Radiation-associated changes in saliva composition of head and neck cancer patients: A systematic review

Xerostomia is a common radiation-associated toxicity in patients with head and neck cancer. Although several studies examined the decrease in saliva production due to radiotherapy (RT) and investigated the factors associated with this side effect, little is known about the change in radiation-associated saliva composition. This systematic review is the first to summarize existing data and give an overview of the change in pH/buffer capacity, electrolytes, proteins, enzymes, and mucins due to radiation to the salivary glands. Literature search was performed in PubMed and Embase with 47 articles finally eligible for the review, analyzing the saliva composition at several time points before, during and/or after RT, or comparing findings in irradiated patients to a healthy control group. Overall, RT leads to a substantial decrease in salivary pH and buffer capacity. For sodium, chloride and calcium ion, and amylase, an increased concentration or activity during RT was reported in most of the studies, followed by a subsequent decrease either already during RT or after the end of treatment. Different trends have been described for the total protein concentration during and after RT. Lactoferrin, however, increased considerably, especially in the first phase of RT. Mucin 5B (MUC5B) concentrations showed a slight increase during RT and concentrations around baseline values again six months post-radiotherapy.

Patient Perspectives on Acute Exacerbations of Chronic Rhinosinusitis: A Qualitative Study

OBJECTIVE

Acute exacerbations of chronic rhinosinusitis (AECRS) are currently defined as a transient worsening of symptoms that return to baseline. This definition is narrow and can only be made retrospectively. The literature has studied this phenomenon from the physician perspective, yet a key stakeholder's-the patient's perspective is not well elucidated in the literature. To understand AECRS from the patient's perspective, we performed this study to further clarify this phenomenon.

STUDY DESIGN

Basic qualitative study via patient interviews using constant comparative methodology was conducted.

SETTING

Tertiary care academic center.

METHODS

Two of the authors served as coders, and via group discussion, a common codebook was created and used to identify recurrent themes. The themes were analyzed for meaning and conclusions were summarized.

RESULTS

Ten interviews were conducted with chronic rhinosinusitis (CRS) patients. Recurring themes included the following: (1) patients identify with the term flare or sinus infection more than exacerbation; (2) consistent with the current definition, patients identify AECRS by worsening sinonasal symptoms but also relate secondary symptoms, including poor sleep, fatigue, exacerbation of lower respiratory tract symptoms, and malaise to AECRS; and (3) patients are greatly affected by AECRS via decreased quality of life (QOL), worsening of general health, and decreasing productivity.

CONCLUSION

Beyond worsening of sinonasal symptoms, the concept of AECRS reflects a more complex construct to patients with associated extranasal symptoms and systemic manifestations. In addition, AECRS have a large impact on patients, and therefore, understanding this component of CRS is pivotal in improving disease control and QOL in this patient population.

Disease control in chronic rhinosinusitis: a qualitative study of patient perspectives

BACKGROUND

The definition of disease control in chronic rhinosinusitis (CRS) is an active area of study. However, investigations have not engaged CRS patients in how they think about disease control. This study seeks to understand the patient perspective on CRS disease control.

METHODS

Qualitative phenomenological study using constant comparative methodology was applied. The research team conducted 10, one-on-one interviews with CRS patients ranging from 22 to 55 minutes in length. The content of the interview protocol was determined through iterative discussion amongst all authors. Two authors served as coders to identify recurrent themes. Themes were analyzed for meaning and conclusions were summarized.

RESULTS

Three recurring themes determined from patients were that (1) use of the terminology "control" adequately represents this phenomenon, (2) components of control could be classified into four main themes relating to CRS symptomatology, exacerbation of comorbid disease, quality of life and acute exacerbations of CRS, and (3) when patients deem their CRS is uncontrolled they are more willing to escalate their treatment to include escalating their daily maintenance regimen, seeking otolaryngology referral, taking rescue medication or undergoing endoscopic sinus surgery.

CONCLUSIONS

CRS patients consider their daily symptoms, the severity and frequency of CRS exacerbations, impact on quality of life as well as exacerbation of comorbid disease when thinking about their disease control. Disease control is a goal of treatment for patients and uncontrolled disease motivates patients to seek further treatment. Physicians should explore all components of CRS control when considering disease status and need for further treatment.

Dedicated Olfaction and Taste Items do not Improve Psychometric Performance of the SNOT-22

Objective

Previous work has shown the chemosensory dysfunction item of the 22‐item Sinonasal Outcome Test (SNOT‐22) that assesses problems with “taste/smell” has poor psychometric performance compared with other items on the SNOT‐22, which we have hypothesized is due to the simultaneous assessment of two different senses. Our aim was to determine whether distinct smell and taste items in the SNOT‐22 would improve psychometric performance.

Methods

One hundred and eighty‐one CRS patients were recruited and completed the SNOT‐22. Additional items querying problems with the senses of “smell” and “taste,” using the same response scale and recall period were given to study participants. Item response theory (IRT) was used to determine IRT parameters, including item discrimination, difficulty, and information provided by each SNOT‐22 item.

