Introduction Chronic rhinosinusitis (CRS) is associated with a significant decrease in general health‐related quality of life (QOL). The EuroQol 5‐dimensional questionnaire measures general health‐related quality of life through a health utility value (EQ‐5D HUV)—based on five domains reflecting mobility, self‐care, activities of daily life, pain/discomfort, and anxiety/depression—and an unbiased visual analog scale (EQ‐5D VAS). We sought to identify characteristics of CRS patients with a high EQ‐5D HUV but low EQ‐5D VAS score. Materials and Methods Retrospective cross‐sectional study of 300 CRS patients with EQ‐5D HUV equal to 1.0 (reflecting perfect health). All patients completed a 22‐item Sinonasal Outcome Test (SNOT‐22)—from which nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated, as well as the EQ‐5D. Low EQ‐5D VAS was defined as a score less than 80. Results On multivariate analysis, low EQ‐5D VAS was associated with only the SNOT‐22 sleep subdomain score (odds ratio [OR] = 1.07, 95%CI: 1.02–1.12, P = .003). Comorbid asthma was also associated with lower EQ‐5D VAS (OR = 2.16, 95%CI: 1.02–4.59, P = .045). In contrast, polyps were negatively associated with having a lower EQ‐5D VAS (OR = 0.34, 95%CI: 0.17–0.69, P = .003). Conclusion There are patients with perfect general health‐related QOL according to a health utility value‐based methodology (like the EQ‐5D HUV) who report low general health‐related QOL on an unbiased measure like the EQ‐5D VAS. In CRS patients with perfect EQ‐5D HUV, poor sleep and asthma were associated with low QOL on the EQ‐5D VAS, while polyps were negatively associated with low QOL. Level of Evidence 3 Laryngoscope , 131:1206–1211, 2021
Objective Disparities in health and health care access are widely prevalent. However, disparities among patients with chronic rhinosinusitis (CRS) are poorly understood. We investigated if CRS severity at presentation according to socioeconomic factors. Study Design Cross‐sectional study. Setting Tertiary rhinology center. Subjects and Methods Three hundred prospectively recruited patients presenting with CRS were included. Outcome variables included CRS symptomatology, as reflected by the 22‐item Sinonasal Outcome Test (SNOT‐22); general health status, as reflected by the EuroQol 5‐dimensional visual analog scale (EQ‐5D VAS); and CRS‐related antibiotic and systemic corticosteroid use. Race/ethnicity, zip code income bracket, education level, and insurance status were used as predictor variables. Regression, controlling for clinical and demographic characteristics, was used to determine associations between predictor and outcome variables. Results Mean SNOT‐22 score was 33.8 (SD, 23.2), and mean EQ‐5D VAS score was 74.2 (SD, 18.9). On multivariable analysis, presenting SNOT‐22 and EQ‐5D VAS scores were not associated with nonwhite patient race/ethnicity ( P =. 634 and P =. 866), education ( P =. 106 and P =. 586), or the percentage of households in zip code with incomes <$50,000 per year ( P =. 917 and P =. 979, respectively). SNOT‐22 scores did not differ by insurance type, but patients receiving Medicare reported worse general health status. Use of oral antibiotics or oral steroids for CRS was not associated with predictor variables. Conclusion Patients with CRS presented to a tertiary rhinology center with similar metrics for CRS severity and pre‐presentation medical management regardless of race/ethnicity, education status, or zip code income level. Patients with Medicare had worse general health status. Further research should investigate potential disparities in diagnosis of CRS, specialist referral, and treatment outcomes.
