Characterization of facial pain associated with chronic rhinosinusitis using validated pain evaluation instruments

Headache and Facial Pain/Pressure in the Chronic Rhinosinusitis Population: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the severity and prevalence of headache and facial pain/pressurere in the chronic rhinosinusitis (CRS) population.

DATA SOURCES

CINAHL, PubMed, Scopus.

REVIEW METHODS

The literature was searched from inception through June 2023 for English language articles documenting "headache" or "facial pain/pressure" and "chronic rhinosinusitis." Data collected included Lund-MacKay computed tomography score, Lund-Kennedy endoscopy score, sinonasal outcome test, and visual analog scale. Meta-analyses were performed on continuous measures (mean), proportions (%), and regression.

RESULTS

A total of 69 studies were included with 8643 CRS patients and 703 control patients. The CRS group had a mean age of 44.1 (range: 16-82; 95% confidence interval [CI]: 40.3-48) and 86.1% [95% CI: 76.4-93.5] with nasal polyposis. The control group had a mean age of 39.2 (range: 17-88; 95% CI: 28.7-49.8). All CRS subgroups had significantly more severe headache and facial pain/pressure when compared to the control (P < .0001). Patients without polyps had significantly more severe facial pain/pressure and headache when compared to patients with polyps (P < .0001). Facial pain/pressure is a moderate problem or worse in 29.8% of polypoid patients versus 56.4% of nonpolypoid patients; Δ26.6% [95% CI: 0.7-50; P = .045].

CONCLUSIONS

Across all outcome metrics, CRS patients experience significantly more severe headache and facial pain/pressure when compared to a control population. Nonpolypoid patients experience significantly more severe facial pain/pressure and headache when compared to polypoid patients. The majority of nonpolypoid patients experience facial pain/pressure that is moderate in severity or worse.

Five-year EuroQol 5-Dimension Outcomes After Endoscopic Sinus Surgery

OBJECTIVE

The EuroQol 5-Dimension (EQ-5D) is a general health survey that is quick to administer, widely used, and directly convertible to health utility values (HUV). We aim to describe the five-year EQ-5D outcomes among patients who undergo surgical treatment for chronic rhinosinusitis (CRS).

STUDY DESIGN

Prospective observational cohort study.

METHODS

Patients with CRS completed the EQ-5D questionnaire preoperatively and annually for five years following endoscopic sinus surgery. Paired t-tests and McNemar's tests were used to compare preoperative and postoperative scores. Mixed-effects modeling was used for multivariate analysis.

RESULTS

Among 1296 patients enrolled in our study, 812 (74.7%) completed the postoperative survey at one year and 336 (38.9%) completed it at five years. There was a significant and sustained reduction of patients reporting pain/discomfort (74.9% vs. 58.0%, p < 0.001) and anxiety/depression (49.6% vs. 38.1%, p = 0.01) out to five years. Frequency of problems reported in the usual activity domain decreased at one year and was sustained through year four (30.6% vs 19.7%, p = 0.003). After multivariable modeling, female gender (p = 0.02), prior sinus surgery (p = 0.01), tobacco use (p = 0.038), headaches (p = 0.013), allergies (p = 0.001), diabetes (p = 0.022), hypertension (p = 0.036), higher preoperative SNOT-22 score (p < 0.001), and a lower preoperative Lund-Mackay score (p < 0.001) were associated with significantly worse EQ-5D HUV over time. Similarly, a worse EQ-5D Visual Analog Scale (VAS) over time was associated with allergies (p = 0.03), diabetes (p < 0.001), hypertension (p = 0.04), higher preoperative SNOT-22 score (p < 0.001), and prior sinus surgery (p < 0.001).

CONCLUSION

Patients with chronic rhinosinusitis experience significant sustained improvements in health-related quality of life up to five years after ESS as measured by the EQ-5D instrument.

LEVEL OF EVIDENCE

Level 2 Laryngoscope, 134:2592-2601, 2024.

Development of the 12-Item Facial Complaints Evaluation Scale (FaCES-12)

OBJECTIVES

Chronic rhinosinusitis and related rhinologic disorders are common in routine otolaryngologic practice. Common presenting symptoms include nasal obstruction, facial pain, facial pressure, headache, and a subjective feeling of the face feeling "swollen," a perceptual distortion. No validated scale exists to assess facial pain in addition to perceptual distortion or headache. The objective was to develop a novel scale for assessment of facial symptoms experienced by patients presenting for rhinologic evaluation.

METHODS

This was a prospective validation cross-sectional study. A patient questionnaire, the 12-item Facial Complaints Evaluation Scale (FaCES-12), was created to evaluate facial symptoms based on clinical experience and the literature, including severity and timing of facial pain, facial pressure, facial perceptual swelling, and headache. Each item was assessed utilizing an 11-point Likert scale ranging from 0 to 10 in severity. Data was collected prospectively from 210 patients in 1 private and 2 academic otolaryngologic practices from August to December 2019 along with the PROMIS Pain Intensity Scale 3a and 22-Item Sino-nasal Outcome Test. Construct validity was determined using Pearson correlation and exploratory factor analysis. Internal consistency and test-retest reliability were assessed by calculating Cronbach's alpha and assessing test-retest scores.

