Braz J Otorhinolaryngol. 2017;83(4):451---456
Brazilian Journal of
OTORHINOLARYNGOLOGY
www.bjorl.org
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 a,∗ , Manuela Garcia Lima a,b ,
Marina Barbosa Guimarães c , Amaury de Machado Gomes a ,
Melina Pinillos Marambaia d , Otávio Marambaia dos Santos e ,
Leonardo Marques Gomes f
a
Escola Bahiana de Medicina e Saúde Pública (Bahiana), Programa de Pós-graduação, Salvador, BA, Brazil
Universidade Federal da Bahia (UFBA), Salvador, BA, Brazil
c
Instituto de Otorrinolaringologia Otorrinos Associados (INOOA), Salvador, BA, Brazil
d
Santa Casa de São Paulo, Otorrinolaringologia, São Paulo, SP, Brazil
e
Universidade do Porto, Bioética, Porto, Portugal
f
Universidade Federal de São Paulo (UNIFESP), Programa de Pós-graduação em Otorrinolaringologia, São Paulo, SP, Brazil
b
Received 4 March 2016; accepted 30 May 2016
Available online 24 June 2016
KEYWORDS
Nasal surgical
procedures;
Quality of life;
Sinusitis
Abstract
Introduction: Chronic rhinosinusitis is a prevalent disease that has a negative impact on the lives
of sufferers. SNOT-22 is considered the most appropriate questionnaire for assessing the quality
of life of these patients and a very effective method of evaluating therapeutic interventions;
however it is not used as a tool for decision-making.
Objective: To test the hypothesis that the SNOT-22 score can predict the outcome of surgical
treatment.
Methods: A retrospective, longitudinal and analytical study. We evaluated the medical records
of patients with chronic rhinosinusitis that completed the SNOT-22 at the time of diagnosis. All
the patients were consecutively receiving care at an otolaryngology service in Salvador, Bahia
from August 2011 to June 2012. The outcomes of the surgical treatment of these patients were
obtained from their medical records. The initial score was compared to a group of patients who
were not referred for surgery. All the patients completed and signed a consent form.
夽 Please cite this article as: Marambaia PP, Lima MG, Guimarães MB, Gomes AM, Marambaia MP, Santos OM, et al. Can we use the questionnaire SNOT-22 as a predictor for the indication of surgical treatment in chronic rhinosinusitis? Braz J Otorhinolaryngol. 2017;83:451---6.
夽夽 Institutions: Escola Bahiana de Medicina e Saúde Pública (Bahiana), Salvador, BA. Instituto de Otorrinolaringologia Otorrinos Associados
(INOOA), Salvador, BA. Site: www.inooa.com.br.
∗ Corresponding author.
E-mail: pablomarambaia@hotmail.com (P.P. Marambaia).
Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial.
http://dx.doi.org/10.1016/j.bjorl.2016.05.010
1808-8694/© 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
452
Marambaia PP et al.
Results: Of the 88 patients with chronic rhinosinusitis, 26 had evolved to surgery over the
last 3 years. The groups were homogeneous regarding gender and respiratory and medication
allergies. The patients of the surgical group were 44.8 + 13.8 years old and the patients of the
clinical group were 38.2 + 12.5 years old (p = 0.517). The average SNOT-22 score of the case
group was 49 + 19 and the average score of the control group was 49 + 27 (p = 0.927).
Conclusion: The SNOT-22 was unable to predict the outcome of surgical patients with chronic
rhinosinusitis.
© 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-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
cirúrgicos nasais;
Qualidade de vida;
Sinusite
Podemos usar o questionário SNOT-22 como preditor para a indicação de tratamento
cirúrgico na rinossinusite crônica?
Resumo
Introdução: A rinossinusite crônica é uma doença prevalente que tem um impacto negativo
sobre a vida dos portadores. O SNOT-22 é considerado o questionário mais adequado para
avaliar a qualidade de vida desses pacientes e um método muito eficaz de avaliar intervenções
terapêuticas; no entanto, ele não é usado como uma ferramenta para a tomada de decisões.
Objetivo: Testa a hipótese de que o escore do SNOT-22 pode prever o desfecho do tratamento
cirúrgico.
Método: Estudo retrospectivo, longitudinal e analítico. Foram avaliados os prontuários de
pacientes com rinossinusite crônica que preencheram o SNOT-22 no momento do diagnóstico.
