Abstract
Rhinosinusitis is a prevalent condition worldwide affecting the developed and the third world countries alike. SNOT-22 is a validated disease-specific questionnaire designed to use in Chronic Rhino Sinusitis (CRS), which means to quantify patients perception of their disease burden. SNOT 22 questionnaire can chart patients nasal as well as psychological symptoms arising due to CRS and very well become marker of individual symptomatic improvement. To study the correlation between disease specific quality of life and endoscopy score after 1 month and 6 months of Endoscopic Sinus Surgery in patients with Chronic Rhinosinusitis. In the present study, ESS surgery showed improvement in Endoscopy score and all the symptoms assessed by SNOT-22. The total percentage of improvement in the SNOT-22 score was 70% after 1 month and 89% at the end of 6 months. We conclude that after the procedure of ESS not only endoscopic evaluation is necessary but also psychological and symptomatic assessment by SNOT 22 is very necessary as nasal and psychological factors were equally decisive for the seeking of the treatment (pharmacological/surgical) by the patient.
Keywords: CRS, SNOT 22, ESS
Introduction
Rhinosinusitis is a very prevalent condition presenting to a Rhinologist causing a significant healthcare burden in developed and third world countries alike [1–4]. Chronic rhinosinusitis (CRS) almost affects 10 percent of the population. In our country due to ignorance and delay in presenting it goes undetected for long until it becomes CRS with nasal polyposis. The spectrum of symptoms in CRS range from typical nasal symptoms to psychological ones affecting the day to day activity as well as sleep.
Gliklich and Metson were the first to demonstrate the impact of CRS on the global quality of life. The quality of life (QOL) is so much affected that it often surpasses that of chronic illness/debilitating diseases [5].
The patient may be having minimal disease but severe symptoms or sometimes severe disease amounting to pan sinusitis without much problem to the patient.
Irrespective of the disease as confirmed by CT Scan and Nasal Endoscopy it is in fact the severity of the patient's symptoms remains the deciding factor in patients seeking treatment which may be medical or surgical.
SNOT-22 (Sino Nasal Outcome Test-22) is a validated disease-specific questionnaire designed to use in Chronic Rhinosinusitis, which means to quantify patients perception of their disease burden both before and after intervention. The Royal College of surgeons of England did a study where the general population’s audit was done and eventually SNOT 22 was accepted for scaling and grading the symptoms of CRS [6]. This questionnaire contains 22 items that cover the most relevant symptoms of sinonasal diseases; each item is graded on a 6-point scale (0 for no problem, 5 for the problem as bad as it can).
This study aims at assessment of symptom improvement on quality of life and its correlation with the change in endoscopic score after Endoscopic Sinus Surgery in patients with CRS.
Methods
Aim
To study the correlation between disease specific quality of life and endoscopy score after 1 month and 6 months of Endoscopic Sinus Surgery in patients with Chronic Rhinosinusitis.
Objectives
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(A)
Primary Objective:
To study the correlation between the improvement in disease specific quality of life and change in endoscopy score in patients with Chronic Rhinosinusitis after 1 month and 6 months of Endoscopic Sinus Surgery.
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(B)
Secondary Objective:
To study the factors affecting improvement in disease specific quality of life in patients with Chronic Rhinosinusitis by Endoscopic Sinus Surgery.
Materials and Methods
Informed consent of the patients, a prospective cohort study was conducted on 60 patients with Chronic Rhinosinusitis undergoing Endoscopic Sinus Surgery.
The sample size-60.
Sample Size Determination- All the in-patients (IPD) of the ENT department who fulfilled the inclusion criterion were selected in the period of the study.
Study site, population and study design.
A prospective cohort study was conducted in patients with chronic Rhinosinusitis undergoing Endoscopic Sinus Surgery to study the correlation between disease specific quality of life and endoscopy score in the patients presenting to a rural tertiary care center.
Study duration—from January 2017 to December 2021.
Inclusion Criteria:
Patients of age 18 years and above, who satisfied clinical criteria for diagnosis of CRS.
Persistent symptoms even after 6 weeks of maximal medical therapy of CRS.
Exclusion criteria.
Patients without a minimum of 6 months follow-up after treatment.
Patients not willing to take part in the study or unwilling to give their written consent for the study.
Patients who did not complete the SNOT-22 questionnaire before and 1 month and 6 months after the treatment.
Patient who had undergone previous nasal surgery.
Patients with granulomatous diseases, cystic fibrosis, ciliary dyskinesia, mucormycosis.
Patients with malignant disease of nose and paranasal sinuses.
Patients who elected to continue with medical therapy.
Duration of individual participation: three visits.
1 st visit: Patients attending ENT OPD with Chronic Rhinosinusitis not responding to medical line of management.
2 nd visit: 1 month after Endoscopic Sinus Surgery.
3 rd visit: 6 months after Endoscopic Sinus Surgery.
Methodology
A total of 60 patients undergoing Endoscopic Sinus Surgery for Chronic Rhinosinusitis, who met eligibility criteria of the study were enrolled.
