scholar]
- 10. Stewart M. G., Witsell D. L., Smith T. L., Weaver E. M., Yueh B., and Hannley M. T., “Development and Validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale1,” Otolaryngology–Head and Neck Surgery 130, no. 2 (2004): 157–163, 10.1016/j.otohns.2003.09.016. [DOI] [PubMed] [Google Scholar]
- 11. Moubayed S. P., Ioannidis J. P. A., Saltychev M., and Most S. P., “The 10‐Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for Functional and Cosmetic Rhinoplasty,” JAMA Facial Plast Surg 20, no. 1 (2018): 37–42, 10.1001/jamafacial.2017.1083. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Kandathil C. K., Saltychev M., Patel P. N., and Most S. P., “Natural History of the Standardized Cosmesis and Health Nasal Outcomes Survey After Rhinoplasty,” Laryngoscope 131, no. 1 (2021): E116–E123, 10.1002/lary.28831. [DOI] [PubMed] [Google Scholar]
- 13. Devlin N. J. and Brooks R., “EQ‐5D and the EuroQol Group: Past, Present and Future,” Applied Health Economics and Health Policy 15, no. 2 (2017): 127–137, 10.1007/s40258-017-0310-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Wang A., Rand K., Yang Z., Brooks R., and Busschbach J., “The Remarkably Frequent Use of EQ‐5D in Non‐Economic Research,” European Journal of Health Economics Prevention Care 23, no. 6 (2022): 1007–1014, 10.1007/s10198-021-01411-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Fuller J. C., Levesque P. A., and Lindsay R. W., “Assessment of the EuroQol 5‐Dimension Questionnaire for Detection of Clinically Significant Global Health‐Related Quality‐Of‐Life Improvement Following Functional Septorhinoplasty,” JAMA Facial Plast Surg 19, no. 2 (2017): 95–100, 10.1001/jamafacial.2016.1410. [DOI] [PubMed] [Google Scholar]
- 16. Gadkaree S. K., Fuller J. C., Justicz N. S., et al., “Health Utility Values as an Outcome Measure in Patients Undergoing Functional Septorhinoplasty,” JAMA Facial Plast Surg 21, no. 5 (2019): 381–386, 10.1001/jamafacial.2019.0234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Corey C. L. and Most S. P., “Treatment of Nasal Obstruction in the Posttraumatic Nose,” Otolaryngologic Clinics of North America 42, no. 3 (2009): 567–578, 10.1016/j.otc.2009.03.002. [DOI] [PubMed] [Google Scholar]
- 18. Kandathil C. K., Saltychev M., Abdelwahab M., Spataro E. A., Moubayed S. P., and Most S. P., “Minimal Clinically Important Difference of the Standardized Cosmesis and Health Nasal Outcomes Survey,” Aesthetic Surgery Journal 39, no. 8 (2019): 837–840, 10.1093/asj/sjz070. [DOI] [PubMed] [Google Scholar]
- 19. Devlin N., Parkin D., and Janssen B., “An Introduction to EQ‐5D Instruments and Their Applications,” in Methods for Analysing and Reporting EQ‐5D Data (Springer International Publishing, 2020), 1–22, 10.1007/978-3-030-47622-9_1. [DOI] [PubMed] [Google Scholar]
- 20. García‐Chabur M. A., Castellanos J., Corredor‐Rojas G., et al., “Improvement in Nasal Obstruction and Quality of Life After Nasal Septoplasty With Turbinoplasty: A Pre‐ and Post‐Study,” International Archives of Otorhinolaryngology 27, no. 2 (2023): e266–e273, 10.1055/s-0042-1743462. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Bulut O. C., Wallner F., Oladokun D., et al., “Long‐Term Quality of Life Changes After Primary Septorhinoplasty,” Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation 27, no. 4 (2018): 987–991, 10.1007/s11136-017-1761-8. [DOI] [PubMed] [Google Scholar]
Associated Data
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Data Availability Statement
The data that supports the findings of this study are available in the supporting information of this article.