PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 1 January – June 2016

ORIGINAL ARTICLES

PhiliPPine Journal of otolaryngology-head and neck Surgery 17

ABSTRACT
Objective: To evaluate the quality of life before, and after Functional Endoscopic Sinus Surgery
(FESS) among patients with nasal obstruction due to nasal polyposis using the Nasal Obstruction
Symptom Evaluation (NOSE) questionnaire translated in Filipino (NOSE-Ph) in a tertiary
government hospital in Metro Manila.

Methods:
Design: Cross-Sectional QOL Study
Setting: Tertiary Government Hospital
Participants: Forty (40) patients with nasal polyposis who underwent FESS from

April 2014 to June 2015 were included in the study. Patients who underwent FESS due to other
nasal tumors other than nasal polyp were excluded. The subjects answered the previously-
validated NOSE-Ph questionnaire pre- and post-operatively and the scores were gathered and
analyzed.

Results: Based on the pre and post-operative scores, there was a statistically significant
improvement in all 5 parameters (1. nasal congestion, 2. nasal obstruction, 3. trouble breathing,
4. trouble sleeping, and 5. inability to get enough air through the nose during exercise).

Conclusion: There was a statistically significant improvement in the quality of life of patients who
underwent FESS based on the pre and post-operative scores using the NOSE-Ph questionnaire
translated in Filipino.

Keywords: nasal obstruction symptom evaluation scale

Nasal Obstruction is a subjective complaint of discomfort manifested by a feeling of
insufficient airflow through the nose.1 This may be due to anatomic obstruction of the ostium,
septal deviation, concha bullosa, paradoxic middle turbinate, nasal polyps and others.2

Several instruments to assess quality of life and quantify improvement or relief of nasal
symptoms after nasal surgery have been formulated, but are quite lengthy.3 The Nasal Obstruction
Symptom Evaluation Scale developed by Stewart in 2004 is composed of only 5 questions that
are very brief and easy to accomplish and understand.4 The questionnaire addresses the severity
of complaints that the patient has been experiencing for the past month: nasal congestion and
stuffiness, nasal blockage and obstruction, trouble breathing through the nose, trouble sleeping
and unable to get enough air through the nose during exercise or exertion.

Quality of Life after FESS among Patients
with Nasal Polyps Using the NOSE Questionnaire

Translated in Filipino (NOSE-Ph)

Mary Ann V. Macasaet, MD1

Emmanuel Tadeus S. Cruz, MD1, 2

1Department of Otolaryngology
Head & Neck Surgery
Quezon City General Hospital

2Department of Otolaryngology
Head & Neck Surgery
Manila Central University - Filemon D. Tanchoco
Medical Foundation Hospital

Correspondence: Dr. Mary Ann V. Macasaet
Department of Otorhinolaryngology-Head & Neck Surgery
Quezon City General Hospital and Medical Center
Seminary Road, Munoz, Quezon City 1106
Philippines
Phone: (632) 426 1314 local 232
Fax: (632) 920 7081; 920 6270
Email: rainmacasaet@gmail.com

The authors declare that this represents original material that is
not being considered for publication or has not been published
or accepted for publication elsewhere in full or in part, in print
or electronic media; that the requirements for authorship have
been met by the author, and that the author believes that the
manuscript represents honest work.

Disclosures: The authors signed a disclosure that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional affiliations
that might lead to a conflict of interest.

Presented at the Philippine Society of Otolaryngology Head
and Neck Surgery Analytical Research Contest (3rd Place), Bella
Ibarra, Quezon City, November 10, 2015.

Philipp J Otolaryngol Head Neck Surg 2016; 31 (1): 17-21 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Creative Commons (CC BY-NC-ND 4.0)
Attribution - NonCommercial - NoDerivatives 4.0 International

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 1 January – June 2016

ORIGINAL ARTICLES

18 PhiliPPine Journal of otolaryngology-head and neck Surgery

The original NOSE questionnaire in English may be difficult to
administer to non-English speakers and has been previously translated
and validated in Spanish,5 Chinese,6 Greek,7 French,8 and Italian.9 This
study aimed to translate and validate the NOSE questionnaire in Filipino
(NOSE-Ph) and to use the NOSE-Ph to evaluate the quality of life before,
and after FESS among patients with nasal obstruction due to nasal
polyposis in a tertiary government hospital in Metro Manila.

