Rhinosinusitis Symptom Inventory Research Articles

Systematic review of patient-reported outcomes after revision endoscopic sinus surgery.

Revision endoscopic sinus surgery (RESS) may be required for partially controlled or uncontrolled chronic rhinosinusitis. Studies that reported technical success, e.g., sinus ostia patency after RESS, do not address whether the patient's symptoms and quality of life (QOL) improve after surgery. However, patient-reported outcome measures (PROM) are useful to assess the impact of sinus surgery on a patient's symptoms and QOL. This systematic review was undertaken to evaluate the impact of RESS on PROMs. Medical literature databases were searched for studies in English. References from retrieved articles and relevant reviews were examined for additional studies. Those studies that reported QOL outcome tools in patients who underwent RESS and with a minimum follow-up of 6 months were included. A search of the sources yielded 1856 citations. There were 72 articles after abstract review and exclusion, identified for full-text review, with 12 studies (which contained data from 1308 patients) that met the inclusion criteria for this systematic review. There were four "good" and eight "fair" studies. Three studies used the Rhinosinusitis Disability Index and Chronic Sinusitis Survey in tandem; two each used the 20-item Sino-Nasal Outcome Test and the 22-item Sino-Nasal Outcome Test; the remaining studies used either the Adelaide Disease Severity Score, Patient Response Score (PRS), Rhinosinusitis Symptom Inventory, Rhinosinusitis Outcome Measure 31, or the Chinese version of the University of Pennsylvania Smell Identification Test. All studies used validated PROMs apart from the study that used PRS. Studies consistently reported improvement in the five key symptoms of nasal obstruction, rhinorrhea, postnasal drip, facial pain, and anosmia, although improvement in halitosis, fever, dental pain, and cough were modest. Several PROMs demonstrated that RESS improves patient's QOL symptoms. Future studies that examine QOL should use a consistent PROM to allow a meta-analysis.

In-Office, Multisinus Balloon Dilation: 1-Year Outcomes from a Prospective, Multicenter, Open Label Trial

The objective of this prospective, multicenter study was to assess 1-year changes in sinonasal symptoms and health care use after office-based multisinus balloon dilation. Adults diagnosed with chronic or recurrent acute rhinosinusitis per the 2007 adult sinusitis guidelines were enrolled in this Institutional Review Board-approved study. Balloon dilation of the maxillary sinuses/ethmoid infundibula with or without frontal or sphenoid ostial dilation was performed in the physician's office under local anesthesia. Intraoperative procedure technical success and subject procedure tolerance were recorded. Efficacy was assessed using the patient-reported 20-item Sino-Nasal Outcome Test (SNOT-20) and Rhinosinusitis Symptom Inventory (RSI). Complications and revision surgeries were also recorded. A total of 313 ostial dilations were attempted and 307 were successfully completed (98.1%) in 81 subjects. Mean procedure tolerance was 2.8 ± 2.2 (0 = no pain; 10 = severe pain). Clinically meaningful and statistically significant (p < 0.0001) mean SNOT-20 symptom improvement was observed at 1 and 6 months and sustained through 1 year. The RSI treatment effect for all major rhinosinusitis symptoms was "large" and improvement in each was significant (p < 0.0001). Compared with the previous 1-year period, patients reported an average of 2.3 fewer acute sinus infections (p < 0.0001), 2.4 fewer antibiotic courses taken (p < 0.0001), and 3.0 fewer sinus-related physician visits (p < 0.0001) after balloon dilation. No serious device or procedure-related adverse events occurred. One subject (1.3%) underwent revision surgery. In-office, multisinus balloon dilation is safe, effective, and well tolerated. Patients reported significant reductions in both sinonasal symptoms and health care use after balloon dilation. Efficacy observed at 1 and 6 month follow-up was sustained through 1 year with a very low rate of revision surgery. This study was a part of the clinical trial NCT01612780 registered at www.clinicaltrials.gov.

