Abstract
The Nasal Obstruction Symptom Evaluation (NOSE) scale is a reliable and valid instrument used widely in otorhinolaryngology to evaluate nasal obstruction symptoms in patients with nasal disorders. The purpose of this study was to assess nasal obstruction symptoms prospectively in patients undergoing surgically assisted rapid maxillary expansion (SARME) using the NOSE scale. Sixteen patients were studied (mean age 31 ± 7.7 years), 10 women and six men, all with a transverse maxillary deficiency and an indication for SARME. Hyrax type devices were placed preoperatively and SARME was performed using Kraut’s technique. The NOSE scale was applied prospectively to assess nasal obstruction symptoms. The results were recorded for each score on a scale ranging from 0 to 4, and these scores were multiplied by 5, generating a balanced scale from 0 to 100. Data were stratified according to NOSE scores, and nasal obstruction was categorized as mild (0–25), moderate (26–50), or severe (>50). The questionnaire was administered twice, first preoperatively and then at 6 months after surgery, and the results compared. Data were analyzed statistically using SAS statistical package software and showed that patients experienced a subjective improvement or did not have a worsening of nasal obstruction symptoms after SARME.
Transverse maxillary deficiency is a pathological condition that may be associated with other dentofacial deformities, with resulting aesthetic and functional implications, including respiratory problems. Bailey et al. observed that the prevalence of posterior crossbite in orthodontic patients is 37.2%, compared to 9.4% in the general population.
The relationship between transverse maxillary deficiency and respiratory problems has received increasing attention in the recent scientific literature. Various studies showing nasal respiratory improvements after surgically assisted rapid maxillary expansion (SARME) have been published. Reports of breathing pattern improvements concomitant with the correction of the transverse maxillary deficiency are numerous and these have used many methodologies to evaluate nasal airflow, such as acoustic rhinometry, rhinomanometry, tomography evaluation, radiographs, and others.
In 2004, the Nasal Obstruction Symptom Evaluation (NOSE) tool was introduced. This consists of a questionnaire administered to patients before and after procedures for the treatment of nasal obstruction and was created specifically to evaluate the symptom of nasal obstruction. This tool was validated in a multicentre study supported by the American Academy of Otolaryngology – Head and Neck Surgery, and shown to be reliable and valuable in the prospective evaluation of nasal obstruction symptoms in patients undergoing surgical procedures.
In 2013, Williams et al. used the methodology proposed by Stewart et al. in a prospective study to assess nasal obstruction symptoms after Le Fort I osteotomy.
The objective of the present study was to apply the NOSE scale to evaluate nasal obstruction symptoms in patients undergoing SARME.
Materials and methods
The present study was approved by the ethics committee of the Dental School of Araraquara (FOAR-UNESP). Informed consent was obtained from all participants prior to commencement of the study.
An initial sample of 17 consecutive patients was considered, however one patient was excluded because of a nasal septum deviation observed on preoperative rhinoscopy. Therefore, 16 adult patients (10 women and six men) who had already reached skeletal maturity, as confirmed by hand and wrist radiographs, were included in the study. Their mean age was 31 ± 7.7 years. All subjects presented a transverse maxillary deficiency with an indication for SARME as part of their treatment ( Table 1 ).
| Patient | Age, years | Gender | Race |
|---|---|---|---|
| 1 | 37 | Female | Caucasian |
| 2 | 22 | Female | Caucasian |
| 3 | 21 | Female | Caucasian |
| 4 | 22 | Male | Caucasian |
| 5 | 41 | Female | Caucasian |
| 6 | 21 | Female | Caucasian |
| 7 | 32 | Male | Caucasian |
| 8 | 37 | Female | Caucasian |
| 9 | 33 | Female | Black |
| 10 | 36 | Female | Caucasian |
| 11 | 38 | Female | Caucasian |
| 12 | 25 | Male | Caucasian |
| 13 | 40 | Male | Caucasian |
| 14 | 23 | Male | Caucasian |
| 15 | 28 | Male | Caucasian |
| 16 | 40 | Female | Caucasian |
The inclusion criteria were age over 20 years, literate, the presence of a maxillary transverse deficiency with or without other associated dentofacial deformities, and compliance with follow-up appointments. Patients with craniofacial anomalies, those who had undergone previous maxillary or nasal surgery, and those with intranasal findings that could cause nasal obstruction, such as turbinate hypertrophy, nasal polyps, septal deviation, and others, were excluded from the study.
Hyrax (tooth-borne) maxillary distractors were installed in all patients by banding the first molars and first premolars. The SARME procedure was performed according to the technique of Kraut (with pterygomaxillary separation). Maxillary expansion was confirmed by intraoperative activation of the distraction device, which was then brought back to the neutral position. Activation was then restarted after the seventh postoperative day and was maintained at a rate of one quarter turn (0.25 mm) three times daily (every 8 h), giving a total 0.75 mm expansion per day, until the target expansion was achieved. All subjects were evaluated three times a week to verify the correct Hyrax activation. After the expansion was achieved, the devices were stabilized and kept in place for 4 months.
The NOSE scale allows prospective and subjective evaluation of nasal obstruction. It is based on a questionnaire with five questions related to the symptoms of nasal obstruction: nasal stuffiness, nasal obstruction, trouble breathing through the nose, trouble sleeping, and inability to get sufficient air through nasal breathing during exercise or exertion ( Table 2 ).
| Symptom | Not a problem | Very mild problem | Moderate problem | Fairly bad problem | Severe problem |
|---|---|---|---|---|---|
| Nasal stuffiness | 0 | 1 | 2 | 3 | 4 |
| Nasal obstruction | 0 | 1 | 2 | 3 | 4 |
| Trouble breathing through the nose | 0 | 1 | 2 | 3 | 4 |
| Trouble sleeping | 0 | 1 | 2 | 3 | 4 |
| Unable to get enough air through the nose during exercise or exertion | 0 | 1 | 2 | 3 | 4 |
For use in this study, the questionnaire was translated from the original English into Portuguese. It was administered twice, by a surgeon who did not take part in the surgery (FM), first on the day of the surgery, prior to the procedure, and then at 6 months after surgery. Each response was graded on a scale from 0 to 4, according to the symptom severity. The resulting scores were multiplied by five, creating a balanced scale from 0 to 100. Data acquired during the study were stratified according to the NOSE topics, and the nasal obstruction was classified as mild (0–25), moderate (26–50), or severe (>50).
Data were then tabulated in Excel 2007 worksheets (Microsoft Corp., Redmond, WA, USA) and analyzed statistically using the SAS 9.02 software package (SAS Institute Inc., Cary, NC, USA).
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