METHODS
Instrument Development

The NOSE questionnaire in English (Figure 1) was separately
translated by a professor of Filipino language from the University of
the Philippines and a physician, and the results were synthesized. The

synthesized version was back - translated by an English teacher. All
versions were submitted to the University of the Philippines – Sentro
ng Wikang Filipino where experts in the Filipino language10 made the
final version (NOSE-Ph): 1. Paninikip ng ilong, 2. Pagbabara ng ilong,
3. Hirap ang paghinga gamit ang ilong, 4. Hirap sa pagtulog, 5. Hindi
makalanghap ng sapat na hangin gamit ang ilong tuwing nag-eehersisyo
o nagbubuhat. This questionnaire required rating of items on a 5 point
scale as follows: 1 - hindi problema, (not a problem) 2 – napakabahagyang
problema, (very mild problem) 3 – katamtamang problema, (moderate
problem) 4 – medyo masamang problema, (fairly bad problem) and 5 –
(malalang problema). (Figure 2) The highest score was 20 with severe
nasal obstruction and the lowest was 0 with no nasal obstruction.

Not a
Problem

Very Mild
Problem

Moderate
Problem

Fairly Bad
Problem

Severe
Problem

1. Nasal
congestion
or stuffiness

2. Nasal
blockage or
obstruction

3. Trouble
breathing
through my
nose

4. Trouble
sleeping

5. Unable to
get enough
air through
my nose
during
exercise or
exertion

Nasal Obstruction Symptom Evaluation Scale (NOSE)

Patient ID: __________________ Age: _______ Date: ____/____/___ __

Over the past ONE month, how much of a problem were the following
conditions for you?
Please circle the most correct response

Figure 1. Nasal Obstruction Symptom Evaluation Scale (NOSE). Adapted, with permission from
Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the
Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004 Feb; 130(2):
157-163

Nose Questionnaire Filipino Translation (NOSE-Ph)

Pangalan __________________ Edad: ______ Petsa: ____/____/___ __

Sa nakaraang ISANG buwan, gaano kalaking problema/sagabal ang
sumusunod na kondisyon sa iyo? Pakibilugan ang pinakatamang/
pinakaangkop na sagot.

Hindi
Problema

Napakabahagya
ang Problema

Katamtamang
Problema

Medyo
Masamang
Problema

Malalang
Problema

1. Paninikip
ng ilong

2. Pagbabara
ng ilong

3. Hirap sa
paghinga
gamit ang
ilong

4. Hirap sa
pagtulog

5. Hindi
makalanghap
ng sapat na
hangin gamit
ang ilong
tuwing nag-
eehersisyo o
nagbubuhat

Figure 2. Nose Questionnaire Filipino Translation (NOSE-Ph)