In-Office Stand-Alone Balloon Dilation of Maxillary Sinus Ostia and Ethmoid Infundibula in Adults with Chronic or Recurrent Acute Rhinosinusitis: A Prospective, Multi-Institutional Study with 1-Year Follow-up

This study evaluated in-office balloon dilation of maxillary sinus ostia and ethmoid infundibula to treat chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS). Seventy-four patients with disease in the maxillary and anterior ethmoid sinuses on computed tomography were prospectively enrolled across 12 study centers. All procedures were performed in the office. The primary outcomes were clinical effectiveness and health-care utilization at 1 year, measured by the validated surveys Sino-Nasal Outcome Test (SNOT-20) and Rhinosinusitis Symptom Inventory (RSI). Dilation was successful in 69 patients (93.2%), and the average periprocedural pain level was 3.2 (scale of 0 to 10). The mean improvement on the SNOT-20 at 1 year was clinically and statistically significant (p < 0.0001), with no significant difference between the CRS and RARS patient outcomes. The treatment effect was the same in the CRS and RARS subgroups and was either "moderate" or "large" for 10 of 12 symptoms. The mean numbers of antibiotic courses (p < or = 0.001), sinus-related physician visits (p < 0.0001), and number of acute sinus infections (p < 0.001) decreased significantly in both subgroups. There were no serious device-related adverse events, and the rate of revision surgery was 5.8%. Stand-alone balloon dilation of the maxillary sinus ostia and ethmoid infundibula performed in the office is well tolerated and effectively treats both CRS and RARS.

Comparison of sinonasal symptoms in patients with nasal septal deviation and patients with chronic rhinosinusitis.

Disorders of the nose and paranasal sinuses are among the most common chronic illnesses. Although considerable progress has been made in the medical and surgical control of these diseases, a large number of questions relating to the diagnosis, evaluation, and treatment of these conditions remain unanswered. The aim of the present study was to evaluate differences in the frequency of symptoms and disease severity in patients with nasal septal deviation (NSD) compared with chronic rhinosinusitis (CRS). A total of 156 patients, divided into NSD and CRS groups, were studied in relation to symptoms and disease severity. Patients were selected from those referred to the Ear, Nose, and Throat (ENT) Wards of the Imam Reza and Ghaem Hospitals, who had not responded to a variety of treatments. Depending on the type of disease, patients were candidates for either septoplasty or endoscopic sinus surgery. The Rhinosinusitis Symptom Inventory was administered to measure the severity of symptoms, with scores assigned based on the answers given by patients (Likert scale). Scores were compared between the CRS and NSD groups. A total of 156 patients (78 with NDS and 78 with CRS) entered the study in overall sinonasal symptoms were more prevalent in CRS group. Nasal congestion, runny nose, earache, toothache, and smelling disorder were significantly more common in the CRS group (P<0.001); while there were no significant differences in symptoms such as facial pressure, fever, or headache between the two groups (P>0.05). Patients with CRS manifested statistically significantly greater sinonasal symptom scores than patients with NSD.

Chronic rhinosinusitis symptoms and computed tomography staging: improved correlation by incorporating radiographic density

Traditional methods for staging of chronic rhinosinusitis (CRS) by computed tomography (CT) have not proven to be predictive of subjective reports of patients' symptoms. An objective measure of CRS severity that correlates well with patients' symptoms, particularly if available from CT data, would be a valuable tool in assessment of disease status and outcomes after surgery. Retrospective chart review of CRS patients with symptom data from the Rhinosinusitis Symptom Inventory (RSI) and objective data from a sinus CT scan. CRS disease severity on CT imaging was measured according to the traditional Lund-Mackay scoring, as well as by raw measures of the densities of sinus opacities (in Hounsfield units [HU]) and density-weighted Lund-Mackay scoring. These data were related to symptom severity scores using a multivariate regression model. There was no significant correlation between either raw density values of sinus opacities or weighted Lund-Mackay scores with facial or total symptom scores. Oropharyngeal symptoms scores were negatively correlated with the sum of "average HU" values (p = 0.036, β = -1.120) but were positively correlated with the sum of "maximum HU" values (p = 0.047, β = 1.221). There was a significant negative correlation between the systemic symptoms score and mean of "average HU" values (p = 0.010, β = -0.272). Finally, there was a positive correlation between "maximum HU" value-weighted Lund-Mackay score with nasal symptom scores (p = 0.016, β = 0.241), systemic symptom scores (p = 0.008, β = 0.605), and total symptom scores (p = 0.078, β = 0.179). Incorporation of radiographic characteristics of sinus opacification with Lund-Mackay scores offers greater predictive power of patients' subjective symptom severity.

