Development and Validation of the Sinonasal Outcome Test-12

OBJECTIVES

Quality of life (QoL) questionnaires are widely used in clinical interviews to assess the impact of medical interventions or measure the outcomes of healthcare services. The main aim of such questionnaires is the subjective assessment of health status and its impact on QoL. This study aimed to develop an efficient, short sinonasal disease assessment instrument, the sinonasal outcomes test-12 (SNOT-12), and to compare it with the preexisting SNOT-22.

METHODS

This was a two-phase cross-sectional study. The study was performed between June 2019 and February 2020 using the electronic files of the ORL department outpatient clinics at King Fahd University Hospital, affiliated with Imam Abdulrahman Bin Faisal University. The study was performed in 2 phases: an item reduction phase, which resulted in an initial SNOT-12 scale, and a validation phase, using a comparative analysis of the initial SNOT-12 and the SNOT-22.

RESULTS

The developed short-form SNOT-12 maintained the 4 latent factors extracted in EFA (nasal, Sleep/extra nasal, psychological, ear/facial). It strongly correlated with SNOT-22 (r = 0.973). It had good construct reliability (0.705-0.901) and validity and a higher discrimination power than the SNOT-22.

CONCLUSIONS

The SNOT-12 is a short, valid, and reliable instrument that may prove useful for the initial screening and monitoring of patients with chronic rhinosinusitis.

The impact of asthma on quality of life and symptoms in patients with chronic rhinosinusitis. Curr Med Res Opin 2020;36:1043-1048. [PMID: 32270714 DOI: 10.1080/03007995.2020.1754189]

Objective: The study aims to evaluate how asthma influences on clinical symptoms, imaging scores and HRQL in CRS patients.Methods: The study enrolled CRS patients and collected data about asthma status, clinical symptoms, allergic sensitization, computed tomography (CT) and 22-item SinoNasal Outcome questionnaire (SNOT-22). Matching pairs of asthmatic and non-asthmatic CRS patients were defined based on age, gender and nasal polyp presence. The difference between pairs in clinical symptoms, CT and SNOT-22 was then analyzed. The study enrolled mild to moderate asthma patients.Results: From 250 CRS patients 65 (26%) had asthma. We found 60 CRS asthma and CRS non-asthma pairs based on age, gender and nasal polyp presence. There was no difference in total SNOT-22 score between asthma (46.5) and non-asthma (43.5) CRS groups (p < .357). There were more patients with allergy positive medical history in asthma group (66.1%) when we stratified for CRS phenotypes, gender and age. Comparing visual analogue scale (VAS) scores for clinical symptoms, smell (p < .013) was the only symptom significantly worse in CRS asthma group. Although there was no difference in Lund-Mackay score, there was a slightly higher osteitis score in CRS asthma group (5.21 vs. 3.45; p = .059).Conclusion: CRS patients with asthma have significantly worse impairment of smell and taste when compared to non-asthmatic CRS patients. This is the only significant difference which is independent of nasal polyp presence, gender, age and allergy.

Increased the risk of depression in patients with chronic rhinosinusitis without polyp: A longitudinal follow up study using a national sample cohort

Previous studies have reported that chronic rhinosinusitis (CRS) is closely related to depression. The present study aims to elucidate the association between CRS without nasal polyp and depression using a national sample cohort. Using the national sample cohort from Korean Health Insurance Review and Assessment Service, we matched patients with CRS (n = 21,707) to control participants (n = 86,828), at a ratio of 1:4, according to age, sex, household income, region of residence. The stratified Cox proportional-hazards model was used to evaluate the hazard ratio (HR) between CRS and depression. A subgroup analysis was performed according to age group and gender. The HR for depression was significantly higher in patients with CRS than in control participants (adjusted HR = 1.41, 95% confidence interval = 1.33-1.48) after adjustment for age, sex, household income, region of residence, and medical history. The risk of depression was also elevated in the subgroup analysis, regardless of age or gender. In conclusion, CRS was significantly associated with the increased risk of depression.

The impact of comorbid depression in chronic rhinosinusitis on post-operative sino-nasal quality of life and pain following endoscopic sinus surgery

BACKGROUND

Depression and chronic pain are debilitating disorders that co-exist with many chronic diseases. Chronic rhinosinusitis (CRS) is no exception. Nonetheless, little is known about the association between these co-related conditions and the treatment of CRS. The objective of this study is to measure outcomes following endoscopic sinus surgery (ESS) in CRS patients reporting significant pre-operative depression and pain.

METHODS

This is a prospective longitudinal cohort study examining patients with CRS who had failed maximal medical therapy and subsequently underwent ESS. Participants completed a several patient-reported outcome (PRO) instruments pre-operatively and 6 months post-operatively. The PROs included the Sinonasal Outcome Test-22 (SNOT-22), the Patient Health Questionnaire (PHQ-9) measuring symptoms of depression and an assessment of chronic pain using the pain intensity (P), interference with enjoyment of life (E) and general (G) activity instrument, the PEG instrument.

RESULTS

The study had 142 participants complete their pre-operative and post-operative surveys. The participation rate was 40.1% among eligible patients. The prevalence of at least moderate depression was 22 patients (15.5%) among participants. Compared with non-depressed participants, the pre-operative sino-nasal disease burden and pain scores were higher among depressed participants (p <  0.001) and the gain in health following surgery was smaller (p <  0.001).

CONCLUSIONS

Pre-operative disease burden is higher among depressed patients. Post-operative gains in sino-nasal quality of life attributable to endoscopic sinus surgery were significantly smaller among depressed participants. Pre-operative screening for depression could identify opportunities for medical intervention and improve outcomes among CRS patients.

Chronic rhinosinusitis: a qualitative study of patient views and experiences of current management in primary and secondary care

OBJECTIVES

To explore patient views and perspectives of current management of chronic rhinosinusitis (CRS) in primary and secondary care.

DESIGN

Semistructured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic RhinOsinusitis).

SETTING

Primary care and secondary care ear, nose and throat outpatient clinics in the UK.

PARTICIPANTS

Twenty-five patients consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis.

RESULTS

CRS has a significant impact on patients' quality of life, affecting their ability to work effectively, their social interactions and daily living. Patients seek help when symptoms become unmanageable, but can become frustrated with the primary care system with difficulties obtaining an appointment, and lack of continuity of care. Patients perceive that general practitioners can be dismissive of CRS symptoms, and patients often prioritise other concerns when they consult. Health system barriers and poor communication can result in delays in accessing appropriate treatment and referral. Adherence to intranasal steroids is a problem and patients are uncertain about correct technique. Nasal irrigation can be time-consuming and difficult for patients to use. Secondary care consultations can appear rushed, and patients would like specialists to take a more 'holistic' approach to their management. Surgery is often considered a temporary solution, appropriate when medical options have been explored.

CONCLUSIONS

Patients are frustrated with the management of their CRS, and poor communication can result in delays in receiving appropriate treatment and timely referral. Patients seek better understanding of their condition and guidance to support treatments decisions in light of uncertainties around the different medical and surgical options. Better coordinated care between general practice and specialist settings and consistency of advice has the potential to increase patient satisfaction and improve outcomes.

