Depression and Anxiety: Considerations for Interpretation of the SNOT-22 (22-Item Sinonasal Outcome Test)

Mendelian randomization and single-cell expression analyses identify the causal relationship between depression and chronic rhinosinusitis

Background

The causative relationship between chronic rhinosinusitis (CRS) and depression remains unclear. Herein we employed Mendelian randomization (MR) coupled with single-cell analysis to investigate the causality between CRS and depression.

Methods

Data pertaining to CRS and depression were mined from the genome-wide association study database, and a single-cell dataset was sourced from the literature. To explore causality, we conducted bidirectional MR analysis using MR-Egger, weighted median, inverse variance weighted (IVW), simple mode, and weighted mode, with IVW representing the most important method. Further, sensitivity analysis was performed to evaluate the robustness of MR analysis results. Candidate genes were analyzed via single-cell combined MR analysis.

Results

Forward MR analysis indicated depression as a risk factor for CRS when depression was the exposure factor and CRS was the outcome (OR = 1.425, P < 0.001). Reverse MR analysis revealed the same positive relationship between CRS and depression when CRS was the exposure factor and depression was the outcome (OR = 1.012, P = 0.038). Sensitivity analysis validated the robustness of bidirectional MR analysis results. Ten cell types (endothelial, ciliated, basal, myeloid, mast, apical, plasma, glandular, fibroblast, and T cells) were identified in the single-cell dataset. The network of receptor-ligand pairs showed that in normal samples, cell-cell interactions were present among various cell types, such as epithelial, mast, myeloid, and endothelial cells. In contrast, CRS samples featured only one specific receptor-ligand pair, confined to myeloid cells. TCF4 and MEF2C emerged as potentially crucial for CRS-associated depression development.

Conclusions

Our findings suggest a bidirectional causal relationship between CRS and depression, offering a new perspective on the association between CRS and depression.

Predictive factors for decreased baseline quality of life in patients with sinonasal malignancies

BACKGROUND

The impact of sinonasal malignancies (SNMs) on quality of life (QOL) at presentation is poorly understood. The Sinonasal Outcome Test (SNOT-22) and University of Washington Quality of Life (UWQOL) are validated QOL instruments with distinctive subdomains. This study aims to identify factors impacting pretreatment QOL in SNM patients to personalize multidisciplinary management and counseling.

METHODS

Patients with previously untreated SNMs were prospectively enrolled (2015-2022) in a multicenter observational study. Baseline pretreatment QOL instruments (SNOT-22, UWQOL) were obtained along with demographics, comorbidities, histopathology/staging, tumor involvement, and symptoms. Multivariable regression models identified factors associated with reduced baseline QOL.

RESULTS

Among 204 patients, presenting baseline QOL was significantly reduced. Multivariable regression showed worse total SNOT-22 QOL in patients with skull base erosion (p = 0.02). SNOT-rhinologic QOL was worse in women (p = 0.009), patients with epistaxis (p = 0.036), and industrial exposure (p = 0.005). SNOT extranasal QOL was worse in patients with industrial exposure (p = 0.016); worse SNOT ear/facial QOL if perineural invasion (PNI) (p = 0.027). Squamous cell carcinoma pathology (p = 0.037), palate involvement (p = 0.012), and pain (p = 0.017) were associated with worse SNOT sleep QOL scores. SNOT psychological subdomain scores were significantly worse in patients with palate lesions (p = 0.022), skull base erosion (p = 0.025), and T1 staging (p = 0.023). Low QOL was more likely in the presence of PNI on UW health (p = 0.019) and orbital erosion on UW overall (p = 0.03). UW social QOL was worse if palatal involvement (p = 0.023) or PNI (p = 0.005).

CONCLUSIONS

Our findings demonstrate a negative impact on baseline QOL in patients with SNMs and suggest sex-specific and symptom-related lower QOL scores, with minimal histopathology association. Anatomical tumor involvement may be more reflective of QOL than T-staging, as orbital and skull base erosion, PNI, and palate lesions are significantly associated with reduced baseline QOL.

The Burden of Migraine on Quality of Life in Chronic Rhinosinusitis

OBJECTIVE

To determine the impact of comorbid migraine on quality of life (QOL) in chronic rhinosinusitis (CRS).

