Development and validation of a new health-related quality of life instrument for patients with sinusitis

BACKGROUND AND OBJECTIVE

There are few validated measures of sinusitis-specific health-related quality of life (HRQL). This study used patient focus and pretesting groups followed by a prospective cohort study to develop and validate a HRQL instrument for patients with sinusitis.

METHODS

Instrument development involved a systematic literature review, use of expert input, and patient focus and pretesting groups. Patients were recruited from the practices of primary care providers and otolaryngologists. The derived survey instrument then underwent prospective testing in patients with acute sinusitis, chronic sinusitis, allergic rhinitis, and asymptomatic controls. Reduced item scales of the original instrument were developed for symptom frequency and bothersomeness. The psychometric properties of the survey instrument were evaluated for reliability, construct validity, responsiveness, and interpretability.

RESULTS

In the prospective study, 47 patients with acute sinusitis and 50 patients with chronic sinusitis were compared to 18 patients with allergic rhinitis and 60 patients without nasal symptoms. Forty-three (91.5%) patients with acute sinusitis completed the questionnaire at baseline and at 1-month follow-up. Internal consistency was high for the symptom impact scale for acute and chronic sinusitis patients. The symptom frequency and especially bothersomeness scales had lower internal consistency particularly for acute sinusitis patients. Reproducibility among surgical patients retested prior to their procedure was good for each scale. A high degree of disciminant validity was demonstrated when comparing sinusitis patients to other groups, and a high degree of convergent validity was seen when the new measures were compared to other HRQL measures at baseline. Among patients with acute sinusitis, the responsiveness and interpretability of the symptom frequency, bothersomeness and impact scales were excellent.

CONCLUSIONS

This study developed and validated a new sinusitis-specific HRQL instrument. The instrument included symptom frequency, bothersomeness and impact scales. It was shown to be valid in patients with acute and chronic sinusitis, and highly responsive and interpretable in acute sinusitis patients managed in the primary care setting.

Validity of a New Health-Related Quality of Life Instrument for Patients with Chronic Sinusitis

OBJECTIVE/HYPOTHESIS

To assess the validity and responsiveness of a new health-related quality of life (HRQL) instrument for patients with chronic sinusitis.

STUDY DESIGN

Prospective case series.

METHODS

Patients with chronic sinusitis undergoing endoscopic sinus surgery were assessed in two otolaryngology practices affiliated with an academic hospital. Patient-reported HRQL was assessed using a new instrument (includes symptom frequency, bothersomeness, and impact scales), the Chronic Sinusitis Survey (CSS), and the generic SF-12 at baseline and 3 months postsurgery. The psychometric properties of the new instrument were assessed including reliability, validity, responsiveness, and interpretability.

RESULTS

Among 50 enrolled patients, 49 underwent surgery and 39 (80%) completed 3-month follow-up. Internal consistency was high for the symptom impact scale. The symptom frequency and, especially, bothersomeness scales had lower internal consistency and were comparable with the CSS. Correlation analyses support the construct validity of the new measure compared with the CSS and SF-12. The responsiveness of the new instrument was excellent and similar to or better than the CSS. The mean score change was linearly related to the patient's global self-assessment, although the CSS symptom and total score better discriminated patients with major or moderate degrees of improvement.

CONCLUSIONS

This study demonstrates the validity and responsiveness of a new rhinosinusitis-specific HRQL instrument, the Rhinosinusitis Quality of Life survey, in patients with chronic sinusitis. The instrument's symptom frequency, bothersomeness, and impact scales compare favorably with a previously validated disease-specific and a generic HRQL measure. If validated in other patient populations, this disease-specific instrument may be useful in assessing severity and outcomes of treatment for sinusitis.

Molecular and cellular staging for the severity of chronic rhinosinusitis

OBJECTIVES

To correlate objective and subjective clinical parameters with molecular, cellular, and histologic markers and to acknowledge the importance of these basic science parameters in a severity classification system for chronic rhinosinusitis (CRS).

STUDY DESIGN

Retrospective analysis of prospectively collected data of consecutive patients undergoing endoscopic sinus surgery for CRS in an academic institution.

