The epidemiology and experience of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a common and debilitating disorder. There is a deficit of knowledge about the epidemiology of CRS or the experience of sufferers. The aims of the study were to identify differences in socio-economic variables and quality of life between patients with chronic rhinosinusitis and healthy controls, to identify any significant associations between CRS and other medical co-morbidities, psychiatric disease or environmental exposures and to explore the experience of CRS from the perspective of CRS sufferers. This study consisted of a self-reported questionnaire distributed from 30 ENT clinics across the UK, and qualitative interviews with 21 patients with CRS. Additional studies were undertaken to support this work including further qualitative interviews with patients who have disturbed olfaction, and studies to assess new or unproven treatment regimens including a feasibility study for Clarithromycin for CRS and a trial of sodium citrate for hyposmia. No clear differences in socioeconomic variables were identified between cases and controls. CRS was found to be strongly associated with asthma and inhaled allergies as well as significantly impairing quality of life. Quality of life issues were very important to sufferers, and had been poorly addressed, particularly with regards to sense of smell. Further research is needed to better understand and manage CRS although better adherence to current guidelines would improve care in the interim

An unmet need:Patients with smell and taste disorders

Objectives: There are large numbers of patients with olfactory disturbance in the UK and shortfalls in assessment and support amongst mainstream practice in both primary and secondary care leading to significant quality-of-life impairment and potential missed diagnoses. The aim of this study was to determine the key themes which can be identified from the accounts of anosmia sufferers and to identify important areas to target for future research or service development. Design: Qualitative analysis of written patient accounts from patients corresponding with a tertiary smell and taste clinic in the UK. This qualitative study utilised unstructured written patient accounts from consenting patients experiencing olfactory disturbances received by the smell and taste clinic. Framework analysis was performed using Nvivo 10 software. Setting: Tertiary smell and taste clinic. Participants: Consenting patients who contacted the smell and taste clinic with accounts of their experiences. Main outcome measures: Themes generated by qualitative analysis with Nvivo software. Results: Accounts submitted by 71 participants were included in the analysis; age range 31-80 years, 45 females, 26 males. Themes identified include negative emotional impact, feelings of isolation, impaired relationships and daily functioning, impact on physical health and the difficulty and financial burden of seeking help. Conclusions: Olfactory disturbances have a wide-ranging impact on the lives of sufferers, compounded by a lack of knowledge of the disorder amongst clinicians. There is a role for further support and education both for sufferers and for clinicians, as well as a need to improve our understanding of olfactory disturbance

A case-control study of medical, psychological and socio-economic factors influencing the severity of chronic rhinosinusitis

BACKGROUND: Chronic rhinosinusitis (CRS) is a common and debilitating disorder. Little is known about the epidemiology of this disease. The aims of the study were to identify differences in socio-economic variables and quality of life between patients with chronic rhinosinusitis and healthy controls, to identify any significant associations between CRS and other medical co-morbidities, psychiatric disease or environmental exposure and to explore the experience of CRS from the perspective of CRS sufferers. METHODS: Participants were recruited from ENT clinics from 30 centres across the UK. They completed a study-specific questionnaire considering environmental, medical and socio-economic factors, and SF-36 and SNOT-22 scores. All participants with CRS were diagnosed by a clinician and categorised as having CRS (with polyposis, without polyposis or allergic fungal rhinosinusitis (AFRS)). Controls included family and friends of those attending ENT outpatient clinics and hospital staff who had no diagnosis of nose or sinus problems and had not been admitted to hospital in the previous 12 months. RESULTS: A total of 1470 study participants (1249 patients and 221 controls) were included in the final analysis. Highly significant differences were seen in generic and disease-specific quality of life scores between CRS sufferers and controls; mean SNOT-22 score 45.0 for CRS compared with 12.1 amongst controls. There were no clear differences in socioeconomic variables including social class, index of multiple deprivation and educational attainment between cases and controls. Common comorbidities with a clear association included respiratory and psychiatric disorders, with a higher frequency of reported upper respiratory tract infections. CONCLUSIONS: CRS is associated with significant impairment in quality of life and with certain medical co-morbidities. In contrast to other common ENT disorders, no socioeconomic differences were found between patients and controls in this study

Eustachian tube symptoms are frequent in chronic rhinosinusitis and respond well to endoscopic sinus surgery

