ORIGINAL ARTICLE

Quality of life improvement from sinus surgery in chronic rhinosinusitis patients with asthma and nasal polyps Zi Zhang, MD, MSCE1 , Nithin D. Adappa, MD2 , Laurel J. Doghramji, RN, BSN2 , Alexander G. Chiu, MD3 , Ebbing Lautenbach, MD, MPH, MSCE1,4 , Noam A. Cohen, MD, PhD2,5 and James N. Palmer, MD2

Background: It is unclear whether chronic rhinosinusitis (CRS) patients with both nasal polyps and asthma have different quality of life (QOL) improvement aer functional endoscopic sinus surgery (FESS). We aimed to determine whether CRS patients with asthma and nasal polyps had a greater QOL improvement aer FESS compared to patients without asthma or polyps. Methods: This retrospective analysis included adult CRS patients who underwent FESS between 2007 and 2011. QOL was measured using the 22-item Sino-Nasal Outcome Test (SNOT-22). Variables collected included baseline demographics, clinical factors, SNOT-22 scores before FESS, and 1 month, 3 months, and 6 months post-FESS. Groups tested were asthma alone, polyps alone, asthma and polyps, and no asthma or polyps. Linear mixed-effects regression model was performed to calculate β-coefficients, which represent the adjusted mean QOL differences. Results: Among the 376 patients included, 40.16% had both asthma and polyps (n = 151), 14.36% had asthma alone (n = 54), 19.45% had polyps alone (n = 75), and 25.53% had no asthma or polyps (n = 96). Aer adjusting for all factors, there were significantly more QOL improvements

in patients with both asthma and nasal polyps from baseline to 1-month (β-coefficient = −10.05; 95% CI, −15.86 to −4.23; p = 0.001) and 3-month follow-up (β-coefficient = −8.27; 95% CI, −14.98 to −1.56; p = 0.016), and patients with asthma alone from baseline to 6-month follow-up (β-coefficient = −8.78; 95% CI, −17.45 to −0.11; p = 0.047), when compared to patients without asthma or nasal polyps. Conclusion: CRS patients with both asthma and nasal polyps or asthma alone experience a larger QOL benefit from FESS immediately aer FESS compared to CRS paC 2014 ARS-AAOA, LLC. tients without asthma or polyps. 

Key Words: chronic rhinosinusitis; quality of life; asthma; nasal polyps; functional endoscopic sinus surgery How to Cite this Article: Zhang Z, Adappa ND, Doghramji LJ, et al. Quality of life improvement from sinus surgery in chronic rhinosinusitis patients with asthma and nasal polyps. Int Forum Allergy Rhinol. 2014;4:885–892.

C 1 Department

of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, U.S.A; 2 Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, U.S.A; 3 Department of Surgery, University of Arizona, Tucson, AZ, U.S.A; 4 Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, U.S.A; 5 Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, U.S.A Correspondence to: Zi Zhang, MD, MSCE, 8th Floor, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail: [email protected] Funding sources for the study: National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (K24 AI080942/AI/NIAID NIH HHS/United States to E.L.). Potential conflict of interest: E.L. received research grant support from Merck, AstraZeneca, and 3M. Received: 15 April 2014; Revised: 29 June 2014; Accepted: 10 July 2014

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hronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses, either accompanied by nasal polyps (CRSwNP) or without nasal polyps (CRSsNP). The National Center for Health Statistics has described the increasingly expensive health care burden that CRS inflicts in the United States. Patients with CRS visit primary care clinicians twice as often as those without the disorder and have 5 times as many prescriptions filled.[1] Current understanding of the pathogenesis of CRS is limited, but CRS has been recognized as a multifactorial disease with many components. CRS is accompanied by nasal polyps (NP) in about 19% to 36% of patients.2, 3 In addition, CRS is frequently associated with lower airway asthma.4–6 Studies have shown

DOI: 10.1002/alr.21406 View this article online at wileyonlinelibrary.com.

