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ORIGINAL ARTICLE
Year : 2018  |  Volume : 21  |  Issue : 9  |  Page : 1228-1233

Is sino-nasal outcome test-22 reliable for guiding chronic rhinosinusitis patients for endoscopic sinus surgery?


Department of ENT and Head and Neck Surgery, Government Medical College and Rajindra Hospital, Patiala, Punjab, India

Date of Acceptance02-May-2018
Date of Web Publication29-Aug-2018

Correspondence Address:
Dr. A Singh
2213, Sector 38 C, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_429_17

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   Abstract 


Chronic rhino-sinusitis (CRS) is a significant health problem whose incidence and prevalence is rising. An emphasis has been placed on diseasespecific quality of life (QoL as the predominant measure for most current outcome studies. Therefore a validated measure of health-related QoL in sinonasal disease is needed. The present prospective and observational study was conducted on 50 patients in the Department of ENT at Govt. Medical College and Rajindra Hospital Patiala, Punjab, India. The primary outcomes were the following: (1) the chance of attaining minimal clinically important difference (MCID) improvements of nine points at the 22-item Sino-Nasal Outcome Test (SNOT-22) after endoscopic sinus surgery (ESS) for different preoperative QoL levels, and (2) the percentage of relative improvement in SNOT-22 after ESS for different preoperative QoL levels. Methods: Patients with CRS who were elected for ESS were prospectively enrolled into an observational cohort study. They were categorized into 10 preoperative SNOT-22 groups based on 10-point increments beginning with a score of 10 and ending at 110. Standard protocol for all patients presenting for evaluation included completion of the SNOT-22 prior to and following surgical intervention. The scores were calculated and the data collected were compiled and analyzed. Results: A total of 50 patients were included in this study. Patients with a SNOT-22 score between 10 and 19 had the lowest chance of achieving an MCID. Patients with a SNOT-22 score greater than 30 had a greater than 90% chance of achieving an MCID, and there was a relative improvement of 43.3% on their preoperative SNOT-22 scores. CRS patients with polyp had better outcomes (47.1% improvement) after ESS than those without polyp (33.2% improvement). Conclusion: There is an increased probability of achieving an MCID at SNOT-22 score >30 and in general the percentage of relative improvement increased with an increase in preoperative SNOT score.

Keywords: Chronic rhinosinusitis, endoscopic sinus surgery, nasal polyp, sino-nasal outcome test-22


How to cite this article:
Singla G, Singh M, Singh A, Kaur I, Harsh K, Jasmeen K. Is sino-nasal outcome test-22 reliable for guiding chronic rhinosinusitis patients for endoscopic sinus surgery?. Niger J Clin Pract 2018;21:1228-33

How to cite this URL:
Singla G, Singh M, Singh A, Kaur I, Harsh K, Jasmeen K. Is sino-nasal outcome test-22 reliable for guiding chronic rhinosinusitis patients for endoscopic sinus surgery?. Niger J Clin Pract [serial online] 2018 [cited 2020 Jul 7];21:1228-33. Available from: http://www.njcponline.com/text.asp?2018/21/9/1228/240069




   Introduction Top


Chronic rhinosinusitis (CRS) is a common and debilitating condition with a significant economic impact.[1] It poses a considerable burden to the health-care providers and patient. Not all the symptoms can be precisely defined by the patient. Hence, a need arises for devising a quantifiable scale for nasal symptoms just like the visual analog scale for pain. A European position paper on rhinosinusitis and nasal polyps [Figure 1] and [Figure 2] recommends the subjective assessment of symptoms using validated questionnaires.[2] Ideally, both patient and physician would possess all information for the outcome of a specific intervention; thus, decisions would be made based on a complete understanding of the benefits, risks, and cost. Unfortunately, the reality is that patients function in health systems with an incomplete understanding of outcomes. As a result, practice patterns may be potentially driven by physician opinion rather than informed patient choice and preference. This can lead to undesired variation in practice and reduce the overall performance of a health-care system. Therefore, it is important to improve the understanding of potential outcomes from an intervention to provide patients with essential information to make an informed and rational decision. CRS refers to a condition that lasts at least 12 weeks despite being treated and shows at least two major or one major and two minor symptoms of the following:

