Psychometric Validation of Hindi Version of Sino-Nasal Outcome Test-22

Abstract

The purpose of this study was assessment of reliability, validity & responsiveness of Hindi version of SNOT 22. 110 cases and controls were recruited in this prospective study. The internal consistency, test–retest reproducibility, construct & criterion validity, and responsiveness of Hindi version of SNOT 22 were assessed. Hindi SNOT 22 showed a good internal consistency (Cronbach’s alpha (α) in cases = 0.823 and in controls = 0.868). Physical and Quality of life subscales also showed good internal consistency (α of 0.711 and 0.87 respectively). Test–retest reproducibility using Spearman’s rank correlation coefficient (r_s) showed very high correlation (r_s = 0.939). There was significant difference in scores (p < 0.00001) between cases and controls (46.99 ± 13.97 and 07.58 ± 6.772 respectively). The mean pre and post-operative scores were 53.43 ± 12.241 and 20.50 ± 06.679 respectively with a significant difference (p = 0.000002) and a large effect size (Hedge’s g = 2.34). Hindi SNOT 22 showed a moderate correlation with visual analogue scale (r_s = 0.663) and a low correlation with Lund Mackay staging (r_s = 0.388). The Hindi version of SNOT 22 is a valid, reliable and a responsive patient reported outcome measure instrument for assessment of chronic rhinosinusitis in adults. It retains most of the important characteristics of the source version (SNOT 22). This can be used as a clinical as well as research tool to aid in diagnosis, to assess quality of life as well as monitoring treatment strategies in the field of CRS in Hindi speaking patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02808-1.

Introduction

Chronic rhinosinusitis (CRS) is one of the most commonly encountered disease in rhinological practice. As per the European position paper on rhinosinusitis and nasal polyps (EPOS) 2020, prevalence of CRS ranges from 5 to 12% worldwide [1]. It adds to a significant burden on society in terms of healthcare consumption and loss of productivity [2]. Those suffering from this ailment are not only troubled by its physical impact, but experience an adverse effect over their psychosocial life as well.

Traditional approach to a disease assessment based on symptoms alone has given way to a more holistic approach, involving assessment of health related quality of life of the patient in addition to physical symptomatology [1]. Various global as well as disease specific patient reported outcome measures (PROM) instruments have been utilized for assessment of the quality of life. Disease specific PROM instruments have proven to be superior, when compared to global measures, in assessment of the severity of disease, defining the aims of treatment strategies as well as measuring the treatment response [3].

Many such disease specific PROM instruments include RQLQ-Rhinoconjunctivitis quality of life questionnaire, SS-sinusitis survey, F-Fairley’s symptom questionnaire, CST-chronic sinusitis type specific questionnaire, CSS-chronic sinusitis survey, RSOM-rhinosinusitis outcome measure, RSDI-rhinosinusitis disability index, RSI-rhinosinusitis symptom inventory, SNOT 20-sino-nasal outcome test-20, SNOT 16-sino-nasal outcome test-16, RSUI-rhinitis symptom utility index, SNAQ-sino-nasal assessment questionnaire, Col-cologne questionnaire, and SNOT 22-sino-nasal outcome test-22 [3, 4].

RSOM is a patient reported outcome measure for CRS, consisting of 31 items [5]. After its validation study, 11 out of 31 items were removed, primarily because of redundancy and non significant contribution on psychometric analysis. This modification led to the development of another disease specific instrument consisting of 20 items—SNOT 20. Further, content validity of RSOM-31 suggested that the commonest complaint made by a patient seeking rhinological care is nasal obstruction. In addition, persistence of hyposmia, even after surgical intervention was suggested. So these two items were added to SNOT-20 and a 22 item questionnaire was framed—SNOT 22 in 2009 [6].

Among various rhinological questionnaires, the SNOT 22, was found to have better internal consistency and responsiveness, proving it to be a superior PROM instrument [3]. This questionnaire being simple, comprehensible and easy to answer, has led to its popularity and frequent use for assessment of CRS [3]. According to a recent systematic review of 15 CRS related PROM instruments, analyzed using Consensus-based Standards for the selection of Health Measurement Instruments, SNOT 22 is now regarded as the most appropriate instrument in the evaluation of health related quality of life impairment in CRS patients [7].