RESULTS

A new 12-item scale named FaCES-12 was developed. FaCES-12 demonstrated high reliability with a Cronbach's alpha of .94 and high test-retest reliability (r = .90). The scale revealed very strong correlation with the PROMIS Pain Intensity Scale 3a (r = .81) and moderate correlation with the Sino-nasal Outcome Test (r = .48). Exploratory factor analysis demonstrated the scale contained interrelated variables that measured unique components of facial sensations.

CONCLUSION

The FaCES-12 is a valid and reliable instrument for use in the evaluation of facial symptoms. Further research into the application of this scale is warranted.

ASSOCIATION BETWEEN SYMPTOM SEVERITY AND INTENSITY OF ACUTE PSYCHOLOGICAL DISTRESS IN NEWLY DIAGNOSED PATIENTS WITH CHRONIC RHINITIS AND CHRONIC RHINOSINUSITIS

Chronic rhinitis and rhinosinusitis (CR and CRS) can lead to impairment of the health-related quality of life (HRQL) with higher psychological perceived distress, resulting in disease worsening and poor treatment outcomes. W aimed to evaluate the potential association between disease severity and HRQL impairment with the perceived acute psychological distress in newly diagnosed CR/CRS patients. This single-center cross-sectional study included otherwise healthy consecutive adults with newly diagnosed CR/CRS (European position paper on rhinosinusitis and nasal polyp criteria and International Consensus Statement on Allergy and Rhinology - Allergic Rhinitis criteria or non-allergic rhinitis), who were evaluated for CR/CRS symptom severity and HRQL (Sino Nasal Outcome Test 22 [SNOT-22], visual analog scale [VAS]) and acute perceived distress (Perceived Stress Scale [PSS]). Principal component analysis (SNOT-22 items, VAS) identified 6 components as CR/CRS severity indicators, i.e,, poor sleep, wakes-up tired, nasopharynx, obstruction, torment and rhinorrhea, which were evaluated for association with PSS score. Of the 63 included patients (20 men, age median 38, range 19-75 years), 27 suffered from CR and 36 from CRS. Upon adjustment for age and sex, higher total SNOT-22 (geometric means ratio [GMR]=1.04, 95% CI 1.01-1.06), higher "torment" (GMR=1.13, 1.04-1.24), higher "poor sleep" (GMR=1.11, 1.02-1.21) and higher "wakes-up tired" (GMR=1.11, 1.01-1.21) scores were each associated with a higher PSS score, overall and consistently in CR and CRS patients. In conclusion, more severe CR/CRS is associated with greater perceived psychological distress already at earlier stages of the disease. Paying attention to patient level of distress and anxiety over time may enable better understanding of the connection between exacerbations, symptom severity and psychological burden of the disease.

Clinical Features and Headache Diagnoses in Patients With Chief Complaint of Craniofacial Pain

OBJECTIVES

Investigate the use of nasal endoscopy, sinus imaging, and neurologic evaluation in patients presenting to a rhinologist primarily for craniofacial pain.

METHODS

This was a retrospective analysis of consecutive outpatients presenting to a rhinologist between 2016 and 2019 with chief complaints of craniofacial pain with or without other sinonasal symptoms, who were then referred to and evaluated by headache specialists. Data analyzed included sinusitis symptoms, Sino-Nasal Outcome Test (SNOT-22) scores (and facial pain subscores), pain location, nasal endoscopy, computed tomography (CT) findings, and headache diagnoses made by headache specialists.

RESULTS

Of the 134 patients with prominent craniofacial pain, the majority of patients were diagnosed with migraine (50%) or tension-type (22%) headache, followed by multiple other non-sinogenic headache disorders. Approximately 5% of patients had headaches attributed to sinusitis. Amongst all patients, 90% had negative nasal endoscopies. Patients with negative endoscopies were significantly less likely to report smell loss (P = .003) compared to those with positive endoscopies. Poor agreement was demonstrated between self-reported pain locations and sinus findings on CT (kappa values < 0.20). Negative nasal endoscopy showed high concurrence with negative CT findings (80%-97%).

CONCLUSIONS

Patients presenting with chief complaints of craniofacial pain generally met criteria for various non-sinogenic headache disorders. Nasal endoscopy was negative in 90% of patients, and CT demonstrated poor agreement with pain locations. Nasal endoscopy and CT shared high concurrence rates for negative sinus findings. The value of nasal endoscopy over sinus imaging in craniofacial pain evaluation should be explored in future studies.