Results

Confirming previous studies, the chemosensory item of the SNOT‐22 (reflecting “taste/smell”) had poor psychometric performance. Use of a distinct smell or taste item instead of the combined “taste/smell” item did not improve psychometric performance. However, a dedicated smell question resulted in a left shift of threshold parameters, showing that the dedicated smell item better captures moderate CRS disease burden than the original taste/smell item of the SNOT‐22, which by virtue of near‐identical IRT parameters appears to more greatly reflect problems with taste.

Conclusions

A dedicated smell‐ or taste‐specific item, rather than the combined “taste/smell” item currently in the SNOT‐22 does not provide significantly greater psychometric performance. However, a dedicated smell item may better capture moderate CRS disease burden compared with the current chemosensory item on the SNOT‐22. Laryngoscope, 132:1644–1651, 2022

[Olfactory and gustatory disorders]

Ziel der vorliegenden Übersicht ist es, einen Überblick über die Ätiologie und Diagnostik von Riech- und Schmeckstörungen zu geben. Da etwa 5 % der Allgemeinbevölkerung betroffen sind, ist es ein häufiges Krankheitsbild. Riechen und Schmecken erhielten v. a. zuletzt Aufmerksamkeit während des Aufkommens der SARS-CoV-2-Pandemie, wobei eine plötzlich aufgetretene Riech- und/oder Schmeckstörung zu den typischen Symptomen zählt. Daneben sind Riechstörungen in der Frühdiagnostik neurodegenerativer Erkrankungen von Bedeutung. Häufig zeigen Patienten mit Riechstörungen Zeichen einer Depression. Die Auswirkungen von Riech‑/Schmeckstörungen sind also umfangreich, die Therapiemöglichkeiten aktuell begrenzt. Nach einem Einblick in die Ätiologie werden Diagnostik und Therapiemöglichkeiten auf dem aktuellen Stand der Literatur erörtert. Auch zukunftsweisende Behandlungsvorstellungen, wie z. B. autologe Schleimhauttransplantationen oder olfaktorische Implantate, werden angesprochen.

Utility of Visual Analog Scale of Subdomain Scores of the 22-Item Sinonasal Outcome Test in Chronic Rhinosinusitis

The burden of chronic rhinosinusitis (CRS) symptomatology is frequently measured with the 22-item Sinonasal Outcome Test (SNOT-22). In some situations, such as when there is need for frequent sampling, a full SNOT-22 may be impractical, and an abbreviated measure may be useful. Herein, we study 4 questions reflecting the 4 SNOT-22 subdomains as accurate reflections of SNOT-22 content. In total, 250 patients with CRS completed a SNOT-22 and answered 4 questions about their total nasal symptoms, poor sleep quality, ear/facial pain, and mood (reflecting SNOT-22 subdomains) using visual analog scales (VASs). The 4 SNOT-22 subdomain VAS scores each correlated strongly with the corresponding SNOT-22 subdomain scores. The sum of the 4 subdomain question VAS scores was highly correlated with the total SNOT-22 score (r = 0.77, P < .001). This preliminary study suggests information from the SNOT-22 may be ascertained through 4 questions reflecting the 4 SNOT-22 subdomains, although further validation is needed.

EPOS 4 Patients

EPOS2020 is the 4th and most recent version of the European Position Paper on Rhinosinusitis and Nasal Polyps which was first published in 2005. It aims to provide the most up to date scientifically robust information on the topic published in the literature which has been critically analysed by an international group of clinicians drawn from all disciplines dealing with these problems together with patients. The guidelines offer evidence-based recommendations and care pathways for acute and chronic rhinosinusitis in both adults and children. Management of these diseases from the patients' perspective is an important part of EPOS2020. Not only is this included in the main document but, for the first time, we have produced a separate supplement dedicated to and in collaboration with patients, EPOS4Patients, which aims to provide information in an accessible format, to answer frequently asked questions about these diseases and their treatment options as well as including useful patient resources and websites. It has never been more important for patients to be actively involved in their care. Being well informed helps you to make the best decisions together with your doctor.

Exploring possibilities for shortening the 22-item Sino-Nasal Outcome Test (SNOT-22) using item response theory

BACKGROUND

Even with a high-quality instrument, such as the 22-item Sino-Nasal Outcome Test (SNOT-22), patients can be overwhelmed by repeated completion of questionnaires, leading to nonadherence and reduced data quality. The aim of this study was to evaluate whether the SNOT-22 could be made more concise without losing the valuable information that it provides.

METHODS

A modern psychometric approach, item response theory (IRT), was used on a sample of 800 patients with chronic rhinosinusitis (CRS). The SNOT-22 was refined based on: (1) the item information criteria, retaining only items with above-average information; and (2) the total test information, retaining only the most discriminating items to cover at least 30% of the information within each subdomain. The preliminary validity and reliability of these refined scales were assessed using Cronbach's alpha and Pearson's correlation.