The items composing the SNOT-22 can be divided into two categories: questions about physical symptoms (P) (first 12 items), which cover rhinologic symptoms as well as aural and facial symptoms, and questions about health and quality of life (Q) (last 10 items), which cover sleep function and psychological issues [6]. Many centres world over have adopted this instrument for a holistic assessment of CRS as well as evaluation of the outcome of treatment strategies [8]. However, a previously validated instrument does not necessarily assure its validity in another temporal, linguistic or cultural context. Since SNOT 22 is a patient reported outcome measure, it is essential for the respondent to comprehend the individual items of the questionnaire by themselves, preferably without any external assistance. Originally, SNOT 22 was developed in English language and there have been various translations and cross cultural adaptation to other languages [9–13]. Hindi is one of the most common spoken language in India and as per 2011 census by the Government of India, 43.63% (528 million) Indians speak Hindi as their mother tongue. Hindi also ranks 3rd in the world as the most spoken language (8.2%) [14]. Although there is an available Hindi version of SNOT 22, there has not been any study on its validation in Hindi speaking population. The purpose of this study was assessment of reliability, validity & responsiveness of the Hindi version of SNOT 22.

Methods

This prospective study was conducted at a tertiary referral centre from November 2020 to April 2021 and was approved by the Institutional Ethics Committee (MMMCH/IEC/20/376; 8A).

Case Definition

All patients above 18 years of age, diagnosed as CRS, having Hindi as their native language and able to read, were included in the study after an informed written consent. For the purpose of study, definition provided by the EPOS 2020 [1] was adopted. The cases underwent diagnostic nasal endoscopy for confirmation of pathology.

Control Definition

Hospital staff, medical and nursing students, and patient’s companions who gave a written informed consent to participate in the study, and were without any sino-nasal complaints/pathology confirmed on diagnostic nasal endoscopy were included in the control group.

Exclusion Criteria

Patients suffering from any pathology other than CRS, history of previous sino-nasal surgery, history of traumatic injury over face, sino-nasal malignancy, anatomical deformity involving head and neck region, history of use of nasal medication, history of psychiatric illness or medication and non Hindi speaking individuals were excluded.

Study Sample

110 cases and 110 controls were included in the study. A decision of sample size to be a minimum 110 cases and controls each was based on the recommended respondent to item ratio of 5:1 [15]. All cases as well as controls were administered the Hindi questionnaire and scores were calculated. A subset of cases was re-administered the questionnaire on second visit after seven days by a different clinician. Another subset of cases, that underwent surgical intervention, was reassessed post-operatively after three months of surgery. Questionnaires with five or more unanswered items were excluded.

As translation of SNOT 22 into Hindi would amount to copyright infringement, the authors first contacted original copyright holders and were provided with a Hindi version of SNOT 22. The authors further proceeded with the process of validation of the Hindi version. In agreement with principles of good practice for the translation and cultural adaptation process for patient‐reported outcomes (PRO) measures [16], cognitive debriefing was performed by administering the Hindi questionnaire to 10 patients and was aimed at testing for alternative wordings as well as to check comprehensibility, interpretation, and cultural relevance. Feedback from cognitive debriefing was utilized and a review was done to conclude that no further amendments were required and the source version was used for the next phases of validation. The Hindi version is provided in Online Appendix 1.

Validation

The translated version needs validation before using as a standardized instrument for assessment. Guidelines including the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) have delineated each step and method for the same and were followed in the present study to validate Hindi SNOT 22 [17]. The steps included evaluation along three domains namely reliability, validity and responsiveness.

Reliability

Reliability is defined as the extent to which a PROM instrument is free from any measurement error. Measurement error is the systematic and random error of a PROM instrument, that can not be attributed to actual changes in the construct of the instrument, which is under assessment. Reliability was assessed on two parameters—Internal consistency and Test–Retest reproducibility.

Internal consistency is defined as the extent to which various items in an instrument are inter-related. It was assessed by analysing Hindi SNOT 22 scores of 110 cases as well as controls, and Cronbach’s alpha (α) was utilized as statistical test. This was calculated for the entire questionnaire as well as after exclusion of individual items.

Test–Retest reproducibility implies the stability of scores over a time period in which symptoms remain unaltered. For Test–Retest reproducibility, 60 cases were re-administered Hindi SNOT 22 after an interval of seven days. During retest, subjects had no access to their previous responses. Correlation between test and retest scores was assessed using Spearman’s rank correlation coefficient (r_s) and intra class coefficient (ICC), both for total scores as well as for individual items included in the questionnaire.

Validity

The degree to which a PROM instrument measures or assesses the construct it claims to, is defined as validity. This was assessed using parameters of the construct and criterion validity.