Zhang et al.

that patients with NP alone, asthma alone, or aspirin triad can benefit from functional endoscopic sinus surgery (FESS) using various measures.3, 7, 8 However, CRS is a multifactorial disease and CRS patients are often presented with a few risk factors at the same time. It remains unclear whether patients with asthma and NP, asthma alone, NP alone, and no asthma or NP can benefit differently from FESS. Recently, the use of patient-reported outcome measures is rapidly growing in studies of clinical effectiveness, and CRS has been shown to have significant impact on quality of life (QOL).9 It has been reported that, at a cohort level, there were no significant differences in changes of mean QOL scores between 6-month, 12-month, and 20-month postoperative follow-up, and thus the 6-month time frame has been recommended as an appropriate primary endpoint for studies using QOL outcomes for FESS.10 In clinical practice, CRS patients are followed up more frequently immediately after FESS and clinical visits are routinely scheduled at 1 month, 3 months, and 6 months post-FESS. However, it remains unclear how patients’ QOL changes at these postoperative follow-up time points, especially patients with both asthma and NP vs patients without asthma or NP. Understanding the relationships between patient disease characteristics and FESS outcomes at postoperative follow-up time points is important for patient-physician communication to help the patients set up appropriate expectations for their postoperative recovery and outcomes of FESS. Thus, the aim of our study was to assess whether patients with asthma and NP, asthma alone, and NP alone, had different QOL improvement after FESS for CRS as compared to patients without asthma or NP.

Patients and methods Study population This was a retrospective cohort study. Adult CRS patients (18 years or older) who underwent FESS between October 1, 2007 and December 31, 2011 at the Division of Rhinology of the Department of Otorhinolaryngology–Head and Neck Surgery at the University of Pennsylvania were included in the analysis. CRS was diagnosed based on the objective and subjective guidelines set forth by the Sinus and Allergy Health Partnership11 and only patients with preoperative QOL measures were included in the study. Patients with cystic fibrosis; congenital or acquired immunodeficiency; congenital mucociliary, noninvasive fungal balls and invasive fungal disease; systemic vasculitis and granulomatous diseases; cocaine abuse; or neoplasia were excluded.12, 13 Approval was obtained by the Institutional Review Board of the University of Pennsylvania to recruit patients to this cohort. FESS is recommended to patients who failed the maximum medical therapy. Because many patients are referred to our institute for FESS after failing maximum medical therapy elsewhere, we did not have a standard way to collect the patients’ maximum courses of medical therapy. However, the medications administered

in the month prior to FESS were collected and evaluated as potential confounders in our analysis.

Collection of QOL The patients’ QOL before FESS, 1 month, 3 months, and 6 months after FESS was measured using a disease-specific health-related QOL instrument: the Sino-Nasal Outcome Test (SNOT-22).14 The SNOT-22 is a disease-specific health-related QOL instrument that is widely used in CRS. Patients rated 22 different symptoms related to both nasal and general health on a score of 0 (no problem) to 5 (problem is as bad as it can be), thus giving a total score of 0 to 110. Higher scores represent worse QOL. Clinically significant change of SNOT-22 score was defined as a difference of at least 0.5 standard deviations (SDs) of the baseline SNOT-22 score in the reference group,15, 16 which is the group of patients without asthma and NP in our study.

Asthma, NP, and other variables We reviewed the patients’ medical records to determine if they had asthma and NP. Then, the CRS patients were put into 4 asthma and NP groups: patients with asthma and NP, patients with asthma alone, patients with NP alone, and patients without asthma and NP. The control group was CRS without asthma and NP and the other 3 groups were compared to the control group for the analysis. In addition, patients’ age, gender, race, allergic rhinitis, obstructive sleep apnea, diabetes, smoking status, gastroesophageal reflux disease (GERD), Samter’s triad, and prior FESS history were also collected from the patients’ medical records. Administered oral antibiotics, nasal steroids, and oral steroids in the month prior to sample collection were also recorded.