Endotyping of Chronic Rhinosinusitis With and Without Polyp Using Transcription Factor Analysis

Inflammation of the nose and paranasal sinus or rhinosinusitis (RS) is a significant global health problem that is both very common and very costly to treat. Previous reports reveal variability in histology and mechanism of inflammation in patients with chronic rhinosinusitis with and without polyp (CRScNP and CRSsNP, respectively). There are various methods and hypothesis that try to explain this variability. Accordingly, the aim of this study was to investigate the incidence of each type of sinonasal inflammation among patients diagnosed with CRScNP or CRSsNP using transcription factor analysis (TFA). This study included mucosa specimens from nose/paranasal sinuses from patients with chronic rhinitis (CR), CRSsNP, or CRScNP that were obtained at the Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during the June 2009 to May 2012 study period. TFA was employed to measure the following transcription factors: T-box transcription factor (T-bet) for Th1, GATA binding protein 3 (GATA-3) for Th2, retinoic acid-related orphan receptor C (RORC) for Th17, and forkhead box P3 (FOXP3) for Treg. Forty-one subjects (22 males, 19 females) were enrolled, with a mean age of 45.93 ± 13 years. Twenty-six patients were diagnosed with CRScNP, 7 with CRSsNP, and 8 with CR (controls). The majority of CRScNP specimens (76.9%) had eosinophil count greater than 100 cells/high-power field (HPF). Mean eosinophil count was 930.08 ± 1,399 cells/HPF (range: 17-5,570). Th2 transcription factor (GATA-3) was statistically significantly higher in the CRScNP group than in the CRS and control groups (p < 0.001); whereas, Treg transcription factor (FOXP3) was statistically significantly lower in the CRScNP group than in the CRSsNP and control groups (p < 0.001). The transcription factors for Th1 and Th17 (T-bet and RORC, respectively) were not significantly different among the three groups. The result of transcription factor analysis revealed hyperfunction of Th2 in patients with CRScNP, which might result in hypereosinophilic infliltration in the polyps. One explanation for this finding is the decreased activity of Treg. Although environment-host interaction is the most probable hypothesis, the etiology of aberrant adaptive immunity needs to be elucidated.

Influence of interpersonal traits on patient outcomes in the treatment of chronic rhinosinusitis

BACKGROUND

Patient-reported outcome measures (PROMs) measure health states in chronic rhinosinusitis (CRS) and have become the dominant metrics of treatment outcomes. Interpersonal traits (IPTs) are patient-specific factors that include personality type, perceived social support, and trust in physicians. The association of IPTs on treatment outcomes among patients with CRS has not been described previously, and IPTs may represent major clinical factors influencing treatment outcomes.

METHODS

Adult patients electing medical or surgical treatment for recalcitrant CRS were prospectively enrolled into a multi-institutional, observational outcomes study. Validated measures of IPTs, including the Big Five Inventory-10 Short Version (BFI-10), Multidimensional Scale of Perceived Social Support (MSPSS), and the Trust in Physician Scale (TPS), were completed and compared with PROMs, which included the 22-item SinoNasal Outcome Test (SNOT-22), the Medical Outcomes Study Short Form-6D (SF-6D), and the Patient Health Questionnaire-2 (PHQ-2).

RESULTS

Three hundred fifty-four participants were included and followed for an average (± standard deviation) of 16.3 (±4.8) months. Significant within-subject improvement in mean PROM scores was reported (all p <0.001). No association was detected between PROM score improvement and baseline BFI-10 or MSPSS scores (p > 0.050). Significant, but weak, absolute correlations were reported between baseline TPS scores and improvement in SNOT-22, SF-6D, and PHQ-2 total scores (p < 0.050; r ≤ 0.138).

CONCLUSION

Personality type and perceived social support do not associate with improvement after treatment for CRS. However, increased trust in physicians is weakly associated with greater posttreatment improvement. Further study is needed to examine the relationship between physician trust, patient satisfaction, and treatment outcomes among patients with CRS.

Incidence and burden of comorbid pain and depression in patients with chronic rhinosinusitis awaiting endoscopic sinus surgery in Canada

BACKGROUND

This study sheds important light on the association between sino-nasal symptoms and global quality of life in patients with chronic rhinosinusitis waiting for endoscopic sinus surgery. Using patient-reported information collected pre-operatively, the primary objective was to report on patients' pre-surgical sino-nasal symptoms and their association with self-reported pain and depression. The secondary objective was to report on levels of depression and pain among patients in the sample reporting severe sleep problems.

METHODS

This is a cross-sectional study of patient-reported outcomes collected prospectively from a cohort of 261 patients assigned to the wait list for elective endoscopic sinus surgery in a large urban region of Canada.

RESULTS

Younger patients and patients with other medical comorbidities were most likely to report significant symptoms of chronic rhinosinusitis and substantial associated pain and depression. In the primary analyses, patients reporting significant symptoms of chronic rhinosinusitis were more likely to report moderate depression or high pain (p < 0.01). Subsequently, chronic rhinosinusitis patients with severe sleep problems were 82% likely to report moderate or severe depression and pain.

CONCLUSION

Preoperative management of depression and pain may be considered in order to improve the health-related quality of life of patients waiting for ESS. As depression and pain were highly prevalent, patients with severe sleep problems may be candidates for prioritized access.

The validity and reliability of Thai Sinonasal Outcome Test-22

Chronic rhinosinusitis (CRS) symptoms can significantly reduce quality of life. The Sinonasal Outcome Test-22 (SNOT-22) is frequently used to assess this disease-specific quality of life, although it has not been translated into Thai language. We translated the original SNOT-22 questionnaire to Thai using forward-backward technique, and validated it in CRS patients [n = 229, mean age of 52.6 (SD = 15.9)] recruited at outpatient Otolaryngology clinic, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand. A construct validity was assessed using factor analysis, reliability was assessed using intra-class correlation coefficient (ICC) after 3 days of taking the first questionnaire, and internal consistency was assessed using Cronbach's alpha. A total of 201 out of 229 patients completed SNOT-22 questionnaire. Factor analysis with oblique rotation was applied and yielded three domains with eigenvalue of 1 or higher. These domains were named as nasal-related, ear-general-psychological, and sleep-related domains. Estimated ICC ranged from 0.49 to 0.71 with a median of 0.64, and Cronbach's alpha was 0.94. The Thai SNOT-22 questionnaire is reliable and valid with three domains. Thai SNOT-22 may be used in research and clinical practice to assess disease-specific quality of life and aid in management plan at CRS clinic.

The Sino-Nasal Outcome Test (SNOT): Can we Make it More Clinically Meaningful?

OBJECTIVE: To test whether subscales should be used when analyzing the Sino-Nasal Outcome Test (SNOT).

STUDY DESIGN AND SETTING: Prospective cohort study involved 87 acute NHS hospitals in England and Wales.

RESULTS: With the use of exploratory factor analysis we found evidence for the existence of four unique constructs within the SNOT. Two constructs address symptoms (rhinologic and ear/facial) and two address aspects of health-related quality of life (psychological issues and sleep function). Subscales of the SNOT that correspond to these constructs provided clinically meaningful information over and above that provided by the SNOT total score on the type of surgical benefits gained by patients with different sino-nasal conditions.

CONCLUSION: The SNOT is not unidimensional and a SNOT total score will mask variation in the true underlying constructs.

SIGNIFICANCE: The SNOT would have greatly improved clinical use if it was scored with appropriate subscales. Such a measure would allow us to tease out the differential impact of sino-nasal conditions, in addition to allowing greater understanding of treatment effects.

Quality of Life in Patients With Chronic Rhinosinusitis and Sleep Dysfunction Undergoing Endoscopic Sinus Surgery: A Pilot Investigation of Comorbid Obstructive Sleep Apnea

IMPORTANCE

Patients with chronic rhinosinusitis (CRS) have reduced sleep quality linked to their overall well-being and disease-specific quality of life (QOL). Other primary sleep disorders also affect QOL.

OBJECTIVE

To determine the impact of comorbid obstructive sleep apnea (OSA) on CRS disease-specific QOL and sleep dysfunction in patients with CRS following functional endoscopic sinus surgery.