Histopathological inflammation and symptom outcomes after endoscopic sinus surgery

To determine if histopathology of the sinus mucosa predicts symptomatic outcomes after endoscopic sinus surgery (ESS). The histopathology of the sinus mucosa and preoperative and postoperative symptom scores from the Rhinosinusitis Symptom Inventory (RSI) for adults undergoing ESS for chronic rhinosinusitis (CRS) without polyposis were reviewed. Linear regression analysis was conducted to examine the relationship between tissue pathology inflammatory severity score and the postoperative RSI symptom scores, adjusting for baseline RSI scores, Lund score, postoperative topical steroid, antihistamine, and antibiotic use. A total of 112 patients were enrolled (average age, 41.2 years; 68.8% female) with a follow-up of 19.1 ± 8.7 months (mean ± standard deviation [SD]). Mean preoperative and postoperative RSI domain scores for nasal symptoms and total symptoms were (52.4, 21.4) and (41.2, 17.7), respectively (p < 0.001). Topical steroid utilization increased from 15.3 to 20.7 weeks (p = 0.086) whereas antihistamine use and antibiotic use decreased by 1.4 and 1.6 weeks, respectively (p = 0.594 and 0.092). Pathology severity score did not significantly predict postoperative symptom scores on any of the RSI symptom domains nor the total symptom score (all p > 0.05). Although pathologic inflammation of the paranasal sinuses is inherent to CRS, increasing pathology severity at ESS does not predict poorer symptomatic outcomes after ESS.

Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy

Objective To validate the diagnosis of chronic rhinosinusitis (CRS) according to recent clinical practice guidelines and determine the added utility of nasal endoscopy. Study Design Prospective diagnostic cohort study. Setting Academic medical center. Subjects and Methods A consecutive series of adult patients presenting for evaluation of CRS were prospectively studied with the use of the rhinosinusitis symptom inventory (RSI), nasal endoscopy, and sinus computed tomography (CT). Symptom scores were tabulated from the RSI. Nasal endoscopy was performed to evaluate for purulence or polyps. Sinus CT scans were scored with the Lund system, with the reviewers blinded to the RSI scores and endoscopic findings. The clinical diagnosis of CRS was determined on the basis of the published adult sinusitis guideline criteria and compared with the diagnostic gold standard, CT. Results A total of 202 patients were studied. The prevalence of CRS was 39.6 percent, as defined by CT (Lund score ≥ 4). For symptom criteria alone, the sensitivity, specificity, positive predictive value, and negative predictive value were 88.7, 12.3, 39.9, and 62.5 percent, respectively, for CRS ( P = 0.82). The addition of endoscopic findings to symptom criteria significantly improved the specificity, predictive value, and negative predictive value to 84.1, 66.0, and 70.3 percent ( P < 0.0001). The odds ratio of a true diagnosis of CRS improved from 1.1 to 4.6 (95% confidence interval, 2.3-9.2). Sensitivity analysis adjusting symptom severity did not significantly alter diagnostic accuracy. Conclusion In patients meeting current guideline symptom criteria for CRS, the addition of nasal endoscopy improves diagnostic accuracy and should be emphasized as an early diagnostic tool. Diagnostic endoscopy may help reduce the use of CT, reducing costs and radiation exposure.

Assessing the Additional Disease Burden of Polyps in Chronic Rhinosinusitis

This study was undertaken to determine the differential disease burden between chronic rhinosinusitis (CRS) cases with and without nasal polyposis (NP). A consecutive series of adult patients who met clinical and radiographic criteria for CRS was assessed with the Rhinosinusitis Symptom Inventory, nasal endoscopy, and computed tomography. Three clinical groups were examined: 1) CRS without NP, 2) CRS with primary NP (no prior surgery), and 3) CRS with recurrent NP (prior surgery). The groups were compared with respect to symptom presentation, medical resource utilization, and medication costs. Two hundred eighty-six CRS cases without NP, 131 CRS cases with primary NP, and 45 CRS cases with recurrent NP were studied; their mean Lund scores were 8.8, 13.2, and 16.3, respectively (p < 0.001). Statistically significant differences in severity for nasal (p = 0.002), facial (p = 0.025), oropharyngeal (p = 0.017), and systemic symptoms (p = 0.042) between groups were noted, whereas total symptoms did not differ between groups (p = 0.339). Medication use and physician visits were similar between groups (p = 0.335 and p = 0.951, respectively). The aggregate yearly medication costs were significantly greater for the recurrent polyp group ($866) than for either the non-polyp group ($570; p = 0.013) or the primary polyp group ($565; p = 0.020). Patients with non-polyp CRS and those with primary polyp CRS present with different symptom phenotypes, but exhibit similar total symptom burdens and medical resource consumption. The presence of polyps does not necessarily confer a dramatic additional disease burden in CRS.

