Braz. j. . vol.83 número4

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Can

we

use

the

questionnaire

SNOT-22

as

a

predictor

for

the

indication

of

surgical

treatment

in

chronic

rhinosinusitis?

夽

,

夽夽

Pablo

Pinillos

Marambaia

,

Manuela

Garcia

Lima

,

Marina

Barbosa

Guimarães

_,

_Amaury

_de

_Machado

_Gomes

_,

Melina

Pinillos

Marambaia

_,

_Otávio

_Marambaia

_dos

_Santos

_,

Leonardo

Marques

Gomes

a_{EscolaBahianadeMedicinaeSaúdePública(Bahiana),ProgramadePós-graduac¸ão,Salvador,BA,Brazil} b_{UniversidadeFederaldaBahia(UFBA),Salvador,BA,Brazil}

c_{InstitutodeOtorrinolaringologiaOtorrinosAssociados(INOOA),Salvador,BA,Brazil} d_{SantaCasadeSãoPaulo,Otorrinolaringologia,SãoPaulo,SP,Brazil}

e_{UniversidadedoPorto,Bioética,Porto,Portugal}

f_{UniversidadeFederaldeSãoPaulo(UNIFESP),ProgramadePós-graduac¸ãoemOtorrinolaringologia,SãoPaulo,SP,Brazil}

Received4March2016;accepted30May2016 Availableonline24June2016

KEYWORDS Nasalsurgical procedures; Qualityoflife; Sinusitis

Abstract

Introduction:Chronicrhinosinusitisisaprevalentdiseasethathasanegativeimpactonthelives ofsufferers.SNOT-22isconsideredthemostappropriatequestionnaireforassessingthequality oflifeofthesepatientsandaveryeffectivemethodofevaluatingtherapeuticinterventions; howeveritisnotusedasatoolfordecision-making.

Objective: TotestthehypothesisthattheSNOT-22scorecanpredicttheoutcomeofsurgical treatment.

Methods:Aretrospective,longitudinalandanalyticalstudy.Weevaluatedthemedicalrecords ofpatientswithchronicrhinosinusitisthatcompletedtheSNOT-22atthetimeofdiagnosis.All thepatientswereconsecutivelyreceivingcareatanotolaryngologyserviceinSalvador,Bahia fromAugust2011toJune2012.Theoutcomesofthesurgicaltreatmentofthesepatientswere obtainedfromtheirmedicalrecords.Theinitialscorewascomparedtoagroupofpatientswho werenotreferredforsurgery.Allthepatientscompletedandsignedaconsentform.

夽

Pleasecitethisarticleas:MarambaiaPP,LimaMG,GuimarãesMB,GomesAM,MarambaiaMP,SantosOM,etal.Canweusethe ques-tionnaireSNOT-22asapredictorfortheindicationofsurgicaltreatmentinchronicrhinosinusitis?BrazJOtorhinolaryngol.2017;83:451---6.

夽夽_{Institutions:EscolaBahianadeMedicinaeSaúdePública(Bahiana),Salvador,BA.InstitutodeOtorrinolaringologiaOtorrinosAssociados}

(INOOA),Salvador,BA.Site:www.inooa.com.br. ∗_{Correspondingauthor.}

E-mail:pablomarambaia@hotmail.com(P.P.Marambaia).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCervico-Facial.

http://dx.doi.org/10.1016/j.bjorl.2016.05.010

Results:Of the 88 patients withchronic rhinosinusitis, 26 hadevolved tosurgery overthe last3years.Thegroupswerehomogeneousregardinggenderandrespiratoryandmedication allergies.Thepatientsofthesurgicalgroupwere44.8+13.8yearsoldandthepatientsofthe clinicalgroupwere 38.2+12.5yearsold(p=0.517).TheaverageSNOT-22scoreofthecase groupwas49+19andtheaveragescoreofthecontrolgroupwas49+27(p=0.927).

Conclusion:TheSNOT-22wasunabletopredicttheoutcomeofsurgicalpatientswithchronic rhinosinusitis.

© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

PALAVRAS-CHAVE Procedimentos cirúrgicosnasais; Qualidadedevida; Sinusite

PodemosusaroquestionárioSNOT-22comopreditorparaaindicac¸ãodetratamento

cirúrgiconarinossinusitecrônica?