DESIGN, SETTING, AND PARTICIPANTS

Prospective multisite cohort study conducted between October 2011 and November 2014 at academic, tertiary referral centers with a population-based sample of 405 adults.

INTERVENTION

Functional endoscopic sinus surgery for medically refractory symptoms of CRS.

MAIN OUTCOMES AND MEASURES

Primary outcome measures consisted of preoperative and postoperative scores operationalized by the Rhinosinusitis Disability Index (RSDI) survey, the 22-item Sinonasal Outcome Test (SNOT-22), and the Pittsburgh Sleep Quality Index (PSQI). Obstructive sleep apnea was the primary, independent risk factor.

RESULTS

Of 405 participants, 60 (15%) had comorbid OSA. A total of 285 (70%) participants provided preoperative and postoperative survey responses, with a mean (SD) of 13.7 (5.3) months of follow-up. Significant postoperative improvement (P < .05) was reported across all mean disease-specific QOL measures for both participants with and without comorbid OSA. Participants without OSA reported significant greater improvement in unadjusted mean (SD) RSDI global scores (−25.0 [23.3] vs. −16.5 [22.1]; P = .03), RSDI physical (−10.7 [9.2] vs. −7.3 [9.1]; P = .03) and functional (−8.4 [8.7] vs. −5.1 [7.5]; P = .03) subdomain scores, and SNOT-22 rhinologic symptom domain scores (−9.1 [7.7] vs. −5.7 [6.9]; P = .008). Participants without OSA also reported greater improvements on mean (SD) PSQI global (−1.9 [4.0] vs. −0.5 [3.7]; P = .03), sleep quality (−0.4 [0.8] vs. −0.03 [0.7]; P = .02), and sleep disturbance (−0.4 [0.7] vs. −0.1 [0.7]; P = .03) scores. The majority of these associations were found to be durable after adjustment for alternate independent cofactors using stepwise linear regression modeling.

CONCLUSIONS AND RELEVANCE

Patients with CRS and comorbid OSA have poor QOL with substantial disease-specific QOL improvements following surgery. Patients who present with CRS should be assessed for primary sleep disorders and, if identified, should be treated concurrently for both CRS and OSA to improve sleep dysfunction to optimize surgical outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01332136.

Impact of rhinosinusitis symptoms on patients' self-esteem before and after FESS

INTRODUCTION

Chronic rhinosinusitis (CRS) is one of the most common diseases in Polish society. According to the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2012 the incidence of CRS among European and US citizens varies from 5 to 16%. Its treatment is based on pharmacotherapy or surgical procedure. The aim of the study was to evaluate the correlation between general health condition of the patients with CRS with each symptom of the disease before and after Functional Endonasal Sinus Surgery (FESS) procedure.

MATERIALS AND METHODS

The study was conducted on 100 patients, who evaluated symptoms and general health condition twice - before and after FESS, by means of visual analogue scale (VAS).

RESULTS

Before FESS the highest severity among all symptoms concerned the nasal blockade and olfactory disorders, while after the procedure this ratio was found to be the opposite. All results were statistically significant (p<0.05).

CONCLUSIONS

The authors emphasize a great role of general health assessment in patients with CRS as the element of proper diagnosis and better comprehension of patients' needs. They indicate that the patient's estimation of the disease and its symptoms differs from the clinician's interpretation to much extent.

The MARS questionnaire: quality of life survey for acute rhinosinusitis

PURPOSE

Acute rhinosinusitis (ARS) significantly reduces the quality of life (QoL). While intensive research has focused on the QoL in patients with chronic rhinosinusitis, data regarding the impact of ARS on the QoL are relatively sparse. The aim of this study was to construct and validate a simple, reliable QoL questionnaire for ARS patients, which is also one of the priorities set for EPOS 2012.

METHODS

The questionnaire was constructed as follows: a review of literature, collection of symptoms as well as social and emotional consequences by a panel of ENT specialists and general practitioners, interviews with patients experiencing ARS, and a pre-test with another patient group. The questionnaire was validated by determining its internal reliability, discriminant validity, and responsiveness. The survey was given to 50 ARS patients at the time of diagnosis and again 14 days after treatment. The ARS diagnosis was established using the EPOS 12 criteria. The control group consisted of 50 medical students without any sinonasal symptoms.

RESULTS

We developed a 13-item questionnaire, called the MARS (Measurement of Acute Rhinosinusitis). Cronbach's alpha was determined to be 0.679. The two-tailed t-test showed a statistically significant difference between the patient group and the control group (p = 0.0000). The SRM coefficient was 1.781.

CONCLUSION

The MARS questionnaire is a QoL instrument developed and validated especially for patients with ARS. This survey demonstrated good internal consistency and excellent discriminant validity, responsiveness, and feasibility for use in daily clinical practice and research.

Disease-specific quality-of-life questionnaires in rhinitis and rhinosinusitis: review and evaluation

Quality of life (QoL) measurements are the best approximation of the burden of disease for the patient. Patient-reported outcome measurements (PROMs) estimate health-related quality of life (HRQoL). PROMs can be generic or disease-specific. Generic PROMs allow comparisons between different diseases but can be relatively insensitive for measuring changes within a disease. Recommended QoL questionnaires in allergic rhinitis and rhinoconjunctivitis are the RQLQ (or adapted versions), in chronic rhinosinusitis, the SNOT-22 or RSOM-31, and in acute rhinosinusitis, the modified SNOT-16. PROMs can be used both for daily clinical work and for research. In daily practice, a quick evaluation of the questionnaire directly indicates how the patient is doing. It makes sure that symptoms important for the patient are not overlooked and, during the consultation, the physician can elaborate on specific aspects of the symptomatology. It is important, especially in research, to realize that disease-specific questionnaires are only validated for specific diseases and are not automatically valid for other diseases.

Evaluation of the quality of life of patients with chronic rhinosinusitis by means of the SNOT-22 questionnaire

SNOT-22 is a questionnaire used to assess the quality of life of patients with chronic rhinosinusitis (CRS). It is broadly utilized to assess the surgical treatment of patients with CRS. In Brazil there are no studies utilizing the SNOT-22 in non-surgical patients.

Objective

To use the SNOT-22 questionnaire to assess the quality of life of individuals with chronic rhinosinusitis without previous surgery and with indication for clinical treatment.

Method

Prospective and analytical cohort and cross-sectional controlled clinical trial. We had 2 groups, one made up of patients with CRS and another one with adult individuals without the sinonasal disease, consecutively seen in an otorhinolaryngology clinic in Salvador, Bahia, between August of 2011 and June of 2012. They all filled out the Consent Form, a registration form and the SNOT-22.

Results

176 patients, 78 with CRS and 98 without the disease, the groups matched as far as gender, medication and respiratory allergies were concerned. Age was 40.7 + 13.5 years in the study group and 37.8 + 12.9 in controls (p = 0.26). The SNOT-22 median value in the study group was 53, compared to 8 in the control group (p = 0.001).

Conclusion

Chronic rhinosinusitis reduces the quality of life of patients, according to the SNOT-22 questionnaire.

The Sino-Nasal Outcome Test 22 validated for Danish patients

INTRODUCTION

Chronic rhinosinusitis (CRS) is a significant health problem whose incidence and prevalence is rising. It calls into attention consensus about diagnosing, assessing symptoms and treatment of patients with CRS. Therefore, a validated Danish measure of health-related quality of life in sinonasal disease is needed.