Relationship between Mucosal Inflammation, Computed Tomography, and Symptomatology in Chronic Rhinosinusitis without Polyposis

This study was an attempt to determine whether sinus mucosal inflammation is related to computed tomographic findings and patients' reported symptoms in chronic rhinosinusitis (CRS) without polyposis. I retrospectively reviewed the clinical symptom scores according to the Rhinosinusitis Symptom Inventory (RSI), the radiographic findings, and the histopathologic findings in the paranasal sinus mucosa for a consecutive series of adult patients who underwent endoscopic sinus surgery for CRS. Linear regression analysis was conducted for the relationship between tissue pathology inflammatory severity score graded on a 5-point Likert scale and the RSI symptom domains. A similar analysis was conducted for the relationship between the pathology inflammatory score and the total Lund score. The study cohort consisted of 115 adult patients (mean age, 40.2 years). The mean Lund score for the cohort was 8.8 (95% confidence interval, 7.9 to 9.7), and the mean pathology severity score was 2.1 (median, 2.0). The mean total symptom score for the overall cohort was 41.3; the mean total symptom scores for pathology severity grades 0, 1, 2, 3, and 4 were 25.0, 43.8, 41.8, 42.4, and 32.8, respectively. No significant association could be identified between pathology severity and any of the 5 RSI symptom domains (nasal, facial, oropharyngeal, systemic, and total symptoms; all p > .436, linear regression). A statistically significant relationship between total Lund score and pathology severity was identified (p < .001). Poor correlation exists between the histopathologic severity of sinonasal inflammation and self-reported symptom scores in CRS. Histopathologic inflammatory grade alone fails to stratify CRS cases according to disease symptom severity. Histopathologic inflammation and computed tomographic findings correlate strongly.

Do Anxiety and Depression Confound Symptom Reporting and Diagnostic Accuracy in Chronic Rhinosinusitis?

We sought to determine the impact of psychiatric comorbidity on symptom reporting and diagnostic accuracy in chronic rhinosinusitis (CRS). A prospective cohort of patients presenting for evaluation of CRS was studied with the Rhinosinusitis Symptom Inventory and the Hospital Anxiety and Depression Scale. Data concerning symptom scores, symptom domains, and psychiatric comorbidity were analyzed with respect to paranasal sinus computed tomography (CT) Lund score. The degree of correlation between sinonasal symptoms and CT scan stage adjusting for anxiety and depression was determined. The relationships between symptoms, psychiatric comorbidity, and the presence of radiographic CRS were determined with multivariate logistic regression. There were 230 patients (mean age, 43.4 years) enrolled. High levels of anxiety and depression were noted in 23.5% and 13.0%, respectively. According to CT criteria, 61.3% to 71.3% of patients had true CRS. Even adjusting for anxiety and depression, only the nasal symptom domain severity had a statistically significant correlation with Lund score (r = 0.240; p = .001); facial, oropharyngeal, systemic, and total symptoms did not correlate with CT score. Similarly, multivariate analysis revealed that even with adjustment for anxiety and depression, sinus symptom domains failed to predict radiographic positivity. Individually, only dysosmia, dental pain, and fatigue were predictive for CRS (odds ratios, 1.29 [p = .032], 1.69 [p = .001], and 0.70 [p = .023], respectively). Although anxiety and depression are prevalent in patients with CRS, they do not influence the correlation between nasal symptoms and CT findings. Markers of psychiatric comorbidity do not correlate with CRS symptoms. The presence of anxiety or depression does not cloud symptom reporting in CRS and should not bias clinical decision-making.