Construct validity is defined as the degree to which the scores of a health questionnaire show consistency with the proposed hypotheses, with regard to the differences between relevant groups i.e. case and the control group. In the present study, this was assessed on the basis of difference in the scores of cases and controls. Statistical test used for this analysis was Mann Whitney U test.

Criterion validity implies the extent to which the scores of a health questionnaire correlate with the gold standard method of assessment or they are an adequate reflection of the same. The Visual analogue scale/VAS is a validated tool and is widely accepted in the research community working with CRS and the Lund-Mackay score/(LMS) is the most commonly used scoring system of sino-nasal inflammatory change and has been validated for assessing quality of life and symptom severity [1, 18, 19]. Out of all the cases which underwent pre-operative planning, including radiological evaluation, 30 cases were randomly selected to assess the criterion validity of Hindi SNOT 22. The severity of the disease in each case was assessed using LMS on non contrast CT Scans of paranasal sinuses and VAS. A 10 point scale was used for VAS, with 0 denoting no/nil symptoms and 10 denoting the worst condition of the disease possible. Data was collected and criterion validity was assessed using Spearman’s rank correlation coefficient.

Responsiveness

It is the sensitivity of a PROM instrument to detect any change in the construct following an intervention. To assess responsiveness, pre- and post-intervention scores were compared. For this, a subset of 30 cases that underwent surgical intervention were re-administered the questionnaire, three months post-surgery, and the scores were compared using Wilcoxon signed Rank test. Correlation between the pre- and post-operative scores were calculated using Spearman’s rank correlation coefficient. The standardized mean difference (SMD) was used as effect measure to calculate magnitude of effect of the intervention. Initially, ‘Cohen’s d’ was calculated which was adjusted for small sample bias to yield ‘Hedge’s g’ [20].

Statistical Analysis

IBM SPSS statistics version 26 was used for statistical analysis. Internal consistency was assessed using Cronbach’s alpha which was interpreted based on the rule of thumb by George and Mallery [21], modified by Tavakol and Dennick [22]. Correlations were evaluated using Spearman’s rank correlation coefficient and was interpreted based on the criteria by Hinckle et al. [23]. Intraclass-Coefficient (ICC) was reported as coefficient value (95% Confidence Interval/CI, lower, upper) and was interpreted on a scale ranging from poor to excellent reliability [24]. Comparison of scores was done using Mann Whitney U test for independent groups and Wilcoxon signed rank test for pre- and post-intervention scores. Effect size was calculated using SMD (‘Hedge’s g’) and was interpreted as < 0.2 = small effect, 0.5 = moderated effect, > 0.8 = large effect [20]. Significance was assigned at p < 0.05.

Results

Internal Consistency

110 diagnosed cases of CRS were recruited in the study and were administered Hindi SNOT 22. Out of 110, 62 (56.36%) were females and 48 (43.64%) were males, with the mean age of 39.14 ± 8.48 years, range being 19–56 years. 110 controls were also given Hindi SNOT 22 and data was collected from both the groups. The mean age was 27 ± 10.23 years (range 20–51 years), and there were 72 (65.45%) males and 38 females (34.54%) in the control group. Cronbach’s alpha (α) of the entire questionnaire in cases and controls was 0.823 and 0.868 respectively, indicating a good internal consistency of Hindi SNOT 22. Cronbach’s alpha for the physical symptoms sub-scale (P) in case group was 0.711 indicating an acceptable internal consistency whereas value for the quality of life sub-scale (Q) showed a good internal consistency (α = 0.87). In the control group, Cronbach’s alpha for the sub scales P (α = 0.755) and Q (α = 0.894) showed an acceptable and a good internal consistency respectively. When Cronbach’s alpha was reassessed, removing one item from the questionnaire at a time, the values ranged from 0.809 to 0.830 in the cases and from 0.853 to 0.878 in the controls. This signifies the homogeneity of all items in the questionnaire indicating a good internal consistency. Cronbach’s alpha values have been tabulated in Table 1.

Table 1.

