Introduction
The Nasal Obstruction Symptom Evaluation (NOSE) scale is a validated and reliable tool developed to assess the severity of nasal obstruction symptoms from the patient’s perspective. First published in 2004 by Michael G. Stewart and colleagues, the NOSE scale provides healthcare professionals with valuable insights into how nasal blockage impacts a patient’s quality of life, both functionally and socially. This brief but impactful 5-item questionnaire has been widely used in clinical and research settings, offering a standardized approach to evaluating nasal obstruction severity and its effects on patients. With over 1450 citations in Google Scholar, the NOSE scale has established itself as the gold standard in rhinology, particularly in the assessment of conditions such as chronic nasal congestion, septal deviations, and post-surgical outcomes.
This article will explore the key features, uses, and limitations of the NOSE scale, as well as its clinical utility.
Key Features of the Nasal Obstruction Symptom Evaluation (NOSE)
Purpose and Use
The NOSE scale is specifically designed to assess the severity and functional impact of nasal obstruction from a patient-reported perspective. It enables clinicians and researchers to understand the degree to which nasal blockage affects nasal airflow, sleep quality, breathing, and overall quality of life.
Target Population
The NOSE scale is designed for use in adults (18+ years) suffering from nasal obstruction of either structural or functional origin, including:
- Young Adults (18-24 years)
- Middle-Aged Adults (25-44 years)
- Older Adults (45-64 years)
- Seniors (65+ years)
While it has been validated in a variety of adult populations, it is not intended for pediatric use.
Structure
The NOSE scale consists of five questions, each evaluating a specific symptom of nasal obstruction such as:
- 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
Scoring Method
The NOSE scale is scored using a Likert scale. Each of the five items is rated from 0 (Not a Problem) to 4 (Severe Problem). The total raw score ranges from 0–20. To convert this score into a 0–100 scale, the total score is multiplied by 5. This allows for easier interpretation, with higher scores reflecting more severe nasal obstruction symptoms.
While there is no defined cut-off score, improvements of 15–20 points on the NOSE scale indicate a clinically meaningful change (MCID). This threshold helps clinicians assess the effectiveness of interventions and monitor the progression of nasal obstruction over time.
Administration Format
The NOSE scale is available in various formats such as:
- paper-based format
- digital (online)
- interview (in person)
- Phone/Video Call
The scale is extremely quick to administer, taking approximately 1–2 minutes for patients to complete, making it suitable for both clinical settings and research.
Since it is a Self-administered scale there is no need for special to administer or interpret the questionnaire
Applications of the Nasal Obstruction Symptom Evaluation (NOSE)
The NOSE is a versatile tool with several key applications in both clinical practice and research:
- Monitoring: The NOSE scale is widely used for monitoring patients with chronic nasal obstruction, providing a quantitative measure of symptom severity and treatment outcomes. It helps healthcare providers track patient-reported improvements or worsening of symptoms over time.
- Research and Treatment Evaluation: In clinical trials, the NOSE scale is invaluable for evaluating treatment efficacy. It has been used to assess the impact of medical treatments (such as intranasal corticosteroids) and surgical interventions (like septoplasty and rhinoplasty) on nasal airflow and overall quality of life.
Languages and availability
The NOSE scale is available in multiple languages, including:
- Arabic
- English
- Spanish
- Portuguese
- German
and others, ensuring its accessibility for diverse patient populations.
The NOSE is an open-access tool, free for clinical and academic use. It is published by Baylor College of Medicine, Department of Otolaryngology–Head and Neck Surgery (in collaboration with Duke University and Washington University)
Reliability and Validity
The NOSE is globally recognized for its robust psychometric properties, consistently demonstrating high reliability and validity across diverse populations and settings. Its psychometric soundness is strongly supported by a high Cronbach’s alpha > 0.80, indicating excellent internal consistency.
Numerous validation studies have confirmed its reliability such as:
Limitations and Considerations
Although the NOSE scale offers a reliable, validated approach to nasal obstruction assessment, there are a few limitations to consider:
- Self-Report Measure: As with many patient-reported outcome measures (PROMs), the NOSE scale is a self-report tool, meaning it is subject to potential biases such as social desirability or response fatigue, especially in patients with severe symptoms.
