The SNOT-22 factorial structure in European patients with chronic rhinosinusitis: new clinical insights

Dupilumab improves sleep quality in chronic rhinosinusitis with nasal polyps

PURPOSE

Chronic rhinosinusitis with nasal polyps (CRSwNP) often alters sleep quality. Dupilumab emerged as an innovative and effective therapy for refractory/recurrent severe CRSwNP. The aim of this observational retrospective study was to evaluate the sleep quality in patients with CRSwNP who underwent treatment with dupilumab.

MATERIALS AND METHODS

Forty-five patients treated with dupilumab for CRSwNP were enrolled. Clinical parameters (age, sex, comorbidities, Nasal Polyp Score - NPS, Asthma Control Test - ACT), nasal cytology, quality of life (Sino Nasal Outcome Test 22 - SNOT-22), sleep quality (Pittsburgh Sleep Quality Index - PSQI, Epworth Sleepiness Scale - ESS), and risk of sleep apnea (STOP-BANG) were recorded before treatment (T0), and after 3 (T1), 6 (T2), and 12 months (T3).

RESULTS

NPS, ACT and SNOT-22 total score improved during treatment (p < 0.05). Meanwhile, all sleep parameters evaluated with SNOT-22, ESS and PSQI improved over time (p < 0.001), expect for PSQI Use of sleeping medications. Indeed, sleep drugs are rarely used before and during the treatment. The global sleep quality was classified as poor in 88.9 % of cases at T0 and decreased to 5.7 % at T3. A high risk of sleep apnea was revealed by the STOP-BANG in 68.9 % of cases at T0 and 2.8 % of patient at T3 (p < 0.001).

CONCLUSIONS

Dupilumab improves the sleep quality and reduce the risk of sleep apnea in patients with severe CRSwNP. Its favorable effect occurs within 3 months and is maintained during the treatment.

Psychological Status as an Effect Modifier of the Association Between Allergy Symptoms and Allergy Testing

OBJECTIVE

Patient-reported outcome measures, while valuable, may not correlate with diagnostic test results. To better understand this potential discrepancy, our objective was to determine whether psychological health is an effect modifier of the association between patient-reported allergy outcome scores and allergy test results.

STUDY DESIGN

Prospective outcomes study.

SETTING

Tertiary care hospital and community-based clinic.

METHODS

This study included 600 patients at least 18 years of age who presented for symptoms related to allergic rhinitis and completed the related sinonasal outcome test (SNOT), which includes validated nasal, allergy, and psychological domains. Stratified analyses of odds ratios and Spearman correlation coefficients were utilized to assess for effect modification by psychological status.

RESULTS

Worse patient-reported allergic rhinitis symptoms were significantly associated with positive allergy test results (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.22-2.34, P = .002) in patients with better psychological health. In contrast, there was no association in patients with worse psychological health (OR 1.06, 95% CI 0.36-3.10, P = .92). These findings were corroborated by assessments of correlation: allergy domain scores were positively correlated with allergy testing scores (Spearman rho 0.18, 95% CI 0.10-0.25, P < .001) in patients with better psychological health, while there was no correlation in patients with worse psychological health (-0.02, 95% CI -0.16-0.12, P = .77).

CONCLUSIONS

Psychological status was an effect modifier of the association between allergy domain and allergy testing data. When assessing the relationship between subjective measures, such as sinonasal validated instruments, and objective measures, such as allergy test results, accounting for effect modifiers such as psychological state can provide clinical and research-related insights.

A Study of Comparison of Outcomes of Submucous Diathermy, Coblation and Micro-debrider Assisted Inferior Turbinoplasty in Patients Having Inferior Turbinate Hypertrophy

The cause of nasal obstruction in most of the patients is either nasal septal deviation or turbinate hypertrophy owing to vasomotor or perennial allergic rhinitis. Most cases of hypertrophic turbinate are usually mild and respond to antihistamine therapy, local decongestions, or allergy desensitization; however, surgery is required in some cases. In our present study, three surgical methods were used for inferior turbinoplasty i.e. Sub-mucous Diathermy, Coblation and Micro-debrider and patients were divided randomly in these groups. The efficacy and outcomes of these methods was compared on the basis of subjective and objective relief of symptoms and their safety, recurrence and post-operative morbidity. Out of 45 patients, highest number of patients belonged to 20-40 years of age with the mean age of 28.7 years and male female ration 0.78:1. All the patients were evaluated on the basis of preoperative Endoscopic grading of inferior turbinate and SNOT22 symptom scores (Sino Nasal Outcome Test 22), intra-operative timing and bleeding and post-operative pain, crusting, SNOT22 scores (Sino Nasal Outcome Test 22) and Endoscopic grading improvement in inferior turbinate. On comparing all the above methods, we found that Coblation and Micro- debrider were more or less equally effective and better than Sub-mucous diathermy for inferior turbinoplasty. Submucous diathermy has least benefits, still most commonly used method because of its simplicity, conventionality and least cost factor while other two methods need capital investment and higher learning curve of the surgeon.

Postinfectious conditions challenge disease-specificity of SNOT-22

PURPOSE

The Sino-Nasal-Outcome-Test 22 (SNOT-22) questionnaire assesses treatment outcome and health-related quality of life (HRQOL) in patients with chronic rhinosinusitis (CRS). However, given the overlap between CRS and olfaction in terms of nasal function and the definition of CRS, a fundamental question arises: can patients with olfactory dysfunction (OD) stemming from other causes attain SNOT-22 scores similar to those seen in CRS, even in the absence of CRS? Our study aimed to explore whether OD arising from various postinfectious mechanisms challenges the disease-specificity of SNOT-22 for CRS. If so, could focus on scores within specific symptom domains of SNOT-22 prove valuable in distinguishing between different etiologies.

METHODS

The study adopted an observational, retrospective cohort design based on prospectively registered patients and related variables using the REDCap platform. 460 patients experiencing OD due to either (1) simple or (2) complex post-COVID-19, (3) postinfectious non-COVID-19, and (4) CRS, were included in the analysis.

RESULTS

The study revealed that the total SNOT-22 score lacks disease-specificity for CRS. This is evident, because complex postinfectious mechanisms resulting from COVID-19 can produce similar symptoms in patients. Notably, elevated total scores were primarily driven by high subdomain scores within the "sleep and cognition" domain.

CONCLUSIONS

The application of SNOT-22 as a screening tool needs to be approached with caution, as the total score alone does not provide disease-specific insights. A more thorough exploration of the four symptom domains and the identification of distinctive scoring patterns within the clinical context may prove pivotal in effectively differentiating between various underlying causes.

Sino-nasal Outcome Test (SNOT22) score in adult population with no known sino-nasal disease

PURPOSE

This cross-sectional study aimed to establish normative values for Sino-Nasal Outcome Test (SNOT-22) score in adult Indian population without known sino-nasal diseases. The purpose was to fill a critical knowledge gap, providing insights into how various host factors influence SNOT-22 scores which seek to serve as reference for clinical studies, facilitating comparisons of symptom severity and aid in patient counselling based on specific score patterns.

METHODS

One thousand and twelve adults meeting inclusion criteria participated in the study. Participants provided demographic information, occupation details, addiction history, and medical background. They completed SNOT-22 questionnaire, grading their symptoms on Likert scale of 0-5 based on severity experienced in the past 2 weeks. The collected data were analysed to derive meaningful insights.

