Nasal Obstruction Symptom Evaluation Scale
Also known as: NOSE
The Nasal Obstruction Symptom Evaluation (NOSE) Scale is a brief 5-item self-report questionnaire specifically designed to measure the severity of nasal obstruction and its impact on quality of life. Developed by Stewart and colleagues (2004), the NOSE is the most widely used nasal obstruction-specific outcome measure in otolaryngology, recommended for clinical practice and clinical trials. It is validated for baseline assessment, monitoring treatment response in medical and surgical rhinology, and outcome evaluation following septoplasty, rhinoplasty, endoscopic sinus surgery, or allergen immunotherapy.
Key highlights
- Nasal obstruction-specific, brief instrument; only 5 items with minimal respondent burden
- Excellent psychometric properties: test-retest reliability (intraclass correlation coefficient = 0.95), internal consistency (Cronbach's α = 0.92)
- Sensitive to change with medical and surgical interventions; widely responsive to septoplasty, turbinate reduction, and FESS
- Validated across diverse nasal obstruction etiologies (septal deviation, turbinate hypertrophy, rhinosinusitis, allergic rhinitis, nasal polyposis)
- Recommended by major otolaryngologic societies (AAO-HNS, European Rhinologic Society) as standard outcome measure
- Simple scoring and interpretation enables easy clinician and patient communication
Intuition
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How it works
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When to use it
The NOSE is used in rhinology and general otolaryngology clinics for all patients presenting with nasal obstruction. Indicated for baseline assessment, monitoring response to medical therapies (intranasal corticosteroids, antihistamines, leukotriene inhibitors), determining surgical candidacy (septoplasty, turbinate reduction, endoscopic sinus surgery for polyps/obstruction), and outcome assessment following nasal or sinus surgery. Standard in research evaluating rhinologic interventions and recommended by the American Academy of Otolaryngology for septoplasty outcome measurement.
Strengths & limitations
- Nasal obstruction-specific, brief instrument; only 5 items with minimal respondent burden
- Excellent psychometric properties: test-retest reliability (intraclass correlation coefficient = 0.95), internal consistency (Cronbach's α = 0.92)
- Sensitive to change with medical and surgical interventions; widely responsive to septoplasty, turbinate reduction, and FESS
- Validated across diverse nasal obstruction etiologies (septal deviation, turbinate hypertrophy, rhinosinusitis, allergic rhinitis, nasal polyposis)
- Recommended by major otolaryngologic societies (AAO-HNS, European Rhinologic Society) as standard outcome measure
- Simple scoring and interpretation enables easy clinician and patient communication
- Nasal obstruction assessment alone; does not measure rhinosinusitis symptoms (drainage, facial pressure), olfactory loss, or other sinonasal complaints. Sino-Nasal Outcome Test (SNOT-22) is more comprehensive for chronic rhinosinusitis
- Does not distinguish unilateral from bilateral obstruction; patient may have asymmetric obstruction (right-sided septal deviation) but report bilateral symptoms
- Does not assess objective anatomic obstruction severity (endoscopic or radiologic findings); high NOSE scores do not necessarily correlate with severe anatomic deviation
- Sleep quality impact captured only indirectly; does not assess apnea-specific symptoms or oxygen desaturation
Common pitfalls
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Applications
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Frequently asked
What NOSE score indicates need for surgery?
NOSE score alone does not determine surgical candidacy. A NOSE score >50 indicates moderate-to-severe patient-perceived obstruction, but surgery is recommended only if: (1) nasal endoscopy documents significant anatomic obstruction (septal deviation, turbinate hypertrophy), and (2) trial of medical therapy (≥2–4 weeks intranasal corticosteroid) provides inadequate improvement. High NOSE in allergic or vasomotor rhinitis may resolve with medical management alone.
How much NOSE improvement indicates successful septoplasty?
A reduction of ≥9–12 points (MCID) on the 0–20 scale indicates clinically meaningful improvement. Most patients with successful septoplasty show 8–16 point reduction. Modest improvement (<9 points) despite good anatomic correction may indicate persistent allergic or vasomotor rhinitis; post-operative intranasal steroids or antihistamines may be needed.
Can NOSE be used to assess unilateral nasal obstruction?
NOSE measures total nasal obstruction perception but does not distinguish side-to-side differences. Patients often cannot accurately report which nostril is more obstructed. Nasal endoscopy is required to identify unilateral obstruction (e.g., right septal deviation vs. left turbinate hypertrophy). NOSE is useful for overall outcome measurement but should not guide laterality decisions alone.
How does NOSE compare to SNOT-22 in chronic rhinosinusitis patients?
NOSE focuses exclusively on nasal obstruction symptoms; SNOT-22 is a 22-item comprehensive measure of rhinosinusitis including obstruction, drainage, facial pressure, olfactory loss, sleep, and mood. In chronic rhinosinusitis with obstruction, BOTH measures should be used: NOSE tracks obstruction-specific outcome; SNOT-22 captures full disease burden. SNOT-22 is recommended for rhinosinusitis surgery trials; NOSE is preferred for isolated septal deviation assessment.
Sources
- 1.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.
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ScholarGate. (2026, June 3). NOSE. ScholarGate. https://scholargate.app/otolaryngology/nose-obstruction-symptom-evaluation