Evaluation of quality of life using Sinonasal Outcome Test-22 among patients with chronic rhinosinusitis postendoscopic sinus surgery: A preliminary report

Abdulrahman O Afolabi; Kenechukwu Uche-Okonkwo; Nasiru Olalekan Shittu; Samuel O Ayodele; Nafeesat O Busari; Segun Segun-Busari; HK Omokanye; Saad O Idris; Biodun S Alabi; Adekunle D Dunmade; Foluwasayo E Ologe

doi:10.4103/bjhs.bjhs_49_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 7 | Issue : 2 | Page : 245-251

Evaluation of quality of life using Sinonasal Outcome Test-22 among patients with chronic rhinosinusitis postendoscopic sinus surgery: A preliminary report

Abdulrahman O Afolabi, Kenechukwu Uche-Okonkwo, Nasiru Olalekan Shittu, Samuel O Ayodele, Nafeesat O Busari, Segun Segun-Busari, HK Omokanye, Saad O Idris, Biodun S Alabi, Adekunle D Dunmade, Foluwasayo E Ologe
Department of Otorhinolaryngology, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin, Nigeria

Date of Submission	24-May-2021
Date of Decision	30-Aug-2021
Date of Acceptance	18-Jan-2022
Date of Web Publication	09-Sep-2022

Correspondence Address:
Abdulrahman O Afolabi
Department of Otorhinolaryngology, University of Ilorin/University of Ilorin Teaching Hospital, PMB 1515, Ilorin
Nigeria

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/bjhs.bjhs_49_21

Abstract

BACKGROUND: The background of this study was to assess the quality of life (QoL) of patients with chronic rhinosinusitis (CRS) before and after endoscopic sinus surgery Sinonasal Outcome Test-22 (SNOT-22).
MATERIALS AND METHODS: This was an observational prospective cohort study carried out at the Ear, Nose and Throat Department of Kogi State Specialist Hospital, Lokoja, and University of Ilorin Teaching Hospital, Ilorin. Both of which are tertiary-level hospitals in North-Central Nigeria offering advanced rhinology services after ethical approval was obtained. The total score for each subject was derived from the 22-item psychometrically validated self-administered SNOT-22 questionnaire. Lower scores postoperatively represent better health-related QoL (HRQOL).
RESULTS: A preliminary report of 40 consecutive patients with rhinosinusitis were enrolled. There were 19 males and 21 females aged between 16 and 80 years (mean age: 34.95 ± 2.69 years). There was a significant improvement in SNOT-22 scores from the preoperative period: 37–88 (mean: 67.45 ± 15.10) to 22–43 (mean: 31.73 ± 5.61) 6 weeks after surgery, giving a percentage improvement of 52.97% (P = 0.0002), thus statistically significant.
CONCLUSION: SNOT-22 tool is a valuable tool to evaluate the HRQOL of patients with CRS and endoscopic sinus surgery as surgical intervention improves the HRQOL of patients with reduction in the mean score of all items in the SNOT-22 in the postoperative state compared to the preoperative state.

Keywords: Functional endoscopic sinus surgery, outcome, quality of life, rhinosinusitis, sinonasal, Sinonasal Outcome Test-22.

How to cite this article:
Afolabi AO, Uche-Okonkwo K, Shittu NO, Ayodele SO, Busari NO, Segun-Busari S, Omokanye H K, Idris SO, Alabi BS, Dunmade AD, Ologe FE. Evaluation of quality of life using Sinonasal Outcome Test-22 among patients with chronic rhinosinusitis postendoscopic sinus surgery: A preliminary report. BLDE Univ J Health Sci 2022;7:245-51

How to cite this URL:
Afolabi AO, Uche-Okonkwo K, Shittu NO, Ayodele SO, Busari NO, Segun-Busari S, Omokanye H K, Idris SO, Alabi BS, Dunmade AD, Ologe FE. Evaluation of quality of life using Sinonasal Outcome Test-22 among patients with chronic rhinosinusitis postendoscopic sinus surgery: A preliminary report. BLDE Univ J Health Sci [serial online] 2022 [cited 2023 Jun 3];7:245-51. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/2/245/355854