Influence of Polyps on Outcomes After Endoscopic Sinus Surgery

To determine clinical and comparative outcomes for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) with polyposis. Two cohorts of adult patients with refractory CRS with and without nasal polyps were prospectively studied before and after ESS (minimum follow-up, 12 months) with the Rhinosinusitis Symptom Inventory (RSI). For the non-polyp and polyp cohorts, RSI symptom domains and medical resource utilization were compared in the preoperative and postoperative states. Corresponding effect sizes were computed and compared between cohorts to determine the effect of polyps on prognosis after ESS. A total of 165 non-polyp and 86 polyp patients were enrolled. Polyps were more common in female patients (2:1, P = .025); age (mean, 42.9 years) and follow-up (18.5 months) were similar between groups. Lund scores were significantly higher for polyp patients (13.7, SD 4.8) vs. non-polyp patients (8.1, SD 5.3, P < .001). At baseline, polyp patients reported lower symptom scores for facial, oropharyngeal, and systemic RSI symptom domains (all P < .012); nasal and total symptom domains were similar between groups. Both non-polyp and polyp groups obtained significant symptomatic benefit from ESS with effect sizes for RSI symptom domain improvements ranging from 0.89 to 1.38 and 0.43 to 1.19, respectively (all P < .001). There were no significant differences between groups in symptomatic improvement, excepting oropharyngeal symptoms (better improvement in non-polyp group, P = .024). Non-polyp patients decreased medical resource consumption more significantly than did polyp patients. Both non-polyp and polyp patients derive similar clinically significant symptomatic improvement after ESS. These similarities suggest that polyp patients do not necessarily have a poorer symptomatic outcome after ESS.

Association of Anxiety and Depression with Reported Disease Severity in Patients Undergoing Evaluation for Chronic Rhinosinusitis

We sought to determine the impact of psychiatric comorbidity on symptom density and resource utilization in chronic rhinosinusitis (CRS). A prospective cohort of patients who sought evaluation of CRS was studied with the Rhinosinusitis Symptom Inventory and the Hospital Anxiety and Depression Scale. Data concerning symptom scores, symptom domains, and psychiatric comorbidity were analyzed to determine the interactions among psychiatric comorbidity, symptom reporting, and resource utilization in CRS. We studied 143 patients (mean age, 43.4 years). Low, moderate, and high levels of anxiety were reported by 48.3%, 25.9%, and 25.9% of patients, respectively. Low, moderate, and high levels of depression were reported by 76.2%, 9.1%, and 14.7%. For the combined psychopathology group, 43.3%, 25.9%, and 30% had low, moderate, and high levels. Patients with high anxiety levels reported significant elevations of oropharyngeal symptoms (p = .013) and total symptoms (p = .030) in comparison with the low group. Patients with high depression levels reported higher oropharyngeal (p = .003), systemic (p = .001), and total symptom (p = .003) scores than did the low group. High combined psychopathology scores were associated with elevated facial, oropharyngeal, and systemic scores (p < .05). Regarding medical utilization, high anxiety levels or high combined psychopathology scores were associated with more frequent physician visits (p < .05). A high level of depression was associated with increased antibiotic use, missed workdays, and physician visits (p < .05). High levels of anxiety and depression are common in patients who undergo evaluation for CRS. Psychiatric comorbidity is associated with increased symptoms in CRS and increased health-care utilization. Anxiety and depression should be identified in these patients to structure appropriate treatment.

(710): The association between psychopathology, pain, and sinus symptoms in chronic sinusitis

Chronic sinusitis (CRS) is characterized by chronic facial pain, pressure, headache, fatigue, and other sinus symptoms. We examined the association between psychiatric comorbidity, symptom profiles, and resource utilization in CRS. With IRB approval, this was a prospective cohort study of adults presenting for a specialist evaluation of CRS, studied with two validated instruments: the Rhinosinusitis Symptom Inventory (RSI) and the Hospital Anxiety and Depression Scale. Since the correlation between anxiety and depression is high, we used established cutoff scores to construct 3 groups, each with 3 levels of symptoms: anxiety, depression, and the combination of anxiety and depression (combined psychopathology group) into Low, Moderate, and High (sensitive and specific for a DSM depression or anxiety disorder).