First-line therapy for the treatment of CRS is aimed at reducing underlying inflammation and facilitating clearance of paranasal sinuses. Antibiotics, topical steroids, and systemic steroids are mainstays of treatment.[3] The objective of this study was to evaluate the proportion of patients receiving a minimal clinically important difference (MCID) and percentage of relative improvement after endoscopic sinus surgery (ESS) based on their preoperative quality of life (QoL) level. Sino-nasal outcome test-22 (SNOT-22) covers the physical problems and functional limitations and also the emotional consequences of patients having CRS. The SNOT-22 has already been adopted by many clinicians both for assessing CRS and evaluating the outcome of treatment of nasal polyposis and in nasal septal surgery. It is vital that inappropriate surgeries in patients with CRS are avoided, and it has been suggested that the SNOT-22 may act as a robust tool for the subjective assessment of patient's symptoms.[2]
Figure 1: Polypoidal mass seen in middle meatus of chronic rhinosinusitis patient

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Figure 2: Intraoperative picture of endoscopic sinus surgery

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   Materials and Methods Top


The present prospective, observational study was conducted at the Department of ENT, Rajindra Hospital, Patiala, Punjab, India, on 50 patients with CRS fulfilling the following inclusion and exclusion criteria:

Inclusion criteria

  • Age >18 years
  • Diagnosed cases of CRS who remained refractory to at least 6 weeks of medical therapy, which includes a minimum 7-day course of systemic corticosteroid, topically administered nasal steroid, and 2-week administration of a broad-spectrum systemic antibiotic
  • Patient's willingness to participate in the study


Exclusion criteria

  • Patient without a minimum of 3-month follow-up after ESS
  • Patients who elected to continue with medical therapy as opposed to receiving sinus surgery
  • Systemic granulomatous disease
  • Recurrent acute rhinosinusitis
  • Cystic fibrosis
  • Ciliary dyskinesia
  • Preoperative SNOT-22 score between 0 and 9
  • Patient's refusal.


Patients with CRS were categorized into 10 preoperative SNOT-22 groups based on 10-point increments beginning with a score of 10 and ending at 110. Standard protocol for all patients presenting for evaluation included completion of the SNOT-22 before and following surgical intervention. Each participant would complete the SNOT-22 during a clinical visit by answering all questions based on 0–5 scale, where 0 defined no problems with the given symptom and 5 defined the maximum problems [Table 1]. The percentage of relative improvement for each preoperative SNOT-22 was calculated using the following formula: [(mean postoperative score) − (mean preoperative score)/mean preoperative score] × 100. The proportion of patients achieving a SNOT-22 MCID of at least nine-point improvement and the percentage of relative improvement (%) for each preoperative SNOT-22 group were calculated.
Table 1: Symptomatic criteria of Chronic Rhinosinusitus

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   Results Top


The mean age in this study ranged from 30.00 + 13.54–46.66 + 12.58 years [Table 2]. A maximum number of patients was in the age group of 26–40 years. There were 70% males and 30% females with 70% being nonsmokers and 30% smokers. The mean preoperative and postoperative SNOT-22 scores for the smokers were 61.06 + 19.30 and 38.33 + 15.69, respectively and those for nonsmokers were 43.20 + 18.65 and 23.88 + 7.71, respectively. Both groups had statistically significant P < 0.001.
Table 2: Distribution of mean age of chronic rhinosinusitis patients across various 22-item sino-nasal outcome test groups

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The patients with depression had higher preoperative SNOT-22 score (59.54 + 12.85) and greater postoperative improvement with mean postoperative score (26.48 + 11.95); however, P was statistically significant for both the groups (P < 0.001).

When considering the CRS cohort as a single entity, 81% achieved an MCID improvement of nine-points after ESS, with an average of 43.3% improvement in their preoperative SNOT-22 scores. There was increased probability of achieving an MCID at SNOT-22 score >30 and percentage of relative improvement increased with increasing preoperative SNOT score. The patients with and without polyp had significant improvement after ESS with P < 0.001 with greater decrease in score in patients with CRS with polyp group (CRSwNP) [Table 3].
Table 3: Probability of chronic rhinosinusitis with nasal polyp patients achieving minimal clinically important difference after endoscopic sinus surgery based on preoperative 22-item sino-nasal outcome test score group

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The patients who had never undergone any FESS and those who underwent FESS showed significant improvement with mean postoperative scores being 28.38 + 12.86 and 25.66 + 3.51, respectively (P < 0.001) [Table 4].
Table 4: Probability of patient with chronic rhinosinusitis (with or without polyps) achieving minimal clinically important difference after endoscopic sinus surgery based on preoperative 22-item sino-nasal outcome test score group

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In this study, preoperatively 68% patients had runny nose. Nasal obstruction was present in 72% of cases preoperatively; however, 74% had hyposmia and 60% had postnasal discharge, which postoperatively reduced to 18%, 16%, 42%, and 22% (P < 0.001, significant).