MATERIAL AND METHODS

The Sino-Nasal Outcome Test 22 (SNOT-22) was translated into Danish and its reproducibility was evaluated by test-retesting 40 patients with CRS. The statistical analyses used were Pearson's correlation coefficient, Cronbach's alpha, kappa and Bland-Altman's plot. Reproducibility was also tested for SNOT-22 subscales.

RESULTS

The results show good internal correlation with a Cronbach's alpha of 0.83 in the initial test and one of 0.92 in the retest. Pearson's correlation coefficient was 0.70 (p < 0.001), revealing good correlation between the initial scores and the retests scores. Kappa was calculated for each item with a mean value of 0.61 showing substantial agreement. The paired t-test revealed no significant difference between the subscales.

CONCLUSION

The Danish version of SNOT-22 is recommended for Danish clinicians and researchers as a patient-reported measure of outcome in sinonasal disorders such as rhinosinusitis and nasal polyposis.

Eczema, sleep, and behavior in children

INTRODUCTION

There is a general consensus that sleep disruption in children causes daytime behavioral deficits. It is unclear if sleep disruption in children with eczema has similar effects particularly after controlling for known comorbid disorders such as asthma and rhinitis.

METHODS

Parents of children (6-16 y) with eczema (n = 77) and healthy controls (n = 30) completed a validated omnibus questionnaire which included the Sleep Disturbance Scale for Children, Conners Parent Rating Scale-Revised (S), Child Health Questionnaire, Children's Dermatology Life Quality Index, and additional items assessing eczema, asthma, rhinitis, and demographics.

RESULTS

Compared to controls, children with eczema had a greater number of sleep problems with a greater percentage in the clinical range, lower quality of life, and higher levels of ADHD and oppositional behavior. They also had elevated rhinitis and asthma severity scores. Importantly, structural equation modelling revealed that the effect of eczema on the behavioral variables of Hyperactivity, ADHD Index, and Oppositional Behaviors were mediated through sleep with no direct effect of eczema on these behaviors. The comorbid atopic disorders of rhinitis and asthma also had independent effects on behavior mediated through their effects on sleep.

CONCLUSIONS

The present findings suggest that the daytime behaviors seen in children with eczema are mediated independently by the effects of eczema, asthma, and rhinitis on sleep quality. These findings highlight the importance of sleep in eczematous children and its role in regulating daytime behavior.

Quality-of-life outcomes after endoscopic sinus surgery: how long is long enough?

OBJECTIVE

To determine the time interval during which quality-of-life (QOL) outcomes stabilize after endoscopic sinus surgery (ESS).

STUDY DESIGN

Multi-institutional, longitudinal cohort.

SETTING

Tertiary rhinology centers.

SUBJECTS AND METHODS

Adults with chronic rhinosinusitis from three medical centers were asked to provide responses to the Rhinosinusitis Disability Index (RSDI) and the Chronic Sinusitis Survey (CSS) at baseline and six months, 12 months, and 20 months after endoscopic sinus surgery. Repeated measures and post-hoc analyses were used to compare QOL scores among follow-up time points. Subgroup analyses were performed in a similar fashion for patients with and without nasal polyposis, asthma, allergies, acetylsalicylic acid intolerance, depression, and previous sinus surgery.

RESULTS

A total of 127 patients provided complete follow-up data for all three time points. Improvement in QOL scores was seen at six months after surgery for both the RSDI and CSS instruments. When comparing changes in mean QOL scores among all follow-up time points, there were no significant differences in either RSDI or CSS total scores (all P ≥ 0.853) or subscale scores (all P ≥ 0.251) between six, 12, and 20 months. Each individual subgroup demonstrated stable QOL scores between six and 20 months' follow-up, including patients with polyposis and those with intolerance to acetylsalicylic acid (all P ≥ 0.275).

CONCLUSION

At a cohort level, improvements in QOL after ESS do not appear to change between six and 20 months. Clinical trial designs incorporating QOL outcomes after ESS should consider the six-month time frame as an appropriate primary end point.

Quality of life in non-allergic rhinitis depends on the predominant inflammatory cell type

Three main types of inflammatory Non-Allergic Rhinitis (NAR) have been defined: NAR infiltrated by eosinophils (NARES), by mast cells (NARMA), and by neutrophils (NARNE). In the absence of studies that investigated the Quality of Life (QoL) in NAR, the present work is aimed at evaluating the Quality of Life of patients with NARES, NARMA, and NARNE. One hundred thirty one (131) NAR patients were prospectively and consecutively evaluated: 54 patients with NARES, 38 with NARMA, and 39 with NARNE. Their history, nasal infiltration and rhinomanometry were characterized, and Quality of Life (using 2 instruments) was evaluated, and associated to clinical and histological features. Quality of Life was significantly different in the 3 groups (p less than 0.001); NARES patients had the worst Quality of Life. Nasal resistances were significantly higher in the NARES group. Significant associations were shown in NARES patients between Quality of Life and nasal function. This study provides the first evidence that Quality of Life is impaired in NAR as well as in allergic rhinitis. Furthermore, Quality of Life impairment differs among the various forms of NAR, and there is a correlation with the cellular infiltrating type.

Quality-assessment of disease-specific quality of life questionnaires for rhinitis and rhinosinusitis: a systematic review

The aim of this systematic review was to give a quality-assessed review of the existing disease-specific health related quality of life (QOL) questionnaires concerning rhinitis and rhinosinusitis for adults. The quality is assessed by defining the characteristics of a QOL questionnaire with assessment criteria. The results of the construction, description, feasibility, and the psychometric performance of the instruments are provided. We finally provide a clinician's guide to choose a questionnaire based on the measurement goals, the discriminant validity, responsiveness and the points obtained in the quality assessment. Of the top scoring instruments regarding the overall quality assessment, only four health related QOL questionnaires for rhinitis and rhinosinusitis met our criteria for the discriminant validity and responsiveness.

Endoscopic and Quality-of-Life Outcomes After Revision Endoscopic Sinus Surgery

OBJECTIVES

First, to examine the impact of endoscopic sinus surgery (ESS) on endoscopic and quality-of-life (QOL) outcomes after revision ESS as compared to primary ESS. Second, to evaluate whether or not other risk factors and/or co-morbidities influence the relationship between revision surgery status and outcomes of ESS.

STUDY DESIGN

Prospective observational study with an internal comparison group.

METHODS

Preoperative computed tomography scores, pre and postoperative endoscopy scores, and two validated disease-specific QOL instruments, the Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS), were collected on a prospective cohort of patients undergoing ESS for chronic rhinosinusitis. Data were analyzed using Pearson's chi and multiple logistic regression models.

RESULTS

Mean preoperative Lund-Mackay computed tomography scan scores were similar in primary and revision surgery patients. In patients without polyps, revision ESS patients were 3.88 times more likely to improve on endoscopy scores than primary ESS patients (95% confidence interval 1.70, 8.83; P = .001). In nasal polyp patients, there was no difference by revision status (odds ratio 0.48; 95% confidence interval 0.15, 1.59; P = .23). The odds of improving on the RSDI (odds ratio 0.51, 95% confidence interval 0.25, 1.04, P = .065) and CSS (odds ratio 0.98, 95% confidence interval 0.51, 1.89, P = .950) were not significantly different by revision status.

CONCLUSIONS

Both revision and primary ESS patients improved after ESS with regard to endoscopy, RSDI, and CSS scores. In non-polyp patients, revision ESS patients were more likely to improve on endoscopy scores than primary ESS patients; there was no difference in polyp patients by revision status. Revision ESS patients and primary ESS patients were equally as likely to improve on two QOL instruments.