Chronic rhinosinusitis (CRS) is one of the most frequent otorhinolaryngology diseases encountered in everyday practice worldwide with great impact on quality of life (QoL), productivity, and finances.^[1],[2] The term CRS encompasses all inflammatory processes, infectious or not, affecting the mucosal lining of the nose and paranasal sinuses producing symptoms ting for over 12 weeks.^[3] The CRS as a diagnosis is essentially clinical and straightforward when following the criteria established by the American Academy of Otorhinolaryngology, by the presence of two or more significant symptoms or major criteria, such as nasal obstruction/congestion/blockage, anterior or posterior rhinorrhea, hyposmia/anosmia, and facial pain/pressure with one minor criterion which includes headache, weakness, toothache, cough, ear pain, or a feeling of pressure in the ears lasting for more than 12 weeks, besides nasal endoscopy and/or computed tomography scan as supportive evidence.^[4] CRS has been a significantly high burden of disease; recent studies estimated the annual economic burden of CRS to be $22 billion USD (direct and indirect costs) in the USA,^[5],[6] but similar data are not available in Nigeria. Furthermore, it has been shown to have a significant impact on QoL, greater in some respects than other chronic diseases such as angina or chronic obstructive pulmonary disease,^[7] and thus poses a considerable burden to the health-care providers and patients. Western literature has reported CRS to be more prevalent than arthritis or hypertension, affecting between 5% and 15% of studied populations.^[6] In Nigeria, the prevalence from a study conducted in Ilorin revealed a prevalence of 9.72%.^[8] Medical therapy is the first-line treatment and the main form of CRS management and this is aimed at reducing underlying inflammation and facilitating clearance of paranasal sinuses and it includes the use of antibiotics, antihistamines, corticosteroids, decongestant, nasal lavage, and immunotherapy.^[9] Surgery is a choice after the failure of medical therapy or in the presence of actual or impending complications.^[10] Functional endoscopic sinus surgery (FESS) is considered a choice treatment for patients who have not responded to medical therapy.^[10] Some studies have shown FESS is superior to medical management.^[6],[7],[11] A systematic review of FESS case series results has shown that surgery is effective at reducing symptoms, with an 88% success rate.^[12]

In order to assess the success rate of FESS, a variety of variable outcome measures exist. One of the main outcomes of intervention is QoL. To assess this, several instruments have been developed, and in recent years, the Sinonasal Outcome Test-22 (SNOT-22) has become the reference questionnaire^[13] to assess the health status and health-related QoL (HRQOL). The SNOT-22 was derived from the Rhinosinusitis Outcome Measure-31, developed by Piccirillo et al.^[14] SNOT-22 is a modification of SNOT-20 with two additional items addressing nasal obstruction and smell/taste problem.^[15] The SNOT-22 consists of 22 individual items (score range of 0–5), with the total score ranging from 0 to 110. The items cover both the functional and psychological aspects of the disease.^[15]

The aim of the manuscript is to give a preliminary report on the QoL assessment of patients with CRS before and after endoscopic sinus surgery in a resource-poor setting in North-Central Nigeria using SNOT-22 questionnaire.

Materials and Methods

Design

This is a hospital-based study using a self-administered questionnaire-based observational prospective cohort study.

Setting

This study was carried out at the Ear, Nose and Throat Department of Kogi State Specialist Hospital, Lokoja, and University of Ilorin Teaching Hospital, Ilorin. Both of which are tertiary-level hospitals in North-Central Nigeria offering advanced rhinology services over a period of 24 months. Ethical approval for this study was obtained from the Ethical Review Committee of the hospital before commencement. Forty-five consecutive consenting patients with CRS that fulfilled the inclusion were recruited after a detailed explanation of the purpose of the study and procedures to the study participants. Written informed consent was obtained.

Inclusion and exclusion criteria

The inclusion criteria were all consented adult patients 16 years and above with diagnosis of CRS based on the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020, Patients who have had 6–8 weeks of medical therapy which includes antibiotics for between 10 and 14 days, systemic decongestant, and local decongestant with steam inhalation using eucalyptus oil and have consented to surgical intervention using endoscopic sinus surgery approach.

The Exclusion criteria include newly diagnosed CRS not yet of medical treatment, Paediatric Patients < 16years with CRS and Patients who do not consent to surgical intervention.

Sampling technique

Consecutive consenting 45 subjects with CRS that met the inclusion criteria who had endoscopic sinus surgery were recruited for this study regardless of their degree of severity of the CRS. All study participants were drawn from among the patients that satisfy the inclusion criteria attending E. N. T clinics at both Kogi State Specialist Hospital, Lokoja, and University of Ilorin Teaching Hospital, Ilorin, and admitted to the ENT ward for endoscopic sinus surgery.