Internal consistency of Hindi SNOT 22

Cases (n = 110)		Controls (n = 110)
	Cronbach’s alpha if item deleted		Cronbach’s alpha if item deleted
Item 1	0.820	Item 1	0.878
Item 2	0.818	Item 2	0.867
Item 3	0.818	Item 3	0.875
Item 4	0.818	Item 4	0.871
Item 5	0.816	Item 5	0.863
Item 6	0.830	Item 6	0.862
Item 7	0.814	Item 7	0.864
Item 8	0.811	Item 8	0.865
Item 9	0.823	Item 9	0.860
Item 10	0.818	Item 10	0.861
Item 11	0.822	Item 11	0.863
Item 12	0.812	Item 12	0.864
Item 13	0.814	Item 13	0.861
Item 14	0.816	Item 14	0.861
Item 15	0.818	Item 15	0.864
Item 16	0.809	Item 16	0.859
Item 17	0.810	Item 17	0.855
Item 18	0.817	Item 18	0.860
Item 19	0.811	Item 19	0.861
Item 20	0.814	Item 20	0.861
Item 21	0.818	Item 21	0.853
Item 22	0.817	Item 22	0.857
P	0.711	P	0.755
Q	0.87	Q	0.894
Total	0.823	Total	0.868

P Items pertaining to Physical symptoms (Item 1–12)

Q Items pertaining to Quality of life symptoms (Item 13–22)

Test–Retest

For test–retest reproducibility, all cases were advised to revisit the out patient department after a week. Out of 110, 66 cases came for the follow-up, out of which, 4 cases had acute exacerbation of the disease and 2 did not give response to all the items in the questionnaire, hence were not included for test–retest study. Finally, 60 cases were evaluated for test–retest reproducibility.

The Spearman’s rank correlation coefficient (r_s) for the total questionnaire showed very high correlation (r_s = 0.939) and the ICC value of 0.973 (95% CI, 0.955, 0.984) indicated an excellent reliability. The test–retest reliability for all the 22 items was satisfactory, ranging from r_s = 0.786 for item number 10 to r_s = 0.911 for item number 20. The sub-scale P had a very high correlation with r_s = 0.917 and ICC = 0.962 (95% CI, 0.936, 0.977); and the items related to Q also showed a very high correlation with r_s = 0.928 and ICC = 0.976 (95% CI, 0.960, 0.986), indicating an excellent reliability (Table 2). The Bland–Altman plot as shown in Fig. 1, showed that the 95% limits of agreement lies between − 9.776 and 6.436, and the differences were located between the threshold values of agreement.

Table 2.

Test–retest reproducibility of Hindi SNOT 22

	rs	ICC (95% CI)
Item 1	0.872	0.917 (0.860,0.950)
Item 2	0.869	0.950 (0.917,0.970)
Item 3	0.866	0.882 (0.803,0.930)
Item 4	0.908	0.922 (0.869,0.953)
Item 5	0.853	0.927 (0.878,0.956)
Item 6	0.831	0.905 (0.841,0.943)
Item 7	0.802	0.898 (0.829,0.939)
Item 8	0.893	0.942 (0.903,0.966)
Item 9	0.90	0.944 (0.906,0.967)
Item 10	0.786	0.884 (0.806,0.931)
Item 11	0.861	0.933 (0.887, 0.960)
Item 12	0.848	0.920 (0.866, 0.952)
Item 13	0.819	0.900 (0.832, 0.941)
Item 14	0.849	0.922 (0.869,0.953)
Item 15	0.82	0.917 (0.859,0.951)
Item 16	0.808	0.885 (0.808,0.932)
Item 17	0.787	0.871 (0.782, 0.924)
Item 18	0.848	0.914 (0.855,0.949)
Item 19	0.846	0.920 (0.865,0.952)
Item 20	0.911	0.949 (0.915, 0.970)
Item 21	0.859	0.908 (0.845,0.945)
Item 22	0.815	0.877 (0.797, 0.927)
P	0.917	0.962 (0.936,0.977)
Q	0.928	0.976 (0.960,0.986)
Total	0.939	0.973 (0.955,0.984)

r_s Spearman’s rank correlation coefficient

ICC Intra-Class Coefficient

CI Confidence Interval

P Items pertaining to Physical symptoms (Item 1–12)

Q Items pertaining to Quality of life symptoms (Item 13–22)

Fig. 1.

Bland–Altman plot for test–retest scores: The two green bold lines represent 95% limits of agreement (-9.776 and 6.436)

Construct Validity

This was calculated by comparing the mean total Hindi SNOT 22 scores of cases and controls. The mean score of case group was 46.99 ± 13.97 and that of the control group was 07.58 ± 6.772. Comparison was done with the aid of Mann Whitney U test and a significant difference (p < 0.00001) was observed in the responses of the two groups. Two sub-scales of the questionnaire also showed a significant difference among the cases and the controls (p < 0.00001) (Table 3).

Table 3.