BACKGROUND: Symptoms of Eustachian tube (ET) dysfunction are seldom assessed in patients with chronic rhinosinusitis (CRS). The Sino-Nasal Outcome Test (SNOT-22) quality-of-life tool includes two questions that specifically screen for symptoms of ET dysfunction (Ear Fullness; Ear Pain). OBJECTIVE: The purpose of this study was to determine the extent to which these ET symptoms were present in patients with CRS, and whether these symptoms respond to endoscopic sinus surgery (ESS). METHODOLOGY: SNOT-22 data collected prospectively at time of recruitment into IRB-approved clinical trials or case-control studies in CRS was pooled to provide a cross section of the frequency and severity of ET dysfunction. When applicable to the trials, the SNOT-22 was repeated at least 3 months following ESS. RESULTS: Five trials rendering 131 patients were available for assessment. The control group comprised of 251 participants from two case-control studies. Ear Fullness of equal/greather than 1 was reported in 80/131 CRS patients compared to 45/251 control patients. Ear Pain of equal/greather than 1 was reported in 39/131 CRS patients compared to 33/251 control patients. Following ESS, mean Ear Fullness and Ear Pain scores decreased to 1.17 and 0.73, respectively. CONCLUSION: Symptoms suggestive of ET dysfunction are frequent in CRS, and for most patients the symptoms will decrease post-ESS to a level comparable with a non-CRS population. Patients whose ET symptoms do not respond to ESS may represent a target population for emerging therapeutic options for ET dysfunction

The Burden of Revision Sinonasal Surgery in the UK – Data from the Chronic Rhinosinusitis Epidemiology Study (CRES); a cross sectional study

Objectives/Hypothesis The aim of this study was to investigate the surgical revision rate in patients with Chronic Rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from national Sinonasal Audit showed that 1459 CRS patients demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%). Setting Thirty secondary care centres around the UK. Participants A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS). Interventions Self-administered questionnaire. Primary outcome measure The need for previous sinonasal surgery. Results A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) of patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2 to 30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0-74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS) (n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS and of those only 30% reported multiple procedures (chi-squared p < 0.001). Conclusions This study demonstrated there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit

Socioeconomic deprivation, urban-rural location and alcohol-related mortality in England and Wales

Background: Many causes of death are directly attributable to the toxic effects of alcohol and deaths from these causes are increasing in the United Kingdom. The aim of this study was to investigate variation in alcohol-related mortality in relation to socioeconomic deprivation, urban-rural location and age within a national context. Methods: An ecological study design was used with data from 8797 standard table wards in England and Wales. The methodology included using the Carstairs Index as a measure of socioeconomic deprivation at the small-area level and the national harmonised classification system for urban and rural areas in England and Wales. Alcohol-related mortality was defined using the National Statistics definition, devised for tracking national trends in alcohol-related deaths. Deaths from liver cirrhosis accounted for 85% of all deaths included in this definition. Deaths from 1999-2003 were examined and 2001 census ward population estimates were used as the denominators. Results: The analysis was based on 28,839 deaths. Alcohol-related mortality rates were higher in men and increased with increasing age, generally reaching peak levels in middle-aged adults. The 45-64 year age group contained a quarter of the total population but accounted for half of all alcohol-related deaths. There was a clear association between alcohol-related mortality and socioeconomic deprivation, with progressively higher rates in more deprived areas. The strength of the association varied with age. Greatest relative inequalities were seen amongst people aged 25-44 years, with relative risks of 4.73 (95% CI 4.00 to 5.59) and 4.24 (95% CI 3.50 to 5.13) for men and women respectively in the most relative to the least deprived quintiles. People living in urban areas experienced higher alcohol-related mortality relative to those living in rural areas, with differences remaining after adjustment for socioeconomic deprivation. Adjusted relative risks for urban relative to rural areas were 1.35 (95% CI 1.20 to 1.52) and 1.13 (95% CI 1.01 to 1.25) for men and women respectively. Conclusions: Large inequalities in alcohol-related mortality exist between sub-groups of the population in England and Wales. These should be considered when designing public health policies to reduce alcohol-related harm

Exploring the association between ingestion of foods with higher potential salicylate content and symptom exacerbation in chronic rhinosinusitis:Data from the National Chronic Rhinosinusitis Epidemiology Study

INTRODUCTION: Pharmacological salicylates are known to trigger respiratory exacerbations in patients with Non-Steroidal Exacerbated Respiratory Disease (N-ERD), a specific phenotype of Chronic Rhinosinusitis (CRS) and asthma. The impact of dietary sources of salicylates across subgroups of CRS is not well understood. The hypothesis is that in patients with nasal polyps present, there is likely to be a higher incidence of symptom exacerbation due to dietary salicylates regardless of any known response to pharmacological salicylate. METHODS: The Chronic Rhinosinusitis Epidemiology Study (CRES) was a questionnaire-based case-control study which sought to characterise the UK CRS population in terms of sociological, economic and medical factors. Using specific questions to examine participant responses relating to symptom exacerbation from food groups thought to be high in salicylate content, this analysis of the CRES database sought to compare an estimate of the prevalence of dietary sensitivity due to food with higher potential salicylate content across patients with CRS with (CRSwNPs) and without nasal polyposis (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS). RESULTS: The CRSwNPs group were significantly more likely than controls to report symptom exacerbation due to ingestion of food groups with higher potential dietary salicylate content. The same trend was observed amongst CRSsNPs participants to a lesser degree. Reported response to the individual specific food groups wine, nuts, spicy foods, fruit and vegetables demonstrated that a statistically significant proportion of CRSwNPs and AFRS participants reported sensitivity to wine. CONCLUSIONS: This analysis suggests that there is an association between symptom exacerbation in response to food products with higher potential salicylate content, specifically wine, in CRS patients both with and without nasal polyposis when compared to controls, but especially in the CRSwNPs and AFRS phenotypes. Further studies are needed to detail if this relationship represents a causal relationship to dietary salicylate. The data present the possibility that a wider group of CRS patients may elicit salicylate sensitivity than those with known N-ERD