RESULTS

Using an IRT approach, we find that it may be possible to shorten the SNOT-22 to an 11-item and six-item version based on psychometric properties. Item information functions of the shortened 11-item and six-item scales demonstrate that both versions accurately covered the CRS symptom-severity continuum. Preliminary reliability and validity analysis showed that both refined scales had good to excellent reliability (Cronbach's alpha ≥ 0.80) and were highly associated with the original full-length scale (r ≥ 0.90).

CONCLUSION

IRT provides data-driven opportunities for the continuous development and refinement of the SNOT-22. While patient and provider input must be accounted for too, our results show that future revisions of the SNOT-22 could include significantly fewer items.

Item Response Theory for Psychometric Properties of the SNOT-22 (22-Item Sinonasal Outcome Test)

OBJECTIVE

The SNOT-22 (22-item Sinonasal Outcome Test) is a high-quality outcome measure that assesses chronic rhinosinusitis-specific quality of life. The aim of this study was to gain greater insight into the information provided by the SNOT-22 by determining its item-based psychometric properties.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic centers.

METHODS

This study used a previously described data set of the SNOT-22 completed by 800 patients with chronic rhinosinusitis. Item response theory graded response models were used to determine parameters reflecting item discrimination, difficulty, and information provided by each item toward the SNOT-22 subdomain to which it belonged.

RESULTS

The unconstrained graded response model fitted the SNOT-22 data best. Item discrimination parameters and total information provided showed the greatest variability within the nasal subdomain, and the item related to sense of smell/taste demonstrated the lowest discrimination and provided the least amount of information overall. The dizziness item provided disparately lower total information and discrimination in the otologic/facial pain subdomain. Items in the sleep and emotional subdomains generally provided high discrimination. While items in the nasal, sleep, and otologic/facial pain subdomains spanned all levels of difficulty, emotional subdomain items covered higher levels of difficulty, indicating greater information provided at higher levels of disease severity.

CONCLUSION

The item-specific psychometric properties of the SNOT-22 support it as a high-quality instrument. Our results suggest the need and possibility for revision of the smell/taste dysfunction item, for example its wording, to improve its ability to discriminate among the different levels of disease burden.

Portable HEPA Purifiers to Eliminate Airborne SARS-CoV-2: A Systematic Review

OBJECTIVE

Current epidemiologic predictions of COVID-19 suggest that SARS-CoV-2 mitigation strategies must be implemented long-term. In-office aerosol-generating procedures pose a risk to staff and patients while necessitating examination room shutdown to allow aerosol decontamination by indwelling ventilation. This review summarizes the current state of knowledge on portable high-efficiency particulate air (HEPA) purifiers' effectiveness in eliminating airborne SARS-CoV-2 from indoor environments.

DATA SOURCES

Medline, Embase, Cochrane Databases, and the World Health Organization's COVID-19 Global Literature on Coronavirus Disease.

REVIEW METHODS

Data sources were systematically searched for original English-language published studies indexed up to January 14, 2021 per the following search strategy: ("HEPA" OR "High-efficiency" OR "High-efficiency particulate air" OR "Efficiency particulate" OR "Purifier" OR "Filter" OR "Cleaner" OR "Filtration") AND ("COVID" OR "COVID-19" OR "SARS-CoV-2" OR "Coronavirus"). Additional relevant studies were identified by searching the reference lists of included articles.

RESULTS

Eleven published studies have evaluated the effectiveness of portable HEPA purifiers in eliminating airborne SARS-CoV-2 with relevantly sized surrogate particles. Ten studies evaluated aerosols and submicron particles similar in size to SARS-CoV-2 virions. In all studies, portable HEPA purifiers were able to significantly reduce airborne SARS-CoV-2-surrogate particles. The addition of portable HEPA purifiers augmented other decontamination strategies such as ventilation.

CONCLUSION

Experimental studies provide evidence for portable HEPA purifiers' potential to eliminate airborne SARS-CoV-2 and augment primary decontamination strategies such as ventilation. Based on filtration rates, additional air exchanges provided by portable HEPA purifiers may be calculated and room shutdown times potentially reduced after aerosol-generating procedures.

Patient perspectives on recall period and response options in patient-reported outcome measures for chronic rhinosinusitis symptomatology: A pilot study

OBJECTIVE

Patient-reported outcome measures (PROMs) for assessment of chronic rhinosinusitis (CRS) employ a variety of recall periods and response scales for reporting CRS symptom burden. CRS patient perspective is unknown with respect to recall periods and response scales in PROMs.

DESIGN

Cross-sectional study.

SETTING

Tertiary rhinology clinic.

PARTICIPANTS

Sixty three adults with CRS.

MAIN OUTCOME MEASURES

Participants were asked to choose which CRS symptom recall period-1 day, 2 weeks, 1 month or greater than 1 month-was most reflective of their current disease state and best to base treatment recommendations (including surgery) upon. Participants were also asked to report which of six response scales (one visual analogue scale [VAS] and five Likert scales ranging from four to eight items) were easiest to use and understand, and most preferred.

RESULTS

A majority of participants felt the current state of their CRS symptoms was best reflected by a recall period of 2 weeks to 1 month; however, patients preferred that recommendations about treatments, including endoscopic sinus surgery, be determined by symptoms experienced over at least a one-month period. Participants generally found the VAS and seven-item Likert scale to be the easiest to use and understand, and their most preferred scales. No patient characteristics associated with preferences for recall periods or response scales.