Todos os pacientes foram consecutivamente atendidos em um serviço de otorrinolaringologia
em Salvador, Bahia, de agosto de 2011 a junho de 2012. Os desfechos do tratamento cirúrgico desses pacientes foram obtidos a partir de seus prontuários médicos. A pontuação inicial
foi comparada com um grupo de pacientes que não foi encaminhado para cirurgia. Todos os
pacientes preencheram e assinaram um termo de consentimento informado.
Resultados: Dos 88 pacientes com rinossinusite crônica, 26 evoluíram para cirurgia nos últimos
três anos. Os grupos foram homogêneos quanto a sexo, alergias respiratórias e medicamentos.
Os pacientes do grupo cirúrgico tinham 44,8 + 13,8 anos e os do grupo clínico tinham 38,2 + 12,5
(p = 0,517). O escore médio do SNOT-22 do grupo do caso foi de 49 + 19 e o escore médio do
grupo controle foi de 49 + 27 (p = 0,927)
Conclusão: O SNOT-22 foi incapaz de prever o desfecho dos pacientes cirúrgicos com rinossinusite crônica.
© 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado
por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http://
creativecommons.org/licenses/by/4.0/).
Introduction
Data on the quality of life of patients with chronic rhinosinusitis (CRS) prove that this disease has a major impact on
the activities of daily living of these patients.
It has already been proved that CRS negatively affects the
QOL of sufferers in comparison to people without the disease
and people with other chronic diseases like congestive heart
failure and chronic obstructive pulmonary disease.1
The main focus of these studies was the use of questionnaires to evaluate the impact of therapeutic interventions.
The same questionnaire is generally applied before and after
intervention to a group of patients. The impact of surgery on
the betterment of patients with CRS has been exhaustively
studied and there seems to be a consensus, especially in the
short-term assessment.2 Studies show that the improvement
rates of surgery range from 76% to 97.5%.3,4
The SinoNasal Outcome Test 22 (SNOT-22) is an easily
applied questionnaire that has been validated for use in
Portuguese.5 This instrument has 22 questions about possible symptoms linked to chronic rhinosinusitis. Each question
receives a score from 0 to 5, where zero is the absence of this
condition and five is the worst possible case of this condition. Similarly, higher total scores represent a worse quality
of life. According to the 2012 European Position Paper on
Rhinosinusitis and Nasal Polyps (EPOS), SNOT-22 is a good
tool for assessing QOL in patients with CRS. Moreover, it
can be used repeatedly and produces graphics (SNOTgrams)
with SNOT-22 scores for more than a given moment in time,
which clearly display the result of medicinal and surgical
interventions and exacerbations over time.6
Since the 1990s, the benefit of functional endoscopic
surgery of the paranasal sinuses has been demonstrated by
assessing specific symptoms such as nasal obstruction, for
SNOT-22: its surgical indication in chronic rhinosinusitis
example. Later, QOL became an additional parameter in this
assessment and several studies have used this tool to evaluate patients. This practice has led to the hope that we can
extrapolate the use of the questionnaires mostly to select
patients for different types of treatment and determine how
to interpret the information of populations outside Brazil
and apply it to our scenario.
The criteria of surgical intervention, for example, are
poorly described in literature and consequently lead to a
broad geographical variation of this indication and a loss of
quality in medical care.7 Measures that can standardise or
facilitate this decision would help improve the follow-up of
these sufferers.
The present study aims to compare the average score of
the SNOT-22 in the initial assessment of patients with chronic
rhinosinusitis and test the hypothesis that the SNOT-22 score
can predict the outcome of surgical therapy.
Methods
This is a descriptive and analytical retrospective longitudinal
study with a convenience sample derived from a previous
study of the same author.
We accessed records of the patients who participated in
the previous study. These patients had received care for the
first time between 2011 and 2012 and continued supervised
care at an otolaryngology service in Salvador, Bahia, until
August 2015.
The inclusion criteria were literate patients with chronic
rhinosinusitis over 18 years of age.
The diagnosis of chronic rhinosinusitis was determined
using the criteria of the EPOS-2012,6 whereby chronic rhinosinusitis is defined by the presence of two or more
symptoms of nasal obstruction/congestion/blockage, anterior or posterior rhinorrhea, anosmia or hyposmia/anosmia
and facial pain/pressure for more than 12 weeks that must
be the result of nasal obstruction/congestion/blockage or
anterior or posterior purulent rhinorrhea.
The criteria for exclusion were illiterate patients, smokers, patients with immune deficiency, cystic fibrosis or
primary ciliary dyskinesia, patients with benign or malignant
nasal tumours, patients with granulomatous diseases and
vasculitis, patients who had previously undergone surgery
and subjects who refused to participate in the study.