Construct validity of Hindi SNOT 22

Items	Mean ± SD (case)	Median (IQ range)	95% CI (lower–upper)	Mean ± SD (control)	Median (IQ range)	95% CI (lower—upper)	Significance
P	29.24 ± 8.740	30.00 (11)	27.58–30.89	4.45 ± 3.634	3 (4)	3.77–5.14	p < 0.00001
Q	17.75 ± 7.744	17 (11)	16.29–19.22	3.13 ± 4.228	2 (4)	2.33–3.93	p < 0.00001
Total	46.99 ± 13.973	45 (19)	44.35–49.63	7.58 ± 6.772	5 (7)	6.30–8.86	p < 0.00001

SD Standard Deviation

IQ Inter Quartile

CI Confidence Interval

P Items pertaining to Physical symptoms (Item 1–12)

Q Items pertaining to Quality of life symptoms (Item 13–22)

Criterion validity

The scores from Hindi SNOT 22, LMS and VAS obtained from 30 cases were correlated and it was found that Spearman’s rank correlation coefficient between Hindi SNOT 22 scores and LMS scores was 0.388 (p = 0.034), thus indicating a low correlation. The coefficient between Hindi SNOT 22 scores and VAS scores was 0.663 (p = 0.000066), showing a moderate correlation between the two.

Responsiveness

30 cases undergoing surgical intervention were assessed for responsiveness and the mean pre- and post-operative scores were 53.43 ± 12.241 and 20.50 ± 06.679 respectively (Table 4). The scores obtained before surgical intervention were significantly higher than those obtained post surgery (p = 0.000002) and a moderate correlation was found between the two scores, r_s = 0.602 (p = 000,428). Cohen’s d was found to be 2.40 (95% CI, 1.77, 3.30). Adjusting for the small sample size, Hedge’s g was calculated and was found to be 2.34 (95% CI, 1.73, 2.95) with a significance of p < 0.0001.

Table 4.

Comparison of Hindi SNOT 22 with the source and other translated versions

Study	Internal consistency	Test retest reproducibility	Validity	Responsiveness	Mean score case	Mean score control	Mean Pre-op score	Mean Post-op score
Hopkins C et al	0.91	0.93	p < 0.0001	p < 0.0001	42.0	9.3	41.7	–
Lachanas VA et al	0.84	0.91	P < 0.0001	p < 0.0001	49.6	13.0	44.3	11.2
Shapira Galitz Y et al	0.94	0.88	p < 0.0001	p < 0.0001	50.4	13.2	49.46	29.64
Vaitkus S et al	0.89	0.72	p < 0.0001	p < 0.0001	52.4	16.8	52.43	22.52
de Dorlodot C et al	0.93	0.78	p < 0.0001	p < 0.0001	41.0	8.3	–	–
de los Santos G et al	0.91	0.87	p < 0.0001	p < 0.0001	47.2	4.5	–	–
Kosugi EM et al	0.88	0.91	p < 0.0001	p < 0.0001	62.39	11.4	64.56	30.00
Mozzanica F et al	0.86	0.85	p = 0.008	p = 0.001	48.9	14.3	44.4	20.1
Adnane C et al	0.968	0.993	p < 0.0001	p < 0.0001	50.39	14.49	50.39	23.43
Cakir Cetin A et al	0.909	0.901	p < 0.0001	p < 0.0001	36.57	23.84	43.42	32.48
Lumyongsatien J et al	0.929	0.935	p < 0.0001	p < 0.0001	50.36	7.70	50.62	28.97
Present study	0.823	0.939	p < 0.0001	p < 0.0001	46.99	07.58	53.43	20.50

– Data not available

Discussion

A wide spectrum of symptomatology has been associated with CRS including physical and psychosocial domains, and it has been claimed globally to have a greater impact on the patient’s health related quality of life, even greater than angina or chronic heart failure [25]. Hence, a wholesome assessment of the disease is of paramount importance.

Surveys using disease specific questionnaires have been commonly used to screen the affected population and to determine the prevalence of disease. This not only adds a valued information to the literature but also strengthens the assessment of the disease severity, its diagnosis as well as monitoring of management [11]. SNOT 22 is such an example of a disease specific questionnaire. It is a validated and a superior PROM instrument for the assessment of CRS, proven in the literature [3]. It was first developed by Hopkins et al. [6] and has been translated and culturally adapted into various languages worldwide [26–30]. Adaptation based on linguistic as well as the cultural aspects is necessary because the health status of a patient can be described by that individual him/herself [5], and for that, the patient should be able to comprehend the assessment tool in the native language thoroughly. Till date, to the best of our knowledge, there is no standardized validated Hindi adaptation of the same, despite being one of the most commonly spoken languages in the world.

