Studies indicate that chronic rhinosinusitis (CRS) is associated with numerous types of symptoms, broadly categorized as nasal and extra-nasal symptoms. The extra-nasal symptoms associated with CRS—such as poor sleep quality, ear and facial discomfort, and mood disturbance—are less often considered.  “Each symptom may be due to different underlying disease mechanisms so each type of symptom can potentially be targeted therapeutically,” says Ahmad R. Sedaghat, MD, PhD. “By identifying the symptoms that drive the greatest quality of life (QOL) decrease, we can identify those that are most beneficial to treat in order to improve a patient’s QOL.”

For a study published in Annals of Allergy, Asthma & Immunology, Dr. Sedaghat and colleagues sought to determine improvement of which symptoms of CRS would be associated with the greatest improvements of QOL and, likewise, which worsening symptoms of CRS would be associated with the most severe worsening of QOL.


Symptoms & QOL

The study team used a prospective, observational study design in which they followed patients with CRS as they were being treated medically (intranasal saline rinses and intranasal steroids) for their sinus disease. The researchers measured the burden of the different types of CRS symptoms (nasal, sleep, ear and facial discomfort, and emotional symptoms; [Table]) using the validated 22-item Sinonasal Outcome Test (SNOT-22) questionnaire and also measured general health-related QOL using the validated 5-dimensional EuroQoL  questionnaire’s visual analog scale (EQ-5D VAS). Symptoms and QOL were measured before and after treatment. The study investigators then analyzed how changes in symptom burdens were associated with changes in QOL.

“The SNOT-22 subdomain scores reflect the burden of the different type of symptoms that are associated with CRS,” explains Dr. Sedaghat. “For example, the nasal subdomain score reflects the burden of nasal symptoms that CRS patients experience.”

The results of the study showed that changes in SNOT-22 were associated with changes in EQ-5D VAS.  When looking more closely at the different SNOT-22 subdomains, the change in EQ-5D VAS was only associated with changes in the sleep and ear/facial discomfort subdomains but not nasal or emotional subdomains.  Dr. Sedaghat says that when accounting for many possible confounding factors in the multivariable analysis, the burden of sleep symptoms and burden of ear and facial discomfort symptoms associated most with QOL in CRS patients (Table). These associations were negative, indicating that as the burden of these symptoms decreases, QOL improves.

Dr. Sedaghat explains, “It is the extra-nasal symptoms that may be the biggest drivers of the decreased QOL that CRS patients experience. Interestingly, this phenomenon may be common across other inflammatory sino-nasal diseases, since we’ve made similar findings for allergic rhinitis as well. I think this work shows that physicians treating patients with inflammatory sino-nasal diseases such as CRS—likely most often allergists/immunologists or otolaryngologists—should be aware of the extra-nasal symptoms of these diseases and think about ancillary treatments—in addition to the mainstay of therapy, which is intranasal corticosteroids—that might improve these extra-nasal symptoms.”


Future Treatment

Extra-nasal symptoms, in particular those relating to poor sleep quality and ear/facial discomfort, should be assessed in the complete evaluation of a CRS patient. Moreover, because symptoms like poor sleep quality or ear and facial discomfort can potentially be treated, an aspect of CRS management should be related to these types of symptoms.

“It is still unclear what causes the extra-nasal symptoms of CRS,” says Dr. Sedaghat. “Is it that the inflammatory reaction becomes systemic? Is it that anatomic obstruction of the nasal passageways or sinus drainage pathways causes these symptoms? Is it some other reason? Probably the underlying cause for each patient is different or a combination of causes. We still need to identify the exact causes on a patient-by-patient basis, as this will allow the most specific and personalized treatments for maximizing QOL in patients with CRS.”