2018 Section 5 - Rhinology and Allergic Disorders

Otolaryngology–Head and Neck Surgery

Table 1. Characteristics of Studies Included in the Systematic Review and Meta-analysis.

Sleep Quality Instruments

MINORS Score a

Sample Size Follow-up, mo b

Study (Year)

Country

Study Type

DeConde (2014) 9

13.5 6 5.7

14 15 12 12 11 12 12

US US

Prospective Prospective

291 219

sdSNOT-22

Alt (2014) 12

6 6 3 6

PSQI

Rotenberg (2015) 13 Tosun (2009) 14 Gunhan (2011) 15 Yalamanchali (2014) 16 Benninger (2010) 17

Canada Prospective

53 27 29 56

PSQI, ESS ESS, AHI ESS, AHI

Turkey Turkey

Prospective Prospective

US US

Case series with chart review

12

AHI

12.7 6 2.4

Case series with chart review 113

sdRSDI

Abbreviations: AHI, Apnea-Hypopnea Index; ESS, Epworth Sleepiness Scale; MINORS, Methodological Index for Non-randomized Studies; PSQI, Pittsburgh Sleep Quality Index; sdRSDI, sleep domain of Rhinosinusitis Disability Index; sdSNOT-22, sleep domain of Sino-Nasal Outcome Test–22. a MINORS score ranges from 0 to 16. A value . 11 indicates low risk of bias. b Values are presented as mean 6 SD or as the stated follow-up period mentioned in the study.

Table 2. Methodological Quality of Included Studies by MINORS Criteria. a

Clearly Stated Aim

Inclusion of Consecutive Patients

Prospective Collection of Data

Endpoints Appropriate to Aim of Study

Unbiased Assessment of Study Endpoint

Appropriate Follow-up Period to Aim of Study

Loss to Follow-up \ 5%

Prospective Calculation of Study Size

Study (Year)

Score

DeConde (2014) 9

14 2 15 2 12 2 12 2 11 2 12 2 12 2

2 2 2 2 2 2 2

2 2 2 2 2 2 2

2 2 2 2 2 2 2

2 2 0 0 0 0 0

2 2 2 2 2 2 2

2 1 1 2 1 2 2

0 2 1 0 0 0 0

Alt (2014) 12

Rotenberg (2015) 13 Tosun (2009) 14 Gunhan (2011) 15 Yalamanchali (2014) 16 Benninger (2010) 17

Abbreviation: MINORS, Methodological Index for Non-randomized Studies. a MINORS score ranges from 0 to 16. A value . 11 indicates low risk of bias. All other items are scored 0 if not reported, 1 if reported but inadequate, and 2 if reported and adequate.

Apnea-Hypopnea Index Three studies 14-16 evaluated the change in AHI after surgery ( Table 3 ). Figure 4 shows a random effects meta-analysis for AHI. The SMD of the pooled result was –0.20 (dia- mond), which indicated a small improvement after surgery. The 95% CI ranged from a trivial (–0.07) to a small (–0.32) effect size. The I 2 of 95% was consistent with high hetero- geneity among studies. Notably, Yalamanchali et al 16 included only patients with obstructive sleep apnea (OSA), while Gunhan et al 15 specifically excluded them. Patient with nasal polyps were included in all 3 studies. Sleep Domain of Sino-Nasal Outcome Test–22 The sdSNOT-22 was utilized by multiple studies to evaluate sleep quality. 9-12,20,21,41-43 These studies had overlapping cohorts of patients from 4 academic tertiary care institutions (Oregon Health & Science University, Medical University of South Carolina, Stanford University, and University of Calgary). Among these studies, DeConde et al 9 was evalu- ated to have the highest MINORS score ( Tables 1 and 2 )

and was included in the final data set ( Figure 1 ). This study involved 291 patients who underwent endoscopic sinus surgery for CRS, as defined by the 2007 American Academy of Otolaryngology—Head and Neck Surgery Foundation’s adult sinusitis clinical guideline. 39 Patient comorbidities included asthma (33%), allergies (11.1%), depression (16.7%), and smoking (1.4%). Nasal polyps were present in about 39% of the study population. The average follow-up was 13.5 months (SD, 5.7 months). The sdSNOT- 22 improved by 5.7 (SD, 7.0), with a statistically significant P value \ .001. Other related studies involving this cohort supported the finding that the sdSNOT-22 significantly improved after endoscopic sinus surgery. Sleep Domain of Rhinosinusitis Disability Index Only 1 study measured sleep quality with the sdRSDI. 17 The study had a MINORS score of 12 and was a case series with chart review involving 113 adult patients with CRS. CRS was defined in this study by the 2003 Rhinosinusitis Task Force guideline. 40 Patient comorbidities included asthma (42.5%), smoking (9.7%), and allergies (38.1%).

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