Does comorbid anxiety predict quality of life outcomes in patients with chronic rhinosinusitis following endoscopic sinus surgery?

Mindfulness-Based Interventions for Surgical Patients and Impact on Postoperative Outcomes, Patient Wellbeing, and Satisfaction

Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.

Rates of Antidepressant, Anxiolytic, and ADHD Medication Use Among Patients Undergoing ESS

Patients with chronic rhinosinusitis (CRS) are estimated to have psychiatric comorbidity at a higher rate than the general population; however, self-report of depression diagnoses or symptoms often underestimates true prevalence in many populations. In the present study, a cohort of 2279 patients undergoing endoscopic sinus surgery (ESS) were matched to an equal number of non-CRS control subjects by age, sex, race and health status. Overall, the rate of antidepressant/anxiolytic utilization among ESS patients was 22.1%versus 11.3% for controls (P < .001, OR = 2.23, 95% CI 1.90-2.63). The rate of ADHD medication utilization among ESS patients was 3.6%versus 2.0% for controls (P = .001, OR = 1.85, 95% CI 1.28-2.68). This study suggests that patients undergoing ESS exhibit significantly higher rates of antidepressant and ADHD medication utilization relative to a matched control population.

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.

Financial Hardship Impacts Depression and Anxiety Among U.S. Patients with Sinusitis

BACKGROUND

Mental health conditions are common in the United States, and recent efforts have examined the development of mental health conditions among patients with sinusitis.

OBJECTIVES

The purpose of this study was to investigate the association between depression, anxiety, and financial hardship among patients with sinusitis.

METHODS

Cross-sectional study using the 2018 National Health Interview Survey (NHIS). Data regarding demographics, perceived financial hardship, self-reported depression and anxiety, mental healthcare utilization, and treatment compliance were obtained.

RESULTS

Among patients with sinusitis (N = 28 million adults), 9% reported depression and 24% reported anxiety. Sinusitis patients with depression and anxiety reported an increased severity of financial insecurity (p < 0.001). On multivariable logistic regression, worsening financial insecurity increased the odds of depression and anxiety. Patients reporting the highest financial insecurity severity had the highest odds of depression (OR = 3.88, 95% CI = 3.84-3.93, p < 0.001) and anxiety (OR = 2.09, 95% CI = 2.08-2.10, p < 0.001) among measures of financial stress. Specific financial stressors were independently associated with patient-reported depression and anxiety. Sinusitis patients with increased financial insecurity were more likely to require mental health services and treatment (p < 0.001), but were also more likely to report cost-related treatment noncompliance (p < 0.001) and reduced access to mental healthcare due to costs (p < 0.001).

CONCLUSION

Perceived financial hardship is associated with self-reported depression and anxiety among patients with sinusitis. Sinusitis patients with financial hardship also face challenges in accessing and maintaining mental health services and treatment due to costs. Understanding the burden of financial insecurity on mental health and access to treatment may improve quality of care through the development of screening tools and individualized treatment strategies.

Cumulative comorbidity burden does not worsen outcomes in management of chronic rhinosinusitis

BACKGROUND

The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients.

METHODS

Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations.

RESULTS

A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p < 0.001, respectively). There was no correlation between FCI and change in SNOT-22 or SF-6D scores after CRS treatment (R = 0.066, p = 0.17 and R = -0.087, p = 0.074, respectively). Achievement of a minimally clinically important difference was also independent of FCI.

CONCLUSION

Although cumulative comorbidity burden, as measured by FCI, is associated with worse baseline SNOT-22 and SF-6D scores, it does not appear to limit posttreatment improvement in either outcome measure. On average, patients with high comorbidity burden report substantial improvement in both QOL and health utility after CRS treatment, similar to those with fewer comorbidities.

Depression and Anxiety: Considerations for Interpretation of the SNOT-22 (22-Item Sinonasal Outcome Test)

OBJECTIVE

The objective of this study was to determine whether depression and anxiety symptoms affect and confound scoring on the 22-item Sinonasal Outcome Test (SNOT-22), a commonly used outcome measure for chronic rhinosinusitis.

STUDY DESIGN

Prospective cross-sectional.

SETTING

Tertiary care academic center.

METHODS

240 participants completed the SNOT-22, from which nasal, sleep, ear/facial pain, and emotional subdomain scores were calculated. They also completed the 8-item Patient Health Questionnaire (PHQ-8) as a reflection of depression symptoms and 7-item Generalized Anxiety Disorder (GAD-7) questionnaire as a reflection of anxiety symptoms. Correlations were calculated between the 4 SNOT-22 subdomains and the PHQ-8 and GAD-7. Additionally, the predictive ability of subdomains and individual items of the SNOT-22 to predict depression and anxiety was calculated.

RESULTS

The SNOT-22 sleep and emotional subdomains most strongly correlated with the PHQ-8 and the GAD-7. The emotional and sleep subdomain scores were predictive of having depression or anxiety. An emotional subdomain score ≥4 had 62.5% sensitivity and 90.1% specificity for detecting depression and 78.8% sensitivity and 88.9% specificity for detecting anxiety. A sleep subdomain score ≥21 had 81.2% sensitivity and 71.4% specificity for detecting depression and 87.9% sensitivity and 68.6% specificity for detecting anxiety. The emotional subdomain item related to sadness and the sleep subdomain items related to functional impairment were most predictive of depression and anxiety.

CONCLUSION

The SNOT-22 emotional and sleep subdomain scores may be used to predict active depression and anxiety symptoms, especially when items related to sadness or functional impairment are scored with moderate burden.