Statistical analysis The primary aim of the statistical analysis was to determine whether the changes of SNOT-22 scores differed over time among patients with asthma and NP, asthma alone, NP alone, and no asthma or NP. First, we compared continuous variables using 1-way analysis of variance (ANOVA) tests and we used Pearson’s χ 2 test to compare categorical variables. We then summarized the means of SNOT-22 scores before FESS, 1 month, 3 months, and 6 months after FESS in CRS patients by asthma and NP groups, and then summarized the changes of SNOT-22 scores from preFESS to 1-month, 3-month, and 6-month post-FESS visits in CRS patients by asthma and NP groups. Finally, we conducted our adjusted analysis using the mixed-effects regression model, with fixed effects for time modeled as a categorical variable, asthma and NP groups, and an interaction between time and asthma and NP groups. This allowed the effects of asthma and NP on the changes of SNOT-22 scores to vary over time. The model also included random effects for patient to account for the correlation between repeated SNOT-22 score measures per patient. If a SNOT-22 score was missing at a certain time point, the rest of the scores from that same patient were still included in the model. To adjust for the effects of other clinical factors in the model,

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all the collected clinical factors were first included in the model and then a manual backward elimination was performed. Variables with p < 0.05 in the model, and potential confounders that can change the point estimate of primary association by 15%, were retained in the final model. The adjusted results from the linear mixed effects regression model were presented as coefficients and 95% confidence intervals (95% CIs). A value of p < .05 was considered statistically significant. Statistical analyses were conducted using STATA 11 (Stata Corp, College Station, TX).

Results Our study included 376 patients with completed pre-FESS SNOT-22 scores who met the inclusion criteria, and this was approximately 55% of all patients who underwent FESS for CRS at this time period in our institute. We compared the characteristics of patients included vs not included and there were no significant differences in patients’ characteristics collected in our study. Among those included, 40.16% had both asthma and NP (n = 151), 14.36% had asthma alone (n = 54), 19.45% had NP alone (n = 75), and 25.53% had no asthma or NP (n = 96). As shown in Table 1, the mean ± SD age of this overall study population was 48.43 ± 13.34 years old; 57.49% were male (n = 215); 89.43% were white (n = 330); and 7.86% were black (n = 29). The clinically significant change of SNOT-22 score was defined as difference of at least 0.5 SD of the baseline SNOT-22 score in patients without asthma and NP16, 17 ; ie, 10.6. The prevalence of allergic rhinitis and Samter’s triad were significantly higher in CRS patients with asthma and NP compared to patients without asthma and NP. CRS patients with asthma and NP also had significantly worse SNOT-22 scores and Lund-Mackay CT scores compared to patients without asthma and NP. In addition, CRS patients with asthma and NP were also significantly more likely to use preoperative nasal rinse, steroids, and have prior FESS compared to patients without asthma and NP. There were no significant differences between the 4 asthma and NP groups in age, race, sleep apnea, diabetes, smoking, GERD, and the use of preoperative antibiotics in the month prior to sample collection. Figure 1 shows the SNOT-22 scores at pre-FESS, 1 month, 3 months, and 6 months post-FESS by the 4 asthma and NP groups, and the higher score is correlated with worse QOL. CRS patients with asthma had the worst SNOT-22 scores at pre-FESS, 1 month, and 3 months post-FESS compared to the other asthma and NP groups. The mean SNOT-22 scores over time by asthma and polyps are summarized in Table 2. Among the 376 patients with baseline SNOT-22 scores, 71% (n = 268), 53% (n = 198), and 50% (n = 187) of patients had 1-month, 3-month, and 6-month postoperative follow-up SNOT-22 scores, respectively, and the numbers of patients in each group at all follow-up time points are also listed in Table 2. We further tested that there were no significant differences in patient characteristics and baseline SNOT-22 scores

