Research
Quality of Life Assessment in Patients Undergoing Septoplasty Using Nose and RhinoQOL Questionnaires
*Chirayata Basu, *ShantanuMandal, *Ankur Gupta, *Rohit Bhardwaj
- *Department of Otorhinolaryngology, VMMC and Safdarjung Hospital, New Delhi, India
- Submitted: Monday July 27, 2020
- Accepted: Tuesday, August 25, 2020
- Published: Sunday, August 30, 2020
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
Abstract
Objective
The purpose of the study was to assess the quality of life before and after nasal septal corrective surgery using the NOSE and RHINOQOL questionnaires.
Materials and Methods
Over a period of 18 months, thirty patients between the age of 17 to 65 years who underwent nasal septal corrective surgery and met the criterion of the study were included. The NOSE and RHINOQOL questionnaire scores were taken before surgery and at 1 and 3 months after surgery.
Results
Thirty patients were included in the study. The mean age was 23.2 years. There was significant improvement in the mean NOSE score by 35 points by 1 month after surgery and 51.17 points by 3 months after surgery. Among the RhinoQOL scores the symptom bothersomeness and impact improved at both 1 and 3 months post surgery while all symptom frequency improved at 3 months post surgery.
Conclusion
As assessed by the NOSE and RhinoQOL questionnaires, there was a significant improvement in the disease specific quality of life in patients of symptomatic nasal obstruction after undergoing septal corrective surgery.
Keywords
Quality of life, septoplasty, NOSE, RhinoQOL
Introduction
Chronic nasal obstruction is a one of the commonest complaints of patients visiting an otorhinolaryngologist[1].
The most important cause of nasal obstruction is septal deviation. Septoplasty is a commonly performed surgical procedure by otorhinolaryngologists and is generally performed to improve quality of life [2].
Patients with deviated nasal septum not only have nasal symptoms but also feature like anosmia, facial pain, difficulty in falling asleep, fatigue, reduced concentration, with possible psychological effects (frustration, restlessness, irritability etc.) [3].
NOSE score is used to measure Quality of Life (QOL) for septoplasty. Patients are made to rate on a scale of 0 to 4, over a month their perceptions of 5 different questions, like nasal congestion. The total score is multiplied by 5 for a score out of 100, where 0 is asymptomatic and 100 is worst-case scenario. [4, 5]
During the last decade, disease-specific instruments that measure nasal obstruction and health-related quality of life (QOL) have been validated to assess the impact of septoplasty.
These tools are reliable, reproducible, and sensitive to change and have an excellent clinical correlation [4 -7].
A new Health Related Quality of Life (HRQL) the Rhinosinusitis Quality of Life survey (RhinoQOL), is a short, relevant, psychometrically sound measure of the severity of sinusitis symptoms (frequency and bothersomeness) and their functional impact. [8]
The hypothesis was that theQuality of life improves in Indian patients undergoing
corrective nasal septal surgery as assessed by NOSE and RhinoQOL questionnaires.
Materials and methods
The study was held over a period of 18 months in our Hospital, a tertiary care hospital, after being approved by the institutional ethical committee and having taken due informed consent from the patients.
Patients between the age of 17 to 65 years of age having symptomatic deviated nasal septum requiring Septoplasty the primary mode of treatment were enrolled for the study.
We excluded patients requiring septal surgery for reasons other than deviated nasal septum, undergoing septal surgery combined with lateral wall of nose surgery, having medical contraindication for surgery, undergoing aesthetic nasal surgery, revision surgery, with acute nasal trauma, with adenoid hypertrophy or having uncontrolled asthma/nasal allergy.
For paired t-tests (where significance level a = 0.05 and Power 1-b = 0.80) the formula for sample size is: 2 + {standard deviation*(za/2 + z1-b) / (mean1 – mean2)} [2]
The statistically significant sample size was found to be 22; hence 30 patients were enrolled for this study
All enrolled patients underwent routine blood investigations and diagnostic nasal endoscopy before surgery. Pre-operative NOSE and RhinoQOL scores were taken.