Comorbidities Known to Affect Physical Function Negatively Impact Baseline Health-Related Quality-of-Life in Patients With Chronic Rhinosinusitis

BACKGROUND

Medical comorbidities are commonly encountered in chronic rhinosinusitis (CRS) and may impact both physical function and patient reported health-related quality-of-life (HRQOL). The functional comorbidity index (FCI) is designed to elucidate the role of comorbidities on functional prognosis. The objective of this study was to understand the impact of comorbidities known to impact physical function on baseline HRQOL using the FCI.Methodology: Patients meeting diagnostic criteria for CRS were prospectively enrolled in a cross-sectional study. Responses from the Sinonasal Outcomes Test-22 (SNOT-22), a measure of patient HRQOL, as well as the Lund-Kennedy and Lund-Mackay scores were recorded at enrollment. FCI was calculated retrospectively using the electronic medical record. Information was collected and compared for patients without (CRSsNP) and with nasal polyps (CRSwNP) using chi-square and t-tests. Spearman's correlations, followed by multivariate regression analysis, were used to assess the association between FCI and SNOT-22 scores.

RESULTS

One hundred and three patients met inclusion criteria for analysis. There were no significant differences in age, gender, and SNOT-22 scores between patients with CRSsNP and those with CRSwNP. FCI was significantly and independently associated with worse SNOT-22 scores (P = .012). FCI did not correlate with endoscopy and computed tomography scores. The mean FCI for patients with CRSsNP and CRSwNP was 2.02 and 2.24, respectively, and did not differ significantly between the two cohorts (P = .565).

CONCLUSIONS

Major medical comorbidities known to affect physical function are associated with worse SNOT-22 scores in patients with CRS as measured by the FCI.

Pain Catastrophizing and Quality of Life in Adults With Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

Psychological comorbidity is common in patients with chronic rhinosinusitis (CRS) and is correlated with decreased overall and disease-specific quality of life (QoL). Prior research reported that anxiety and depression, as measured by the hospital anxiety and depression scale (HADS), are associated with worse CRS-specific QoL, as assessed via the Rhinosinusitis Disability Index (RSDI). Furthermore, patients prone to anxiety/depression may display an exaggerated response to real or anticipated discomfort; the pain catastrophizing scale (PCS) is a validated instrument designed to measure this phenomenon. This study is intended to explore the role of pain catastrophizing in relation to anxiety, depression, and disease-specific QoL in patients with facial pain attributed to CRS.

STUDY DESIGN

Prospective cohort study.

METHODS

Diagnosis of presumed CRS was based upon current American Academy of Otolaryngology - Head & Neck Surgery (AAO-HNS) guidelines; all participants reported facial pain as a component of their CRS symptomatology. RSDI, HADS, and PCS questionnaires were administered upon presentation prior to intervention, and objective measurements of sinonasal inflammation were obtained via nasal endoscopy and computed tomography (CT).

RESULTS

Seventy-five patients were enrolled in the study. Significant positive correlations were found between PCS and HADS, total RSDI, and RSDI emotional sub-scores (P < .05). The incidence of objective evidence of disease, as measured via nasal endoscopy and CT, was not significantly different in catastrophizing patients.

CONCLUSIONS

Pain catastrophizing correlates with anxiety/depression and worse disease-specific QoL in patients meeting symptomatic criteria for CRS. Otolaryngologists should be aware that catastrophic thinking can intensify a patient's perception of sinonasal symptoms, and clinicians may consider management of psychological comorbidity to optimize rhinologic outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1939-1945, 2021.

Emotional and Personality Traits are Determinants of Activity Avoidance in Chronic Rhinosinusitis Patients

OBJECTIVES

Chronic rhinosinusitis (CRS), like other sinonasal diseases, may be associated with avoidance of daily activities. Our goal was to identify characteristics associated with avoidance of activities due to CRS.

MATERIALS AND METHODS

A total of 194 CRS patients were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort and emotional/psychological subdomain scores were calculated. Depressed mood was assessed using the two-item Patient Health Questionnaire (PHQ-2). Personality traits including conscientiousness, neuroticism, agreeableness, openness, and extraversion were assessed using the Big Five Inventory-10 (BFI-10) questionnaire. As the primary outcome, participants rated how often in the prior week that they had avoided any activities in day-to-day life due to their nasal or sinus symptoms on a scale of "never," "rarely," "sometimes," "often," or "extremely often." Ordinal regression models, with bootstrap validation, were used to identify associations between activity avoidance and participants' characteristics.

RESULTS

On multivariable analysis, SNOT-22 score (odds ratio [OR] = 1.03, 95% CI, 1.01-1.04, P = .026), and conscientiousness personality trait (OR = 1.38, 95% CI, 1.05-1.81, P = .019) were positively associated with activity avoidance while age (OR = 0.98, 95% CI, 0.96-0.99, P = .049) was negatively associated with activity avoidance. Of CRS symptom burden/SNOT-22 subdomains, only the emotional/psychological subdomain score (OR = 1.28, 95% CI, 1.12-1.46, P < .001) was associated with activity avoidance.

CONCLUSION

Younger age and the conscientiousness personality trait were associated with activity avoidance in CRS patients. Of CRS-associated symptomatology, sadness and embarrassment were associated with activity avoidance. Emotional traits and personality most strongly predict avoidance of activities in CRS patients.

LEVEL OF EVIDENCE

2c. Laryngoscope, 131:707-712, 2021.

Effect of Functional Endoscopic Sinus Surgery on Outcomes in Chronic Rhinosinusitis​

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) has a significant negative impact on quality of life (QoL). Surgical treatment of CRS is indicated when medical therapy fails to achieve adequate symptom control. This review summarizes the latest information on the outcomes after endoscopic sinus surgery (ESS) with relation to QoL, revision rates, olfaction, absenteeism, asthma control, use of systemic medications, quality of sleep and complications. We also provide an update regarding the factors that can impact outcomes.

RECENT FINDINGS

CRS has classically been divided into two phenotypes depending on the presence or absence of nasal polyps. However, this is an oversimplification as many factors impact disease burden and outcome after treatment. It has been demonstrated that in many cases, ESS fails to meet the expectations of the patients. Evidence based patient counselling is key to help surgeons guide their patients in the best possible way to make well-informed decisions. Repeatedly it has been demonstrated that ESS improves QoL, improves olfaction, leads to better asthma control and less use of systemic antibiotics. However, various patient characteristics including phenotype, disease burden, comorbidities, age, gender and surgical technique can influence the outcome after ESSIt is of paramount importance to include a follow-up period when discussing revision rates. Based on available data, the genuine revision rate is probably 15-20% after five to ten years of follow-up. The revision rate is also affected by various factors and comorbidities.

