Cognitive function in chronic rhinosinusitis: a controlled clinical study

Potential roles of inhalation aromatherapy on stress-induced depression by inhibiting inflammation in the peripheral olfactory system

According to principles of Traditional Chinese Medicine, the nose is the passage for exogenous evil to invade the body, while essential or volatile oils extracted from herbs have the effects of dispelling melancholy, repelling foulness, and resuscitation with aromatics. Inhalation aromatherapy can target the brain and has a potential therapeutic effect on mood disorders. However, in particular, the mechanism of the effect of inhalation aromatherapy on the olfactory mucosa (OM) of the nasal cavity at the peripheral level, the first step in olfactory detection, where olfactory sensory neurons (OSNs) relay information to brain for signal processing, remains unclear. Here, we examined the roles of inhalation aromatherapy with compound essential oils derived from Bergamot, Peppermint and Rosa rugose on chronic unpredictable mild stress (CUMS)-induced depression and explored potential therapeutic targets in the peripheral OM. We found that inhalation aromatherapy effectively ameliorated CUMS-induced depression and olfactory dysfunction in rats. Strikingly, inhalation aromatherapy improved pathological changes, significantly reduced apoptosis levels, and promoted olfactory neurogenesis in the OM, which may contribute to the beneficial effects on the olfactory function of depressed rats. Further, inhalation aromatherapy significantly may reverse inflammation levels in the OM through Sirt1/FKBP5/GR/NF-κB signaling pathway, and prevented neuroinflammation in other parts of the olfactory system such as the hippocampus and prefrontal cortex, which may play a role in the olfactory impairments in rats with depression. Collectively, we have demonstrated that inhalation aromatherapy could efficiently prevent the local inflammatory responses in the OM of CUMS depression model rats. These findings provide new insights into the treatment of depression with aromatherapy, as well as new concept for the identification of novel antidepressant strategies.

The Impact of Sinus Surgery for Chronic Rhinosinusitis on Concomitant Depression and Anxiety Symptoms: A Systematic Review and Meta-analysis

BACKGROUND

Both anxiety and depression are prevalent among patients with chronic rhinosinusitis (CRS) and associated with poorer outcomes following treatment for CRS. However, the impact of treatment on CRS on mental health remains uncertain. Therefore, this study seeks to evaluate if surgical intervention for CRS may alleviate comorbid depression and anxiety.

METHODS

PubMed, Embase, and Scopus databases were searched for retrospective and prospective cohort studies, cross-sectional studies, and randomized controlled trials relating to CRS treatment using sinus surgery from inception to April 30, 2024, using the Population, Intervention, Comparison, and Outcomes (PICO) framework. Three blinded reviewers selected observational studies and randomized controlled trials investigating levels of depression and anxiety pre- and post-surgical treatment of CRS. Eleven studies comprising 3067 patients were included, of which five studies were quantitatively analyzed. After which, data were extracted from included articles into a structured proforma and the Newcastle-Ottawa Scale was used to evaluate study bias, following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and a PROSPERO-registered protocol (CRD42022351855). Meta-analyses of the ratio of means were conducted in a random-effects model.

RESULTS

Overall, sinus surgery was associated with significant improvement in test scores of depression (ratio of means (ROM) = 1.47, 95% confidence interval [CI] = 1.03‒2.10), anxiety (ROM = 1.10, 95% CI = 0.81‒1.49), and quality of life markers, which are closely correlated to mental health outcomes.

CONCLUSIONS

Sinus surgery for CRS may improve mental health outcomes (both depression and anxiety) for patients.

Challenges to medication adherence with intranasal corticosteroid irrigations

BACKGROUND

The purpose of this study was to investigate real-world adherence to intranasal corticosteroid irrigations using pharmacy data and assess factors associated with low adherence.

METHODS

Patients undergoing treatment with corticosteroid irrigations for any diagnosis during a 2-year period were prospectively recruited. Subjects completed a one-time set of questionnaires including the Barriers to Care Questionnaire (BCQ), 22-item Sino-Nasal Outcome Test (SNOT-22), and a questionnaire assessing their experience with corticosteroid irrigations. Pharmacy data was used to calculate the medication possession ratio (MPR), a measure of medication adherence graded from 0 to 1.

RESULTS

Seventy-one patients were enrolled. Patient diagnoses included chronic rhinosinusitis (CRS) without nasal polyps (n = 37), CRS with nasal polyps (n = 24), or a non-CRS diagnosis, most commonly chronic rhinitis (n = 10). The MPR for the overall group was 0.44 ± 0.33. Just 9.9% of patients had a perfect MPR of 1. Despite low MPR, only 19.7% of patients reported problems taking the medication when directly asked. Lower education resulted in lower MPR (unstandardized B = 0.065, p = 0.046). Increasing BCQ score, indicating higher barriers to care, was associated with lower MPR (unstandardized B = -0.010, p = 0.033). The lower the MPR, the worse the patient SNOT-22 scores (unstandardized B = -15.980, p = 0.036).

CONCLUSION

Adherence to corticosteroid irrigations was low and patients underreported issues with their medication. Education and barriers to care were associated with lower adherence, which, in turn, was associated with worse sinonasal quality of life.

Prevalence and influencing factors of sleep disorders in patients with CRS: a protocol for systematic review and meta-analysis

BACKGROUND

Chronic rhinosinusitis (CRS) is a common chronic disease that seriously affects patients' quality of life and imposes a heavy physical and mental burden on patients. There is growing evidence that sleep disorders are strongly associated with patients with CRS. However, there is no systematic evidence to clarify the prevalence and influencing factors of sleep disorders in patients with CRS with nasal polyps (NP) (CRSwNP) and CRS without NP (CRSsNP). For this reason, this study will systematically analyse the prevalence of sleep disorders in patients with CRSwNP and CRSsNP and explore the related influencing factors.

METHODS AND ANALYSIS

We will electronically search PubMed, Web of Science, Embase, Cochrane, Ovid, Scopus, the China National Knowledge Infrastructure, the Wanfang database, the China Biomedical Literature Database and the China Scientific Journals Database from the establishment of the database to September 2023 to collect the prevalence of sleep disorders in patients with CRSwNP or CRSsNP and related studies on factors affecting sleep disorders. Two researchers will independently conduct literature screening and data extraction and evaluate the quality of the included studies using the Newcastle-Ottawa Quality Scale and Agency for Healthcare Research and Quality scales. The extracted data will be meta-analysed using Review Manager 5.3 and Stata 14.0 software, and the quality of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation. Publication bias will be assessed using the funnel plots, Egger's test and Begg's test.