Sleep Dysfunction is an Independent Predictor of Productivity Losses in Patients with Chronic Rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is known to have a significant impact on economic productivity. Sleep dysfunction is associated with staggering productivity losses and is highly prevalent in patients with CRS. The effect of sleep dysfunction on productivity in CRS has not been elucidated. The objective of this study was to determine the relationship between sleep dysfunction and lost productivity in patients with CRS.

METHODS

Eighty-two adult patients with CRS were prospectively enrolled into a cross-sectional cohort study. Patients with obstructive sleep apnea were excluded. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Presenteeism (reduced work efficiency), absenteeism (missed work days), and lost work, household, and overall productivity were analyzed. The primary aim was assessing the correlation between PSQI and productivity. Regression analyses were performed to account for disease severity, pain, and depression.

RESULTS

Sleep dysfunction is significantly correlated with overall lost productivity (R² = 0.397, P < .05). Presenteeism is the most strongly affected by sleep dysfunction (R² = -0.441, P < .001). Higher PSQI scores were significantly associated with productivity losses, whereas lower scores were not. Sleep remained an independent predictor of productivity when regression analysis accounted for disease severity, depression, and pain.

CONCLUSION

Sleep dysfunction has a significant association with lost productivity in patients with CRS, particularly with worsening PSQI scores. More clearly defining those components of CRS that most impact a patient's daily function will allow clinicians to more optimally manage and counsel patients with CRS.

A systematic review to examine the relationship between objective and patient-reported outcome measures in sinonasal disorders: recommendations for use in research and clinical practice

BACKGROUND

Common sinonasal disorders include chronic rhinosinusitis (CRS), allergic rhinitis (AR), and a deviated nasal septum (DNS), which often coexist with shared common symptoms including nasal obstruction, olfactory dysfunction, and rhinorrhea. Various objective outcome measures and patient-reported outcome measures (PROMs) are used to assess disease severity; however, there is limited evidence in the literature on the correlation between them. This systematic review aims to examine the relationship between them and provide recommendations.

METHODS

A search of MEDLINE and EMBASE identified studies quantifying correlations between objective outcome measures and PROMs for the sinonasal conditions using a narrative synthesis.

RESULTS

In total, 59 studies met inclusion criteria. For nasal obstruction, rhinomanometry shows a lack of correlation whereas peak nasal inspiratory flow (PNIF) shows the strongest correlation with PROMs (r > 0.5). The Sniffin' Stick test shows a stronger correlation with PROMs (r > 0.5) than the University of Pennsylvania Smell Identification Test (UPSIT) (r < 0.5). Computed tomography (CT) sinus scores show little evidence of correlation with PROMs and nasal endoscopic ratings (weak correlation, r < 0.5).

CONCLUSION

Overall, objective outcome measures and PROMs assessing sinonasal symptoms are poorly correlated, and we recommend that objective outcome measures be used with validated PROMs depending on the setting. PNIF should be used in routine clinical practice for nasal obstruction; rhinomanometry and acoustic rhinometry may be useful in research. The Sniffin' Sticks test is recommended for olfactory dysfunction with UPSIT as an alternative. CT scores should be excluded as a routine CRS outcome measure, and endoscopic scores should be used in combination with PROMs until further research is conducted.

Systematic literature review of humanistic and economic burdens of chronic rhinosinusitis with nasal polyposis

OBJECTIVES

We conducted a systematic literature review (SLR) of randomized controlled trials and real-world evidence (RWE) studies to determine the humanistic (e.g. health-related/disease-specific quality of life [QOL]) and economic (e.g. direct and indirect costs) burdens of chronic rhinosinusitis with nasal polyposis (CRSwNP).

METHODS

The SLR adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, MEDLINE and Evidence-Based Medicine Reviews databases were searched using OVID. Relevant studies involving adult patients with CRSwNP published between 1 January 2008 and 16 February 2019 were included, with relevant conference abstracts from 1 January 2017, onward.

RESULTS

Sino-Nasal Outcomes Test (SNOT)-22 was the most frequently used disease-specific health-related QOL/patient-reported outcomes instrument for patients with CRSwNP. Baseline SNOT-22 scores ranged from 25 to 73 for surgical candidates and from 14 to 56 for medically managed patients with CRSwNP. Mean baseline EuroQol-5 Dimensions (EQ-5D) index for patients with CRSwNP ranged from 0.81 to 0.86, and mean baseline Short Form-6 Dimensions (SF-6D) ranged from 0.67 to 0.75. Three months (EQ-5D) and 5 years (SF-6D) post-endoscopic sinus surgery (ESS), rates increased from 0.81 to 0.89 and from 0.69 to 0.80, respectively. One year post-diagnosis, patients with CRSwNP had significantly more systemic prescriptions, underwent significantly more medical procedures, demonstrated greater health care resource utilization and had significantly greater mean health care costs compared with matched controls (all p < .001). Overall, for patients with initial ESS, CRSwNP was associated with higher disease-related expenditures compared with CRS without nasal polyposis (NP), even for patients who did not undergo revision surgery.