Chronic rhinosinusitis (CRS) is a heterogeneous inflammatory condition of the sinonasal cavity. CRS may be preceded by other sinonasal inflammatory diseases including allergic rhinitis (AR). It is unclear what factors may predispose patients with AR to develop CRS.We performed a retrospective review of all patients diagnosed with AR (and not CRS) that presented to an otolaryngology clinic at a tertiary care center as part of a multidisciplinary allergy evaluation between March 2004 and November 2011. Medical records were evaluated for clinicodemographic factors including age, gender, smoking history, asthma, gastroesophageal reflux disease (GERD), aspirin sensitivity, nasal polyposis, seasonal AR, perennial AR, categories of positive antigens on formal allergy testing, and the following sinonasal anatomic variants on computed tomography (CT): infraorbital (Haller) cells, concha bullosa, frontal intersinus cells, and anterior ethmoid frontal recess cells. Patients who did not develop CRS after at least 4 years of follow-up were grouped into the AR cohort. Patients who developed CRS after at least 6 months of follow-up were grouped into the AR-CRS cohort.We found a statistically significant association between the presence of infraorbital (Haller) cells (odds ratio [OR] = 6.27) and frontal intersinus cells (OR = 18.37) with development of CRS on both univariate and multivariate logistical regressions.Sinonasal anatomical variants, specifically infraorbital and frontal intersinus cells, are associated with development of CRS in patients with AR. The presence of these variants identifies patients who should be counseled on compliance with medical therapy for AR to potentially prevent progression to CRS.
Allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are a major burden to the healthcare system. Although no causal relationship has been established, previous work has demonstrated a strong association of AR with CRS. In this study, we sought to identify risk factors that may influence speed of development of CRS in patients with AR.Retrospective review of all patients diagnosed with AR without CRS presenting to an otolaryngology clinic at a tertiary medical center as part of a multidisciplinary allergy evaluation between March 2004 and November 2011. Medical records were evaluated for clinicodemographic factors including age, gender, smoking history, medical comorbidities, categories of AR based on formal allergy testing, the presence of sinonasal anatomic variants on computed tomography as well as subsequent development of CRS.Faster progression to CRS in patients with AR was associated with comorbid asthma (hazard ratio [HR] = 3.97) as well as sinonasal anatomic variants, such as infraorbital cells (HR = 7.39), and frontal intersinus cells (HR = 68.03), on multivariate survival analysis. A statistically significant but negative interaction between infraorbital cells and frontal intersinus cells suggests that concomitant presence of both leads to a less than additive increase in the rate of CRS progression.Sinonasal anatomical variants, infraorbital cells, and frontal intersinus cells, as well as comorbid asthma are associated with faster development of CRS in patients with AR. The presence of these clinical risk factors identifies patients who should be counseled on compliance with medical therapy for AR.
Background Previous studies have identified subdomains of the 22‐item Sino‐Nasal Outcome Test (SNOT‐22), reflecting distinct and largely independent categories of chronic rhinosinusitis (CRS) symptoms. However, no study has validated the subdomain structure of the SNOT‐22. This study aims to validate the existence of underlying symptom subdomains of the SNOT‐22 using confirmatory factor analysis (CFA) and to develop a subdomain model that practitioners and researchers can use to describe CRS symptomatology. Methods A total of 800 patients with CRS were included into this cross‐sectional study (400 CRS patients from Boston, MA, and 400 CRS patients from Reno, NV). Their SNOT‐22 responses were analyzed using exploratory factor analysis (EFA) to determine the number of symptom subdomains. A CFA was performed to develop a validated measurement model for the underlying SNOT‐22 subdomains along with various tests of validity and goodness of fit. Results EFA demonstrated 4 distinct factors reflecting: sleep, nasal, otologic/facial pain, and emotional symptoms (Cronbach's alpha, >0.7; Bartlett's test of sphericity, p < 0.001; Kaiser‐Meyer‐Olkin >0.90), independent of geographic locale. The corresponding CFA measurement model demonstrated excellent measures of fit (root mean square error of approximation, <0.06; standardized root mean square residual, <0.08; comparative fit index, >0.95; Tucker‐Lewis index, >0.95) and measures of construct validity (heterotrait‐monotrait [HTMT] ratio, <0.85; composite reliability, >0.7), again independent of geographic locale. Conclusion The use of the 4‐subdomain structure for SNOT‐22 (reflecting sleep, nasal, otologic/facial pain, and emotional symptoms of CRS) was validated as the most appropriate to calculate SNOT‐22 subdomain scores for patients from different geographic regions using CFA.