ETHICS AND DISSEMINATION

This review will not require ethical approval, as we will only use research data from the published documents. Our final findings will be published in a peer-reviewed, open-access journal for dissemination.

PROSPERO REGISTRATION NUMBER

CRD42023446833.

Exploring Olfactory Dysfunction as a Marker of Frailty and Postoperative Outcomes in Head and Neck Cancer

Importance

Olfactory dysfunction (OD) is increasingly recognized as a robust marker of frailty and mortality. Despite broad recognition of frailty as a critical component of head and neck cancer (HNC) care, there is no standardized frailty assessment.

Objective

To assess the prevalence of OD and its association with frailty and postoperative outcomes in HNC.

Design, Setting, and Participants

In this prospective cohort study with enrollment between February 17, 2021, to September 29, 2021, at a tertiary academic medical center, 85 eligible adult patients with primary, treatment-naive HNC of mucosal or cutaneous origin were included. Patients with a history of COVID-19, neurocognitive, or primary smell/taste disorders were excluded.

Exposures

Prospective olfactory assessments (self-reported, visual analog scale [VAS] and psychophysical, University of Pennsylvania Smell Identification Test [UPSIT]) with concurrent frailty assessment (Risk Analysis Index [RAI]) were used. Olfactory-specific quality of life (QOL) was examined with brief Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS).

Main Outcome(s) and Measure(s)

The primary outcome was the prevalence of OD as assessed by VAS (0-10, no to normal smell) and UPSIT (0-40, higher scores reflect better olfaction) and its association with frailty (RAI, 0-81, higher scores indicate greater frailty). For surgical patients, secondary outcomes were associations between OD and postoperative length of stay (LOS), 30-day postoperative outcomes, and QOD-NS (0-21, higher scores indicate worse QOL).

Results

Among 51 patients with HNC (mean [SD] age, 63 [10] years; 39 [77%] male participants; 41 [80%] White participants), 24 (47%) were frail, and 4 (8%) were very frail. Despite median (IQR) self-reported olfaction by VAS of 9 (8-10), 30 (59%) patients demonstrated measured OD with psychophysical testing. No meaningful association was found between self-reported and psychophysical testing (Hodges-Lehmann, <0.001; 95% CI, -2 to 1); a total of 46 (90%) patients did not report decreased olfaction-specific QOL. Median UPSIT scores were lower in frail patients (Hodges-Lehmann, 6; 95% CI, 2-12). Multivariate modeling demonstrated severe microsmia/anosmia was associated with 1.75 (95% CI, 1.09-2.80) times odds of being frail/very frail and approximately 3 days increased LOS (β, 2.96; 95% CI, 0.29-5.62).

Conclusions and Relevance

Although patients with HNC are unaware of olfactory changes, OD is common and may serve as a bellwether of frailty. In this prospective cohort study, a dose-dependent association was demonstrated between increasing degrees of OD and frailty, and the potential utility of olfaction was highlighted as a touchstone in the assessment of HNC frailty.

Nanotechnology-enabled topical delivery of therapeutics in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the paranasal sinuses which represents a significant health burden due to its widespread prevalence and impact on patients' quality of life. As the molecular pathways driving and sustaining inflammation in CRS become better elucidated, the diversity of treatment options is likely to widen significantly. Nanotechnology offers several tools to enhance the effectiveness of topical therapies, which has been limited by factors such as poor drug retention, mucosal permeation and adhesion, removal by epithelial efflux pumps and the inability to effectively penetrate biofilms. In this review, we highlight the successful application of nanomedicine in the field of CRS therapeutics, discuss current limitations and propose opportunities for future work.

Understanding the CRSwNP Patient as Whole

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a distinct inflammatory disease of the upper airways with a significant impact on the health and quality of life of affected patients. Several comorbid conditions such as allergic rhinitis, asthma, sleep disorders, and gastroesophageal reflux disease are commonly reported in patients with CRSwNP.

OBJECTIVE

In this article, we intended to review the UpToDate information on how these comorbidities can impact CRSwNP patients' health and well-being.

METHODS

A PUBMED search was performed to review relevant recent article on the topic.

RESULTS

While there have been significant advances in the knowledge and management options for CRSwNP in the past few years, additional studies are needed to understand the underlying pathophysiologic mechanisms of these associations. In addition, awareness of the impact of CRSwNP on mental health, quality of life, and cognition is paramount to treating this condition.

CONCLUSION

Recognition and addressing CRSwNP comorbidities such as allergic rhinitis, asthma, sleep disorders, gastroesophageal reflux disease, and cognitive function impairment are important to optimally understand and manage the patient with CRSwNP as a whole.

Olfactory Dysfunction in Mental Illness

PURPOSE OF REVIEW

Olfactory dysfunction contributes to the psychopathology of mental illness. In this review, we describe the neurobiology of olfaction, and the most common olfactory alterations in several mental illnesses. We also highlight the role, hitherto underestimated, that the olfactory pathways play in the regulation of higher brain functions and its involvement in the pathophysiology of psychiatric disorders, as well as the effect of inflammation on neurogenesis as a possible mechanism involved in olfactory dysfunction in psychiatric conditions.

RECENT FINDINGS

The olfactory deficits present in anxiety, depression, schizophrenia or bipolar disorder consist of specific alterations of different components of the sense of smell, mainly the identification of odours, as well as the qualifications of their hedonic valence (pleasant or unpleasant). Epidemiological findings have shown that both environmental factors, such as air pollutants, and inflammatory disease of the upper respiratory tract, can contribute to an increased risk of mental illness, at least in part, due to peripheral inflammatory mechanisms of the olfactory system. In this review, we describe the neurobiology of olfaction, and the most common olfactory function alterations in several psychiatric conditions and its role as a useful symptom for the differential diagnosis. We also highlight the effect of inflammation on neurogenesis as a possible mechanism involved in olfactory dysfunction in these psychiatric conditions.

Prevalence of Depression and Anxiety in Patients With Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

OBJECTIVE

We performed a meta-analysis and estimated the prevalence of depression and anxiety and their related factors among patients with chronic rhinosinusitis (CRS).

DATA SOURCES

PubMed, Embase, Web of Science, Cochrane Library, CINAHL, PsycINFO, and CBM databases.

REVIEW METHODS

A systematic search was performed for relevant studies published before August 17, 2021. A random effects model was used to estimate the prevalence of depression and anxiety. Subgroup analysis was performed by continent or region, study setting, sex, sample size, diagnosis, and assessment method.