RESULTS

Mean SNOT-22 score for the study population was 6.80, with 90% scoring below 15, and 40% within 0-3 range. Females exhibited significantly lower mean scores than males. Residents of rural areas reported higher scores than urban counterparts. Education levels had no significant influence on scores. Occupational exposure to aeroallergens, addiction (especially tobacco), and a history of allergies, bronchial asthma, or atopy were associated with significantly higher SNOT-22 scores. Principal component analysis identified four distinct domains, with the nasal symptom domain consistently emerging as the major contributor to differences in subgroups with significantly different total SNOT-22 scores.

CONCLUSION

The normative data and subgroup analyses established in this study serve as a foundation for future research, aiding clinicians in predicting symptoms and providing tailored counselling for individuals with sino-nasal pathologies.

Validation of a Novel Allergy-Specific Domain for the 22-Item Sino-Nasal Outcomes Test

OBJECTIVES

To develop and assess the validity of a novel allergy-specific domain for the 22-item sino-nasal outcomes test (SNOT-22), to provide a new tool that efficiently quantifies the impact of allergic rhinitis (AR) concurrent with chronic rhinosinusitis.

STUDY DESIGN

Prospective validation study.

SETTING

Tertiary care hospital and community-based clinic.

METHODS

Proposed items were developed based on clinician and patient input, and further assessed via factor analysis and for internal consistency (n = 1987). Items were then additionally assessed for convergent and discriminant validity (n = 415), applying data from concurrent completions of the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE), Mini-Rhinoconjunctivitis Quality-of-Life Questionnaire (MiniRQLQ), and validated global health assessments. Assessments of intra-rater reliability, responsiveness to change, and qualitative input were also performed.

RESULTS

Factor analysis demonstrated that proposed allergy items mapped to a single domain. Items were internally consistent (Cronbach α: 0.80 within domain, 0.91 within all SNOT). In assessments of convergent validity, domain scores were associated with MiniRQLQ (Spearman's ρ: 0.46, 95% confidence interval [CI]: 0.30-0.59) and NOSE scores (0.36, 95% CI: 0.27-0.44). The novel items also discriminated among clinical states: a 1-point increase in domain score was associated with an 8.32 (95% CI: 5.43-12.75) increase in the odds of prompting a visit for allergy-related symptoms and a 1.52 (95% CI: 1.13-2.05) increase in the odds of positive allergy testing. Intra-rater reliability was substantial (Cohen's κ: 0.8, 95% CI: 0.8-0.9), and responsiveness to change was demonstrated (mean difference: -0.6, 95% CI: -0.8 to -0.4).

CONCLUSIONS

This novel domain is a valid, efficient measure of AR alongside rhinosinusitis.

The Frequency and Clinical Assessment of COVID-19 in Patients With Chronic Rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS), as an inflammatory airway disease, could be a risk factor for COVID-19 patients. This study aimed to investigate the frequency and severity of symptoms of COVID-19 in patients with CRS and to assess the association between the status of CRS symptoms and the quality of life (QoL) of the patients.

METHODS

In this observational and cross-sectional study, 207 adult CRS patients participated. The patients, who presented the symptoms of COVID-19, were examined by taking the reverse transcription-polymerase chain reaction test. A questionnaire was completed by each patient, regarding their demographic and clinical data. In addition, the GA2LEN and Sino-Nasal Outcome Test (SNOT-22) standard questionnaires were used to identify the comorbid allergic condition and QoL of CRS patients.

RESULTS

The frequency of patients with COVID-19 was 25 (12.1%) of which 22 were treated as outpatients, 2 of them admitted in wards and 1 at intensive care unit. The severity of hyposmia in the patients was 2 (8%) as mild, 5 (20%) moderate, and 11 (72%) as anosmia. The most common allergic and underlying comorbid diseases were allergic rhinitis (88%) and thyroid disorders (28%). Further, the average SNOT-22 score in 4 SNOT-22 domains (nasal, otologic, sleep, and emotional symptoms) was significantly decreased in CRS patients after a period of one year since the pandemic started (40.1 ± 18.0 vs. 46.3 ± 17.7; P < .0001).

DISCUSSION

This study showed a low frequency of COVID-19 in patients with CRS and about the same rate of infection positivity in the general population; therefore, we concluded that CRS could not be considered as a risk factor for COVID-19. Interestingly, the lower average score of SNOT-22 after one year of the pandemic in the patients with CRS confirmed the necessity for performing the standard health protocols by the patients.

Normative data for interpreting the SNOT-22

Objectives

The Sino-Nasal Outcome Test 22 (SNOT-22) is a validated patient-reported outcome instrument to evaluate the health-related quality of life (HRQoL) in patients with chronic rhinosinusitis (CRS). There are no published normative SNOT-22 scores, limiting its interpretation.

Methods

Symptom scores from 1,000 SNOT-22 questionnaires were analysed by principal component analysis (PCA) and exploratory factor analyses. Data were derived from a survey with 1,000 healthy Europeans (reference cohort) who were recruited using the Respondi panel for market and social science research. This subsample was quoted to the population distribution of the German Microcensus and selected from a non-probability panel.

Results

The overall normative SNOT-22 score can be detected to be 20.2 ± 19.44. Male (18.49 ± 19.15) and older (> 50 years old; 18.3 ± 17.49) participants had overall lower SNOT-22 mean results than females (21.8 ± 19.6) and younger (21.4 ± 20.55) participants, indicating higher levels of satisfaction. PCA proposed two SNOT-22 domains ("physiological well-being" and "psychological well-being"), which explained 65% of the variance.

Conclusions

These are the first published (German) normative scores for the SNOT-22 and provide a clinical reference point for the interpretation of data.

The Impact of Sinonasal Symptoms in Relation to Potentially Life-Threatening Comorbidities

OBJECTIVE

While general health may be influenced by sinonasal symptoms, their effects may be overshadowed by comorbid states which may be more serious. To assess the validity of this postulate, we measured the extent to which sinonasal symptoms and concurrent conditions influenced general health.

STUDY DESIGN

Observational outcomes study.

SETTING

Academic medical center, community care sites.

METHODS

Adults with sinonasal symptoms completed the 22-item Sinonasal Outcome Test, along with the Patient-Reported Outcomes Measurement Information System global health short form. Comorbidities were categorized with the Deyo modification of the Charlson comorbidity index. Multivariate regression analyses were utilized to determine the relative impact of sinonasal symptoms and concurrent comorbid conditions on general health.

RESULTS

Data from 219 consecutive patients demonstrated that sinonasal symptoms were associated with significantly diminished general physical (β = -1.431, p < .001), mental (β = -1.000, p < .001), overall (β = -1.026, p < .001), and social health (β = -0.872, p = .003), regardless of the presence of potentially life-threatening comorbid conditions. Comorbid conditions included cardiovascular disease, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer, diabetes mellitus, and hepatic disease. The effect of sinonasal symptoms was neither subsumed nor overshadowed by the effects of comorbid states. Nasal, ear, sleep, and psychological domain scores were also associated with general physical, mental, and global health while adjusting for the impact of comorbidities.

CONCLUSION

Sinonasal symptoms have a substantial effect on general health which is not subsumed by the presence of potentially life-threatening concurrent comorbidities. These data may help support the importance of funding and resource allocation for conditions causing sinonasal symptoms.

