Abstract
Objectives/Hypothesis: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS. Study Design: Retrospective outcomes research. Methods: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed. Results: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P <.001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P =.031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P =.005). Conclusions: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS. Level of Evidence: 2c Laryngoscope, 2019.
| Original language | English (US) |
|---|---|
| Pages (from-to) | E736-E741 |
| Journal | Laryngoscope |
| Volume | 130 |
| Issue number | 12 |
| DOIs | |
| State | Published - Dec 2020 |
Keywords
- Recurrent acute rhinosinusitis
- chronic disease
- diagnosis
- exacerbation
- outcome assessment (healthcare)
- patient-reported outcome measures
- quality of life
- sinusitis
ASJC Scopus subject areas
- Otorhinolaryngology
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Acute Exacerbations in Recurrent Acute Rhinosinusitis : Differences in Quality of Life and Endoscopy. / Beswick, Daniel M.; Ayoub, Noel F.; Mace, Jess C. et al.
In: Laryngoscope, Vol. 130, No. 12, 12.2020, p. E736-E741.Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - Acute Exacerbations in Recurrent Acute Rhinosinusitis
T2 - Differences in Quality of Life and Endoscopy
AU - Beswick, Daniel M.
AU - Ayoub, Noel F.
AU - Mace, Jess C.
AU - Mowery, Alia
AU - Hwang, Peter H.
AU - Smith, Timothy L.
N1 - Funding Information: Data collection was conducted as part of an investigator-monitored, observational research study of adult human subjects funded by the National Institute on Deafness and Other Communication Disorders (Bethesda, Maryland; federal grant #R01 DC005805) at Oregon Health and Science University (OHSU; Portland, Oregon) combined with an additional adult patient outcomes data repository at Stanford University (Palo Alto, California) collected per routine clinical practice. Study data were prospectively and retrospectively collected from heterogeneous patient populations referred to these two academic, rhinology clinics for symptoms associated with RARS. Symptomatic, adult patients (>18 years of age) with a confirmed diagnosis of RARS from a fellowship-trained rhinologist were included, with all patients having at least four annual episodes of ABRS according to published guideline criteria.11 Diagnostic criteria have been established by current clinical practice guidelines for adult sinusitis from the American Academy of Otolaryngology–Head and Neck Surgery. Patients were treated in accordance with clinical standard of care (SOC) for RARS, including medical and surgical management when indicated. The institutional review board (IRB) at both OHSU (IRB #7198) and Stanford University (IRB #36074) provided ethical oversight, review of research protocols, and data safety. Data collection methods were determined minimal risk and did not deviate from the SOC for the treatment of RARS. Data collection was conducted as part of an investigator-monitored, observational research study of adult human subjects funded by the National Institute on Deafness and Other Communication Disorders (Bethesda, Maryland; federal grant #R01 DC005805) at Oregon Health and Science University (OHSU; Portland, Oregon) combined with an additional adult patient outcomes data repository at Stanford University (Palo Alto, California) collected per routine clinical practice. Study data were prospectively and retrospectively collected from heterogeneous patient populations referred to these two academic, rhinology clinics for symptoms associated with RARS. Symptomatic, adult patients (>18 years of age) with a confirmed diagnosis of RARS from a fellowship-trained rhinologist were included, with all patients having at least four annual episodes of ABRS according to published guideline criteria.11 Diagnostic criteria have been established by current clinical practice guidelines for adult sinusitis from the American Academy of Otolaryngology–Head and Neck Surgery. Patients were treated in accordance with clinical standard of care (SOC) for RARS, including medical and surgical management when indicated. The institutional review board (IRB) at both OHSU (IRB #7198) and Stanford University (IRB #36074) provided ethical oversight, review of research protocols, and data safety. Data collection methods were determined minimal risk and did not deviate from the SOC for the treatment of RARS. Patients were excluded from final statistical analysis if they presented with any variant of comorbid primary ciliary dyskinesia due to differential disease pathology and treatment considerations, as well as increased likelihood of exacerbated symptoms associated with sinusitis. Patient-reported outcome measures (PROMs) and endoscopy scores collected in the 6-month period following endoscopic sinus surgery (ESS) were excluded due to potential confounding effects in symptom severity during postoperative healing. Additional exclusions included patients unable or unwilling to complete PROMs during routine clinical appointments. Each study participant provided a comprehensive medical and social history during baseline enrollment meetings or during initial clinical presentation per the SOC. Patients were also instructed to provide complete responses to the 22-item Sino-Nasal Outcome Test (SNOT-22) survey, the primary outcome of interest, to quantify current sinonasal symptom severity at the time of presentation. The SNOT-22 is a widely used, validated, survey instrument designed to quantify the severity of symptoms associated