RESULTS

Twenty-two articles covering 40,956 patients were included in the meta-analysis. The pooled crude prevalence estimates of depression and anxiety were 25.2% (95% CI, 20.9%-29.6%) and 28.9% (95% CI, 16.1%-41.6%), respectively. Subgroup analyses revealed the following: (1) continent or region, study setting, sex, sample size, depression assessment method, and CRS diagnosis were significantly correlated with the prevalence of depression, and (2) continent or region, study setting, sample size, anxiety assessment method, and CRS diagnosis were significantly correlated with the prevalence of anxiety. Meta-regression analysis revealed that study setting and sample size were negatively associated with the pooled prevalence of depression. In contrast, CRS diagnosis and anxiety assessment method were positively associated with the pooled prevalence of anxiety.

CONCLUSION

Depression and anxiety are common in patients with CRS, especially among clinics. Therefore, in patients with CRS, screening and early diagnosis of depression and anxiety are necessary for prevention and treatment.

Association between cognition and olfaction-specific parameters in patients with chronic rhinosinusitis

BACKGROUND

Patients with chronic rhinosinusitis (CRS) have reported significantly cognitive and olfactory dysfunction. This study aimed to explore the relationship between cognitive function and olfaction-specific parameters in patients with CRS.

METHODS

A cross-sectional survey method was used to investigate 98 participants, including 75 patients with CRS and 23 healthy controls. Cognitive function and psychophysical olfactory tests were performed. Olfactory cleft endoscopy scale and olfactory cleft computed tomography (CT) scores were obtained. Multivariate logistic regression was used to analyze the risk factors of Mild Cognitive Impairment (MCI) in patients with CRS.

RESULTS

There are significant differences in age, Montreal Cognitive Assessment (MoCA) scores, number of MCI, Lund-Mackay olfactory cleft (LM-OC) score, and blood eosinophil count between CRS with and without olfactory dysfunction groups (all P < 0.05). Total MoCA scores were positively correlated with thresholds-discrimination-identification (TDI) score (r = 0.541, P < 0.001), olfactory threshold (OT) (r = 0.440, P < 0.001), olfactory discrimination (OD) (r = 0.541, P < 0.001), and olfactory identification (OI) (r = 0.382, P = 0.001) scores. Furthermore, total MoCA scores were negatively correlated with LM-OC scores (r =  - 0.351, P = 0.002). After adjusting for patient demographics, only the OD score was an independent risk factor for MCI among patients with CRS (odds ratio = 0.792; P = 0.039). The OD scores less than 11.5 were the best predictor of MCI in patients with CRS.

CONCLUSION

Olfaction-specific clinical parameters were highly correlated with cognitive function in patients with CRS and the OD score was an independent risk factor for MCI in patients with CRS.

A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022

The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.

Olfactory impairment in psychiatric disorders: Does nasal inflammation impact disease psychophysiology?

Olfactory impairments contribute to the psychopathology of mental illnesses such as schizophrenia and depression. Recent neuroscience research has shed light on the previously underappreciated olfactory neural circuits involved in regulation of higher brain functions. Although environmental factors such as air pollutants and respiratory viral infections are known to contribute to the risk for psychiatric disorders, the role of nasal inflammation in neurobehavioral outcomes and disease pathophysiology remains poorly understood. Here, we will first provide an overview of published findings on the impact of nasal inflammation in the olfactory system. We will then summarize clinical studies on olfactory impairments in schizophrenia and depression, followed by preclinical evidence on the neurobehavioral outcomes produced by olfactory dysfunction. Lastly, we will discuss the potential impact of nasal inflammation on brain development and function, as well as how we can address the role of nasal inflammation in the pathophysiological mechanisms underlying psychiatric disorders. Considering the current outbreak of Coronavirus Disease 2019 (COVID-19), which often causes nasal inflammation and serious adverse effects for olfactory function that might result in long-lasting neuropsychiatric sequelae, this line of research is particularly critical to understanding of the potential significance of nasal inflammation in the pathophysiology of psychiatric disorders.

Dupilumab improves health related quality of life: Results from the phase 3 SINUS studies

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a predominantly type 2-mediated inflammatory disease with high symptom burden and reduced health-related quality of life (HRQoL). This report aimed to comprehensively understand the effects of dupilumab on domains of HRQoL, their individual elements, and health status in patients with severe CRSwNP from phase 3 SINUS-24 (NCT02912468) and SINUS-52 (NCT02898454) trials.

METHODS

Patients were randomized to dupilumab (n = 438) or placebo (n = 286) for 24 weeks (SINUS-24), or 52 weeks (SINUS-52). Disease-specific HRQoL using 22-item sino-nasal outcome test (SNOT-22), and health status using EuroQoL-visual analog scale (EQ-VAS) was evaluated in the pooled intention-to-treat (ITT) population (Week 24), SINUS-52 ITT (Week 52) and in the subgroups with/without asthma; non-steroidal anti-inflammatory drug-exacerbated respiratory disease (NSAID-ERD); and prior sinus surgery.

RESULTS

At baseline, patients had poor disease-specific HRQoL and general health status and identified "Decreased sense of smell/taste" and "Nasal blockage" as the most important symptoms. Dupilumab significantly improved SNOT-22 total, domain (Nasal, Sleep, Function, Emotion, and Ear/facial), and 22-item scores, and EQ-VAS, at Week 24 vs placebo (all p < .0001), with continued improvements to Week 52 in SINUS-52. Improvements occurred irrespective of comorbid asthma, NSAID-ERD, or prior surgery. A significantly greater proportion of dupilumab-treated patients exceeded clinically meaningful thresholds for SNOT-22 total score and EQ-VAS vs placebo (all subgroups p < .05 except patients without surgery at Week 24).

CONCLUSIONS

Dupilumab treatment led to significant clinically meaningful improvements across all aspects of disease-specific HRQoL, and general health status in patients with severe CRSwNP.

Clinical Assessment of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disease that affects >10% of the adult population in Europe and the United States. It has been delineated phenotypically into CRS without nasal polyps and CRS with nasal polyps. Both have a high disease burden and an overlapping spectrum of symptoms such as nasal obstruction, olfactory dysfunction, facial pain, pressure, and nasal discharge. Primary assessment includes evaluation of patient symptoms and impact on quality of life, nasal endoscopic examination, and imaging. Significant progress has been made in the understanding of CRS pathophysiology. There is a move toward describing CRS in terms of the predominant endotype or inflammatory pattern pathomechanism rather than the traditional classification of patients with and without nasal polyps. An increased elucidation of the disease endotypes, as characterized by their inflammatory pathways and mediators, is leading to a tailored more personalized treatment approach to the different disease subtypes.