CONCLUSION

Future PROMs for CRS symptoms should consider assessment of symptoms over a one-month time frame and use either a VAS or seven-item Likert response scale to optimally balance reflection of current disease state, need for intervention and patient preference.

Individual importance of olfaction decreases with duration of smell loss

BACKGROUND

The personal importance of a lost neurologic - motor or sensory - function in several conditions has been shown to decrease as the afflicted patient becomes accustomed to not having that function. It is unknown how the importance of olfaction changes with duration of olfactory dysfunction (OD). The aim of this study was to evaluate the association between duration of smell loss and individual significance of olfaction, and whether this relationship would be modulated by other factors, such as etiology of smell loss.

METHODS

This is a retrospective study including a total 163 subjects with different degrees of olfactory function. Individual significance of olfaction was measured using the Importance of Olfaction Questionnaire (IOQ). Demographics, olfactory function, duration and etiology of OD were evaluated. Group comparisons, bivariate correlations, analyses of variance and multivariate linear regression were applied to detect differences and associations with the outcome measure of IOQ.

RESULTS

A significant negative correlation was found between duration of OD and the IOQ. Other important findings include a significantly higher IOQ in patients with posttraumatic- compared to idiopathic OD and in patients with higher aggravation scores compared to the lower aggravation group. Multivariate regression analysis further confirmed that duration of smell loss was independently associated with IOQ.

CONCLUSIONS

The duration of smell loss is negatively correlated with the individual importance of olfaction, suggesting that patients develop coping mechanisms for adjusting to OD.

Olfactory Dysfunction is not a Determinant Of Patient-Reported Chronic Rhinosinusitis Disease Control

OBJECTIVES/HYPOTHESIS

As a cardinal symptom of chronic rhinosinusitis (CRS), hyposmia has been recommended to be assessed as a component of CRS disease control. Herein we determine the significance of hyposmia in CRS in the context of nasal obstruction and drainage symptoms.

STUDY DESIGN

Prospective, cross-sectional METHODS: Cross-sectional study of 308 CRS patients (102 CRSwNP, 206 CRSsNP) without prior endoscopic sinus surgery. The burden of nasal obstruction and hyposmia were assessed using the corresponding item scores on the 22-item Sinonasal Outcome Test (SNOT-22). Burden of nasal discharge was assessed using the mean of "thick nasal discharge" and "thick post-nasal discharge" SNOT-22 item scores. Patients were all asked to rate their CRS symptom control as "not at all," "a little," "somewhat," "very," or "completely."

RESULTS

In CRSwNP, only 4.9% had a hyposmia score > 1 with nasal obstruction and drainage scores less than or equal to 1. In CRSsNP, only 1.9% had a hyposmia score > 1 with nasal obstruction and drainage scores less than or equal to 1. On univariate association, CRS symptom control was significantly associated with nasal obstruction, hyposmia, and drainage in both CRSwNP and CRSsNP (P < .05 in all cases). Using multivariable regression to account for all nasal symptoms, only nasal obstruction and nasal discharge scores (but not hyposmia) were significantly associated with CRS symptom control.

CONCLUSIONS

Hyposmia rarely occurs without nasal obstruction or nasal drainage, and may therefore be redundant to assess for CRS disease control. Moreover, hyposmia was not associated with patient-reported CRS symptom control when accounting for the burden of nasal obstruction and drainage.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2116-E2120, 2021.

Self-perceived Taste and Flavor Perception: Associations With Quality of Life in Patients With Olfactory Loss

OBJECTIVE

To evaluate associations between self-perceived chemosensory functions of smell, taste, and flavor perception with olfactory-specific quality of life (QoL) in patients with olfactory dysfunction (OD) and whether these associations would be influenced by other factors, such as duration or etiology of smell loss.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care, academic center.

METHODS

Olfactory-specific QoL was measured with the Questionnaire of Olfactory Disorders (QOD). The QOD measures the impact of OD on QoL (QOD-negative statements) and the ability of patients to cope with smell loss (QOD-positive statements). Orthonasal olfactory function, patients' demographics, self-perceived chemosensory perception, and duration and etiology of OD were retrospectively collected in a cohort of patients with quantitative OD. Correlations and multivariable linear regression models were computed to determine possible associations with the outcome measure of QOD-negative and QOD-positive statement scores.

RESULTS

A total of 133 patients with OD were included. Analysis revealed a positive correlation between self-perceived taste and flavor perception with QOD-negative statement scores, while self-perceived smell showed no significant correlation. Similarly, longer duration of smell loss and higher age were also correlated with higher QOD-positive statement scores. Multivariable regression models confirmed that self-perceived taste was independently associated with the QOD-negative statement score, while age and duration of OD were independently associated with the QOD-positive statement score.

CONCLUSIONS

These findings suggest that the impact of diminished flavor perception during eating and drinking has a stronger impact on the QoL of patients with OD as compared with decreased orthonasal olfaction.

