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Introduction

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;

• with/without hypo-/anosmia;

• symptoms lasting for at least 12 weeks.

• The exclusion criteria were:

• less than 18 years of age;

• cystic fibrosis;

• marked immunodeficiency (either congenital, or acquired);

• fungus-ball or invasive fungal sinusitis;

• systemic vasculitis;

• neoplasia.

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.

Conclusions

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.