Evaluation of smoking as a modifying factor in chronic rhinosinusitis

Importance: The negative association of smoking with the respiratory tract is well known; however, the association between smoking and chronic rhinosinusitis (CRS) has not been well characterized. Objective: To analyze whether active smoking was a risk factor for CRS development, smoking was associated with disease-specific quality of life, and smokers experience an increased symptom burden than nonsmokers.  Design, Setting, and Participants: This subanalysis of the Chronic Rhinosinusitis Epidemiology Study (CRES), a prospective, questionnaire-based case-control study conducted between October 2007 and September 2013 was conducted across 30 UK tertiary/secondary care sites. Participants were identified at ear, nose, and throat outpatient clinics and classified into CRS phenotypes as per European Position Paper on Rhinosinusitis and Nasal Polyps 2012 criteria. The overall response rate of those identified to take part in the study was 66%. A total of 1535 questionnaires were returned, with 1470 considered eligible for inclusion. Data analysis was conducted in January 2020.  Main Outcomes and Measures: The CRES was designed to distinguish differences in socioeconomic status, geography, medical comorbidities, lifestyle, and quality of life between patients with CRS and healthy controls.  Results: A total of 1450 patients completed the smoking question, comprising 219 controls (15.1%; mean [SD] age, 47.3 [14.9] years; 143 women [68%]), 546 participants with CRS (37.7%; mean [SD] age, 51.8 [15.3] years; 259 women [53%]) without nasal polyps (CRSsNPs), and 685 participants (47.2%; mean [SD] age, 56.0 [14.5] years; 204 women [33%]) with CRS and nasal polyps/allergic fungal rhinosinusitis (CRSwNPs+). The mean age was similar, with a greater female preponderance in the control group and male in the CRSwNP group. The greatest number of active smokers was found among control participants (33 [15%]), with a lower rate of smokers in the patients with CRSwNPs+ (9.9%) and CRSsNPs (13.9%), respectively. We found a clinically significant difference in the mean difference in Sino-nasal Outcome Test (SNOT-22) scores between active smokers and nonsmokers for both CRS phenotypes (4.49, 12.25). In both CRS subgroups active smokers had significantly worse SNOT-22 scores than nonsmokers by a mean (SD) magnitude of 10 (18.99, 24.14) points. Nonsmokers also demonstrated a higher percentage of surgical procedures (1 or more), although this was not clinically or statistically different (0.34, 1.10).  Conclusions and Relevance: This questionnaire-based case-control study demonstrated a clinically significant symptom burden associated with active cigarette smoking, with worse SNOT-22 scores in the smoking cohort by a mean magnitude of 10 points. We could find no demonstrable evidence that smoking increases the likelihood of need for revision sinus surgery. Clinicians should encourage smoking cessation alongside general CRS medical management

Socioeconomic, comorbidity, lifestyle, and quality of life comparisons between chronic rhinosinusitis phenotypes

Background: Chronic rhinosinusitis (CRS) is a heterogeneous group of inflammatory sinonasal disorders with key defining symptoms, but traditionally separated into phenotypes by clinical/endoscopic findings. It is not known whether the two phenotypes have differing socioeconomic, comorbidity, and lifestyle differences. This analysis of the Chronic Rhinosinusitis Epidemiology Study (CRES) database sought to analyze any key differences in the socioeconomic variables between those with CRS with nasal polyps (CRSwNPs) and those without nasal polyps (CRSsNPs). We also sought to analyze differences in comorbidities, lifestyle, and quality of life. Methods: Patients with a confirmed diagnosis of CRS in secondary and tertiary care outpatient settings in the UK were invited to participate in a questionnaire-based case–control study. Variables included demographics, socioeconomic factors, comorbidities, lifestyle factors, and health-related quality of life (HRQoL) (level 3 evidence). Results: A total of 1204 patients' data were analyzed: 553 CRSsNP and 651 CRSwNP participants. The key socioeconomic variables did not demonstrate any notable differences, nor did lifestyle variables other than alcohol consumption being higher in those with CRSwNP (P = .032), but the latter was not significant after adjusting for age and sex. Aside from confirmation of asthma being more common in CRSwNP, it was notable that this group complained less of upper respiratory tract infections (URTIs), and CRSsNP participants showed evidence of worse HRQoL scores in respect of body pain (P = .001). Conclusions: Patients with CRSwNP experience higher rates of asthma and lower rates of URTIs; patients with CRSsNP have worse body pain scores. Otherwise, there are no demonstrable significant socioeconomic, comorbidity, lifestyle, or quality of life differences between the two phenotypes