Objectives/Hypothesis Antibiotics and oral corticosteroids are used in the treatment of acute exacerbations of chronic rhinosinusitis (AECRS) and reflect poor disease control. We sought to characterize utilization of these systemic medications after appropriate medical management of chronic rhinosinusitis (CRS). Study Design Prospective observational study. Methods One hundred fifty patients undergoing medical management for CRS were studied. Data were collected at enrollment and follow‐up 3 to 12 months later. All patients were asked to report the number of CRS‐related antibiotics and oral corticosteroids used in the last 3 months. CRS symptom burden was measured using the 22‐item Sino‐Nasal Outcome Test (SNOT‐22). Associations were sought between CRS‐related antibiotics and oral corticosteroids use at follow‐up compared to enrollment. Results From enrollment to follow‐up, the mean number of CRS‐related antibiotics courses used decreased by 0.2 courses (95% confidence interval [CI]: 0.1–0.4, P = .012), and the mean number of CRS‐related oral corticosteroid courses used also decreased by 0.2 courses (95% CI: 0.1–0.3, P = .029). The number of CRS‐related antibiotics used at follow‐up was associated with CRS‐related antibiotic use at enrollment (adjusted rate ratio [RR] = 1.58, 95% CI: 1.17–2.13, P = .003). The number of CRS‐related oral corticosteroids used at follow‐up was associated with reported CRS‐related oral corticosteroid use at enrollment (adjusted RR = 3.20, 95% CI: 1.69–6.07, P < .001). SNOT‐22 results at enrollment were also not predictive of future systemic medication use. Conclusions Appropriate medical management of CRS is associated with decreased use of oral antibiotics and corticosteroids. Previous utilization of antibiotics and oral corticosteroids for CRS is associated with future use of these medications. Level of Evidence 2c Laryngoscope , 2019
Objective We sought to determine whether chronic rhinosinusitis (CRS) symptom severity, endoscopic exam findings, and acute exacerbation of CRS (AECRS) frequency-all important and distinct clinical manifestations of CRS-would be predictive of each other and, therefore, inform when further assessment of each other metric should be pursued. Study Design Cross-sectional cohort study. Setting Tertiary academic rhinology clinic. Subjects and Methods In total, 241 patients with CRS were prospectively recruited and completed the 22-item Sinonasal Outcome Test (SNOT-22) to reflect CRS symptom severity. AECRS frequency was assessed using the number of sinus infections as well as CRS-related antibiotics and CRS-related oral corticosteroids used in the past 3 months. An endoscopy score was calculated for each patient. Results SNOT-22 score and AECRS were predictive of each other while AECRS and endoscopy score were not predictive of each other. SNOT-22 score could be used to predict having had, in the past 3 months, at least 1 sinus infection (area under the curve [AUC] = 0.727; P < .001), at least 1 CRS-related antibiotic used (AUC = 0.691; P < .001), or at least 1 CRS-related oral corticosteroid course used (AUC = 0.655; P < .001). Having a SNOT-22 score ≥30 could be predicted by reporting at least 1 sinus infection (AUC = 0.634; P < .001), CRS-related antibiotics (AUC = 0.614; P < .001), or CRS-related oral corticosteroids (AUC = 0.616; P < .001) in the past 3 months. These relationships held for patients with and without nasal polyps. Conclusion The predictive power of CRS outcome measures reflecting symptomatology, AECRS frequency, and endoscopic findings may be of clinical utility in situations where time or resources are limited to perform an ideally full assessment of patients with CRS.