Pilot Investigation: Prospective Needs Assessment of Knowledge, Attitude, and Insight About Mental Health Treatment Options in Patients With Chronic Rhinosinusitis

INTRODUCTION

Mood disorders frequently coexist with chronic rhinosinusitis (CRS), yet patient views of how mental health impacts their disease, and their willingness to engage in treatment is not well understood.

METHODS

Subjects with CRS were enrolled regardless of their mental health status and completed a needs questionnaire on mental health as it related to CRS. In addition, demographic and disease-specific data were collected.

RESULTS

We enrolled 55 subjects. In addition, 29.1% of them had polyps, with mean endoscopy/computed tomography (CT)/Sino-Nasal Outcome Test (SNOT-22) scores of 3.9/9.7/41.2, respectively and 45% thought depression was common in CRS patients. In total, 78.2% were open to taking a depression screener and would be comfortable discussing mental health with their Ear Nose and Throat provider, 76.4% of patients felt that treating mental health problems could improve sinus-related quality of life (QOL), and 87.3% were open to meeting with a mental health professional or participating in a course on managing stress/anxiety/mental health issues. The multivariate regression model of whether patients felt that treating the mind would improve sinus-related QOL as predicted by age, gender, SNOT-22, CT scores, and endoscopy scores was statistically significant (P = .027) and explained 42% of the variance in answers, but only age and gender approached statistical significance (P = .06 and .04).

CONCLUSIONS

CRS patients acknowledged the high prevalence of comorbid mood disorders and were willing to discuss and be treated for mental health issues. Many patients felt that treating their mental health would improve their disease-specific QOL. These findings warrant further study of how to incorporate the management of metal health into CRS treatment algorithms.

Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies

PURPOSE OF REVIEW

To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS.

RECENT FINDINGS

Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials.

SUMMARY

The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.

Quality of life and emotional burden after transnasal and transcranial anterior skull base surgery

OBJECTIVE

To analyze psychopathological outcome and health-related quality of life (QOL) for cohorts of patients undergoing transcranial or transnasal anterior skull base surgery.

METHODS

A prospective study of patients undergoing elective surgery for various entities of the anterior skull base was performed. Evaluation for depression (ADS-K score) and anxiety (PTSS, STAI-S, STAI-T, and ASI-3 scores) was done before surgery, at 3 and 12 months after surgery. The correlation between preoperative psychological burden and postoperative quality of life as measured by the SF-36 and EuroQol questionnaires was analyzed. Incidence and influence of these psychiatric comorbidities on clinical outcome were examined and compared between transnasal and transcranial subgroups.

RESULTS

We included 54 patients scheduled for surgery of a pituitary adenoma or meningioma of the anterior skull base between January 2013 and July 2017. Of these, a cohort of 40 (74.1%) completed follow-up interviews after 3 and 12 months. There were 60.0% female patients, median age was 57 years. 57.5% of patients had a meningioma and were operated transcranially, while 42.5% of patients received transnasal surgery for pituitary adenoma. The proportion of pathological anxiety scores significantly decreased from 75.0 to 45.0% (p = 0.002), without difference between transnasal and transcranial subgroups. After 3 months, mean EuroQol VAS score non-significantly increased by 0.07 (p = 0.236) across the entire cohort without significant difference between transcranial and transnasal subgroups (p = 0.478). The transnasal cohort tended to score higher in anxiety scores, whereas the transcranial cohort demonstrated higher depression scores without significant difference, respectively. The individually declared emotional burden significantly decreased from 6.7 to 4.0 on the ten-point Likert scale (p < 0.001) equally for both subgroups (transnasal, - 2.3; transcranial, - 3.0; p = 0.174). On last examination, about half of the patients in each subgroup (41.2% vs. 52.2%; p = 0.491) expressed a considerable recovery of preoperative bodily complaints such as headaches, dizziness, and unrest defined as a score of at least 8 on the Likert scaled item.

CONCLUSION

Both transnasal and transcranial approaches yield favorable postoperative QOL and psychopathological outcomes. The postoperative increase in QOL is partly influenced by preoperative expression of mental distress, which tends to resolve postoperatively.

Concha Bullosa Affects Baseline and Postoperative Quality-of-Life Measures in Surgically Managed Chronic Rhinosinusitis

Background

Concha bullosa (CB) is a prevalent anatomic variant and frequent surgical target in endoscopic sinus surgery (ESS). However, whether CB impacts quality-of-life (QOL) in chronic rhinosinusitis (CRS) is not well established. The purpose of this study was to investigate baseline and post-ESS QOL differences in patients with medically recalcitrant CRS with and without CB.

Methods

Demographic and surgical characteristics, baseline and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores for 137 patients with CRS who underwent primary ESS at our institution were recorded. Computed tomography (CT) scans were reviewed for Lund–Mackay score and presence of CB. Multiplanar CT was used to measure CB dimensions and estimate volume. Multivariable analysis was performed to identify differences in SNOT-22 overall and symptom-domain scores between patients with upper quartile (≥0.8 mL) CB and without CB.

Results

CB was found in 37% of patients with mean volume of 0.67 mL. There were no significant differences in distribution of clinicodemographic variables by large CB status. At baseline, large CB was associated with higher SNOT-22 extranasal-rhinologic domain score (9.8 vs 6.0, P < .01). Following ESS, patients with large CB reported greater improvement in SNOT-22 extranasal-rhinologic domain score (multivariable mean absolute improvement 3.8, P = .01; relative 56% vs 30%).

Conclusion

Patients with medically recalcitrant CRS and concomitant large CB have higher SNOT-22 extranasal-rhinologic domain scores at baseline, but also report greater intradomain improvement exceeding the subdomain’s mean clinically important difference. To our knowledge, this is the first demonstration that CB has a clinically significant impact on QOL in CRS, and surgical intervention may be helpful to address these symptoms.

