The objectives of this study were to translate the Sinonasal Outcome Test-22 (SNOT-22) in Romanian in an accessible form that would ensure the patients’ compliance, to verify the sensitivity of the translated test, and to establish the utility of using this test in assessing the quality of life of patients with chronic rhinosinusitis in Romania, taking into account the demographic peculiarities of the Romanian population. Introduction. There are many and specific instruments for assessing the quality of life (QoL) in patients with chronic rhinosinusitis. Of all these tests, SNOT-22 is widely used. This is the first study that analyzes how the SNOT-22 test can be used to assess the quality of life of the patients with chronic rhinosinusitis in Romania. Materials and method. The study is based on the analysis of 90 subjects’ responses to the SNOT-22. Among them, 80 individuals were diagnosed by an ENT physician with chronic rhinosinusitis, with or without nasal polyposis. The other 10 individuals were healthy volunteers (they did not show any modifications in the nasal cavity, such as inferior/medium turbinate hypertrophy, or deviated septum). The translation of the SNOT-22 questionnaire was done by the authors of the study. The statistical analysis used the Chi-square (χ2) test, which was used to assess the significance of demographic variables. The significant differences were determined using a standard 0.05 alpha level. The statistical results were obtained using the SPSS software version 22. The analysis was performed on the responses of the 80 patients diagnosed with chronic rhinosinusitis (the analysis did not include the 10 healthy volunteers). Results and discussion. The group of patients was homogeneous in terms of gender and age: 42 women (52.5%) and 38 men (47.5%); the patients were aged between 20 and 86 years old. The average age of the patients was 46.8 years old, with a standard deviation of 17.2 for the entire group (46.7±17.2 years); the average age among men was 43.4±16.8 years old, and among women 49.8±17.2 years old. In terms of environmental origin, the average age of patients was 47.9±19.1 years old in rural areas, and 46.2±16.5 years old among patients from urban areas. Conclusion. The Romanian version of the SNOT-22 questionnaire is a valid and reliable instrument for assessing sinonasal diseases in Romanian people.
chronic rhinosinusitis, Sinonasal Outcome Test 22, quality of life
Obiectivele acestui studiu au fost de a traduce Sinonasal Outcome Test-22 (SNOT-22) în limba română într-o formă accesibilă care să asigure complianţa pacienţilor, de a verifica sensibilitatea testului tradus şi de a stabili utilitatea testului în evaluarea calităţii vieţii pacienţilor cu rinosinuzită cronică din România, ţinând cont de particularităţile demografice ale populaţiei româneşti. Introducere. Există numeroase instrumente specifice pentru a evalua calitatea vieţii (QoL) la pacienţii cu rinosinuzită cronică. Dintre acestea, SNOT-22 este utilizat pe larg. Acesta este primul studiu care analizează modul în care SNOT-22 poate fi utilizat pentru a evalua calitatea vieţii la pacienţii cu rinosinuzită cronică din România. Materiale şi metodă. Acest studiu are la bază analiza răspunsurilor la testul SNOT-22 a 90 de subiecţi. Dintre aceştia, 80 au fost diagnosticaţi de către un medic specialist ORL cu rinosinuzită cronică, cu sau fără polipi nazali. Restul de 10 subiecţi au fost voluntari sănătoşi (nu au prezentat modificări la nivelul cavităţii nazale, cum ar fi hipertrofie turbinală inferioară/medie sau deviaţie de sept). Traducerea chestionarului SNOT-22 a fost realizată de autorii studiului. Analiza statistică a utilizat testul Chi-pătrat (χ2), folosit pentru a evalua semnificaţia statistică a variabilelor demografice. Diferenţele semnificative au fost determinate utilizând un nivel standard alfa de semnificaţie statistică de 0,05. Rezultatele statistice au fost obţinute utilizând programul SPSS versiunea 22. Analiza a fost realizată pe baza răspunsurilor celor 80 de pacienţi diagnosticaţi cu rinosinuzită cronică (analiza nu a inclus cei 10 voluntari sănătoşi). Rezultate şi discuţii. Grupul pacienţilor a fost omogen în ceea ce priveşte genul şi vârsta: 42 de femei (52%) şi 38 de bărbaţi (47,5%); vârsta pacienţilor a fost cuprinsă între 20 şi 86 de ani. Vârsta medie a pacienţilor a fost 46,8 ani, cu o deviaţie standard de 17,2 ani pentru întregul grup (46,8±17,2); vârsta medie a bărbaţilor incluşi în studiu a fost 43,4±16,8 ani, iar cea a femeilor a fost 49,8±17,2 ani. În ceea ce priveşte mediul de rezidenţă, vârsta medie a pacienţilor din mediul rural a fost 47,9±19,1 ani, iar vârsta medie a celor din mediul urban a fost 46,2±16,5 ani. Concluzie. Versiunea în limba română a chestionarului SNOT-22 este un instrument valid şi fidel de evaluare a bolii sinonazale la pacienţii din România.