Rhinitis, rhinosinusitis and quality of life in children

Quality of life (QoL) or, rather, health-related QoL, is currently regarded as a crucial aspect of the general well-being of patients and, in consequence, of the effects of a disease and its treatment. This is particularly true for respiratory allergy (asthma and rhinitis), which are chronic diseases and also for sinusitis (rhinosinusitis). A number of questionnaires (instruments), either generic or specific, have been developed and validated to assess the QoL in adults and children, for asthma and rhinitis, whereas there are few specific instruments for chronic rhinosinusitis. The literature provides strong evidence of the effects of allergic rhinitis, asthma and their treatments on QoL in paediatric patients, as well as in adults, whereas the number of experimental data on rhinosinusitis is limited, especially in children. Clinical trials evidenced some controversial points, mainly the weak correlation existing between QoL and traditional objective parameters. It has become clear that the QoL questionnaires measure the aspects of the disease that partially differ from the routinely evaluated parameters and that QoL should integrate, not replace, the objective measurements.

Allergic rhinitis and asthma ad hoc survey: clinical and psychological perspectives

BACKGROUND

Several studies have provided evidence of a strong association between asthma and rhinitis, with consequences in terms of therapy and disease management.

OBJECTIVES

The aims of our study were to evaluate physicians' knowledge about rhinitis/asthma comorbidity, to note the patients' management behaviour and to assess the patients' experience about symptoms and expectations, and to investigate the clinical and psychological meaning of general practitioners' and patients' awareness.

METHODS

One hundred and one general practitioners and 504 asthmatic patients participated in the study. General practitioners and patients filled in two different multiple choice questionnaires concerning asthma-rhinitis link and impact.

RESULTS

34.7% of general practitioners are aware of the link between asthma and rhinitis, and 43.6% of them hypothesize the comorbidity on the basis of their clinical experience. 21.8% of physicians make the diagnosis autonomously. 27.8% of asthmatic patients experience three or less rhinitic symptoms, 41% from four to six symptoms and 31.2 more than six symptoms. These symptoms deeply interfere with daily life, causing sleep problems (87.3%), lack of concentration (78.9%), difficulties in spare time (71.8%) and sport (71.7%). Rhinitis symptoms are responsible for the worsening of asthma, with an increase in dyspnoea (86.3%), cough (73.9%), and wheezing (59%). Ninety-three percent of patients expressed an interest in a combination therapy approach.

CONCLUSIONS

Asthma and rhinitis interact in the development of clinical burden and impact on quality of life. The survey results showed different perspectives when evaluated from clinical and psychological points of view.

Development and validation of an electronic version of the Rhinoconjunctivitis Quality of Life Questionnaire

BACKGROUND

As clinicians and pharmaceutical companies move from paper versions of health status questionnaires to electronic versions, it cannot be assumed that adaptations to other media will produce valid data.

AIMS

The aims of this study were to (1) adapt the Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ(S); standardized version], for the Palm Treo 650, (2) test the device for ease and accuracy of understanding and (3) examine the validity of the electronic version by comparing it with the original paper version of the RQLQ(S).

METHODS

Seventy adults with current rhinoconjunctivitis symptoms completed the electronic and paper versions of the RQLQ(S). They were randomized to complete either the paper or the electronic version first. After a 2-h break, they completed the other version.

RESULTS

Concordance between paper and electronic versions for the overall RQLQ(S) score was acceptable with an intraclass correlation coefficient of 0.95 and there was no evidence of bias (P = 0.13). Concordance for the seven individual domains ranged from 0.86 to 0.94. A small but significant bias was observed in the activity and sleep domains (P = 0.02). Completion times were quicker with paper (4.1 vs 4.9 min, P < 0.0001). About 51% of patients preferred electronic, 17% preferred paper and 31% had no preference.

CONCLUSIONS

This electronic version of the RQLQ(S) was easy for patients to use and the concordance between paper and this version on the Palm Treo 650 provides evidence of the validity of this electronic version.

Atopic dermatitis in adolescent boys is associated with greater psychological morbidity compared with girls of the same age: the Young-HUNT study

BACKGROUND

Having atopic dermatitis (AD) as well as other chronic diseases is often associated with reduced mental health. Adolescents with AD are thought to be especially vulnerable, but few studies have included an ample number of young people.

OBJECTIVES

To study self-reported mental distress among boys and girls 13-19 years of age with AD compared with mental distress among healthy adolescents as well as mental distress among adolescents with other chronic diseases or complaints, such as headache, neck or shoulder pain, asthma, allergy and rhinitis.

METHODS

The Young-HUNT study was conducted as a cross-sectional, population-based survey in 1995-97. All students in Nord-Trondelag County, Norway, aged 13-19 years were invited, and some 89% participated. A questionnaire on mental and somatic health, life-style and social conditions was completed during one school hour.

RESULTS

A total of 4384 girls and 4433 boys participated. The prevalence of mental distress was higher among older teenagers, and more than every fourth girl aged 17-19 reported mental distress. Although more girls than boys reported mental distress, AD, headache and neck or shoulder pain, the odds for reporting both AD and mental distress were higher for boys [odds ratio (OR) = 2.1 (1.6-2.9)] compared with girls [OR = 1.3 (1.1-1.6)]. A corresponding sex difference in reporting mental distress was also seen for some other chronic diseases or complaints.

CONCLUSIONS

In adolescents aged 13-19 years there was a strong and significant association between self-reported mental distress and AD as well as headache and neck or shoulder pain for both sexes. Although boys reported fewer complaints as AD, they perceived the complaints a heavier burden than did the girls.

Personality: A vulnerability factor in rhinitis?

Personality traits were assessed in 63 patients with persistent allergic or non-allergic rhinitis with the Karolinska Scales of Personality, developed with the aim of measuring psychobiological vulnerability factors, and were compared with a reference group comprising a random sample of 400 sex- and age-stratified subjects. The patients' personality profile differed slightly - within one standard deviation - but significantly from the reference group on a number of factors together suggestive of a disinhibitory disposition, an inclination to express anxiety through somatic rather than psychological channels, difficulties in maintaining emotional distance to others, and a limited awareness of aggressive affect, a pattern that suggests that they expose themselves to more stimulation than they can process in terms of thought and feelings, generating sustained physiological arousal that may contribute to the development of their intolerance reactions.

Impact of depression on disease-specific symptoms and quality of life in patients with chronic rhinosinusitis

BACKGROUND

Depression is associated with increased symptom burden in the setting of chronic medical conditions. Studies investigating the influence of depression on the symptoms of chronic rhinosinusitis (CRS) are lacking. The purpose of this project was to establish the prevalence of depression in patients with CRS and to explore the impact of this disorder on disease-specific symptoms and general quality of life (QOL) in the preoperative and postoperative setting.

METHODS

We reviewed the records of 320 consecutive patients presenting with sinonasal symptoms to our specialty sinus clinic. Patients with CRS were evaluated by nasal endoscopy, CT imaging, and validated questionnaires including the Chronic Sinusitis Survey and SF-8 Health Survey, a QOL measurement. Findings in CRS patients with depression were compared with a matched-control group of CRS patients without depression before and after endoscopic sinus surgery.

RESULTS

Overall, 26% of patients presenting with sinonasal symptoms had a diagnosis of depression. After evaluation including CT imaging, 33% of the initial population was diagnosed with CRS. The prevalence of depression in these CRS patients was 25%. Disease-specific symptoms were similar between groups; however, depressed CRS patients reported significantly worse pain and energy level and difficulty with daily activities (p < 0.050) when compared with a control group of CRS patients without depression. Postoperatively, nondepressed patients showed a marked improvement in disease-specific as well as general QOL scores (p < 0.050), whereas depressed patients did not.