Detailed history was taken for each patient and completed the Sino Nasal Outcome Test (SNOT-22) questionnaire. In the form of questionnaire scoring was done preoperatively.
Each symptom given the scoring as follows: no problem (0), very mild problem (1), mild problem (2), moderate problem (3), severe problem (4) and problem as bad as it can be (5). Thus, the scoring ranged from minimum of 0 to maximum of 5.
Any history of co-existing bronchial asthma, respiratory illness and other systemic ailments and co morbid illnesses were looked into.
Personal habits with regard to smoking and alcohol intake were asked for.
A complete Ear Nose and Throat examination was done for each patient.
Diagnostic Nasal Endoscopy was performed on each patient, and the Lund-Kennedy endoscopic score was recorded.
The Lund-Kennedy endoscopic scoring system grades visual pathologic states within the nose and paranasal sinuses, including polyps, discharge, oedema, scarring, and crusting (score range, 0–20). Thus, the scoring ranged from a minimum of 0 to a maximum of 20.
Computed tomography of the nose and paranasal sinuses is done to look for normal or anatomical varaiations of the paranasal sinuses, determine the extent of the disease, the condition of the Osteo Meatal Unit (OMU).
Once the diagnosis and extent of the disease was established, the patients were taken up for ESS after a pre anesthetic evaluation. The operation was performed under general anesthesia.
One senior surgeon performed the surgical procedures in the operating room under strict aseptic precautions.
The procedures included uncinectomy, middle turbinate reduction, middle meatal antrostomy, anterior and posterior ethmoidectomy, sphenoidotomy, and frontal sinusotomy. The various surgical procedures performed depended upon the laterality and extent of the disease.
Post-operatively patients were started on appropriate antibiotics (Ceftriaxone), NSAIDS, oral decongestants and antacids. Nasal packs were removed 24–48 h after surgery depending on the extent of surgery. Local decongestants started after pack removal.
On the 2nd or 3rd postoperative day, the patients were sent home with the medications for an additional 5 days and asked to come back for a review after one week.
During the postoperative follow-up, the patient was asked to follow-up once a week for the first month and once a month for the next 2 months and one at the end of 6 months. Endoscopy was performed at each visit, and crusts were removed and suction clearance of the secretions done. Alkaline nasal douching once or twice a day was continued depending upon the amount of crusting seen during the follow-up nasal endoscopic examination.
Postoperative SNOT22 questionnaire and Lund-Kennedy endoscopic scoring were evaluated 1 month post op and later 6 months post op.
Statistical Methods
Data are collected using MS-Excel expressed as the mean ± standard deviation for continuous variable and frequency percentage for categorical variable.
Percentage Improvement of 1 month and 6 month calculated using [(mean postoperative score-mean preoperative score)/(mean preoperative score)]*100.
Comparison between three variables were performed using Friedman test.
Correlation between two variables performed using Spearman’s Correlation test.
A P-value less than 0.05 was considered to be significant. Statistical analyses were performed using SPSS (Version 26.0) software (IBM, Chicago, IL, USA).
Results
A total of 60 patients were included and assessed by SNOT-22 questionnaire and Diagnostic Nasal Endoscopy to assess correlation between disease specific quality of life and endoscopy score after ESS surgery. All patients had CRS with polyposis refractory to medical treatment (Fig. 1).
Age distribution
Fig. 1.
Age distribution
Improvement of each symptom in SNOT-22 with age group.
Age group of ≤ 30 years showed 72% improvement in SNOT-22 score and the > 30 age group showed 65% improvement after 1 month of ESS. After 6 months of ESS age group of ≤ 30 years showed 87% improvement and the > 30 age group showed 85% improvement.
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2.
Gender distribution
Among the 30 participants, 45 (75.0%) patients were males and 15 (25.00%) patients were females (Fig. 2).
Fig. 2.
Gender distribution
The male and female subjects showed 65% of improvement in SNOT-22 score after 1 month of ESS. After 6 months male subjects showed 85% overall improvement while the female subjects showed 90.6% overall improvement.
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3.
Smoking habit
Improvement of each symptom in SNOT-22 in relation to Smoking habit (Fig. 3).
Fig. 3.
Smoking habit
The smoking group showed 72% improvement against the non-smoking group 82% after 1 month of ESS. After 6 months the smoking group showed 90% overall improvement while the non-smoking group showed 90% overall improvement.
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4.
Bronchial asthma
The bronchial asthma showed 62% improvement against the non-bronchial asthma 75% after 1 month of ESS. After 6 months the bronchial showed 82% overall improvement while the non-smoking group showed 88% overall improvement (Fig. 4).
Fig. 4.
Patients suffering from bronchial asthma
The smoking group showed 72% improvement against the non-smoking group 82% after 1 month of ESS. After 6 months the smoking group showed 90% overall improvement while the non-smoking group showed 90% overall improvement.