Resumo

Introduc¸ão:A rinossinusitecrônicaéuma doenc¸a prevalenteque temum impactonegativo sobre avida dos portadores. OSNOT-22 é considerado o questionário maisadequado para avaliaraqualidadedevidadessespacienteseummétodomuitoeficazdeavaliarintervenc¸ões terapêuticas;noentanto,elenãoéusadocomoumaferramentaparaatomadadedecisões. Objetivo:TestaahipótesedequeoescoredoSNOT-22podepreverodesfechodotratamento cirúrgico.

Método: Estudo retrospectivo, longitudinal e analítico. Foram avaliados os prontuários de pacientescomrinossinusitecrônicaquepreencheramoSNOT-22nomomentododiagnóstico. Todosospacientesforamconsecutivamenteatendidosemumservic¸odeotorrinolaringologia em Salvador,Bahia,deagostode 2011ajunho de2012. Osdesfechos dotratamento cirúr-gicodessespacientesforamobtidosapartirdeseusprontuáriosmédicos.Apontuac¸ãoinicial foicomparadacomum grupodepacientesquenão foiencaminhadoparacirurgia.Todosos pacientespreencherameassinaramumtermodeconsentimentoinformado.

Resultados: Dos88pacientescomrinossinusitecrônica,26evoluíramparacirurgianosúltimos trêsanos.Osgruposforamhomogêneosquantoasexo,alergiasrespiratóriasemedicamentos. Ospacientesdogrupocirúrgicotinham44,8+13,8anoseosdogrupoclínicotinham38,2+12,5 (p=0,517).OescoremédiodoSNOT-22dogrupodocasofoide49+19eoescoremédiodo grupocontrolefoide49+27(p=0,927)

Conclusão:OSNOT-22foiincapazdepreverodesfechodospacientescirúrgicoscom rinossi-nusitecrônica.

© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Dataonthequalityoflifeofpatientswithchronic rhinosi-nusitis(CRS)provethatthisdiseasehasamajorimpacton theactivitiesofdailylivingofthesepatients.

IthasalreadybeenprovedthatCRSnegativelyaffectsthe QOLofsufferersincomparisontopeoplewithoutthedisease andpeoplewithotherchronicdiseaseslikecongestiveheart failureandchronicobstructivepulmonarydisease.1

Themainfocusofthesestudieswastheuseof question-nairestoevaluatetheimpactoftherapeuticinterventions. Thesamequestionnaireisgenerallyappliedbeforeandafter interventiontoagroupofpatients.Theimpactofsurgeryon thebettermentofpatientswithCRShasbeenexhaustively studiedandthereseemstobeaconsensus,especiallyinthe short-termassessment.2_{Studiesshowthattheimprovement}

ratesofsurgeryrangefrom76%to97.5%.3,4

The SinoNasal Outcome Test 22 (SNOT-22) is an easily applied questionnaire that has been validated for use in Portuguese.5_{Thisinstrumenthas22questionsabout}

possi-blesymptomslinkedtochronicrhinosinusitis.Eachquestion receivesascorefrom0to5,wherezeroistheabsenceofthis conditionandfiveistheworstpossible caseofthis condi-tion.Similarly,highertotalscoresrepresentaworsequality of life.According tothe 2012European Position Paperon Rhinosinusitis and Nasal Polyps(EPOS), SNOT-22is a good tool for assessing QOL in patients with CRS. Moreover, it canbeusedrepeatedlyandproducesgraphics(SNOTgrams) withSNOT-22scoresformorethanagivenmomentintime, which clearly display the resultof medicinal and surgical interventionsandexacerbationsovertime.6

example.Later,QOLbecameanadditionalparameterinthis assessmentandseveralstudieshaveusedthistoolto evalu-atepatients.Thispracticehasledtothehopethatwecan extrapolatetheuseof thequestionnairesmostlytoselect patientsfordifferenttypesoftreatmentanddeterminehow tointerpret the informationof populations outside Brazil andapplyittoourscenario.

The criteria of surgical intervention, for example, are poorly described in literature andconsequently lead to a broadgeographicalvariationofthisindicationandalossof qualityinmedicalcare.7 _{Measuresthatcanstandardiseor}

facilitatethisdecisionwouldhelpimprovethefollow-upof thesesufferers.

Thepresentstudyaimstocomparetheaveragescoreof theSNOT-22intheinitialassessmentofpatientswithchronic rhinosinusitisandtestthehypothesisthattheSNOT-22score canpredicttheoutcomeofsurgicaltherapy.

Methods

Thisisadescriptiveandanalyticalretrospectivelongitudinal study withaconvenience sample derivedfrom aprevious studyofthesameauthor.