Patient-Reported Outcome Measures and Provocative Testing in the Workup of Empty Nose Syndrome-Advances in Diagnosis: A Systematic Review

Background

The last 5 years have seen a surge of both clinical and scientific interest in empty nose syndrome (ENS). Although ENS is still considered a controversial diagnosis plagued by a lack of standardized diagnostic criteria, ENS is increasingly becoming recognized as a legitimate, physiologic disease entity. As such, it is important for clinicians to understand the most up-to-date diagnostic tools to assess ENS, confirm the diagnosis, and create a more standardized means to counsel these complex patients.

Objective

Contemporary literature review to discuss diagnostic modalities in the evaluation of ENS, in order to introduce evidence-based diagnostic criteria.

Methods

A systematic review was conducted in PubMed and Embase (2013–2019) using the search term “empty nose syndrome” to identify peer-reviewed articles on the topic of ENS. Articles advancing contemporary methods of ENS diagnosis and testing were included. A quality assessment was conducted using The Rational Clinical Examination Levels of Evidence.

Results

The novel development of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) offers the clinician a validated patient-reported outcome measure to supplement history and physical examination. The in-office cotton test, performed by placing an endoscopically directed cotton plug in the site of tissue loss, may help to identify patients who may benefit from turbinate augmentation. Tools such as the sinus computed tomography scan, computational fluid dynamics, and intranasal trigeminal nerve function testing currently have insufficient evidence to support routine use in the workup of ENS. Up to 66% of ENS patients present with comorbid anxiety or depression.

Conclusion

The ENS6Q and cotton test assist in creating a standardized approach to the evaluation of patients suspected of ENS. These instruments should be used as an adjunct, rather than the sole criteria, on which to ascertain the presumptive diagnosis. Patients suspected of ENS should be screened for comorbid psychological dysfunction.

[Depression and anxiety : Prevalence among ENT outpatients]

BACKGROUND

Few data exist on the prevalence of comorbid mental disorders among ENT patients. This investigation aimed to assess the prevalence of two disorders frequent in our society, namely depression and anxiety, in patients of an ENT outpatient clinic.

PATIENTS AND METHODS

During a 2‑week period, 101 consecutive patients were interviewed with the Beck Depression Inventory-II (BDI II) and Beck Anxiety Inventory (BAI) screening aids.

RESULTS

Of 97 evaluated tests, 38% contained indications of a psychiatric problem or mental comorbidity. The proportion of moderate and severe depressive syndromes, anxiety disorders, and combined disorders was only 11.3%. There were no significant differences between genders or in terms of acute vs. chronic ENT diseases. The highest frequency of pathological test results was observed in the group of patients with cochleovestibular disorders. An astoundingly high number of conspicuous test results were seen in patients with trivial diseases and disorders, as well as among those with chronic obstructive disorders of the nose and sinuses.

CONCLUSION

The finding of a considerable prevalence of psychiatric comorbidities among ENT patients represents important information for the treating physician. BDI II and BAI were found to be reliable and easy to apply in the outpatient clinic.

Somatization, Depression, and Anxiety Disorders in a Rhinology Practice

Background

Patients present to rhinology clinics with various complaints. Symptoms may be attributable to objective findings, some remain unexplained. The objective is to investigate the incidence of psychological disorders in a rhinologic practice and evaluate a correlation of these psychiatric diseases with rhinologic symptoms.

Methods

Patients presenting to a rhinology clinic were administered the Generalized Anxiety Disorder 7 (GAD 7), Patient Health Questionnaire 9 (PHQ 9), and PHQ 15, psychometric instruments that can screen for generalized anxiety, major depression, and somatization disorder, respectively. Patients’ symptoms, endoscopic findings, medication, and psychiatric history were recorded. Multivariable analysis was performed for patients showed moderate-to-severe anxiety, depression, and somatic symptoms via 3 logistic regressions where the outcome was a GAD 7, PHQ 9, or PHQ 15 above 10.

Results

One hundred ninety-six patients were included for this study. There were 109 females and 87 males with a mean age of 49 years. Overall, 9%, 14%, and 21% exhibited moderate-to-severe anxiety, depressive, and somatization symptoms, respectively. Nasal obstruction was the only statistically significant variable that increased the odds of having moderate-to-severe anxiety symptoms. Similarly, headache, nasal obstruction, and anosmia/hyposmia were associated with increased odds of having depressive symptoms, and female gender, headache, and nasal discharge increased the odds of somatic symptom disorder. Edema was the only objective endoscopic finding, which was associated with depression only.

Conclusions

Patients should be counseled about the pathophysiology and psychiatric comorbidities affecting their primary rhinologic complaints. The provider needs to set realistic treatment expectations in order to achieve the desired clinical outcomes.

Symptom importance, patient expectations, and satisfaction in chronic rhinosinusitis

BACKGROUND

Sinonasal symptoms and poor quality of life (QOL) prompt chronic rhinosinusitis (CRS) patients to undergo sinus surgery (ESS). However, little is known regarding the symptoms most important to patients and how these impact expectations and postoperative satisfaction.

METHODS

A prospective, multi-institutional cohort study of 100 CRS patients undergoing ESS completed a novel adaptation of the 22-item Sino-Nasal Outcome Test (SNOT-22) wherein they rated how important it was for specific symptoms to improve after surgery, along with preoperative expectations and postoperative satisfaction. The primary satisfaction measure was whether a patient would choose to undergo endoscopic sinus surgery (ESS) again. A multivariate, logistic regression model was built using demographics, objective measures, and the adapted SNOT-22 data. Spearman correlation analysis was also performed.

RESULTS

Nasal obstruction was rated as "extremely" or "very" important by 93% of patients, followed by smell/taste, thick nasal discharge, need to blow nose, postnasal discharge, and sleep symptoms (range, 61-72%). Symptoms like sadness and embarrassment were not considered important by preoperative patients (≤28%). In multivariate logistic regression, postoperative satisfaction depended on preoperative expectations being met and ESS improving their most important symptoms (odds rato, 19.6-27.5; p < 0.005). Postoperative satisfaction was not correlated with achieving a minimal clinically important difference, but it was correlated with magnitude of change in SNOT-22 (r = 0.35; p < 0.05).

