Article

Sleep quality improves with endoscopic sinus surgery in patients with chronic rhinosinusitis and nasal polyposis

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Background: Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) is a chronic disease that has a major impact on generic and disease-specific quality of life. Little is known about the influence of CRSwNP on sleep and what effect surgery for CRSwNP has on sleep quality. The aim of the study was to investigate sleep quality in patients with CRSwNP before and after endoscopic surgery. Methodology: Forty-two patients filled out four validated sleep questionnaires and one sino/nasal, disease specific quality of life questionnaire before surgery and three months later. A healthy control group filled out the same questionnaires at baseline and after three months. Results: An impact on sleep patterns was found in all sleep questionnaires and surgery clearly improved the quality of sleep. The Sino-nasal outcome test sum score decreased from median 51,5 to 26,5. Epworth sleepiness scale showed a decline in score from score 7.5 to 6.0. Surgery also reduced the risk for obstructive sleep apnoea in 13 patients evaluated by the Berlin Questionnaire and Multivariable Apnea Prediction Index. Conclusions: Patients with CRSwNP had impaired sleep quality, daytime sleepiness, nasal patency, and risk for sleep apnea, all of which improved after corrective surgery.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... CRS has been shown to influence sleep and quality of life due to an immunemediated inflammatory response that reaches the central nervous system [10]. Furthermore, chronic rhinosinusitis with nasal polyps (CRSwNP), a severe inflammatory status of sinonasal mucosa [2,[10][11][12], may have a role in SDB, but the involvement of CRS in the clinical presentation of OSA is still unclear. Uzdan et al. [11], recently found a significant improvement in rhinomanometric nasal resistance, apnea-hypopnea index (AHI), minimal oxygen saturation (SaO 2 ), and quality of life scores following polypectomy in 22 patients with CRSwNP by functional endoscopic sinus surgery [11]. ...
... Uzdan et al. [11], recently found a significant improvement in rhinomanometric nasal resistance, apnea-hypopnea index (AHI), minimal oxygen saturation (SaO 2 ), and quality of life scores following polypectomy in 22 patients with CRSwNP by functional endoscopic sinus surgery [11]. Another study reported an improvement of sleep quality and a reduction in excessive somnolence three months after polypectomy in 42 subjects [12]. ...
... patients with atypical clinical presentation (low BMI and little snoring) may be explained by the inflammatory process and different nasal flow compared to patients without NP [1,12,14]. ...
... Patients with CRSwNP complain of its negative effect on their quality of life and sleep, with reports of symptoms such as such as mouth breathing, sleep disturbance, and snoring being common [9,10]. Research has suggested that impaired sleep quality is closely correlated with CRSwNP [11]. However, the aforementioned studies investigated the relationship between sleep quality and CRSwNP via subjective questionnaires, not objective data. ...
... Another study also showed a reduction in the risk of OSA and an improvement in sleep quality after surgery [11]. These findings indicate a close relationship between OSA and CRSwNP; however, the inherent link between OSA and CRSwNP has not yet been elucidated. ...
... Nasal breathing increases ventilatory drive and nasal airway obstruction, which may decrease the quality of sleep [21]. Sleep disturbance is also a universal disease accompanied by CRSwNP [11]. In recent years, various studies have investigated the relationship between CRSwNP and sleep quality. ...
Article
Full-text available
Purpose Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have a higher risk of obstructive sleep apnea (OSA). However, the relationship between CRSwNP and OSA remains unclear. The aim of this research study was to evaluate the association of multiple single nucleotide polymorphism (SNP) variations in CRSwNP with sleep- and breath-related parameters in men with OSA. Methods We included eight CRSwNP SNPs in 2320 participants after strict screening. For each participant, the genetic risk score (GRS) was calculated based on the cumulative effect of multiple genetic variants of CRSwNP. A bivariate correlation analysis was used to assess the relationship between CRSwNP genetic polymorphisms and polysomnography parameters in men with OSA. Logistic regression analyses were used to assess the relationship between the risk of OSA and CRSwNP genetic polymorphisms. Results In moderate OSA, rs28383314 was related to the oxygen desaturation index, and rs4807532 was positively associated with the microarousal index ( r = 0.09, P = 0.03 and r = 0.11, P = 0.01, respectively). The CRSwNP GRS was positively correlated with the oxygen desaturation index and cumulative time percentage with SpO 2 < 90% in moderate OSA ( r = 0.13, P < 0.001 and r = 0.1, P = 0.01, respectively). There was no association between the CRSwNP GRS and the risk of OSA (OR = 1.007; 95% CI, 0.973–1.042; P = 0.702). Conclusion In men with moderate OSA, single CRSwNP genetic variations correlated with sleep-related parameters, and the cumulative effects of CRSwNP genetic variations were associated with the hypoxic index. CRSwNP may be a predisposing condition for sleep disorders in men with moderate OSA.
... Firstly, allergic rhinitis and chronic rhinosinusitis are interlinked with airway diseases and specifically asthma (11)(12)(13) . Patients with atopy often present to otolaryngologists, whose role in early recognition, prevention, as well as holistic management of asthma is integral (15) . However, the link between respiratory and ENT specialists extends beyond allergy. ...
... However, the link between respiratory and ENT specialists extends beyond allergy. Upper airway pathology is often the cause of obstructive sleep apnea (14)(15)(16)(17)(18)(19) . More importantly, vocal cord dysfunction, a significantly under-recognised and misdiagnosed cause of respiratory morbidity, can be easily identified by the experienced and sensitised otolaryngologist during laryngoscopy (20) . ...
Article
Full-text available
Despite an expansion of fellowship opportunities over the last three decades, there is still incomplete regulation and standar-disation of fellowship training. The aim of this comprehensive review was to examine existing evidence about the ear, nose and throat (ENT) training, especially focused on surgical and non-surgical aspects of the training. It is challenging to critically evaluate and compare training programmes across nations for several reasons. Studies on the subject rely entirely on trainee self-reports, without any objective comparators between groups. No evidence exists that directly compares the theoretical or practical attainment of trainees between nations. More fundamentally, trainee exposure to, and competence in, elective surgical procedures, is not the sole measure of a training programme, nor can it be viewed in isolation from the health system's expectations of a newly-qualified specialist, which may vary. During recent years, the Internet and e-learning methods were implemented into the training curriculum. Also, there is an increasing number of platforms that can host the ENT learning content free of charge. Novel educational tools are powerful alternative to standard teaching techniques within otorhinolaryngology education for both residents and medical students. Overall evidence for virtual reality (VR) simulators could be implemented as adjunct in training programs but cannot replace conventional methods. This is mainly due to the fact that actual surgical outcomes after VR training have not been studied so far, but may be the content of future larger scale studies. The otolaryngologists' non-surgical training needs to extend beyond the limits of ENT as skills and experience in areas of ENT, respiratory medicine, allergology, infectious diseases, radiology and oncology are required in the diagnosis and management of ENT diseases.
... Nasal surgery, including septomeatoplasty, turbinate surgery, or functional endoscopic sinus surgery (FESS), which aims to reduce upper airway resistance, has been reported to benefit sleep quality [6][7][8][9]. Sukato et al. [8] conducted a meta-analysis regarding the effect of FESS on obstructive sleep apnea syndrome (OSAS). They discovered only 7 studies showing that FESS could benefit sleep quality and possibly improve apnea hypopnea index (AHI), although the results displayed high heterogeneity among studies. ...
... It seemed that the sleep quality of CRS patients was improved following FESS because of decreased rhinosinusitis severity, unless they had severe OSAS. In a study by Rotenberg and Pan on patients without polyps, and in a study by Varendh et al. on patients with polyps, sleep quality also improved after FESS [7,17]. A recent systematic review reported that FESS has demonstrated encouraging results in improving sleep function in OSAS patients [8]. ...
Article
Full-text available
Purpose: Chronic rhinosinusitis (CRS) patients often complain of nasal obstruction, which may cause sleep impairment for them. The goal of this study was to investigate the influence of functional endoscopic sinus surgery (FESS) on sleep related outcomes in CRS patients. Materials and methods: CRS patients who received FESS were included in this study. Prior to FESS and 3 months after surgery the patients were asked about the severity of nasal obstruction and completed the 20-item Sinonasal Outcome Test (SNOT-20), along with the Epworth Sleepiness Scale (ESS) questionnaire. Endoscopic examination, acoustic rhinometry, and polysomnography were performed in all patients. They were divided into four groups according to their preoperative apnea hypopnea index (AHI) scores: nonobstructive sleep apnea syndrome (non-OSAS), mild OSAS, moderate OSAS, and severe OSAS. Results: A total of 96 subjects completed the study. The scores of the sleep domain of the SNOT-20 and ESS decreased in all of the AHI groups, with the exception of the severe OSAS group, after FESS. A reduction in the AHI of less than 5 was achieved in 9 patients (13.2%) after FESS. Conclusions: Our results showed that FESS improved sleep quality in CRS patients, except those with severe OSAS, and a preoperative lower AHI was the only significant predictor of post-FESS OSAS outcome.
... With a mean value of 12.5 AE 4.9, the sleepiness will most probably have an impact upon everyday life. Our results are therefore in agreement with previous studies showing that nasal obstruction has an impact upon daytime sleepiness (Ishii et al., 2015;Li et al., 2011;V€ arendh et al., 2017). ...