CONCLUSIONS

This SLR identified substantial humanistic burden among surgery candidates. RWE shows that surgeries were used to treat relatively more severe CRSwNP patients as recommended by guidelines. Patient QOL is improved significantly after surgery; however, there is a lack of evidence on patients with revision surgery. Surgery is also associated with higher costs, and the presence of NP was a predictor of revision surgery. Patients with CRSwNP demonstrate greater health care resource utilization and costs compared to those with CRS without NP. Costs associated with different severity of CRSwNP and revision surgery need to be assessed further.

Headache and rhinosinusitis: A review

PURPOSE OF REVIEW

To explain our current understanding of headache attributed to rhinosinusitis, an often inappropriately diagnosed secondary headache.

RECENT FINDINGS

Recent studies have shown that headache attributed to rhinosinusitis is often over-diagnosed in patients who actually have primary headache disorders, most commonly migraine. Failure to recognize and treat rhinosinusitis, however, can have devastating consequences. Abnormalities of the sinuses may also be treatable by surgical means, which may provide headache relief in appropriately selected patients.

SUMMARY

It is important for the practicing physician to understand how rhinosinusitis fits into the differential diagnosis of headache, both to avoid overdiagnosis in patients with primary headache, and to avoid underdiagnosis in patients with serious sinus disease.

Are objective 'findings' the same as subjective 'severity'? A study of the relationship between computed tomography findings and subjective severity in preoperative CRSwNP patients

In pre-surgical patients with chronic rhinosinusitis with nasal polyps (CRSwNPs), positive findings on computed tomography (CT) scans and an exacerbation of symptoms are two possible factors that indicate surgery. However, the relationship between these factors remains unclear. Confirmed CRSwNP patients ready for sinus surgery were consecutively enrolled. The Sino-Nasal Outcome Test 22 (SNOT-22) and visual analog scale (VAS) scoring were completed by these patients, and scores were subjected to factor analysis using a principal component analysis (PCA) to evaluate subjective symptom components related to CRS. Patient CT scores, measured by the Lund-Mackay score (LMS), together with their demographics, medical treatment, and atopy status, were collected and analyzed. A total of 288 patients who met the criteria for CRSwNP and underwent CT scanning prior to surgery in the Eye, Ear, Nose, and Throat Hospital of Fudan University were enrolled. Five components were identified from the PCA of the SNOT-22 results and VAS scores related to subjective symptoms. More severe ‘nasal’ symptoms (P=0.03; 95% CI, 0.092-1.824), loss of smell and taste (P<0.001; 95% CI, 0.961-1.767) and lower facial pain (P=0.001; 95% CI 1.811 to -0.475), derived from the SNOT-22, were significantly associated with total CT score. For the VAS PCA components, less severe ‘ocular’ symptoms (P=0.004; 95% CI -1.852 to -0.352), a reduced ‘pain’ component (P<0.001; 95% CI -2.133 to -0.715), a higher ‘nasal’ symptom component (P<0.001; 95% CI 0.752-2.257) and, again, loss of smell and taste (P<0.001; 95% CI 0.437-0.811) showed an association with total CT score. ‘Allergy-associated symptoms’ in both the SNOT-22 and VAS scores and ‘loss of smell or taste’ and ‘hyposmia’ were significantly more severe in patients with ethmoid sinus/maxillary sinus (E/M) ratios of >2.59 compared with patients with E/M ratios <2.59. Loss of smell and taste alone was correlated with the LMS in patients with highly positive CT scores. The present study demonstrated associations between several subjective symptoms and objective severity in preoperative CRSwNP patients. Nasal symptoms, including olfaction loss, were correlated positively with CT scores, while ocular- and pain-related symptoms showed an opposite pattern. However, this relationship was not confirmed in patients with highly positive CT scores. A subset analysis confirmed, in terms of symptoms, the value of the E/M ratio for indicating eosinophilic chronic rhinosinusitis.

Cost-effectiveness of Endoscopic Polypectomy in Clinic compared to Endoscopic Sinus Surgery: A modelling study

OBJECTIVE

To compare costs and quality-adjusted life years of patients receiving endoscopic polypectomy in the clinic those receiving endoscopic sinus surgery from the perspective of Canada's health system.

METHOD

We developed a Markov model to simulate costs and quality-adjusted life years among a cohort of patients with chronic rhinosinusitis with polyps who received endoscopic polypectomy in clinic or endoscopic sinus surgery, over a patient's lifetime. Our study focused on patients with chronic rhinosinusitis with polyps who have the predominant symptom of bilateral nasal obstruction. Cost data were obtained from Canadian sources. Health utility values were derived from Sino-nasal Outcome Test (SNOT-22) scores reported in the published literature. A cycle length of six months was used. Both costs and quality-adjusted life years were discounted using an annual rate of 1.5%. We conducted one-way and probabilistic sensitivity analyses to assess the robustness of the study findings.