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between patients with and without follow-up SNOT-22 scores. In addition, Fig. 2 shows the changes of SNOT-22 scores from baseline to postoperative 1-month, 3-month, and 6-month visits by the 4 asthma and NP groups, and higher negative scores are correlated with more QOL improvement after FESS. CRS patients with asthma had the most improvement in SNOT-22 scores from pre-FESS to 1 month, and 3 months post-FESS compared to the other asthma and NP groups. All the improvement in SNOT-22 scores from pre-FESS to 1 month, 3 months, and 6 months post-FESS in Fig. 2 were greater than the 0.5 SD of the baseline SNOT-22 score in patients without asthma and NP, ie, 10.6, and thus, the QOL improvements after FESS in all 4 asthma and NP groups were clinically significant. The mixed effects regression models were performed to evaluate the differences of the changes of SNOT-22 scores over time between the 4 asthma and NP groups, and the results are shown in Table 3. After adjusting for all clinical factors, compared to patients without asthma and NP, there were significantly more improvements in postoperative QOL in patients with both asthma and NP from baseline to 1-month (β-coefficient = −10.05; 95% CI, −15.86 to −4.23; p = 0.001) and 3-month follow-up (β-coefficient = −8.27; 95% CI, −14.98 to −1.56; p = 0.016), and patients with asthma alone from baseline to 6-month follow-up (β-coefficient = −8.78; 95% CI, −17.45 to −0.11; p = 0.047). Age, race, and sleep apnea were retained in the final model because they were significantly associated with the changes of SNOT-22 scores in the model or they changed the point estimate of the association between asthma, nasal polyps, and changes of SNOT-22 scores by 15%. Other variables that did not meet the criteria that we stated in the Patients and methods section were not included in the final model, including gender, allergic rhinitis, obstructive sleep apnea, diabetes, smoking status, GERD, Samter’s triad, prior FESS history, as well as the use of oral antibiotics, nasal steroids, and oral steroids in the month prior to sample collection.

Discussion NP and asthma were 2 of the most important factors that have been associated with the refractory nature of CRS.4, 6 Our previous study has found that asthma and NP independently associated with revision FESS for CRS after adjustment for the other clinical factors,17 and previous studies have shown that CRS patients with either NP or asthma can benefit from FESS using different measures.7, 8, 18 In this study, we found that 40.19% of patients had both asthma and NP, and the QOL improvement after FESS was significantly different in CRS patients with asthma and NP, asthma alone, and NP alone, as compared to CRS patients without asthma or NP. In clinical practice, CRS patients are followed up more frequently within 6 months post-FESS, and the knowledge gained in our study regarding patients’ QOL changes at these follow-up time points can potentially assist patient-physician communication preoperatively and

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TABLE 1. Patients’ characteristics by asthma and polyps Asthma and polyps Characteristics

Age

Total

None

Asthma

Polyps

Both

p

48.43 ± 13.34

49.24 ± 14.48

47.26 ± 14.53

50.08 ± 12.53

47.51 ± 12.53

0.457

Sex

0.008

Female

159 (42.51)

41 (42.71)

34 (62.96)

26 (34.67)

58 (38.93)

Male

215 (57.49)

55 (57.29)

20 (37.04)

49 (65.33)

91 (61.07)

Race

0.796

White

330 (89.43)

87 (93.55)

47 (88.68)

67 (89.33)

129 (87.16)

Black

29 (7.86)

6 (6.45)

4 (7.55)

5 (6.67)

14 (9.46)

Asian

7 (1.90)

0 (0.00)

1 (1.89)

2 (2.67)

4 (2.70)

Hispanic

3 (0.81)

0 (0.00)

1 (1.89)

1 (1.33)

1 (0.68)

Allergic rhinitis

248 (65.96)

39 (40.63)

39 (72.22)

45 (60.00)

125 (82.78)

< 0.001

Sleep apnea

17 (4.52)

5 (5.21)

2 (3.70)

2 (2.67)

8 (5.30)

0.802

Diabetes

26 (6.92)

4 (4.17)

3 (5.55)

7 (9.33)

12 (7.95)

0.529

Smoking

0.985

Nonsmoker

250 (66.49)

63 (65.63)