CONCLUSION

CRS patients with and without depression have similarly poor disease-specific symptoms. However, depressed CRS patients have poorer disease-specific and overall QOL outcomes after sinus surgery.

Outcomes of endoscopic sinus surgery for chronic rhinosinusitis associated with sinonasal polyposis

BACKGROUND

The aim of this study was is to investigate the outcomes of endoscopic sinus surgery (ESS) when performed for chronic rhinosinusitis associated with sinonasal polyps.

METHODS

Forty-three patients with polyps were compared with 76 patients without polyps before and after ESS. Mean follow-up was 1.5 years. Patients were analyzed prospectively based on computed tomography (CT), endoscopy, quality-of-life (QOL) assessment, and visual analog scales (VASs). Univariate analyses were performed to evaluate whether the presence of polyps was predictive of outcome.

RESULTS

Patients with polyps had worse CT and endoscopy scores both pre- and postoperatively when compared with patients without polyps (p < 0.0001 for each). All patients, regardless of polyps, improved on endoscopic exam; however, patients with polyps showed a greater degree of improvement (p = 0.002). Despite this, postoperative endoscopic scores in patients with polyps were worse than those without polyps (p < 0.0001). Patients with polyps had better QOL as measured by the Chronic Sinusitis Survey (CSS) both pre- and postoperatively (p = 0.001 and 0.044, respectively). The preoperative VAS indicated that patients with polyps had increased nasal obstruction compared with patients without polyps (p = 0.002) while having less facial pain and headache (p = 0.002 and 0.005, respectively). Patients with polyps showed a greater postoperative improvement in nasal congestion (p = 0.003) but no difference in level of improvement in postoperative headache or pressure.

CONCLUSION

Despite significantly worse objective testing scores, patients with polyps report significantly better QOL as measured by the CSS and less facial pain/headache as measured by VAS scores pre- and postoperatively. Polyps were not found to be predictive of QOL or endoscopic outcome.

Quality of life in nonallergic rhinitis

Health-related quality-of-life questionnaires are instruments to assess the burden of a disease as perceived by the patient. Few data are available on the health-related quality of life of patients with nonallergic rhinitis, but data from studies of patients with allergic rhinitis show that rhinitis predominantly affects mental quality of life. This burden of rhinitis is associated with impaired sleep, excessive daytime sleepiness, concentration problems, and increased irritability.

Effect of Usuhiratake (Pleurotus pulmonarius) on Sneezing and Nasal Rubbing in BALB/c Mice

The anti-rhinitis properties of Pleurotus pulmonarius were investigated in BALB/c mice. A single administration of Pleurotus Pulmonarius caused no significant effect on antigen-induced nasal rubbing and sneezing at a dose of 500 mg/kg, but a significant inhibition was observed after 2 weeks of repeated treatment at this dose, and at a dose of 200 mg/kg, it also caused a significant inhibition after repeated administration for 4 weeks. Pleurotus pulmonarius showed no significant inhibitory effect on the production of IgE. In addition, Pleurotus pulmonarius caused no inhibition of histamine-induced nasal rubbing and sneezing at a dose of 500 mg/kg, but in vitro study, it inhibited histamine release from rat mast cells induced by compound 48/80 at the soluble supernatant solution of 30 and 100 microg/ml of Pleurotus pulmonarius suspended in PBS. These results demonstrated that Pleurotus pulmonarius may be effective in the relief of symptoms of allergic rhinitis through inhibition of histamine release.

Gender and age differences in the relative burden of rhinitis and asthma on health-related quality of life--a Swedish population study

The aim of this study was to investigate the relative burden of rhinitis and asthma on health-related quality of life (HRQL) as a function of gender and age in the general population. A cross-sectional, general population survey was conducted, comprising 5918 men and women aged 16-64 years. The SF-36 Health Survey was administered by mail, along with questions regarding nasal complaints after 15 years of age and physician-diagnosed asthma. Overall, rhinitis and asthma were each associated with impaired HRQL compared with non-cases and the burden of these illnesses in combination was incremental. In the age group 16-49 years, men and women with rhinitis alone had significantly worse health profiles on most scales than non-cases, while asthmatics, with or without rhinitis, showed further decrements on only a few scales. In the age group 50-64 years, men with rhinitis did not differ from non-cases and no differences were found between asthmatics and rhinitis victims on any scale. In contrast, women aged 50-64 years with rhinitis had significantly worse scores than non-cases on bodily pain and general well-being scales (GH, VT), and asthmatics scored much lower on all scales than those with rhinitis alone. The negative association of rhinitis and asthma with HRQL differs by age and sex in the general population. Women aged 50-64 years with one or both ailments are particularly affected. Such gender and age differences should be taken into consideration in the care and treatment of patients with rhinitis and asthma.

Skin test results and self-reported symptom severity in allergic rhinitis: the role of psychological factors

BACKGROUND

In allergic conditions, the degree of skin test reactivity does not always correlate with the severity of clinical symptoms. Additional factors may contribute to the reported symptom severity.

OBJECTIVES

To investigate the association between the magnitude of the skin prick test (SPT) response and the reported symptom severity in patients with allergic rhinitis and the possible modifying role of psychological factors.

METHODS

One hundred four patients with allergic rhinitis and 23 with non-allergic rhinitis, classified according to their SPT response to 19 aeroallergens, were asked to rate the severity of five symptoms and to indicate whether their symptoms intensified on exposure to five common aeroallergens. They also completed a psychological questionnaire. Results Reported symptom severity of allergic rhinitis did not correlate with weal size for any of the aeroallergens tested or with the number of positive responses on SPT. It was not related to patient age, sex, or education. The reported symptoms severity correlated positively (0.29, P < 0.01) with reported symptom intensification on exposure to allergens. Moreover, both outcomes were positively associated with the psychological factors of hypochondriasis (0.20, P < 0.05 and 0.18, P < 0.05, respectively), and somatic awareness (0.24, P < 0.05 and 0.33, P < 0.01, respectively), but not with neuroticism.

CONCLUSIONS

The severity of symptoms experienced by patients with allergic rhinitis is apparently not related to the magnitude of SPT response, but rather to psychological factors of hypochondriasis and somatic awareness. Physicians should be aware of the contribution of psychological factors to patient perceptions of the intensity of symptoms and of the intensification of symptoms on their exposure to allergens.

Allergic diseases and their impact on quality of life

OBJECTIVE

To review the results of studies that have evaluated the impact of allergic diseases on patients' health-related quality of life (HRQL).

DATA SOURCES

We performed a MEDLINE search of the literature published between January 1990 and May 2006 (English language only) on HRQL and allergic diseases.

STUDY SELECTION

Representative studies that used validated questionnaires that assessed the effect of allergic diseases on HRQL were selected for inclusion in this review.

RESULTS

Allergic diseases can deeply interfere with patients' HRQL, with detrimental effects on the physical, psychological, and social dimensions of life. Numerous validated questionnaires that are now available can easily be adopted; most of them are specifically developed for rhinitis and asthma.

CONCLUSIONS

HRQL has become an increasingly important aspect in outcome evaluation in health care research, providing a more comprehensive approach to the patient and proving that nowadays we cannot renounce this tool. Most of the studies evaluate patients with respiratory allergy. Further studies are needed to explore HRQL in other allergic conditions (urticaria, food allergy, sting allergy, drug allergy) by means of specific, validated questionnaires.

Do patients with skin allergies have higher levels of anxiety than patients with allergic respiratory diseases? Results of a large-scale cross-sectional study in a French population

BACKGROUND

Psychological comorbidity is a known aspect of allergic disease. However, there is recent evidence that a large proportion of allergic patients remains undiagnosed and untreated for psychological disease. In addition, the complexities of the anxiety-allergy relationship, i.e. differences for current and past disease, or differences among allergic disease types, are not well understood.