RESULTS

Endoscopic polypectomy in clinic was a cost-saving option as it had a lower cost (C$736 vs. C$6,728) and produced more quality-adjusted life years (13.85 vs 13.06) compared to endoscopic sinus surgery. Our findings were, however, highly sensitive to health utility values. Results from probabilistic sensitivity analysis showed that endoscopic polypectomy in clinic had a lower cost and was more effective compared to endoscopic sinus surgery in 99.86% of iterations.

CONCLUSION

From the perspective of the publicly funded healthcare system, endoscopic polypectomy in clinic was economically attractive compared to endoscopic sinus surgery for chronic rhinosinusitis with polyps patients who have a primary symptom of bilateral nasal obstruction. The cost-effectiveness results are, however, highly dependent on the relative impact of endoscopic polypectomy in the clinic and endoscopic sinus surgery on post-surgery health utility values.

Evolving Rhinology: Understanding the Burden of Chronic Rhinosinusitis Today, Tomorrow, and Beyond

PURPOSE OF REVIEW

To improve our appreciation of the burden of chronic rhinosinusitis (CRS) and to understand better how to ease that burden.

RECENT FINDINGS

The burden of CRS is high. At an individual level, this burden is due to rhinologic symptoms as well as more systemic symptoms. At a societal level, the indirect costs of CRS, mostly due to reduced productivity, are higher than the direct costs. Surgical treatment has been found to be effective in addressing both the individual and societal burdens. Endotyping is just beginning to usher in the potential for personalized, precision treatments in CRS. We understand much about the burden of CRS but more remains to be learned, especially as newer expensive treatments become available. By appreciating the high burden of CRS, we can fulfill our mission to effectively lift that burden.

Microcurrent technology for rapid relief of sinus pain: a randomized, placebo-controlled, double-blinded clinical trial

Background

Transcutaneous electrical nerve stimulation has proven to be effective in alleviating chronic pain from facial myalgias. We evaluated the efficacy of a novel handheld microcurrent‐emitting device in short‐term, office‐based treatment of patients with sinus pain. This device, which is U.S. Food and Drug Administration (FDA)‐cleared, detects and treats regions corresponding to nerve fibers.

Methods

Randomized, double‐blinded, placebo‐controlled trial. Seventy‐one participants with facial pain attributed to self‐reported nasal/sinus disease were recruited from a tertiary rhinologic practice and the surrounding community and randomly assigned to either office‐based use of an active (n = 38) or placebo (n = 33) microcurrent emitter. The study device was repetitively applied by each patient to the bilateral periorbital areas for 5 minutes. A visual analogue scale (VAS) for pain severity was administered before, and 10 minutes after, treatment.

Results

Active microcurrent‐treated patients had a reduction in mean pain score from 5.63 pretreatment to 3.97 posttreatment (mean difference, 1.66; 95% confidence interval [CI], 1.20 to 2.12). Patients using the sham device also reported sinus pain reductions (mean difference, 0.91; 95% CI, 0.61 to 1.21). However, the active device demonstrated a significantly greater reduction in pain compared to sham (0.75‐point difference, p = 0.007). Notably, 23.7% of patients using the active device had a reduction of 3 or more points by VAS compared to 0% of sham device patients (p = 0.003). One minor occurrence of transient facial skin erythema was noted.

Conclusion

This trial suggests that treatment of rhinologic facial pain using this noninvasive microcurrent device is safe and effective in providing rapid relief of nasal/sinus pain. Additional studies with longer term follow‐up are warranted.

Facial pain: sinus or not?

Facial pain remains a diagnostic and therapeutic challenge for both clinicians and patients. In clinical practice, patients suffering from facial pain generally undergo multiple repeated consultations with different specialists and receive various treatments, including surgery. Many patients, as well as their primary care physicians, mistakenly attribute their pain as being due to rhinosinusitis when this is not the case. It is important to exclude non-sinus-related causes of facial pain before considering sinus surgery to avoid inappropriate treatment. Unfortunately, a significant proportion of patients have persistent facial pain after endoscopic sinus surgery (ESS) due to erroneous considerations on aetiology of facial pain by physicians. It should be taken into account that neurological and sinus diseases may share overlapping symptoms, but they frequently co-exist as comorbidities. The aim of this review was to clarify the diagnostic criteria of facial pain in order to improve discrimination between sinogenic and non-sinogenic facial pain and provide some clinical and diagnostic criteria that may help clinicians in addressing differential diagnosis.

Predictive value of SNOT-22 on additional opiate prescriptions after endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is generally well tolerated, yet a subset of patients require an additional opiate prescription in the postoperative period. The purpose of this study was to quantify differences in both preoperative and immediate postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores between patients with a single prescription and those requiring additional opiate prescriptions (AOPs).