Clinical Symptomatology and Paranasal Sinus Involvement With Nasal Septal Perforation

Determine the symptom manifestations, clinical impact, and incidence of chronic rhinosinusitis (CRS) in patients with newly diagnosed nasal septal perforation. A consecutive series of adult patients with nasal septal perforation were prospectively studied at the time of endoscopic diagnosis with the rhinosinusitis symptom inventory (RSI) and sinus computed tomography (CT). Patients' symptoms in the RSI symptom domains were computed. From the CT scan, septal perforation size and Lund scores were obtained. A separate (control) cohort of patients with CRS without septal perforation was matched to these patients for age, sex, and Lund score. RSI symptom domain comparisons were conducted between groups to determine the additional symptom burden conferred by septal perforation. Thirty-three patients with septal perforation were enrolled (mean age, 48.2 yr; 69.7% female). Mean perforation size was 1.9 (SD, 2.1) cm. The mean Lund score was 5.8 (SD, 5.3); 16 (57.1%) patients met radiographic criteria for a concurrent diagnoses of CRS. Patients with septal perforation reported significant nasal and facial symptom domain scores (56.8 and 47.0, respectively [range, 0-100]). Oropharyngeal and systemic symptoms were less severe (29.7 and 34.7, respectively). However, after comparison with the matched control patients, no statistically significant differences were identified in sinonasal symptoms between patients with and without septal perforation (all P > .131). Concurrent CRS may frequently accompany nasal septal perforation and may require appropriate treatment along with the perforation itself. The presence of septal perforation does not appear to significantly augment symptom severity in CRS.

Surgical Treatment of Chronic Recurrent Rhinosinusitis: A Preliminary Report

The objective of this study was to determine if endoscopic sinus surgery (ESS) is effective in the management of chronic recurrent rhinosinusitis (CRRS). A consecutive series of patients with CRRS diagnosed according to stringent criteria was prospectively examined before and at least 1 year after ESS. Paranasal sinus computed tomography scans were staged and ESS was performed targeting radiographic disease and the ostiomeatal complex. Preoperative and postoperative disease severities in terms of symptom scores, medicine utilization, and resource factors were assessed using the rhinosinusitis symptom inventory (RSI). Improvements in RSI symptom domains, medical and economic resource factors were determined using effect sizes and statistical comparison before and after ESS. Nineteen patients (mean age, 42.3 years) completed the study with a mean follow up of 19.1 months. The mean Lund score was 3.42 (standard deviation, 4.09). Statistically significant decreases in nasal (-36.1), facial (-28.4), oropharyngeal (-34.6), systemic (-24.7), and total (-31.9) RSI symptom domain scores were observed (all P < .003) with effect sizes ranging from 0.87 to 1.63 (strong surgical effect). Statistically significant decreases in antihistamine use (-30%, P = .031), number of workdays missed as a result of CRRS (-1.9, P = .035), and number of acute infectious episodes (-2.5, P = .006) were also observed. However, declines in weeks of antibiotic use (-2.8 weeks, P = .293) and number of antibiotic courses (-1.7, P = .118) were not significant. Patients with CRRS may substantially benefit both symptomatically and medically from ESS. Although surgery should be used cautiously in treating CRRS, further trials of ESS for CRRS are warranted.

Associations between Fatigue and Medication Use in Chronic Rhinosinusitis

We conducted a prospective study of 586 adults to determine if associations exist between fatigue symptom scores and three classes of medications prescribed for the treatment of chronic rhinosinusitis (CRS): prescription nonsedating antihistamines, topical nasal steroids, and antibiotics. Patients were assessed with the assistance of the Rhinosinusitis Symptom Inventory and Likert-scale fatigue symptom scores. On multivariate analysis and correcting or disease severity, we found that significantly higher fatigue symptom scores were associated with the use of nonsedating antihistamines (mean Likert score: 2.75 vs. 2.27 for patients not taking a nonsedating antihistamine; p = 0.029). Higher fatigue scores were also associated with a greater number of antibiotic courses and more total weeks of antibiotic use (p < 0.001 in both cases). No association was seen between fatigue scores and the use of topical nasal steroids (mean Likert score: 2.65 vs. 2.24; p = 0.658). We recommend that long-term use of a nonsedating antihistamine be scrutinized in CRS patients who report symptoms of fatigue.