METHODS

The preoperative computed tomography (CT) scans of all patients with CRS scheduled for surgery were graded according to Lund and Mackay. The patients completed a Sino-Nasal Outcome Test (SNOT)-20 questionnaire and had a preoperative nasal endoscopy performed, which was graded by assigning an endoscopy score according to Lanza and Kennedy. Subjects had a medical questionnaire regarding presence of aspirin sensitivity, allergic rhinitis, asthma, and medication usage. Subjects also underwent pulmonary function testing and had skin tests for allergies. At the time of surgery, blood was drawn to determine the level of peripheral eosinophilia and the degree of polymorphisms of the leukotriene C4 synthase gene. Sinus mucosal and polyp tissue was examined pathologically for the number of eosinophils per high-powered filed (HPF) and was stained for EG2 to determine the portion of activated eosinophils. Leukotriene C4 levels (pg/g of tissue) were determined using a sensitive competitive enzyme immunoassay. Endoscopy and SNOT-20 scores were reevaluated 1 year after surgery. Data were analyzed for disease-severity correlation to recommend a severity classification system for CRS that incorporates the contribution of clinical, molecular, cellular, and histologic parameters.

RESULTS

The presence of polyps resulted in higher preoperative CT scores and higher preoperative and postoperative symptom scores. Average preoperative CT scores were significantly higher in asthmatics and allergy patients and correlated with endoscopy scores. Patients with more than five eosinophils/HPF of sinus tissue had higher frequency of polyps and asthma and higher CT and endoscopy scores than patients without sinus tissue eosinophilia (less than or equal to 5 cells/HPF sinus tissue). The subgroup of patients with eosinophilic nasal polyps (eosinophilic hyperplastic rhinosinusitis) had more severe disease by CT and endoscopy than the subgroup of patients with nasal polyps (hyperplastic rhinosinusitis) but without eosinophilia. Similarly, patients without polyps but with tissue eosinophilia had more severe disease than patients without polyps and without eosinophilia. Leukotriene C4 levels were elevated in all patient groups. Symptom scores did not correlate with any of the parameters.

CONCLUSION

We suggest the following severity classification system for CRS: 1) eosinophilic chronic hyperplastic rhinosinusitis (ECHRS): patients with polyps and sinus tissue eosinophilia; 2) noneosinophilic chronic hyperplastic rhinosinusitis (NECHRS): patients with polyps but without sinus tissue eosinophilia; 3) eosinophilic chronic rhinosinusitis (ECRS): patients without polyps but with sinus tissue eosinophilia; 4) noneosinophilic chronic rhinosinusitis (NECRS): patients without polyps and without sinus tissue eosinophilia.

Significance of nasal polyps in chronic rhinosinusitis: symptoms and surgical outcomes

PURPOSE

To demonstrate the significance of nasal polyps on the symptoms of chronic rhinosinusitis (CRS) and their influence on surgical outcomes.

METHODS

Retrospective analysis of prospectively collected data comparing two groups of patients diagnosed with CRS with and without nasal polyps that underwent surgical management with a minimum 1-year follow-up period. Subjective scoring was performed using the Sino-Nasal Outcome Test (SNOT-20) questionnaire. Computed tomography (CT) scans were compared using the Lund-Mackay scoring system. The two groups were analyzed for the need of revision surgery.

RESULTS

Two hundred one patients underwent surgical management of CRS over a 3-year period. One hundred four were male, 97 were female, and the average age was 49 (range 18-80) years. Polyps were present in 78 patients with CRS, whereas 123 patients did not have polyps. The average CT score was 18 for the polyp group and 9.5 for the patients without polyps (P = .0000). Nonpolyp group SNOT-20 scores were 26.5 preoperatively with improvement to 5.1 at 6 months and 5.0 at 12 months postoperatively (85% improvement). Polyp group SNOT-20 preoperative scores averaged 32.2 with improvement to 9.2 at 6 months and 9.1 at 12 months postoperatively (81% improvement, P = .003). Nine patients required revision surgery (4.5%), eight (10%) who had polyps and one (0.8%) who did not (P = .002).

CONCLUSION

The presence of nasal polyps has a significant negative impact on patients with CRS. Patients with nasal polyps have more severe symptoms with less improvement after operative intervention, higher CT scores at presentation, and a significantly higher need for revision surgery.

Health-related quality of life in patients with sinusitis

The goal of treatment for patients with sinusitis is the prompt and complete relief of symptoms and consequent improvement in health-related quality of life (HRQL). HRQL has been defined as the component of overall quality of life, determined primarily by the person's health, which can be influenced by clinical interventions. HRQL is especially useful for conditions like sinusitis in which there is no gold-standard diagnostic test, and "objective" tests correlate poorly with disease severity and outcomes. Patients with sinusitis have measurable, significant decrements in HRQL. Many studies evaluating treatment efficacy in patients with sinusitis have used unvalidated HRQL measures, making their findings, at best, difficult to interpret or, at worst, potentially biased. In this article, we review the definition of HRQL, the meaning and importance of validating HRQL measures, the impact of sinusitis on HRQL, and validated measures of HRQL for use in research and in clinical practice.