Managing Chronic Rhinosinusitis with Nasal Polyps in the Elderly: Challenges and Solutions

The proportion of the population over 65 years old continues to grow. Chronic rhinosinusitis is common in this population and causes a reduction in quality of life and an increase in health care utilization. Diagnosis of chronic rhinosinusitis with nasal polyps follows the same principles for elderly patients as in the general population, but the elderly population presents some diagnostic challenges worth considering. Presbynasalis, the anatomic and functional changes of the nose and paranasal sinuses associated with aging must be accounted for when caring for these patients. In addition, polypharmacy and other medical issues that can cause similar symptoms must be considered. Medical therapy is generally similar to the general population but with additional concerns given the propensity for geriatric patients to be on multiple medications and to suffer from multiple medical issues. Sinus surgery should be considered following the same indications as in the general population. While some authors have found higher complication rates in endoscopic sinus surgery, others have found higher rates of success. As always, the risks of surgery must be considered with the possible benefits on a patient-to-patient basis.

Role and Function of Regulatory T Cell in Chronic Rhinosinusitis with Nasal Polyposis

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a subtype of chronic rhinosinusitis characterized by high edema in the stroma, albumin deposition, and formation of pseudocysts. The pathogenesis of CRSwNP is not yet fully understood. Regulatory T (Treg) cells are a subset of CD4+ T cells that play a suppressive immunoregulatory role in the process of CRSwNP. Recent studies have found that there was a significant reduction in Treg cells in polyp tissues, which leads to the onset of CRSwNP. An imbalance between Th17 and Treg cells can also aggravate inflammation toward the Th2 type. This review focuses on our understanding of the function and role of Treg cells and their regulatory factors and clinical significance in CRSwNP. We also summarize the current drug treatments for CRSwNP with Tregs as the potential therapeutic target, which will provide new ideas for the treatment of CRSwNP in the future.

Association of Sinonasal Inflammation With Functional Brain Connectivity

Importance

In recent years, there have been several meaningful advances in the understanding of the cognitive effects of chronic rhinosinusitis. However, an investigation exploring the potential link between the underlying inflammatory disease and higher-order neural processing has not yet been performed.

Objective

To describe the association of sinonasal inflammation with functional brain connectivity (Fc), which may underlie chronic rhinosinusitis-related cognitive changes.

Design, Setting, and Participants

This is a case-control study using the Human Connectome Project (Washington University-University of Minnesota Consortium of the Human Connectome Project 1200 release), an open-access and publicly available data set that includes demographic, imaging, and behavioral data for 1206 healthy adults aged 22 to 35 years. Twenty-two participants demonstrated sinonasal inflammation (Lund-Mackay score [LMS] ≥ 10) and were compared with age-matched and sex-matched healthy controls (LMS = 0). These participants were further stratified into moderate (LMS < 14, n = 13) and severe (LMS ≥ 14, n = 9) inflammation groups. Participants were screened and excluded if they had a history of psychiatric disorder and/or neurological or genetic diseases. Participants with diabetes or cardiovascular disease were also excluded, as these conditions may affect neuroimaging quality. The data were accessed between October 2019 and August 2020. Data analysis was performed between May 2020 and August 2020.

Main Outcomes and Measures

The primary outcome was the difference in resting state Fc within and between the default mode, frontoparietal, salience, and dorsal attention brain networks. Secondary outcomes included assessments of cognitive function using the National Institutes of Health Toolbox Cognition Battery.

Results

A total of 22 patients with chronic rhinosinusitis and 22 healthy controls (2 [5%] were aged 22-25 years, 26 [59%] were aged 26-30 years, and 16 [36%] were aged 31-35 years; 30 [68%] were men) were included in the analysis. Participants with sinonasal inflammation showed decreased Fc within the frontoparietal network, in a region involving bilateral frontal medial cortices. This region demonstrated increased Fc to 2 nodes within the default-mode network and decreased Fc to 1 node within the salience network. The magnitude of these differences increased with inflammation severity (dose dependent). There were no significant associations seen on cognitive testing.

Conclusions and Relevance

In this case-control study, participants with sinonasal inflammation showed decreased brain connectivity within a major functional hub with a central role in modulating cognition. This region also shows increased connectivity to areas that are activated during introspective and self-referential processing and decreased connectivity to areas involved in detection and response to stimuli. Future prospective studies are warranted to determine the applicability of these findings to a clinical chronic rhinosinusitis population.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Does Cognitive Dysfunction Correlate With Dizziness Severity in Meniére's Disease Patients

OBJECTIVE

Characterize the relationship between cognitive dysfunction and the dizziness severity in Meniére's disease (MD) patients.

STUDY DESIGN

Retrospective review.

SETTING

University-based tertiary medical center.

PATIENTS

Three hundred patients were evaluated for MD from 2015 to 2019. Excluding comorbid or alternative vestibular disorders, 29 patients with definite MD and available pre- and postintervention data were included for analysis.

INTERVENTIONS

A progressive protocol of salt restriction, diuretics, steroid and/or gentamycin injection, and endolymphatic sac decompression for those refractory to medical therapy.

MAIN OUTCOME MEASURES

Quality of life measured with the Dizziness Handicap Inventory (DHI) and cognitive function measured with the Cognitive Failures Questionnaire (CFQ). Pre- and posttreatment DHI and DHI subscale scores and change in these scores were correlated with pre- and posttreatment CFQ scores and change in CFQ with therapy.

RESULTS

Analysis showed a number of limited associations between improvement in DHI and improvement in CFQ. Total DHI scores failed to correlate scores or variation in scores with change in CFQ (p = 0.091 and p = 0.085, respectively). Improvement in the CFQ false-triggering domain was significantly associated with improvement in the DHI physical subscale (r = 0.491, p = 0.007) and was nonsignificantly associated with improvement in total DHI and DHI emotional subscale scores (r = 0.422, p = 0.016 and r = 0.399, p = 0.032).

CONCLUSIONS

The DHI correlates with several pre- and posttreatment measures of cognitive dysfunction (CFQ) in MD patients. However, change in DHI and CFQ with therapy correlate poorly. Overall, the commonly used DHI may fail to adequately assess cognitive dysfunction in MD patients possibly due to factors not directly implicated by measures of vestibular dysfunction, such as central nervous system or cognitive dysfunction; however, the specific physical and emotional subscales may offer helpful insight into cognitive dysfunction change/improvement with treatment.

