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

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

OBJECTIVE

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

DATA SOURCES

CINAHL, PubMed, Scopus.

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

[Short-term quality of life assessment after sinus surgery for chronic rhinosinusitis]

BACKGROUND

Chronic rhinosinusitis (CRS) has a negative impact on health-related quality of life (HRQoL). Functional endoscopic sinus surgery (FESS) is the treatment of choice for those not responding to medical treatments. To date, the short-term effects of FESS on HRQoL are still unclear.

OBJECTIVE

Evaluation of the short-term effects of FESS on HRQoL in CRS patients using the SNOT-22 questionnaire.

METHODS

The results of the validated German version of the Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire were analysed from 89 patients with CRS before surgery and 10-14 days (n = 77), four (n = 77), six weeks (n = 76) and 6 months (n = 71) after FESS, and compared with those of 1,000 healthy controls selected using a non-probability quota sample in accordance to the distribution of the German Microcensus.

RESULTS

Compared to the preoperative mean SNOT-22 score (47.35), CRS patients significantly improved in HRQoL 10-14 days (31.75, p < 0.01), 4 weeks (25.84, p < 0.01), 6 weeks (24.16, p < 0.01) and 6 months after FESS (27.16, p < 0.01). Pre- and 6 months postoperatively, the five most important SNOT-22 items were nasal obstruction, smell and taste reduction, thick, mucous nasal secretions, need to blow the nose and postnasal drip. At the 2, 4 and 6-week follow-up, the reduction in smell and taste was most frequently perceived as limiting the HRQoL.

CONCLUSIONS

This follow-up study shows for the first time that the reduction in smell and taste should be treated and controlled concervatively in the short term after FESS.

Chinese adaptation and validation of the chronic rhinosinusitis-patient-reported outcome: Assessment of health-related quality-of-life

BACKGROUND

The chronic rhinosinusitis patient-reported outcome (CRS-PRO) is a recently published disease-specific questionnaire designed for CRS patients, with fewer entries and ease of completion. This study aimed to translate the CRS-PRO questionnaire into Chinese and assess its reliability, validity, and responsiveness to provide Chinese patients with a more concise and efficient subjective assessment instrument.

METHODS

The Chinese version of the CRS-PRO was created through forward-backward translations and cultural adaptation. Here, 168 CRS patients (118 patients CRS with nasal polyps [CRSwNP] and 50 patients with CRS without nasal polyps [CRSsNP]) and 43 healthy individuals were enrolled. All participants completed the CRS-PRO, 22-item Sinonasal Outcome Test (SNOT-22), and EuroQol five dimensions questionnaire (EQ-5D) questionnaires preoperatively as well as 3 and 6 months after surgery.

RESULTS

The Chinese version of the CRS-PRO demonstrated good internal consistency, with a Cronbach's α of 0.813. It also exhibited a higher criterion validity (r = 0.65, p < 0.05) than the SNOT-22. A moderate association was found between the CRS-PRO and objective indicators such as the Lund-Mackay and endoscopic scores. Furthermore, the CRS-PRO, like the SNOT-22, could clearly distinguish CRS patients from healthy subjects (p < 0.01), as well as between the CRSwNP and CRSsNP subtypes (p < 0.01). Additionally, changes in the CRS-PRO exhibited a larger effect size compared to changes in the SNOT-22 (Cohen's d = 1.05 and 0.93 vs. 0.71 and 0.90 for 3 and 6 months, respectively, all p < 0.01).

CONCLUSIONS

The Chinese version of the CRS-PRO is a concise, reliable, and responsive instrument that can be utilized as a novel subjective evaluation tool for future clinical practice.

The "fascia taco" for nasal septum perforation closure-A retrospective Cohort study on success rates and patient reported outcomes

Objective

Nasal septum perforation (NSP) is a common condition affecting ~1.2% of the general population and is still considered challenging to treat. Therapeutic strategies range from conservative local treatments and septal button closures to over 40 different surgical approaches. This study aimed to present a novel secure approach.