Rhinosinusitis: establishing definitions for clinical research and patient care

Background

There is a need for more research on all forms of rhinosinusitis. Progress in this area has been hampered by a lack of consensus definitions and the limited number of published clinical trials.

Objectives

To develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials.

Methods

Five national societies, The American Academy of Allergy, Asthma and Immunology; The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology Head and Neck Surgery; The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society formed an expert panel from multiple disciplines. Over two days, the panel developed definitions for rhinosinusitis and outlined strategies for design of clinical trials.

Results

Committee members agreed to adopt the term “rhinosinusitis” and reached consensus on definitions and strategies for clinical research on acute presumed bacterial rhinosinusitis, chronic rhinosinusitis without polyposis, chronic rhinosinusitis with polyposis, and classic allergic fungal rhinosinusitis. Symptom and objective criteria, measures for monitoring research progress, and use of symptom scoring tools, quality-of-life instruments, radiologic studies, and rhinoscopic assessment were outlined for each condition.

Conclusion

The recommendations from this conference should improve accuracy of clinical diagnosis and serve as a starting point for design of rhinosinusitis clinical trials.

Rhinosinusitis: Establishing definitions for clinical research and patient care

Background

There is a need for more research on all forms of rhinosinusitis. Progress in this area has been hampered by a lack of consensus definitions and the limited number of published clinical trials.

Objectives

To develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials.

Study design

Five national societies, The American Academy of Allergy, Asthma and Immunology; The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology Head and Neck Surgery; The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society formed an expert panel from multiple disciplines. Over two days, the panel developed definitions for rhinosinusitis and outlined strategies for design of clinical trials.

Results

Committee members agreed to adopt the term “rhinosinusitis” and reached consensus on definitions and strategies for clinical research on acute presumed bacterial rhinosinusitis, chronic rhinosinusitis without polyposis, chronic rhinosinusitis with polyposis, and classic allergic fungal rhinosinusitis. Symptom and objective criteria, measures for monitoring research progress, and use of symptom scoring tools, quality-of-life instruments, radiologic studies, and rhinoscopic assessment were outlined for each condition.

Conclusions

The recommendations from this conference should improve accuracy of clinical diagnosis and serve as a starting point for design of rhinosinusitis clinical trials.

Diagnosis and pathology of unilateral maxillary sinus opacification with or without evidence of contralateral disease

OBJECTIVE

Determine the diagnostic criteria and etiology of complete unilateral maxillary sinus opacification.

METHODS

A prospective analysis was performed on patients presenting to a tertiary care rhinology practice with complaints of chronic rhinosinusitis or acute exacerbation. Sixty-four consecutive patients were identified with unilateral maxillary sinus opacification on computed tomography (CT) scan after at least a 3-week medical therapy for rhinosinusitis. The study population comprised 30 men and 34 women with a mean age of 47.0 years. All patients completed a symptom score questionnaire, received nasal endoscopy, and CT imaging. Patient symptoms and endoscopic and radiographic findings were analyzed to determine patterns related to final diagnosis.

RESULTS

All 64 patients underwent functional endoscopic sinus surgery. Each surgical specimen was sent for pathologic confirmation of the diagnosis. Sixteen mucoceles, 12 cases of nasal polyposis, 27 cases of acute or chronic sinusitis, 7 cases of inverting papilloma, and 2 cases of mycetoma were identified. Endoscopic and radiographic appearances were correlated with each disease process.

CONCLUSION

Unilateral maxillary sinus opacification is a relatively common finding. Early identification of inverting papillomas and mucoceles may avoid delay in surgical intervention, whereas acute/chronic rhinosinusitis and nasal polyposis can initially be managed medically. Careful history, endoscopic examination, and radiographic studies can often determine the responsible disease process.

Nebulization of antibiotics in management of sinusitis

Chronic sinusitis with recurrent acute infections continues to be a significant medical problem. Even after aggressive medical and surgical management, some patients continue to have recurrent infections. These infections are often multidrug-resistant. Topical delivery of medications into body cavities has been practiced for decades. Recently, the use of prescription antibiotic, antifungal, and anti-inflammatory topical medications has increased for sinus patients. This article examines emerging data on nebulized antimicrobials for patients with sinusitis.

Prognostic staging system and therapeutic effectiveness for recurrent or chronic sinusitis in children

OBJECTIVE

We sought to assess the clinical status of pediatric sinusitis patients after a minimum of 2 years follow-up and to evaluate relative treatment effectiveness. Study design We conducted a medical record review of 308 patients, with a 2-year follow-up questionnaire.