All enrolled study participants were asked to fill the SNOT chart 22 where he/she scored his/her symptoms preoperatively either in the outpatient clinic or during the admission on the ward. The cohort age varied from the youngest of 16 years old to the oldest of 80 years old. All patients had endoscopic sinus surgery with or without nasal polypectomy. Postoperatively, all patients had gloved finger anterior nasal packs which was removed after 48hrs they all received intravenous antibiotics (cefuroxime 500– 750 mg 8hrly for 48h) depending on the body weight, then converted to oral cefuroxime (250–500 mg for 7 days), After anterior nasal pack removal all patients had oxymetazoline nasal drops (0.1%) 2 drops twice daily for 3–5 days followed by steam inhalation with eucalyptus oil, Tab Actifed ½ nocte and steroid nasal sprays twice daily for 2 weeks.

Then, 6 weeks postoperatively at follow-up, he/she was asked to score again her symptoms using SNOT-22 questionnaire unaware of their preoperative SNOT-22 scores.

Outcome measures

Total score for each subject was derived from the 22-item psychometrically validated self-administered SNOT-22 questionnaire.^[13] Lower scores postoperatively represent better HRQOL. All data were entered into SPSS version 21 IBM version (IBM, Armonk, New York 10504-1722, United State) and result presented in tables and figures.

Results

A total of 45 patients were enrolled in the study based on the inclusion criteria, however, only 40 completed the postoperative SNOT-22 questionnaire for QoL assessment 6 weeks after surgery during the follow-up and thus had complete data for analysis. None of the patients recruited had ever undergone endoscopic sinus surgery or any nasal surgery in the past.

About two patients did not come for follow-up, while three did not complete the study pro forma 6 weeks postsurgical intervention and were deemed not to have completed the study and were excluded from the final analysis. All subjects were followed up for 6–12 months after FESS. The subjects were 19 males (47.5%) and 21 females (52.5%). The male-to-female ratio was1:1.1. The mean age of the studied population was 34.95 ± 2.69 years (16–80 years). The patients aged between 16 years and 39 years accounted for over two-thirds of our sample population. The modal age group was between 21 and 30 years for males and 31–40 years for females, respectively [Table 1].

Table 1: Age-gender frequency for patients with rhinosinusitis

Click here to view

The total sinonasal outcome mean score for the preoperative SNOT-22 was 67.45 ± 15.10 (37–88) and the mean score of the postoperative SNOT-22 was 31.73 ± 5.61 (22–43). Overall, patients reported substantial relief in all symptom domains as evaluated by the SNOT-22. Average total scores were seen to improve by 52.97%, from 67.45 to 31.73, pre-and post-FESS, respectively [Table 2].

Table 2: The mean score of the discrete domains of the Sinonasal Outcome Test-22

Click here to view

Comparative analysis of the SNOT-22 questionnaire pre- and post-FESS showed a reduced mean score of all the items in the SNOT-22 questionnaire postoperatively which is interpreted as an improved QoL as lower scores postoperatively represent better HRQOL.

Correlation test was also done to assess the relationship between the total score before and after the FESS. The results of the test showed that there was a significant relationship between the total score pre- and post-FESS, in which the increase in presurgical score increases the gain after surgical intervention. Spearman correlation coefficient: 0.632 and a P value of 0.002 which is statistically significant was found [Table 3]. Correlation between age and improvement percentage showed no relationship with Spearman correlation coefficient of 0.254 and a P value of 0.117, thus no correlation as the P value is > 0.05 [Table 3]. Correlation between gender and improvement percentage showed no relationship with Spearman correlation coefficient of 0.169 and a P value of 0.297, thus no correlation as the P value is > 0.05 [Table 3].

Table 3: Sex distribution of mean preoperative and postoperative Sinonasal Outcome Test-22 scores

Click here to view

Patients experienced the most marked improvements in aural and facial symptoms such as facial pain/pressure, ear pain, ear fullness, and vertigo. Average post-FESS scores dropped to 2.45 from 10.10 pre-FESS, indicating 75.74% improvement in this domain of the SNOT-22 questionnaire [Figure 2] and [Table 2].

Figure 1: Aural/facial symptom domain pre- and postendoscopic sinus surgery

Click here to view

Figure 2: Psychological symptom domain pre- and postendoscopic sinus surgery score

Click here to view

Psychosocial symptoms such as feelings of irritability, sadness, and shame/embarrassment stemming from rhinosinusitis symptoms also improved by an average of 59.28%, after dropping from 10.38 to 4.23 [Figure 3] and [Table 2].