35 (64.82)

48 (64.00)

104 (68.87)

Former

75 (19.95)

20 (20.83)

12 (22.22)

15 (20.00)

28 (18.54)

Current

51 (13.56)

13 (13.54)

7 (12.96)

12 (16.00)

19 (12.58)

GERD

96 (25.60)

22 (23.16)

16 (29.63)

13 (17.33)

45 (29.80)

0.985

Samter’s triad

30 (7.98)

0 (0.00)

2 (3.70)

4 (5.33)

24 (15.89)

< 0.001

Preoperative antibiotics

67 (17.91)

20 (20.83)

14 (25.93)

9 (12.16)

24 (16.00)

0.175 < 0.001

Nasal rinse None

242 (64.90)

76 (79.17)

36 (66.67)

53 (71.62)

77 (51.68)

Saline

123 (32.98)

19 (19.79)

17 (31.48)

18 (24.32)

69 (46.31)

8 (2.15)

1 (1.04)

1 (1.85)

3 (4.05)

3 (2.01)

With medications

< 0.001

Steroid use None

158 (42.36)

64 (66.67)

23 (43.40)

35 (47.30)

36 (24.00)

Nasal

65 (17.43)

12 (12.50)

11 (20.76)

13 (17.57)

29 (19.33)

Oral

119 (31.90)

18 (18.75)

18 (33.96)

19 (25.68)

64 (42.68)

Both

31 (8.31)

2 (2.08)

1 (1.89)

7 (9.46)

21 (14.00)

Prior FESS

227 (60.70)

37 (38.54)

34 (62.96)

48 (64.87)

108 (72.00)

< 0.001

SNOT-22 scores

40.38 ± 22.45

34.60 ± 21.29

45.52 ± 22.79

36.67 ± 22.31

44.05 ± 22.20

0.0015

Lund-Mackay CT scores

13.57 ± 6.46

8.70 ± 6.02

11.05 ± 5.32

14.33 ± 5.73

16.26 ± 5.78

< 0.001

376

96 (25.53)

54 (14.36)

75 (19.45)

151 (40.16)

Total (row%)

CT = computed tomography; FESS = functional endoscopic sinus surgery; GERD = gastroesophageal reflux disease; SNOT-22 = 22-item Sino-Nasal Outcome Test.

postoperatively to help the patients set up appropriate expectations about postoperative recovery and outcomes of FESS, especially CRS patients with both asthma and NP. Our study showed that, compared to CRS patients without asthma and NP, CRS patients with both asthma and

NP may be able to expect significantly more QOL improvement from preoperative visits to 1-month and 3-month postoperative visits, but this difference becomes nonsignificant from pre-FESS to the 6-month postoperative visit. This may be due to the decreased QOL improvement in the NP

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FIGURE 1. SNOT-22 scores over time, by asthma and polyps. FESS = functional endoscopic sinus surgery; SNOT-22 = Sino-Nasal Outcome Test.

TABLE 2. Changes of SNOT-22 scores over time by asthma and polyps* Total

None

Asthma

Polyps

Both

40.38 ± 22.45 (376)

34.60 ± 21.29 (96)

45.52 ± 22.79 (54)

36.67 ± 22.31 (75)

44.05 ± 22.20 (151)

1 month

19.62 ± 18.34 (268)

17.73 ± 17.26 (64)

27.14 ± 19.80 (37)

20.25 ± 21.75 (55)

17.91 ± 16.08 (112)

3 months

19.90 ± 17.53 (198)

18.83 ± 15.51 (40)

25.25 ± 20.78 (32)

18.18 ± 16.87 (34)

19.15 ± 17.31 (92)

6 months

21.10 ± 19.62 (187)

16.79 ± 17.85 (42)

20.96 ± 17.32 (28)

24.44 ± 18.84 (39)

21.79 ± 21.53 (78)

Pre-FESS Post-FESS

*All values are mean ± SD (n). FESS = functional endoscopic sinus surgery; SNOT-22 = 22-item Sino-Nasal Outcome Study.