RESULTS

Overall, 55% of children were "much improved." A 4-stage prognostic system was developed and used to compare results in 133 patients who had not responded to medical treatment and who had positive sinus computed tomography scans. Endoscopic sinus surgery (ESS) had no apparent advantages in stages I and IV, but in stages II and III, rates of "much improved" for ESS versus medical therapy were 79% versus 54% and 68% versus 42%, respectively.

CONCLUSION

These results suggest that ESS may be particularly effective for patients from intermediate prognostic stages.

SIGNIFICANCE

This type of prognostic staging and evaluation of treatment effectiveness is necessary and important in chronic sinusitis, where randomized trials are unlikely to be performed.

Clinical outcomes for the surgical treatment of sinonasal headache

OBJECTIVE

This study was designed to explore the changes in patient-relevant clinical outcomes in a selected group undergoing surgery for nasal septal and turbinate abnormalities. Study design Seventy-nine consecutive patients with headache and correctable anatomic nasal obstruction were seen at the study institution from March 1998 to May 2000. These patients were evaluated for changes in patient-relevant clinical outcomes measures after surgical correction of their anatomic abnormalities.

RESULTS

Seventy-one patients underwent surgical correction of nasal obstruction. More than half of these patients had contact points preoperatively. Statistically significant improvements were observed in the patient population with respect to 8 of the 10 clinical outcomes measures. Importantly, a decrease in the severity and frequency of headaches was noted after surgery, especially after the correction of contact points.

CONCLUSION

The surgical correction of the septum and turbinates resulted in predictable improvement in headache and a majority of other important outcomes measures. Clinical significance Pain may improve after surgical correction of septal and turbinate abnormalities in a properly selected group.

Measures of health-related quality of life for adults with acute sinusitis. A systematic review

CONTEXT

Symptoms suggestive of acute sinusitis are a common reason for patients to visit primary care providers. Since objective measures of outcome have not been shown to be related to patient reported outcomes, measures of treatment success have focused on symptom relief and improved health-related quality of life (HRQL). Assessing the appropriate role of treatment - for example, antibiotics for patients with acute sinusitis - requires valid, reliable, and responsive measures of outcome. We identified symptom scores and HRQL instruments for adults with sinusitis and assessed their performance characteristics.

DATA SOURCES

Articles identified through computer searches of the medline, premedline, and embase databases, the Cochrane Library, and internet documents; inquiries to experts in sinusitis and outcomes assessment; and review of reference lists.

STUDY SELECTION

Studies that used HRQL instruments or evaluated the performance characteristics of symptom scores in adults with sinusitis, published in English after 1966.

DATA EXTRACTION

Two reviewers independently extracted data on study design, setting, and patient characteristics; instrument length and format; and instrument validity, reliability, responsiveness to change, and interpretability. Study quality was assessed using a 10-point score.

DATA SYNTHESIS

Of 1,340 articles in the original search, 29 articles using 16 HRQL instruments and 5 symptoms scores met inclusion and exclusion criteria. The overall quality of these studies was low; only 4 studies scored higher than 4 of 10 points. Four studies included patients with acute sinusitis, but only 2 included exclusively acute sinusitis patients. Three instruments have been shown to meet basic requirements for validity, reliability, and responsiveness: the Chronic Sinusitis Survey, the Rhinosinusitis Outcome Measure-31, and the Sinonasal Outcome Test-16. No instrument has been validated in a primary care setting or for patients with acute sinusitis.

CONCLUSIONS

Few validated measures of sinusitis-specific HRQL are available. The 3 instruments shown to be valid, reliable, and responsive have been assessed in patients with chronic sinusitis. No measure has been validated in primary care settings or for patients with acute sinusitis. A lack of valid, responsive outcome measures may limit current treatment recommendations for patients with acute sinusitis.

A randomized double-blind study to compare the effects of nasal fluticasone and betamethasone on the hypothalamo-pituitary-adrenal axis and bone turnover in patients with nasal polyposis

Treatment of nasal polyposis with topical betamethasone is associated with suppression of the hypothalamo-pituitary-adrenal (HPA) axis and, potentially, has adverse effects on bone turnover. Fluticasone propionate is a potent corticosteroid with negligible absorption across the nasal mucosa and extensive first-pass hepatic metabolism. We performed a randomized double-blind study, in patients with nasal polyposis, comparing the effects of 8 weeks' treatment with betamethasone drops or fluticasone nasules on the HPA axis using the 1 micro g tetracosactide test, and on bone turnover using two serum markers. Nine patients were allocated to each treatment. Betamethasone resulted in significant suppression in the tetracosactide test (P = 0.006), but fluticasone did not (P = 0.113). There were no differences in bone turnover or treatment efficacy between treatments. Treatment of nasal polyposis with topical betamethasone drops, but not with fluticasone nasules, suppresses the HPA axis and, given comparable efficacy, fluticasone administered via nasule should be the preferred agent.