OBJECTIVES

To measure the level of anxiety in a large allergic population in France using a standardized measure, the State/Trait Anxiety Inventory (STAI).

METHODS

Allergy patients in France (n = 3939) who visited their allergy specialists participated in the study. The patients completed a questionnaire which was then linked to the questionnaire completed by their physician. Only patients with both subject and physician questionnaire were kept in the analyses. Mean STAI scores for the State (S) and Trait (T) scales were obtained for each allergic disease. ANCOVA models testing group differences on the mean scores, using the categories "current disease", "past disease" and "allergic disease ever", were assessed along with relevant confounders.

RESULTS

Allergic rhinitis (AR), asthma and atopic dermatitis (AD) were the most prevalent conditions of the 12 allergic diseases assessed in the study. Women had higher mean STAI S/T scores than men and age was also found to be associated with higher S scores; therefore, both age and gender were included as covariates where relevant. A single ANCOVA model for each STAI scale showed a statistical difference among the various allergic diseases. Using the category "current disease" each allergic disease was assessed separately regarding the presence or absence of that disease. Higher, statistically significant mean STAI scores were found for AD and allergic urticaria on the S scale and for AD on the T scale. Similarly, for the category "allergic disease ever", AD and allergic urticaria reached statistical significance on the S scale, while on the T scale only AD was statistically significant. When patients were assessed for anxiety based on their past disease, asthma, AR and sinusitis were significant on the S scale while asthma and nasal polyps were statistically significant on the T scale. When asthma and AD were tested simultaneously, only the latter was significant.

CONCLUSIONS

High mean scores for State and Trait anxiety were mostly associated with AD.

General and Rhinosinusitis-Related Quality of Life in Patients With Wegener???s Granulomatosis

OBJECTIVES

The objectives of this cross-sectional study were to outline the pattern of sinonasal morbidity and determine its effects on the quality of life (QOL) of patients with Wegener's granulomatosis (WG).

METHODS

The authors conducted a survey of 199 patients with WG, including two validated (QOL) instruments to assess general (SF-36) and rhinosinusitis-specific quality of life (Sinonasal Outcome Test [SNOT-22]).

RESULTS

Patients with WG who have sinonasal involvement reported significantly lower general QOL scores than their unaffected counterparts (P = .000006-0.04) for all SF-36 subsets except for emotional role. WG-related sinonasal morbidity was comparable to the high levels previously demonstrated in the general rhinosinusitis population. A total of 38.2% of all patients with WG reported a nasal symptom as their most troublesome from a list of nasal and constitutional symptoms. Twenty-three percent of all patients with WG rated nasal crusting and 17% rated epistaxis as one of their top three most troublesome symptoms even in the setting of multisystem disease. The inclusion of crusting, bleeding, and nasal deformity in the SNOT scoring significantly increased average scores of patients with WG (P = .024, paired t test).

CONCLUSIONS

Sinonasal involvement impacts significantly on the general QOL of patients with WG and is at least as significant as that of the general rhinosinusitis population. Nasal symptoms that are of particular relevance to this patient group include nasal crusting and epistaxis.

[Does experience influence perception of dyspnea?]

OBJECTIVE

The perception of somatic sensations like dyspnea can be influenced by such factors as an individual s personality, experiences, or ability to adapt to stimuli. Our aim was to determine whether the perception of acute bronchoconstriction is different for patients with asthma and patients who have never experienced an episode of airway obstruction.

PATIENTS AND METHOD

We studied 2 groups of patients. The first consisted of 24 subjects with intermittent rhinitis and asthma (10 females and 14 males) with a mean (SD) age of 25 (7) years. All reported not feeling dyspnea at rest on a Borg scale. The second group consisted of 24 subjects who only had rhinitis but no lung disease (no episode of asthma) or dyspnea at rest (12 females and 12 males) with a mean age of 27 (6) years. There were no significant differences between the groups with regard to sex, smoking, economic or educational level, anxiety (determined by the trait portion of the State-Trait Anxiety Inventory), depression (Beck Depression Inventory), or spirometric parameters. All took a histamine bronchial provocation test in which the patient assessed dyspnea on a modified Borg scale after each histamine dose. The provocation dose needed to produce a 20% decrease (PD20) in forced expiratory volume in the first second (FEV1) was calculated. We also recorded dyspnea perception score when FEV1 fell 5%, 10%, 15%, and 20%.

RESULTS

No dyspnea was perceived at PS20 by 12.5% of the asthmatics and by 45% of nonasthmatics (P< .0001). The mean PS20 was 2.4 (2.1) (range, 0-7) in the first group and 0.37 (0.48) (range, 0-3) in the second (P< .0001). More asthma patients than nonasthmatics perceived dyspnea at all degrees of bronchial obstruction. PD20 was different in the 2 groups (1.6 [2] vs 6.03 [5] for the first and second groups, respectively; P< .003), but there was no significant relation between PD20 and PS20 (Spearman s correlation coefficient, 0.19; P= .221).

CONCLUSION

Our findings support the hypothesis that appropriate perception of dyspnea is grounded in prior experience and learning.

Clinical outcomes after endoscopic sinus surgery

PURPOSE OF REVIEW

Chronic rhinosinusitis continues to present diagnostic and therapeutic challenges for clinicians. Recently, attention has been focused on reliable and valid measures of outcomes for many sinonasal diseases. As a significant fraction of patients with chronic rhinosinusitis will come to endoscopic sinus surgery, there has been a dedicated focus on determining objective clinical outcomes after medical and surgical treatment for CRS. This has been aided by validated instruments for measuring both symptom outcomes and quality of life after endoscopic sinus surgery.

RECENT FINDINGS

Recent studies have demonstrated that endoscopic sinus surgery provides statistically and clinically significant improvements in most sinonasal symptoms. These benefits are maintained more than 1 year after surgery. In addition, the significant adverse effects of chronic rhinosinusitis on quality of life can be reversed with appropriate endoscopic sinus surgery. Certain sub-populations do not fare as well with endoscopic sinus surgery, however; adjunctive medical management is required to maintain symptomatic and quality-of-life improvements for patients with nasal polyposis. Unfortunately, paranasal sinus computed tomography scan findings do not predict symptomatic or quality-of-life improvements after endoscopic sinus surgery.

SUMMARY

With reliable objective evidence of the health benefits of endoscopic sinus surgery, patients should be considered for such surgery after failure of medical management. Further work is required to characterize outcomes for sub-populations, and to stage and select patients who will derive appropriate benefit from endoscopic sinus surgery.

A review of sinonasal outcome scoring systems - which is best?

* In patients undergoing endoscopic sinus surgery for chronic rhinosinusitis, there is a lack of a universally accepted system for the evaluation of outcome. * This makes critical comparison between results less meaningful. * To determine the most suitable sinonasal outcome scoring system for use in our own practice, we reviewed the available literature and known systems in existence. * We analysed 15 known disease-specific sinonasal outcome indices with emphasis on reliability, validity and responsiveness. * We concluded by choosing one quality of life outcome tool for our departmental use, the Sinonasal Outcome Test-22, due to its reliability, validity, responsiveness and ease of use. * It has been validated to distinguish between disease-affected patient groups and those without rhinosinusitis, demonstrate a worse score if the condition gets worse and show an appropriateness of items and scales in the questionnaire. This has been demonstrated in 3128 British patients.