Under local anaesthesia and aseptic precautions, hemitransfixion incision applied. Mucoperichondrial and mucoperiosteal flaps raised till bony
cartilaginous junction posteriorly following which mucoperiosteal and mucoperichondrial flaps were raised on the opposite side. All deviated parts of the
cartilaginous septum removed preserving the dorsal strut. Maxillary crest and the deviated parts of bony septum were removed. Nasal cavities were packing with medicated Merocel packs, which were removed after 48 hours of surgery.
In subsequent follow up after one and three months of surgery, the NOSE and
RhinoQOL questionnaire scores were again taken.
Pre-operative and post-operative NOSE and RhinoQol scores were taken using the English version of the questionnaires, which were translated to Hindi by the examining specialist doctor.
The pre and post- operative scores were then correlated to derive the results.
Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± SD and median. Normality of data was tested by Kolmogorov-Smirnov test. If the normality was rejected then non parametric test was used.
Statistical tests were applied as follows-
1. Quantitative variables were compared using Wilcoxon signed rank test between pre and postoperative.
2. Qualitative variables were correlated using Chi-Square test.
A p value o<0.05 was considered statistically significant.
The data was entered in MS EXCEL spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 25.0.
Results
All the 30 patients who were enrolled in the study returned at 1 month and 3 months post operative period for the respective postoperative nose and RhinoQOL scores and the values were considered for the statistical analysis. The mean age was 23.2 with a range between 17 to 38 years (Table 1).
| |
Sample size |
Mean ± St dev |
Median |
Min-Max |
Inter quartile Range |
| Age |
30 |
23.2 ± 5.85 |
21 |
17-38 |
19-25 |
Out of the 30 patients 2 were females and rest were males. 13 patients had right sided Deviated nasal septum, 16 patients had left sided deviated nasal septum while 1 patient had ‘S’ shaped deviated nasal septum. 16 patients had Deviated nasal septum only. Of the remaining patients, 9 had spurred, 2 had buckling and 3 had caudal deviation.
Following septoplasty there was significant improvement scores, both at 1 and 3 months of follow up.
A p value of <0.05 was considered statistically significant.
The baseline NOSE score out of 100 was 62.5 with a standard deviation of ±16.3, while the score at 1 month after surgery was 27.5 with a standard deviation of ± 17.7 and at 3 months after surgery was 11.33 with a standard deviation of ± 11.59 (Table 2. and (Figure 1).
| NOSE Score |
Mean ± Stdev |
Median(IQR) |
P value(comparison with pre op) |
| Pre operative |
62.5 ± 16.23 |
65(50 - 75) |
|
| Post-operative 1 month |
27.5 ± 17.7 |
30(15 - 40) |
<.0001 |
| Post-operative 3 months |
11.33 ± 11.59 |
10(0 - 15)
|
<.0001 |
Figure 1: Comparison of pre-operative NOSE score with post-operative 1 and 3 months.
All of the five Items on NOSE score improved after surgery.
There was statistically significant improvement in the first 4 items of the NOSE score (i.e Nasal congestion or stuffiness, Nasal blockage or obstruction, Trouble breathing through nose and Trouble sleeping) in the 1 month post operative score, and statistically significant improvement in all the 5 items (above mentioned 4 along with inability to get enough air through the nose during exercise or exertion) in the 3 months post operative score as can be seen from the increasing number and percentage of patients selecting lower scores with successive evaluations (Table 3).