Evaluation of Improvement in Chronic Rhinosinusitis After Endoscopic Sinus Surgery Using Sino-Nasal Outcome Test-22 (SNOT22) Symptom Score

Sino-Nasal Outcome Test (SNOT-22) symptom score is the most widely used questionnaire due to its easy interpretation with respect to quality of life (QOL) in patients with chronic rhinosinusitis (CRS). It helps in deciding further treatment plan in patients with refractory CRS despite maximal medical therapy (MMT). Endoscopic sinus surgery (ESS) is suggested in patients not responding to medical treatment. The preoperative and post-operative QOL for patients with CRS is assessed using SNOT-22. To assess SNOT-22 score change in CRS resistant to MMT. This is a longitudinal study conducted from April 2021-September 2022 included patients diagnosed to have CRS, satisfying the inclusion criteria. SNOT-22 for symptom severity assessed at the first visit, 1 week and 12 weeks and after MMT. Patients who failed MMT, posted for ESS. Post-operatively SNOT-22 symptom score re-assessed at 15 days, 1 month, 2 months and 3 months. 56 patients (male-51% and female-49%) who failed to respond to MMT included in the study. The five major troublesome symptoms nasal blockage (92.86%), need to blow nose (75%), facial pressure/pain (53.57%), post nasal discharge (51.79%), and sneezing (42.86%). The mean SNOT-22 symptom score when compared with pre-operatively (69.54 ± 8.973) and after FESS (2.09 ± 1.881) had improved significantly (p < 0.001). CRS is more frequently seen in males aged between 21 and 30 years. The patient-based outcome measures, like SNOT-22 helps to foresee the extent of post- operative improvement. The effective management of CRS is by surgical intervention.

Management of Mechanical Nasal Obstruction Isolated or Associated to Upper Airway Inflammatory Diseases in Real Life: Use of both Subjective and Objective Criteria

PURPOSE OF REVIEW

Mechanical nasal obstruction (MNO) is a prevalent condition with a high impact on patient's quality-of-life (QoL) and socio-economic burden. The aim of this study was to determine the usefulness of both subjective and objective criteria in the appropriate management of MNO, either alone or associated to upper airway inflammatory diseases such as allergic rhinitis (AR) or chronic rhinosinusitis with nasal polyps (CRSwNP).

RECENT FINDINGS

A long debate persists about the usefulness of subjective and objective methods for making decisions on the management of patients with nasal obstruction. Establishing standards and ranges of symptom scales and questionnaires is essential to measure the success of an intervention and its impact on QoL. To our knowledge this is the first real-life study to describe the management of MNO using both subjective and objective criteria in MNO isolated or associated to upper airway inflammatory diseases (AR or CRSwNP). Medical treatment (intranasal corticosteroids) has a minor but significant improvement in MNO subjective outcomes (NO, NOSE, and CQ7) with no changes in loss of smell and objective outcomes. After surgery, all MNO patients reported a significant improvement in both subjective and objective outcomes, this improvement being higher in CRSwNP. We concluded that in daily clinical practice, the therapeutic recommendation for MNO should be based on both subjective and objective outcomes, nasal corrective surgery being the treatment of choice in MNO, either isolated or associated to upper airway inflammatory diseases, AR or CRSwNP.

The role of intranasal corticosteroids in chronic rhinosinusitis with nasal polyposis treated with dupilumab

PURPOSE

Dupilumab represents an innovative and effective therapy for refractory/recurrent severe chronic rhinosinusitis with nasal polyps (CRSwNP). Intranasal corticosteroids should be used during treatment with biological agents. However, adherence to nasal therapy may not be complete. The aim of this study was to evaluate the role of intranasal corticosteroids in patients with CRSwNP who underwent treatment with dupilumab.

MATERIALS AND METHODS

Fifty-two patients treated with dupilumab for CRSwNP were enrolled. Clinical parameters (age, sex, comorbidities, blood eosinophils, Nasal Polyp Score - NPS, Visual Analogue Scale - VAS - for smell loss, Asthma Control Test - ACT), quality of life (Sino Nasal Outcome Test 22 - SNOT-22 questionnaire), nasal cytology, and adherence to regular administration of intranasal corticosteroids were recorded before treatment (T0), and after 3 (T1), 6 (T2), and 12 months (T3).

RESULTS

NPS, VAS for smell, ACT and SNOT-22 total score and subscores improved during treatment (p < 0.05). Blood eosinophils reached a peak at T1-T2 and then decreased toward baseline at T3. Adherence to regular treatment with intranasal steroids was 61.5 %. No statistically significant differences in all the clinical outcomes were observed between patients who regularly used intranasal steroids and other subjects (p > 0.05). Nasal cytology showed a decrease of eosinophils and an increase of neutrophils during treatment.

CONCLUSIONS

Dupilumab is still effective in patients who are using topical nasal steroids with variable adherence (real world settings).

A Systematic Review and Meta-analysis of SNOT-22 Outcomes After Sinus Surgery

Background: All stakeholders in the healthcare system have prioritized and will continue to prioritize enhancing care quality. The measurement of sinus-specific quality of life (QOL) is potentially the most commonly used QOL parameter for chronic rhinosinusitis (CRS). Objective: A systematic review and meta-analysis were used in this study to determine the mean change in patients' scores on the 22-item Sino-Nasal Outcome Test (SNOT-22) before and after endoscopic sinus surgery (ESS) for CRS. Methods: PubMed, Google Scholar, and ScienceDirect were searched for articles that compared SNOT-22 scores before and after ESS in adult patients with CRS and were published between January 2000 and March 2023. The mean post-op change, 95% confidence interval (CI), forest plot, and inverse variance weighting were all generated using a random effects model. A mixed-effects meta-regression was used to analyze the effect of patient-specific characteristics across studies. Results: Fifteen prospective patient cohorts published from 2009 to 2023 were included in this meta-analysis. At an average follow-up of 25.5 months, all studies demonstrated a statistically significant difference in mean SNOT-22 scores between baseline and post-op time periods (P < .05), ranging from 5.1 to 55.4. Across all studies, the mean SNOT-22 changed significantly by 26.02 (95% CI: 12.83-38.60). According to a stepwise multivariate analysis, studies with higher mean age and mean pre-op SNOT-22 scores had greater changes in SNOT-22 scores following ESS, whereas trials with longer mean follow-up duration had smaller changes in SNOT-22 scores. Conclusion: Research utilizing the SNOT-22 instrument has demonstrated that endoscopic sinus surgery (ESS) leads to enhanced quality of life (QOL) outcomes. The literature reports that improvement is influenced by the initial SNOT-22 score, the mean age of the patients, and the duration of the follow-up period.

Meaningful changes for efficacy outcomes in patients with chronic rhinosinusitis with nasal polyps

Objective

Nasal Polyp Score (NPS) and Nasal Congestion Score (NCS) are commonly used clinical trial endpoints to determine improvements in response to treatment in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). However, limited information is available on within-patient meaningful change thresholds (MCTs) and between-group minimal important differences (MIDs) for NPS and NCS, which would aid interpretation of results.

Methods

Data from phase 3 placebo-controlled trials of omalizumab in patients with CRSwNP (POLYP 1 and POLYP 2) were used to estimate MCTs and MIDs for both NPS and NCS using anchor-based methods. Sino-Nasal Outcome Test-22 (SNOT-22) and SNOT-22 Sino-Nasal Symptoms Subscale (SNSS) scores were used as anchors (≥0.35 correlation with NPS and NCS). Within- and between-group differences in NPS and NCS change scores were used to estimate MCTs and MIDs, respectively. Identified MCTs were used in unblinded responder analyses to compare the proportions of patients per treatment group achieving a meaningful improvement.