Weaccessedrecordsofthepatientswhoparticipatedin thepreviousstudy.Thesepatientshadreceivedcareforthe firsttimebetween2011and2012andcontinuedsupervised care at anotolaryngologyservice in Salvador,Bahia, until August2015.

Theinclusioncriteriawereliteratepatientswithchronic rhinosinusitisover18yearsofage.

The diagnosis of chronic rhinosinusitiswas determined usingthecriteriaof theEPOS-2012,6_{whereby chronic}

rhi-nosinusitis is defined by the presence of two or more symptomsofnasalobstruction/congestion/blockage, ante-riororposteriorrhinorrhea,anosmiaorhyposmia/anosmia andfacialpain/pressureformorethan12weeksthatmust bethe resultof nasalobstruction/congestion/blockage or anteriororposteriorpurulentrhinorrhea.

Thecriteriaforexclusionwereilliteratepatients, smok-ers, patients with immune deficiency, cystic fibrosis or primaryciliarydyskinesia,patientswithbenignormalignant nasal tumours, patients with granulomatous diseases and vasculitis, patients whohad previously undergone surgery andsubjectswhorefusedtoparticipateinthestudy.

Allthepatients wereevaluatedduring thefirst consul-tation and after the confirmation of CRS. The patients subsequently completed a registration form with demo-graphic data, the SNOT-22 questionnaire validated for Portuguese8_{andaninformedconsentstatement.}

The SNOT-22questionnairewasappliedduring thefirst consultationwhenthepatientswereevaluatedbythesame professional,in2011and2012.

After3years,themedicalrecordswerereviewedto ver-ifythereferralforclinicalorsurgicaltreatmentovertime. This referralwasmadebythesame ENTprofessionalwho wasblindedtotheSNOT-22score.

The subjectswere divided into twogroups: The group thatevolvedtothereferralfor surgeryduringthestudied periodandthegroupthatcontinuedwithclinicaltreatment. Surgerywasreferredaftermaximumclinicaltreatment hadfailedforatleast3weeks.Maximumclinicaltreatment

isdefinedastheuseoftopicalorsystemiccorticosteroids, antibiotictherapyandsalinenasalirrigation.

Thefailureofclinicaltreatmentwasdefinedasthelack ofimprovementinsymptomsreferredbytheactualpatient. In the absence of a response, an assessment computed tomographywasrequested, aswellaspossible scheduling ofafuturesurgery.

Surgery was also indicated when tomographic analysis ledto the diagnosis of a condition that required surgical treatment,namely significant anatomicalchangessuch as obstructiveseptum deviation,large or obstructive middle turbinatepneumatisationorextensive sinonasalpolyposis, andrhinosinusitisofdentalorfungalorigin.

Furthermore, surgery was indicated according to the mentionedcriteriaandtheconductofasingleprofessional, although not all the patients were necessarily operated sinceelementssuchasmotivation,personalpreferenceand expectationsregardingtheprocedureinfluencedthe deci-sion.

ThisstudywasapprovedbytheEthicsCommitteeofthe institution,underprotocoln◦_181/2011.

Dataanalysis

ThesamplesizewascalculatedusingWinPepiversion11.62, withastandarddeviationoftheSNOT-22scoreofaprevious Brazilianstudyinvolving surgical patients(DP=25),Kosugi etal.,8 _{to detect a difference of 20 points. In this case,}

50 patients would beneeded, divided into two groups of 25subjects.Consequently,thesampleofthepresentstudy exceedstherequirednumberofparticipants.

The resultswere tabulated andanalysed usingSPSS-17 software.

Thecategoricaldemographicdatalikegenderand pres-enceofcomorbiditiesandallergieswerearrangedusingthe validpercentile.The chi-squaretest wasusedtocompare categoricalvariablesbetweenthegroups.

The score of the SNOT-22questionnaire was described usingtheaverageandstandarddeviationsincethesample distributionwasnormal.

Theaveragesbetweenthegroupswerecomparedusing theunpairedt-test.

Theunpairedt-testwasalsousedtocomparetheaverage scoreofeachitemoftheSNOT-22individually.

The alpha error was considered acceptable when the valueofp<0.05.

Results

A total of 88 patients were analysed, of which 26 were patientsreferredforsurgeryand62evolvedtodrugtherapy. Table 1 shows the demographic characteristics of the sample.

Withregard totheSNOT-22score inthe first consulta-tion,itwasfound thatthe groupthat evolvedtosurgical treatment scored 49.4±19.8 and clinical group averaged 49.9±27(Table2andFig.1).