All the patients were evaluated during the first consultation and after the confirmation of CRS. The patients
subsequently completed a registration form with demographic data, the SNOT-22 questionnaire validated for
Portuguese8 and an informed consent statement.
The SNOT-22 questionnaire was applied during the first
consultation when the patients were evaluated by the same
professional, in 2011 and 2012.
After 3 years, the medical records were reviewed to verify the referral for clinical or surgical treatment over time.
This referral was made by the same ENT professional who
was blinded to the SNOT-22 score.
The subjects were divided into two groups: The group
that evolved to the referral for surgery during the studied
period and the group that continued with clinical treatment.
Surgery was referred after maximum clinical treatment
had failed for at least 3 weeks. Maximum clinical treatment
453
is defined as the use of topical or systemic corticosteroids,
antibiotic therapy and saline nasal irrigation.
The failure of clinical treatment was defined as the lack
of improvement in symptoms referred by the actual patient.
In the absence of a response, an assessment computed
tomography was requested, as well as possible scheduling
of a future surgery.
Surgery was also indicated when tomographic analysis
led to the diagnosis of a condition that required surgical
treatment, namely significant anatomical changes such as
obstructive septum deviation, large or obstructive middle
turbinate pneumatisation or extensive sinonasal polyposis,
and rhinosinusitis of dental or fungal origin.
Furthermore, surgery was indicated according to the
mentioned criteria and the conduct of a single professional,
although not all the patients were necessarily operated
since elements such as motivation, personal preference and
expectations regarding the procedure influenced the decision.
This study was approved by the Ethics Committee of the
institution, under protocol n◦ 181/2011.
Data analysis
The sample size was calculated using WinPepi version 11.62,
with a standard deviation of the SNOT-22 score of a previous
Brazilian study involving surgical patients (DP = 25), Kosugi
et al.,8 to detect a difference of 20 points. In this case,
50 patients would be needed, divided into two groups of
25 subjects. Consequently, the sample of the present study
exceeds the required number of participants.
The results were tabulated and analysed using SPSS-17
software.
The categorical demographic data like gender and presence of comorbidities and allergies were arranged using the
valid percentile. The chi-square test was used to compare
categorical variables between the groups.
The score of the SNOT-22 questionnaire was described
using the average and standard deviation since the sample
distribution was normal.
The averages between the groups were compared using
the unpaired t-test.
The unpaired t-test was also used to compare the average
score of each item of the SNOT-22 individually.
The alpha error was considered acceptable when the
value of p < 0.05.
Results
A total of 88 patients were analysed, of which 26 were
patients referred for surgery and 62 evolved to drug therapy.
Table 1 shows the demographic characteristics of the
sample.
With regard to the SNOT-22 score in the first consultation, it was found that the group that evolved to surgical
treatment scored 49.4 ± 19.8 and clinical group averaged
49.9 ± 27 (Table 2 and Fig. 1).
The comparison of each item (symptom) of the SNOT22 questionnaire did not show any difference between the
groups.
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Marambaia PP et al.
Table 1 Sociodemographic characteristics of patients with chronic rhinosinusitis referred for surgery (surgery group) and of
patients with chronic rhinosinusitis referred for clinical treatment (clinical group).
Variables
Surgery group (n = 26)
Clinical group (n = 62)
Significance (p)
Gender (%)
Male
Female
12 (41)
14 (59)
24 (40.8)
38
0.517
0.517
Age (years)
44.8 + 13.8
38.2 + 12.5
0.438
Comorbidities
SAH
DM
Asthma
03
0
04
02
02
02
0.81
0.307
0.167
Allergy to medication (%)
Yes
No
07 (22.8)
19 (77.2)
12 (13.3)
50 (86.7)
0.594
Respiratory allergy (%)
Yes
No
02 (7.7)
24 (92.3)
05 (8.1)
57 (91.9)
0.810
Surgery group, patients referred for surgery; clinical group, patients referred for clinical treatment.
Significance level p < 0.05.
Table 2
Quality of life score with SNOT-22 of the groups.
Variable
Surgery group
Clinical group
Significance (p)
SNOT-22
49 (±19)
49 (±27)
0.927
SNOT-22, Sino Nasal Outcome Test.
Significance level p < 0.05. Unpaired t-test. Average (standard deviation).