Nebulized Antibiotics for the Treatment of Acute Exacerbations of Chronic Rhinosinusitis

We studied the effectiveness of aerosol delivery of antibiotics to the sinuses via a nebulizer in 41 patients who had chronic, recurrent sinusitis that had persisted despite endoscopic sinus surgery and that had not responded to multiple courses of oral antibiotics. We compared pre- and post-treatment symptom scores in five categories: nasal obstruction, facial pain, pressure, mucopurulent rhinorrhea, and malaise. Following 3 to 6 weeks of treatment, 34 patients (82.9%) experienced either an excellent or good response to treatment. Side effects were infrequent, mild, and transient. We conclude that nebulized antibiotics should be considered for all patients with chronic sinusitis who have undergone functional endoscopic sinus surgery and who have failed to respond to oral antibiotics or who do not tolerate them.

Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20)

A valid measure of rhinosinusitis health status and quality of life is required for the complete assessment of treatment effectiveness. The purpose of this study was to analyze the psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20), a disease-specific, health-related quality-of-life measure for rhinosinusitis. The SNOT-20 is a modification of the 31-Item Rhinosinusitis Outcome Measure, and it contains 20 nose, sinus, and general items. To complete the instrument, patients indicate how much they are affected in each area and identify the 5 most important items. The SNOT-20 was completed by 102, 72, and 46 patients at the initial visit and at 6 months and 1 year after treatment commencement, respectively. Cronbach's alpha was 0.9; test-retest scores were highly correlated (r = 0.9). Patients who were more affected had greater SNOT-20 scores (P < 0.002), and patients who had improved had greater change scores (P < 0.04). Items identified as important had greater scores (P < 0.0001) and showed greater change scores (P < 0.0002). The SNOT-20 is a valid outcome measure for patients with rhinosinusitis; it describes the health burden and is sensitive to clinical change.

Longitudinal effects of botulinum toxin injections on voice-related quality of life (V-RQOL) for patients with adductory spasmodic dysphonia

Adductory spasmodic dysphonia is a focal dystonia of laryngeal muscles. Patients with this disorder typically have severe vocal difficulties, with significant functional, social, and emotional consequences. There is no widely accepted cure for this condition, however, botulinum toxin injections of the thyroarytenoid muscles are considered by most voice clinicians to be the state of the art treatment. Based on extensive experience treating patients for adductory spasmodic dysphonia, we feel that traditional means of voice assessment do not adequately measure either the disease severity or the treatment outcomes. That is, listening to or acoustically analyzing limited phonatory samples does not capture the functional, social, and emotional consequences of this disorder. These consequences will be reflected in a patient's voice-related quality of life (V-RQOL). Using a validated voice outcomes instrument, the V-RQOL Measure, the purpose of this study was to quantify longitudinal changes in the V-RQOL of patients with adductory spasmodic dysphonia who are undergoing botulinum toxin injections. Twenty-seven consecutive new patients presenting with dysphonia to our institution during an 18-month period were diagnosed with adductory spasmodic dysphonia, and treated patients were evaluated prospectively using the V-RQOL Measure. Results indicated that (1) V-RQOL was initially very low for these patients, (2) botulinum toxin injections improved it significantly for each injection cycle studied, and (3) the magnitude of the treatment effect appears to change across injections.

The development of a General Nasal Patient Inventory

Most available clinical outcome measures for rhinology patients relate to specific nasal disease or general quality of life. Fairley's validated 12-item questionnaire measures general nasal symptoms, but is a 'physician-derived' clinical tool and may not reflect all the problems that rhinology patients experience. Our aims were to develop a patient-orientated questionnaire, representing the concerns of a large number of rhinology patients, called the General Nasal Patient Inventory (GNPI) and compare this with the Fairley nasal questionnaire (FNQ). The GNPI was developed from the open-ended problem lists of 211 rhinology patients, from the 45 most frequent complaints. Both questionnaires were then administered to 153 general rhinology patients and the results compared. The highest-ranking items for each questionnaire were different, but the total scores were highly correlated (r = 0.79, P < 0.0001). Factor analysis showed six factors to account for 75% of FNQ variance and 18 factors for 78% of GNPI variance. The 45-item GNPI, the first patient-derived, comprehensive nasal questionnaire could be a time-saving tool in rhinology clinics and more sensitive to change after intervention than other available measures.

Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan

OBJECTIVES

We designed a prospective study to determine whether there is a correlation between the severity of sinus symptoms and the severity of computed tomography (CT) scan evidence of rhinosinusitis.

METHODS

Acute and chronic rhinosinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day. A Likert severity scale and standardized CT scoring system were used. Data were analyzed by nonparametric methods with Kendall's rank correlation coefficient.