Cognitive dysfunction and quality of life during pollen season in children with seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis often gives rise to impaired quality of life and is believed to also affect cognitive function. We aimed to examine whether cognitive functions were impaired during grass pollen season in symptomatic allergic children and to relate the degree of impairment to quality of life and biomarkers related to stress and inflammation.

METHODS

Forty-three grass pollen-allergic children (age 8-17 years) with non-satisfactory effect of medication (antihistamines and nasal steroids daily) during previous seasons were included. In addition, 26 matched non-allergic children were included as controls. Both groups performed cognitive tests (CANTAB) and completed Quality of Life questionnaires outside and during the pollen season. Blood samples were collected and analyzed for stress and inflammatory biomarkers. Pollen level was measured daily.

RESULTS

Impaired cognitive function was found in spatial working memory, where the allergic group made more errors compared to the non-allergic group during pollen season, but not off-season. No significant differences could be seen between the allergic group and the controls in the other tests investigating visual memory or attention. Quality of health questionnaires revealed more symptoms and impaired quality of life in allergic compared to non-allergic children, and increased symptoms in allergic children were associated with longer reaction time for simple movement during pollen season. No differences in stress or inflammatory biomarkers could be found between the groups.

CONCLUSION

Cognitive function was affected during pollen season in pollen-allergic children, and the more symptoms the allergic children had, the longer the reaction time in the cognitive tests.

Adult chronic rhinosinusitis

Chronic rhinosinusitis (CRS) occurs in >10% of the adult population in Europe and the USA and can be differentiated into CRS without nasal polyps and CRS with nasal polyps (CRSwNP). Both phenotypes are characterized by a high disease burden and an overlapping spectrum of symptoms, with facial pain and loss of smell being the most differentiating. Great progress has been made in the understanding of CRS pathophysiology: from the epithelium and epithelial-mesenchymal transition to innate and adaptive immunity pathways and, finally, on the role of eosinophils and Staphylococcus aureus in the persistence of disease. Although clinical manifestations and diagnostic tools (including nasal endoscopy and imaging) have undergone major changes over the past few years, management (including pharmacotherapy, surgery and biologics) has experienced enormous progress based on the growing knowledge of key mediators in severe CRSwNP. The introduction of endotyping has led to a differentiation of 'tailored' surgical approaches, focusing on the mucosal concept in those with severe CRSwNP and on the identification of patients eligible for extended surgery and possibly biologics in the future.

Association between neurodegenerative dementia and chronic rhinosinusitis: A nested case-control study using a national health screening cohort

The aim of this case-control study was to evaluate the association between chronic rhinosinusitis (CRS) and neurodegenerative dementia in a large representative Korean population. The ≥ 50-year-old population was selected from the Korean Health Insurance Review and Assessment Service - National Sample Cohort from 2002 to 2015. A total of 17,634 neurodegenerative dementia patients were matched in a 1:4 ratio with 70,536 control participants for age, sex, income, and region of residence. Neurodegenerative dementia was defined using the ICD-10 codes G30 and F00. CRS was identified based on the ICD-10 code J32. Among the cohort, we selected participants who were treated ≥ 2 times and those who underwent head and neck computed tomography. The odds ratio (OR) for CRS in patients with dementia was analyzed using a conditional logistic regression model. Subgroup analyses were conducted according to age and sex. There was no difference in the prevalence of CRS with/without nasal polyps between the dementia (1.1%) and control (1.2%) groups (P = .825). CRS with/without nasal polyps was not significantly associated with dementia (adjusted OR = 0.96, 95% CI = 0.82-1.13, P = .653). In the subgroup analyses according to age and sex, the adjusted ORs for CRS with/without nasal polyps were not higher in the dementia group than in the control group. Previous CRS was not associated with neurodegenerative dementia in the Korean population.

Vestibular Characteristics of Patients with Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disease entity with symptoms that may extend beyond the sinonasal tract. Limited data exist regarding the relationship between CRS and the vestibular system, and no previous study has investigated the association between objective vestibular findings on videonystagmography (VNG) and the diagnosis of CRS. We analyzed a prospective database of 3078 patients who underwent VNG at our institution over an 8-year period, which included 70 subjects who had a diagnosis of CRS assigned by an otolaryngologist. Overall, the VNG findings for patients with CRS were similar to those of the general population, with 50% exhibiting normal vestibular function. Peripheral lesions were the most common abnormal VNG finding, with a wide range of subjective symptom descriptions. This preliminary report of the prevalence of objective vestibular findings in patients with CRS may form the basis for future study.

Intravenous vitamin C in the treatment of allergies: an interim subgroup analysis of a long-term observational study

Objective Oxidative stress appears to be a key factor in the pathogenesis of allergic diseases and a potential therapeutic target in allergy treatment. Allergic diseases are reportedly associated with reduced plasma levels of ascorbate, which is a key physiological antioxidant. Ascorbate prevents excessive inflammation without reducing the defensive capacity of the immune system. Methods An interim analysis of a multicenter, prospective, observational study was conducted to investigate the change in disease-specific and nonspecific symptoms (fatigue, sleep disorders, depression, and lack of mental concentration) during adjuvant treatment with intravenous vitamin C (Pascorbin®; Pascoe, Giessen, Germany) in 71 patients with allergy-related respiratory or cutaneous indications. Results Between the start and end of treatment, the mean sum score of three disease-specific symptoms decreased significantly by 4.71 points and that of four nonspecific symptoms decreased significantly by 4.84 points. More than 50% of patients took no other allergy-related medication besides vitamin C. Conclusions Our observations suggest that treatment with intravenous high-dose vitamin C reduces allergy-related symptoms. Our observations form a basis for planning a randomized controlled clinical trial to obtain more definitive evidence of the clinical relevance of our findings. We also obtained evidence of ascorbate deficiency in allergy-related diseases.

TRIAL REGISTRATION

Clinical Trials NCT02422901.