Methods

We describe our novel and unique NSP closure approach using a "fascia taco," in which conchal cartilage is enveloped by temporalis fascia like a taco and splints are left in place for 6-8 weeks. A review of patient charts was conducted and questionnaires including the German-SNOT-22 and D-NOSE were sent by mail to all eligible patients who received a fascia taco between 2016 and 2021.

Results

Thirty-three patients were identified. The questionnaire response rate was 54.5%. The mean operative time (cut to sew) for all patients who only underwent NSP closure was 90.4 min. The overall success rate in terms of postoperative NSP closure was 81.8%. We found an apparent but nonsignificant association between closure failure and smoking (failure rate 66.6% in smokers vs. 15.4% in nonsmokers; X 2 = 3.4188, p = .064). Questionnaire analysis showed a significant postoperative reduction of mean values in D-NOSE from 60.8 to 33.1 (p = .009) and in German-SNOT-22 from 38.6 to 21.2 (p = .005).

Conclusion

The fascia taco technique is an easy-to-apply, safe procedure for NSP closure that is short in duration and associated with a low morbidity, resulting in excellent patient satisfaction.

Level of Evidence

4.

Quality of Life Improvement in Concurrent Septorhinoplasty and Endoscopic Sinus Surgery

OBJECTIVES

Septorhinoplasty (SRPL) and functional endoscopic sinus surgery (FESS) are two frequently performed surgeries to improve quality of life (QoL) in patients with nasal symptoms. It has been demonstrated as a safe combination regarding complication rates, but patient satisfaction in concurrent surgery has not been adequately studied yet.

METHODS

Patients undergoing sole FESS due to chronic rhinosinusitis (n = 57), sole SRPL (n = 148), and concurrent surgery (n = 62) were prospectively evaluated for their disease-specific QoL before and one year after surgery. Each procedure was performed by the same surgeon (OCB). For SRPL, the patient-reported outcome measures Rhinoplasty Outcomes Evaluation (ROE) and Functional Rhinoplasty Outcome Inventory (FROI-17) were utilized, and for chronic rhinosinusitis, the Sino-Nasal Outcome Test-22 (SNOT22).

RESULTS

All three groups showed significant improvement in the postoperative QoL measurements (all p < 0.01). The postoperative improvements were slightly smaller in the concurrent surgery group compared with the single surgery groups measured with ROE (combined: +55.2 ± 9.3, single: +58.8 ± 9.8, p = 0.02), FROI total score (combined: +47.6 ± 5.2, single: +49 ± 5.4; p = 0.08) and SNOT22 (combined: +33.1 ± 6.7, single +34.5 ± 7, p = 0.26).

CONCLUSIONS

SRPL, FESS, and combined surgery improve disease-specific QoL. When applicable, surgeons may offer the benefits of a combined procedure without compromising the QoL gain.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1239-1245, 2024.

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 "real life" efficacy of dupilumab is independent of initial polyp size and concomitant steroids in CRSwNP

BACKGROUND

Dupilumab significantly improves symptom control in chronic rhinosinusitis with nasal polyps (CRSwNP). Patients with large polyps at the initiation of treatment (total polyp score (TPS) ≥ 5) have been the focus in published studies. Patients with significant burden of disease but small polyps (TPS ≤ 4) have not yet been evaluated for clinical response. This study set out to evaluate the benefit of dupilumab treatment on cohorts of small (TPS ≤ 4) compared to large polyps (TPS ≥ 5). Furthermore, benefit of concomitant oral and/or nasal steroid therapy has been evaluated.

METHODS

97 patients with CRSwNP, who were begun on dupilumab between January 2020 and October 2021, were included. All patients were followed-up for 6 months. At each visit they underwent nasal endoscopy, smell identification tests and filled out validated patient questionnaires.

RESULTS

Significant drops in TPS were seen in both patient groups after 6 months of therapy, dropping from a median score of 3 to 0 and from 6 to 2 in patients with small and large polyps respectively. Furthermore, a linear mixed model calculated a drop of 22% and 24% in TPS per month in patients with small and large polyps respectively with no significant difference in rate of decline. Finally the model showed that neither oral nor nasal steroids influenced the rate of response to dupilumab therapy.