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 1 January – June 2016

ORIGINAL ARTICLES

PhiliPPine Journal of otolaryngology-head and neck Surgery 19

n =
(Zα + β)2 (SD

1
+ SD

2
)2

e 2

Table 1. Inter-Item Correlation Matrix

Nasal
congestion

or
stuffiness

Nasal
blockage

or
obstruction

Trouble
breathing

through my
nose

Trouble
sleeping

Unable to
get enough
air through

my nose
during

exercise or
exertion

Nasal
congestion
or stuffiness

Nasal
blockage or
obstruction

Trouble
breathing
through my
nose

Trouble
sleeping

Unable to
get enough
air through
my nose
during
exercise or
exertion

1.000

0.539

-0.87

0.265

0.306

0.539

1.000

0.149

0.422

0.470

-0.087

0.149

1.000

0.113

0.126

0.265

0.422

0.113

1.000

0.278

0.306

0.470

0.126

0.278

1.000

Table 2. Item Total Statistics

Scale Mean
if Item

Deleted

Scale
Variance if

Item
Deleted

Corrected
Item Total

Correlation

Squared
Multiple

Correlation

Chronbach’s
Alpha if

Item
Deleted

Nasal
congestion
or stuffiness

Nasal
blockage or
obstruction

Trouble
breathing
through my
nose

Trouble
sleeping

Unable to
get enough
air through
my nose
during
exercise or
exertion

15.00

14.98

15.03

14.93

1.846

1.410

2.333

1.820

1.866

0.410

0.652

0.105

0.416

0.461

0.326

0.459

0.071

0.191

0.236

0.696

0.554

0.774

0.694

0.675

The minimum number of samples for the assessment of the
improvement of quality of life after FESS was computed using a 95%
level of confidence and 80% power of the study. With estimated
standard deviations of 11.46 and 3.86 for the pre- and post- operative
nose scores respectively based on a previous study,11 less than 10
subjects were needed.

Where:
n = number of subjects needed
SD1 = standard deviation pre nose score = 11.46
SD2 = standard deviation post nose score = 3.86
e = measure of effect or the difference in the pre and post

nose score = 61.63 – 8.75 = 52.88
Zα = 95% confidence level = 1.96
Zβ= 80% power of the study = 1.28

The NOSE-Ph was pre-tested and validated among 10 subjects
with nasal polyposis based on the computed sample size. The results
revealed that the NOSE-Ph questionnaire was valid with Cronbach’s
alpha of 0.752 showing that it is a reliable questionnaire. Inter-item and
Item-total correlations demonstrated associations. (Table 1 and 2) Each
question contributed to the total reliability of the questionnaire since it
did not increase the Cronbach’s alpha when each item was deleted.

Subject Selection and Questionnaire Administration
With institutional review board approval, this cross-sectional study

considered patients with nasal polyposis who underwent FESS at a
tertiary government hospital from April 2014 to June 2015 for inclusion.
Patients with nasal tumors other than nasal polyp were excluded.
After obtaining written informed consent, a complete history and ENT
examination with emphasis on nasal problems was obtained for each
patient. Nasal endoscopy was performed by 2 senior ENT residents
using a zero degree, 4 mm rigid nasal endoscope (CHAMMED, China)
and the following rhinologic findings were recorded: grade of the nasal
polyp using the Mackay classification12 and severity of nasal disease on
PNS CT using Lund - Mackay scores.13

Patients underwent FESS (anterior to posterior approach) with or
without Caldwell luc and/or septoplasty by senior ENT residents, and
were discharged after polyvinyl alcohol nasal pack (Netcell, Network
Medical Products Ltd., UK) removal. They were asked to accomplish the

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 1 January – June 2016

ORIGINAL ARTICLES

20 PhiliPPine Journal of otolaryngology-head and neck Surgery

Table 3. Comparison of the Pre and Post Nasal Obstruction Symptom Evaluation Scores
of Subjects

Pre
Mean ± SD
(Median)

Post
Mean ± SD
(Median)

p-value*

1. Nasal congestion
or stuffiness

2. Nasal blockage
or obstruction

3. Trouble breathing through
my nose

4. Trouble sleeping

5. Unable to get enough air
through my nose during
exercise or exertion

3.70 ± 0.52 (4)

3.73 ± 0.59 (4)

3.78 ± 0.42 (4)

3.62 ± 0.54 (4)

3.75 ± 0.49 (4)

0.25 ± 0.58 (0)

0.18 ± 0.38 (0)

0.15 ± 0.36 (0)

0.25 ± 0.58 (0)

<0.0001 (S)

* p-values >0.05- Not significant; p-values ≤0.05-Significant

N Mean Rank Sum of
ranks

Q2TOT-Q1TOT Negative Ranks
Positive Ranks
Ties
Total

40a

20.50
0.00

820.00
0.00

Q2TOT-Q1TOT
Z
Asymp. Sig. (2-tailed)

-5.567a

0.000

Table 4. Wilcoxon Signed Rank Test

a. Q2TOT < Q1TOT b. Q2TOT>Q1TOT c. Q2TOT=Q1TOT

a. Based on positive ranks

NOSE-Ph questionnaire pre-operatively and upon follow up 1 month
after surgery. They were advised to ask questions if they needed any
clarification.

Outcome measure
The main outcome measure was improvement of the quality of life

based on the NOSE-Ph questionnaire scores pre- and 1 month post-
surgery.