METHODS

A total of 213 adult patients with CRS were recruited. All participants completed the 22-item Sinonasal Outcome Test (SNOT-22), from which total and validated nasal, ear/facial pain, sleep, and emotional subdomain scores were calculated, and the 5-dimension EuroQol general health questionnaire (EQ-5D), from which the visual analogue scale (VAS) and health utility value (HUV) were calculated. The presence of comorbid migraine was determined by a score of ≥4 on the 5-item Migraine Screen Questionnaire (MS-Q).

RESULTS

Of the participants, 36.2% were screened positive for having comorbid migraine. The mean SNOT-22 score was 64.9 (SD: 18.7) in participants with migraine and 41.5 (SD: 21.1) in participants without migraine (p < 0.001). The mean EQ-5D VAS and HUV were 60.2 (SD: 21.9) and 0.69 (SD: 0.18), respectively, in participants with migraine and 71.4 (SD: 19.4) and 0.84 (SD: 0.13), respectively, in participants without migraine (p < 0.001 for both). Higher ear/facial pain (OR = 1.22, 95% CI: 1.10-1.36, p < 0.001) and sleep (OR = 1.11, 95% CI: 1.04-1.18, p = 0.002) SNOT-22 subdomain scores were positively associated with migraine. The SNOT-22 item scores related to dizziness, reduced concentration, and facial pain, in descending order, were most associated with migraine. The presence of nasal polyps (OR = 0.24, 95% CI: 0.07 - 0.80, p = 0.020) was negatively associated with migraine.

CONCLUSION

Comorbid migraine may be relatively common amongst CRS patients, and its presence is associated with significantly worse QOL. Dizziness as a symptom in CRS patients may be particularly indicative of migraine.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3279-3284, 2023.

The Impact of Gender on Long-Term Quality of Life After Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

To identify the impact of gender on the clinical outcomes of endoscopic sinus surgery (ESS) through the comparison of quality of life measures in female and male patients who undergo surgical treatment for chronic rhinosinusitis (CRS).

STUDY DESIGN

Prospective observational cohort study.

METHODS

Patients with CRS completed the 22-item Sino-Nasal Outcome Test (SNOT-22) and EuroQol 5-Dimension Survey (EQ-5D) preoperatively and annually for 5 years following ESS. Health utility values (HUV) were calculated from EQ-5D scores. Comparisons of cohort characteristics were performed with chi-square and t-tests. A multivariable linear mixed effects model evaluated changes in SNOT-22 and HUV over time by gender.

RESULTS

Among the 1268 patients (54% female) enrolled, 789 and 343 completed postoperative surveys at one and 5 years, respectively. Preoperatively, females experienced more severe symptoms: mean SNOT-22 score (51.1 ± 20.9 female vs. 44.7 ± 20.0 male, p < 0.001) and HUV (0.80 ± 0.14 female vs. 0.84 ± 0.11 male, p < 0.001). These gender differences were resolved by year one postoperatively (SNOT-22: p = 0.083; HUV: p = 0.465). Two years after surgery, however, females reported more severe symptoms (SNOT-22: 25.6 ± 20.7 female vs. 21.5 ± 17.4 male, p = 0.005; HUV: 0.88 ± 0.12 female vs. 0.90 ± 0.11 male, p = 0.018), a difference that persisted at year five. These gender-related differences remained after adjusting for age, race, ethnicity, nasal polyps, history of prior ESS, and smoking status (p < 0.001). Within-subject improvement was comparable between genders (SNOT-22: p = 0.869; HUV: p = 0.611).

CONCLUSION

Females with CRS reported more severe symptoms both before and 5 years after surgery compared to their male counterparts. Understanding the mechanism behind these gender-related differences is important for optimizing CRS treatment.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3319-3326, 2023.

Validation of the Dutch version of the 22-item Sino-Nasal Outcome Test (SNOT-22)

Background: The 22-item Sino-Nasal Outcome Test (SNOT-22) is a widely used questionnaire to measure disease-specific health-related quality of life in patients with chronic rhinosinusitis (CRS). The Dutch version has not been validated yet. Methods: The SNOT-22 was translated through a forward-backward translation technique and validated by a test-retest protocol in CRS patients, a responsiveness analysis in CRS patients treated with dupilumab, while using healthy individuals as controls. Results: The Dutch SNOT-22 showed excellent test-retest properties, good responsiveness to treatment with dupilumab, and a clear distinction between outcomes of CRS patients and healthy controls. Conclusion: The Dutch version of the SNOT-22 is a valid outcome measure in CRS patients.