Clinical and Symptom Criteria for the Accurate Diagnosis of Chronic Rhinosinusitis

The objectives of this prospective, double-blind diagnostic cohort study were to explore the relationship between patients' reported symptoms of chronic rhinosinusitis (CRS) and radiographic findings in CRS to define clinically based diagnostic criteria for CRS and to determine a classification scheme that would allow for the accurate diagnosis of patients with CRS. A prospective series of adult patients undergoing evaluation for potential chronic rhinosinusitis was studied. Patients' symptoms were tabulated with the Rhinosinusitis Symptom Inventory (RSI), which records symptoms associated with CRS on a Likert scale (5 = maximally severe). Medication and resource utilization were also tabulated. Scores for nasal, facial, oropharyngeal, systemic, and total symptom domains were computed (100 = maximum severity). Concurrent paranasal sinus computed tomography was obtained for each patient and scored according to the Lund-McKay system with reviewer blinding. Patients were classified as normal or representing true CRS according to previously published diagnostic radiographic criteria under two analyses. In analysis 1, Lund scores < or = 1 were considered nondiseased and scores > or = 2 were considered as representing true CRS. In analysis 2, Lund scores < or = 3 represented normal and scores > or = 4 represented true CRS. For each analysis, univariate statistics were computed to determine differences among patients' reported symptoms with and without true CRS. Subsequently, classification analysis using classification regression trees was conducted to determine heuristics among clinically based criteria for the diagnosis of CRS. Seven hundred three adult patients were enrolled (mean age, 43.1 years). The most commonly reported symptoms in order of decreasing severity and presence were nasal obstruction, nasal congestion, discharge, fatigue, headache, facial pressure, and dysosmia, all with mean severity scores > or = 2.0. Patients were previously treated for approximately 3 months each with topical nasal steroids, oral antihistamines, and oral antibiotics. Patients missed substantial workdays (mean, 3.8/year) and incurred significant physician visits (mean, 3.5/year) as a result of CRS. The nasal symptom domain exhibited the greatest severity (51.8) followed closely by the facial symptom domain (47.3). According to the analysis 1, 144 (20.5%) patients were classified as normal and 559 (79.5%) as true CRS. Only the presence of polyps (P < .001) and dysosmia (P = .008) distinguished between normal and diseased patients; there were no significant differences between groups for the other symptoms and RSI domains. Classification analysis revealed that the presence of polyps, absence of dental pain, and low congestion/obstruction scores in the presence of dental pain predicted true CRS. Finally, a history of extended antibiotic courses before presentation also predicted true CRS. In the second analysis, 243 (34.6%) were normal versus 460 (65.4%) with true CRS. Only polyp presence and dysosmia exhibited statistically significant differences between normal and diseased patients (P < .001). The mean RSI nasal domain was higher for true patients with CRS (P = .01). Classification analysis identified polyp presence and dysosmia score >2 effectively predicted CRS. Fatigue < or = 2, discharge < or = 4, and obstruction < or = 3 further predicted for CRS. Symptoms despite a > or = 5.5-week trial of nasal steroids also predicted CRS. Other major and minor symptoms, RSI domains, and resource factors failed to influence diagnostic classification. The diagnosis of CRS based on symptom criteria is difficult because most symptoms (other than dysosmia) do not distinguish between radiographically normal and diseased patients. A classification scheme for CRS based on the presence or absence of polyps is valid. It is possible to classify patients with true CRS based on symptoms, but this requires complicated heuristics. Corroborating radiographic evidence should be required to establish the diagnosis of CRS before long periods of therapy or surgical intervention.

Radiographic Stage Fails to Predict Symptom Outcomes after Endoscopic Sinus Surgery for Chronic Rhinosinusitis

To determine whether preoperative computed tomography (CT) stage predicts degree of symptom improvement after endoscopic sinus surgery (ESS). A series of adult patients undergoing ESS was prospectively evaluated with CT and the rhinosinusitis symptom inventory (RSI) preoperatively and at a minimum of 12 months postoperatively. Symptom domains (nasal, facial, oropharyngeal, systemic, and total) were computed and both absolute change and percentage change in symptom domain scores before and after ESS were correlated with the preoperative CT scan stage according to three staging systems: Lund-MacKay, Kennedy, and Harvard. One-hundred sixty-one patients (mean age, 40.2 years) completed the study with a mean follow-up of 19.4 months. Overall, statistically significant decreases in RSI symptom domains were noted for the nasal (net change -30.1 [range -100 to +100]), facial (-26.1), oropharyngeal (-13.4), systemic (-17.0), and total (-20.8) symptom scores (all P < .001). For the absolute change in total symptom score, no statistically significant correlation with CT stage was demonstrated for any of the staging systems (Lund: Spearman rho = -0.004, P = .962; Kennedy: rho = -0.008, P = .918; Harvard: rho = -0.011, P= .891). Similarly, no significant correlation with CT stage was demonstrated with the other symptom domains. Additionally, no significant correlation was identified between preoperative CT stage and percentage change in symptom domain scores. Although CT scan is widely accepted as an accurate diagnostic tool for chronic rhinosinusitis, CT scan stage alone does not significantly predict symptom outcomes after chronic rhinosinusitis, regardless of staging system utilized.