Measuring the quality of life (QoL) of patients with chronic rhinosinusitis is a useful indicator for the disease, classifying the severity, obtaining the best treatment, and evaluating the outcome. There are many and specific instruments for assessing the QoL in patients with chronic rhinosinusitis.
The first validated test on the quality of life for patients with rhinosinusal diseases was set by Fairley in 1993(1). This test consisted in 12 questions and was based on the responses displayed along a scale of 0 to 3. This questionnaire is not widely used.
The first person who decided to observe the impact of the rhinosinusal pathology on the quality of life by means of a complex questionnaire was Piccirillo in 2002(2). His questionnaire, called SNOT-20 (Sinonasal Outcome Test 20), consists in 20 questions, which can be divided into five smaller groups (nasal symptoms, sinusal symptoms, sleep-related symptoms, social and emotional impact). The assessment of these symptoms was based on a scale ranging from 0 to 5, wherein 0 meant no problem and 5 meant a severe problem. SNOT-20 has long been considered the most important questionnaire and it was used on a large scale, mostly because of the patients’ compliance. In 2006, Hopkins et al.(3) decided to improve the SNOT-20 by adding two questions, referring to nasal obstruction and loss of smell, thus resulting the SNOT-22. This new questionnaire was used by the Royal College of Surgeons of England within an ample study, conducted on 3,128 patients – National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis. In 2009, SNOT-22 was validated by Hopkins(4), and it was recommended in medical practice for patients suffering from CRS.
The SNOT-22 questionnaire was translated in several countries, and its efficiency was proved both for patients experiencing rhinosinusal problems, and for those suffering from chronic rhinosinusitis. In Brazil, two studies conducted by different teams aimed at having the SNOT-22 translated into the Portuguese dialect spoken in Brazil(5,6). Another study also conducted in Brazil(7) aimed at observing the way in which patients suffering from chronic rhinosinusitis who had not been subjected to reparatory surgery report a lower quality of life, based on the same SNOT-22 questionnaire. This test also proves to be efficient in determining the impact of chronic rhinosinusitis on the patients’ quality of life.
In Europe, the SNOT-22 was initially validated in Denmark(8). The conclusion of the test was that the Danish version of the questionnaire was recommended for the Danish researchers and practitioners as an effective way of assessing the rhinosinusal inflammatory processes – rhinosinusitis and nasal polyposis. In Italy(9), the SNOT-22 is recommended in order to assess the quality of life as described by the patients suffering from chronic rhinosinusitis.
In Iran, the possibility of having the test translated and used in patients experiencing rhinosinusal pathology was considered as well(10).
Materials and method
The study was conducted from September 2013 to June 2016 in a secondary ENT center in Craiova, Romania. The study included only adults, older than 18 years old.
The study included 80 patients, diagnosed according to the EP3OS criteria as suffering from chronic rhinosinusitis, with or without nasal polyposis(11):
the presence of two or more symptoms, one of which being nasal obstruction/congestion or nasal discharge (either anterior, or posterior);
with/without cephalea/facial tension;
symptoms lasting for at least 12 weeks.
The exclusion criteria were:
less than 18 years of age;
marked immunodeficiency (either congenital, or acquired);
fungus-ball or invasive fungal sinusitis;
All patients filled in the SNOT-22 questionnaire.
The translation of the SNOT-22 questionnaire was done by the authors of the study, who tried to use simple, easy-to-understand words. After having translated the test, it was forwarded to five family care doctors for assessment and further suggestions.
The SNOT-22 consists a list of 22 symptoms. Some of them are caused by the changes at the level of the nasal fossa – nasal obstruction, posterior rhinorrhea, purulent rhinorrhea, the constant need of blowing one’s nose, anosmia, sneezing. Other symptoms refer to auricular damage (the senzation of stuffy ear, ear pain), and general illness (sickness, cephalea). An important part of the questionnaire refers to the way chronic rhinosinusitis affects the patient’s quality of life: difficulty in falling asleep, waking up during the night, feeling tired after a night sleep, drowsiness, low work productivity, frustration/irritability, embarrassment, sadness.
The patient is required to answer specific questions, wherein 0 means that the respective symptom is not present, and 5 means that the respective symptom causes serious problems. The statistical analysis was performed using SPSS software version 22.