CONCLUSIONS

Nasal, smell, and sleep-related symptoms were consdidered most important by this cohort. Meeting of preoperative expectations, improvement of the most important symptoms, and the magnitude of change in the SNOT-22 may drive postoperative satisfaction.

The impact of chronic airway disease on symptom severity and global suffering in Canadian rhinosinusitis patients

Background

Patients with Chronic Rhinosinusitis (CRS) can suffer from a significant decline in their quality of life. CRS patients have a high prevalence of comorbid conditions and it is important to understand the impact of these conditions on their CRS-related quality of life. This study measures the impacts of chronic pulmonary comorbidities on quality of life, pain, and depression scores among patients with CRS awaiting Endoscopic Sinus Surgery (ESS).

Methods

This study is based on cross-sectional analysis of prospectively collected patient-reported outcome data collected pre-operatively from patients waiting for ESS. Surveys were administered to patients to assess sino-nasal morbidity (SNOT-22), depression and pain. The impact of pulmonary comorbidity on SNOT-22 scores, pain and depression was measured.

Results

Two hundred fifthy-three patients were included in the study, 91 with chronic pulmonary comorbidity. The mean SNOT-22 scores were significantly higher among patients with chronic pulmonary comorbidities than among patients without (37 and 48, respectively). This difference is large enough to be clinically significant. Patients with chronic pulmonary comorbidities reported slightly higher depression scores than those without.

Conclusions

This study found that among CRS patients waiting for ESS, chronic pulmonary comorbidities are strongly associated with significantly higher symptom burden.

Systematic Review and Meta-analysis of SNOT-22 Outcomes after Surgery for Chronic Rhinosinusitis with Nasal Polyposis

Objective Wide variation exists regarding reported outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP). This study seeks to combine data across studies to generate a summary measure and explore factors that might lead to variation. Data Sources OVID Medline, Scopus, EbscoHost, Database of Abstracts and Reviews of Effects, Health Technology Assessment, and National Health Service Economic Evaluation Database. Review Methods A search was performed following the PRISMA guidelines. Two independent researchers conducted a search using the mentioned data sources. Studies published before August 29, 2016, that involved ESS to treat CRSwNP were included. Mean changes in Sinonasal Outcome Test-22 (SNOT-22) scores were determined through metaregression of the following independent variables: publication year, sex, age, allergy status, asthma, tobacco use, prior surgery, follow-up length, and preoperative SNOT-22. Results Fifteen articles with 3048 patients treated with ESS met inclusion criteria. Pooled analyses of SNOT-22 scores revealed a mean change of 23.0 points (95% CI, 20.2-25.8; P < .001). A metaregression of patient factor effects on the mean change of SNOT-22 scores demonstrated that age ( r = 0.71, P = .01), asthma ( r = 0.21, P = .01), prior ESS ( r = 0.29, P = .01), and preoperative SNOT-22 score ( r = 0.4, P < .01) correlated with greater improvement in SNOT-22 scores. Tobacco use ( r = -0.91, P = .01) and longer lengths of follow-up ( r = -0.45, P < .01) were associated with less improvement in SNOT-22 scores. Conclusions Quality-of-life outcomes are significantly improved after ESS among patients with CRSwNP. Patient-specific factors may affect the degree of SNOT-22 change after surgery.

Predictive factors of a beneficial quality of life outcome in patients undergoing primary sinonasal surgery: a population-based prospective cohort study

PURPOSE

To assess predictive factors of a beneficial quality of life (QoL) outcome after primary sinonasal surgery.

METHODS

A population-based prospective cohort study among 160 adult patients undergoing primary sinonasal surgery (76 septoplasties, SP; 84 endoscopic sinus surgeries, ESS) was conducted. We collected QoL data using the Sinonasal Outcome Test-22 (SNOT-22) before and after surgery. A beneficial QoL outcome was defined as a SNOT-22 score change ≥ 9 points 12 months after surgery. Various demographic, clinical and symptom-related factors predicting a beneficial QoL outcome were sought using binary logistic regression analysis.

RESULTS

The mean age of the patients was 39 years (range 18-61) and 82 (51%) were males. The SNOT-22 score change varied markedly after SP (range - 17 to + 80) and ESS (range - 20 to + 58), but on average it improved (median + 15 after SP and + 16 after ESS). 41 patients (64%) achieved beneficial QoL outcome after SP and 46 (66%) after ESS. In a multivariate analysis, poor QoL before surgery (preoperative SNOT-22 ≥ 20 points) predicted a beneficial QoL outcome after SP and ESS (adjusted odds ratio 10; 95% confidence interval 1.6-64 and 12; 2.5-55, respectively) and a senior surgeon operating after SP (9.9; 1.5-67). On receiver operating characteristic curve analysis, the integer threshold value for the preoperative SNOT-22 score that gave the highest sensitivity (74%) and specificity (70%) was 30.

CONCLUSIONS

QoL change after primary SP and ESS varies. A preoperative SNOT-22 score of at least 30 best predicted a beneficial QoL outcome after both procedures.

Effect of generalized anxiety disorders on the success of pessary treatment for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Our aim was to evaluate the impact of generalized anxiety disorders (GAD) on the effectiveness of pessary treatment for pelvic organ prolapse (POP) in postmenopausal women.

METHODS

One-hundred and ten women with symptomatic POP who underwent pessary treatment were enrolled in this prospective study. Subjective evaluations of pelvic floor symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), both at baseline and at the 3-month follow-up visit after pessary use. GAD was measured by the Generalized Anxiety Disorder-7 (GAD-7). Independent samples t tests, Mann-Whitney U test, chi-square test, Fisher's exact test, and Wilcoxon signed rank test were used to analyze data.