Article
Full-text available
The prevalence and consequences of nasal obstruction in untreated obstructive sleep apnea patients are not known. The study objectives were to investigate the frequency of subjective and objective nasal obstruction in untreated sleep apnea patients and the associations with sleep and quality of life. Patients in the Icelandic Sleep Apnea Cohort were subjected to a type 3 sleep study, answered questionnaires and had their nasal dimensions measured by acoustic rhinometry. In total, 810 patients participated (including 153 females), aged 54.5 ± 10.6 years [mean ± standard deviation (SD)] with an apnea/hypopnea index 44.7 ± 20.7 h−1. Nocturnal nasal obstruction (greater than or equal to three times per week) was reported by 35% of the patients. These patients had smaller nasal dimensions measured by the minimum cross-sectional area within the smaller nasal valve (0.42 ± 0.17 versus 0.45 ± 0.16 cm2, P = 0.013), reported more daytime sleepiness (Epworth Sleepiness Scale score 12.5 ± 4.9 versus 10.8 ± 5.0; P < 0.001) and slightly lower mental quality of life than patients without nocturnal nasal obstruction. Nocturnal nasal obstruction is reported in one-third of the sleep apnea patients and they are more likely to suffer from daytime sleepiness and slightly reduced quality of life than other sleep apnea patients.
... We explain our patients that the primary goal of the surgery is to open the sinuses and improve the access for local treatment and that nasal irrigations (8) and anti-inflammatory treatment after surgery is mandatory (9) . Although we know certain symptoms, like smell (10) and postnasal drip are more difficult to treat than others like blockage (11) and sleep impairment (12,13) , in recent years a number of studies have evaluated appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) (14)(15)(16) . Interestingly and contrary to earlier findings (17) socioeconomic differences do not seem to have an influence on the prevalence of CRS (18) . ...
Article
Over the last few decades, rhinology has been one of the most dynamic and progressive areas of ENT. We have not experienced such an intense period of development since the introduction of nasal corticosteroids in the 1970s.
... With a mean value of 12.5 AE 4.9, the sleepiness will most probably have an impact upon everyday life. Our results are therefore in agreement with previous studies showing that nasal obstruction has an impact upon daytime sleepiness (Ishii et al., 2015;Li et al., 2011;V€ arendh et al., 2017). ...
... We explain our patients that the primary goal of the surgery is to open the sinuses and improve the access for local treatment and that nasal irrigations (8) and anti-inflammatory treatment after surgery is mandatory (9) . Although we know certain symptoms, like smell (10) and postnasal drip are more difficult to treat than others like blockage (11) and sleep impairment (12,13) , in recent years a number of studies have evaluated appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) (14)(15)(16) . Interestingly and contrary to earlier findings (17) socioeconomic differences do not seem to have an influence on the prevalence of CRS (18) . ...
... We also know that CRS has a significant impact on QOL and interestingly that different types of CRS symptoms -most prominently otologic/facial pain and sleep-related symptoms -and their underlying pathophysiologic mechanisms may differentially affect the general health-related QOL detriment associated with CRS (11)(12)(13)(14) . We also know that FESS has significant positive effects on most aspects of quality of life (14)(15)(16) including sleep (17,18) . ...
Article
Let us start this first editorial of 2018 with wishing you all a marvelous year where most of your dreams come true. In the last years, the editors of Rhinology felt often very unhappy when again we had to refuse papers send to us for Rhinology. Unfortunately, every year we can only accept around 15% of the papers we receive. With pain in our hearts, we often have to refuse papers of good quality but just not innovative enough or with slight methodological imperfections. The editorial board of Rhinology recognized this feeling and we decided to start a new journal: Rhinology Online to have space for all those papers that are good but just do not make the cut for Rhinology. Rhinology Online is a journal of the European Rhinologic Society, and will provide a platform for the dissemination of rhinologic research and reviews, as well as position papers, task force reports and guidelines, amongst an international scientific audience.
... We also know that CRS has a significant impact on QOL and interestingly that different types of CRS symptoms -most prominently otologic/facial pain and sleep-related symptoms -and their underlying pathophysiologic mechanisms may differentially affect the general health-related QOL detriment associated with CRS (11)(12)(13)(14) . We also know that FESS has significant positive effects on most aspects of quality of life (14)(15)(16) including sleep (17,18) . ...
... Its beneficial effect on QoL appears to be more pronounced in patients with nasal polyposis and asthma (65,66) . Approximately 75% of patients with medically refractory CRS report sleep disturbances, and sinus surgery has been shown to offer improvement in this domain (67)(68)(69) . A recent prospective study (70) showed that ESS significantly improved the HRQoL and decreased absenteeism in patients with either CRS phenotype. ...
Article
Full-text available
Abstract Background: Chronic rhinosinusitis has been shown to have a significant impact on patients’ quality of life (QoL). We present and summarize current knowledge on assessment methods of Chronic Rhinosinusitis (CRS) burden and QoL.Methodology: Review of the literature using the PubMed database (search of terms “chronic rhinosinusitis”, “CRS”, “quality of life”, “QoL”, “outcome measures”, “assessment of CRS”, “CRS burden” separately or combined) limited to articles published in the English language.Results: Despite the plethora of objective methods available to assess and quantify burden of CRS, discrepancies are occasionally encountered when correlation with subjective measures of QoL is attempted via numerous patient self-reporting tools.Conclusion: CRS has a detrimental effect on QoL and assessing disease severity and burden is a difficult goal. The applicability of known assessment methodologies should be re-evaluated and validated according to research findings on CRS pathophysiology, and new tools should be developed based on the emerging knowledge and the need for personalized treatment and evaluation methods.Key words: chronic rhinosinusitis, QoL, burden of disease, outcome measures, disease-specific QoL questionnaires (3) (PDF) Assessing quality of life and burden of disease in chronic rhinosinusitis: a review. Available from: https://www.researchgate.net/publication/333254771_Assessing_quality_of_life_and_burden_of_disease_in_chronic_rhinosinusitis_a_review [accessed Mar 13 2020].
... It was concluded that CRS patients can recover normal sleep quality, matching that of the control group, after surgical treatment. A similar comparison was also made by Värendh et al, 3 and the improvement of sleep quality and daytime sleepiness was significant after corrective surgery; however, in this study, sleep quality remained worse than that of the control group (Basic Nordic Sleep Questionnaire: ...
... Significant changes in erectile dysfunction have previously been reported following surgical treatment. 18 Unlike prior studies, our study comprised patients with different conditions that cause nasal airway obstruction, including nasal septal deviation, nasal polyposis, concha bullosa and inferior turbinate hypertrophy. We aimed to investigate the effect of these conditions on quality of life relating to the sexual functions of patients before and after surgical treatment. ...
Article
Full-text available
Objective. To investigate the effects of surgical treatment for nasal obstruction on sexual functions, regardless of the condition causing the nasal obstruction. Methods. Of 238 patients identified with nasal obstruction, 57 complained of erectile dysfunction and were included in the analysis. Patients underwent septoplasty, functional endoscopic sinus surgery, concha bullosa excision or radiofrequency ablation of the inferior turbinates, depending on their obstruction-causing disease. Pre- and post-operative evaluation of perceived nasal obstruction was performed using the Nasal Obstruction Symptom Evaluation questionnaire. Pre- and post-operative assessment of sexual functions was performed using the International Index of Erectile Function. Results. Mean post-operative scores for erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall sexual satisfaction were significantly higher compared to the pre-operative scores ( p = 0.022, p = 0.036, p = 0.033, p = 0.016 and p = 0.029, respectively). Conclusion. Surgical treatment of nasal obstruction by septoplasty, endoscopic sinus surgery, concha bullosa excision or radiofrequency can significantly improve sexual performance.
... Five RCTs [14][15][16][17][18] and 25 RWE studies 65] reported mean baseline SNOT-22 scores in the moderate range. Five RCTs [19][20][21][22][23] and 17 RWE studies [48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64] reported severe mean baseline SNOT-22 scores. These findings were consistent with the treatment plan for CRSwNP provided by Fokkens et al. [92], which recommended surgery as treatment for patients with more severe symptoms or with polyps that are recalcitrant to medical management. ...
Article
Full-text available
Objectives: We conducted a systematic literature review (SLR) of randomized controlled trials and real-world evidence (RWE) studies to determine the humanistic (e.g., health-related/disease-specific quality of life [QOL]) and economic (e.g., direct and indirect costs) burdens of chronic rhinosinusitis with nasal polyps (CRSwNP) and describe how the addition of biologics has affected outcomes for patients with CRSwNP. Methods: The SLR adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, MEDLINE, and Evidence-Based Medicine Reviews databases were searched using OVID. Relevant studies involving adult patients with CRSwNP published between 1/1/2018 and 2/16/2019 were included, with relevant conference abstracts from 1/1/2017, onward. Results: Sino-Nasal Outcomes Test (SNOT)-22 was the most frequently used disease-specific health-related QOL/patient-reported outcomes instrument for patients with CRSwNP. Baseline SNOT-22 scores ranged from 25–73 for surgical candidates and from 14–56 for medically managed patients with CRSwNP. Mean baseline EuroQOL-5 Dimensions (EQ-5D) for patients with CRSwNP ranged from 0.81 to 0.86, and mean baseline Short Form-6 Dimensions (SF-6D) ranged from 0.67 to 0.75. Three months (EQ-5D) and 5 years (SF-6D) post-endoscopic sinus surgery (ESS) rates increased from 0.81 to 0.89 and from 0.69 to 0.80, respectively. One year post-diagnosis, patients with CRSwNP had significantly more systemic prescriptions, underwent significantly more medical procedures, demonstrated greater health care resource utilization, and had significantly greater mean health care costs compared with matched controls (all p < 0.001). Overall, for patients with initial ESS, CRSwNP was associated with higher disease-related expenditures compared with CRS without NP, even for patients who did not undergo revision surgery. Conclusions: This SLR identified substantial humanistic burden among surgery candidates. RWE shows that surgeries were used to treat relatively more severe CRSwNP patients as recommended by guidelines. Patient QOL is improved significantly after surgery; however, there is a lack of evidence on patients with revision surgery. Surgery is also associated with higher costs, and the presence of NP was a predictor of revision surgery. Patients with CRSwNP demonstrate greater health care resource utilization and costs compared to those with CRSsNP. Costs associated with different severity of CRSwNP and revision surgery need to be assessed further.