| NOSE score response |
Preoperative |
Postoperative 1 month |
Postoperative 3 months |
| N1 - Nasal congestion or stuffiness |
| No problem |
1(3.33%) |
8(26.67%) |
18(60.00%) |
| Very mild problem |
2(6.67%) |
7(23.33%) |
5(16.67%) |
| Mild to moderate problem |
10(33.33%) |
9(30.00%) |
6(20.00%) |
| Moderate problem |
12(40.00%) |
3(10.00%) |
1(3.33%) |
| Severe problem |
5(16.67%) |
3(10.00%) |
0(0.00%) |
| P value |
|
0.007 |
<.0001 |
| N2 - Nasal blockage or obstruction |
| No problem |
0(0.00%) |
7(23.33%) |
17(56.67%) |
| Very mild problem |
0(0.00%) |
9(30.00%) |
9(30.00%) |
| Mild to moderate problem |
7(23.33%) |
5(16.67%) |
3(10.00%) |
| Moderate problem |
10(33.33%) |
9(30.00%) |
1(3.33%) |
| Severe problem |
13(43.33%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
| N3 - Trouble breathing through my nose |
| No problem |
2(6.67%) |
13(43.33%) |
25(83.33%) |
| Very mild problem |
1(3.33%) |
11(36.67%) |
3(10.00%) |
| Mild to moderate problem |
7(23.33%) |
3(10.00%) |
1(3.33%) |
| Moderate problem |
14(46.67%) |
3(10.00%) |
1(3.33%) |
| Severe problem |
6(20.00%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
| N4 - Trouble sleeping |
| No problem |
4(13.33%) |
16(53.33%) |
23(76.67%) |
| Very mild problem |
5(16.67%) |
10(33.33%) |
6(20.00%) |
| Mild to moderate problem |
9(30.00%) |
3(10.00%) |
1(3.33%) |
| Moderate problem |
7(23.33%) |
1(3.33%) |
0(0.00%) |
| Severe problem |
5(16.67%) |
0(0.00%) |
0(0.00%) |
| P value |
|
0.0003 |
<.0001 |
| N5 - Unable to get enough air through my nose during
exercise or exertion |
| No problem |
4(13.33%) |
13(43.33%) |
21(70.00%) |
| Very mild problem |
10(33.33%) |
9(30.00%) |
7(23.33%) |
| Mild to moderate problem |
7(23.33%) |
6(20.00%) |
0(0.00%) |
| Moderate problem |
4(13.33%) |
1(3.33%) |
1(3.33%) |
| Severe problem |
5(16.67%) |
1(3.33%) |
1(3.33%) |
| P value |
|
0.053 |
0.053 |
As per the RhinoQOL questionnaire, of the symptom frequency scale blocked/stuffy nose, thick nasal discharge and runny nose showed significant improvement by the first month after surgery. In the 3 months post operative scores all the frequency items showed statistically significant improvement Table 4.
| |
Preoperative |
Postoperative 1 month |
Postoperative 3 months |
| R1 - In the last 7 days how much of the time did you
have sinus headaches, facial pain or facial pressure ? |
| None of the time |
2(6.67%) |
9(30.00%) |
14(46.67%) |
| A little of the time |
5(16.67%) |
5(16.67%) |
4(13.33%) |
| Some of the time |
5(16.67%) |
6(20.00%) |
7(23.33%) |
| Most of the time |
9(30.00%) |
3(10.00%) |
1(3.33%) |
| All of the time |
9(30.00%) |
7(23.33%) |
4(13.33%) |
| P value |
|
0.099 |
0.001 |
| R2 - In the last 7 days how much of the time did you
have a blocked or stuffy nose ? |
| None of the time |
0(0.00%) |
7(23.33%) |
18(60.00%) |
| A little of the time |
1(3.33%) |
9(30.00%) |
18(60.00%) |
| Some of the time |
1(3.33%) |
8(26.67%) |
4(13.33%) |
| Most of the time |
11(36.67%) |
3(10.00%) |
0(0.00%) |
| All of the time |
17(56.67%) |
3(10.00%) |
1(3.33%) |
| P value |
|
<.0001 |
<.0001 |
| R3 - In the last 7 days how much of the time did you
have postnasal drip ? |
| None of the time |
5(16.67%) |
14(46.67%) |
18(60.00%) |
| A little of the time |
4(13.33%) |
5(16.67%) |