Mood, Anxiety and Olfactory Dysfunction in COVID-19: Evidence of Central Nervous System Involvement?

Objective

The objective of this study was to determine the burden of depressed mood and anxiety in COVID‐19, and associated disease characteristics.

Materials and Methods

This is a prospective, cross‐sectional study of 114 COVID‐19 positive patients diagnosed using RT‐PCR‐based testing over a 6‐week period. The two‐item Patient Health Questionnaire (PHQ‐2) and the two‐item Generalized Anxiety Disorder questionnaire (GAD‐2) were used to measure depressed mood and anxiety level, respectively, at enrollment and for participants' baseline, pre‐COVID‐19 state. Severity of smell loss, loss of taste, nasal obstruction, rhinorrhea/mucus production, fever, cough, and shortness of breath (SOB) during COVID‐19 were assessed.

Results

PHQ‐2 and GAD‐2 significantly (P < .001) increased from baseline to enrollment. PHQ‐2 was associated with smell loss (adjusted incidence rate ratio [aIRR] = 1.40, 95% CI, 1.10–1.78, P = .006), age (aIRR = 1.02, 95% CI, 1.01–1.04, P = .006), and baseline PHQ‐2 score (aIRR = 1.39, 95% CI, 1.09–1.76, P = .007). GAD‐2 score was associated with smell loss (aIRR = 1.29, 95% CI, 1.02–1.62, P = .035), age (aIRR = 1.02, 95% CI, 1.01–1.04, P = .025) and baseline GAD‐2 score (aIRR = 1.55, 95% CI, 1.24–1.93, P < .001). Loss of taste also exhibited similar associations with PHQ‐2 and GAD‐2. PHQ‐2 and GAD‐2 scores were not associated with severities of any other symptoms during the COVID‐19 course.

Conclusions

Despite the occurrence of symptoms—such as SOB—associated with severe manifestations of COVID‐19, only the severities of smell and taste loss were associated with depressed mood and anxiety. These results may raise the novel possibility of emotional disturbance as a CNS manifestation of COVID‐19 given trans‐olfactory tract penetration of the central nervous system (CNS) by coronaviruses.

Level of Evidence

3 Laryngoscope, 130:2520–2525, 2020

Emotional and Personality Traits are Determinants of Activity Avoidance in Chronic Rhinosinusitis Patients

OBJECTIVES

Chronic rhinosinusitis (CRS), like other sinonasal diseases, may be associated with avoidance of daily activities. Our goal was to identify characteristics associated with avoidance of activities due to CRS.

MATERIALS AND METHODS

A total of 194 CRS patients were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort and emotional/psychological subdomain scores were calculated. Depressed mood was assessed using the two-item Patient Health Questionnaire (PHQ-2). Personality traits including conscientiousness, neuroticism, agreeableness, openness, and extraversion were assessed using the Big Five Inventory-10 (BFI-10) questionnaire. As the primary outcome, participants rated how often in the prior week that they had avoided any activities in day-to-day life due to their nasal or sinus symptoms on a scale of "never," "rarely," "sometimes," "often," or "extremely often." Ordinal regression models, with bootstrap validation, were used to identify associations between activity avoidance and participants' characteristics.

RESULTS

On multivariable analysis, SNOT-22 score (odds ratio [OR] = 1.03, 95% CI, 1.01-1.04, P = .026), and conscientiousness personality trait (OR = 1.38, 95% CI, 1.05-1.81, P = .019) were positively associated with activity avoidance while age (OR = 0.98, 95% CI, 0.96-0.99, P = .049) was negatively associated with activity avoidance. Of CRS symptom burden/SNOT-22 subdomains, only the emotional/psychological subdomain score (OR = 1.28, 95% CI, 1.12-1.46, P < .001) was associated with activity avoidance.

CONCLUSION

Younger age and the conscientiousness personality trait were associated with activity avoidance in CRS patients. Of CRS-associated symptomatology, sadness and embarrassment were associated with activity avoidance. Emotional traits and personality most strongly predict avoidance of activities in CRS patients.

LEVEL OF EVIDENCE

2c. Laryngoscope, 131:707-712, 2021.

Sinonasal pathophysiology of SARS-CoV-2 and COVID-19: A systematic review of the current evidence

OBJECTIVE

The ongoing pandemic of coronavirus disease (2019 coronavirus disease [COVID-19]), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, is highly contagious with high morbidity and mortality. The role of the nasal and paranasal sinus cavities is increasingly recognized for COVID-19 symptomatology and transmission. We therefore conducted a systematic review, synthesizing existing scientific evidence about sinonasal pathophysiology in COVID-19.

STUDY DESIGN

Systematic review.

METHODS

Systematic searches were performed of all indexed studies in PubMed/Medline and Cochrane databases through 28 March 2020 and studies searchable on preprints.com (including ArXiv and Scilit repositories) through 30 March 2020. Data extraction focused on sinonasal pathophysiology in COVID-19.