RESULTS

Twenty-one patients (20.6%) had GAD at baseline. After 3 months of pessary use, PFIQ-7, PFDI-20, and GAD scores were significantly improved in all participants (P < 0.001). In the GAD-negative group, total PFIQ-7 and PFDI-20 scores, including all subscales scores, were significantly decreased from baseline to posttreatment (P < 0.05). However, in the GAD-positive group, both PFIQ-7 and PFDI-20 scores, including subscales, were also significantly decreased from baseline to posttreatment (P < 0.05), except for subscale Colorectal-Anal Impact Questionnaire (CRAIQ-7) of PFIQ-7 (P = 0.225), which represented the impact on quality of life (QoL) from bowel dysfunction.

CONCLUSIONS

Both groups of women with or without GAD showed significant improvement in QoL scores after 3 months of pessary treatment. GAD had no influence on the success of pessary treatment for POP.

Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

The goal of the study was to perform a systematic review with meta-analysis to determine the mean change in the 22-item Sino-Nasal Outcome Test (SNOT-22) across patients who have had endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) in the literature.

METHODS

A literature search was performed to identify studies that assessed SNOT-22 scores before and after ESS in adult patients with CRS. A random effects model with inverse variance weighting was used to generate the mean change after surgery, along with the forest plot and 95% confidence interval (CI). The impact of patient-specific factors across studies was assessed using a mixed-effects meta-regression.

RESULTS

The final study list included 40 unique patient cohorts published from 2008 to 2016. All studies showed a statistically significant change in mean SNOT-22 scores between baseline and postoperative time points (P < .001), ranging from 12.7 to 44.8, at an average follow-up of 10.6 months. The summary change in mean SNOT-22 across all studies was 24.4 (95% CI: 22.0-26.8). After forward, step-wise multivariate modeling, studies with higher mean preoperative SNOT-22 score and higher asthma prevalence were associated with greater changes in SNOT-22 score after ESS, whereas studies with longer mean follow-up had smaller changes in SNOT-22 score.

CONCLUSIONS

Studies evaluating quality-of-life outcomes after sinus surgery using the SNOT-22 instrument universally show significant improvement after ESS. Across the published literature, the magnitude of change is quite variable and appears to be influenced by a number of factors including baseline SNOT-22 score, asthma prevalence, and length of follow-up. Laryngoscope, 128:581-592, 2018.

Effect of diabetes mellitus on postoperative endoscopic sinus surgery outcomes

BACKGROUND

Endoscopic sinus surgery (ESS) has become the treatment of choice for a variety of nasal conditions. The purpose of this study was to analyze the effect of diabetes mellitus (DM) on postoperative outcomes in ESS.

METHODS

Data on endoscopic sinus surgery performed from 2005 to 2013 were collected from the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Two groups were created, based on the presence of a DM diagnosis, and were analyzed for preoperative variables, comorbidities, and postoperative complications using SPSS statistical software.

RESULTS

There were 644 patients included in the analysis, 85 of whom (13.2%) had a diagnosis of DM. Patients with DM were more likely to have higher rates of preoperative dyspnea and hypertension. After accounting for confounding factors, DM patients undergoing ESS were at higher risk of overall medical complications, pneumonia, unplanned reintubation, ventilator use of >48 hours, and mortality. However, after separating patients into outpatient and inpatient groups, DM was found to be an independent predictor of urinary tract infection in outpatients and of ventilator use >48 hours in inpatients.

CONCLUSION

DM patients undergoing ESS are at increased risk for postoperative medical complications. However, DM does not appear to increase the postoperative surgical complication rate in this population. Furthermore, DM does not appear to have an impact on ESS mortality, readmission, or reoperation rates.

Comparing surgeon outcomes in endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objective of this investigation was to evaluate endoscopic sinus surgery (ESS) outcomes for chronic rhinosinusitis (CRS) between medical centers to determine if differences in quality-of-life outcomes were detectable. In addition, we sought to identify significant, independent cofactors toward the development of an ESS-specific risk-adjustment model so that ESS outcomes may be appropriately compared between institutions and healthcare providers.

STUDY DESIGN

Prospective, multicenter, observational cohort.

METHODS

Study participants electing ESS for CRS were enrolled and randomly selected in equal numbers from three academic clinical practices in North America between April 2011 and May 2015. The magnitude of average 6-month postoperative improvement in patient-related outcome measures (PROMs) was compared between enrollment sites using multivariate linear regression modeling.

RESULTS

A total of 228 participants met inclusion criteria and were included for final analyses (n = 76 per site). The prevalence of septal deviation/septoplasty and oral corticosteroid-dependent conditions was significantly different between enrollment sites (P ≤ 0.004). Each enrollment site generated significant within-subject improvement across all PROMs after ESS (P < 0.001); however, average unadjusted magnitudes of improvement were significantly different between sites for the primary outcome measure. After controlling for baseline PROMs, septal deviation, steroid-dependent conditions, and medication use variables, enrollment site was no longer associated with significant outcome differences (P = 0.535).

CONCLUSION

Comparison of surgeon outcomes of ESS is feasible and must take into account a number of baseline patient characteristics. Further studies will be critical toward developing an ESS-specific risk-adjustment model and enabling a robust comparison of surgeon outcomes.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:14-21, 2017.

Longitudinal improvement and stability of olfactory function in the evaluation of surgical management for chronic rhinosinusitis

BACKGROUND

Abnormal olfaction is common with chronic rhinosinusitis (CRS) and associates with various measures of sinonasal inflammation. The Brief Smell Identification Test (BSIT) has demonstrated improvements in abnormal olfactory detection following endoscopic sinus surgery (ESS), but olfaction remains understudied using this instrument. Discerning longitudinal, postoperative durability in olfaction is critical for patient counseling.

METHODS

Adult participants with medically recalcitrant CRS were prospectively enrolled into a multi-institutional cohort study and observed for 18 months after ESS. Olfaction was operationalized using BSIT scores collected at baseline, 6 months, 12 months, and 18 months postoperatively and compared using repeated measures analysis of variance (ANOVA).