alone group from pre-FESS to the 6-month post-FESS visit, despite the continuous improvement of QOL in the asthma alone group from pre-FESS to the 6-month post-FESS visit. CRS patients with asthma alone can expect significantly more QOL improvement from preoperative visits to the 6-month postoperative visit. This may be because FESS for asthma may lead to reduced postoperative asthma symptoms by improving upper respiratory structure. However, patients with asthma usually suffer from impaired pulmonary function,19 which may need time to improve and may lead to the worse cross-sectional QOL within 6 months post-FESS. On the other hand, our findings suggest that the CRS patients with NP may be experiencing symptom rebound by 6-month postoperative visits, despite the initial significantly short-term QOL improvement.

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Our study also emphasized that when evaluating the benefit of FESS to CRS patients, the cross-sectional SNOT-22 scores may provide different information as compared to the longitudinal change of SNOT-22 scores from preoperative to postoperative visits. The different information provided by these 2 different ways of using QOL as outcome measures can potentially affect the clinical decision-making process when recommending treatment options to CRS patients. For example, our study showed that even though patients with asthma alone had the worst cross-sectional value of SNOT-22 scores at postoperative follow-up visits, when looking at the longitudinal change of the SNOT22 scores, they may actually benefit the most from FESS by 6-month post-FESS follow up. Alobid et al.20 reported that both medical and surgical treatments lead to similar

Zhang et al.

FIGURE 2. Changes of SNOT-22 scores from baseline to postoperative 1-month, 3-month, and 6-month visits, by asthma and polyps. FESS = functional endoscopic sinus surgery; SNOT-22 = Sino-Nasal Outcome Test.

improvement in the QOL of CRS and NP patients. However, Deal and Kountakis21 showed that patients with NP had more severe symptoms with less improvement after FESS, higher preoperative CT scores, and a significantly higher need for revision surgery. Bugten et al.22 suggested that NP and CRS were different entities due to the differences in symptom severity, nasal endoscopy, age of patients and prevalence of asthma but both conditions responded similarly to FESS. However, none of the studies distinguished the differences between cross-sectional QOL or symptoms at postoperative visits and the longitudinal change of QOL or symptoms from preoperative to postoperative visits, and thus, the conflicting findings may be due to the different outcome measures used. The SNOT-22 score was used as the QOL outcome for our study. The SNOT-20 and its derivatives, SNOT-22, the Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS) are the most commonly used CRS-specific QOL instruments.23 Different disease-specific CRS QOL instruments measure different aspects of the patient’s experience. The RSDI and SNOT-22 are more sensitive to measuring the emotional impact of CRS, whereas the CSS examines medication use and symptoms.23 SNOT-22 is a modification of the SNOT-20, and has 2 additional items that are common symptoms of CRS24 ; ie, nasal blockage and loss of sense of taste and smell. The reliability, validity, responsiveness, and ease of use of SNOT-22 scores have been well tested and reported in previous studies.14, 25 The patterns of QOL improvement after FESS in CRS patients

with NP alone and asthma alone in our study agree with previous studies using other QOL measures.3, 7 In our final linear mixed effects regression model, age, race, and sleep apnea were potential confounders identified and thus were retained in the final model. Smith et al.3, 26 suggested that very few patient factors were predictive of QOL outcomes of FESS after adjusting for the patient factors. The clinical factors that we collected were initially all entered into the linear mixed effects regression model, and then we did a backward selection to exclude the ones that did not add any additional information to the model and did not change the magnitude of the associations between the changes of SNOT-22 scores and asthma and NP groups. For example, history of prior FESS was not significantly associated with the changes of SNOT-22 scores in our study, which was consistent with our previous study.27 Smith et al.26 found patients undergoing primary surgery were significantly more likely to improve on the QOL measured by RSDI and CSS after an average of 17.4 months postoperative follow-up. The differences in our findings can be due to many reasons, such as the different QOL instruments, different clinical factors collected and evaluated as potential confounders, and different lengths of follow-up. There are a few limitations of our study. First, not all CRS patients who underwent FESS in our institute during the same time period were included in this study, mainly because many patients were missing baseline SNOT-22 scores collected during routine clinical practice, and not every patient completed the postoperative SNOT-22 scores

