Sleep Apnea Research Group

  Measures of Nasal Airway

Development and Validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale

Principal Investigators: Michael G. Stewart, MD, MPH
Co-Investigators: David L. Witsell, MD, MHS; Timothy L. Smith, MD, MPH; Edward M. Weaver, MD, MPH; Bevan Yueh, MD, MPH; Maureen T. Hannley, PhD

Otolaryngology- Head& Neck Surger 2004;130:157-63

Objective - The study goal was to validate a disease-specific health status instrument for use in patients with nasal obstruction.

Design, Setting, and Patients - The study consisted of a prospective instrument validation conducted at 4 academic medical centers with 32 adults with nasal septal deformity.

Methods - Prospective instrument validation occurred in 2 stages. Stage 1 was the development of a preliminary (alpha-version) instrument of potential items. Stage 2 was a test of the alpha-version for item performance, internal consistency, and test-retest reliability; construct, discriminant, criterion validity, and responsiveness; and creation of the final instrument.

Results - Items with poor performance were eliminated from the alpha-version instrument. In testing the final instrument, test-retest reliability was adequate at 0.702; internal consistency reliability was also adequate at 0.785. Validity was confirmed using correlation and comparison analysis, and response sensitivity was excellent.

Conclusions - The Nasal Obstruction Symptom Evaluation Scale is a valid, reliable, and responsive instrument that is brief and easy to complete and has potential use for outcomes studies in adults with nasal obstruction.

Article: Development and Validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale

Acoustic Rhinometry Reliability

Principal Investigator: Edward M. Weaver, MD, MPH
Co-Investigators: Judy Stenstrom LPN, BA

This study confirms the inter-rater and test-retest reliabilities of minimum cross-sectional area measurements of the nasal airway using acoustic rhinometry.

Methods - Two separate examiners measured minimum cross-sectional area with acoustic rhinometry on 25 normal volunteers on three consecutive days. Intraclass correlation coefficients were calculated.

Results - The overall mean minimum cross-sectional area was 0.61 ± 0.20 cm2, consistent with published norms. Inter-rater correlation was 0.83. Test-retest correlations over 15-minute, one-day, and two-day intervals were 0.80, 0.74, and 0.57, respectively. Decreased test-retest correlation over two days likely represents gradual real change in the intranasal dimensions.

Interpretation - Acoustic rhinometry has good to excellent reliability.

Comparison of Anatomic, Physiologic, and Subjective Measures of the Nasal Airway

Principal Investigator: Derek J. Lam, MD
Co-Principal Investigator: Edward M. Weaver, MD, MPH
Co-Investigators: Kathryn T. James, PA, MPH

American Journal of Rhinology (in press)

Background - Studies comparing different categories of nasal measures have reported inconsistent results. We sought to compare validated measures of the nasal airway: anatomic (acoustic rhinometry), physiologic (nasal peak inspiratory flow), and subjective experience (Nasal Obstruction Symptom Evaluation Scale and a visual analog scale).

Methods - This prospective cross-sectional study of 290 non-rhinologic patients included upright and supine rhinometry (minimum cross sectional area and volume) and flow (mean and maximum) measurerments, as well as subjective measures. Associations between measures were evaluated with Spearman correlations and multivariate linear regression, adjusting for age, sex, race, body mass index, and smoking history.

Results - Correlations between objective (rhinometry and flow) and subjective categories of nasal measures ranged from -0.16 to 0.03 (mean correlation -0.07±0.05), with 0 significant correlations of 16 tested. Correlations between anatomic (rhinometry) and physiologic (flow) categories ranged from 0.04 to 0.15 (mean correlation 0.10±0.03), with 0 significant correlations of 16 tested. In contrast, within each category (rhinometry, flow, and subjective), all correlations were significant (13 correlations, all p<0.001) and ranged from 0.62 to 0.99. Of 16 adjusted associations between objective and subjective measures, 14 were not significant (p>0.05); only uppright and supine minimum cross sectional area were significantly associated with the visual analog scale (both p<0.05).

Conclusions - Validated anatomic, physiologic, and subjective nasal measures may assess different aspects of the nasal airway and provide complementary information. Future studies should aim to develop a composite measure including components from all three categories of nasal measurement.

Development of a Composite Measure of the Nasal Airway

Prinipal Investigator: Derek J. Lam, MD
Co-Prinipal Investigator: Edward M. Weaver, MD, MPH
Co-Investigators: Kathryn T. James, PA, MPH; Danna Lei, BS; Aliya Hashemi BS; Benjamin Reed

Sponsor: American Academy of Otolaryngology-Head & Neck Surgery


  1. Develop a composite measure of the nasal airway including objective and subjective validated parameters.
  2. Validate the composite measure in an independent sample of patients.

Background - Acoustic rhinometry and nasal peak inspiratory flow are validated methods for measuring anatomic and functional aspects of the nasal airway. The Nasal Obstruction Subjective Evaluation (NOSE) scale is a validated measure of the subjective experience of nasal airway obstruction and a visual analog scale is another means of measuring subjective nasal obstruction. Our preliminary data indicate that the objective nasal parameters do not correlate with the subjective measures of nasal obstruction, suggesting they may measure different aspects of the nasal airway. We hypothesize that a composite measure will be a more sensitive and responsive measure of the nasal airway compared to any single measure.

Study Design - Prospective cohort study of 300 consecutive new sleep apnea patients being evaluated with multiple nasal measures at baseline and followed for CPAP use. Instrument will be developed with first 200 patients and validated with next 100 patients.

Methods - The instrument will be developed using 1) multivariable linear regression analysis to develop a multivariable model, and 2) conjunctive consolidation to create a three-stage “nasal obstruction index,” using components of the NOSE scale, nasal obstruction visual analog scale, physician nasal exam, acoustic rhinometry parameters, and nasal flow parameters that are most strongly associated with nasal outcomes. These components will be combined in a single composite score (linear regression model) or a three-stage index (conjunctive consolidation), and each will be tested in an independent sample for hypothesized associations between the nasal airway and other relevant variables.

Conclusion - A composite score will represent a more comprehensive measure of the nasal airway compared to any single measure. We predict such a measure will offer superior prognostication of nasal outcomes and will have broad applications in otolaryngology and related fields.

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