CONCLUSIONS

Polyp size at the initiation of dupilumab therapy and whether patients continue to take steroid therapy does not appear to influence effectiveness of dupilumab treatment.

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.

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.

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.

[Adaption of the "Empty Nose 6 Item Questionnaire" (ENS6Q) into German language]

OBJECTIVE

The English "Empty-Nose-6-Item-Questionnaire" (ENS6Q) is a validated tool to assess subjective and disease-specific complaints of patients suffering from empty nose syndrome. The aim of this study was to create a validated German adapted version (GAV) of the ENS6Q.

MATERIAL AND METHODS

The ENS6Q was translated into German language using a multistage process. Subsequently the translated questionnaire was completed twice by a group of patients suffering from empty nose syndrome (n = 36), a healthy control group (n = 77) and a group of patients with a symptomatic pathology of the nasal septum (n = 78). Additionally, the NOSE© questionnaire was completed twice by all groups. The ENS6Q was then examined regarding internal consistency, test-retest reliability, discriminant validity, sensitivity and specificity.

RESULTS

The ENS6Q-GAV shows high internal consistency with Cronbachs α = 0,760 and α = 0,795. It also shows good test-retest reliability with an interclass correlation coefficient of 0,947 [0,930 - 0,961]. The ENS6Q-GAV discriminated significantly between empty nose syndrome patients and the control group. The receiver-operating characteristics curve showed a sensitivity of 83,3 % and a specificity of 88,3 % using a cut-off point of 8,5. The area-under-the-curve threshold score was 0,914 ± 0,029 [0,856 - 0,971].

CONCLUSIONS

The ENS6Q-GAV is the first validated disease-specific questionnaire in German to help identify patients suspected of developing ENS more reliably.

Validation of the Dutch version of the 22-item Sino-Nasal Outcome Test (SNOT-22)

Background: The 22-item Sino-Nasal Outcome Test (SNOT-22) is a widely used questionnaire to measure disease-specific health-related quality of life in patients with chronic rhinosinusitis (CRS). The Dutch version has not been validated yet. Methods: The SNOT-22 was translated through a forward-backward translation technique and validated by a test-retest protocol in CRS patients, a responsiveness analysis in CRS patients treated with dupilumab, while using healthy individuals as controls. Results: The Dutch SNOT-22 showed excellent test-retest properties, good responsiveness to treatment with dupilumab, and a clear distinction between outcomes of CRS patients and healthy controls. Conclusion: The Dutch version of the SNOT-22 is a valid outcome measure in CRS patients.

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.

Cross-cultural adaptation and validation of the 22-item sinonasal outcome test (SNOT-22) in German-speaking patients: a prospective, multicenter cohort study

Purpose

Chronic rhinosinusitis (CRS) is a common condition associated with a significant reduction of the health-related quality of life. One of the most widely used assessment tools in CRS is the disease-specific, health-related questionnaire SNOT-22. The aim of this study was to translate and validate the SNOT-22 into the German language.

Methods

The questionnaire was translated using the forward–backward translation technique. After the translation its reliability, validity, and sensitivity were evaluated. For this purpose, the questionnaire was completed by patients diagnosed with CRS before, 3 months and 1 year after endoscopic sinus surgery and by healthy individuals as controls at three university hospitals in Germany. The individual scores of the questionnaire before surgery was correlated with the Lund–Mackay score as well as a global disease-specific question.

Results

A total of 139 CRS patients and 31 healthy individuals participated in the study. Internal consistency at all timepoints was very good, with Cronbach’s alpha scores of 0.897, 0.941, and 0.945. The questionnaire was able to discriminate between CRS patients and control subjects (p < 0.0001) and scores improved significantly 3 month and 1 year after sinus surgery (p < 0.0001), indicating a good test–retest reliability, validity, and responsiveness. A significant correlation to the single global disease-specific question could be found (p < 0.0001), but no correlation with the Lund–Mackay score.

Conclusion

The German Version of the SNOT-22 is a reliable, valid, and sensitive instrument for measuring health-related quality of life in patients with CRS. It can be recommended for clinical practice and outcome research for German-speaking patients.