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TABLE 3. Adjusted coefficients and 95% CIs for the associations between asthma, polyps, and SNOT-22 score changes from the adjusted linear mixed effects regression model Adjusted

Difference of natural log– transformed SNOT-22 scores

Coefficient

95% CI

p

From pre-FESS to 1 month post-FESS None

Reference

Asthma

−2.68

−10.34 to 4.98

0.492

Polyps

−1.77

−8.58 to 5.03

0.608

Both

−10.05

−15.86 to −4.23

0.001

From pre-FESS to 3 months post-FESS None

Reference

Asthma

−4.24

−12.74 to 4.27

0.329

Polyps

−1.90

−10.05 to 6.24

0.647

Both

−8.27

−14.98 to −1.56

0.016

From pre-FESS to 6 months post-FESS None

Reference

Asthma

−8.78

−17.45 to −0.11

0.047

Polyps

4.84

−2.98 to 12.65

0.225

−5.19

−11.91 to 1.53

0.130

Both

From pre-FESS to postoperative visits with vs without covariates belowa −0.17

Age

−0.30 to −0.04

0.010

Race White

Reference

Black

5.64

−0.91 to 12.20

0.092

Asian

−2.04

−13.99 to 9.91

0.738

Hispanic

10.00

−8.89 to 28.89

0.300

Sleep apnea

−8.99

−16.99 to −1.00

0.027

a Their effects on QOL improvement were averaged across all postoperative follow-up time points. CI = confidence interval; FESS = functional endoscopic sinus surgery; QOL = quality of life; SNOT-22 = 22-item Sino-Nasal Outcome Study.

at 1-month, 3-month, and 6-month follow-up visits. We compared patient characteristics, and there was no significant difference in characteristics collected between patients included vs not included, as well as between patients with and without follow-up SNOT-22 scores. Thus, instead of excluding patients without follow-up SNOT-22 scores, we used a mixed effect regression model for the analysis, which can provide an unbiased estimate when the patients with missing follow-up data had similar characteristics compared to patients without missing follow-up data. If a SNOT-22 score was missing at a certain time point, the rest of the scores from that same patient were still included in the mixed effects model; using all available follow-up data can actually decrease selection bias due to missing data as compared to excluding all patients without follow-up data. Second, we did not have long-term follow-up SNOT-22 scores after FESS to further evaluate the disease progress after 6-month follow up, but the literature has shown that QOL does not change significantly after 6-month postoperative follow-up.10 Finally, the variables were collected from patients’ medical records and we cannot rule out the possibility that there may be some undiagnosed conditions, such as asthma, but if undiagnosed asthma patients were misclassified as non-asthma, the effects would be biased toward the null, so the real effects would be strengthened.

Conclusion Our study showed that compared to CRS patients without asthma or NP, CRS patients with both asthma and NP had significantly more QOL improvement after FESS from preoperative visit to 1-month and 3-month postoperative follow-up visits, and CRS patients with asthma alone had continuous QOL improvement and their QOL improvement was significantly better from the preoperative visit to the 6-month postoperative follow-up visit. However, the information we get can be different when choosing between the cross-sectional SNOT-22 scores at postoperative visits and the longitudinal change of SNOT-22 scores from preoperative to postoperative visits for QOL outcome measures. The knowledge gained in our study can potentially assist patient-physician communication preoperatively and postoperatively to set up appropriate patient expectations about postoperative recovery and outcomes of FESS, especially CRS patients with both asthma and NP.

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Quality of life improvement from sinus surgery in chronic rhinosinusitis patients with asthma and nasal polyps.

It is unclear whether chronic rhinosinusitis (CRS) patients with both nasal polyps and asthma have different quality of life (QOL) improvement after f...
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