6(20.00%) |
| Some of the time |
5(16.67%) |
5(16.67%) |
5(16.67%) |
| Most of the time |
4(13.33%) |
2(6.67%) |
0(0.00%) |
| All of the time |
12(40.00%) |
4(13.33%) |
1(3.33%) |
| P value |
|
0.06 |
0.0003 |
| R4 - In the past 7 days how much of the time did you
have a thick nasal discharge? |
| None of the time |
1(3.33%) |
23(76.67%) |
27(90.00%) |
| A little of the time |
5(16.67%) |
4(13.33%) |
1(3.33%) |
| Some of the time |
6(20.00%) |
1(3.33%) |
1(3.33%) |
| Most of the time |
7(23.33%) |
0(0.00%) |
1(3.33%) |
| All of the time |
11(36.67%) |
2(6.67%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
| R5 - In the past 7 days how much of the time did you
have a runny nose? |
| None of the time |
1(3.33%) |
10(33.33%) |
17(56.67%) |
| A little of the time |
2(6.67%) |
5(16.67%) |
2(6.67%) |
| Some of the time |
7(23.33%) |
8(26.67%) |
6(20.00%) |
| Most of the time |
5(16.67%) |
1(3.33%) |
2(6.67%) |
| All of the time |
5(16.67%) |
6(20.00%) |
3(10.00%) |
| P value |
|
0.004 |
0.0001 |
All the items on symptom bothersomeness scale showed statistically significant improvement in the scores at both 1 and 3 months after surgery (Table 5).
| |
Preoperative |
Postoperative 1 month |
Postoperative 3 month |
| R1a - How much were you bothered by the sinus headaches,
facial pain or facial pressure?a |
| Mean ± Stdev |
6.27 ± 2.91 |
3.43 ± 2.97 |
2.33 ± 2.98 |
| Median |
6 |
4 |
1 |
| P value |
|
0.0004 |
<.0001 |
| R2a - How much were you bothered by having a blocked or
stuffy nose? |
| Mean ± Stdev |
7.93 ± 1.34 |
1.9 ± 2.2 |
1.07 ± 2.02 |
| Median |
8 |
0.5 0 |
0 |
| P value |
|
<.0001 < |
<.0001 < |
| R3a - How much were you bothered by
postnasal drip ? |
| Mean ± Stdev |
4.73 ± 3.46 |
1.97 ± 2.44 |
1.3 ± 1.99 |
| Median |
4 |
0 |
0 |
| P value |
|
0.0003 |
0.0001 |
Among the items in symptom impact scale, all showed statistically significant improvement in the scores at both 1 and 3 months after surgery (Table 6).
| |
Preoperative |
Postoperative 1 month |
Postoperative 3 month |
| R6 - In the last 7 days, how much of the time did you
feel tired or fatigued because of your nasal symptoms ? |
| None of the time |
0(0.00%) |
15(50.00%) |
22(73.33%) |
| A little of the time |
2(6.67%) |
3(10.00%) |
3(10.00%) |
| Some of the time |
2(6.67%) |
6(20.00%) |
2(6.67%) |
| Most of the time |
5(16.67%) |
6(20.00%) |
2(6.67%) |
| All of the tim |
21(70.00%) |
0(0.00%) |
1(3.33%) |
| P value |
|
<.0001 |
<.0001 |
| R7 - In the last 7 days how much of the time did you
have trouble sleeping because of your nasal symptoms? |
| None of the time |
2(6.67%) |
20(66.67%) |
26(86.67%) |
| A little of the time |
4(13.33%) |
6(20.00%) |
1(3.33%) |
| Some of the time |
3(10.00%) |
3(10.00%) |
2(6.67%) |
| Most of the time |
6(20.00%) |
1(3.33%) |
1(3.33%) |
| All of the time |
15(50.00%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
| R8 - In the last 7 days how much of the time did you
feel it was harder to concentrate because of your nasal symptoms? |
| None of the time |
0(0.00%) |
21(70.00%) |
25(83.33%) |
| A little of the time |
5(16.67%) |
3(10.00%) |
3(10.00%) |
| Some of the time |
2(6.67%) |
5(16.67%) |
1(3.33%) |
| Most of the time |
7(23.33%) |
1(3.33%) |
1(3.33%) |
| All of the time |
