Effect of endoscopic sinus surgery on general health related quality of life domains in chronic rhino sinusitis patients

INTRODUCTION

Chronic rhino sinusitis (CRS) is a common health problem causing frequent visits to primary care physicians and ear, nose, throat specialists. It affects around 5-12% of the general population in a year.¹ Chronic rhinosinusitis have two phenotypes; CRS with polyps (CRSwNP) and without polyps (CRSsNP). Treatment of CRS consist of medical and surgical management. Surgical management is considered when patient is not responding to maximal medical treatment or in case of complication.²

A number of health-related quality-of-life (HRQOL) evaluating instruments have been developed in past few decades. According to recent systematic reviews Sino-nasal outcome test 22 (SNOT- 22) is considered as the most appropriate instrument in the evaluation of HRQOL impairment in CRS patients.³ SNOT-22 questionnaire scoring was analysed by dividing the questions into five domains.⁴ These are sinus-specific symptom domains (rhino logic, extra rhino logic and ear/facial symptoms) and general health-related QOL domains (psychological and sleep dysfunction).⁵ Our study evaluated general health related QOL domains and changes following endoscopic sinus surgery.

METHODS

After getting approval from departmental scientific review committee, institutional review board and ethical committee the study was initiated in February 2018. Consenting patients satisfying the inclusion criteria were selected for the study. Details of the patients were enquired which includes age, gender, and duration of medical therapy. After a detailed history during preoperative period, patients were provided with the standard Sino Nasal Outcome Test (SNOT-22) questionnaire (Table 1) which was translated to Malayalam. It is a 22-symptom questionnaire.

Sino-nasal outcome test [snot-22] scores. A. Considering severity and frequency of your problem, please rate each item below on how ”bad” it is by circling the number that corresponds with how you feel using this scale. Grand total (all columns together); B. Please check off the most important items affecting your health in the last column (max of five items)

Scoring was conducted using Likert scale response according to which 0=” No problem”, 1=” Very mild problem”, 2=” Mild or slight problem”, 3=” Moderate problem”, 4=” Severe problem”, and 5=” Problem as bad as it can be”. Total score was then calculated and mean score of all patients were computed. After clinical examination routine pre-operative investigations like computed tomography (CT) scan para nasal sinus and diagnostic nasal endoscopy were done. CT scan findings were evaluated using Lund- Mackay CT score and endoscopy findings using Lund-Kennedy score.^6,7 Post procedure SNOT-22 questionnaire was given to patient during usual follow up consultations i.e. at the end of 1st week, 1st month and 3rd month. During analysis we evaluated general health related QOL4 domains separately (Table 2).

Data collected were coded and entered in Microsoft excel and analysed using Statistical package for the social sciences (SPSS) software. Qualitative variables were summarized using mean frequency and percentage, while quantitative variables were summarized using mean and standard deviation. Association between qualitative variable were tested using chi-square test. Association between quantitative variables were tested using independent and paired t test, significance level will be fixed at a p< 0.05.

RESULTS

The results of our study are presented in table 3-5. Mean age of study population was 42.55 with standard deviation (SD) of 12.8 years. Study population consisted of 64.2% males and 35.85% females. In the total population, 66% were chronic rhinosinusitis (CRSwNP) with polyposis and rest were chronic rhinosinusitis without polyposis (CRSsNP) (table 3).

Preoperative CT (Lund and MacKay) score was 11.17 (SD 4.7) while nasal endoscopy (Lund and Kennedy) score was 7.85 (SD 2.7). Baseline SNOT-22 score for study population was 37.51 (SD 15.2). During analysis of scores of general health related quality of life domains, we observed serial decrease in scores in all the three follow ups. The score for psychological dysfunction and sleep dysfunction decreased from 10.72, 6.00 to 1.58 and 1.02 respectively. The subdomain scores were statistically significant (p<0.001) (table 4).

