xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

269

Orlandi et al.

are often the drivers of overall health-state utility scores and patient decision-making. 65,66,67,68 Severe fatigue is commonly reported by patients with CRS. A systematic review with meta-analysis, including data on 3427 patients from 28 studies, examined fatigue in patients with CRS. 69 The baseline median prevalence of fatigue was 54%, ranging from 11% to 73% across stud ies. Another systemic review with meta-analysis exam ined bodily pain in 11 studies with 1019 patients. 249 Using primarily the SF-36 instrument, pooled mean bodily pain scores were 0.89 standard deviations below national or local population norms ( p < 0.001), exceeding bodily pain scores reported in patient populations aged 25 years older. Both fatigue and bodily pain were shown to significantly improve after sinus surgery, with combined effects sizes of 0.77 (95% CI, 0.59-0.95) for fatigue and 0.55 (95% CI, 0.45 0.64) for bodily pain. Poor sleep quality is a frequent complaint of patients with CRS and this impact has been the focus of recent investigations. Using the PSQI, subjective sleep quality was assessed in a multi-institutional cohort of 268 patients with CRS. 70 The PSQI is a self-reported questionnaire (range: 0-21 with higher scores indicating worse sleep) measuring sleep quality and disturbance over the preceding 1-month period. The mean PSQI score in this group was 9.4, with 75% reporting “poor” sleep based on accepted cut-offs (ie, abnormal is > 5). In this group, PSQI scores significantly correlated with sinus-specific QoL scores on both the SNOT-22 and RSDI instruments (r = 0.55 and r = 0.53 respectively). 71,72 Similarly, 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 A recent multi-institutional, case control study explored objective sleep changes, finding that patients with CRS have increased number of awaken ings during a night’s sleep, increased rapid eye movement sleep latency, and spent a greater portion of the night snor ing at > 40 dB. 250 Potential mechanisms of sleep dysfunc tion in CRS include alterations in nasal airflow and direct effects of antisomnogenic cytokines, but these hypotheses remain speculative and further research is required to understand the association between CRS and sleep. 251 The impact of CRS on cognitive function is a newer area of inquiry. A case-control study found that patients with CRS report significantly worse scores on the Cogni tive Failures Questionnaire as compared with controls. 74 Additionally, CRS patients had worse simple reaction time scores compared to controls on computerized neurocogni tive testing, a difference that persisted regardless of polyp status. Since this initial report, several 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 increased preva lence of depression. A systematic review found prevalence rates for depression in CRS ranging from 11% to 40%. 78–84 This wide range likely reflects differences in patient pop ulations and the diagnostic accuracy for depression (ie, patient-report, physician diagnosis, validated question naire). Regardless, the frequency of depression in patients with CRS is above 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 The comorbid presence of depression is associated with worse sinus-specific and general QoL compared to CRS patients who are not depressed. 80,81,83 Not surprisingly, those CRS patients with depression have higher healthcare utiliza tion, including increased antibiotic usage and physician visits, as well as more missed workdays than CRS patients without this comorbidity. 82,252 A number of studies have examined the impact of depression on outcomes after sinus surgery. 78,80,81,83 Universally, patients with comor bid depression and CRS have worse sinus-specific QoL at both baseline and postoperative time points compared to those without depression even after controlling for other factors. Importantly, however, patients with depression do appear to have a similar degree of overall improvement after surgery compared to those without depression. Fur ther studies are required to understand whether depres sion is simply a common comorbid disease or whether the presence of CRS contributes to depression. VI.C Disease Measurement In both clinical practice and research, CRS is frequently characterized with clinical evaluation and patient based assessment, including endoscopic examinations, radio logic studies, and patient-reported, disease-specific QoL assessments (Table VI-1). These data are integrated to establish the diagnosis of CRS, guide intervention, and assess treatment outcomes. Interestingly, objective endo scopic and radiographic findings have not been shown to correlate strongly with subjective, patient-reported out comes. Rather than a weakness of these measures, it more reflects that different aspects of the disease are being measured. In the assessment and treatment of CRS, it is important to quantify both objective findings and how the patient’s QoL is affected. A hallmark of both diagnosis and post-treatment disease monitoring in CRS is the endoscopic examination. Multi ple grading systems such as the Lund Kennedy, modifica tions thereof, the Perioperative Sinus Endoscopy (POSE), and the Davos nasal polyp score have been created in an attempt to standardize results of this examination. 253–257