The Completely Opacified Frontal or Sphenoid Sinus: A Marker of More Severe Disease in Chronic Rhinosinusitis?

Determine whether complete opacification of the sphenoid or frontal sinus is associated with increased clinical severity of chronic rhinosinusitis (CRS). Adult patients undergoing evaluation for CRS prospectively completed the rhinosinusitis symptom inventory (RSI) and underwent computed tomography of the paranasal sinuses. A cohort with at least one completely opacified frontal sinus was identified. To each patient in this opacified cohort, a control patient without complete frontal sinus opacification was matched with corresponding Lund score. Symptom scores for headache, facial pressure, RSI symptom domains, and medical resource consumption were statistically compared. Similar analysis was conducted for patients with complete sphenoid sinus opacification. Fifty-four patients with at least one completely opacified frontal sinus were matched for Lund score to the control group (mean Lund score 17.1). There was no statistically significant difference in headache (2.1 vs. 2.8) or pressure scores (2.0 vs. 2.3) or in the RSI symptom domains between those patients with completely opacified frontal sinuses and controls, respectively. Although completely opacified patients received more antibiotic treatment and missed more workdays, only the increased numbers of physicians visits (4.0 vs. 2.1, P = .02) was significant. Thirty-four of 35 completely opacified sphenoid patients were matched to control patients (mean Lund score 16.7). Again, differences in symptom scores for headache (2.5 vs. 2.5), facial pressure (2.3 vs. 2.3), and RSI symptom domains were not statistically significant. Increased use of antibiotics (9.6 vs. 3.9, P = .036) and physician visits (5.8 vs. 1.8, P = .024) for sphenoid opacification patients was statistically significant. Patients with a completely opacified sphenoid or frontal sinus do not necessarily manifest more severe clinical symptoms of CRS. Thus, a higher radiographic stage should not be automatically assigned to patients with a completely opacified sphenoid of frontal sinus in CRS.

Symptom and Disease Severity Differences Between Nasal Septal Deviation and Chronic Rhinosinusitis

To determine whether patients with chronic rhinosinusitis (CRS) exhibit more severe sinonasal symptom scores as compared with patients with nasal septal deviation (NSD) alone. Two patient cohorts were prospectively identified: patients undergoing surgery for NSD alone and those undergoing endoscopic sinus surgery for CRS without NSD. Patients in the NSD group were required to have normal paranasal sinus CT scans, whereas patients in the CRS group were required to have radiographic evidence of CRS. All patients completed the Rhinosinusitis Symptom Inventory (RSI). Statistical comparisons were conducted between cohorts with respect to RSI symptom domains and medical resource utilization. A total of 42 patients were identified in the NSD group (mean age, 40.8 years) and 155 patients were identified in the CRS group (mean age, 44.9). Patients with CRS demonstrated higher severity scores for the nasal symptom domains (60.3 [CRS] versus 53.9 [NSD], P = 0.037). Oropharyngeal symptoms and total symptoms were also worse for the CRS group versus the NSD group (29.8 versus 23.1, P = 0.014 and 43.0 versus 37.0, P = 0.030). Facial and systemic symptom scores did not differ between groups. Patients with CRS demonstrated significantly higher utilization rates for topical nasal steroids (21.2 versus 12.2 weeks, P = 0.006) and oral antibiotics (7.9 weeks versus 2.1 weeks, P < 0.001), but not for oral antihistamines (P = 0.420). Although patients with CRS manifest higher sinonasal symptom scores than patients with NSD alone, differentiating these 2 diagnoses on the basis of symptoms alone is difficult. These data suggest that as a disease process, CRS confers a significant disease burden with more significant negative symptom impact.