METHODS

Patients undergoing ESS between November 2016 and August 2017 were reviewed retrospectively. The Medical and Controlled Substance Utilization Review and Evaluation System (CURES) records were reviewed; patients requiring AOP within 60 days after surgery were identified. The primary and secondary outcomes of interest were the association of baseline and first postoperative visit SNOT-22 total and domain scores with AOP.

RESULTS

A total of 121 patients were reviewed, 22 (18.2%) required AOP. Baseline SNOT-22 scores were higher in aggregate (58.7 ± 16.0 vs 46.1 ± 22.5) and ear/facial domain (11.4 ± 4.8 vs 8.5 ± 5.4) in the AOP group (p < 0.01). AOP patients also demonstrated higher scores across all SNOT-22 domains (p < 0.001) at the immediate preoperative visit. There was no difference in the absolute improvement between groups (15.5 ± 18.30 vs 12.3 ± 23.9, p = 0.54). AOP patients experienced less relative improvement (20.2% vs 34.8%, p < 0.05) and smaller mean effect size (0.57 vs 0.70, p < 0.001) after ESS.

CONCLUSION

Patients reporting increased ear and facial symptoms at baseline have an increased risk of additional opiate prescription after surgery; preoperative SNOT-22 scores may provide utility in identifying these patients. Subjects in both cohorts report symptomatic improvement after ESS; however, relative, not absolute, improvement in SNOT-22 scores is more predictive of AOP.

The price of pain in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with productivity losses exceeding US$13 billion annually. Although pain is well known to significantly affect patient productivity in other diseases, its economic impact on CRS-related lost productivity has not been examined. The objective of this study was to determine whether CRS-related facial pain correlates with lost productivity in patients with CRS.

METHODS

Seventy patients with CRS were enrolled in a cross-sectional investigation. Patients with a history of systemic inflammatory disease, ciliary dysfunction, chronic pain syndromes, migraines, and fibromyalgia were excluded. Pain was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short-Form McGill Pain Questionnaire (SF-MPQ). Presenteeism, absenteeism and lost work, and household and overall productivity were assessed. Regression analysis was performed to assess potential confounders, including depression.

RESULTS

Pain as measured with BPI-SF and SF-MPQ total scores correlated with all domains of productivity losses. Overall, lost productivity was significantly correlated with pain (R range, 0.354-0.485; p < 0.001). Presenteeism (reduced work efficiency) had the highest correlation with all of the overall pain scores (R range, -0.366 to -0.515; p < 0.001). Lost household productivity time was the least affected by pain (R range, 0.267-0.389; p < 0.05). These correlations remained statistically significant after regression analysis, which accounted for depression (p < 0.05).

CONCLUSION

A significant correlation exists between CRS-related facial pain and productivity losses in patients with CRS that is independent of depression. Facial pain has the strongest correlation with presenteeism, which is the main driver of productivity losses and indirect costs associated with CRS.

Diagnostic Accuracy of Symptoms, Endoscopy, and Imaging Signs of Chronic Rhinosinusitis Without Nasal Polyps Compared to Allergic Rhinitis

Objectives The diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) and distinguishing it from allergic rhinitis is difficult. Yet, early detection of CRSsNP is important to prevent progressive and severe chronic rhinosinusitis. Our aim was to compare diagnostic accuracy of symptoms, endoscopy, and imaging signs of CRSsNP and allergic rhinitis -only phenotypes. Setting Prospective controlled follow-up study. Participants Forty-two nonsmoking patients visiting tertiary care due to CRSsNP and 19 nonsmoking volunteer controls with allergic rhinitis filled a symptoms questionnaire and underwent nasal endoscopy off-seasonally. All CRSsNP patients underwent computed tomography scans of paranasal sinuses. All the allergic rhinitis control subjects and 14 of the CRSsNP patients underwent sinus magnetic resonance imaging. Results Radiologic Lund-Mackay score, duration of symptoms, visual analogue scale scores of symptoms, and Sinonasal Outcome Test 22 were significantly higher in the CRSsNP group compared to allergic rhinitis control group. These factors also correlated in part with each other. Endoscopic score did not correlate with other factors, nor did it differ between CRSsNP and allergic rhinitis groups. The highest area under curve value was demonstrated for visual analogue scale score of facial pain/pressure (0.93) and score ≥4/10 showed 60% sensitivity and 95% specificity for detecting CRSsNP group ( P < .001). Radiologic sign of obstructed osteomeatal complex showed 100% specificity and 38% sensitivity for detecting CRSsNP group ( P < .001). Conclusions CRSsNP phenotype could be primarily distinguished from allergic rhinitis by higher facial pain/pressure score and secondarily by radiologic sings of obstructed ostiomeatal complex and higher Lund-Mackay score. Endoscopic score has limited value in distinguishing CRSsNP from allergic rhinitis.