Relationship Between Rhinosinusitis Symptoms and Mucociliary Clearance Time

OBJECTIVE

To determine the correlation between rhinosinusitis symptoms as assessed by the Sino-Nasal Outcomes Test-20 (SNOT-20) and mucociliary clearance as assessed by the saccharin method.

STUDY DESIGN AND SETTING

This was a cross-sectional study of 50 adult volunteers. Subjects completed the SNOT-20, and mucociliary clearance was determined with the saccharine method. Correlation coefficients (Spearman's Rho) were calculated for the global SNOT-20 score.

RESULTS

The SNOT-20 scores varied from 20 to 54 (mean 30.28) with a possible range of 20 to 100. Clearance times varied from 418 to 2865 seconds (mean 999). There was no significant correlation between global SNOT-20 score and clearance time (r = 0.196).

CONCLUSIONS

There is no significant correlation between rhinosinusitis symptoms as assessed by SNOT-20 scores and mucociliary clearance.

SIGNIFICANCE

Mucociliary clearance is important for the health of the sinonasal cavities, but clearance time does not appear to be associated with symptom severity in the population studied.

EBM RATING

A-1b.

Predictive factors and outcomes in endoscopic sinus surgery for chronic rhinosinusitis

PURPOSE

To assess objective and quality of life (QOL) outcomes before and after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS) and to determine preoperative factors that predict surgical outcome in these patients.

METHODS

One hundred nineteen adult patients with CRS and a mean follow-up of 1.4 +/- 0.35 years were evaluated prospectively including the following patient factors: prior sinus surgery, polyps, asthma, acetylsalicylic acid intolerance (ASA), smoking, allergy, depression, and sex. Computed tomography (CT), endoscopy, and QOL assessment was performed. Predictive value of patient factors was determined based on change in endoscopy and QOL scores after ESS.

RESULTS

Objective outcomes: preoperative CT scores were significantly worse in patients with polyps, asthma, and ASA, whereas CT score was unaffected by prior sinus surgery, smoking, allergy, depression, and sex. Patients with CRS demonstrated significant improvement on nasal endoscopy after ESS, but preoperative, postoperative, and change in scores were affected by certain patient factors. Endoscopy scores were significantly worse in patients with prior sinus surgery, polyps, asthma, and ASA, but these patients also experienced the greatest improvement in endoscopy scores. Smokers and patients with depression had the least change in endoscopy scores. QOL outcomes: patients with CRS experienced improvement in QOL after ESS. Pre- and postoperative QOL was positively affected by polyps and adversely affected by ASA, depression, and female sex, but these groups still experienced significant improvement in QOL scores. Pre- and postoperative QOL was unaffected by prior sinus surgery, asthma, smoking, and allergies, and all of these groups experienced significant improvement in QOL scores. Factors predictive of outcome: ASA and depression were predictive of worse outcome. Preoperative CT scores approached significance as being predictive of outcome.

CONCLUSION

Surgical management of CRS was associated with significant improvement on objective and QOL measures; however, specific patient factors, in particular ASA and depression, predict poorer outcome. Preoperative CT may be a predictor of endoscopic and QOL outcome and deserves further study.

Psychiatric distress amplifies symptoms after surgery for chronic rhinosinusitis

BACKGROUND

Psychiatric disorders are associated with increased symptom burden when combined with chronic medical conditions. However, there are no reports of how psychiatric distress influences outcomes with surgical treatment for chronic rhinosinusitis (CRS). We hypothesized that subjects with psychiatric distress (somatization, anxiety, and depression) would report more severe long-term sinus symptoms and worse quality of life (QOL) than subjects without psychiatric distress.

METHODS

This is a community-based, prospective, observational cohort study of patients diagnosed with CRS presenting for surgery. Patients were interviewed before surgery; CT scans were reviewed, and questionnaires were completed about sinusitis-related symptoms (SNOT-16), general health status and QOL (SF-36), and psychiatric distress (BSI and PHQ). Outcomes were also assessed 1, 3, 6, and 12 months postoperatively.

RESULTS

Ninety-five patients had complete records for analysis. Psychiatric distress was prevalent, with 31% screening positive for somatization, 17% positive for anxiety, and 25% positive for depressive disorders. Subjects with somatization had significantly worse SNOT-16 scores at each time point compared with those without somatization ( P < 0.05). Subjects with depression reported more severe symptoms at 6 and 12 months after surgery than those without depression ( P < 0.05). The presence of somatization preoperatively was also independently associated with worse symptom severity 12-months after surgery, even after adjusting for prior sinus surgery, CT stage, Charlson Index, and deviated septum. In addition, subjects with psychiatric distress reported significantly worse SF-36 physical and mental component summary scores 12-months after surgery than subjects without psychiatric distress.

CONCLUSIONS

Psychiatric distress is associated with worse reported sinus symptoms and lower QOL throughout surgical management of chronic rhinosinusitis. Despite this, subjects with psychiatric distress report a similar degree of improvement in sinus symptoms after surgery compared with those without distress.

CLINICAL SIGNIFICANCE

Psychiatric distress should be considered in patients with persistent symptoms after surgery. Psychiatric distress should also be considered in efforts to design a chronic sinusitis staging system.

Quality of life in non-infectious rhinitis and asthma

In this study we evaluated how the quality of life in subjects with asthma was affected by a history of non-infectious rhinitis. The study comprised 180 persons with asthma and 156 controls, who answered the Short Form 36 quality of life questionnaire. Both the asthma subjects and the controls were stratified according to a history of non-infectious rhinitis (NIR). The global physical quality of life score (PCS) was significantly lower for all the asthma subjects regardless of their previous history of NIR compared to controls (NIR positive asthma, -8, p=O,001, NIR negative asthma, -9, p=0, 001). The subjects with asthma and a positive history of NIR obtained significantly lower scores for their global mental quality of life (MCS) than the controls (46 vs 51, p=0.004). The subjects with asthma and a negative history of NIR obtained MCS scores that were similar to those of the controls (50 and 51, p=0.9). In this population based study, the physical Qol of the subjects with asthma was lower regardless of a previous history of NIR compared to controls. A positive history of NIR in asthma was however associated with a poorer mental Qol.

[Validation of the Spanish version of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ)]

OBJECTIVE

Validate the questionnaire Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) in conditions of regular clinical practice.

METHODS

Two hundred and eighty four adult patients with a diagnosis of rhinoconjunctivitis (RC) cared in 37 centers of specialized health care in allergy or otorhinolaryngology services in Spain were analyzed. Patients with RC were included in two groups: clinically non-stable patients who received treatment with an oral second generation antihistaminic (group A), and clinically stable patients (group B). Sociodemographic and clinical variables were collected and the questionnaires RQLQ and EQ-5D were administered in the initial visit and in the second visit 15 days after. Feasibility, validity, reliability and sensitivity related to the change of the RQLQ were analyzed.

RESULTS

The mean period (standard deviation) of administration was 9.67 (6.25) minutes and 85.6% of patients needed assistance in order to fill the RQLQ, especially the selection of the characteristics (62.5%). The dimensions of the RQLQ showed a greater association with the dimensions of the EQ-5D that assessed similar aspects and the symptoms in which a greater relation was expected. The alpha Cronbach coefficient of the scorings of the RQLQ fluctuated between 0.85 and 0.96 and the intraclass correlation coefficient fluctuated between 0.68 and 0.89. The sensitivity to the change of the dimensions of the RQLQ, evaluated through the magnitude of the effect between the two visits, ranged between 0.76 and 1.46.

CONCLUSIONS

The Spanish version of the RQLQ proved to be a valid instrument for assessing the Health-Related Quality of Life (HRQL) in adult patients with seasonal or perennial RC.