The effect of nasal polyposis related nasal obstruction on cognitive functions

Chronic rhinosinusitis with nasal polyposis is a chronic inflammatory disease of the respiratory mucosa of the nasal cavity and paranasal sinuses. The aim of this study was investigate the effect of nasal obstruction related to chronic rhinosinusitis with nasal polyposis on cognitive functions. Patients with chronic rhinosinusitis with nasal polyposis causing bilateral total or near total nasal obstruction were enrolled in the study. Symptoms of nasal congestion, loss of smell, postnasal drip, headaches, snoring, concentration difficulties and blunted affect were evaluated by Visual Analog Scale. Brief symptom inventory test, Stroop test, visual aural digit span, serial digit learning test and P300 test were used to evaluate cognitive functions. Three months after treatment, the tests done before surgery were repeated and the results were compared. A total of 30 patients were included in the study. On the Visual Analog Scale, all symptoms showed significant postoperative improvement in all patients (p < 0.001 for all symptoms). Preoperative nasal congestion accompanied with impaired concentration were detected in 27 patients (90%), and these symptoms recovered in all these patients after treatment (p = 0.035) (correlation coefficient 0.4). Only 22 patients completed the neuropsychological tests. The mean preoperative Stroop test (23.16 ± 5.30), visual aural digit span test (24.68 ± 3.52), and serial digit learning test (16.18 ± 5.35) scores were showed significant improvement compared with mean postoperative Stroop test (21.12 ± 5.69), visual aural digit span test (26.45 ± 2.98), and serial digit learning test (19.31 ± 4.47) scores (p = 0.047, p = 0.022, p = 0.005 respectively). The postoperative P300 latency values improved in 19 (63%) patients. The preoperative and postoperative latency values for P300 showed a significant difference (p = 0.029), whereas the preoperative and postoperative amplitude values for P300 did not differ (p = 0.096). In conclusion, the results of this study indicate that chronic rhinosinusitis with nasal polyposis (CRSwNP) has negative effects on cognitive functions, such as the ability to focus and maintain concentration. These cognitive functions improve after the patients undergo endoscopic sinus surgery to treat their CRSwNP.

Allergic rhinitis and rhinosinusitis synergistically compromise the mental health and health-related quality of life of Korean adults: A nationwide population-based survey

Background

Allergic rhinitis (AR) and rhinosinusitis (RS) negatively impact psychological well-being and health-related quality of life (HRQoL). However, few population-based studies have investigated the effects of these conditions on mental health and HRQoL.

Purpose

To explore independent associations of AR and/or RS with mental health and HRQoL using data from the 2013–2015 Korea National Health and Nutrition Examination Survey (KNHANES).

Methods

The KNHANES is a nationwide cross-sectional survey of the non-institutionalized population of Korea. A total of 15,441 adults completed the clinical examination and the health questionnaire. We divided all participants into four groups: AR-/RS-, AR-/RS+, AR+/RS-, and AR+/RS+. Logistic regression analyses were performed after adjustment for sociodemographic characteristics, general health behaviors, and other comorbidities.

Results

The AR+/RS+ group contained the highest proportion of subjects with perceived stress and depressed mood. Subjects with AR+/RS+ also had more frequent problems in terms of pain/discomfort and anxiety/depression. After adjusting for all confounders, the odds ratios (ORs) were 2.96 (p = 0.009) for depressed mood and 3.17 (p = 0.013) for suicidal ideation in the AR+/RS+ group compared with in the AR-/RS- group. The AR+/RS- group reported more perceived stress (OR, 1.56, p = 0.003) and depression (OR, 1.72, p = 0.024) compared with the AR-/RS- group. In terms of the ORs for HRQoL, the AR+/RS+ group reported more problems in terms of self-care (OR, 3.73, p = 0.038) and more pain/discomfort (OR 2.19, p = 0.006) compared with the AR-/RS- group.

Conclusions

In the Korean population, AR and RS exerted a synergistic negative impact on mental health and HRQoL, especially suicidal ideation. Most patients seek help from clinicians for impaired HRQoL. Therefore, clinicians should consider the underlying mental health and HRQoL of patients with AR and/or RS, as these may be impaired by their conditions.

Depression symptoms and lost productivity in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with significant losses of patient productivity that cost billions of dollars every year. The causative factors for decreases in productivity in patients with CRS have yet to be determined.

OBJECTIVE

To determine which patterns of CRS symptoms drive lost productivity.

METHODS

Prospective, cross-sectional cohort study of 107 patients with CRS. Sinonasal symptom severity was measured using the 22-item Sinonasal Outcomes Test, from which sleep, nasal, otologic or facial pain, and emotional function subdomain scores were calculated using principal component analysis. Depression risk was assessed with the 2-item Patient Health Questionnaire (PHQ-2), whereas nasal obstruction was assessed with the Nasal Obstruction Symptom Evaluation (NOSE) instrument. Lost productivity was assessed by asking participants how many days of work and/or school they missed in the last 3 months because of CRS. Associations were sought between lost productivity and CRS symptoms.

RESULTS

A total of 107 patients were recruited. Patients missed a mean (SD) of 3.1 (12.9) days of work or school because of CRS. Lost productivity was most strongly associated with the emotional function subdomain (β = 7.48; 95% confidence interval [CI], 5.71-9.25; P < .001). Reinforcing this finding, lost productivity was associated with PHQ-2 score (β = 4.72; 95% CI, 2.62-6.83; P < .001). Lost productivity was less strongly associated with the nasal symptom subdomain score (β = 2.65; 95% CI, 0.77-4.52; P = .007), and there was no association between lost productivity and NOSE score (β = 0.01; 95% CI, -0.12 to 0.13; P = .91).

CONCLUSION

Symptoms associated with depression are most strongly associated with missed days of work or school because of CRS. Further treatment focusing on depression-associated symptoms in patients with CRS may reduce losses in productivity.

Burden of illness: A systematic review of depression in chronic rhinosinusitis

BACKGROUND

Depression has been reported in patients with chronic rhinosinusitis (CRS), but its prevalence varies across studies, and uncertainty remains regarding the association with baseline disease severity and treatment outcomes.

OBJECTIVE

To systematically assess the prevalence of depression in CRS and to review its relationship to baseline disease severity and outcomes after treatment.

METHODS

A systematic review of the prevalence of possible depression was performed by using the available methods to diagnose depression, and the results were pooled. Studies that examined the relationship of depression on baseline disease severity and treatment outcomes were organized and reported individually.

RESULTS

Thirteen studies met inclusion criteria for prevalence analysis. The prevalence of possible or likely depression in patients with CRS ranged from 11.0 to 40.0%, depending on the method of diagnosis and sensitivity of various depression instruments. Positive depression screening was consistently associated with worse CRS-specific quality of life (QOL), medication usage, and health care utilization, but there were no reliable CRS-specific factors to predict the presence of depression. Patients with possible depression who underwent medical or surgical treatment for CRS tended to have improvements in CRS-specific QOL but did not achieve the same degree of QOL as patients who were not depressed. Depression-specific QOL seemed to improve after treatment for CRS.

CONCLUSION

Positive depression screening was common in patients with CRS and had a negative association on the entire spectrum of QOL, health care utilization, and productivity. CRS-specific treatments were still beneficial in patients who seemed to be depressed and improved both depression-specific and CRS-specific QOL.