16(53.33%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
| R9 -In the last 7 days how much of the time did you feel
it was harder to do things you normally do because of your nasal
symptoms? |
| None of the time |
0(0.00%) |
19(63.33%) |
27(90.00%) |
| A little of the time |
3(10.00%) |
3(10.00%) |
0(0.00%) |
| Some of the time |
4(13.33%) |
5(16.67%) |
2(6.67%) |
| Most of the time |
5(16.67%) |
3(10.00%) |
1(3.33%) |
| All of the time |
18(60.00%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001
|
<.0001
|
| R10 -In the last 7 days how much of the time did you
feel embarrassed because of your nasal symptoms? |
| None of the time |
1(3.33%) |
23(76.67%) |
26(86.67%) |
| A little of the time |
4(13.33%) |
3(10.00%) |
3(10.00%) |
| Some of the time |
4(13.33%) |
2(6.67%) |
0(0.00%) |
| Most of the time |
3(10.00%) |
2(6.67%) |
1(3.33%) |
| All of the time |
18(60.00%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
| R11 - In the last 7 days how much of the time did you
feel frustrated because of your nasal symptoms? |
| None of the time |
1(3.33%) |
18(60.00%) |
23(76.67%) |
| A little of the time |
0(0.00%) |
6(20.00%) |
4(13.33%) |
| Some of the time |
1(3.33%) |
4(13.33%) |
1(3.33%) |
| All of the time |
25(83.33%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
| R12 - In the last 7 days how much of thetime did you
feel irritable because of your nasal symptoms? |
| None of the time |
1(3.33%) |
18(60.00%) |
19(63.33%) |
| A little of the time |
1(3.33%) |
2(6.67%) |
7(23.33%) |
| Some of the time |
1(3.33%) |
6(20.00%) |
0(0.00%) |
| Most of the time |
6(20.00%) |
4(13.33%) |
3(10.00%) |
| All of the time |
21(70.00%) |
0(0.00%) |
1(3.33%) |
| P value |
|
<.0001 |
<.0001 |
| R13 - In the last 7 days how much of the time did you
feel sad or depressed because of your nasal symptoms? |
| None of the time |
2(6.67%) |
18(60.00%) |
22(73.33%) |
| A little of the time |
3(10.00%) |
7(23.33%) |
4(13.33%) |
| Some of the time |
2(6.67%) |
4(13.33%) |
2(6.67%) |
| Most of the time |
4(13.33%) |
1(3.33%) |
1(3.33%) |
| All of the time |
19(63.33%) |
0(0.00%) |
0(0.00%) |
| P value |
<.0001 |
<.0001 |
|
| R14 - In the last 7 days how much of the time did you
think about your nasal symptoms? |
| None of the time |
2(6.67%) |
18(60.00%) |
20(66.67%) |
| A little of the time |
2(6.67%) |
4(13.33%) |
5(16.67%) |
| Some of the time |
2(6.67%) |
5(16.67%) |
3(10.00%) |
| Most of the time |
5(16.67%) |
3(10.00%) |
2(6.67%) |
| All of the time |
19(63.33%) |
0(0.00%) |
0(0.00%) |
| P value |
|
<.0001 |
<.0001 |
Discussion
Nasal obstruction is the most common symptom requiring septal surgery. We wanted to assess the outcome of the surgery on the quality of life in and Indian setup. [9]Various studies have been conducted in the past to assess the outcome of nasal septal surgery, and mostly results have been similar with significant improvement in symptoms. However many of these include studies that were retrospective [10, 11,12, 13], chart reviews, telephone surveys[12] and studies utilizing tools not specific to nasal obstruction (Glasgow Benefit Inventory) [11]. In our prospective interventional study we have used 2 scoring systems targeting symptoms of nasal obstruction and taken scores at 1 and 3 months into the post operative period.