Results

MCTs and MIDs were estimated at -1.0 and -0.5 for NPS and -0.50 and -0.35 for NCS, respectively, and were consistent across studies. Overall, 57.0% of patients achieved the MCT in NPS with omalizumab vs 29.9% with placebo (p < 0.0001). Similarly, 58.9% of patients achieved the MCT in NCS with omalizumab vs 30.7% with placebo (p < 0.0001). Group differences in mean change were statistically significant and exceeded the estimated MIDs.

Conclusions

Meaningful change estimates for NPS and NCS could be used to assess response to treatment for patients with chronic rhinosinusitis with nasal polyps.Trial registration: POLYP1: clinicaltrails.gov NCT03280550; registered September 12, 2017; https://clinicaltrials.gov/ct2/show/NCT03280550). POLYP2 (clinicaltrials.gov NCT03280537; registered September 12, 2017; https://clinicaltrials.gov/ct2/show/NCT03280537).

Effects of CFTR-modulator triple therapy on sinunasal symptoms in children and adults with cystic fibrosis

PURPOSE

Sinunasal symptoms and chronic rhinusinutitis are common in patients with cystic fibrosis. Cystic fibrosis transmembrane regulator (CFTR) modulators have led to dramatic improvements of respiratory symptoms and quality of life in patients with cystic fibrosis. This study aims to evaluate subjective and objective sinunasal symptoms after start of CFTR-modulator triple therapy.

METHODS

43 patients (n = 6 < 18 years), treated with highly effective CFTR-modulator therapy with elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA) were included, as were 20 controls with cystic fibrosis but without CFTR-modulator therapy (n = 6 < 18 years). All assessed their sinunasal symptoms retrospectively and the intervention group at a mean of 9.3 (2-16) months after start of ELX/TEZ/IVA.

RESULTS

Improvements in SNOT-22 overall score from m = 32.7 to m = 15.7 points (p < 0.0001) as well in the nasal, emotional, otologic, and sleep subdomains could be demonstrated in the intervention group. No changes were found in the control group. Children showed lower SNOT-22 scores than adults and a reduction of SNOT-22 total score from m = 9.4 to m = 2.2 (p = 0.25) was found. 8 patients were evaluated by an otorhinolaryngologist before and after start of ELX/TEZ/IVA and showed pronounced objective clinical improvement.

CONCLUSIONS

Highly effective CFTR-modulator therapy has a significant positive impact on both subjective and objective sinunasal symptoms in patients with CF and some improvement could be demonstrated in children < 18 years as well.

Mepolizumab improvements in health-related quality of life and disease symptoms in a patient population with very severe chronic rhinosinusitis with nasal polyps: psychometric and efficacy analyses from the SYNAPSE study

BACKGROUND

Although the psychometric properties of patient-reported outcome measures (e.g. the 22-item Sino-nasal Outcomes Test [SNOT-22]) in chronic rhinosinusitis with nasal polyps (CRSwNP) have been defined, these definitions have not been extensively studied in patients with very severe CRSwNP, as defined by recurrent disease despite ≥ 1 previous surgery and a current need for further surgery. Therefore, the psychometric properties of the symptoms visual analogue scales (VAS) were evaluated, and meaningful within-patient change thresholds were calculated for VAS and SNOT-22.

METHODS

SYNAPSE (NCT03085797), a randomized, double-blind, placebo-controlled, 52-week trial, assessed the efficacy and safety of 4-weekly mepolizumab 100 mg subcutaneously added to standard of care in very severe CRSwNP. Enrolled patients (n = 407) completed symptom VAS (six items) daily and SNOT-22 every 4 weeks from baseline until Week 52. Blinded psychometric assessment of individual and composite VAS was performed post hoc, including anchor-based thresholds for meaningful within-patient changes for VAS and SNOT-22, supported by cumulative distribution function and probability density function plots. The effect of mepolizumab versus placebo for 52 weeks on VAS and SNOT-22 scores was then determined using these thresholds using unblinded data.

RESULTS

Internal consistency was acceptable for VAS and SNOT-22 scores (Cronbach's α-coefficients ≥ 0.70). Test-retest reliability was demonstrated for all symptom VAS (Intra-Class Correlation coefficients > 0.75). Construct validity was acceptable between individual and composite VAS and SNOT-22 total score (r = 0.461-0.598) and between individual symptom VAS and corresponding SNOT-22 items (r = 0.560-0.780), based upon pre-specified ranges. Known-groups validity assessment demonstrated generally acceptable validity based on factors associated with respiratory health, with all VAS responsive to change. Mepolizumab treatment was associated with significantly increased odds of meeting or exceeding meaningful within-patient change thresholds, derived for this very severe cohort using six anchor groups for individual VAS (odds ratio [OR] 2.19-2.68) at Weeks 49-52, and SNOT-22 (OR 1.61-2.96) throughout the study.

CONCLUSIONS

Symptoms VAS and SNOT-22 had acceptable psychometric properties for use in very severe CRSwNP. Mepolizumab provided meaningful within-patient improvements in symptom severity and health-related quality of life versus placebo, indicating mepolizumab provides substantial clinical benefits in very severe CRSwNP.

Man flu is not a thing - Gender-specific secondary analysis of a prospective randomized-controlled trial for acute rhinosinusitis

BACKGROUND

'Man flu' is a popular term to describe hypersensitivity to acute rhinosinusitis (ARS) in men. While this pop-cultural description may influence the social perspective of ARS, so far, no prospective observational data on the gender-specific natural development of ARS is available.

METHODS

Secondary data analyses were performed from the placebo arm of a prospective, interventional phase IV clinical trial. Objective measurement of ARS symptoms were assessed with the Major Symptom Score (MSS), a clinician-rated assessment tool. The Sino-Nasal Outcome Test-22 (SNOT-22) was used for symptom self-report. Repeated measures analysis of variance (ANOVA) with gender as a group variable were used to investigate changes in MMS and SNOT-22 total score and subscales over time.

RESULTS

While MMS scores did not differ at baseline, women showed a significantly greater reduction than men with a medium effect size (p = .040) over time. In the patient-reported symptom score, women showed a significantly higher symptom load at baseline (p = .038), but also a significantly faster subjective improvement of symptoms than men during the course of time with a medium effect size (p = .020). However, when separately assessing the SNOT-22 subscales, a significant time*gender effect was only found for emotional symptoms (p = .047). No gender effect was found for neither nasal, otological, or sleep symptoms (all p > .05).

DISCUSSION

Although a certain gender difference was found both in the clinician- as well as patient-rated ARS symptoms, the hypothesis of a 'man flu' should be disregarded. Gender differences in ARS symptomatology should be carefully evaluated without stigmatizing symptom distress based on gender perceptions.

Prevalence, determinants of chronic rhinosinusitis and its impact on quality of life among students in Karachi, Pakistan

Background

Chronic rhinosinusitis (CRS) is a common public health issue among students.

Methodology

 A total of 300 undergraduate students were selected through multistage cluster sampling from three public-sector universities. Sino-nasal Outcome Test (SNOT-22) and Rhinosinusitis Disability Index (RSDI) were used for determining the quality of life. Chi-square and independent t-test were used.