Table1 Sociodemographiccharacteristicsofpatientswithchronicrhinosinusitisreferredforsurgery(surgerygroup)andof patientswithchronicrhinosinusitisreferredforclinicaltreatment(clinicalgroup).

Variables Surgerygroup(n=26) Clinicalgroup(n=62) Significance(p)

Gender(%)

Male 12(41) 24(40.8) 0.517

Female 14(59) 38 0.517

Age(years) 44.8+13.8 38.2+12.5 0.438

Comorbidities

SAH 03 02 0.81

DM 0 02 0.307

Asthma 04 02 0.167

Allergytomedication(%)

Yes 07(22.8) 12(13.3) 0.594

No 19(77.2) 50(86.7)

Respiratoryallergy(%)

Yes 02(7.7) 05(8.1) 0.810

No 24(92.3) 57(91.9)

Surgerygroup,patientsreferredforsurgery;clinicalgroup,patientsreferredforclinicaltreatment. Significancelevelp<0.05.

Table2 QualityoflifescorewithSNOT-22ofthegroups.

Variable Surgerygroup Clinicalgroup Significance(p)

SNOT-22 49(±19) 49(±27) 0.927

SNOT-22,SinoNasalOutcomeTest.

Significancelevelp<0.05.Unpairedt-test.Average(standarddeviation).

Discussion

The QOL assessment of patients with CRS requires spe-cific questionnaires to measure the results, such as those obtained after interventions with medication and surgery.Avastamount ofstudiesusetheseinstrumentsto assesssurgicaltreatment3,4 _{andsome authorsbelievethat}

p=.927

120.00

100.00

80.00

60.00

40.00

20.00

0.00

SNO

T-22 scor

e

Surgical

Surgical treatment or clinical group Clinical

Figure1 ShowsthecomparisonoftheSNOT-22scoreaverages ofthegroups.

questionnairescanprovideadditionalinformationfor diag-nosesanddecisionmaking.9

Soleretal.9_{alsoreportedthatalowscoreofthe}

ques-tionnairewastheonlyfactorthatwasrelatedtothedecision to undergo surgery and concluded that questionnaires to assess quality of life should be incorporated into clinical practice.

Smith et al.10 _{conducted a prospective study that}

showedthatpatientswithworsescoresbenefitmorefrom surgery. Moreover, patients with clinical monitoring and worse quality of life scores could switch to the surgi-cal group, which led to a significant improvement of the scores.

Birchetal.11 _{suggest thatpatients whoarewaitingfor}

surgery should have worse endoscopic scores, more CRS symptomsandworseQOLscores.

Rudmiketal.12 _{concludethatthepatientwitha}

SNOT-22scoreabove30pointshavea75%chanceofsignificantly changingtheir clinicalcondition withsurgery.These same patientsimprovedtheirqualityoflifeby45%.Ontheother hand,patientswithSNOT-22scores under20didnotshow significantimprovementsaftersurgery.

Inthepresentstudy,nostatisticallysignificantdifference wasfoundbetweentheaveragesoftheSNOT-22scoreofthe firstconsultationofpatientsforthegroupsthatevolvedto surgicalorclinicalreferrals.

InastudythatvalidatedSNOT-22toPortuguese,Kosugi et al.8 _{applied the questionnaire to 89 patients before}

preoperativescoreforthegroupwiththediseaseof62.39 comparedto49+19ofoursample.

Inaprospectivestudy,Mascarenhasetal.13_evaluated60

patientswithreferralsforsurgerypriortosinonasalsurgery andobtainedascoreof61.3±24.

Thepresentstudywaslongitudinalandretrospectiveand thepatientsofthissample wereinitiallytreatedclinically andreferredforsurgeryduringtheirENTmedicalfollow-up. Sincecollectionswerenotcarriedoutperiodicallyoratthe exactmomentofthesurgicalreferral,itisnotpossibleto confirmwhetherthescoredeceasedovertimeor whether thescoreofthesepatientswasworsethanthescoreofthe firstassessmentatthetimeofthesurgicalreferral.

The studies of Kosugi etal.8 _{and Mascarenhas et al.}13

were conducted with patients with a confirmed surgical referral,which differsfromtheprofileofoursample that didnothavethatconfirmation.

IntheBrazilianscenario,thedifferencefoundbetween thescoresmayalsocorrespondtothefactthatoursample usedaservicethatattendsprivatepatients.Thismeansthat thestudiedsubjectsmayhavehadabettersocioeconomic statusthanthepatientsofthestudiesofKosugietal.8_and

Mascarenhaset al.13 _{whose subjects used a publichealth}

service.