RESULTS

The severity of 5 symptoms correlated with severity of disease on CT scan. Headache and facial pain or pressure had no correlation.

CONCLUSION

The certainty of a clinical diagnosis of rhinosinusitis requiring treatment is enhanced in patients with high symptom severity scores for fatigue, sleep disturbance, nasal discharge, nasal blockage, or decreased sense of smell. Isolated headache and facial pain or pressure are less reliable predictors of CT scan findings supporting the diagnosis rhinosinusitis.

Nasal irrigation for the alleviation of sinonasal symptoms

OBJECTIVE

To determine the effect of nasal irrigation on sinonasal symptoms.

STUDY DESIGN AND SETTING

A total of 150 adult subjects with chronic sinusitis symptoms were recruited from the community and assigned to 1 of 3 treatment groups: nasal irrigation with bulb syringe, nasal irrigation with nasal irrigation pot, or control treatment with reflexology massage. Groups 1 and 2 performed daily hypertonic saline irrigation with 1 device for 2 weeks and then with the other device for 2 weeks. Group 3 performed reflexology massage daily for 2 weeks. Prospective data collected included pretreatment Medical Outcomes Study Short Form, pretreatment and posttreatment Rhinosinusitis Outcomes Measure, daily medication use, subjective treatment efficacy, and preference of irrigation method.

RESULTS

There was a significant and equivalent improvement in Rhinosinusitis Outcomes Measure 31 score after 2 weeks of intervention in each treatment group; 35% of subjects reported decreased use of sinus medication.

CONCLUSION

Daily nasal irrigation using either a bulb syringe, nasal irrigation pot, and daily reflexology massage were equally efficacious and resulted in improvement in the symptoms of chronic sinusitis in over 70% of subjects. Medication usage was decreased in approximately one third of participants regardless of intervention.

Use of the Rhinosinusitis Disability Index (RSDI) in rhinologic disease

Chronic rhinosinusitis has been shown to have an adverse impact on the quality of life in those afflicted as determined by a number of standardized outcome tools. We have utilized a standardized, statistically validated, disease-specific tool, the Rhinosinusitis Disability Index (RSDI), to investigate the disability suffered by 292 consecutive patients with nine unique rhinologic diagnoses, including chronic rhinosinusitis. Physical, functional, and emotional domains were assessed. We have found that individuals with rhinologic disease in general have lower physical scores, followed by functional scores and emotional scores. Individuals with chronic rhinosinusitis and allergic rhinitis have the greatest level of disability, while those with aspirin triad are least affected.

Evidence-based surgery in chronic rhinosinusitis

Considerable interest has been focused in recent years on an evidence-based approach to clinical medicine. For obvious reasons, however, it has proved difficult to examine the benefit of surgical procedures in randomized, double-blind. placebo-controlled trials. This review considers the evidence available in the literature for surgery in chronic rhinosinusitis and examines the validity of the studies in the context of evidence-based medicine.

Efficacy of immunotherapy based on skin end-point titration

OBJECTIVE

The purpose of this study is to examine the efficacy of skin end-point titration (SET) as a method of assessing skin responsiveness, selecting antigens, and initiating treatment for successful inhalant immunotherapy.

STUDY DESIGN

This study is a prospective, randomized, controlled, double-blind investigation. Eighteen patients were randomly assigned to 1 of 2 groups: an experimental group treated for all positive antigens, and a control group treated for all positive antigens, with the exception of the study antigens. Quality of life was assessed with 3 dependent measures, and response to nasal challenge and nasal endoscopic evaluations were conducted. Ten patients completed the 6-month study.

RESULTS

There were significant improvements in the emotional component of sinus-related disability, in response to nasal challenge, and in the endoscopic appearance of the mucosa, regardless of patient group. There was a trend toward improved quality of life among experimental subjects.

CONCLUSIONS

SET-based immunotherapy reduces self-rated disability over time. In addition, SET-based immunotherapy allows decrease in nasal reactivity and normalizes the endoscopic appearance of the nose.

Clinical outcomes in patients with chronic sinusitis

Although sinusitis is one of the most common chronic illnesses in this country, relatively little is known about the effect of this disease or its treatment on quality of life. In a series of studies utilizing both disease-specific and general health instruments, patients with chronic sinusitis were found to have significant decrements in several subscales of general health, including bodily pain and social functioning (P<.05), compared with the general US population. Surgery for sinus disease was shown to result in significant reduction in both symptoms and medication usage (P<.05) after 12 months. These same outcome instruments can be used by health care providers to document clinical outcomes in similar populations of patients with chronic sinusitis.

