Symptomatic assessment in patients undergoing full-house functional endoscopic sinus surgery for pansinusitis using nonpowered instruments through the Sinonasal Outcome Test-22 Questionnaire in the rural population Thejas SR, Prashanth N, Yogesh T, Nilavan S B, Raj MR, Vipanchi S,

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ORIGINAL ARTICLE

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Symptomatic assessment in patients undergoing full-house functional endoscopic sinus surgery for pansinusitis using nonpowered instruments through the Sinonasal Outcome Test-22 Questionnaire in the rural population

Saai Ram Thejas¹, Nampally Prashanth¹, Tekuru Yogesh², SB Nilavan², Madhamshetty Ritesh Raj², Samudrala Vipanchi²
¹ Department of Otorhinolaryngology and Head and Neck Surgery, RVM Institute of Medical Sciences, Siddipet, Telangana, India
² Department of Internal Medicine, RVM Institute of Medical Sciences, Siddipet, Telangana, India

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Date of Submission	04-Aug-2022
Date of Decision	04-Sep-2022
Date of Acceptance	06-Oct-2022

Abstract

Background: Functional endoscopic sinus surgery (FESS) is a powerful method to achieve good clearance of sinus disease and is being practiced for the better part of the last three decades. The Sinonasal Outcome Test (SNOT)-22 Questionnaire was developed as a modification of the SNOT – 20 in 2009 and helps in better understanding of the disease process before and after surgery as it includes the functioning of special senses.
Objective: The objective of this study was to assess the role and reliability of SNOT-22 in pansinusitis undergoing full-house FESS.
Materials and Methods: The study was conducted in a tertiary hospital in rural South India from July 2021 to December 2021. Two hundred and thirteen patients were evaluated, and out of these, only 69 patients met the inclusion criteria. Surgery was performed under general anesthesia using cold steel instruments. SNOT-22 was administered 1 day before surgery and after 12 weeks postsurgery.
Observations and Results: The average preoperative score in the SNOT-22 scale was 46.16 out of a maximum of 110 and the average postoperative score was 18.70 (an improvement of 59.50%, P < 0.05). Forty-two males and 27 females made it to the final study. The most common age of the patient at the time of presentation was between 21 and 30.
Conclusion: Performing a full-house FESS for pansinusitis in cases with improper follow-up can be done without any side effects provided they are monitored with the SNOT-22 Questionnaire. This study can help practitioners achieve good success rates with lower revision surgery requirements.

Keywords: Chronic rhinosinusitis, functional endoscopic sinus surgery, pansinusitis, sinonasal outcome test

How to cite this URL:
Thejas SR, Prashanth N, Yogesh T, Nilavan S B, Raj MR, Vipanchi S. Symptomatic assessment in patients undergoing full-house functional endoscopic sinus surgery for pansinusitis using nonpowered instruments through the Sinonasal Outcome Test-22 Questionnaire in the rural population. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=359959

Introduction

Functional endoscopic sinus surgery (FESS) is a powerful method to achieve good clearance of sinus disease and is being practiced for the better part of the last three decades. First explained by Stammberger, it has now become commonplace and has replaced older invasive methods.^[1]

FESS is used on a regular basis for almost all types of nasal pathology, not just limited to chronic rhinosinusitis (CRS), sinonasal polyposis, and nasal tumors but also as an initial approach to various other skull base lesions (pituitary tumors).

The usual complaints related to sinusitis are nasal obstruction, nasal discharge, headache, facial pain, and loss of smell among others. The primary management includes reducing the inflammatory component in the nose and sinuses along with facilitating the drainage of secretions from inside the sinus.

Pansinusitis is clearly a radiological finding and can be defined as a disease being present in three or more sinuses irrespective of the side or amount of involvement inside the sinuses.

FESS is basically performed if the first-line maximum medical therapy fails. Full-house FESS (complete sphenoethmoidectomy with frontal sinusotomy and middle meatal antrostomy) as an entity has been used primarily for revision cases as seen before.^[2] The use of this method is usually limited to recalcitrant cases and aggressive fungal infections which require multiple sittings of surgery.