The pain-depression dyad and the association with sleep dysfunction in chronic rhinosinusitis

BACKGROUND

Depression, pain, and sleep disturbance is a symptom cluster often found in patients with chronic illness, exerting a large impact on quality of life (QOL). A wealth of literature exists demonstrating a significant association between depression, pain, and sleep dysfunction in other chronic diseases. This relationship has not been described in patients with chronic rhinosinusitis (CRS).

METHODS

Sixty-eight adult patients with CRS were prospectively enrolled. Patients at risk for depression were identified using the Patient Health Questionnaire-2 (PHQ-2) using a cut-off score of ≥1. Pain experience was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short Form McGill Pain Questionnaire (SF-MPQ). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Forty-seven patients were at risk for depression. Significant positive correlations were found between total PSQI scores and all pain measures (R = 0.38-0.61, p ≤ 0.05) and between total PSQI scores and PHQ-2 scores (R = 0.46, p < 0.05). For patients at risk for depression, significant, positive correlations were found between pain measures, the total PSQI score, and the 3 PSQI subdomains (sleep latency, sleep quality, and daytime dysfunction; R = 0.31-0.61, p < 0.05). The relationship between pain and sleep dysfunction scores was not seen in the absence of depression.

CONCLUSION

Depression, pain, and sleep dysfunction are interrelated in patients with CRS. In the absence of depression, significant correlations between pain and sleep are not observed, suggesting that depression plays a key role in this interaction. Further research is needed to investigate the complex relationship between depression, pain, and sleep dysfunction in CRS.

The Association Between Olfaction and Depression: A Systematic Review

Previous studies on the relationship between olfaction and depression have revealed mixed results. In addition, few have focused on the reciprocity of this association. The aim of this study is to combine depression and olfactory data in two separate patient populations to further understand their association. A systematic literature review was conducted using 3 online databases to identify studies correlating olfaction and depression in patients presenting with either primary depression or primary olfactory dysfunction. For the depressed population, weighted means and standard deviations for the Sniffin' Sticks Test and the 40-item Smell Identification Test were combined using 10 studies. For the olfactory dysfunction population, weighted means of Beck's Depression Inventory were combined using 3 studies. Independent t-tests were used to compare differences between groups. Comparing primary depressed patients with controls, depressed patients showed decreased scores in olfactory threshold (6.31±1.38 vs. 6.78±0.88, P = 0.0005), discrimination (12.05±1.44 vs. 12.66±1.36, P = 0.0073), identification (12.57±0.74 vs. 12.98±0.90, P < 0.0001), and 40-Item Smell Identification Test (35.31±1.91 vs. 37.41±1.45, P < 0.0001). In patients with primary olfactory dysfunction, Beck's Depression Inventory scores were significantly different between patients classified as normosmics, hyposmics and anosmics (5.21±4.73 vs. 10.93±9.25 vs. 14.15±5.39, P ≤ 0.0274 for all 3 comparisons). In conclusion, patients with depression have reduced olfactory performance when compared with the healthy controls and conversely, patients with olfactory dysfunction, have symptoms of depression that worsen with severity of smell loss.

Outcomes of chronic frontal sinusitis treated with ethmoidectomy: a prospective study

BACKGROUND

In medically refractory chronic frontal sinusitis, ethmoidectomy without instrumentation of the frontal ostium may resolve frontal disease. Our aim was to determine the efficacy of ethmoidectomy alone for the treatment of chronic frontal sinusitis.

METHODS

Adults with chronic rhinosinusitis prospectively enrolled in a multicenter study who demonstrated frontal sinusitis on computed tomography were divided into 2 groups: (1) endoscopic sinus surgery (ESS) incorporating ethmoidectomy, but excluding frontal sinusotomy; and (2) ESS incorporating frontal sinusotomy. The primary outcome was improvement in 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Secondary outcomes included endoscopic scores and use of corticosteroids and antibiotics.

RESULTS

A total of 196 cases undergoing frontal sinusotomy and 30 cases treated with ethmoidectomy without frontal sinusotomy were analyzed and were comparable demographically. The prevalence of nasal polyps, previous ESS, asthma, and aspirin intolerance was more common in the frontal sinusotomy group (p < 0.050). Preoperative endoscopy and computed tomography scores were higher in the frontal sinusotomy group (p ≤ 0.001). Postoperatively, both groups showed comparable SNOT-22 scores with worse endoscopy scores in the frontal sinusotomy group (p = 0.038). Postoperative improvement in SNOT-22 total and subdomain scores was comparable between groups. Nasal endoscopy scores improved to a greater degree in the frontal sinusotomy group (p = 0.023). Duration of postoperative topical steroid use was higher in the frontal sinusotomy group (p = 0.007). Revision surgery was needed in 2.6% of frontal sinusotomy patients and 0% of patients without frontal sinusotomy.

CONCLUSION

The treatment of chronic frontal sinusitis through ethmoidectomy is a potential alternative to frontal sinusotomy achieving similar quality of life (QOL) improvements in patients manifesting less severe sinus disease.