Validation of outcomes survey for adults with chronic suppurative otitis media

Currently, there is no valid, disease-specific outcomes measure to evaluate health impact and treatment effectiveness for patients with chronic suppurative otitis media (CSOM). The Chronic Ear Survey (CES) is a new, disease-specific outcomes measure for CSOM that was administered in a prospective manner to 91 patients with CSOM. It was then validated according to established criteria for reliability, validity, and sensitivity to clinical change by correlation with objective data and self-assessment questionnaires such as the Hearing Handicap Inventory for Adults (HHIA) and the generic 36-Item Short-Form Health Survey (SF-36). Significant correlations between subscale scores of the CES and audiometric data and between subscale scores of the HHIA and SF-36 were found. The standardized response mean for the CES total score was 0.42, indicating moderate sensitivity to clinical change. Overall, results demonstrated that the CES is a reliable and valid instrument for investigation of health status and health-related quality-of-life outcomes.

Validation of an instrument to measure voice-related quality of life (V-RQOL)

When a patient presents for care of a voice disorder, the clinician attempts to diagnose the problem, quantify the degree of dysphonia, and prescribe appropriate treatment. Quantification of the degree of dysphonia is often difficult, as no universal index of vocal function exists. Decisions about the nature and intensity of treatment are often based on the magnitude of the voice-related problems experienced by the patient and the importance that the patient places on those problems, that is, the impact that the voice disorder is having on the patient's voice-related quality of life (V-RQOL). Measurement of post-treatment outcome is also not standardized. Regardless of how the clinician measures response to treatment, it will typically be measured by the patient in terms of how his or her voice-related problems are affected by the treatment. Measurement of quality of life has not been a traditional part of the evaluation of the dysphonic patient. This study was undertaken to develop and validate an instrument for measuring V-RQOL using a population of 109 voice and 22 non-voice patients. The 10-item V-RQOL measure performs well in tests of reliability, validity, and responsiveness, and it carries a low burden. Measurement of V-RQOL is a valuable addition to the evaluation of dysphonic patients and their treatment outcomes.

Clinimetric evaluation of the Sinonasal Outcome Test-16. Student Research Award 1998

This study describes the reliability, validity, and responsiveness of the Sinonasal Outcome Test-16 (SNOT-16), a rhinosinusitis-specific health-related quality-of-life instrument, in the University of Washington Department of Otolaryngology-Head and Neck Surgery patient population. The SNOT-16 was completed by 47, 24, and 22 patients at weeks 0, 6, and 12, respectively. In addition, all 47 patients completed the Short-form 36-item Health Survey (SF-36) at week 0. Furthermore, an additional cohort of patients from the otology clinic who denied symptoms of rhinosinusitis or previous physician diagnoses of rhinosinusitis were asked to complete the SNOT-16. These scores were subsequently used to determine discriminant validity of the instrument. Cronbach's alpha was 0.89, indicating a high degree of homogeneity of the test items. The SNOT-16 demonstrated excellent discriminant validity, and mean total SNOT-16 scores were significantly correlated with patient-reported overall health, overall bother, and 7 of the 8 SF-36 subscales. The standardized response mean calculated between weeks 0 and 6 was 0.69, indicating moderate sensitivity to change. We conclude that the SNOT-16 is a reliable, valid, and responsive instrument for measuring rhinosinusitis-specific health-related quality of life.

Severity staging in chronic sinusitis: are CT scan findings related to patient symptoms?

Chronic sinusitis is a prevalent problem. The symptoms of CS cause patients to seek medical attention, and therefore the presence of symptoms drives the use of health care resources. There is widespread clinical belief that computed tomography (CT) scan findings may be a reasonable proxy for disease severity in chronic sinusitis, and many authors have proposed that CT scan findings make up the key component in severity staging systems for chronic sinusitis. However, the relationship between symptom severity and CT scan findings in chronic sinusitis has not been well explained to date. To explore this relationship further, we examined data from consecutive patients with both a CT scan and a sinusitis symptom score, from ongoing prospective outcomes studies at two large academic centers in different cities (n = 254). CT scans were graded using two validated staging systems; symptom severity was assessed using two validated health status instruments and summary items. In addition, we explored multiple statistical modifications and permutations of CT staging to identify potential relationships between the two variables. In summary, no association between CT scan findings and symptom severity could be identified using both CT staging systems and patient-based symptom instruments. For instance, CT scans were examined: after eliminating normal scans, using different scoring algorithms, by worst side, by nonlinear association, when grouped into strata, and by eliminating patients with very severe disease; no statistical association was found between CT findings and patient-based symptoms using any of those techniques. Since symptom severity is a pivotal outcome measure in chronic sinusitis, these findings have significant implications for outcomes research and the development of severity staging systems.