Chapter
Atopic dermatitis, or eczema, is chronic inflammatory pruritic skin disorder, affecting both children and adults. Patients with atopic dermatitis often experience sleep disturbance, especially during flares of their skin disease. Sleep disturbances in atopic dermatitis range from difficulty falling asleep, shorter sleep duration, nighttime awakenings, and daytime sleepiness and fatigue. In addition, atopic dermatitis has also been associated with parasomnias and sleep-related breathing disorders. In children with atopic dermatitis, sleep disturbance may extend from the child to adult caregiver. The effects of sleep disruption in this setting are widespread including increased risk of mood disorders, impaired ability to perform activities of daily living, and decreased quality of life.
Chapter
Allergic disease can have profound influence on sleep through several anatomical and physiological mechanisms. When medical therapies fail to adequately alleviate symptoms, surgery can play a role in improving sleep quality. Here we describe the treatment modalities available to address the allergic patient that presents with complaints of sleep disturbance and discuss relevant literature for these interventions.
Article
Objective: Nasal obstruction is considered to be one of the risk factors for obstructive sleep apnea, together with a high arched narrow palate, elongated uvula, malocclusion, and tongue and tonsil size. The impact of nasal obstruction on sleep apnea is controversial, however, and its relation to sleep quality is rarely discussed. The purpose of this study was to investigate the independent effect of nasal obstruction on sleep quality. Methods: Sixty-nine patients with nasal obstructive symptoms and without sleep apnea episodes were enrolled from September 2018 to August 2019, and compared before and after surgery with thirty-four patients who had benign diseases of the thyroid or parathyroid as a control group, to investigate effects of surgery. Sleep quality was evaluated using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J). All cases were reassessed at three months after surgery. Results: The postoperative PSQI scores in the nasal surgery group were significantly lower than the preoperative scores (p < 0.001). In contrast, there was no statistically significance difference between the pre- and postoperative PSQI scores in the neck surgery group. Difference of PSQI scores before and after surgery in the nasal surgery group was significantly higher than the neck surgery group. Conclusions: This double-arm study suggests that reduction of nasal disfunction with nasal surgery contributes significantly to sleep quality, in patients who may not have noticed their impaired quality of sleep previously because of their long-term nasal symptoms.
Article
Background Rhinologic disease can be responsible for systemic symptoms affecting mood, cognition, and sleep. It is unclear whether sleep disturbance in specific rhinologic disorders (chronic rhinosinusitis [CRS], rhinitis, and nasal septal deviation [NSD]) is an obstructive phenomenon or due to other mechanisms. In this review we examine the impact of CRS, rhinitis, and NSD on objective and subjective sleep outcome metrics and draw comparisons to normal controls and patients with known obstructive sleep apnea (OSA). Methods A systematic review of 4 databases (PubMed, Scopus, Cochrane Library, and Web of Science) was performed. Studies reporting on objective (apnea‐hypopnea index [AHI], respiratory disturbance index [RDI], oxygen nadir) and subjective (Epworth Sleepiness Scale [EpSS], Pittsburgh Sleep Quality Index [PSQI], Fatigue Severity Scale [FSS]) sleep parameters and disease‐specific patient‐reported outcome measures (PROMs; 22‐item Sino‐Nasal Outcome Test [SNOT‐22], Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ], Nasal Obstruction Symptom Evaluation [NOSE]) were included. Results The database search yielded 1414 unique articles, of which 103 were included for analysis. Baseline PROMs were at the high end of normal to abnormal for all 3 conditions: EpSS: CRS (9.8 ± 4.0), rhinitis (9.7 ± 4.3), and NSD (8.9 ± 4.6); and PSQI: CRS (11.0 ± 4.5), rhinitis (6.1 ± 3.7), and NSD (8.6 ± 3.5). Objective measures demonstrated a mild to moderate OSA in the studied diseases: AHI: CRS (10.4 ± 11.5), rhinitis (8.6 ± 8.8), and NSD (13.0 ± 6.9). There were significant differences when compared with reported norms in all measured outcomes (p < 0.001). Conclusion Sleep quality is impacted by rhinologic (CRS, rhinitis, NSD) disease. There is likely a mild obstructive component contributing to poor sleep, but other contributing factors may be involved.
Article
Objective: Chronic rhinosinusitis (CRS) with nasal polyp (wNP) is a more severe inflammatory form of CRS that often coexists with obstructive sleep apnea (OSA). However, little is known the relationship between OSA and immunologic profile on patients with CRSwNP. We aimed to investigate the immune profile of patients with CRSwNP according to OSA severity. Methods: This study included 63 patients with CRSwNP and nine control subjects. Protein levels of inflammatory mediators were determined using multiplex immunoassay. All patients underwent standard polysomnography. Results: We found that, in patients with eosinophilic CRSwNP (ECRSwNP), IL-6 and CXCL-1 (type 1 immune-related markers) were upregulated in cases of moderate-to-severe OSA. Additionally, IL-4, IL-13, CCL-11, CCL-24 (type 2 immune-related markers), and IL-17A (type 3 immune-related marker) were increased in patients with moderate-to-severe OSA. Though there were no significant differences in type 1, 2, or 3 immune-related markers among patients with non-eosinophilic CRSwNP (NECRSwNP) according to the severity of OSA, TGF--β expression was increased in those with moderate-to-severe OSA. Furthermore, in ECRSwNP with moderate-to-severe OSA, associations were detected between serum markers and some upregulated inflammatory markers. Conclusion: Our findings revealed that OSA may increase the heterogeneity of immune profiles (types 1, 2, and 3) in patients with ECRSwNP but not in those with NECRSwNP.
Article
Full-text available
BACKGROUND Among patients with chronic rhinosinusitis with nasal polyps (CRSwNP), randomized clinical trials (RCTs) of biologics, such as anti-IL-4/IL-13 (dupilumab) and anti-immunoglobulin E (omalizumab), have demonstrated efficacy versus intranasal corticosteroids (INCS). However, no head-to-head RCTs exist between biologics. OBJECTIVE To perform an indirect treatment comparison (ITC) of the efficacy of biologics plus INCS versus placebo (INCS) as a common comparator. METHODS Embase®, MEDLINE®, and Cochrane were searched for RCTs of biologics in CRSwNP. Bucher ITCs were performed for outcomes at Week 24: nasal polyp score (NPS; range 0–8), nasal congestion (NC; 0–3), loss of smell (LoS; 0–3), University of Pennsylvania Smell Identification Test (UPSIT; 0–40), total symptom score (TSS; 0–12), sino-nasal outcomes test (SNOT-22; 0–110), and responder analyses based on NPS/NC improvement ≥1. RESULTS Assessment of trial design, baseline characteristics, and outcome measures suggested ITC was feasible with four phase 3 RCTs: dupilumab SINUS-24/-52 (NCT02912468/NCT02898454); omalizumab POLYP1/2 (NCT03280550/NCT03280537). In the intent-to-treat population, dupilumab had significantly greater improvements from baseline to Week 24 versus omalizumab across key outcomes: NPS (least squares mean difference [95% CI] −1.04 [−1.63, −0.44]), NC (−0.35 [−0.60, −0.11]), LoS (−0.66 [−0.90, −0.42]), UPSIT (6.70 [4.67, 8.73]), and TSS (−1.18 [−1.95, −0.41]). Improvement in SNOT-22 was greater in dupilumab versus omalizumab but was not statistically significant. Dupilumab patients were significantly more likely to achieve ≥1-point improvement in NPS (odds ratio [95% CI] 3.85 [1.82, 7.04]) and NC (2.13 [1.12, 4.04]) versus omalizumab. CONCLUSION Although ITCs have limitations, these results demonstrated dupilumab had consistently greater improvements in key CRSwNP outcomes versus omalizumab at Week 24.