DISCUSSION

This study was conducted on 53 patients who were diagnosed to have chronic rhinosinusitis; of these patients 66% were CRSwNP and 34% CRSsNP. The demography of our study cohort showed CRSwNP were more common in males (77%) and CRSsNP is more in females (61%). This variation was found to be statistically significant (p=0.006). Vedantam8 et al also reported CRSwNP to be more common among males with a sex ratio of 2:1. The mean age of study population was 42.55 years. and maximum number of patients were found between 21-60 years of age. (86.8%). Similar age distribution was observed in other studies also.^9,10

Preoperative Lund Kennedy endoscopy score and Lund Mackay CT score were 7.85 and 11.17 respectively. In our study baseline CT score for CRSsNP and CRSwNP were 9.44 and 12.06 respectively (table 5). In another study by Nair et al, there observed a significant difference in the mean Lund MacKay CT score between CRSsNP (8.7) and CRSwNP (14.2).¹¹ Higher value in endoscopy and CT score indicates worse disease severity.¹²

Preoperative SNOT 22 average score obtained in our study was 37.15 (15.218). The SNOT-22 can be categorized into ‘mild’ defined in the SNOT-22 score as 8-20, ‘moderate’ as more than 20-50 and ‘severe’ as more than 50.¹³ According to multiple studies.^14,15 SNOT-22 scores are influenced by several demographic confounders and other factors like gender, smoking, asthma and mental illness including anxiety and depression.

General HRQOL domains

Psychosocial dysfunction

Preoperative score for CRSwNP and CRSsNP were 11.69 and 8.83. It reduced to 2.37 and 2.06 respectively (table:6,7). Levy et al observed overall improvement in psychological domain i.e, score in the SNOT-22 decreased from 15.9 to 8.5 in CRSwNP, and 16.3 to 8.9 in CRSsNP.¹⁶ In our observation difference in psychosocial symptoms was a bit higher when compared to the above study. The scores obtained in all the follow ups were significant statistically. We observed higher score for this domain in patients with nasal polyps preoperatively. The smallest change in a given outcome measure that can be detected by a patient as a perceptible change is called minimal clinically important difference (MCID).¹ In study of Chowdhury et al, average MCID for psychosocial dysfunction following ESS is 3.9.¹⁷ Our study population has difference in score more than this value. One of the main cause of psychological dysfunction identified was coexisting anxiety and depressive disorder.^16,18 These groups showed worst postoperative score.

Sleep dysfunction

Sleep related problems in CRS have shown to cause a significant decrease in quality of life. Exact mechanisms underlying sleep disruption and poor sleep quality in CRS are unknown. According to various studies any condition resulting in nasal air passage obstruction causes sleep disruption.^19,20 Complete nasal obstruction can increase apneic episodes and transient hypoxia in healthy individuals which indicates that nasal obstruction causes sleep related problems.²¹ In our observation most of the CRS patients from both phenotypes exhibit sleep disruption. Preoperative average score for sleep dysfunction domain was 7.03 and 4 in CRSwNP and CRSsNP respectively. These patients showed significant reduction in symptom related scores after ESS i.e. score reduced to 1.11 and 0.83 at the end of 3 months (table 6,7). El Rassi et al also noticed similar improvement sleep dysfunction postoperatively.²² Another study reported that 90 percentage of the patients with chronic rhinosinusitis have improved sleep quality postoperatively.²³ The average minimal clinically important difference (MCID) for sleep dysfunction domain is 2.9.