RESULTS

A total of 19 studies were identified. The sinonasal cavity may be a major site of infection by SARS-CoV-2, where susceptibility genes required for infection are expressed at high levels and may be modulated by environmental and host factors. Viral shedding appears to be highest from the nose, therefore reflecting a major source for transmission. This has been highlighted by multiple reports of health care-associated infection (HAI) during rhinologic procedures, which are now consequently considered to be high risk for SARS-CoV-2 transmission to health care workers. While sinonasal symptomatology, such as rhinorrhea or congestion, appears to be a rarer symptom of COVID-19, anosmia without nasal obstruction is reported as highly specific predictor of COVID-19+ patients.

CONCLUSION

Sinonasal pathophysiology is increasingly important in our understanding of COVID-19. The sinonasal tract may be an important site of infection while sinonasal viral shedding may be an important transmission mechanism-including HAI. Anosmia without nasal obstruction may be a highly specific indicator of COVID-19.

LEVEL OF EVIDENCE

2a.

Chronic Rhinosinusitis Patients With and Without Polyps Experience Different Symptom Perception and Quality of Life Burdens

Objective

We sought to determine if chronic rhinosinusitis (CRS) patients with nasal polyps (CRSwNP) differentially perceived CRS symptom burden compared to patients without nasal polyps (CRSsNP) and to what extent CRS symptom severity was associated with quality of life (QOL) and patient-reported symptom control in the 2 groups.

Methods

A total of 600 patients (266 CRSwNP and 334 CRSsNP) presenting with CRS were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated. General health-related QOL was assessed with the visual analog scale of the 5-dimensional EuroQol questionnaire (EQ-5D VAS). Patients rated their CRS symptom control on a 5-point scale.

Results

SNOT-22 scores did not differ between CRSwNP (mean: 35.6) and CRSsNP (mean: 36.3). There were no differences in nasal, sleep, and emotional subdomains of the SNOT-22. CRSsNP had higher ( P = .003) ear/facial subdomain scores than CRSwNP, while CRSwNP reported greater hyposmia ( P < .001). EQ-5D VAS was significantly lower ( P = .011) in CRSsNP (mean: 68.9) compared to CRSwNP (mean: 73.2). However, CRSwNP patients reported significantly less symptom control, compared to CRSsNP, in association with nasal and emotional symptoms.

Conclusion

CRSwNP and CRSsNP have differences in symptom profile, effect on health-related QOL, and patient-perceived symptom control. CRSsNP experience significantly greater burden of ear/facial discomfort, while CRSwNP report greater hyposmia. Although CRSsNP reports lower general health-related QOL overall, CRSwNP patients had lower levels of CRS symptom control for every incremental increase in symptom burden suggesting greater sensitivity/intolerance to CRS symptoms.

Olfactory Dysfunction and Sinonasal Symptomatology in COVID-19: Prevalence, Severity, Timing, and Associated Characteristics

Objective

Olfactory dysfunction (OD)—hyposmia or anosmia—is a symptom of coronavirus disease 2019 (COVID-19), caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We sought to better determine prevalence, severity, and timing of OD in COVID-19 relative to other sinonasal and pulmonary symptoms.

Study Design

Prospective, cross-sectional.

Setting

Regional/cantonal hospital.

Subjects

In total, 103 patients diagnosed with COVID-19 with reverse transcription polymerase chain reaction (RT-PCR)–based testing.

Methods

All patients testing positive for COVID-19 at Kantonsspital Aarau over a 6-week period were approached. Timing and severity (at its worst, on scale of 0 [none], 1 [mild], 2 [moderate], and 3 [severe]) of OD, loss of taste, nasal obstruction, rhinorrhea/mucus production, fever, cough and shortness of breath (SOB) were assessed for each patient.

Results

Prevalence of OD was 61.2%, and severity of OD was strongly correlated with severity of loss of taste experienced (ρ = 0.87, P < .001). OD was experienced on the first day of COVID-19 by 8.7% and overall occurred at median infection day 3 (mean, 3.4; range, 0-12). Most experiencing OD reported anosmia, and mean severity of all with OD was moderate to severe (mean [SD], 2.7 [0.6]). Nasal obstruction (49.5%) and rhinorrhea (35.0%) were frequently reported but not correlated with OD. SOB was more severe in patients with OD. OD was associated negatively with older age (OR, 0.96; 95% CI, 0.93-0.99; P = .007) and positively with female sex (OR, 2.46; 95% CI, 0.98-6.19; P = .056).

Conclusions

OD is highly prevalent during COVID-19, occurring early and severely, often in conjunction with loss of taste. OD is associated negatively with older age and positively with female sex. Patients with OD may also experience more severe SOB.

Olfactory Dysfunction: A Highly Prevalent Symptom of COVID-19 With Public Health Significance

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is a global pandemic affecting millions of individuals, killing hundreds of thousands. Although typically described with characteristic symptoms of fever, cough, and shortness of breath, greater understanding of COVID-19 has revealed myriad clinical manifestations. Olfactory dysfunction (OD)-hyposmia and anosmia-has recently been recognized as an important symptom of COVID-19 and increasingly gained traction as a public health tool for identifying COVID-19 patients, in particular otherwise asymptomatic carriers who, unawares, may be major drivers of disease spread. The objective of this study is to review the scientific evidence about anosmia in COVID-19.