Article
Full-text available
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a predominantly type 2 inflammation-mediated disease of the nasal mucosa and paranasal sinuses with an under-recognized clinical, humanistic, and economic burden. Patients with CRSwNP experience a high symptom burden, including nasal congestion, loss of smell, and rhinorrhea, which has a negative impact on physical and mental health-related quality of life, including sleep quality. Existing medical and surgical interventions, including local and systemic corticosteroids and endoscopic sinus surgery, may be associated with recurrence of nasal polyps and associated symptoms and with an increased risk of short- and long-term adverse effects, especially with repeated or long-term use. Because type 2 inflammation is implicated in the pathogenesis of several coexisting diseases, patients with CRSwNP often have comorbid asthma and/or nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. These patients, as well as those with high corticosteroid use and/or sinonasal surgical history, have more severe disease and associated symptom burden and represent a difficult-to-treat population under the existing management paradigm. This article reviews the clinical, humanistic, and economic burden of CRSwNP; it highlights the unmet need for effective and safe CRSwNP therapies that effectively control symptoms and minimize recurrence by targeting the underlying type 2 inflammatory disease pathophysiology.
Article
Objective Up to 75% of patients with chronic rhinosinusitis (CRS) suffer with poor sleep quality and reduced quality of life. Endoscopic sinus surgery has demonstrated encouraging results in improving sleep function. The aim of this systematic review is to assess the change in sleep quality after surgery for CRS. Data Sources PubMed, Web of Science, EMBASE. Review Methods An electronic search was conducted with the keywords “sinusitis” or “rhinosinusitis” and “sleep.” Studies were included only when adults underwent endoscopic sinus surgery and were evaluated pre- and postoperatively by the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Apnea-Hypopnea Index (AHI), the sleep domain of Sino-Nasal Outcome Test–22, or the sleep domain of Rhinosinusitis Disability Index. Results The database search yielded 1939 studies, of which 7 remained after dual-investigator screening. The standardized mean differences (95% CI) for the ESS, PSQI, and AHI were −0.94 (−1.63 to −0.26), −0.80 (−1.46 to −0.14), and −0.20 (−0.32 to −0.07), indicating large, moderate to large, and small improvements, respectively. All analyses displayed high heterogeneity ( I ² = 95%-99%). Conclusion Sleep quality, as measured by the ESS and PSQI surveys, shows substantial improvement after surgery for CRS, with smaller improvement seen for AHI. Generalizability of our results is limited by high heterogeneity among studies and by broad confidence intervals that cannot exclude small to trivial changes. The findings of this meta-analysis provide insight into the effect of CRS-related endoscopic sinus surgery on sleep quality, which should guide future research direction and counseling of patients in the clinical setting.
Article
Background Chronic rhinosinusitis (CRS) presents with broad and systemic manifestations, including impaired sleep; however, the impact of CRS treatments upon sleep is unknown. Objective To establish the effect of medical or surgical CRS treatment on subjective and objective sleep metrics for patients not previously diagnosed with sleep apnea. Methods Review of PubMed, Scopus, Web of Science, and the Cochrane Library was performed from the databases’ date of inception through August 13, 2020, for studies evaluating the effect of CRS treatment on sleep quality. All studies reporting on subjective and objective sleep parameters for patients with CRS, with completed pre- and posttreatment data were included. Studies composed of patients with diagnosed sleep apnea were excluded. Results Sixteen unique studies reporting data on a total of 1770 patients (mean age, 50.6 ± 15.6 (n = 1675) years) following treatment for CRS were included. Patient-reported outcome measures, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Fatigue Severity Scale, demonstrated mean posttreatment differences of −2.8 (95% CI: −4.9 to −0.7), −2.4 (95% CI: −3.7 to −1.2), and −1.2 (95% CI: −1.6 to −0.7), respectively. The SNOT-22 and its sleep domain demonstrated a mean posttreatment difference of −23.5 (95% CI: −31.7 to −15.3) and −5.4 (95% CI: −6.8 to −4.0), respectively. EpSS, FSS and SNOT-22 exceeded their respective reported MCID values. Objective findings did not significantly change with treatment; mean difference: AHI: 0.7 (95% CI: −1.5 to 2.9), oxygen nadir: 0.3 (95% CI: −0.4 to 0.9). Conclusions Treatment of CRS may lead to clinically meaningful reduction in disease burden and improvements in both overall sleep quality and patient-reported fatigue. Despite clinically meaningful quality of life improvements, objective sleep parameters did not demonstrate corresponding posttreatment improvements.
Article
Full-text available
Background In primary care and epidemiological studies of chronic rhinosinusitis (CRS), symptom-based diagnosis is common, yet limited, because endoscopic and radiological signs are not considered. Objectives To evaluate the correlation between symptoms and objective findings of CRS to improve its symptom-based diagnosis for primary care and epidemiological studies by using data from a large-scale nationwide epidemiological study, the Korean National Health and Nutrition Examination Survey (KNHANES). Design Cross-sectional study. Setting Data from 2008 to 2012 KNHANES. Participants 29 225 Adults aged >19 years. Outcome measures Questionnaires targeted two major (nasal blockage and anterior/posterior nasal drip) and two minor (facial pain/pressure and reduction or loss of smell) symptoms. Nasal polyps or mucopurulent discharge from the middle meatus was defined as positive endoscopic findings for diagnosing CRS. Results Of the four symptoms, reduction or loss of smell was the symptom most significantly related to positive endoscopic findings in multivariable analysis (OR=1.936 (95% CI 1.604 to 2.337)). The combinations of symptoms showed higher ORs than individual symptoms and combinations of reduction or loss of smell with other symptoms were statistically more reliable for positive endoscopic findings than other combinations. Conclusions Our results show that reduction or loss of smell was the symptom most significantly related to positive nasal endoscopic findings. Therefore, symptom-based diagnosis of CRS can be improved by considering reduction or loss of smell as an important symptom for positive endoscopic findings of CRS.
Article
Full-text available
Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and asthma are strongly associated, and patients suffering from both diseases are often difficult to treat. However, no guidelines about the management of patients with CRS and coexisting asthma exist. The purpose of this systematic review was to evaluate the management of CRSwNP and coexisting asthma. We systematically searched electronic databases and included clinical trials in which the clinical outcomes after medical or surgical treatment of patients with CRSwNP and asthma were assessed. The strength of the evidence for each outcome was graded on the basis of study quality and consistency in findings. We included seven trials in which the effect of montelukast, omalizumab, erythromycin, and functional endoscopic sinus surgery (FESS) were studied in 317 adults with CRSwNP and asthma. All the interventions improved the majority of subjective and objective nasal outcomes significantly. However, few studies found significant effects on pulmonary function tests. The strength of the evidence was low overall. Both FESS and medical interventions with systemic anti-inflammatory drugs improved nasal outcomes, although their efficacy in relation to the lower airways remains unclear. A low number of studies met inclusion criteria for this systematic review, which emphasizes the need for high-quality trials to explore the treatment of patients with CRSwNP and coexisting asthma.
Article
Full-text available
Aims: This study summarises the health-related quality of life (HRQOL) scores and absenteeism caused by sinus problems in patients awaiting surgery with the diagnoses recurrent acute rhinosinusitis (RARS), chronic rhinosinusitis with nasal polyps (CRS+NP) or CRS without nasal polyps (CRS-NP), in a prospective multi-centre study. Methodology: Two hundred and seven patients with RARS, CRS+NP or CRS-NP were enrolled. EP3OS definitions of CRS and NP were used. The patients completed the 22 Sinonasal Outcome Test (SNOT-22), the short-form 36-item questionnaire (SF-36), the Hospital Anxiety and Depression Scale (HAD) and a total Visual Analogue Scale (VAS) regarding rhinosinusitis symptoms. Results: SNOT-22 and VAS scores indicated severe disease. Comparison of the HRQOL scores in the three rhinosinusitis subgroups showed statistical differences in nine of the SNOT-22 items and in the SF-36 subscale of bodily pain. Mean scores of SF-36 were significantly lower than that of the normal Swedish population. According to the HAD scores, 28% of the patients had probable or possible anxiety or depression disorder. Fifty-seven percent of the patients reported absenteeism from work due to sinus problems. Conclusions: RARS, CRS+NP and CRS-NP significantly decrease HRQOL. Some statistically significant differences in HRQOL were found between the three rhinosinusitis subgroups. Absenteeism due to chronic sinus conditions is considerable.
Article
Full-text available
Objective: To identify a normal SNOT-22 score in subjects not known to be suffering from rhino-sinusitis in India. Study design: Analysis of SNOT 22 scores in participants with no sinonasal disease. Setting: Tertiary care hospital in Central India. Participants: 230 participants from medical institution. Results: Results were obtained from 97 men and 133 women with a mean age of 21 (range 18-24). SNOT scores ranged from 0–35 with a mean score of 8.09. The mode was 0 and the median score 7. Conclusion: Due to the skewed nature of the data, the median score (7) is taken as the normal SNOT 22 score. It is recommended that in a clinical situation a SNOT 22 score of 7 be used as a guide for ''normal'', and that caution be exercised when suggesting treatment to patients with a score below 7. It appears feasible that this test be applied pre and post operatively for appropriate selection and judging the outcome respectively.