with sinonasal disorders using Likert scale (item score range = 0–5) response options (Washington University, St. Louis, MO).12 Validated factor analysis of SNOT-22 item scores in a patient population with chronic rhinosinusitis (CRS) has previously identified five symptom domains that can be categorized and summarized into rhinologic (score range = 0–30), extranasal rhinologic (score range = 0–15), ear and/or facial (score range = 0–25), psychological dysfunction (score range = 0–35), and sleep dysfunction (score range = 0–25).13 Higher summarized SNOT-22 total score (range = 0–110) and domain scores reflect overall worse sinonasal symptom severity. The paranasal sinuses were evaluated bilaterally using rigid endoscopes (Karl Storz, Tuttlingen, Germany) during routine clinical appointments according to the SOC. Endoscopic findings were quantified by each enrolling physician using the Lund-Kennedy (LK) scoring system (total score range = 0–20), which quantifies visualized pathologic attributes within the paranasal sinuses including the presence and severity of nasal polyposis, discharge, edema, scarring, and crusting.14 Higher summarized LK total scores indicate worse overall disease severity. Although endoscopy was performed on all patients, full LK scores were only available for a subset of patients. As the primary predictor of interest to this investigation, study participants were classified as either presenting with or without an AE of rhinosinusitis concurrent with completion of the SNOT-22 instrument. Acute exacerbations were defined according to established criteria as worsening symptoms such as facial pain or pressure, nasal obstruction, and nasal discharge according to clinical guidelines.2 Patients who met criteria for an acute exacerbation were designated as “with” or “during” an exacerbation, whereas patients who did not meet criteria and presented for routine, scheduled follow-up were designated as “without” or “between” exacerbations. The dichotomous designations of RARS exacerbation were made through retrospective chart review. Endoscopic findings were not factored into designation of group status, as they are not part of the guideline definition of an ABRS episode.2 Investigational data were secured through the assignment of unique study identification numbers for study participants and removal of all protected health information prior to transfer into a centralized database in a closed environment at OHSU (Access [Microsoft, Redmond, WA]) in compliance with the Health Insurance Portability and Accountability Act of 1996. All descriptive and statistical comparisons were completed using SPSS software (version 24.0; IBM, Armonk, NY). Statistical analyses were directed after all scaled measures were evaluated for assumptions of normality and linearity using graphical analysis and Shapiro-Wilk testing. Comparisons of independent observations of patients with and without acute exacerbations of RARS were evaluated using Mann-Whitney U test statistics, which compares rank differences in median score. Interquartile range (IQR), determined by calculating the difference between the 1st and 3rd quartiles, is reported when appropriate. Differences in score frequency between patients with and without AE of RARS were also compared using χ2 testing where appropriate. Funding Information: j.c.m., p.h.h., and t.l.s. were supported for this investigation by a grant from the National Institute on Deafness and Other Communication Disorders, one of the National Institutes of Health (Bethesda, Maryland; R01 DC005805). Public clinical trial registration ( www.clinicaltrials.gov ) ID# NCT02720653. This funding organization did not contribute to the design or conduct of this study; preparation, review, approval or decision to submit this manuscript for publication. p.h.h. is a consultant for Canon Medical Systems, Lyra Therapeutics, Medtronic, and Stryker, none of which are affiliated with this investigation. Publisher Copyright: © 2019 The American Laryngological, Rhinological and Otological Society, Inc.
PY - 2020/12
Y1 - 2020/12
N2 - Objectives/Hypothesis: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS. Study Design: Retrospective outcomes research. Methods: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed. Results: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P <.001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P =.031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P =.005). Conclusions: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS. Level of Evidence: 2c Laryngoscope, 2019.
AB - Objectives/Hypothesis: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS. Study Design: Retrospective outcomes research. Methods: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed. Results: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P <.001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P =.031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P =.005). Conclusions: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS. Level of Evidence: 2c Laryngoscope, 2019.
KW - Recurrent acute rhinosinusitis
KW - chronic disease
KW - diagnosis
KW - exacerbation
KW - outcome assessment (healthcare)
KW - patient-reported outcome measures
KW - quality of life
KW - sinusitis
UR - http://www.scopus.com/inward/record.url?scp=85077026791&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85077026791&partnerID=8YFLogxK
U2 - 10.1002/lary.28460
DO - 10.1002/lary.28460
M3 - Article
C2 - 31837149
AN - SCOPUS:85077026791
SN - 0023-852X
VL - 130
SP - E736-E741
JO - Laryngoscope
JF - Laryngoscope
IS - 12
ER -