RESULTS

A total of 122 participants met inclusion criteria and were recruited between March 2011 and February 2014. Improvement in mean BSIT scores at 6-month follow-up were reported for all participants (p = 0.014) with greatest improvement in subjects with nasal polyposis (p = 0.001). No differences in mean BSIT scores were found between 6 months and 18 months overall; however, subjects with comorbid asthma (F₍₂₎ = 5.29; p = 0.010) and nasal polyposis (F₍₂₎ = 3.99; p = 0.033) reported significant mean worsening. Prevalence of abnormal olfaction decreased from 28% preoperatively to 17% at 6 months (p = 0.015), for all subjects, without significant change at 12 months (19%; p = 0.791) or at 18 months (21%; p = 0.581) postoperatively.

CONCLUSION

Postoperative improvement in olfaction was reported 6 months after ESS using BSIT scores, with greatest improvements in patients undergoing polypectomy. Overall improvement persisted between 6 months and 18 months after ESS for most patient subgroups; however, dysosmia worsened after initial improvement in patients with asthma and nasal polyps, highlighting the need for further identification of prognostic factors associated with abnormal olfaction in CRS.

Productivity outcomes following endoscopic sinus surgery for recurrent acute rhinosinusitis

OBJECTIVES/HYPOTHESIS

We sought to evaluate preoperative and postoperative productivity losses and quality of life (QOL) impairment reported by patients with recurrent acute rhinosinusitis (RARS) as compared to patients with chronic rhinosinusitis without nasal polyposis (CRSsNP).

STUDY DESIGN

Prospective, multi-institutional, nested case-control.

METHODS

Participants with RARS (n = 20) and CRSsNP (n = 20) undergoing endoscopic sinus surgery (ESS) were enrolled as part of a prospective cohort study. For comparison, participants diagnosed with RARS cases were age/gender-matched to control participants diagnosed with CRSsNP using a 1:1 ratio.

RESULTS

RARS and CRSsNP participants were followed for ∼14 months postoperatively. Productivity losses were reported as the number of days missed from normal productive activities out of the previous 90 days. RARS participants reported similar baseline productivity losses (12.6 ± 27.1 [standard deviation]) as participants with CRSsNP (11.7 ± 20.9; P = .314). Postoperatively, improvement in productivity losses was similar between RARS participants and CRSsNP controls (-6.7 ± 20.0 vs. -9.8 ± 19.1; P = .253). Preoperative and postoperative disease-specific QOL measures (Sino-Nasal Outcomes Test-22 and Rhinosinusitis Disability Index) were similar between the two groups. RARS participants reported a significant decrease in days of previous antibiotic (P = .009) and nasal decongestant (P = .004) use following ESS, whereas participants with CRSsNP reported a significant decrease in antibiotic (P = .002) and oral corticosteroid use (P = .002).

CONCLUSIONS

RARS patients report baseline productivity losses and disease-specific QOL impairment to levels that parallel those with CRSsNP. Patients with RARS report improvement in QOL following ESS in all disease-specific QOL measures and in several medication measures. Productivity losses and postoperative improvements are similar between patients with RARS and CRSsNP.

LEVEL OF EVIDENCE

3b Laryngoscope, 126:1046-1053, 2016.

Improvements in psychological dysfunction after endoscopic sinus surgery for patients with chronic rhinosinusitis

BACKGROUND

Psychological dysfunction is highly prevalent among patients with chronic rhinosinusitis (CRS). Previous study has identified various measures of anxiety and depression as predictors of quality-of-life outcomes following endoscopic sinus surgery (ESS). Psychological dysfunction scores, as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22), have been found to influence treatment decision making in CRS. This study aims to further elucidate improvement in discrete psychological symptoms following ESS for CRS.

METHODS

Adult patients with medically recalcitrant CRS electing to undergo ESS were prospectively enrolled into a multi-institutional, observational cohort. Psychological-related symptom severity and postoperative outcomes were assessed using psychological domain items of the SNOT-22, including subgroup analysis of patients with and without comorbid depression.

RESULTS

A total of 374 participants met inclusion criteria and were followed postoperatively for a mean ± standard deviation (SD) of 14.6 ± 5.0 months. Total mean psychological domain scores improved from 15.9 ± 8.2 to 8.5 ± 8.4 (p < 0.001). Significant relative mean improvements were reported in "waking up tired" (23%; p < 0.001), "fatigue" (25%; p < 0.001), "reduced productivity" (28%; p < 0.001), "reduced concentration" (27%; p < 0.001), " frustrated/restless/irritable" (27%; p < 0.001), "sad" (15%; p < 0.001), and "embarrassed" (8%; p < 0.001) scores. A total of 64% to 66% of participants reported improvement in "reduced productivity," "waking up tired," "fatigue," and "frustrated/restless/irritable," compared to 46% and 38% reporting improvement in "sad" and "embarrassed," respectively.

CONCLUSION

Patients with CRS report significant improvement in common mental health-related symptoms following ESS. Despite these improvements, some degree of persistent postoperative psychological dysfunction was reported. Further study is necessary to determine which factors are associated with persistent psychological dysfunction after ESS in order to optimize treatment outcomes.

Patient-centered decision making: the role of the baseline SNOT-22 in predicting outcomes for medical management of chronic rhinosinusitis

BACKGROUND

For patients with chronic rhinosinusitis (CRS), the decision to elect continued medical management vs surgery is complex and involves tradeoffs between benefits, risks, and overall effectiveness of each therapy. The purpose of this study is to investigate whether baseline disease-specific quality of life (QOL) can assist in predicting outcomes in patients with refractory CRS who elect continued medical management.

METHODS

CRS patients electing medical management were enrolled in a prospective, multi-institutional cohort study. Patients were stratified into pretreatment 22-item Sino-Nasal Outcome Test (SNOT-22) subgroups based on 10-point score increments (eg, 10 to 19, 20 to 29, 30 to 39, etc.) to capture potential outcome differences by baseline SNOT-22 disease burden. The proportion of patients achieving minimal clinically important difference (MCID≥9 points) and relative improvement (%) for each score category were calculated.