Patients experienced a statistically significant mean reduction in inflammatory disease characteristics of the sino nasal mucosa as measured by Lund-Kennedy Endoscopic Score and improvement in symptoms assessed by SNOT-22 Score after 6 months of ESS.
Total percentage of improvement in this study was found to be 70% after 1 month and 89% after 6 months.
Maximum improvement was noted in the reduced productivity, sad and embarrassed state of mind and least improvement in sneezing.
Major symptoms like nasal blockage showed 92%, post-nasal discharge showed 88%, thick nasal discharge showed 81%, facial pain/pressure 88%, decreased sense of smell/taste 60% improvement after 6 months of ESS.
Minor symptoms like fatigue 82%, cough 78%, ear pain 92% and ear fullness 92% improvement after 6 months of ESS.
In the present study, ESS surgery showed improvement in Endoscopy score and all the symptoms assessed by SNOT-22. The total percentage of improvement in the SNOT-22 score was 70% after 1 month and 89% at the end of 6 months after the procedure of ESS.
Reduced productivity, sadness, and embarrassment showed the most (100%) improvement, while sneezing showed the least (48%) improvement. Major symptoms like nasal blockage (76%), post-nasal discharge (83%), thick nasal discharge (97%), facial pain/pressure (89%), decreased sense of smell/taste (84%) and minor symptoms like fatigue (97%), cough (72%), ear pain (97%) and ear fullness (97%) also improved after 6 months of ESS.
Discussion
Patients suffering from the CRS who are refractory to the medical treatment are advised ESS. Preoperatively they are evaluated by CT Scan, Lund Kennedy score and SNOT 22 Score.
The male and female subjects showed 85 and 90.6% improvement on the SNOT 22 scale at the end of 6 months.
Gender did not influence any difference in the results.
Krishnaswami et al. performed a prospective study and reported that male subjects showed 44.28% overall improvement while the female subjects showed 45.6% overall improvement [7].
Gender did not influence any difference in the results in our study as well as above study.
Both smoking and non smoking group showed 90% improvement in our study at the end of 6 months.
Krzeski et al. stated that there was no significant difference in the postoperative SNOT22 scores between smokers and non-smokers [8]. Our study correlated well with this study. It means smoking status is not predictive of improvement after ESS.
As we observe through the results all patients undergoing ESS for CRS have improved SNOT 22 Scale. Age, gender, smoking status or bronchial asthma, irrespective of the above conditions postoperative patients had improved SNOT 22 scale.
The SNOT-22 has utility to assess QOL and symptom control in CRS, and it is both reliable and responsive in its application to patients with CRS. The SNOT-22 may therefore be a convenient and versatile tool in the clinical assessment of patients with AR.
Morley et al. recommended the use of SNOT 22 especially when assessing which patients would benefit from surgery and again when assessing the outcome of surgery [9].
This study validates ESS as the standard treatment protocol for medically refractory CRS. All the patients irrespective of their age, gender, baseline medical condition or personal habits improved from the treatment.
SNOT 22 proved to be an effective tool in documenting the symptomatic improvement.
Koshiken et al. concluded in a study in Finland SNOT-22 questionnaire combined with imaging and endoscopy findings is an effective tool to assess rhinologic patients’ disease burden and outcome of a given treatment in Finland [10].
There are studies which validate the use of SNOT 22 Scale.
G Singla et al. noticed greater improvement in the SNOT 22 Score post operatively in CRS with polyposis [11].
Regi Kurien et al. noticed that CRS with nasal polyposis had higher frequency of Bronchial Ashthma and after ESS showed significant improvement in the SNOT scores [12].
This study found statistically significant improvement on SNOT- 22 Scores and a correlation was established between preoperative scores and postoperative improved scores (p < 0.001).
Gender, smoking status, bronchial asthma did not affect the improvement in the patients condition as per the SNOT 22 Scoring. Irrespective of the above conditions all patients showed marked symptomatic improvement as evident by the SNOT scoring.
Conclusion
SNOT-22 offers validated methods for objectively quantifying patients' perceptions of disease burden in terms of symptoms before and after surgical intervention namely ESS.
The baseline SNOT-22 scores can be used to guide treatment decisions for CRS and to inform patients about their expected QOL outcomes following sinus surgery.
ESS improves both endoscopic and quality of life outcomes for patients with CRS. This study determined that significant postsurgical improvement in endoscopy score correlates with significant improvement in disease-specific QOL score for patients electing ESS.
Thus we conclude that after the procedure of ESS not only endoscopic evaluation is necessary but also psychological and symptomatic assessment by SNOT 22 is very necessary as nasal and psychological factors were equally decisive for the seeking of the treatment (pharmacological/surgical) by the patient.
We also conclude age, gender, smoking status or any respiratory illness did not affect the results after ESS.
Acknowledgements
The study was done at UPUMS, Saifai.
Authors Contributions
RG: manuscript writing.
Funding
None.
Declarations
Conflict of interest
None.
Research involving human participants and/or animals
None.
Informed consent
Taken from the participant.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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