Other symptoms such as sneezing, facial pain, and ear fullness showed significant results with greater improvement postoperatively after ESS. In this study, those clusters that related to nasal and to ear and facial symptoms were significantly associated with postoperative improvement (P < 0.05) with the exception of cough. Some of the symptoms such as “difficulty falling asleep,” “waking up tired,” and “embarrassed” also showed significant improvement [Table 5].
Table 5: Improvement in individual 22-item sino-nasal outcome test score categories

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   Discussion Top


Accurate and sensitive measures of how interventions affect QoL are critical for our subspecialty. The rationing of national healthcare resources is inevitable. Accurately capturing the impact of an intervention on our patients will be essential in guiding an individual and societal decision on the value of any given intervention.

In this study, the mean age ranged from 30.00 ± 13.54–46.66 ± 12.58 years. Rudmik et al.,[4] Sedaghat et al.[5] Vishal et al.,[6] and Lange et al.[7] reported the same age incidence of fourth to fifth decade of life. Savastano et al.[8] conducted a study with 63.6% males and 36.4% females with a male to female ratio being 1.75:1. Cabrera-Ramírez et al.[9] conducted a study with 66.7% males and 33.3% females. In this study, males were the predominant sex. This may be due to either higher prevalence of CRS in males or higher male attendance in the hospital.

Kennedy et al.[1] demonstrated comparable subjective outcomes between smokers and nonsmokers after ESS in a cohort with 19% of smokers. Polley[10] and Krzeski et al.[11] also stated that there was no significant difference in the postoperative QoL scale scores between smokers and nonsmokers. This study correlated well with these studies. It means smoking status is not predictive of improvement after ESS.

Depression had worse baseline QoL scores than other patients with CRS. In this study, patients with depression experienced similar disease-specific QoL improvements from sinus surgery compared with other patients with CRS. Various studies[12],[13] have drawn the same inference although patients with depression had worse pre and postoperative health-related QoL scores.

Hopkins et al.[14] stated that the CRS patients with polyps had greater improvement than CRS patients without polyp. A study by Vishal et al.[6] demonstrated significant improvement in SNOT-22 scores in CRS patients with polyp (27.75 ± 2.78) as well as without polyp (21.47 ± 2.24), but scores after 3 months were much better in CRS patients with polyp. In this study, 76% patients had polyps. Both the patients with polyp and without polyp had significant improvement (47.1% vs. 33.2%, P < 0.001) after ESS with greater decrease in score in polyp group (CRSwNP).

In this study, 81% patients achieved an MCID improvement of nine-points after ESS with an average of 43.3% improvement in their preoperative SNOT-22 scores. There is increased probability of achieving an MCID at SNOT-22 score >30 and in general percentage of relative improvement increased with an increase in preoperative SNOT score. Rudmik et al.[4] studied a cohort that showed 80% patients achieved MCID after ESS and on an average, patients achieved 46.4% improvement. Patients can be guided accordingly regarding relative improvement after ESS based on which they can take decisions whether to undergo surgery or not.

A study by Pade and Hummel[15] evaluated 206 patients with an olfactory impairment who elected ESS for CRS. They demonstrated that 23% patients experienced improvement, 68% experienced no change, and the CRS of 9% got worse after ESS. The results suggested that the presence of nasal polyposis and eosinophilia predicted olfactory improvement. In contrast to the above studies, a recent study by Jiang et al.[16] showed that ESS had no impact on olfactory improvement. In this study, hyposmia improved significantly with P = 0.028. Although the improvement was there, it was still less compared to other nasal symptoms.

Deconde et al.[17] showed surgical cohort experienced greater improvement than the medical cohort across all domains (P < 0.001) with marginally lesser improvement in psychological and sleep domains. Savastano et al.[8] described significant improvement for only four symptoms: need to blow nose, runny nose, dense nasal drip, and nasal obstruction. Due to many of the questions in the SNOT-22 cluster together, we grouped questions into main categories: nasal symptoms (need to blow nose, nasal blockage, sneezing, runny nose, thick nasal discharge, and decreased sense of smell), ear symptoms (ear fullness, dizziness, and ear pain), oropharyngeal and facial symptoms (cough, postnasal drip, and facial pain), sleep-related symptoms (difficulty falling sleep, wake up at night, lack of good night sleep, and wake up tired), and systemic symptoms (fatigue, reduced productivity, reduced concentration, frustrated, sad, and embarrassed). In this study, those clusters that were related to nasal and to ear and facial symptoms were significantly associated with postoperative improvement (P < 0.05) with the exception of a cough. Some of the symptoms such as “difficulty falling asleep,” “waking up tired,” and “embarrassed” also showed significant improvement. It was found that the patients with more of systemic and sleep domains score were less likely to benefit from ESS.