Article
Full-text available
Short-term outcome and side effects after Uvulopalatopharyngoplasty (UPPP) are well recognized. However, there is a lack of knowledge of the long-term outcome and side effects after this surgery. This study was completed to investigate the outcome and side effects 20 years after UPPP for snoring and obstructive sleep apnoea. Medical records of patients who underwent UPPP surgery for sleep apnoea and snoring between 1985 and 1991 were investigated retrospectively. A specific questionnaire focusing on the present health profile, side effects of previous UPPP surgery and present sleeping patterns of patients was mailed out. UPPP patients, 186 (including 11 females) were identified. Of these, 35 (19%) had passed away and 7 (4%) were not located. 129 patients (mean: age 68 years, range 43-83) of the possible 144 patients answered the questionnaire (response rate 90%). At follow-up, 41 patients (32%) used continuous positive airway pressure (CPAP). 66 of the patients (52%) were satisfied with the result of the operation, but 61 (47%) were not satisfied. 49 patients (38%) reported persistent side effects (problems with nasal regurgitation 18 (14%), swallowing 26 (20%), changed voice 15 (12%), and pain in the oral cavity 15 (12%). Almost 50% of patients operated with UPPP were not satisfied with the result of the operation after about 20 years, and one third used CPAP at follow-up. A large proportion of patients still experienced side effects, which, after this time, are likely to be permanent.
Article
Full-text available
The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007. The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed. This executive summary for otorhinolaryngologists focuses on the most important changes and issues for otorhinolaryngologists. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.
Article
Full-text available
The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.
Article
Full-text available
Many clinical trials groups now routinely consider including Quality of Life (QoL) assessment in trials. Indeed, several have policies stating that QoL should be considered as a potential endpoint in all new trials and that if it is not to be evaluated the applicants should justify not doing so. However, inclusion of QoL in clinical trials presents a number of difficult organisational issues, and serious problems in compliance have frequently been reported. Thus, in multicentre clinical trials many of the expected QoL questionnaires fail to be successfully completed and returned, although a few groups have claimed high success rates. However, it is well recognised that if questionnaires are missing, there may be bias in the interpretation of trial results, and the estimates of treatment differences and the overall level of QoL may be inaccurate and misleading. Hence it is important to seek methods of improving compliance, at the level of both the participating institution and the patient. We describe a number of methods for addressing these issues, which we suggest should be considered by all those writing clinical trial protocols involving QoL assessment. These are based upon over a decade of experience with assessing QoL in Medical Research Council (MRC) cancer clinical trials. In particular, we provide a checklist for points that should be covered in protocols. Examples are given from a range of current MRC Cancer Trials Office protocols, which it is proposed might act as templates when writing new protocols.
Article
Full-text available
Endoscopy is needed for reliable evaluation of the treatment of nasal polyposis. In this study, we compared the reproducibility of various score systems for staging nasal polyposis and the inter-individual variations between investigators. The mass of the polyps was assessed by five methods, three new techniques (numbers 1, 2 and 3) and two established ones (numbers 4 and 5). These were: 1, lateral imaging projecting the extension of the polyps by drawing on a schematic picture of the lateral wall of each nasal cavity; 2, assessment of polyp obstruction estimating the proportion of the total nasal cavity volume occupied by polyps; 3, nasal airway patency--determining the relationship between the patient's patent airway lumen and an imaginary maximal nasal airway lumen; 4, a score system with four steps ad modum Lildholdt et al.--determining their relationship to fixed anatomical landmarks; and 5, a score system with three steps ad modum Lund and Mackay--determining their relationship to the middle meatus. High correlations were found between the first and the second assessments by a given investigator with all five methods used to score nasal polyposis. High correlations were also shown between the various methods. When three investigators examined a given patient, there were no significant differences between the investigators using score systems 1, 3 and 4. However, with score systems 2 and 5, there was insufficient agreement between the investigators. The patient's symptom of nasal blockage was not a good indicator of the size of the polyps, especially as regards small polyps. Two of the best methods tested (1 and 4) were selected for further clinical studies regarding evaluation of the sensitivity of score systems to detect changes in polyp size during treatment.
Article
Full-text available
Healthy subjects with normal nasal resistance breathe almost exclusively through the nose during sleep. This study tested the hypothesis that a mechanical advantage might explain this preponderance of nasal over oral breathing during sleep. A randomised, single-blind, crossover design was used to compare upper airway resistance during sleep in the nasal and oral breathing conditions in 12 (seven male) healthy subjects with normal nasal resistance, aged 30+/-4 (mean+/-SEM) yrs, and with a body mass index of 23+/-1 kg x m2. During wakefulness, upper airway resistance was similar between the oral and nasal breathing routes. However, during sleep (supine, stage two) upper airway resistance was much higher while breathing orally (median 12.4 cmH2O x L(-1) x s(-1), range 4.5-40.2) than nasally (5.2 cmH2O x L(-1) x s(-1), 1.7-10.8). In addition, obstructive (but not central) apnoeas and hypopnoeas were profoundly more frequent when breathing orally (apnoea-hypopnoea index 43+/-6) than nasally (1.5+/-0.5). Upper airway resistance during sleep and the propensity to obstructive sleep apnoea are significantly lower while breathing nasally rather than orally. This mechanical advantage may explain the preponderance of nasal breathing during sleep in normal subjects.
Article
Full-text available
The calibre of the upper airway is thought to be dependant upon its passive anatomy/collapsibility and the activation of pharyngeal dilator muscles. During awake periods, the more collapsible upper airway in obstructive sleep apnoea (OSA) increases the dilator muscle activity through a negative-pressure reflex. A direct correlation between the critical closing pressure (P(crit)), as a measure of anatomy/collapsability and electromyogram (EMG) activity of genioglossus EMG (GG-EMG) and tensor palatini EMG (TP-EMG), was hypothesised. The relationship between these indices and pharyngeal resistance (R(phar)) was also examined. The study involved eight males with a mean age of 48 (interquartile range 46-52) yrs with OSA, and an apnoea/hypopnoea index of 75 (65-101).hr(-1) on two nights breathing normally and on nasal continuous positive airway pressure (nCPAP). The P(crit )was measured during nonrapid eye movement sleep on nCPAP using brief, incremental reductions in mask pressure. GG-EMG and TP-EMG were measured breath-by-breath, awake, during sleep onset and on nCPAP. R(phar) was measured using airway pressures and flow. Wakeful GG-EMG, early sleep TP-EMG and the sleep decrement in TP-EMG were directly related to P(crit). Muscle activation was negatively correlated with R(phar) for TP-EMG awake and GG-EMG early in sleep. In conclusion these results confirm that dilator muscle activation is directly related to airway narrowing and reduces resistance across patients with obstructive sleep apnoea.
Article
Full-text available
Based on a review of literature and consensus, the Portable Monitoring Task Force of the American Academy of Sleep Medicine (AASM) makes the following recommendations: unattended portable monitoring (PM) for the diagnosis of obstructive sleep apnea (OSA) should be performed only in conjunction with a comprehensive sleep evaluation. Clinical sleep evaluations using PM must be supervised by a practitioner with board certification in sleep medicine or an individual who fulfills the eligibility criteria for the sleep medicine certification examination. PM may be used as an alternative to polysomnography (PSG) for the diagnosis of OSA in patients with a high pretest probability of moderate to severe OSA. PM is not appropriate for the diagnosis of OSA in patients with significant comorbid medical conditions that may degrade the accuracy of PM. PM is not appropriate for the diagnostic evaluation of patients suspected of having comorbid sleep disorders. PM is not appropriate for general screening of asymptomatic populations. PM may be indicated for the diagnosis of OSA in patients for whom in-laboratory PSG is not possible by virtue of immobility, safety, or critical illness. PM may also be indicated to monitor the response to non-CPAP treatments for sleep apnea. At a minimum, PM must record airflow, respiratory effort, and blood oxygenation. The airflow, effort, and oximetric biosensors conventionally used for in-laboratory PSG should be used in PM. The Task Force recommends that PM testing be performed under the auspices of an AASM-accredited comprehensive sleep medicine program with written policies and procedures. An experienced sleep technologist/technician must apply the sensors or directly educate patients in sensor application. The PM device must allow for display of raw data with the capability of manual scoring or editing of automated scoring by a qualified sleep technician/technologist. A board certified sleep specialist, or an individual who fulfills the eligibility criteria for the sleep medicine certification examination, must review the raw data from PM using scoring criteria consistent with current published AASM standards. Under the conditions specified above, PM may be used for unattended studies in the patient's home. Afollow-up visit to review test results should be performed for all patients undergoing PM. Negative or technically inadequate PM tests in patients with a high pretest probability of moderate to severe OSA should prompt in-laboratory polysomnography.
Article
Background: The nose plays an important role in sleep quality. Very little is known about sleep problems in patients with chronic rhinosinusitis (CRS). The aim of this study was to investigate the impact of CRS on sleep-disordered breathing. Methodology: CRS patients who underwent functional endoscopic sinus surgery were collected between July 2010 and May 2015. Before surgery, they filled 20-item Sino-Nasal Outcome Test and Epworth Sleepiness Scale questionnaires, were asked about the severity of nasal obstruction, and received acoustic rhinometry, smell test, an endoscopic examination, sinus computed tomography, and a one-night polysomnography. Sleep quality was evaluated in these patients and was correlated with the severity of rhinosinusitis. Results: One hundred and thirty-nine CRS patients were enrolled in the study. Among them, 38.1% complained of daytime sleepiness, and this sleep problem was correlated with the symptom of nasal obstruction. Obstructive sleep apnea syndrome (OSAS) was diagnosed in 64.7% of the patients, but there was no correlation with the severity of rhinosinusitis. Nasal polyps did not worsen sleep problems in the CRS patients. Conclusions: This study showed that CRS patents had a high prevalence of OSAS, and worse OSAS in CRS patients was not correlated with the severity of rhinosinusitis.