In the present study, Hindi SNOT 22 was validated and other psychometric properties were also evaluated as per the standard guidelines [17]. Hindi SNOT 22 showed a good internal consistency, with a Cronbach’s alpha of 0.823, which is similar to previous studies (α ranging from 0.84 by Lachanas et al.[31] to 0.96 by Adnane et al. [27]), including the source version by Hopkins et al. [6] (α = 0.91). A comparison with some of the other versions have been summarised in Table 4.

The Test–retest score analysis (r_s = 0.939 and ICC = 0.973) demonstrated a very high stability and an excellent reproducibility of Hindi SNOT 22 over time, similar to the original SNOT 22 [6]. Similarly, multiple other studies showed high to very high test–retest reproducibility of their respective translated versions [13, 26, 27, 31, 32].

Hindi SNOT 22 has also been proven to be a valid assessment instrument, being able to significantly differentiate CRS cases from the healthy controls (p < 0.00001). The mean Hindi SNOT 22 score in CRS group (46.99) and in controls (07.58) was similar to the original English questionnaire (42 and 9.3) [6]. Similarities have also been noted with previous studies translating SNOT 22 to respective native languages [29, 31, 33].

Hindi SNOT 22, when evaluated for the criterion validity, was found to have a moderate correlation with the visual analogue scale, which is in agreement with various other studies [18, 34]. This suggested that Hindi SNOT 22 not only explains the subjective physical condition of the patient but also assesses their general well being. When Hindi SNOT 22 scores were compared with LMS, there was a low correlation between the two. Various other studies have previously reported a nil or low correlation between the two [35–38]. In short, Hindi SNOT 22 retains the characteristics of its source version (SNOT-22).

SNOT 22 proved to be superior instrument mainly owing to its better responsiveness [3]. When the pre- and post-operative Hindi SNOT 22 scores were compared, a significant reduction (p = 0.000002) in the latter was recorded, with a significant post-surgery effect size, thus proving that Hindi SNOT 22 could be used as an efficient tool to monitor the response of treatment strategies. Hopkins et al. [6] have reported the effect size as 0.81, whereas various other studies including the present study have shown a higher magnitude of effect post intervention such as Kosugi et al. [13] (1.57), Vaitkus et al. [11] (1.48), and Lachanas et al. [31] (2.75). High effect size could be attributed to the smaller sample size in these studies when compared to a sample size of 2077 in the source version [6]. Another contributing factor could be higher pre-operative scores in these studies leading to a higher post-intervention effect size. A large surgical cohort used an anchor-based methodology and reported the minimal clinically important difference/MCID to be a change in 8.9 points on the SNOT-22, while for patients undergoing medical intervention, an MCID of 12 has been reported [39]. We observed a difference of 32.93 among the pre- and post-operative scores which is almost thrice the MCID.

Limitations

One of the most important limitations of the study is non-segregation of CRS with and without polyps. This could have potential effects on the responsiveness of the questionnaire. The study being conducted at a tertiary referral centre meant that majority of our cases presented to us after a trial of medical management implying possibility of skewing of scores towards severe side of symptomatology. For the assessment of responsiveness, the study did not evaluate medical intervention and focussed only on surgical intervention, which could be another limitation. However, these limitations would mostly affect the scores rather than the characteristic of the adapted version.

Conclusions

The Hindi version of SNOT 22, is a valid, reliable and a responsive patient reported outcome measure instrument for assessment of chronic rhinosinusitis in adults. It retains most of the important characteristics of the source version (SNOT 22). This can be used as a clinical as well as research tool to aid in diagnosis, to assess quality of life as well as monitoring treatment strategies in the field of CRS in Hindi speaking patients.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

Conceptualization: PT; Methodology: PT, VG; Formal analysis and investigation: PT, VG, MSN, SB; Data analysis, interpretation, original draft preparation: PT; Writing-review and editing: PT, SB.

Funding

None.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Consent for Publication

Not Applicable, No identifying information submitted in the article. The Manuscript submitted does not contain information about medical device(s)/drug(s). Copy righted material has been used in the manuscript after obtaining adequate permission.

Data Availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethical Approval

Approval by Institutional Ethical Committee was obtained. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Ethics Committee of the Medical University (MMMCH/IEC/20/376-8A).