Results

About 46% and 54% (p = 0.001) of social science and health science students were suffering from CRS, respectively. Around 7% and 9% of CRS patients had poor quality of life according to SNOT-22 and RSDI, respectively (p = 0.042 and p = 0.032, respectively).

Conclusion

Quality of life was affected in all domains of SNOT-22 and RSDI.

The efficacy of itraconazole, fluticasone and doxycycline in chronic rhinosinusitis

BACKGROUND

Different treatment strategies for chronic rhinosinusitis (CRS) have been evaluated. Here we aimed to investigate the effects of fluticasone spray alone and in combination with itraconazole or doxycycline.

METHODS

This is an open-label clinical trial performed in 2020-2021 in Isfahan on patients with CRS. This survey's Iranian Registry of Clinical Trials (IRCT) code was IRCT20200825048515N50 (https://en.irct.ir/trial/60826). Demographic data of all patients including age and gender and duration of CRS, were obtained. The SNOT-22 and Lund-Kennedy questionnaires were evaluated and recorded for the symptomatology of CRS. Patients were randomly assigned to the treatment groups to receive 100 mg of doxycycline with intranasal fluticasone spray, intranasal fluticasone spray alone, or itraconazole 100 mg capsules with intranasal fluticasone spray. After one month of treatment, the scores and patient satisfaction were evaluated and compared.

RESULTS

Data of 104 patients was analyzed. Patients had improvements in their symptoms and SNOTT-22 scores. The mean SNOTT-22 score was 55.36±8.36 in all patients. During the study, patients had improvements in their symptoms and SNOTT-22 scores. The mean final SNOTT-22 score was 47.77±7.36 at the end of the survey (P=0.02). Our data also demonstrated significant improvements in the Lund-Kennedy score in all patients during the study (P<0.05).

CONCLUSION

There were no significant differences between the clinical condition of patients receiving intranasal fluticasone, intranasal fluticasone in combination with doxycycline or itraconazole.

Expert Opinion on Biological Treatment of Chronic Rhinosinusitis with Nasal Polyps in the Gulf Region

Chronic rhinosinusitis (CRS) is defined as the inflammation of nose and paranasal sinuses, affecting the patients' quality of life and productivity. Chronic rhinosinusitis with nasal polyps (CRSwNP) is a principal clinical entity confirmed by the existence of chronic sinonasal inflammation and is characterized by anterior or posterior rhinorrhea, nasal congestion, hyposmia and/or facial pressure or facial pain. Several epidemiologic studies have revealed wide variations in the incidence of CRS among regions globally ranging from 4.6% to 12%. The Gulf countries are also witnessing an unprecedented burden of CRSwNP. According to the current clinical guidelines, glucocorticosteroids and antibiotics are the principal pharmacotherapeutic approaches. Endoscopic sinus surgery is recommended for those who have failed maximal pharmacotherapy. Recently, biologics are considered as an alternative best approach due to the complications associated with medical therapy and surgery. However, precise data on the clinical position of biologic agents in the management of CRSwNP in the Gulf region is not available. The present review article addresses the current diagnostic and management approaches for CRSwNP and also emphasizes the role of emerging biologics in the current treatment strategies for CRSwNP in the Gulf region. Further, a consensus protocol was convened to rationalize the guideline recommendations, strategize the best practices with biologics, and develop clinical practice guidelines for all primary-care specialists in the Gulf region. The consensus-based report will be a useful reference tool for primary-care physicians in primary-healthcare settings, regarding the appropriate time for the initiation of biological treatment in the Gulf region.

A Tool for Rapid Assessment of Functional Outcomes in Patients with Head and Neck Cancer

Head and neck cancer (HNC) and its treatment can lead to various functional impairments. We developed and validated an instrument for rapid physician-rated assessment of basic functional outcomes in HNC patients. HNC-relevant functional domains were identified through a literature review and assigned to verbal ratings based on observable criteria. The instrument draft was subjected to systematic expert review to assess its face and content validity. Finally, the empirical validity, reliability, and responsiveness of the expert-adapted Functional Integrity in Head and Neck Cancer (HNC-FIT) scales were assessed in healthy controls and in HNC patients. A matrix of the 6 functional domains of oral food intake, respiration, speech, pain, mood, and neck and shoulder mobility was created, each with 5 verbal rating levels. Face and content validity levels of the HNC-FIT scales were judged to be adequate by 17 experts. In 37 control subjects, 24 patients with HNC before treatment, and in 60 HNC patients after treatment, the HNC-FIT ratings in the 3 groups behaved as expected and functional domains correlated closely with the outcome of corresponding scales of the EORTC-HN35-QoL questionnaire, indicating good construct and criterion validity. Interrater reliability (rICC) was ≥0.9 for all functional domains and retest reliability (rICC) was ≥0.93 for all domains except mood (rICC = 0.71). The treatment effect size (eta-square) as a measure of responsiveness was ≥0.15 (p < 0.01) for fall domains except for breathing and neck and shoulder mobility. The median HNC-FIT scale completion time was 1 min 17 s. The HNC-FIT scale is a rapid tool for physician-rated assessment of functional outcomes in HNC patients with good validity, reliability, and responsiveness.

Development of Sinonasal Outcome Test (SNOT-22) Domains in Chronic Rhinosinusitis With Nasal Polyps

Objectives/Hypothesis

The 22‐item Sinonasal Outcome Test (SNOT‐22) is a validated chronic rhinosinusitis health‐related quality‐of‐life outcome (HRQoL) measure; however, SNOT‐22 domains have not been validated specifically for chronic rhinosinusitis with nasal polyps (CRSwNP).

Study Design

Validation of SNOT‐22 domain structure, using data from 3 randomized, placebo‐controlled, double‐blinded, multicenter clinical trials of dupilumab in adults with moderate‐to‐severe CRSwNP.

Methods

Preliminary dimensional structure was derived by exploratory factor analyses of SNOT‐22 data from a phase 2 trial (NCT01920893) of dupilumab for the treatment of CRSwNP. Data from 2 phase 3 clinical trials (NCT02912468 and NCT02898454) were then used for confirmatory factor analysis, and evaluated for reliability, construct validity, and responsiveness. In all three trials, the SNOT‐22 was administered electronically on a tablet and trial participants were required to answer all items.

Results

Factor analysis supported five domains: Nasal, Ear/Facial, Sleep, Function, and Emotion. Correlations between domains were moderate to high, ranging from 0.53 (Nasal–Emotion) to 0.88 (Function–Sleep). Construct validity was mostly supported; relationships with other measures were almost always in the intended direction and magnitude. Internal consistency reliability also confirmed questionnaire structure with strong Cronbach's alpha values (all >0.80). Moderate‐to‐high correlations were observed between change in SNOT‐22 domain scores and other study patient‐reported outcome measures, along with large effect‐size estimates (≥0.7), demonstrating responsiveness of the Nasal, Sleep, and Function domains. Emotion and Ear/Facial domains had small‐to‐moderate effect sizes.