Discussion
The QOL assessment of patients with CRS requires specific questionnaires to measure the results, such as
those obtained after interventions with medication and
surgery. A vast amount of studies use these instruments to
assess surgical treatment3,4 and some authors believe that
120.00
p=.927
SNOT-22 score
100.00
80.00
60.00
40.00
20.00
0.00
Surgical
Clinical
Surgical treatment or clinical group
Figure 1 Shows the comparison of the SNOT-22 score averages
of the groups.
questionnaires can provide additional information for diagnoses and decision making.9
Soler et al.9 also reported that a low score of the questionnaire was the only factor that was related to the decision
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
showed that patients with worse scores benefit more from
surgery. Moreover, patients with clinical monitoring and
worse quality of life scores could switch to the surgical group, which led to a significant improvement of the
scores.
Birch et al.11 suggest that patients who are waiting for
surgery should have worse endoscopic scores, more CRS
symptoms and worse QOL scores.
Rudmik et al.12 conclude that the patient with a SNOT22 score above 30 points have a 75% chance of significantly
changing their clinical condition with surgery. These same
patients improved their quality of life by 45%. On the other
hand, patients with SNOT-22 scores under 20 did not show
significant improvements after surgery.
In the present study, no statistically significant difference
was found between the averages of the SNOT-22 score of the
first consultation of patients for the groups that evolved to
surgical or clinical referrals.
In a study that validated SNOT-22 to Portuguese, Kosugi
et al.8 applied the questionnaire to 89 patients before
and after sinonasal surgery and obtained an average
SNOT-22: its surgical indication in chronic rhinosinusitis
preoperative score for the group with the disease of 62.39
compared to 49 + 19 of our sample.
In a prospective study, Mascarenhas et al.13 evaluated 60
patients with referrals for surgery prior to sinonasal surgery
and obtained a score of 61.3 ± 24.
The present study was longitudinal and retrospective and
the patients of this sample were initially treated clinically
and referred for surgery during their ENT medical follow-up.
Since collections were not carried out periodically or at the
exact moment of the surgical referral, it is not possible to
confirm whether the score deceased over time or whether
the score of these patients was worse than the score of the
first assessment at the time of the surgical referral.
The studies of Kosugi et al.8 and Mascarenhas et al.13
were conducted with patients with a confirmed surgical
referral, which differs from the profile of our sample that
did not have that confirmation.
In the Brazilian scenario, the difference found between
the scores may also correspond to the fact that our sample
used a service that attends private patients. This means that
the studied subjects may have had a better socioeconomic
status than the patients of the studies of Kosugi et al.8 and
Mascarenhas et al.13 whose subjects used a public health
service.
The expected pathophysiological rationale is that
patients with referrals for surgery obtain higher scores and
that this could explain the better scores of patients with
referrals for clinical treatment. Soler et al.8 conducted a
study with 242 patients analysed over time and found that
patients selected for the surgical treatment obtained worse
SNOT-22 scores than patients who chose clinical treatment.
Factors such as demographic characteristics, patient-doctor
relationship, comorbidities and personality did not influence
the surgical outcome.
In the present study, there was no difference between
the demographic characteristics of the groups. With respect
to the doctor---patient relationship, the authors believe that
the use of a single evaluator minimises this bias.
The outcome analysed in this study is the surgery indicated by the physician. This decision also depends on
subjective factors, such as motivation, personal preference
and expectations of the patients regarding the procedure.
Of the patients of this study, four patients did not undergo
surgery and decided to continue with clinical treatment.
The criterion for surgical indications was the failure of
maximum clinical treatment after three weeks. Information
from the actual patients regarding the absence of improvement in symptoms or even the worsening of symptoms and
the will of the health professionals make selection more
reliable and reduce the subjectivity of multiple observers.
The authors believe that these findings do not invalidate the information that the serial analysis and prospective
follow-up of these patients can significantly enable a change
of conduct and option for the right moment of surgical referral. Over time, considering the natural evolution of the
disease or failure of clinical treatment with maintenance
or worsening of scores of the questionnaire, this could lead
to a significant difference between the groups that evolves
to surgery to the detriment of clinical treatment.
Hopkins et al.,14 who validated the SNOT-22 for the first
time in the United Kingdom, applied the questionnaire to
2077 surgical patients and obtained a preoperative score of
455
41.7, which is lower than the score found in the present
study. This difference between the Brazilian studies and UK
study suggests that the different lifestyles and cultures of
the nations may influence the concept of quality of life.
However, the UK sample of surgical patients consisted of
subjects from several centres. Such a diverse criteria suggests that the sample included patients with few symptoms
or a milder form of disease, which would be an error and
may lead to over-referrals of surgical treatment.