Article
Background: Chronic rhinosinusitis (CRS) and asthma describe inflammation of the upper and lower airway, respectively. Not surprisingly, the prevalence of CRS and asthma has been linked, with up to 50% asthma prevalence in CRS with nasal polyposis (CRSwNP) patients. However, these prevalence rates do not address subtypes of CRSwNP including allergic fungal rhinosinusitis (AFRS). This study sets out to objectively determine asthma prevalence in CRS subtypes prospectively. Methods: A prospective prevalence study of adult CRS patients was conducted over a 1-year period at a tertiary care center. Patients were grouped into CRSwNP, CRS without nasal polyposis (CRSsNP), or AFRS. Patients were administered the Asthma Screening Questionnaire (ASQ) and asthma was confirmed by pulmonary function testing (PFT) if positive on the ASQ. Chi square analysis was performed to compare the asthma prevalence among the CRS subtypes. Results: A total of 410 patients (age 48.1 ± 16.4; 53.5% male) were included. Of these, 178 (43.4%) had CRSwNP, 166 (40.5%) had CRSsNP, and 66 (16.1%) met criteria for AFRS. Analysis revealed that 48.3% of CRSwNP patients, 16.5% of CRSsNP patients, and 23.6% of AFRS patients had asthma confirmed by PFTs. Chi square analysis showed a significant difference in asthma prevalence between CRSwNP and AFRS (p = 0.0016) and CRSwNP and CRSsNP (p = 0.0000), but no significant difference between CRSsNP and AFRS (p = 0.2380). Conclusion: There is a significant difference in the prevalence of asthma between CRSwNP and AFRS, suggesting a fundamental distinction in their etiologies despite similar immunologic profiles. Further efforts to delineate these biological disparities are underway.
Article
Obstructive sleep apnea leads to recurrent arousals from sleep, oxygen desaturations, daytime sleepiness and fatigue. This can have an adverse impact on quality of life. The aims of this study were to compare: (i) quality of life between the general population and untreated patients with obstructive sleep apnea; and (ii) changes of quality of life among patients with obstructive sleep apnea after 2 years of positive airway pressure treatment between adherent patients and non-users. Propensity score methodologies were used in order to minimize selection bias and strengthen causal inferences. The enrolled obstructive sleep apnea subjects (n = 822) were newly diagnosed with moderate to severe obstructive sleep apnea who were starting positive airway pressure treatment, and the general population subjects (n = 742) were randomly selected Icelanders. The Short Form 12 was used to measure quality of life. Untreated patients with obstructive sleep apnea had a worse quality of life when compared with the general population. This effect remained significant after using propensity scores to select samples, balanced with regard to age, body mass index, gender, smoking, diabetes, hypertension and cardiovascular disease. We did not find significant overall differences between full and non-users of positive airway pressure in improvement of quality of life from baseline to follow-up. However, there was a trend towards more improvement in physical quality of life for positive airway pressure-adherent patients, and the most obese subjects improved their physical quality of life more. The results suggest that co-morbidities of obstructive sleep apnea, such as obesity, insomnia and daytime sleepiness, have a great effect on life qualities and need to be taken into account and addressed with additional interventions. © 2014 European Sleep Research Society.
Article
ObjectivesSNOT-22 is a disease-specific outcomes measure questionnaire that combines rhinologic issues with general health issues. These issues may have variable weight on quality of life perception and the influence of several factors such as gender, ethnicity, age, socio-cultural status and comorbidities is unknown. The aim of this study was to evaluate the influence of gender and age on normal values of SNOT-22.DesignCross-sectional study based on application of SNOT-22 questionnaires to healthy volunteers. Participants were divided according to gender and each gender was subdivided into age groups: 18-30 years, 31-40 years, 41-50 years, 51-60 years and over 60 years.SettingRhinology Section, Sao Paulo Federal University.ParticipantsA total of 539 healthy volunteers (253 men and 286 women) were selected, so that each age group of each gender consisted of at least 50 individuals.Main Outcomes MeasuresWe applied SNOT-22 questionnaire to volunteers with no nasal or sinus disease. Median of score distribution was used as normal reference.ResultsMen presented lower scores than women (7 vs. 9, p=0.005). Subjects over 60 years presented significant lower scores than other age groups (18-30 years = 10; 31-40 years = 8; 41-50 years = 9; 51-60 years = 9; over 60 years = 7). Men presented lower scores than women especially in 41-50 years and 51-60 years groups.Conclusion Men and elderly presented the lowest Brazilian version SNOT-22 scores. The range of 0 to 8 points seemed to be more suitable as a normal value for this instrument, but this cut-off score could be tailored to age and gender specificities.This article is protected by copyright. All rights reserved.
Article
Patients with chronic rhinosinusitis (CRS) exhibit centrally mediated behavioral changes commonly referred to as "sickness behavior." Sleep alteration is a component of sickness behavior which is estimated to affect up to 70 million patients annually. Patients with CRS have poor sleep quality, and little is known about the underlying etiology and pathophysiology. This narrative review aims to further organize and present the current knowledge associating sleep and CRS. A literature search was conducted of the OVID MEDLINE database using key search words including: "chronic rhinosinusitis," "sleep," "sleep disorders," and "sleep dysfunction." Additional keywords "nasal obstruction," "nasal polyp," and "fatigue" were identified and used to further delineate relevant articles. The articles that specifically addressed sleep and CRS were dissected and presented as follows: (1) chronic rhinosinusitis and sleep; (2) chronic rhinosinusitis and fatigue; (3) chronic rhinosinusitis, nasal obstruction, and sleep; and (4) pathophysiology of sleep in chronic rhinosinusitis (cytokines in both sleep and chronic rhinosinusitis and their association to the neuroimmune biology of chronic rhinosinusitis). Patients with CRS have sleep dysfunction that is associated with their disease severity and overall quality of life. The etiology of sleep dysfunction in CRS is most likely multifactorial. Increasing evidence suggests sleep dysfunction in patients with CRS is partly due to the inflammatory disease process, and sleep physiology in patients with CRS may be actively regulated by the inflammatory component of the disease.
Article
SUMMARY Sleep-related breathing disturbances, especially obstructive sleep apnoea syndrome (OSAS), are commonly encountered. Epidemiological studies from different countries have shown that poor sleep and complaints about insufficient sleep or poor sleep are often related to poor health. Different studies are, however, difficult to compare with each other. One of the main reasons for this is the frequent methodological differences between questionnaires. There is a need for uniform methods: we need to know the prevalence and incidence of sleep disorders, judged using the same criteria, and also the severity of each problem, i.e. how often a problem or a symptom happens/occurs. In 1988 the Scandinavian Sleep Research Society formed a task group for developing a standardized questionnaire that could be used as a basis for questionnaires used in the Nordic countries. In this article we describe the Basic Nordic Sleep Questionnaire (BNSQ). The main change compared to many previous questionnaires is the five-point scale (scale from 1 to 5) stressing on how many nights/days per week something happens. The basic scale is: 1, ‘never or less than once per month’; 2, ‘less than once per week’; 3, ‘on 1–2 nights per week’; 4, ‘on 3–5 nights per week’; and 5, ‘every night or almost every night’. For questions about specific rare events the first category may be divided into ‘never’ and ‘less than once per month’. Habitually occurring events such as ‘habitual snoring’ are defined here as snoring every night or almost every night. The BNSQ has been used widely in a variety of studies performed in Nordic countries during the last years, and it has proven to be a valid tool.
Article
Visceral adipose tissue (VAT) is associated with abnormal cardiovascular and metabolic profiles. Total VAT volume of the abdominal compartment by magnetic resonance imaging (MRI) is the gold-standard measurement for VAT but is costly and time consuming. Prior studies suggest VAT area on a single slice MR image may serve as a surrogate for total VAT volume but it is unknown if this relationship is maintained in overweight and obese men and women. Untreated sleep apnea subjects enrolled into the Icelandic Sleep Apnea Cohort (ISAC) underwent abdominal MRI. VAT area and subcutaneous adipose tissue (SAT) area at the L2-L3 and L4-L5 interspaces and total VAT and SAT volumes were determined by manual examination using image analysis software; 539 men and 129 women with mean ages of 54.1 and 58.8 years and mean BMI of 32.2 kg/m(2) and 33.7 kg/m(2), respectively, were studied. Mean total VAT volume was 40% smaller and mean total SAT was 25% larger among females compared with males. The correlation with VAT volume was significantly larger for L2-L3 VAT area (r = 0.96) compared to L4-L5 VAT area (r = 0.83). The difference in correlation coefficients was statistically significant (nonparametric bootstrap P < 0.001 with 95% confidence interval (CI) for the difference from 0.11 to 0.15. VAT area at L2-L3 was also significantly better correlated with VAT volume than traditional anthropometric variables. Linear regression analyses demonstrated that L2-L3 area alone was sufficient for predicting total VAT volume and that the nature of the linear association was maintained across all levels of obesity and in both genders.