Stewart MG et al had established NOSE scale as a valid tool to assess the effect of septoplasty[4].
Atlas SJ et al used the RhinoQol score with its symptom impact assessment to help observe the improvement of the non nasal / general physical outcomes of nasal obstruction and thus get a better idea of the overall quality of life of the individual [6].
Hence we chose these two questionnaires as the NOSE score was specifically made to assess the quality of life in patients undergoing septoplasty, and the items in the RhinoQol questionnaire closely related to the complaints and their impact on life of the patients presenting to us for symptomatic nasal obstruction due to nasal septal deviation.
No problems were encountered while using these two questionnaires in the Indian setupand could be easily translated to the patient by the specialist doctor.
We not only found that the symptoms had improved at the 1 month post operative period but also sustained or improved further in majority of the patients at 3 months post operative period. The trend was similar irrespective of the age, gender or other deformities of the nasal septum.
The RhinoQoL score with its symptom impact assessment helped us observe the improvement of the non nasal / general physical outcomes of nasal obstruction and thus get a better idea of the overall quality of life of the individual
A study was conducted by Mondina et al in 2012 for the assessment of nasal septoplasty using NOSE and RhinoQoL questionnaires. 100 patients met the inclusion criteria. Patients who returned the questionnaires after surgery were considered for statistical analysis.64% was male and36% were female. BMI was [25 kg/m2 in40%; 26% were smokers and 28% had allergic rhinitis treated by only oral antihistaminics of which 60% were permanent and moderate.The mean NOSE and RhinoQoL scores at baseline and those at 6 months after were considered. There was a highly significant improvement in each score after septoplasty at 6 months (p\0.00001).
All NOSE components were improved after treatment (p\0.00001).
The frequency of nasal obstruction, rhinorrhea and facial pain was significantly reduced (p\0.00001–0.004 and0.01, respectively). On the bothersomeness score, only
Nasal obstruction and rhinorrhea were improved with a statistically significant difference (p\0.00001 and0.0005, respectively). This was not the case for facial pain (p>0.05). All items on the impact score were significantly improved showing that septoplasty had a meaningful physical, cognitive, mood, sleep and social impact(p\0.00001).[14]
Another study conducted by Bezerra et alin 2012, used NOSE questionnaire, before and 3 months after nasal septal surgery, showed that septoplasy results in a statistically significant improvement in quality of life. [15]
In 2019 Grant s Gillman et al conducted a prospective observational cohort study to assess outcome of septoplasty 3 and 6 months after surgery using NOSE scale and Ease-of-breathing (EOB) likert scale.Statistically significant (p<0.0001) in scores were seen again at 3 and 6 months post operative evaluations as compared to baseline.[16]
In our study we documented the NOSE and RhinoQoL scores befoare and at 1 and 3 months after surgery and arrived at the results as discussed earlier, i.e signficant improvement in symptoms as per both scores after septoplasty.
Other scales like SNOT-22 questionnaire have also been used to assess the quality of life following septoplasty, but in our setup the complaints and sypmtoms of the patients related more closely to the items on RhinoQoL questionnaire. The advantage of the RhinoQol questionnaire also lies in the fact that it can be used to assess both the nasal as well as the general health symptoms without the requirement of a separate questionnaire (eg. General Health Questionnaire) for the assessment of the latter.
Not having a control group can be considered a weakness of the study; however, the treatment of such symptomatic deviated nasal septum is surgical correction itself.
Conclusion
With this study we can conclude that there is a significant improvement in the disease specific quality of life after undergoing septal corrective surgery as assessed by the NOSE and RhinoQoL questionnaires in patients of symptomatic nasal obstruction due to septal deformities.
Authors' Contribution
CB: Proposal for the study, data collection, surgical
intervention, statistical analysis and data compilation.