   Conclusion Top


We believe that SNOT-22 can be used by the clinician to obtain information about the range of problems associated with rhinosinusitis. It can help researchers in diagnosing and assessing the effect of rhinosinusitis on health status and treating patients with CRS. If routinely used, it is likely that the SNOT-22 can measure the effectiveness of treatment, including surgery, and may identify patient factors that predict maximum treatment response.

There are no conflicts of interest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kennedy JL, Hubbard MA, Huyett P, Patrie JT, Borish L, Payne SC, et al. Sino-nasal outcome test (SNOT-22): A predictor of postsurgical improvement in patients with chronic sinusitis. Ann Allergy Asthma Immunol 2013;111:246-5100.  Back to cited text no. 1
    
2.
Yeolekar AM, Dasgupta KS, Khode S, Joshi D, Gosrani N. A study of SNOT 22 scores in adults with no sinonasal disease. J Rhinolaryngo-Otol 2013;1:6-10.  Back to cited text no. 2
    
3.
Benninger Michael S. The Nose and Paranasal Sinuses. Scott-Brown's Otorhinolaryngology Head and Neck Surgery. 7th ed., Ch. 113. London: Hodder Arnold; 2008. p. 1439-44.  Back to cited text no. 3
    
4.
Rudmik L, Soler ZM, Mace JC, DeConde AS, Schlosser RJ, Smith TL, et al. Using preoperative SNOT-22 score to inform patient decision for endoscopic sinus surgery. Laryngoscope 2015;125:1517-22.  Back to cited text no. 4
    
5.
Sedaghat AR, Gray ST, Caradonna SD, Caradonna DS. Clustering of chronic rhinosinusitis symptomatology reveals novel associations with objective clinical and demographic characteristics. Am J Rhinol Allergy 2015;29:100-5.  Back to cited text no. 5
    
6.
Sharma V, Rajbhandari S, Sathian B. Functional endoscopic sinus surgery comparison in a tertiary care hospital. Am J Public Health Res 2015;3:44-7.  Back to cited text no. 6
    
7.
Lange B, Thilsing T, Al-kalemji A, Baelum J, Martinussen T, Kjeldsen A, et al. The sino-nasal outcome test 22 validated for Danish patients. Dan Med Bull 2011;58:A4235.  Back to cited text no. 7
    
8.
Savastano V, Bertin S, Vittori T, Tripodi C, Magliulo G. Evaluation of chronic rhinosinusitis management using the SNOT-22 in adult cystic fibrosis patients. Eur Rev Med Pharmacol Sci 2014;18:1985-9.  Back to cited text no. 8
    
9.
Cabrera-Ramírez MS, Domínguez-Sosa MS, Borkoski-Barreiro SA, Falcón-González JC, Ramos-Macías Á. Analysis and results of endoscopic sinus surgery in chronic rhinosinusitis with polyps. Acta Otorrinolaringol Esp 2017;68:80-5.  Back to cited text no. 9
    
10.
Polley SJ. Is endoscopic sinus surgery contraindicated for smokers. Laryngoscope2007;2:6-7.  Back to cited text no. 10
    
11.
Krzeski A, Galewicz A, Chmielewski R, Kisiel M. Influence of cigarette smoking on endoscopic sinus surgery long-term outcomes. Rhinology 2011;49:577-82.  Back to cited text no. 11
    
12.
Litvack JR, Mace J, Smith TL. Role of depression in outcomes of endoscopic sinus surgery. Otolaryngol Head Neck Surg 2011;144:446-51.  Back to cited text no. 12
    
13.
Mace J, Michael YL, Carlson NE, Litvack JR, Smith TL. Effects of depression on quality of life improvement after endoscopic sinus surgery. Laryngoscope 2008;118:528-34.  Back to cited text no. 13
    
14.
Hopkins C, Rudmik L, Lund VJ. The predictive value of the preoperative sinonasal outcome test-22 score in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope 2015;125:1779-84.  Back to cited text no. 14
    
15.
Pade J, Hummel T. Olfactory function following nasal surgery. Laryngoscope 2008;118:1260-4.  Back to cited text no. 15
    
16.
Jiang RS, Lu FJ, Liang KL, Shiao JY, Su MC, Hsin CH, et al. Olfactory function in patients with chronic rhinosinusitis before and after functional endoscopic sinus surgery. Am J Rhinol 2008;22:445-8.  Back to cited text no. 16
    
17.
DeConde AS, Mace JC, Bodner T, Hwang PH, Rudmik L, Soler ZM, et al. SNOT-22 quality of life domains differentially predict treatment modality selection in chronic rhinosinusitis. Int Forum Allergy Rhinol 2014;4:972-9.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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