Conclusions

Psychometric analyses support the validity, reliability, and responsiveness of five domains of SNOT‐22 (Nasal, Ear/Facial, Sleep, Function, and Emotion) for assessing symptoms and impact on HRQoL in patients with CRSwNP. Laryngoscope, 132:933–941, 2022

The Manukau Salivary Symptoms Score for Assessing the Impact of Sialendoscopy in Recurrent Obstructive Sialadenitis

OBJECTIVE

To examine the Manukau Salivary Symptom Score (MSSS) questionnaire as a validated tool to assess obstructive sialadenitis-specific symptoms to both indicate disease severity and assess the outcome after sialendoscopic procedures.

STUDY DESIGN

A prospective observational study was performed from 2010 to 2019 comprising 164 patients undergoing sialendoscopy for nonneoplastic chronic obstructive salivary gland disease (COSGD).

SETTING

Department of Otolaryngology-Head and Neck Surgery at the Manukau Surgical Centre, Auckland, New Zealand, between June 2010 and September 2019.

METHODS

A prospective observational study was performed from 2010 to 2019 comprising 164 patients undergoing sialendoscopy for nonneoplastic COSGD. Patients completed the MSSS preoperatively and at postoperative follow-up. Statistical tests were used to compare pre- and postoperative answers. Cronbach's α was used to measure internal consistency. Finally, construct validity was determined by comparing the 5-question MSSS questionnaire to the preexisting 20-question Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire.

RESULTS

Postoperatively, patients had significant improvements in pain, eating, talking, swelling, and quality of life (P < .001). The MSSS questionnaire was found to have high internal consistency (α = 0.938). Questions in the MSSS had a very strong positive correlation with 3 COSS questions, a strong positive correlation with 8, a moderate positive correlation with 4, and a weak positive correlation with 1. Four COSS questions were not considered relevant and were not included in the MSSS questionnaire.

CONCLUSION

The MSSS questionnaire is a simple, validated questionnaire that is useful for assessing the impact of sialendoscopy in patients with COSGD.

Quality of Life and Morbidity after Endoscopic Endonasal Skull Base Surgeries Using the Sinonasal Outcomes Test (SNOT): A Tertiary Hospital Experience

Introduction

Endoscopic endonasal skull base surgery (EESBS) has been associated with a minimally invasive and effective approach for pathology of the anterior skull base and associated with less overall morbidity compared with open approaches. However, it is associated with its own potential morbidity related to surgical manipulation or resection of normal and noninflamed intranasal structures to gain adequate access. The assessment of sinonasal QOL (quality of life) postsurgery is therefore a vital aspect in follow-up of these patients.

Objectives

To assess quality of life and morbidity after endoscopic endonasal skull base surgery using the Sinonasal Outcomes Test (SNOT-22). Methodology. A single-center retrospective cross-sectional review with a sample of 80-100 patients undergoing endoscopic endonasal transsphenoidal surgery was conducted at the ENT and Neurosurgery departments of King Fahad Specialist Hospital-Dammam (KFSH-D) for a period of 10 years from March 2010 to March 2020. Data were collected through hospital records and database, as well as from patients through phone call interviews. Records were reviewed for diagnosis, demographic features, and 22-item Sinonasal Outcomes Test (SNOT-22) scores noted at three points in time: prior to procedure and after, at 3 months and 6 months.

Results

Within the study cohort comprising 96 patients, the mean age of the participants was 39.5 ± 12.1 years, and diagnostic typing before and after histopathological investigations revealed maximum pituitary adenomas (46.9%) closely followed by CSF-related ailments (41.7%). The changes in the mean and standard deviation of the total SNOT-22 scores postoperatively at the 3^rd month (9.5 ± 5.4) and the 6^th month (8.8 ± 5.2) were statistically significant (p < 0.001) when compared to the preoperative score (10.8 ± 5.1).

Conclusion

Although there was a predicted passivity of symptoms in the post-EESBS period, several significant positive outcomes were seen. The increase in discomfort in the sleep domains postsurgery is an issue to pursue and reason out. The overall SNOT-22 scores noted preoperatively and 3 and 6 months postoperatively showed statistically significant improvements in QOL with no long-term effects.

Responsiveness and convergent validity of the chronic rhinosinusitis patient-reported outcome (CRS-PRO) measure in CRS patients undergoing endoscopic sinus surgery

BACKGROUND

The chronic rhinosinusitis patient-reported outcome (CRS-PRO) measure is a 12-item measure with previously demonstrated validity in chronic rhinosinusitis (CRS) patients receiving medical therapy. This study establishes the factor structure, responsiveness, and convergent validity of the CRS-PRO following endoscopic sinus surgery (ESS).

METHODS

Northwestern CRS Subject Registry patients had pre-ESS, 3-month (n = 111; CRS without nasal polyps [CRSsNP] = 60, CRS with nasal polyps [CRSwNP] = 51), and 6-month (n = 86; CRSsNP = 47, CRSwNP = 39) post-ESS assessments where patients completed the CRS-PRO, 22-item Sino-Nasal Outcome Test (SNOT-22), and four Patient-Reported Outcomes Measurement (PROM) Information System (PROMIS) short forms (general health measures). Patients had pre-ESS objective testing (endoscopic and radiographic assessment). Factor analysis was conducted using principal axis factoring with varimax rotation on the baseline CRS-PRO. The clinically important difference (CID) was estimated using both distribution-based and anchor-based methods.

RESULTS

Factor analysis found the CRS-PRO comprised the "rhino-psychologic," "facial discomfort," and "cough" factors, which were responsive to ESS and correlated with the other PROMs. The changes observed in the CRS-PRO at 3 months had strong correlation with the corresponding changes in SNOT-22 (r = 0.792, p < 0.0001) and moderate correlations with changes in PROMIS fatigue and sleep domains. These changes had a very large effect size (Cohen's d 1.44) comparable to the longer SNOT-22 (Cohen's d 1.41) with slightly larger effect sizes observed in CRSwNP compared to CRSsNP patients. Similar convergent validity and responsiveness were observed in the 6-month data. The CRS-PRO CID was estimated to be between 5.0 and 7.5 (midpoint 6.0) using distribution-based and anchor-based methods.

CONCLUSION

This study demonstrates the validity and responsiveness of the CRS-PRO in subjects receiving ESS.

Assessment of health-related quality-of-life in patients with chronic Rhinosinusitis - Validation of the German Sino-Nasal Outcome Test-22 (German-SNOT-22)

PURPOSE

The Sino-Nasal-Outcome-Test-22 (SNOT-22) represents the reference questionnaire to assess symptoms, health-related quality-of-life (HRQOL) and treatment-response in patients with chronic rhinosinusitis (CRS). The SNOT-22 has been validated for various languages, yet no validation is available for the German version. Thus, we provide a validation of the SNOT-22 for German.

METHODS

In this prospective observational study 139 CRS-patients and 36 control-participants were included. CRS-patients completed the German-SNOT-22 before treatment (T0) and four (T1), twelve (T2) and 48 weeks after inclusion (T3). At T0, Mackay-Naclerio-, Lund-Mackay- and Brief-Symptom-Inventory-18 (BSI-18) scores were collected as external reference for the German-SNOT-22 and its subscales. At T1, T2, and T3 health-transition-items (HTIs) were raised to explore responsivity. Control-participants completed the German-SNOT-22 at T0. Reliability (internal consistency, item-total correlation), validity (concurrent validity, discriminatory validity) and responsiveness (distribution- and anchor-based) were explored for the German-SNOT-22.