Functional endoscopic sinus surgery: do ratings of appropriateness predict patient outcomes?

Sinus surgery appropriateness ratings were recently developed by Value Health Sciences in cooperation with AAO-HNS. The goal of this study was to assess the relationships among three ratings of sinus surgery appropriateness (Appropriate, Inappropriate, or Equivocal) and symptom response. The enrolled population included 49 patients who completed the Smo-Nasal Outcome Test-20 (SNOT-20) presurgery and 6 months postsurgery. The SNOT-20 is a patient-based measure of sinusitis-related health status and quality of life. Overall, the mean percent difference (delta %) between pre- and postsurgery SNOT scores was 38%, a statistically and clinically significant improvement. However, there was no relationship between the appropriateness rating for the surgery and the delta % SNOT score (i = 1.83, p-value = 0.171); 20 patients with an Equivocal rating demonstrated the greatest delta % (49%), 20 patients with an Appropriate rating showed the least delta % (26%), and 9 patients with an Inappropriate rating had an intermediate delta % (39%). Furthermore, those patients having an Appropriate rating at the time of surgery reported a greater persistence of bothersome symptoms at 6 months (p-value = 0.02) then patients in either the Equivocal or Inappropriate rating. These results suggest that appropriateness ratings may not predict which patients will obtain the greatest symptom improvement from sinus surgery.

Economic Implications of Chronic Sinusitis

An approach to cost analysis useful in understanding the economic implications of surgical intervention on chronic sinusitis is break-even time analysis. The break-even time is the time until cost savings associated with improved health status after surgery equal the upfront costs of the operation itself. Data from 100 consecutive patients undergoing sinus operation were obtained by survey before surgery and at quarterly intervals for 1 year with statistically validated outcome measures (Medical Outcome Study Short Form 36-Item Health Survey, Chronic Sinusitis Survey). Direct and indirect costs were obtained or derived for this cohort. The cost of sinus medications, including over-the-counter remedies, nasal steroid sprays, and antibiotics, averaged $1220 per patient per year before surgery and $629 after surgery ( p < 0.0001), which is a 48% reduction. Surgical costs averaged $6490 per patient. Economic modeling predicted a break-even time of approximately 7 years assuming a 3% surgical revision rate per year, a 3% decrease in sickness-related disability, and a 5% discount rate. The model was sensitive to changes in the total cost of operation, the surgical revision rate, and the anticipated disability benefit. We conclude that significant direct and indirect medical cost savings may be achieved after surgical intervention for chronic sinusitis and these savings eventually break even with the total cost of surgery itself.

Indications for sinus surgery: how appropriate are the guidelines?

Sinusitis is the most commonly reported chronic disorder in America. More than 75,000 sinus surgical procedures were performed in 1993. Evaluating the appropriateness of procedures is a major focus of health care reform. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) collaborated with Value Health Sciences, Inc. (VHS) to develop guidelines for the use of sinus surgery. The clinical utility of these guidelines is presented. Patients undergoing sinus surgery at Barnes Hospital in St. Louis, Missouri, between November 1994 and July 1995 were eligible. Relevant patient information was used to prospectively rate surgery on the nine-point VHS appropriateness scale (1 to 3, inappropriate; 4 to 6, equivocal; 7 to 9, appropriate). Of 55 patients, 37 (67%) had chronic sinusitis, 10 (18%) recurrent sinusitis, five (9%) chronic sinusitis with nasal polyps, and three (6%) sinusitis with moderate to severe asthma; 27 (49%) had previous sinus surgery. Appropriateness ratings ranged from 1 to 9, with nine (16%) procedures rated as inappropriate, 22 (40%) uncertain, and 24 (44%) appropriate. There were no significant differences in the ratings of appropriateness between the group of patients who had undergone previous sinus surgery and the group of patients who had not. Overall, the guidelines were easily applied and clinically pertinent.

A retrospective study of the role of the argon laser in the management of epistaxis secondary to hereditary haemorrhagic telangiectasia

Epistaxis is a common symptom in patients with hereditary haemorrhagic telangiectasia. It may vary in severity from infrequent mild bleeds to regular severe bleeding, the latter requiring multiple blood transfusions. Laser, which can be used to coagulate the telangiectasia without destroying the overlying nasal mucosa, would theoretically seem to be the ideal mode of treatment. In this pilot study, an argon laser has been used on nineteen patients with hereditary haemorrhagic telangiectasia and is shown to be beneficial in patients with mild or moderate epistaxis. Patients with severe epistaxis, or who fail argon laser treatment, are candidates for alternative therapeutic strategies such as a modified Young's procedure.