Improvements in sleep-related symptoms after endoscopic sinus surgery in patients with chronic rhinosinusitis

BACKGROUND

Sleep impairment is highly prevalent in patients with chronic rhinosinusitis (CRS). Although endoscopic sinus surgery (ESS) has been shown to improve overall patient-reported sleep quality, the postoperative impact on individual sleep symptoms remains unclear.

METHODS

Patients with medically-recalcitrant CRS who elected to undergo ESS were prospectively enrolled into a multi-institutional, observational cohort study. Sleep-related symptom severity and treatment outcomes were assessed using the sleep domain questions within the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

A total of 334 participants met criteria and were followed postoperatively for an average of 14.5 ± 4.9 months (mean ± standard deviation [SD]). Mean SNOT-22 sleep domain scores improved from 13.7 ± 6.8 to 7.7 ± 6.6 (p < 0.001). Significant mean relative improvements were reported for "difficulty falling asleep" (45%; p < 0.001), "waking up at night" (40%; p < 0.001), "lack of a good night's sleep" (43%; p < 0.001), "waking up tired" (40%; p < 0.001), and "fatigue" (42%; p < 0.001) scores. A total of 66% of study participants reported postoperative improvement in "lack of a good night's sleep," "waking up tired," and "fatigue"; 62% reported improvement in "waking up at night"; and 58% reported improvement in "difficulty falling asleep."

CONCLUSION

Patients with CRS report significant and sustained improvements following ESS in common sleep-related symptoms as assessed by the SNOT-22 sleep domain. Despite these significant improvements, some degree of persistent postoperative sleep impairment was reported. Further study is necessary to determine what factors are associated with continued sleep dysfunction after sinus surgery.

Dyad of pain and depression in chronic rhinosinusitis

BACKGROUND

Pain and depression often coexist as comorbidities in patients with chronic disease and exert a major impact on quality of life (QOL). Little is known about the relationship between pain and depression in chronic rhinosinusitis (CRS). Our objective was to investigate this relationship and to analyze the effect of pain and depression on QOL in CRS.

METHODS

Patients with CRS were prospectively recruited as part of an observational cohort study. A total of 70 participants provided pain scores using both the Brief Pain Inventory Short Form (BPI-SF) and the Short Form McGill Pain Questionnaire (SF-MPQ). Patients at risk for depression were identified using the Patient Health Questionnaire-2 (PHQ-2). CRS-specific QOL was determined using the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

Significant positive correlations were found between depression scores and all pain measures (R = 0.475 to 0.644, p < 0.001). Patients with a PHQ-2 score ≥1 had significantly higher scores on all reported pain measures. Significant positive correlations were found between all pain measures, the total SNOT-22 score, and 3 SNOT-22 subdomains (sleep, psychological dysfunction, and ear/facial symptoms; R = 0.323 to 0.608, p < 0.05).

CONCLUSION

Adult patients with CRS at risk for depression experience more pain and have overall worse disease-specific QOL. Further research investigating the complex interactions between depression and pain and the role it plays in CRS disease-specific QOL is warranted.

Cognitive dysfunction associated with pain and quality of life in chronic rhinosinusitis

BACKGROUND

Cognitive dysfunction and its relationship to both pain and disease-specific quality of life (QOL) in chronic rhinosinusitis (CRS) have not been investigated previously. We sought to analyze the correlations of pain and disease-specific QOL with cognitive function in CRS.

METHODS

Adults with CRS were prospectively enrolled in a cross-sectional study. Participants' cognitive function was assessed using the Cognitive Failures Questionnaire. Pain was characterized using the Short-Form McGill Pain Questionnaire (SF-MPQ) and the Brief Pain Inventory Short Form. Disease-specific QOL was ascertained using the Rhinosinusitis Disability Index (RSDI) and 22-item Sinonasal Outcome Test (SNOT-22). Disease severity was assessed using nasal endoscopy and computed tomography. Bivariate correlations of pain and cognitive dysfunction, disease-specific QOL, and clinical measures of disease severity were ascertained.

RESULTS

In patients with CRS (n = 70) there was a significant correlation between cognitive dysfunction and pain severity scores (Spearman's correlation [R(s)] = 0.321, p < 0.01). A similar correlation was identified with pain interference (R(s) = 0.317, p < 0.01) and cognitive dysfunction scores. This is mirrored by a significant correlation between another measure of pain severity, the SF-MPQ and cognitive dysfunction (R(s) = 0.498, p < 0.01). In patients with CRS there was a significant correlation between disease-specific QOL scores and cognitive function scores as measured by the SNOT-22 (R(s) = 0.395, p < 0.01) and the RSDI (R(s) = 0.528, p < 0.01).

CONCLUSION

In patients with CRS, increasing pain and worse QOL are associated with cognitive dysfunction. Possible mechanisms for this cognitive dysfunction include differential neural activation secondary to chronic pain and/or the sequela of a chronic inflammatory state.