Sleep disruption in chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is a common disease of the upper airways and paranasal sinuses with a marked decline in quality of life (QOL). CRS patients suffer from sleep disruption at a significantly higher proportion (60 to 75%) than in the general population (8-18 %). Sleep disruption in CRS causes decreased QOL and is linked to poor functional outcomes such as impaired cognitive function and depression. Areas covered: A systematic PubMed/Medline search was done to assess the results of studies that have investigated sleep and sleep disturbances in CRS. Expert commentary: These studies reported sleep disruption in most CRS patients. The main risk factors for sleep disruption in CRS include allergic rhinitis, smoking, and high SNOT-22 total scores. The literature is inconsistent with regard to the prevalence of sleep-related disordered breathing (e.g. obstructive sleep apnea) in CRS patients. Although nasal obstruction is linked to sleep disruption, the extent of sleep disruption in CRS seems to expand beyond that expected from physical blockage of the upper airways alone. Despite the high prevalence of sleep disruption in CRS, and its detrimental effects on QOL, the literature contains a paucity of studies that have investigated the mechanisms underlying this major problem in CRS.

Chronic rhinosinusitis: Epidemiology and burden of disease

BACKGROUND

Chronic rhinosinusitis (CRS) is based on sinonasal symptoms coupled with sinonasal tissue inflammation. Establishing the epidemiology and prevalence of CRS, therefore, is challenging given that confirming objective evidence of sinonasal inflammation on a large scale is not feasible. Although the sinonasal symptoms are well documented at the sinonasal level, analysis of emerging data indicates that the impact on the general-health-related domains of health are the symptoms that are most bothersome to patients' quality of life.

OBJECTIVE

To review the literature on the epidemiology and the societal and individual burdens of CRS.

METHODS

A literature review.

RESULTS

A refinement of questionnaire-based surveys coupled with sampling of respondents for accuracy likely provides the most accurate assessment of prevalence. There is geographic variation, but, in North American and European countries, the rates range from 4.5 to 12%. Although CRS is marked by sinonasal symptoms, the most problematic symptoms for patients seem to be the symptoms that affect general-health-related domains. Diminished sleep, productivity, cognition, mood, and fatigue are associated with the decision to elect surgical intervention and are associated with diminished healthy utility values. Direct costs of CRS have been well documented, but new data on the indirect costs of decreased productivity surpass direct costs, at $12.8 billion dollars per year in the United States.

CONCLUSION

CRS is a common disease with a large and vast symptom burden with high indirect costs. Although clinicians are focused by guidelines on sinus-specific symptoms, patients seem to be most impacted by the general-health-related consequences of CRS. An expanded understanding of the extent and costs of these symptoms will allow for a cost-effective allocation of limited health care resources.

Depression in chronic rhinosinusitis: A controlled cohort study

BACKGROUND

Depression in patients with chronic rhinosinusitis (CRS) is underdiagnosed but significantly impacts treatment outcomes and health care utilization.

OBJECTIVE

To compare undiagnosed depression in a CRS cohort with a healthy, non-CRS control cohort.

METHODS

A case-control study of patients with symptomatic CRS and a non-CRS control cohort was performed. Demographic and comorbidity factors were correlated to depression-specific outcomes by using the Beck Depression Inventory II (BDI).

RESULTS

We enrolled 42 patients with CRS and 88 control patients with no history of CRS. Physician-diagnosed depression was equivalent in CRS and control patients (6% and 9%, respectively). BDI-detected depression was higher among patients with CRS compared with controls (31% versus 14.8%, respectively; p = 0.031). BDI scores were higher in patients with CRS even when controlling for comorbid asthma, allergy, and aspirin sensitivity. When examined by polyp status, the patients without polyps had more depression than did the controls (38% versus 14.8%; p = 0.048). The somatic subscale scores of the BDI were worse in patients with CRS (p = 0.004), whereas the cognitive subscale trended toward significance (p = 0.081).

CONCLUSION

Depression may be more common in CRS than previously recognized, especially in patients without polyps. Somatic subscale scores of the BDI are increased in CRS and may impact future treatment outcomes.

Depression-Specific Outcomes After Treatment of Chronic Rhinosinusitis

IMPORTANCE

Depression is frequently undiagnosed in patients with chronic rhinosinusitis (CRS) and affects quality of life, productivity, and health care use.

OBJECTIVE

To examine depression-specific outcomes after medical or surgical treatment of CRS.

DESIGN, SETTING, AND PARTICIPANTS

A multi-institutional, prospective study of patients with refractory CRS treated at tertiary academic rhinology centers was performed from March 1, 2011, to November 1, 2015. Data analysis was performed from October 1, 2015, to November 1, 2015.

INTERVENTIONS

Patients self-selected to undergo continued medical management or endoscopic sinus surgery for refractory CRS.

MAIN OUTCOMES AND MEASURES

Patients completed the 22-item Sinonasal Outcome Test (SNOT22), Rhinosinusitis Disability Index (RSDI), Pittsburgh Sleep Quality Index (PSQI), and missed productivity and medication use questionnaires before and at least 6 months after treatment. Computed tomography and endoscopy scoring were performed with reviewers masked to patient-reported data. Depression-specific outcomes were recorded using the 2-item Patient Health Questionnaire (PHQ2).

RESULTS

Baseline data were available on 685 patients, with 167 (24.4%) having depression according to the PHQ2 scores. The mean (SD) age of the patients was 50.5 (15.0) years, and 332 (48.4%) were male. Revision surgery status was the only baseline factor associated with depression (53.9% vs 38.0%, P < .001). Patients with depression had worse baseline SNOT22 (mean, 64.5 vs 47.6), PSQI (mean, 12.8 vs 8.4), productivity (mean, 22.8 vs 5.2 days missed), and medication use scores for oral antibiotics (mean, 23.8 vs 14.8) and oral corticosteroids (mean, 17.8 vs 9.9) (P < .001 for all). Medical and surgical treatments had similar outcomes for patients with depression with mean improvement in the PHQ2 scores from 3.96 to 1.91 (P < .001), and 110 of 167 patients (65.9%) categorized as having depression at baseline were categorized as not having depression after treatment. Improvements in the PHQ2 scores were associated with improvements in the SNOT22, PSQI, oral antibiotic use, and productivity scores (P ≤ .001 for all).

CONCLUSIONS AND RELEVANCE

Depression is a common comorbidity in patients with CRS and affects numerous quality-of-life and health care outcomes. There are few objective baseline factors to aid physicians in identifying depression in patients with CRS. Medical and surgical treatments for CRS improve depression and related clinical outcomes.