Data Processing and Analysis
Data were encoded and tallied in SPSS version 10.0 for windows

(IBM, Armonk, NY, USA). Descriptive statistics were generated for
all variables. For nominal data frequencies and percentages were
computed. For numerical data, mean ± SD were generated. Analysis
of the different variables was done using the following test statistics
to compare the pre-operative and post-operative NOSE-Ph scores of
the patients: Paired t-test to compare two groups with numerical data
that are dependent and Wilcoxon Signed ranks test, a non-parametric
equivalent of the paired t-test.

RESULTS
A total of 42 patients underwent FESS in our institution during the

study period. The NOSE-Ph questionnaire was administered pre- and
post-operatively among the patients with nasal polyps who met the
inclusion criteria. Excluded were two patients whose histopath results
revealed inverting papilloma and squamous cell carcinoma, respectively.
Subsequently, 40 patients were finally included, 20 males (50%) and 20
females (50%), age 10 to 77 years with a mean age of 38.85 years.

The grade of the nasal polyps were as follows: grade 1 - 0 (0%), 2
- 5 (12.5%), and 3 – 35 (87.5%). Lund - Mackay Scores were obtained
individually for the right and left and combination of right and left
nasal cavities based on the PNS CT scan. The total Lund - Mackay score
ranged from 3-24 with a mean of 17.96± 6.63.

Surgical procedures performed were: FESS, 17 (45.94%), FESS with
Caldwell luc, 20 (54.06%) and FESS with septoplasty, 3 patients (7.5%).

Before FESS, there were 29 (72.5%) subjects with severe nasal
congestion or stuffiness, 10 (25.0%) with fairly bad, and 1 (2.5%) with
moderate nasal congestion. After FESS, 82.5% were relieved of nasal
congestion or stuffiness while 4 (10%) and 3 (7.5%) had a very mild or
moderate problem respectively.

Based on the pre-operative nasal obstruction scores, 31 (77.5%)
had severe nasal congestion or stuffiness, 8 (20.0%) had fairly bad, and
1 (2.5%) had very mild nasal congestion. Post-operatively, 33 (82.5%)
were relieved from nasal blockage or obstruction while 7 (17.5%) had
a mild problem.

With regards to trouble breathing through the nose before FESS,
31 (77.5%) had severe trouble breathing while 9 (22.5%) had fairly bad
trouble breathing through the nose. After FESS, 34 (85%) had no trouble
breathing through nose while 6 (15%) had very mild problem.

With regards to trouble sleeping, preoperatively, there were 26
(65%) subjects with severe trouble sleeping, while 13 (32.5%) had fairly
bad trouble sleeping. Postoperatively, 34 (85%) had no trouble sleeping,
and 6 (15%) had a very mild problem.

With regards to inability to get enough air through the nose during
exercise or exertion, prior to FESS, 33 (82.5%) subjects were unable to
get enough air through the nose during exercise or exertion, while 6
(15%) and 1 (2.5%) had a fairly bad and moderate problem, respectively.
After FESS, 32 (80%) improved while 6 (15%) and 2 (5%) had moderate
and a fairly bad problem, respectively.

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 1 January – June 2016

ORIGINAL ARTICLES

PhiliPPine Journal of otolaryngology-head and neck Surgery 21

REFERENCES
1. Jessen M, Malm M. Definition, prevalence and development of nasal obstruction. Allergy 1997:

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2. Stankiewicz J, Lal D. Primary Sinus Surgery. In: Flint P, Haughey B, Lund V, Niparko J, Robbins K,

Tomas JR, et al. Cummings Otolarygology Head and Neck Surgey Sixth Edition. Philadelphia:
Elsevier. 2015; 752-782.

3. Baumann I. Subjective Outcomes Assessment in Chronic Rhinosinusitis. The Open
Otorhinolaryngology Journal. 2010; 4:28-33.

4. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation
of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004
Feb; 130(2): 157-163.

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Za Zhi. 2014 Jan; 49(1):20-26.