Results and discussion
The structure of the group of patients was the following:
42 women (52.5%) and 38 men (47.5%);
56 patients from urban areas (U) – 70%, and 24 patients from rural areas (R) – 30%;
patients were aged between 20 and 86 years old. The mean age of patients was 46.8 years old, with a standard deviation of 17.2 for the entire group (46.7±17.2 years old); the mean age was 43.4±16.8 years old for men, and 49.8±17.2 years old for women. In terms of environmental origin, the average age of patients was 47.9±19.1 years old in rural areas, and 46.2±16.5 years old for patients from urban areas.
The group was homogeneous in terms of age, both regarding the average and the standard deviation. There was also a balanced proportion of men and women, but it is worth noticing the fact that, in terms of the patients’ origins, those who lived in a city were twice as many as those who lived in rural areas.
The average score on the SNOT-22 of the entire group of patients included in the study (80 patients) was 69. Within our study, the smallest number of points was 21, and the largest was 110. The number of points scored by healthy patients ranged between 0 and 37.
The average of the SNOT-22 was quite different in terms of the patients’ sex and origin (Table 1).
Given the fact that the lot of patients included in the study was homogeneous in terms of the patients’ sex, it was justified the calculation of the odds ratio for the score of the SNOT-22 (Table 2).
Therefore, the probability for a woman to score more points than the average was 25:17=1.47:1; the probability for a man to score more SNOT-22 points than the average was 16:22=0.73:1.
Further analysis revealed the fact that the Odds Ratio was 1.47/0.73=2.02, which means that a woman was twice more likely to score more points than the SNOT-22 average, as compared to men.
The statistical analysis went on with the Chi-Square test (Table 3).
The P-value is over 0.05, which makes it statistically insignificant.
The above data revealed the fact that there was no connection between the patients’ sex and the number of SNOT-22 points.
The same calculation was used to refer to the number of SNOT-22 points in relation to the patients’ origin (Table 4).
Therefore, the probability for a patient originating in the rural area to score more than the SNOT-22 average was 13:11=1.18:1; the probability for a patient originating in the urban area to score more than the SNOT-22 average is 28:28=1:1. It is worth noticing the fact that the group was not homogeneous in terms of the patients’ origin, as it included twice as many patients originating in the urban area compared to those from the rural area; the distribution is not even.
Odds ratio (OR)=1.18/1=1.18, which means that a person originating in the rural area scored approximately the same number of points as someone from the urban area.
The average of the SNOT-22 for the entire set of patients was 69 points; the smallest number of points was 21, whereas the largest was 110. It is our opinion that these results are accurate, as they suggest a rhinosinusal inflammatory pathology; the existing studies emphasize the fact that healthy people, who do not suffer from chronic rhinosinusitis, score very low: between 0 and 50, with an average of 9.3 (Gilette, 2009(12)). In the case of our study, the results of the healthy voluntaries ranged between 0 and 37, with an average of 11.05.
The analysis of the score of each symptom included in the SNOT-22 indicates the fact that the most significant values were scored in the case of the symptoms which are characteristic to chronic rhinosinusitis: stuffy nose (average 4.537, standard deviation 0.692), loss of taste or smell (average 4.025, standard deviation 1.302), nasal secretions – average 3.675, standard deviation 1.290 (including purulent nasal secretions, with average 3.375, standard deviation 1.444, or nasal secretions, which run down towards the posterior area, inside the throat – average 3.525, standard deviation 1.431). Among the symptoms which are specific to chronic rhinosinusitis (according to EPOS), only face soreness or pressure scored lower, with an average of 2.912 and a standard deviation of 1.715. Therefore, the highest ranking symptoms of chronic rhinosinusitis were stuffy nose and loss of taste/smell.
All of these values clearly prove that the SNOT-22 is effective in assessing the symptoms related to chronic rhinosinusitis.
The first conclusion of this statistical analysis is the fact that there is no statistically significant relation between the SNOT-22 and the patients’ sex.
The second conclusion of this statistical analysis is that the patients’ origin is of no relevance in relation with the SNOT-22. It is therefore certified the fact that the SNOT-22 can be applied to patients suffering from chronic rhinosinusitis, and that the results thereof cannot be influenced by the participants’ sex or origin.
The statistical analysis presented proves that the SNOT-22 can be used for the anamnestic and diagnostic investigation of the patients suffering from chronic rhinosinusitis, with or without nasal polyposis. Therefore, we believe the large-scale implementation of the SNOT-22 is justified as a method for diagnosing patients suffering from chronic rhinosinusitis, with or without nasal polyposis.
Acknowledgments: This work was supported by POSCCE, ID1540, SMIS code: 43692.
Authors’ contribution: All authors have equal contribution. The study concept was developed by Alina Căpitănescu. The statistical analysis and data interpretation were performed by Iulia Bianca Mitroi. The critical revision of the manuscript was done by Mihaela Roxana Mitroi.
Financial disclosure: Nothing to report.
Conflict of interests: The authors declare no conflict of interests.
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