The Sinonasal Outcome Test (SNOT)-22 Questionnaire was developed as a modification of the SNOT – 20 in 2009 by the National Comparative Audit of Surgery for Nasal Polyposis and CRS in England and Wales. This modified questionnaire helps in a better understanding of the disease process before and after surgery as it includes the functioning of special senses.

The relevance of SNOT-22 in the long-term management of pansinusitis undergoing full-house FESS is a relatively unknown entity with not a lot of research because this has been limited to revision cases as of today. The presence of biofilms and resistant bacteria has made the new age surgery more challenging.

In our study, we aim to assess the viability and feasibility of SNOT-22 in our local population in cases which undergo full-house FESS with cold steel instruments for pansinusitis of bacterial origin.

Materials and Methods

This study was performed at a rural Hospital in South India over a period of 6 months from July 2021 to December 2021. Ethical committee approval was obtained and each patient signed a consent form to be part of the study.

All patients presenting to the outpatient department of otorhinolaryngology with complaints of nasal obstruction, headache, nasal discharge, loss of smell, and associated complaints with regard to the nose such as fever and weakness were evaluated.

Each patient underwent a detailed examination of the ear, nose, and throat along with computed tomography of the paranasal sinuses and nasal endoscopy.

The inclusion criteria comprised complaints involving more than 10 parameters of the SNOT-22^[3] scale, radiographical evidence of mucosal thickening in three or more sinuses on both sides, endoscopic evidence of sinusitis of bacterial origin based on discharge, patients willing for a 3-month follow-up, and a failure of medical management after a period of 12 weeks.

The exclusion criteria comprised benign and malignant space-occupying lesions of the nose and nasopharynx, fungal sinusitis, patients unfit for general anesthesia, septal deviations, and spurs predisposing to CRS and allergic rhinitis (seasonal or perennial).

Two hundred and thirteen patients presented with the aforementioned complaints and were evaluated. Out of these, only 69 patients met the inclusion criteria. Thus, they made it to the final study and the remaining 144 were excluded from the study.

After obtaining adequate consent for anesthesia, surgery, and follow-up, all the patients were taken up for surgery under general anesthesia. It was performed by the same surgeon under the same environment and instruments to avoid bias.

Under general anesthesia, patient was placed in a supine position with the head end elevated by 15°. Uncinectomy, middle meatal antrostomy, anterior and posterior ethmoidectomy, transethmoid sphenoidotomy, and removal of the frontal sinus floor between the middle turbinate and lamina papyracea were performed. Adrenaline, when used, was 1:1,00,000 and a maximum of 10 ml was used. 0° and 30° endoscopes were used with conventional cold steel instruments.^[4] Postsurgery, the anterior nasal pack was paced for a period of 24 h. The pack was removed, and alkaline nasal douching was done 6 times a day for 1 week.

The SNOT-22 scale was administered to each patient 1 day before surgery and then after 12 weeks postsurgery.^[5] The language used was English and it was taken by the same practitioner for all the patients to prevent interviewer bias. A translation to the local language was not performed. The SNOT-22 has a Cronbach alpha value of 0.803 which is significant and thus makes it easy and reliable.^[6]

Statistical analysis was done using a paired Student's t-test. They were performed using the SPSS Statistics 19 Software for Windows (by IBM Corp., Armonk, United States of America). Paired t-test was used for the sampling process. P < 0.05 was considered statistically significant. The confidence interval was set at 95%.

Observations and Results

Out of the 69 patients taken for the study, 42 were male and 27 were female [Figure 1]. Three were below the age of 20, 25 between ages 21 and 30, 18 between ages 31 and 40, 11 between ages 41 and 50, 9 between ages 51 and 60, and 3 above the age of 60 [Figure 2].