7. Lachanas VA, Tsiouvaka S, Tsea M, Hajiioannou JK, Skoulakis CE. Validation of the nasal
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8. Marro M, Mondina M, Stoll D, de Gabory L. French validation of the NOSE and RhinoQOL
questionnaires in the management of nasal obstruction. Otolaryngol Head Neck Surg. 2011
Jun;144(6):988-93.

9. Mozzanica F, Urbanni E, Atac M, Scotta G, Luciano K, Bulgheroni C, et al. Reliability and validity
of the Italian nose obstruction symptom evaluation (I-NOSE) scale. Eur Arch Otorhinolaryngol.
2013 Nov; 270(12):3087-3094.

10. Camagay L, Isang Institusyonal na Kasaysayan: Ang Kaso ng Sentro ng wikang Filipino. Manual ng
Sentro ng Wikang Filipino. Philippine Humanities Review. 2014;(1):43-52.

11. Beg MAA, Ahmed M. Evaluation of Septoplasty Outcome using Nose (Nasal Obstruction
Symptom Evaluation) Scale. International Journal of Scientific Research. 2014 Feb; 3:2.

12. Mackay IS, Lund VJ. Imaging and Staging. In: Mygind N, Lindholdt Y. ed. Nasal Polyposis: An
Inflammatory Disease and its Treatment. Copenhagen, Munksgaard, 1997:137-144.

13. Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryngol Head Neck Surg 1997 Sep; 117(3 Pt
2): S35-S40.

Comparison between the mean preoperative 18.55 ± 1.76 and
postoperative 0.95 ± 1.26 scores showed that there was a significant
difference noted, with all p values <0.0001. The scores significantly
decreased after nasal surgery in all 5 parameters as follows: nasal
congestion or stuffiness, nasal blockage or obstruction, trouble
breathing through nose, trouble sleeping and trouble getting enough
air through nose during exercise or exertion. (Table 3)

Using the Wilcoxon signed rank test (p value < 0.000, mean: 20.5),
there was a significant decrease between the pre- and post-operative
NOSE-Ph scores implying relief from the 5 symptoms after FESS and
subsequent improvement in the quality of life. (Table 4)

DISCUSSION
When administered to 40 subjects with nasal polyps who underwent

FESS, there was statistically significant improvement in all 5 variables of
the NOSE-Ph questionnaire and no difficulty was reported during the
administration and course of the study.

The NOSE-Ph scores significantly decreased from baseline 18.55 ±
1.76 to 0.95 ± 1.26 after FESS in all 5 parameters: nasal congestion, nasal
blockage, trouble breathing through nose, trouble sleeping and trouble
getting enough air through nose during exercise. This implies that
FESS may result in postoperative improvement of the Quality of Life of
patients with nasal obstruction. That the majority of patients (87%) had
grade 3 nasal polyps with mean Lund Mackay Scores of 17.96 reflecting
relatively severe nasal disease associated with nasal obstruction was
also noteworthy.

The NOSE questionnaire was selected because it specifically deals
with nasal obstruction. It only includes a minimum of 5 variables. It
is brief, simple, and direct to the point and when translated in a local
language is relatively easy to understand as shown by the outcome of
this study.

The NOSE-Ph demonstrated internal consistency reliability, test-
retest reliability and validity which are consistent with the original
English language validation by Stewart4 as well as several previous
adaptations of NOSE questionnaire in Spanish,5 Chinese,6 Greek,7
French,8 and Italian.9

In this study, subjects were not randomized and included patients
who underwent FESS within a time period. The study focused primarily
on the viability and applicability of using the NOSE-Ph questionnaire
in evaluating the quality of life of actual patients who underwent
nasal surgery. Normal or asymptomatic subjects with no complaints
of nasal obstruction were excluded because the study aimed primarily
to evaluate improvement in the quality of life after nasal surgery and
did not intend to differentiate those with or without symptoms of nasal

obstruction. Inclusion of normal subjects may be considered when
a given test aims to identify those with and without disease which is
beyond the scope of the present study.

In future studies, it is also important to consider comorbid conditions
such as allergic rhinitis, asthma, COPD and others which may affect the
outcome of the scores post-operatively. The NOSE-Ph questionnaire
may be validated through serial monitoring of improvement of quality
of life among patients suffering from nasal obstruction in the outpatient
clinic, and in different centers.