Article
Insomnia and obstructive sleep apnea (OSA) often coexist, but the nature of their relationship is unclear. The aims of this study were to compare the prevalence of initial and middle insomnia between OSA patients and controls from the general population as well as to study the influence of insomnia on sleepiness and quality of life in OSA patients. Two groups were compared, untreated OSA patients (n = 824) and controls ≥ 40 years from the general population in Iceland (n = 762). All subjects answered the same questionnaires on health and sleep and OSA patients underwent a sleep study. Altogether, 53% of controls were males compared to 81% of OSA patients. Difficulties maintaining sleep (DMS) were more common among men and women with OSA compared to the general population (52 versus 31% and 62 versus 31%, respectively, P < 0.0001). Difficulties initiating sleep (DIS) and DIS + DMS were more common among women with OSA compared to women without OSA. OSA patients with DMS were sleepier than patients without DMS (Epworth Sleepiness Scale: 12.2 versus 10.9, P < 0.001), while both DMS and DIS were related to lower quality of life in OSA patients as measured by the Short Form 12 (physical score 39 versus 42 and mental score 36 versus 41, P < 0.001). DIS and DMS were not related to OSA severity. Insomnia is common among OSA patients and has a negative influence on quality of life and sleepiness in this patient group. It is relevant to screen for insomnia among OSA patients and treat both conditions when they co-occur.
Article
The Berlin Questionnaire (BQ) is a widely used screening tool for obstructive sleep apnea (OSA), but its performance in the general population setting is unknown. The prevalence of OSA in middle-aged adults is not known in Norway. Accordingly, the aims of the current study were to evaluate the utility of the BQ for OSA screening in the general population and to estimate the prevalence of OSA in Norway. The study population consisted of 29,258 subjects (aged 30-65 years, 50% female) who received the BQ by mail. Of these, 16,302 (55.7%) responded. Five-hundred and eighteen subjects were included in the clinical sample and underwent in-hospital polysomnography. Screening properties and prevalence were estimated by a statistical model that adjusted for bias in the sampling procedure. Among the 16,302 respondents, 24.3% (95% confidence interval (CI)=23.6-25.0%) were classified by the BQ to be at high-risk of having OSA. Defining OSA as an apnea-hypopnea index (AHI) ≥5, the positive predictive value of the BQ was estimated to be 61.3%, the negative predictive value 66.2%, the sensitivity 37.2% and the specificity 84.0%. Estimated prevalences of OSA were 16% for AHI≥5 and 8% for AHI≥15. In conclusion, the BQ classified one out of four middle-aged Norwegians to be at high-risk of having OSA, but the screening properties of the BQ were suboptimal. The estimated prevalence of OSA was comparable to previous estimates from general populations in the USA, Australia and Europe.
Article
We set out to determine the psychometric validation of a disease-specific health related quality of life instrument for use in chronic rhinosinusitis, the 22 item Sinonasal Outcome Test (SNOT-22), a modification of a pre-existing instrument, the SNOT-20. The National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis was a prospective cohort study collecting data on 3128 adult patients undergoing sinonasal surgery in 87 NHS hospitals in England and Wales. Data were collected preoperatively and at 3 months after surgery, and analysed to determine validity of the SNOT-22. Test-retest reliability was assessed in a separate cohort of patients in a single centre. The SNOT-22, a derivative of the SNOT-20 was the main outcome measure. Patients were also asked to report whether they felt better, the same or worse following surgery. To evaluate the SNOT-22, the internal consistency, responsiveness, known group differences and validity were analysed. Preoperative SNOT-22 scores were completed by 2803 patients. 3-month postoperative SNOT-22 scores were available for 2284 patients of all patients who completed a preoperative form (81.5% response rate). The Cronbach's alpha scores for the SNOT-22 were 0.91 indicating high internal consistency. The test-retest reliability coefficient was 0.93, indicating high reliability of repeated measures. The SNOT-22 was able to discriminate between patients known to suffer with chronic rhinosinusitis and a group of healthy controls (P < 0.0001, t = 85.3). It was also able to identify statistically significant differences in sub-groups of patients with chronic rhinosinusitis. There was a statistically significant (P < 0.0001, t = 39.94) decrease in patient reported SNOT-22 scores at 3 months. At 3 months the overall effect size in all patients was 0.81, which is considered large. We found the minimally important difference that is the smallest change in SNOT-22 score that can be detected by a patient, to be 8.9 points. We have found the SNOT-22 to be valid and easy to use. It can be used to facilitate routine clinical practice to highlight the impact of chronic rhinosinusitis on the patient's quality of life, and may also be used to measure the outcome of surgical intervention. The minimally important difference allows us to interpret scores in a clinical context, and may help to improve patient selection for surgery.
Article
The effect of comorbid conditions such as asthma and atopy on the severity of chronic rhinosinusitis (CRS) and the presence of nasal polyps (NPs) remains an area of investigation. We sought to elucidate the relationship among these entities. The study population included 106 consecutive patients who were referred to a multidisciplinary, university-based allergy and sinus clinic that underwent computed tomography (CT) scan, skin-prick testing, and had CRS. Data were analyzed to determine Lund-MacKay score (LMS), presence of NPs, asthma status, and sensitivity to seven classes of aeroallergens. Skin tests were positive in 52 cases and negative in 54 cases. Although, there was no statistical relationship between LMS and atopic status in the entire group, among the asthmatic subgroup, mean LMS was greater in nonatopic asthmatic patients than in atopic asthmatic patients. Asthmatic patients had a higher LMS than nonasthmatic patients (p < 0.0001). Asthmatic patients were more likely than nonasthmatic patients to have NPs (57.6% versus 25%; p = 0.0015), regardless of atopic status. Mean LMS was higher in NP patients compared with nonpolyp patients (p < 0.0001), independent of atopic status. Mean LMS was not affected by sensitivity to any particular allergen, with the exception of cockroach-allergic patients who were more likely to have an LMS of >10 (p = 0.0236) and had more severe maxillary sinus involvement (p = 0.0391). These data indicate a strong relationship between CRS severity, as measured by LMS, and chronic airway inflammatory diseases, asthma, and NPs. The association between LMS and atopic status appears weak. The present study suggests that CRS is an inflammatory disease that occurs independently of systemic IgE-mediated pathways.
Article
1. To determine the afferent pathways mediating pharyngeal dilator muscle activation in response to negative airway pressure in man, we recorded genioglossus electromyogram (EMG) activity (via intra-oral bipolar surface electrodes) in response to 500 ms duration pressure stimuli of -15 and -25 cm H2O in normal, conscious, supine subjects relaxed at end-expiration; responses were compared before and after upper airway anaesthesia. 2. Six rectified and integrated EMG responses were bin averaged for pressure stimuli applied with the glottis open (GO) and closed (GC) and to the outside of the face only (controls). Response magnitude was quantified as the ratio of the EMG activity for an 80 ms post-stimulus period (before the subject's reaction time for tongue protrusion) to an 80 ms pre-stimulus period. 3. In eight subjects, upper airway anaesthesia reduced the EMG responses with GC to a level indistinguishable from controls. After anaesthesia, responses with GO remained higher than those with GC. 4. With GC, the mean EMG responses decreased by 43% after selective anaesthesia of the nasal mucosa (trigeminal nerves) in two subjects, 32% after selective anaesthesia of the laryngeal mucosa (superior laryngeal nerves) in six subjects and by 21% after selective anaesthesia of the oropharyngeal mucosa (glossopharyngeal and lingual nerves) in four subjects. 5. We conclude that upper airway afferents mediate pharyngeal dilator muscle activation in response to negative pressure with GC and that subglottal receptors caused the increased activation with GO. With GC, the trigeminal and superior laryngeal nerves mediate an important component of the responses with the glossopharyngeal nerves playing a less important role.
Article
We present our experience with short- and long-term beneficial results obtained from surgery of the nasal valve area in carefully selected patients with obstructive sleep apnea (OSA). In six cases reported here, surgical treatment resulted in subjective improvement in snoring and daytime somnolence. Objective improvement was noted in three patients who had nasal valve area obstruction. Although the role of surgery in patients with mild OSA needs further assessment, surgical correction of nasal valve area obstruction in patients with moderately severe to severe OSA appears clearly indicated.
Article
We investigated the influence of mouth opening on upper airway (UA) collapsibility in six healthy sleeping volunteers. UA collapsibility was measured during continuous negative airway pressure trials that consisted of the progressive decrease in pressure in a nasal mask, with simultaneous recording of esophageal pressure and instantaneous flow. Measurements were made under two experimental conditions: mouth closed (MC), and mouth open (MO). Cephalometric measurements were obtained with subjects awake in the same position for both experimental conditions. UA critical pressure (Pcrit) was derived from the relationship between the breath-by-breath values of the maximal inspiratory airflow and the corresponding mask pressure. Pcrit was significantly less negative during MO than during MC (MO, -12.7 +/- 4.8 cm H2O; MC, -16.4 +/- 6 cm H2O, mean +/- SD; p = 0.03). Mouth opening was associated with a significant increase in the total respiratory resistance (MO, 3.8 +/- 1.6 cm H2O/ml/s; MC, 3.0 +/- 1.6 cm H2O/ml/s-1, p = 0.03). Besides an increase in the distance between the teeth and a reduction in the distance between the hyoid bone and the mandible, no significant changes in cephalometric parameters were found between MO and MC. We conclude that mouth opening increases UA collapsibility during sleep and that mouth opening may contribute to the occurrence of sleep-related breathing abnormalities.