Gillett et al.15 conducted a study and used the SNOT-22
on 116 patients without sinonasal disease in the United Kingdom to know the score of the questionnaire among patients
without sinonasal disease. The justification was that many
patients who underwent surgery in other studies obtained a
relatively low SNOT-22 score, which suggests that the referral may have been inappropriate. Patients with low scores
may have oligosymptomatic CRS or may have been overdiagnosed.
In our sample, patients were recruited from a single
service and the referral was indicated by a single doctor,
which minimises the risk of changes in criterion. Blinding in
relation to the initial score also enables more robust data.
A limitation of this study is the non-discrimination of
the CRS groups. We did not distinguish the subjects with
sinonasal polyposis from the subjects with eosinophilia, for
example. The intention was to help the otolaryngologist
indicate surgical treatment irrespective of the type of disease. Furthermore, the size of the sample did not allow the
creation of subgroups.
Conclusion
Although this study did not include multiple and serial analysis, the first assessment showed that the SNOT-22 does not
predict surgical outcome. It is therefore impossible to affirm
whether these results over time, with serial assessments
based on the questionnaire, could establish the SNOT-22 as
a good decision-making tool.
Conflicts of interest
The authors declare no conflicts of interest.
References
1. Glicklich RE, Metson R. The health impact of chronic sinusitis in
patients seeking otolaryngologic care. Otolaryngol Head Neck
Surg. 1995;113:104---9.
2. Smith TL, Batra PS, Seiden AM, Hannley M. Evidence supporting endoscopic sinus surgery in the management of adult
chronic rhinosinusitis: a systematic review. Am J Rhinol.
2005;19:537---43.
3. Ling FT, Kountakis SE. Important clinical symptoms in patients
undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope. 2007;117:1090---3.
4. Bhattacharyya N. Symptom outcomes after endoscopic sinus
surgery for chronic rhinosinusitis. Arch Otolaryngol Head Neck
Surg. 2004;130:329---33.
5. Morley AD, Sharp HR. A review of sinonasal outcome scoring
systems --- which is best? Clin Otolaryngol. 2006;31:103---9.
6. Fokkens W, Lund V, Mullol J. European position paper on rhinosinusitis and nasal polyps. Rhinol Suppl. 2012;23:1---298.
456
7. Rudmik L, Soler ZM, Hopkins C, Schlosser RJ, Peters A, White
AA, et al. Defining appropriateness criteria for endoscopic sinus
surgery during management of uncomplicated adult chronic
rhinosinusitis: a RAND/UCLA appropriateness study. Rhinology.
2016;54:117---28.
8. Kosugi EM, Chen VG, Fonseca VMG, Cursino MMP, Mendes
Neto JA, Gregório LC. Translation, cross-cultural adaptation and validation of SinoNasal Outcome Test (SNOT) --- 22
to Brazilian Portuguese. Braz J Otorhinolaryngol. 2011;77:
663---9.
9. Soler ZM, Rudmik L, Hwang PH, Mace JC, Schlosser RJ, Smith TL.
Patient-centered decision making in the treatment of chronic
rhinosinusitis. Laryngoscope. 2013;123:2341---6.
10. Smith TL, Kern RC, Palmer JN, Schlosser RJ, Chandra RK, Chiu
AG, et al. Medical therapy vs surgery for chronic rhinosinusitis: a
prospective, multiinstitutional study. Int Forum Allergy Rhinol.
2011;1:235---41.
Marambaia PP et al.
11. Birch DS, Saleh HA, Wodehouse T, Simpson IN, Mackay IS.
Assessing the quality of life for patients with chronic rhinosinusitis using the rhinosinusitis disability index. Rhinology.
2001;39:191---6.
12. Rudmik L, Soler ZM, Mace JC, DeConde AS, Schlosser RJ, Smith
TL. Using preoperative SNOT-22 score to inform patient decision
for endoscopic sinus surgery. Laryngoscope. 2015;125:1517---22.
13. Mascarenhas JG, Fonseca VMG, Chen VG, Itamoto CH, Pontes da
Silva CA, Gregório LC, et al. Long-term outcomes of endoscopic
sinus surgery for chronic rhinosinusitis with and without nasal
polyps. Braz J Otorhinolaryngol. 2013;79:306---11.
14. Hopkins C, Browne JP, Slack R, Lund V, Topham J, Reeves B, et al.
The national comparative audit of surgery for nasal polyposis
and chronic rhinosinusitis. Clin Otolaryngol. 2006;31:390---8.
15. Gillett S, Hopkins C, Slack R, Browne JP. A pilot study of
the SNOT 22 score in adults with no sinonasal disease. Clin
Otolaryngol. 2009;34:467---9.