DATA SOURCES

PubMed, Google Scholar, and Web of Science.

REVIEW METHODS

Comprehensive literature search of primary studies pertinent to the objectives of this review using the chosen data sources.

CONCLUSIONS

Current evidence shows that OD is highly prevalent in COVID-19, with up to 80% of patients reporting subjective OD and objective olfactory testing potentially showing even higher prevalence. OD is frequently accompanied by taste dysfunction. Up to 25% of COVID-19 patients may experience sudden-onset OD as the first symptom. A large proportion of COVID-19 OD cases may resolve over the period of a few weeks.

IMPLICATIONS FOR PRACTICE

Sudden anosmia should be considered a symptom of COVID-19. Assessing for sudden-onset anosmia may increase sensitivity of COVID-19 screening strategies, in particular for identifying patients at the earliest stages of disease. Since many cases of OD due to COVID-19 may resolve in the short term, conservative management, including observation, is reasonable, while advanced imaging is unnecessary.

Responsiveness and minimal clinically important difference for the EQ-5D in chronic rhinosinusitis

BACKGROUND

The 5-dimensional EuroQol questionnaire (EQ-5D) is validated to measure general health-related quality of life (QOL). Our objective was to determine the responsiveness and minimal clinically important difference (MCID) of the EQ-5D health utility value (EQ-5D HUV) and visual analog scale (EQ-5D VAS) in chronic rhinosinusitis (CRS).

METHODS

203 adults undergoing medical management for CRS were prospectively recruited. General health-related QOL (using EQ-5D HUV and EQ-5D VAS) and CRS-specific QOL (using the 22-item Sinonasal Outcome Test [SNOT-22]) were measured at enrollment and a subsequent follow-up time point 2-12 months later. At follow-up, participants also rated change in general health as Much worse, A little worse, About the same, A little better or Much better compared to enrollment. The EQ-5D HUV and EQ-5D VAS MCIDs were calculated using distribution-based, anchor-based, and receiver operator characteristic (ROC) curve-based methods.

RESULTS

Change in SNOT-22 score was correlated with EQ-5D HUV and EQ-5D VAS change. Using the different methods of calculating MCID, we find the EQ-5D HUV MCID to be 0.04 and EQ-5D VAS MCID to be 8.0. The calculated EQ-5D MCIDs had approximately a sensitivity of 40-50% and specificity of 80% in detecting patients experiencing noticeable improvement in general health.

CONCLUSIONS

The EQ-5D responds well to changing CRS symptomatology. We propose MCIDs for EQ-5D HUV of 0.04 and EQ-5D VAS of 8 in CRS patients, which although specific, are not sensitive for detecting patients experiencing improvement in general health.

Longitudinal improvement in nasal obstruction symptoms of chronic rhinosinusitis directly associates with improvement in mood

PURPOSE

The effects of nasal obstruction in patients with chronic rhinosinusitis (CRS) are associated with depressed mood. We sought to validate this finding by determining whether improvement in nasal obstruction would translate to improvement in depressed mood.

METHODS

This was a prospective observational study of 150 patients undergoing medical management for CRS. Data were collected at two timepoints: enrollment and a subsequent follow-up visit 3-12 months later. Impact of nasal obstruction was measured using the Nasal Obstruction Symptom Evaluation (NOSE) instrument and depressed mood was measured using the 2-item Patient Health Questionnaire (PHQ-2). Sinonasal symptoms associated with CRS were also measured using the 22-item Sinonasal Outcome Test (SNOT-22). Clinical and demographic characteristics were collected. The relationship between changes in PHQ-2 and NOSE scores was determined with correlation and linear regression.

RESULTS

Change in PHQ-2 score was significantly correlated with change in NOSE score (ρ = 0.30, p < 0.001). After controlling for covariates, change in PHQ-2 score was associated with change in NOSE score (adjusted linear regression coefficient [β] = 0.014, 95% CI 0.006-0.022, p = 0.001). We confirmed these relationships, finding that change in PHQ-2 was associated (adjusted β  = 0.037, 95% CI 0.013-0.061, p = 0.003) with change in the nasal subdomain score of the SNOT-22. Improvement in NOSE score by greater than 22 points was predictive of improvement in PHQ-2 score with sensitivity 54.5% and 83.8% specificity (p < 0.001).

CONCLUSION

These results provide evidence that improvements in nasal manifestations/symptoms of CRS translate to significant improvements in mood.

Changes in chronic rhinosinusitis symptoms differentially associate with improvement in general health-related quality of life

BACKGROUND

Previous work has shown that the symptoms of chronic rhinosinusitis (CRS) differentially associate with decreased general health-related quality of life (QOL).

OBJECTIVE

We sought to determine whether longitudinal changes in different types of CRS symptomatology lead to correspondingly different magnitude changes in general health-related QOL.