RESULTS

At T0, the mean German-SNOT-22 total-score for CRS patients was 38.0 (± 20.9) and responded to treatment (T1 = 26.3 ± 19.1; T2 = 25.8 ± 20.6; T3 = 20.5 ± 16.3). For control-participants, the mean total-score at T0 was 15.1 (±10.9). The German-SNOT-22 was reliable (excellent internal consistency α = 0.93; good overall item-total correlations r = 0.39-0.85), valid (significant correlations between Mackay-Naclerio-, Lund-Mackay- and BSI-18 scores, all r > 0.39, p < 0.01) and responsive (significant correlations between HTIs and mean change in German-SNOT-22 total-score F = 9.57, p < 0.001).

CONCLUSION

The German-SNOT-22 validated here matches the original SNOT-22. It is a reliable, valid and responsive questionnaire to assess symptoms, HRQOL and treatment-response in CRS-patients. Good psychometric properties were observed.

Sinonasal Outcome Scores and Imaging: A Concurrent Assessment of Factors Influencing Their Association

OBJECTIVE

The overall discriminatory ability of validated instrument scores for computed tomography (CT) findings of chronic rhinosinusitis has limitations and may be modified by multiple factors. To support optimal methods for assessment, we studied which factors could influence this relationship, including the concurrent impact of multiple discrete CT scoring mechanisms, colocalized imaging findings, and nasal comorbid conditions.

STUDY DESIGN

Observational outcomes study.

SETTING

Academic medical center.

METHODS

Patients with sinonasal complaints who completed the 22-item Sinonasal Outcome Test (SNOT-22) and underwent CT were included. Multivariate ordinal regression was utilized to assess associations. CT data were quantified with the Lund-Mackay system, Zinreich system, and a direct measure of maximal mucosal thickness. The impact of incidental findings (mucous retention cysts, periapical dental disease) and nasal comorbid conditions was also assessed.

RESULTS

A total of 233 patients were included. SNOT-22 nasal scores were significantly associated with CT results when those with incidental findings were excluded, regardless of the radiologic scoring mechanism utilized: Lund-Mackay regression coefficient, 0.321 (P = .046); Zinreich, 0.340 (P = .033); and maximum mucosal thickness, 0.316 (P = .040). This relationship subsided when incidental findings were present. SNOT-22 overall scores, sleep scores, and psychological domain scores had no significant association with imaging results, regardless of radiologic scoring system utilized. Nasal comorbid conditions had inconsistent associations.

CONCLUSIONS

SNOT-22 nasal domain scores were associated with all 3 radiologic scoring systems when incidental findings were absent but not when they were present. Delineating the presence or absence of these colocalized findings affected the relationship between SNOT-22 scores and radiological results, beyond other concurrent factors.

The Sinonasal Outcome Test-22 or European Position Paper: Which Is More Indicative of Imaging Results?

Objective

The 22-item Sinonasal Outcome Test (SNOT-22) is a trusted measure of symptom severity in chronic rhinosinusitis. The European Position Paper on Rhinosinusitis (EPOS) provides widely accepted diagnostic criteria, which include sinonasal symptoms, their duration, and imaging results. Our objective was to compare these approaches to assessing symptoms to determine if either was more indicative of radiologic findings, to support decisions in telehealth.

Study Design

Observational outcomes study.

Setting

Tertiary care center.

Methods

In total, 162 consecutive patients provided a structured sinonasal history, completed the SNOT-22, and underwent sinus computed tomography (CT) within 1 month. SNOT-22 scores, EPOS-defined symptom sets, and Lund-Mackay results were assessed. To facilitate direct comparisons, we performed stepwise evaluations of sinonasal symptoms alone and combined with duration. The discriminatory capacity for imaging results was determined through areas under the receiver operating characteristic curves (ROC-AUC) for dichotomous outcomes and ordinal regression for multilevel outcomes.

Results

In ROC-AUC analyses, SNOT-22 and EPOS-defined symptoms had similar discriminatory capacity for Lund-Mackay scores, regardless of duration. Within ordinal regression analyses, SNOT-22 nasal scores were significantly associated with Lund-Mackay scores, while EPOS-defined nasal symptoms were not statistically significantly related.

Conclusions

SNOT-22 nasal scores and EPOS-defined nasal symptoms may have similar associations with imaging results when assessed via ROC-AUC, while SNOT-22 may have more association within ordinal data. Understanding the implications of discrete patterns of symptoms may confer benefit, particularly when in-person and fiberoptic exams are limited.

Chronic rhinosinusitis in COPD: A prevalent but unrecognized comorbidity impacting health related quality of life

INTRODUCTION

Unified airway disease where upper respiratory tract inflammation including chronic rhinosinusitis (CRS) affects lower airway disease is known from asthma, bronchiectasis, cystic fibrosis and primary ciliary dyskinesia but little is known about CRS and health related quality of life in COPD. We investigate firstly, the prevalence of CRS in COPD. Secondly the impact of CRS on HRQoL. Thirdly, risk factors for CRS in COPD.

METHODS

cross-sectional study of CRS in 222 COPD patients from 2017 to 2019 according to EPOS2012/2020 and GOLD2019 criteria. Patients completed the COPD assessment test (CAT), Medical Research Council dyspnea scale and Sinonasal outcome test 22 (SNOT22) and questions on CRS symptoms. They then had a physical examination including flexible nasal endoscopy, CT-sinus scan and HRCT-thorax.

RESULTS

22.5% of COPD patients had CRS and 82% of these were undiagnosed prior to the study. HRQoL (CAT, SNOT22 and the SNOT22-nasal symptom subscore) was significantly worse in COPD patients with CRS compared with those without CRS and healthy controls. Multiple logistic regression analysis suggests that the most likely candidate for having CRS was a male COPD patient who actively smoked, took inhaled steroids, had a high CAT and SNOT22_nasal symptom subscore.

DISCUSSION

the largest clinical study of CRS in COPD and the only study diagnosing CRS according to EPOS and GOLD. This study supports unified airway disease in COPD. The SNOT22_nasal symptoms subscore is recommended as a standard questionnaire for COPD patients and patients at risk should be referred to an otorhinolaryngologist.

The effect of surgical menopause after bilateral oophorectomy on hormonal changes, mucociliary clearance, and quality of life

PURPOSE

The removal of the ovaries for any reason causes surgical menopause. Hormonal changes that occur progressively over 5-10 years in natural menopause occur acutely in surgical menopause. Signs of estrogen deficiency appear suddenly and are permanent after this surgery. This study investigated the short- and long-term effects of estrogen deficiency occurring after surgical menopause on both nasal mucociliary activity and sinonasal symptoms.

METHODS

This prospective study included women aged 20-45 years who were not in the menopause, who had a planned bilateral oophorectomy and who attended the Gynecology Clinic at the Faculty of Medicine at a university hospital between January 2018 and December 2019. The nasal mucociliary clearance time, and blood Estradiol (E2) and FSH levels were measured once in the preoperative period, and at the postoperative 3rd, 6th, 9^th, and 12th months. At the same times, the Sinonasal Outcome Test 22 (SNOT-22) was also applied.

