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International consensus statement on rhinosinusitis

FIGURE I-2 A. Estimated prevalence of rhinosinusitis by phenotype (Boxes represent low, median, and high estimates based on best available evidence). B. Estimated prevalence of endotype (Types (T) 1, 2, and 3) within each phenotype and non-exhaustive list of associ ated endotypic biomarkers (T-helper (Th), Interferon (IF), Tumor Necrosis Factor (TNF), Interleukin (IL), Eosinophil Cationic Protein (ECP), P-glycoprotein (P-gp); adapted from Stevens et al., J Allergy Clin Immunol, 2019 61 )

review with meta-analysis. 69 Poor sleep quality is also a frequent complaint of patients with CRS and this impact has been the focus of recent investigations. The mean Pittsburgh Sleep Quality Index (PSQI) score in a multi institutional cohort of 268 patients with CRS was 9.4, with 75% reporting “poor” sleep based on accepted cut-offs. 70 In this group, PSQI scores significantly correlated with sinus specific QoL scores on both the Sino-Nasal Outcome Test 22 (SNOT-22) and Rhinosinusitis Disability Index (RSDI) instruments (r = 0.55 and r = 0.53 respectively). 71,72 Sim ilarly, a large population-based study in Europe found that sleep problems were 50% to 90% more common among subjects with CRS as compared with the general population. 73 The impact of CRS on cognitive function represents a more recent area of inquiry. A case-control study found that patients with CRS report significantly worse scores on the Cognitive Failures Questionnaire as compared with controls. 74 Several subsequent studies have found improvements in patient-reported and objective cogni tive function after both medical and surgical treatment of CRS. 75–77 Another prominent factor that impacts overall QoL and wellbeing in patients with CRS is the presence of depression. A systematic review found prevalence rates for depression in CRS ranging from 11% to 40%. 78–84 This fre quency of depression in CRS exceeds population norms of between 5% and 10% with a recent population study from Asia estimating an adjusted hazard ratio of 1.56 (95% CI, 1.43-1.70). 85,86

evidence that differentiating type 2 vs non-type 2 endo types is clinically meaningful, as type 2 immune reactions are associated with asthma, 49 an increased risk of recur rence after surgery, 55 and are the basis for the use of inno vative type 2 biologics. 56–60 As work in this field evolves, it is likely that future evidence-based recommendation state ments will increasingly utilize endotypic classifications of disease. I.C.3 Individual Burden of Disease By definition, patients with CRS will suffer with some combination of cardinal sinonasal symptoms. However CRS can also have profound effects on functional well being and general health-related quality of life (QoL). Using transformations of the Short Form 6D instru ment (SF-6D), health states of 230 patients with CRS were found to average 0.65 (0 = death, 1 = per fect health), a valuation that was worse than conges tive heart failure, chronic obstructive pulmonary disor der, and Parkinson’s disease. 62 Similar studies have val idated these findings using the Short-Form 36 (SF-36) and Euroqol 5 Dimension (EQD-5) questionnaires. 63–65 Interestingly, it is often the extra-sinus manifestations which drive overall health-state utility scores and patient decision-making. 65,66,67,68 Severe fatigue is commonly reported by patients with CRS. The baseline median prevalence of fatigue was 54%, ranging from 11% to 73% across studies in a systematic