METHODS

Prospective observational study of 145 patients undergoing medical management for CRS. Chronic rhinosinusitis symptom severity was measured using the 22-item Sinonasal Outcome Test (SNOT-22) and associated nasal, sleep, ear/facial discomfort, and emotional subdomains of the SNOT-22. General health-related QOL was measured using the 5-dimensional EuroQoL questionnaire's visual analog scale (EQ-5D VAS). These data were collected at 2 time points: at enrollment and at a subsequent follow-up visit within the next 2 to 6 months. Associations were sought between the changes in SNOT-22 and EQ-5D VAS.

RESULTS

The change in SNOT-22 was associated with change in EQ-5D VAS (adjusted linear regression coefficient [β] = -0.37, 95%CI: -0.51 to -0.24, P < .001). The change in EQ-5D VAS was only associated with changes in the sleep (adjusted β = -0.42, 95% confidence interval [95%CI]: -0.81 to -0.04, P = .034) and ear/facial discomfort (adjusted β = -1.00, 95%CI: -1.89 to -0.10, P = .031) subdomains but not nasal (adjusted β = -0.12, 95%CI: -0.52 to 0.28, P = .564) or emotional (adjusted β = -0.17, 95%CI: -1.83 to 1.49, P = .840) subdomains.

CONCLUSION

Changes in the severity of sleep and ear/facial discomfort symptoms associate most greatly with the change in general health-related QOL that CRS patients experience during routine medical management. Reduction of these extranasal symptoms of CRS may therefore lead to the greatest improvement in general health-related QOL.

Reciprocal Predictive Accuracy of Sinonasal Symptom Severity, Nasal Endoscopy, and Frequency of Past Chronic Rhinosinusitis Exacerbations

Objective We sought to determine whether chronic rhinosinusitis (CRS) symptom severity, endoscopic exam findings, and acute exacerbation of CRS (AECRS) frequency-all important and distinct clinical manifestations of CRS-would be predictive of each other and, therefore, inform when further assessment of each other metric should be pursued. Study Design Cross-sectional cohort study. Setting Tertiary academic rhinology clinic. Subjects and Methods In total, 241 patients with CRS were prospectively recruited and completed the 22-item Sinonasal Outcome Test (SNOT-22) to reflect CRS symptom severity. AECRS frequency was assessed using the number of sinus infections as well as CRS-related antibiotics and CRS-related oral corticosteroids used in the past 3 months. An endoscopy score was calculated for each patient. Results SNOT-22 score and AECRS were predictive of each other while AECRS and endoscopy score were not predictive of each other. SNOT-22 score could be used to predict having had, in the past 3 months, at least 1 sinus infection (area under the curve [AUC] = 0.727; P < .001), at least 1 CRS-related antibiotic used (AUC = 0.691; P < .001), or at least 1 CRS-related oral corticosteroid course used (AUC = 0.655; P < .001). Having a SNOT-22 score ≥30 could be predicted by reporting at least 1 sinus infection (AUC = 0.634; P < .001), CRS-related antibiotics (AUC = 0.614; P < .001), or CRS-related oral corticosteroids (AUC = 0.616; P < .001) in the past 3 months. These relationships held for patients with and without nasal polyps. Conclusion The predictive power of CRS outcome measures reflecting symptomatology, AECRS frequency, and endoscopic findings may be of clinical utility in situations where time or resources are limited to perform an ideally full assessment of patients with CRS.

Association between Symptoms of Allergic Rhinitis with Decreased General Health–Related Quality of Life

Background

The impact of specific allergic rhinitis symptoms on patient quality of life (QOL) is currently unknown.

Objective

In this study, we sought to determine the association between nasal and extranasal symptoms of allergic rhinitis with general health–related QOL.

Methods

A total of 150 participants with ages > 18 years and persistent allergic rhinitis were prospectively recruited for this cross-sectional study. General health–related QOL was measured by using the visual analog scale (VAS) from the five-dimension EuroQol QOL survey (EQ-5D). The severity of nasal and extranasal symptoms was measured by using the 22-item Sino-Nasal Outcome Test (SNOT-22). The severity of nasal obstruction was measured by using the Nasal Obstruction Severity Evaluation (NOSE) scale. Each participant also completed a Rhinitis Control Assessment Test (RCAT).

Results

The total SNOT-22 score was significantly correlated with RCAT (r = -0.68 [95% confidence interval {CI}, -0.75 to -0.58]; p < 0.001) and EQ-5D VAS (r = -0.44 [95% CI, -0.56 to -0.30]; p < 0.001). Of the 22 symptoms assessed on the SNOT-22, sleep-related symptoms, and otologic symptoms were associated with the greatest decrease in general health–related QOL. Nasal symptoms were least associated with general health–related QOL. The symptom of nasal obstruction was not at all associated with general health–related QOL (p = 0.267). We confirmed this finding by showing no significant correlation between the NOSE score and EQ-5D VAS (r = -0.05 [95% CI, -0.21 to 0.12]; p = 0.582).

Conclusion

Sleep and otologic symptoms were associated with the greatest negative impact on QOL in adults with persistent allergic rhinitis and should be routinely assessed in their clinical evaluation.