Figure 3: Quality of life symptom domain pre- and postendoscopic sinus surgery score

Click here to view

QoL symptom scores were at an average of 24.35. However, patients experienced a 49.59% improvement in this domain post-FESS, with average score dropping to 12.23 [Figure 4] and [Table 2].

Figure 4: Nasal symptom domain pre- and postendoscopic sinus surgery score

Click here to view

Similarly, nasal symptoms also showed a significant improvement post-FESS. Falling from an average score of 22.65–12.68, thereby improving 44.02% [Figure 5] and [Table 2].

Figure 5: Relationship between the total Sinonasal Outcome Test-22 preoperative and total Sinonasal Outcome Test-22 postoperative scores

Click here to view

Discussion

CRS negatively affects multiple aspects of a patient's life, including work productivity, resulting in a high socioeconomic burden, however, there has been no gold standards for its evaluation and treatment, especially when surgical interventions are planned.^[16]

QoL is a unique personal experience that reflects not only health status but also other factors in a patient's life that can only be described by each individual patient as it was done in our study to enquire about their personal experience before and after surgical intervention using SNOT-22 questionnaire.^[14] A part of the overall QoL is HRQOL, which is influenced by the health of patients and can be changed through treatment which in our study was endoscopic sinus surgery. HRQOL was defined by Carr and Higginson^[17] as those aspects of an individual's subjective experience that relate both directly and indirectly to health, disease, disability, and impairment. The demographic from our study revealed about 70% of the forty participants were ≤40 years with a mean age of 34.95 years [Table 1] higher than findings by Singla et al.,^[15] similar to findings from a Morocco study^[1] but lower than reports from Iran^[18] and Brazil.^[19] Based on the above anecdotal evidence, this has a negative effect the work productivity and high economic burden which was not part of the objective of this study. Correlation between gender and improved HRQOL as well as in the individual domain showed no relationship with Spearman correlation coefficient of 0.169 and 0.254, a P value of 0.297 and 0.114 (P > 0.05), respectively [Table 3].

In our study, there were more female gender than the male counterpart this may be as a result of female accessing more health care than the male which is similar to findings from Morocco^[1] but at variance with most other studies accessed.^[18],[19]

Previous literature from multi-institutional cohort data has demonstrated that patients with CRS with or without nasal polyps improve on the disease-specific QoL scores to a greater degree with surgical intervention.^[20] Findings from our study also demonstrated improved disease-specific QoL with reduced value outcome of the domains of the aural and facial (extranasal), nasal, psychological, and QoL [Figure 1],[Figure 2],[Figure 3],[Figure 4].^{[21],[22],[23]} Each of these domains was assessed by each of the participants presurgical and postsurgical intervention, and a comparative analysis was done for each component of the domain. The scores from each of the domains preoperatively were higher than the postoperative scores which demonstrated an improvement in the specific compared symptoms, as shown in [Figure 2],[Figure 3],[Figure 4],[Figure 5] for each of the domains, while [Figure 2] shows the summary of all the domains. The scores range from 0 to 5, with 0 being interpreted as no problem while 5 being interpreted as worst possible problem.^[23] In the questionnaire, the average for each symptom was calculated as well as for the domains and the average or mean found then compared for the preoperative and postoperative. The nasal has the least difference, thus with the least improvement in symptoms after 6–12 weeks of reassessment, while the highest difference was the psychological domain which indicated the best improvement noticed by the patients, as shown in [Table 2]. Although the assessment is subjective and patient dependent. The overall assessment of improved QoL using the average total scores was seen to improve by 52.97% before and after endoscopic sinus surgery, respectively [Table 2], with Spearman coefficient: 0.0502 and a P value of 0.002 which is statistically significant. Furthermore, statistical analysis showed no relationship between the age, gender, and the overall QoL [Table 3] and [Table 4].

Table 4: Correlation between age and percentage improvement in Sinonasal Outcome Test-22 score

Click here to view

The results of the statistical analysis showed that FESS as surgical intervention improves the QoL of patients following a significant reduction in the mean score of all items in the SNOT-22. This finding is similar to reports from other centers assessing the QoL of patients pre- and post-FESS.^{[1],[6],[7],[17],[18],[19],[23]}

Conclusion

SNOT-22 tool is a valuable tool to evaluate the HRQOL of patients with CRS pre- and postoperative to assess improvement in symptoms as there was overall improved QoL by 52.97% after endoscopic sinus surgery using the average total domain scores.

