Facial Plastic Surgery, Austin, TX, United States of America.
Department of Otolaryngology - Head and Neck Surgery, UT Southwestern, Dallas, TX, United States of America.
Am J Otolaryngol. 2021 Nov-Dec;42(6):103039. doi: 10.1016/j.amjoto.2021.103039. Epub 2021 Apr 24.
Nasal obstruction is a common patient complaint and has a variety of etiologies, and a specific anatomical abnormality can often be found within the nasal cavity on physical examination. In practice, this observed pathology does not always correlate with the laterality, severity, and exact intranasal site of the patients' perceived obstruction.
We seek to answer the following questions: 1) Does a physician's evaluation of nasal obstruction correlate with subjective patient complaints? 2) Is there reasonable correlation between physicians of similar training in the routine evaluation of nasal obstruction?
First, we asked patients presenting to the otolaryngology clinic with a primary complaint of nasal obstruction to fill out a modified NOSE survey. Nasal endoscopy was performed on all subjects to assess all potential sites of obstruction. We then determined whether there is an association between patient complaints and findings on physical examination. Second, we determined if there is correlation between similarly trained physicians in their interpretation of a basic nasal examination. Otolaryngologists were shown a series of standardized videos of an endoscopic nasal examination that were recorded with a primary complaint of nasal obstruction. Findings were reported in an anonymous online survey focusing on laterality, severity, and specific site of perceived obstruction.
A total of 38 patients were included in the first part of the study. The Cohen's kappa coefficient was used to determine the interrater agreement between the patient and physician in the degree of nasal obstruction. The kappa coefficient was 0.03 (p value 0.372) for the comparison of the left-sided scores (fair agreement), and 0.16 (p value 0.014) for the right-sided scores (slight agreement). A comparison was also done between the side of the nose the patient felt was most obstructed to the most obstructed side found on physical exam by the otolaryngologist. Thirteen of the 38 patients (34%) had perceived nasal obstruction on the opposite side of that noted to be most obstructed on physical exam. Despite this, the kappa coefficient in this comparison was 0.43 (p value <0.001) revealing moderate agreement between the two groups. Seventeen otolaryngologists participated in the second part of the study. Data extrapolated revealed very little agreement among the physicians in reporting which side of the nose was most obstructed, what anatomical structure contributed to the obstruction the most, and what percentage obstruction was present.
Based on our findings, patients can reasonably determine based on their symptoms which side is most obstructed, but symptoms do not correlate with severity of obstruction when compared to physical exam. There is also very little consistency between otolaryngologists in their assessment of the degree of nasal obstruction on exam. The results of this study may have far-reaching implications for patient management, surgical intervention, and medicolegal documentation as it relates to the current surgical treatment of nasal obstruction.
鼻塞是一种常见的患者主诉，其病因多种多样，体格检查时通常可在鼻腔内发现特定的解剖结构异常。但实际上，这种观察到的病理变化并不总是与患者感知到的鼻塞的侧别、严重程度和确切的鼻腔内位置相关。
我们旨在解答以下问题：1）医生对鼻塞的评估是否与患者的主观主诉相关？2）在对鼻塞的常规评估中，接受过相似培训的医生之间是否存在合理的相关性？
首先，我们要求就诊于耳鼻喉科门诊、主诉为鼻塞的患者填写改良的 NOSE 问卷调查表。对所有患者进行鼻内镜检查，以评估所有潜在的鼻塞部位。然后，我们确定患者的主诉与体格检查结果之间是否存在关联。其次，我们确定在解释基本的鼻腔检查结果方面，接受过相似培训的医生之间是否存在相关性。耳鼻喉科医生观看了一系列记录有鼻塞主诉的鼻内镜检查的标准化视频，然后在一项匿名的在线调查中报告他们对侧别、严重程度和感知到的特定鼻塞部位的判断。
本研究的第一部分共纳入 38 例患者。我们使用 Cohen's kappa 系数来评估患者和医生在鼻塞严重程度评估方面的评分一致性。左侧评分的 Cohen's kappa 系数为 0.03（p 值为 0.372）（一致性差），右侧评分的 Cohen's kappa 系数为 0.16（p 值为 0.014）（一致性弱）。我们还比较了患者自我报告感觉最阻塞的鼻腔侧别与耳鼻喉科医生在体格检查中发现的最阻塞侧别的相关性。在 38 例患者中，有 13 例（34%）患者感觉鼻塞的侧别与体格检查发现的最阻塞侧别相反。尽管如此，两组之间的 Cohen's kappa 系数为 0.43（p 值＜0.001），表明两组之间存在中度一致性。17 名耳鼻喉科医生参与了本研究的第二部分。推断的数据显示，医生在报告哪一侧鼻腔最阻塞、哪一解剖结构最导致阻塞以及存在多大程度的阻塞方面几乎没有一致性。
根据我们的发现，患者可以根据症状合理判断哪一侧鼻塞最严重，但与体格检查相比，症状与鼻塞的严重程度并不相关。耳鼻喉科医生在评估鼻塞程度方面也几乎没有一致性。这项研究的结果可能对患者管理、手术干预和与当前鼻阻塞手术治疗相关的医疗法律文件具有深远的意义。