SM: Ethical
clearance for the study, surgical intervention and data compilation.
AG:
Selection, preparation and surgical intervention of participating patients.
RB: Selection, preparation and surgical intervention of participating patients.
Conflict of Interest
None.
Statement of Ethics and Consent
The study was approved by the Institute Ethical Committee and
written informed consent was obtained from all participants.
References
[1]Buckland Jr,Thomas S,Harries PG, Can the Sinonasal Outcome Test(SNOT-22) be used as a reliable outcome measure for successful septal surgery?.Clinical Otolaryngology 2003; 28:43-47. [PubMed]
[2]Manoukian PD, Wyatt JR, Leopold DA. Recent trends in utilization of procedures in otolaryngology head and neck surgery. Laryngoscope 1997 ;107;472-7[PubMed]
[3].Pannu KK, Chadha S,Kaur IP. Evaluation of benefits of nasal septal surgery on nasal symptoms and general health. Indian Journal of Otolaryngology Head &Neck Surgery 2009; 61:59-65.[PubMed] [PMC full Text]
[4].Stewart MG, Witsell DL, Smith TL,Weaver EM,Yueh B, Hannley MT. Development and validation ofthe Nasal Obstruction Symptom Evaluation (NOSE)scale. Otolaryngol Head Neck Surg.2004;130:157-163. .[pUbmed]
[5].Stewart MG, Smith TL,Weaver EM.Outcomes after nasal septoplasty: results from theNasal Obstruction Septoplasty Effectiveness(NOSE) study. Otolaryngol Head Neck Surg.2004;130:283-290. [PubMed]
[6]SAtlas SJ, Gallagher PM, Wu YA. Development andvalidation of a new health-related quality of life instrument forpatients with sinusitis. Qual Life Res. 2005;14(5):1375–86. [PubMed]
[7]Atlas SJ, Metson RB, Singer DE, Wu YA, Gliklich RE Validity of a new health-related quality of life instrument forpatients with chronic sinusitis. Laryngoscope 2005;115(5):846–54.[Pubmed]
[8]Atlas SJ, Gallagher PM, Wu YA. Development and validation of a new health-related quality of life instrument for patients with sinusitis. Qual Life Res. 2005;14(5):1375–86. [Pubmed]
[9]Arunachalam p.s., Kitcher e., Gray j. Nasal septal surgery: evaluation of symptomatic and general healt outcomes. Clin. Otolaryngol.2001; 26, 367–70. [Pubmed]
[10]. Jessen M, Ivarsson A, Malm L. Nasal airway resistance and symptoms after functional septoplasty: comparison of findings at 9 months and 9 years. Clin Otolaryngol 1989;14:231-4. [Pubmed]
[11]Stewart EJ, Robinson K, Wilson JA. Assessment of patient’s benefit from rhinoplasty. Rhinology 1996;34:57- 9. [PubMed]
[12Samad I, Stevens HE, Maloney A. The efficacy of nasal septal surgery. J Otolaryngol 1992;21:88-91.[Pubmed]
[13]Hwang PH, McLaughlin RB, Lanza DC, et al. Endoscopic septoplasty: indications, technique, and results. Otolaryngol Head Neck Surg 1999;120:678-82. [PubMed]
[14Mondina M, Marro M, Maurice S, Stoll D, de Gabory L.Assessment of nasal septoplasty using NOSE and RhinoQoLquestionnaires. Eur Arch Otorhinolaryngol. 2012;269:2189-95. [Pubmed]
[15]. Bezerra TF, Stewart MG, Fornazieri MA. Quality of life assessment septoplasty in patient with nasal obstruction. Braz J Otorhinolaryngol 2003;78:57-62. [PubMed]
[16]Gillman GS, Staltari GV, Chang YF, Mattos JL. A Prospective Study of Outcomes of Septoplasty with Turbinate Reductions in Patients with Allergic Rhinitis. Otolaryngology–Head and Neck Surgery. 2019 Jun;160(6):1118-23.[Pubmed]