FESS as surgical intervention improves the HRQOL of patients following a significant reduction in the mean score of all items in the SNOT-22 from preoperatively state compared to the postoperative state, the mean age from our study was 34.95 years with about 70% of the participants falling ≤40 years, and more female gender was also found than the male counterpart and there is no relationship between the age, gender, and the overall QoL.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	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.
2.	Deepthi NV, Menon UK, Madhumita K. Chronic rhinosinusitis – An overview. Amrita J Med 2012;8:1-44.
3.	Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, et al. Rhinosinusitis: Establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg 2004;131:S1-62.
4.	Bhattacharyya N, Lee LN. Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy. Otolaryngol Head Neck Surg 2010;143:147-51.
5.	Smith KA, Orlandi RR, Rudmik L. Cost of adult chronic rhinosinusitis: A systematic review. Laryngoscope 2015;125:1547-56.
6.	Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology 2012;50:1-12.
7.	Fokkens WJ, Lund VJ, Hopkins C, Hellings PW, Kern R, Reitsma S, et al. European position paper on rhinosinusitis and nasal polyps 2020. Rhinology 2020;58:1-464.
8.	Afolabi OA, Alabi BS, Omokanye HK, Ayodele SO, Segun Busari S, Dunmade AD, et al. Management and outcome of rhinosinusitis in Nigeria. OTO Open. 2017;1(1): 2473974X16685545. Published online 2017 Jan 18. doi: 10.1177/2473974X16685545
9.	Cherry WB, Li JT. Chronic rhinosinusitis in adults. Am J Med 2008;121:185-9.
10.	Jiang XJ, Guo XY, Yuan W, Li Q, Zhong C. Long-term improvements in quality of life after functional endoscopic sinus surgery for adolescents with chronic rhinosinusitis. Acta Oto 2012;132:798-802.
11.	Lusk RP, Bothwell MR, Piccirillo J. Long-term follow-up for children treated with surgical intervention for chronic rhinosinusitis. Laryngoscope 2006;116:2099-107.
12.	Hebert RL 2^nd, Bent JP 3^rd. Meta-analysis of outcomes of pediatric functional endoscopic sinus surgery. Laryngoscope 1998;108:796-9.
13.	Hopkins C, Gillett S, Slack R, Lund VJ, Browne JP. Psychometric validity of the 22-item Sinonasal outcome test. Clin Otolaryngol 2009;34:447-54.
14.	Piccirillo JF, Merritt MG Jr., Richards ML. Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg 2002;126:41-7.
15.	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. [PUBMED] [Full text]
16.	Klonaris D, Doulaptsi M, Karatzanis A, Velegrakis S, Milioni A, Prokopakis E. Assessing quality of life and burden of disease in chronic rhinosinusitis: A review Rhinol Online 2019;2:6-13.
17.	Carr AJ, Higginson IJ. Are quality of life measures patient centred? BMJ 2001;322:1357.
18.	Aghdas MM, Shahidi N, Sheikhzadeh D, Ebrahimzadeh M. Quality of life in patients with chronic rhinosinusitis with nasal polyposis before and after functional endoscopic sinus surgery. A study based on sinonasal outcome test. ABC Med 2018:6;11-4.
19.	Bezerra TF, Piccirillo JF, Fornazieri MA, Pilan RR, Pinna Fde R, Padua FG, et al. Assessment of quality of life after endoscopic sinus surgery for chronic rhinosinusitis. Braz J Otorhinolaryngol 2012;78:96-102.
20.	Smith TL, Kern R, Palmer JN, Schlosser R, Chandra RK, Chiu AG, et al. Medical therapy vs. surgery for chronic rhinosinusitis: A prospective, multi-institutional study with 1-year follow-up. Int Forum Allergy Rhinol 2013;3:4-9.
21.	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.
22.	Costello AB, Osborne WJ. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Practical Assessment, Research, and Evaluation: 2005:10; Article 7. DOI: https://doi.org/10.7275/jyj1-4868.
23.	Dejaco D, Riedl D, Huber A, Moschen R, Giotakis AI, Bektic-Tadic L, et al. The SNOT-22 factorial structure in European patients with chronic rhinosinusitis: New clinical insights. Eur Arch Otorhinolaryngol 2019;276:1355-65.