RESULTS

Seventy-five CRS patients with a mean ± standard deviation pretreatment SNOT-22 score of 45.2 ± 16.6 were followed for a mean of 14.9 months. The majority of participants electing medical therapy failed to improve 1 MCID (57%) with a mean relative score improvement of 16%. Overall, 37% of patients maintained baseline SNOT-22 QOL status, whereas 20% of patients deteriorated >1 MCID. When treatment crossover patients (to endoscopic sinus surgery [ESS]) were included (n = 117), approximately 1 in 4 (27%) patients achieved an MCID.

CONCLUSION

Results from this study suggest that the majority of CRS patients electing ongoing medical management with low baseline disease-specific QOL impairment maintain stable QOL with continued medical management. Furthermore, of CRS patients electing ongoing medical therapy, approximately 1 in 4 patients achieved MCID, whereas 1 in 5 experienced deterioration by >1 MCID.

A survey on chronic rhinosinusitis: opinions from experts of 50 countries

Chronic rhinosinusitis (CRS) is a very prevalent inflammatory disease. Treatments vary in different countries. In the present study, we explored the approaches of physicians in 50 countries. In this cross-sectional study, a rhinosinusitis survey (RSS) was completed by Honorary and Corresponding Members (otorhinolaryngologists) of the Italian Society of Rhinology. In 79.1 % of the 50 countries, the proportion of patients suffering from CRS was 15 %. Nasal symptoms were more intense in winter (46 % of countries), and spring and autumn (22 %). The most common symptoms were nasal obstruction (86 %), postnasal drip (82 %) and headache (52 %). The most common investigative modalities in the assessment of CRS are paranasal sinus CT, fiberoptic endoscopy, and anterior rhinoscopy. CRS patients were principally treated by otorhinolaryngologists (70 %). Medical treatments included nasal corticosteroids (90 %), nasal washes (68 %), and nasal decongestants (32 %). In 88 % of countries, more than 50 %, or "about 50 %", of all patients reported subjective symptom improvement after treatment. In most of the countries, surgery was required by 20-35 % of all CRS patients. During post-surgery follow-up, nasal washes (90 %), nasal corticosteroids (76 %), and systemic antibiotics (32 %) were prescribed. In 20-40 % of all patients, CRS was associated with nasal polyps. In such patients, the medical treatment options were nasal corticosteroids (90 %), systemic corticosteroids (50 %), nasal washes (46 %), and systemic antibiotics (34 %). Treatment of CRS patients varies in different countries. Paranasal sinus CT is the most common investigative modality in the assessment of CRS, and nasal corticosteroids are the first-line treatment, in the absence or presence of nasal polyps.

Twenty-two-item Sino-Nasal Outcome Test in a control population: a cross-sectional study and systematic review

BACKGROUND

The 22-item Sino-Nasal Outcome Test (SNOT-22) is a commonly utilized outcome measure for chronic rhinosinusitis (CRS). However, what constitutes a normal score remains poorly defined. The goal of this study was to evaluate SNOT-22 scores in a control population without CRS and perform a systematic review and meta-analysis of "normal" values.

METHODS

Ninety-nine subjects without CRS were enrolled, with 95 fully completing the SNOT-22 questionnaire. Multivariable linear regression was used to determine whether demographic factors or medical comorbidities influence SNOT-22 scores in a population without CRS. A systematic literature search was performed, identifying studies that evaluated the SNOT-22 in a non-CRS population and estimates for SNOT-22 values were pooled.

RESULTS

Thirty-six males and 59 females were included in the primary analysis with a mean age of 53.4 ± 17.3 years (range, 18-88 years). The mean SNOT-22 score was 16.4 ± 15.2. Asthma (p = 0.003) and depression (p = 0.002) were found to be independent predictors of higher SNOT-22 scores. Thirteen articles were identified in the literature search and 1 was provided via author correspondence, with 10 reporting sufficient data to be included in the meta-analysis. Weighted mean SNOT-22 score was 11 ± 9.4 (n = 1517). Our data differed significantly from published data (mean difference = 5.4; 95% confidence interval [CI], 3.4 to 7.5; p < 0.0001) likely owing to differences in comorbidities.

CONCLUSION

SNOT-22 scores vary in non-CRS populations depending upon the group queried. Asthma and depression are associated with higher SNOT-22 scores and should be considered when determining what constitutes a normal value.

Patients electing medical vs surgical treatment: emotional domain of the Rhinosinusitis Disability Index associates with treatment selection

BACKGROUND

The Rhinosinusitis Disability Index (RSDI) consists of multiple subdomains shown to be useful in studying chronic rhinosinusitis (CRS). The objective of this study was to determine if RSDI subdomain scores are associated with selection of treatment modality (endoscopic sinus surgery [ESS] or continued medical management [CMM]) in subjects with CRS.

METHODS

Patients with CRS were prospectively enrolled into a multi-institutional cohort study. Following an initial period of medical management, patients elected to undergo treatment with either ESS or CMM. Baseline RSDI total and subdomain scores were compared between patients electing different treatment modalities.

RESULTS

A total of 684 subjects were enrolled with 122 (17.8%) electing CMM and 562 (82.2%) electing ESS. When compared to patients undergoing CMM, patients electing ESS exhibited significantly higher mean baseline RSDI total scores (mean ± standard deviation [SD]: 48.1 ± 24.9 vs 40.1 ± 24.1; p = 0.001) and subdomain scores (emotional: 13.2 ± 9.1 vs 10.4 ± 8.3; p = 0.001; functional: 15.3 ± 8.9 vs 12.6 ± 8.4; p = 0.002; and physical: 19.6 ± 9.3 vs 17.1 ± 9.6; p = 0.007). Emotional subdomain scores were found to be the most associated with choice of treatment modality.

CONCLUSION

Patients with CRS electing ESS had worse baseline RSDI total and subdomain scores compared to those electing CMM. Although both rhinologic and nonrhinologic symptoms contributed to the selection of treatment modality, emotional symptoms appeared to exhibit the greatest influence on patient-centered treatment decisions.