The expected pathophysiological rationale is that patientswithreferralsforsurgeryobtainhigherscoresand that this couldexplain thebetter scores of patients with referralsfor clinical treatment. Soler etal.8 _{conducted a}

studywith242patientsanalysedovertimeandfoundthat patientsselectedforthesurgicaltreatmentobtainedworse SNOT-22scoresthanpatientswhochoseclinicaltreatment. Factorssuchasdemographiccharacteristics,patient-doctor relationship,comorbiditiesandpersonalitydidnotinfluence thesurgicaloutcome.

In thepresent study,therewasnodifferencebetween thedemographiccharacteristicsofthegroups.Withrespect tothedoctor---patientrelationship,theauthorsbelievethat theuseofasingleevaluatorminimisesthisbias.

The outcome analysedin thisstudyis thesurgery indi-cated by the physician. This decision also depends on subjectivefactors,suchasmotivation,personalpreference andexpectationsofthepatientsregardingtheprocedure. Ofthepatientsofthisstudy,fourpatientsdidnotundergo surgeryanddecidedtocontinuewithclinicaltreatment.

The criterionfor surgical indicationswasthefailureof maximumclinicaltreatmentafterthreeweeks.Information fromtheactualpatientsregardingtheabsenceof improve-mentinsymptomsoreventheworseningofsymptomsand the will of the health professionals make selection more reliableandreducethesubjectivityofmultipleobservers.

The authors believe that these findings do not invali-datetheinformationthattheserialanalysisandprospective follow-upofthesepatientscansignificantlyenableachange ofconductandoptionfortherightmomentofsurgical refer-ral. Over time, considering the natural evolution of the disease or failure of clinical treatment with maintenance orworseningofscoresofthequestionnaire,thiscouldlead toasignificantdifferencebetweenthegroupsthatevolves tosurgerytothedetrimentofclinicaltreatment.

Hopkinsetal.,14 _{whovalidatedtheSNOT-22forthefirst}

timein theUnited Kingdom, appliedthequestionnaire to 2077surgicalpatientsandobtainedapreoperativescoreof

41.7,which is lower than thescore found in the present study.ThisdifferencebetweentheBrazilianstudiesandUK studysuggeststhatthedifferentlifestylesandculturesof the nationsmay influence the concept of quality of life. However,the UK sample of surgical patients consisted of subjectsfromseveralcentres.Suchadiversecriteria sug-geststhatthesampleincludedpatientswithfewsymptoms ora milderformofdisease,which wouldbean errorand mayleadtoover-referralsofsurgicaltreatment.

Gillettetal.15_{conductedastudyandusedtheSNOT-22}

on116patientswithoutsinonasaldiseaseintheUnited King-domtoknowthescoreofthequestionnaireamongpatients withoutsinonasaldisease.The justificationwasthatmany patientswhounderwentsurgeryinotherstudiesobtaineda relativelylowSNOT-22score,whichsuggeststhatthe refer-ralmayhave beeninappropriate.Patientswithlowscores mayhaveoligosymptomaticCRSormayhavebeen overdiag-nosed.

In our sample, patients were recruited from a single service andthe referral wasindicated by a singledoctor, whichminimisestheriskofchangesincriterion.Blindingin relationtotheinitialscorealsoenablesmorerobustdata.

A limitation of this study is the non-discrimination of the CRS groups. We did not distinguish the subjects with sinonasalpolyposisfromthesubjectswitheosinophilia,for example. The intention was to help the otolaryngologist indicatesurgicaltreatmentirrespectiveofthetypeof dis-ease.Furthermore,thesizeofthesampledidnotallowthe creationofsubgroups.

Conclusion

Althoughthisstudydidnotincludemultipleandserial anal-ysis,thefirstassessmentshowedthattheSNOT-22doesnot predictsurgicaloutcome.Itisthereforeimpossibletoaffirm whether these results over time, with serial assessments basedonthequestionnaire,couldestablishtheSNOT-22as agooddecision-makingtool.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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14.HopkinsC,BrowneJP,SlackR,LundV,TophamJ,ReevesB,etal. Thenationalcomparativeauditofsurgeryfornasalpolyposis andchronicrhinosinusitis.ClinOtolaryngol.2006;31:390---8. 15.Gillett S, Hopkins C, Slack R, Browne JP. A pilot study of