RESULTS

 The average age of the 47 patients was 41.2 ± 2.7. The mean serum estradiol levels of the women were 164.7 ± 63.4 pg/ml in the preoperative period, 14.8 ± 3.7 pg/ml at the postoperative 3rd month, 12.5 ± 3.5 pg/ml at the postoperative 6th month, 11.6 ± 3.0 pg/ml at the postoperative 9th month, and 11.1 ± 2.7 pg/ml at the postoperative 12th month. The mean FSH levels of the women were 9.4 ± 2.4 mIU/ml in the preoperative period, 60.5 ± 9.6 mIU/ml at the postoperative 3rd month, 61.9 ± 9.4 mIU/ml at the postoperative 6th month, 63.0 ± 9.3 mIU/ml at the postoperative 9th month, and 64.6 ± 8.7 mIU/ml at the postoperative 12th month. The changes in postoperative mean estradiol and FSH levels over a year were significant and consistent with menopausal symptoms (p < 0.001). The mean mucociliary clearance times were 12.6 ± 1.2 before menopause, 13.2 ± 1.7 at the postoperative 3rd month, 14.5 ± 1.7 at the postoperative 6th month, 17.5 ± 1.6 at the postoperative 9th month, and 19.4 ± 1.9 at the postoperative 12th month. The extension of the mean mucociliary clearance time over 1 year was significant (p < 0.001). The mean scores for the SNOT-22 were 17.3 ± 6.9 before the operation, 17.8 ± 6.0 at the postoperative 3rd month, 19.6 ± 6.9 at the postoperative 6th month, 23.4 ± 10.4 at the postoperative 9th month, and 36.1 ± 10.0 at the postoperative 12th month. The mean scores for rhinologic symptoms were 5.2 ± 1.9 (3-11) in the preoperative period, 5.7 ± 2.0 (3-12) at the postoperative 3rd month, 7.1 ± 2.3 (4-14) at the postoperative 6th month, 9.3 ± 3.3 (4-16) at the postoperative 9th month, and 11.9 ± 3.3 (6-18) at the postoperative 12th month. The 1-year change in the SNOT-22 scores was found to be significant (p < 0.001).

CONCLUSION

After bilateral oophorectomy, menopausal hormonal values were acutely high in women. At the 1-year postmenopausal follow-up, the mean scores for the SNOT-22 had increased significantly. In other words, quality of life decreased in parallel with prolonged nasal mucociliary clearance time.

Psychological Status as an Effect Modifier of the Association Between Sinonasal Instrument and Imaging Results

OBJECTIVE

To determine whether psychological status is an effect modifier of the previously observed low discriminatory capacity of Sinonasal Outcome Test-22 (SNOT-22) scores for Lund-Mackay computed tomography (CT) results.

STUDY DESIGN

Observational outcomes study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

We assessed patients presenting with chronic sinonasal complaints who underwent CT of the sinuses within 1 month of completing the SNOT-22 instrument. SNOT-22 overall and domain scores were calculated, as were Lund-Mackay CT scores. The discriminatory capacity of SNOT-22 scores for CT results was determined using the receiver-operator characteristic area under the curve (ROC-AUC). Patient-Reported Outcome Measurement Information System (PROMIS) mental health T-scores were assessed, and stratified analyses were used to test for effect modification by psychological status.

RESULTS

In stratified analyses, patients with better PROMIS mental health scores had SNOT-22 overall (ROC-AUC 0.96) and nasal domain scores (ROC-AUC 0.97-0.98) that were highly discriminatory for Lund-Mackay scores, while those with worse mental health scores did not (ROC-AUC 0.42-0.55, P < .007). Patients with better SNOT-22 psychological domain scores also had nasal scores that discriminated among CT results significantly better than those with worse psychological domain scores (ROC-AUC 0.65-0.69 and 0.34-0.35, respectively, P < .013).

CONCLUSIONS

Psychological status is an effect modifier of the relationship between SNOT-22 and Lund-Mackay scores. SNOT-22 scores were discriminatory for Lund-Mackay CT results in patients with better psychological status, while they were nondiscriminatory in those with worse psychological status. When assessing the relationship between subjective and objective measures of chronic rhinosinusitis, accounting for effect modification may have practical utility.

Association of cough with asthma in chronic rhinosinusitis patients

OBJECTIVE

To determine whether the complaint of cough in chronic rhinosinusitis (CRS) patients is associated with asthma and if there is a potential predictive value for asthma diagnosis.

METHOD

Consecutive patients presenting for initial evaluation at a tertiary rhinology clinic who were diagnosed with CRS were considered for inclusion in a cross-sectional study. The presence and severity of cough was determined using the 22-item Sinonasal Outcome Test (SNOT-22). Subgroup analysis included asthma diagnosis confirmed by pulmonary function testing (PFT) in our institution, and for chronic rhinosinusitis patients with (CRSwNP) and without nasal polyps (CRSsNP).

RESULTS

The total study population included 297 patients with a diagnosis of CRS, with 63.9% of patients reporting cough. Physician-confirmed diagnosis of asthma was made in 38.7% of patients, and confirmed in 69.6% by PFT. Cough was more frequently reported by CRS patients diagnosed with asthma (relative risk [RR] = 1.60, 95% confidence interval [CI], 1.13-2.25), with sensitivity of 73.9% (95% CI, 65.0%-81.1%). This remained significant in the CRSsNP subgroup (RR = 2.65, 95% CI, 1.32-5.30), with sensitivity of 83.3% (95% CI, 70.4%-91.3%) and specificity of 41.2% (95% CI, 33.2%-49.8%). Cough was not associated with asthma in CRSwNP patients (RR = 1.26, 95% CI, 0.89-1.79). Cough severity had poor predication for asthma diagnosis (AUC = 0.60, 95% CI, 0.54-0.65).

CONCLUSIONS

Complaint of cough is associated with diagnosis of asthma in CRS patients. In CRSsNP, complaint of cough was sensitive for asthma diagnosis, although specificity was low. Cough in CRS patients can be multifactorial and asthma may be an important diagnostic consideration.

LEVEL OF EVIDENCE

4.

Associations between the Quality of Life and Nasal Polyp Size in Patients Suffering from Chronic Rhinosinusitis without Nasal Polyps, with Nasal Polyps or Aspirin-Exacerbated Respiratory Disease

Chronic rhinosinusitis (CRS) is a common disease that substantially impairs the quality of life (QoL). Here, we aimed to assess patients' QoL in different subtypes of CRS and correlated this with nasal polyp size to improve the clinical understanding of the burden of disease. In this retrospective single-center study, 107 patients with the following diagnoses were analyzed: CRS without nasal polyps (CRSsNP), CRS with nasal polyps (CRSwNP), or aspirin-exacerbated respiratory disease (AERD). Sino-Nasal Outcome Test-20 German Adapted Version (SNOT-20 GAV) scores and their correlation with endoscopic Total Polyp Scores (TPS) were evaluated. The mean SNOT-20 GAV scores were highest in patients with AERD (AERD = 43.4, CRSwNP = 36.3, CRSsNP = 30.9). A statistically significant correlation of total SNOT-20 GAV score with TPS was observed in CRSwNP patients (r = 0.3398, p = 0.0195), but not in AERD patients (r = 0.2341, p = 0.1407). When analyzing single SNOT-20 parameters, a strong correlation with TPS was observed for blockage/congestion of the nose, particularly in AERD patients (r = 0.65, p < 0.0001). The impact of nasal polyp size on the QoL differs amongst the subgroups of CRS. Nasal symptoms have the greatest impact on QoL in patients suffering from AERD. CRSwNP and AERD patients should be separately analyzed in clinical investigations and interpretations due to significant differences in QoL.