Figure 1: Gender distribution

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Figure 2: Age distribution

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The average preoperative score was 46.16 out of a maximum of 110 and the average postoperative score was 18.70 out of a maximum of 110 [an improvement of 59.50%, P < 0.05, [Table 1]].

Table 1: Paired samples correlations and statistics

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The symptom which affected the study population the most was “nasal blockage” (average of 3.13 out of 5) and the one which affected least was “embarrassment” (average of 1.43 out of 5). The symptom which improved the most was “ear pain” (75.43%) and the symptom which improved the least was “reduced productivity” (31.94%) [Table 2].

Table 2: Average symptom score for Sinonasal Outcome Test-22

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Discussion

Extensive FESS for diseases of the sinuses has been performed for the better part of the last three decades now.^[7],[8] Most of these surgeries are performed in local anesthesia in smaller setups and in cases of need, general anesthesia can be used. It can also be done as a day-care procedure and the recovery rate is usually quick.

Various causes for sinusitis and the symptoms of the same have been reported in the literature. It can vary from various bacteria and fungi to biofilms.^[9],[10]

There are a lot of approved questionnaires in the assessment of changes seen in the nasal cavity after various rhinological surgeries.^[11] The SNOT-20 score was the gold standard for such situations and is still used in a large scale as of today.^[12] The SNOT-22 was formulated later and two new symptoms (nasal block and decreased sense of smell and taste) were added for better understanding. Ever since that this new scale is being used widely since it is easy to use, practical, and inexpensive.

The SNOT-22 scoring has been used to good effect in septal surgeries including rhinoplasties^[13],[14] and FESS.^[3]

One particular study in the United Kingdom reported that 52% of patients had responded well to a 5-year follow-up and that SNOT-22 was found to be useful in the global awareness of the disease.^[15]

A few other studies from the United States of America have stated that the SNOT-22 helped in getting a good perception of the nature of CRS before surgery to counsel the patients about the amount of improvement in the quality of life and also help in sustaining the improved symptoms for a longer time with proper medical therapy.^[16],[17]

Although there has been extensive data and information about the use of this scoring in revision cases of CRS, there is yet to be extensive research about how this scale works in pansinusitis undergoing full-house FESS during the first sitting. Our aim of the study was to throw light on this situation as the follow-up in rural populations is not always strong and the presentation of the patient is usually late. As ideal situations are not possible in our rural setup, we had to go for a more radical surgery for pansinusitis which is usually not performed in places with better amenities and communication.

There has been a study in India about FESS in geriatric population where the SNOT-20 was used.^[18] As far as documented research is concerned, the use of SNOT-22 in the rural Indian population has not been done on a large scale. Thus, this makes our research more viable for surgeons in similar backgrounds all around the World where either there is a lack of follow-up/financial restraints/late presentation/poor literacy rates. The lack of powered instruments and complicated investigations does not necessarily prove to be a hindrance in the management of such cases. Hence, we aim to achieve some community reach as well for such practitioners.

The study was unidirectional since there is enough evidence that the symptoms will improve after FESS. The aim was to understand the magnitude of the relevance of SNOT-22 in the local population. The external validity of this study is positive and relevant since symptoms of sinusitis are not affected based on demographic locations and personal habits. The major limitation of the study is that we used nonpowered tools since the use of better instruments needed more expenses which could not be borne by the patients in this rural setup. Furthermore, the scale can be translated into the local language for further use.

Conclusion

Understanding the nature and progression of CRS among the local population is comparatively poor as compared to other societies. SNOT-22 is an inexpensive tool and can be easily used for recording the symptoms associated with CRS. If the score is significantly high and more than 10 symptoms are involved, it becomes essential to monitor those cases closely. In our study, the symptoms have improved significantly after surgery with no large-scale complications. Thus, we conclude that performing a full-house FESS for pansinusitis in cases with improper follow-up can be done without any side effects provided they are monitored with the SNOT-22 Questionnaire. This study can help practitioners achieve good success rates with lower revision surgery requirements in the rural population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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