- Limited Focus: The NOSE scale focuses specifically on nasal obstruction symptoms, which may overlook other related symptoms such as sinus congestion, headaches, or other upper respiratory issues that could also affect patients’ quality of life.
- Cultural Bias: certain language barriers may arise when administering the scale to non-native speakers, despite its availability in multiple languages.
- Age Restrictions: While it has been validated in a variety of adult populations, it is not intended for pediatric use
Other Versions and Related Questionnairs
Researchers should be aware of other versions of the NOSE such as:
- Modified NOSE (linguistic adaptations)
- NOSE-E (esthetic variant)
- SCHNOS (expanded derivative)
- digital NOSE forms.
It should be noted that only the original 5-item version is officially validated.
The NOSE is often used alongside other assessment tools to assess nasal obstruction and functional outcomes, such as
- SNOT-22
- VAS
- ROE
- SCHNOS
Additional Resources
- For inquiries, contact Dr. Michael G. Stewart, MD, MPH at Weill Cornell Medicine, New York, USA. Email: migstew@med.cornell.edu
- For additional NOSE resources, consult Baylor College of Medicine, Duke University, or Washington University
Frequently Asked Questions (FAQ)
- Who can use the NOSE scale?
The NOSE scale is designed for adults (≥18 years) with nasal obstruction caused by functional or structural issues, and it is suitable for use in both clinical practice and research. - How long does it take to complete the NOSE scale?
The NOSE scale typically takes around 1–2 minutes to complete, making it a quick and effective tool for both clinical settings and research studies. - How is the NOSE scale administered?
The NOSE scale can be administered in multiple formats, including paper, digital, or as an interview. Its flexibility allows healthcare providers to choose the method that best suits the patient’s needs. - Is there any cost to using the NOSE scale?
The NOSE scale is free for clinical and academic use, though citation is required when it is used in research or publications.
A Word from ResRef about the Nasal Obstruction Symptom Evaluation (NOSE)
The NOSE scale is an essential, reliable, and validated tool for evaluating nasal obstruction severity. Whether you are a researcher investigating treatment effectiveness or a clinician working to improve patient outcomes, this simple yet powerful scale provides crucial insights into how nasal blockage impacts daily life. By understanding patient experiences more clearly, the NOSE scale helps optimize clinical decisions and research outcomes, leading to better care and improved quality of life for patients.
References
- Stewart, M. G., Witsell, D. L., Smith, T. L., Weaver, E. M., Yueh, B., & Hannley, M. T. (2004). Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngology—Head and Neck Surgery, 130(2), 157-163. link
- Elwany, S., Atef, A., Ismail, A. S., Hussein, W. K., Ibrahim, A. A., Abdelnaby, M., … & Elwany, M. (2021). Arabic translation and validation of the nasal obstruction symptom evaluation (NOSE) scale. The Egyptian Journal of Otolaryngology, 37(1), 92. link
- Karahatay, S., TAŞLI, H., Karakoç, Ö., AYDIN, Ü., & Türker, T. (2018). Reliability and validity of the Turkish nose obstruction symptom evaluation (NOSE) scale. Turkish Journal of Medical Sciences, 48(2), 212-216. link
- Bezerra, T. F., Padua, F. G., de M Pilan, R. R., Stewart, M. G., & Voegels, R. L. (2011). Cross-cultural adaptation and validation of a quality of life questionnaire: the Nasal Obstruction Symptom Evaluation questionnaire. Rhinology, 49(2), 227. link
- Quer-Castells, M., Alegre, B., Rojas-Lechuga, M. J., & Alobid, I. (2024). Adaptation and validation of the Spanish version of NOSE-Perf questionnaire for septal perforations. Acta Otorrinolaringologica (English Edition), 75(4), 231-237. link
- Marro, M., Mondina, M., Stoll, D., & de Gabory, L. (2011). French validation of the NOSE and RhinoQOL questionnaires in the management of nasal obstruction. Otolaryngology–Head and Neck Surgery, 144(6), 988-993. link