An acetaminophen icon helps reduce medication decision errors in an experimental setting

OBJECTIVES

To assess the effect of adding an acetaminophen ingredient icon to acetaminophen medication labels on consumer decision making about concomitant use of acetaminophen medications to avoid overdose, which is associated with liver injury.

DESIGN

Parallel-group randomized study.

SETTING

Consumer research facilities in Indianapolis, Baltimore, and Los Angeles.

PARTICIPANTS

A total of 517 adults (30% with limited health literacy) recruited at 3 consumer research sites.

INTERVENTION

Participants were randomized to a non-icon condition in which medications carried current labeling or an icon condition in which all acetaminophen medications were additionally marked with an icon.

MAIN OUTCOME MEASURES

Participants were presented with a medicine cabinet containing 12 diverse prescription and non-prescription medications, one-half containing acetaminophen, and made decisions about which medications were appropriate to take after an acetaminophen medication had already been taken. Outcome measures were errors in medication decisions and response time.

RESULTS

The icon reduced the odds of participants making medication-decision errors by 53% (CI 31%-68%), with effects evident across medication categories. The icon eliminated a trend for those with lower health literacy or less education to have a greater likelihood of making errors. The icon also reduced response times, indicating reduced cognitive load for decisions.

CONCLUSION

An icon can improve decision making regarding acetaminophen-containing medications, particularly among individuals with limited health literacy or education.

Endoscopic sinus surgery improves cognitive dysfunction in patients with chronic rhinosinusitis

BACKGROUND

Patients with chronic rhinosinusitis (CRS) have been found to have cognitive deficit, as identified using the Cognitive Failures Questionnaire (CFQ), but the exact etiology of cognitive decline is unknown. In this study we aimed to determine whether improvement in concomitant inflammation and disease burden in CRS, using endoscopic sinus surgery (ESS), improves cognitive deficit. We also sought to identify comorbid conditions that effect improvement likelihood.

METHODS

Study participants (n = 247) with and without nasal polyposis (CRSwNP, CRSsNP) were prospectively enrolled in this multi-institutional, observational outcomes study. Pre- and postoperative cognitive dysfunction was evaluated using the CFQ instrument. Quality of life (QOL) and disease burden was also evaluated using the Rhinosinusitis Disability Index (RSDI), the 22-item SinoNasal Outcome Test (SNOT-22), nasal endoscopy, computed tomography, and the 2-item Patient Health Questionnaire (PHQ-2).

RESULTS

Average CFQ total scores improved significantly (p = 0.012) after ESS for patients with follow-up (n = 141). Participants with CRSwNP (n = 51) reported significant postoperative improvements in mean CFQ total scores (p = 0.002) and CFQ distractibility and blunders domain scores (p ≤ 0.006). No significant postoperative improvement for any average CFQ score was found in CRSsNP (p > 0.086). The magnitude of postoperative improvement in CFQ total and domain mean scores was statistically similar between CRSsNP and CRSwNP (p > 0.115). Depressive disorder, identified using PHQ-2 screening, was the only comorbid condition significantly associated with measurable cognitive deficit (p < 0.001).

CONCLUSIONS

Patients with CRS have measurable cognitive decline, and ESS may modestly improve cognitive deficit/CFQ scores. Future investigations are needed to further elucidate the underlying mechanisms responsible for cognitive deficit in patients with CRS and significant associations with depression.

The Association Between Olfaction and Depression: A Systematic Review

Previous studies on the relationship between olfaction and depression have revealed mixed results. In addition, few have focused on the reciprocity of this association. The aim of this study is to combine depression and olfactory data in two separate patient populations to further understand their association. A systematic literature review was conducted using 3 online databases to identify studies correlating olfaction and depression in patients presenting with either primary depression or primary olfactory dysfunction. For the depressed population, weighted means and standard deviations for the Sniffin' Sticks Test and the 40-item Smell Identification Test were combined using 10 studies. For the olfactory dysfunction population, weighted means of Beck's Depression Inventory were combined using 3 studies. Independent t-tests were used to compare differences between groups. Comparing primary depressed patients with controls, depressed patients showed decreased scores in olfactory threshold (6.31±1.38 vs. 6.78±0.88, P = 0.0005), discrimination (12.05±1.44 vs. 12.66±1.36, P = 0.0073), identification (12.57±0.74 vs. 12.98±0.90, P < 0.0001), and 40-Item Smell Identification Test (35.31±1.91 vs. 37.41±1.45, P < 0.0001). In patients with primary olfactory dysfunction, Beck's Depression Inventory scores were significantly different between patients classified as normosmics, hyposmics and anosmics (5.21±4.73 vs. 10.93±9.25 vs. 14.15±5.39, P ≤ 0.0274 for all 3 comparisons). In conclusion, patients with depression have reduced olfactory performance when compared with the healthy controls and conversely, patients with olfactory dysfunction, have symptoms of depression that worsen with severity of smell loss.

Twenty-two-item Sino-Nasal Outcome Test in a control population: a cross-sectional study and systematic review

BACKGROUND

The 22-item Sino-Nasal Outcome Test (SNOT-22) is a commonly utilized outcome measure for chronic rhinosinusitis (CRS). However, what constitutes a normal score remains poorly defined. The goal of this study was to evaluate SNOT-22 scores in a control population without CRS and perform a systematic review and meta-analysis of "normal" values.

METHODS

Ninety-nine subjects without CRS were enrolled, with 95 fully completing the SNOT-22 questionnaire. Multivariable linear regression was used to determine whether demographic factors or medical comorbidities influence SNOT-22 scores in a population without CRS. A systematic literature search was performed, identifying studies that evaluated the SNOT-22 in a non-CRS population and estimates for SNOT-22 values were pooled.

RESULTS

Thirty-six males and 59 females were included in the primary analysis with a mean age of 53.4 ± 17.3 years (range, 18-88 years). The mean SNOT-22 score was 16.4 ± 15.2. Asthma (p = 0.003) and depression (p = 0.002) were found to be independent predictors of higher SNOT-22 scores. Thirteen articles were identified in the literature search and 1 was provided via author correspondence, with 10 reporting sufficient data to be included in the meta-analysis. Weighted mean SNOT-22 score was 11 ± 9.4 (n = 1517). Our data differed significantly from published data (mean difference = 5.4; 95% confidence interval [CI], 3.4 to 7.5; p < 0.0001) likely owing to differences in comorbidities.

CONCLUSION

SNOT-22 scores vary in non-CRS populations depending upon the group queried. Asthma and depression are associated with higher SNOT-22 scores and should be considered when determining what constitutes a normal value.