CONCLUSION

The two phenotypes of CRS had different gender predominance. CRS with polyposis were seen commonly in male with more than 2/3 of total cases. Similarly, CRS without polyposis had a definite female predilection. Lund Mackay CT score and Lund Kennedy endoscopy score had definitive role in assessing extent of disease. Both scores were high in CRSwNP phenotype. Chronic rhinosinusitis patients with associated psychosocial dysfunction and sleep related symptoms have worse quality of life. These patients showed significant improvement after endoscopic sinus surgery. But associated anxiety and depressive disorders can reduce quality of life even after surgery. Therefore, these associated conditions have to be address separately during treatment of chronic rhinosinusitis.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Fokkens W, Lund V, Hopkins C, Hellings PW, Kern R, Reitsma S, et al. European Position Paper on Rhinosinusitis and Nasal Polyps. Rhinology journal. 2020;58:1-464.
2. 2. Agache I, Hellings P. Implementing Precision Medicine in Best Practices of Chronic Airway Diseases. Academic Press; 2018: 236.
3. 3. Rudmik L, Hopkins C, Peters A, Smith TL, Schlosser RJ, Soler ZM. Patient-reported outcome measures for adult chronic rhinosinusitis: A systematic review and quality assessment. J Allergy Clin Immunol. 2015;136(6):1532-40.
4. 4. DeConde AS, Mace JC, Alt JA, Rudmik L, Soler ZM, Smith TL. Longitudinal improvement and stability of the SNOT-22 survey in the evaluation of surgical management for chronic rhinosinusitis. Int Forum Allergy Rhinol. 2015;5(3):233-9.
5. 5. Laababsi R, Abdulhakeem bushra, Elkrimi Z, Allouane A, Rouadi S, Abada R, et al. Quality of life outcomes of patients with chronic rhinosinusitis after functional endoscopic sinus surgery, prospective cohort study. Ann Med Surg (Lond). 2019;40:9-13.
6. 6. Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinol. 1993;31:183-18.
7. 7. Lund DVJ, Kennedy DDW. Staging for Rhinosinusitis: Otolaryngology–Head and Neck Surgery. 2016. Available from: https://journals.sagepub.com/doi/10.1016/S0194-59989770005-6. Last accessed on 4 June 2020.
8. 8. Vedantam R, Kurien R, Sunny E. Impact of Functional Endoscopic Sinus Surgery on Patients with Chronic Rhinosinusitis: A Prospective, Cohort Study among Indian Patients. An International Journal Clinical Rhinol. 2018;11:1-6.
9. 9. Farahani F, Mashouf YR, Hashemian F, Esmaeili R. Antimicrobial Resistance Patterns of Aerobic Organisms in Patients with Chronic Rhino sinusitis in Hamadan, Iran. Avicenna Journal of Clinical Microbiology and Infection. 2014 Aug 1;1.
10. 10. Murphy MP, Fishman P, Short SO, Sullivan SD, Yueh B, Weymuller EA. Health care utilization and cost among adults with chronic rhinosinusitis enrolled in a health maintenance organization. Otolaryngology - Head and Neck Surgery. 2002;127(5):367-76.
11. 11. Nair S, Dutta A, Rajagopalan R, Nambiar S. Endoscopic Sinus Surgery in Chronic Rhinosinusitis and Nasal Polyposis: A Comparative Study. Indian J Otolaryngology Head Neck Surg. 2011;63(1):50-5.
12. 12. Soler ZM, Sauer DA, Mace J, Smith TL. Relationship between Clinical Measures and Histopathologic Findings in Chronic Rhinosinusitis. Otolaryngology Head Neck Surg. 2009;141(4):454-61.
13. 13. Toma S, Hopkins C. Stratification of SNOT-22 scores into mild, moderate or severe and relationship with other subjective instruments. Rhinol. 2016;54(2):129-33.
14. 14. Wu D, Gray ST, Holbrook EH, BuSaba NY, Bleier BS. SNOT-22 score patterns strongly negatively predict chronic rhinosinusitis in patients with headache. Int Forum Allergy Rhinol. 2019;9(1):9-15.
15. 15. 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(2):100-5.
16. 16. Levy JM, Mace JC, DeConde AS, Steele TO, Smith TL. Improvements in psychological dysfunction after endoscopic sinus surgery for patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2016;6(9):906-13.
17. 17. Chowdhury NI, Mace JC, Bodner TE, Alt JA, Deconde AS, Levy JM, et al. Does Medical Therapy Improve SNOT-22 Domain Scores? An Analysis of Clinically Important Differences. Laryngoscope. 2019;129(1):31-6.
18. 18. Gharaati N, Amini E, Abdollahi M, Maracy MR, Abtahi S, Kheirabadi GR. Mood Disorders among Chronic Rhino-Sinusitis Patients. Journal of Psychiatry. 2017;1:20.
19. 19. Kohler M, Bloch KE, Stradling JR. The role of the nose in the pathogenesis of obstructive sleep apnea and snoring. Eur Respir J. 2007;30(6):1208-15.
20. 20. Mahdavinia M, Schleimer RP, Keshavarzian A. Sleep disruption in chronic rhinosinusitis. Expert Rev Anti Infect Ther. 2017;15(5):457-65.
21. 21. Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. Otolaryngol Head Neck Surg. 1981;89(5):804-10.
22. 22. El Rassi E, Mace JC, Steele TO, Alt JA, Smith TL. Improvements in sleep-related symptoms after endoscopic sinus surgery in patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2016;6(4):414-22.
23. 23. Guttemberg MDA, Mata FAF da, Nakanishi M, de Andrade KRC, Pereira MG, Guttemberg MDA, et al. Sleep quality assessment in chronic rhinosinusitis patients submitted to endoscopic sinus surgery: a meta-analysis. Brazilian J Otorhinolaryngol. 2019;85(6):780-7.