Article
The treatment of nasal polyps is controversial, and medical treatment alone has been little investigated to our knowledge. To examine the efficacy of therapy using only topical budesonide powder and topical budesonide powder supplemented with surgical removal or intramuscular betamethasone. Randomized, double-blind comparison of 2 dosages and additional treatment, if therapy failed. After 1 year, treatment with medication was stopped, and the demand for renewed treatment was monitored for another year. Patients with bilateral nasal polyps who demanded treatment were consecutively enrolled in a hospital outpatient clinic or specialty private practice. During a 15-month period from 1990 to 1992, a total of 126 patients entered the 2-year study. In phase 1, randomized and double-blind treatment with a topical medication, budesonide powder, 800 micrograms or 400 micrograms daily, or a placebo was given for 1 month. In phase 2, randomized and double-blind treatment with budesonide powder, 800 micrograms or 400 micrograms daily, was given. At the end of phase 1, failed therapy was supplemented by randomly assigned treatment of either surgical removal or a single injection of sustained released betamethasone. In phase 3, treatment with the medication was discontinued, and patients were monitored for another year. The time when treatment was required again was noted. The present article deals with phases 2 and 3. Patients' scores of treatment efficacy as well as symptoms and signs. Semiquantitative measurement of sense of smell and calculation of peak expiratory flow rate index based on nasal and oral peak expiratory flow. In all outcome measures, a comparison of the data before treatment with the corresponding figures during phase 2 showed statistically significant efficacy. The clinical course was described at the end of phase 2. About 85% of the patients, including those who received additional therapy because the initial therapy failed, rated total or substantial control over the symptoms. The 2 dosages investigated showed equal results. These findings were consistent with the signs recorded and the peak expiratory flow rate index. The results of phase 3 showed that 50% of patients had demanded treatment after 4 months, while 34% managed without medication after 1 year. The clinical course in this study showed that most patients with nasal polyps do well with medical treatment. Therefore, surgery was required in few patients. However, the potential of medical treatment should be further explored in future studies.
Article
Assessment of patient perception of disability and outcomes from treatment has become an integral part of medical care. General quality-of-life measurement tools have led to the development of disease-specific quality instruments. Conventional methods for evaluating nasal-sinus disease are inadequate to assess the impact of these disorders on everyday life. Therefore, using methods that are well established and validated for creating instruments, the Rhinosinusitis Disability Index was created to evaluate the self-perceived impact of disease-specific head and neck disorders. The development of the preliminary and final versions (30 items) of the Rhinosinusitis Disability Index is described. Content-related validity using Cronbach's α measurement and construct-related validity were accomplished. A comparison of the responses between patients with and without documented nasal or sinus disease was used to verify that the Rhinosinusitis Disability Index is a valid measuring instrument for patients with sinus disease, and test-retest validity reveals reliability over time. Arch Otolaryngol Head Neck Surg. 1997;123:1175-1179
Article
Although sleep apnea is common, it often goes undiagnosed in primary care encounters. To test the Berlin Questionnaire as a means of identifying patients with sleep apnea. Survey followed by portable, unattended sleep studies in a subset of patients. Five primary care sites in Cleveland, Ohio. 744 adults (of 1008 surveyed [74%]), of whom 100 underwent sleep studies. Survey items addressed the presence and frequency of snoring behavior, waketime sleepiness or fatigue, and history of obesity or hypertension. Patients with persistent and frequent symptoms in any two of these three domains were considered to be at high risk for sleep apnea. Portable sleep monitoring was conducted to measure the number of respiratory events per hour in bed (respiratory disturbance index [RDI]). Questions about symptoms demonstrated internal consistency (Cronbach correlations, 0.86 to 0.92). Of the 744 respondents, 279 (37.5%) were in a high-risk group that was defined a priori. For the 100 patients who underwent sleep studies, risk grouping was useful in prediction of the RDI. For example, being in the high-risk group predicted an RDI greater than 5 with a sensitivity of 0.86, a specificity of 0.77, a positive predictive value of 0.89, and a likelihood ratio of 3.79. The Berlin Questionnaire provides a means of identifying patients who are likely to have sleep apnea.
Article
A valid measure of rhinosinusitis health status and quality of life is required for the complete assessment of treatment effectiveness. The purpose of this study was to analyze the psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20), a disease-specific, health-related quality-of-life measure for rhinosinusitis. The SNOT-20 is a modification of the 31-Item Rhinosinusitis Outcome Measure, and it contains 20 nose, sinus, and general items. To complete the instrument, patients indicate how much they are affected in each area and identify the 5 most important items. The SNOT-20 was completed by 102, 72, and 46 patients at the initial visit and at 6 months and 1 year after treatment commencement, respectively. Cronbach's alpha was 0.9; test-retest scores were highly correlated (r = 0.9). Patients who were more affected had greater SNOT-20 scores (P < 0.002), and patients who had improved had greater change scores (P < 0.04). Items identified as important had greater scores (P < 0.0001) and showed greater change scores (P < 0.0002). The SNOT-20 is a valid outcome measure for patients with rhinosinusitis; it describes the health burden and is sensitive to clinical change.
Article
In this paper we review the problem of defining and estimating intrarater, interrater and test-retest reliability of continuous measurements. We argue that the usual notion of product-moment correlation is well adapted in a test-retest situation, whereas the concept of intraclass correlation should be used for intrarater and interrater reliability. The key difference between these two approaches is the treatment of systematic error, which is often due to a learning effect for test-retest data. We also consider the reliability of a sum and a difference of variables and illustrate the effects on components. Further, we compare these approaches of reliability with the concept of limits of agreement proposed by Bland and Altman (for evaluating the agreement between two methods of clinical measurements) and show how product-moment correlation is related to it. We then propose new kinds of limits of agreement which are related to intraclass correlation. A test battery to study the development of neuro-motor functions in children and adolescents illustrates our purpose throughout the paper.
Article
The oral and nasal contributions to inhaled ventilation were simultaneously quantified during sleep in 10 healthy subjects (5 men, 5 women) aged 43 +/- 5 yr, with normal nasal resistance (mean 2.0 +/- 0.3 cmH(2)O. l(-1). s(-1)) by use of a divided oral and nasal mask. Minute ventilation awake (5.9 +/- 0.3 l/min) was higher than that during sleep (5.2 +/- 0.3 l/min; P < 0.0001), but there was no significant difference in minute ventilation between different sleep stages (P = 0.44): stage 2 5.3 +/- 0.3, slow-wave 5.2 +/- 0.2, and rapid-eye-movement sleep 5.2 +/- 0.2 l/min. The oral fraction of inhaled ventilation during wakefulness (7.6 +/- 4%) was not significantly different from that during sleep (4.3 +/- 2%; mean difference 3.3%, 95% confidence interval -2.1-8.8%, P = 0.19), and no significant difference (P = 0.14) in oral fraction was observed between different sleep stages: stage two 5.1 +/- 2.8, slow-wave 4.2 +/- 1.8, rapid-eye-movement 3.1 +/- 1.7%. Thus the inhaled oral fraction in normal subjects is small and does not change significantly with sleep stage.
Article
To evaluate the impact of nasal surgery alone on quality of life (QOL) in patients with obstructive sleep apnea and nasal obstruction using generic and disease-specific QOL questionnaires. Prospective, longitudinal cohort study. Fifty-one consecutive patients with obstructive sleep apnea (50 men and 1 woman; mean age, 39 years; mean [SD] apnea-hypopnea index, 37.4 [28.9] events/h; and mean +/- SD body mass index [calculated as weight in kilograms divided by height in meters squared], 26.0 [3.5]) with symptoms of nasal obstruction due to a deviated nasal septum. Septomeatoplasty. Surgical outcomes were measured using the Snore Outcomes Survey, the Epworth Sleepiness Scale, and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) 3 months after surgery. We compared baseline and postoperative scores. Normative SF-36 data obtained from 4591 age- and sex-matched adults were used as references. Nasal obstruction symptoms significantly improved (mean [SD] visual analog scale score, -5.2 [1.4]; P < .001). Assessments also showed significant improvement in the Snore Outcomes Survey (P < .001) and Epworth Sleepiness Scale (P < .001) scores and 6 of the 8 SF-36 subscale scores (P < .05). Remarkable improvements were observed in disease-specific Snore Outcomes Survey (by 43.1%), Epworth Sleepiness Scale (by 27.3%), and generic SF-36 role-emotional (by 30.4%) and role-physical (by 20.7%) QOL subscales. The postoperative role-emotional, bodily pain, and social function dimensions of health were indistinguishable from referential population data (P > .05). Correction of an obstructed nasal airway significantly improves disease-specific and generic QOL in adult patients with obstructive sleep apnea who also have nasal obstruction symptoms. After nasal surgery, patients may experience greater improvement in snoring and daytime sleepiness than in other generic health status. Our findings substantiate the role of nasal surgery in treating patients with obstructive sleep apnea and nasal obstruction.
Johannis Freind Commentarii novem de febribus ad Hippocratis de Morbis popularibus libros primum et tertium accomodati
  • J Freind
  • R Frewin
Freind J, Frewin R. Johannis Freind Commentarii novem de febribus ad Hippocratis de Morbis popularibus libros primum et tertium accomodati. 1717;3-236.
Staging in rhinosinusitus
  • V J Lund
  • I S Mackay
Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology. 1993;31(4):183-4.