Since the mid-1980s, there has been an enormous improvement both in our understanding of rhinosinusitis and in our ability to manage patients with this disorder. According to the emerging theories, there is general agreement that chronic rhinosinusitis is a disorder in which there is a tendency toward hyperreactivity, whether associated with chronic infection, atopy, ASA (Salycilate) intolerance, or idiopathic. More recent hypotheses also propose a role for underlying osteitis in the perpetuation of the chronic inflammatory process. The management of these patients is multifaceted and includes medication, specific allergy treatment, and endoscopic sinus surgery. Thus, chronic rhinosinusitis can be said to be a medical disease in which surgery plays a therapeutic role. Consequently, close postoperative follow-up is an integral part of the management of this disorder. What has been repeatedly demonstrated in recent years is that there is often a discrepancy between the subjective symptoms experienced by patients and their objective endoscopic findings.1, 2 The controversy that remains is to evaluate whether the subjective or objective outcomes are more important and/or relevant from a prognostic perspective. Obviously, from the patient’s point of view, and from the standpoint of third-party carriers, what may be most important is the short-to medium-term symptomatic relief. However, we have demonstrated that this does not correspond to long-term disease resolution or freedom from the potential for recurrent surgery. In a 7.8-year follow-up of surgical patients, we demonstrated that endoscopic resolution of disease by 1.5 years postoperatively correlated with subsequent avoidance of further surgical intervention.¹ Indeed, no patients whose cavity was normal or almost normal endoscopically at 1.5 years required further surgical intervention during the subsequent period.

Evaluation Scales and Staging Systems

Several evaluation scales currently exist for patients with chronic rhinosinusitis.³ For subjective evaluation there are general health status instruments, such as the Medical Outcomes Study Short Form-36 (SF-36), as well as disease-specific instruments such as the Chronic Sinusitis Survey (CSS), the Rhinosinusitis Outcome Measure (RSOM-31)/Sinonasal Outcome Test (SNOT-20), and the Rhinosinusitis Disability Index (RSDI). A recently released comprehensive tool for the subjective evaluation of chronic rhinosinusitis is the Chronic Sinusitis TyPE Specific Questionnaire, published by the Health Outcomes Institute.

Objective staging systems for rhinosinusitis also exist. Although an ideal and widely accepted staging scale remains elusive, two staging systems have achieved reasonable acceptance and utility. Kennedy’s¹ detailed analysis of a patient cohort permitted the proposal of a rational staging system that incorporated surgical findings and radiological appearance and this system has been shown to be predictive of outcome. The more recently proposed Lund–MacKay^{4, 5} system also uses radiologic findings as its primary determinant and was recently recommended by the Rhinosinusitis Task Force⁶ for validation in large clinical studies because of its ease of use and high degree of inter- and intra-observer agreement.

Subjective Outcomes Measures

The SF-36 is a general health status instrument that permits the evaluation of a patient’s overall response to treatment.⁷ It provides information concerning the functional well-being of the individual and may serve to evaluate not only the response to treatment, but also the need for subsequent intervention through medical or surgical means. The limiting factor of general health status measures is that they do not provide specific evaluation of the disease in question.

Disease-specific health measurement tools are available as well. The CSS, developed at the Massachusetts Eye and Ear Infirmary, is duration-based and monitors both symptoms and need for medical therapy over an 8-week period.⁸ Studies have demonstrated that the CSS is statistically reliable and is sensitive to clinical change over time. The CSS has been used as a research tool to evaluate the outcomes of sinus surgery on quality of life and seems like a reasonable candidate to use in the evaluation and management of patients with chronic rhinosinusitis.⁹ This clinical use remains to be formally evaluated and the potential shortcomings for the CSS include a limited range of symptoms and psychometric data.

The RSOM-31 includes components that address health status and quality-of-life measures.¹⁰ It permits the evaluation of both the magnitude of a symptom and its importance to the patient. In this sense, the RSOM-31 is perhaps a more sensitive instrument. The RSOM-31 has undergone modifications since its original publication and now exists in its newest incarnation as the SNOT-20. The more cumbersome RSOM-31 has been reduced by 11 items and the SNOT-20 is easier and faster to complete. With respect to the responsiveness to therapeutic intervention, the RSOM-31 has been shown to be sensitive; however, the responsiveness of the SNOT-20 remains to be determined, and this would clearly be required before its use in a clinical or research setting.

The RSDI is a unique disease-specific outcome measure in that it evaluates the self-perceived impact of chronic rhinosinusitis in a first-person descriptive format.¹¹ It is unclear whether this format is more helpful in gathering useful clinical or research data but this measurement tool has been tested and found reliable and valid.

Another recently released tool for outcomes assessment is the Chronic Sinusitis TyPE (Technology of Patient Experience) Specification form, which has been used in recent outcomes studies.12 This instrument has three forms, the first of which provides an initial evaluation of the patient and previous interventions, if any. The third component is a post-treatment survey. This TyPE Specific Questionnaire is publicly available and has been recommended by the Rhinosinusitis Task Force for thorough evaluation.

In terms of clinical value in the management of patients with chronic rhinosinusitis, the CSS and TyPE (third component) appear to be simple to use and provide temporal information regarding the efficacy of treatment. The Post-Treatment Survey portion of the Chronic Sinusitis Form (TyPE Specification) is similar to the CSS in that both examine symptoms and requirement of medication over an 8-week period. After statistical and clinical validation in a controlled fashion, these forms appear to provide the best potential for usefulness as management parameters.

Objective Outcome Measures and Staging Systems

In an effort to objectify the severity of chronic rhinosinusitis and the response to medical therapy, numerous staging systems have been proposed. Theoretically, a uniform reporting scheme and a uniformly accepted staging system would improve scientific and accurate communication between otolaryngologists. Such a staging system might also permit the subsequent re-staging of patients after therapeutic intervention and thus become a management tool. To date, however, such a staging system has remained elusive.

Early attempts to devise such objective staging systems incorporated measures of disease severity (e.g., localized vs diffuse disease) combined with the presence or absence of related factors (e.g., asthma, allergy, polyposis).^{13, 14} Extensions and refinements of these techniques have been proposed more recently. The first significant step forward was made by Kennedy¹ in 1992 and, more recently, the Lund–MacKay staging system was endorsed by the Rhinosinusitis Task Force for future outcomes research.³

Kennedy’s close follow-up and data collection of a patient cohort was the first to emphasize the importance of objective endoscopic follow-up after surgery. Kennedy pointed out that early recurrent disease is often detectable objectively on nasal endoscopy before the development of subjective symptoms. This provided the opportunity to treat such recurrent disease, either medically or with surgical debridement, at an early stage, when it is more manageable.

With respect to outcome measures and prognostic factors, Kennedy’s study identified extent of disease as the primary predictor. Other seemingly related and important factors such as asthma, allergies, and ASA sensitivity, when severity of disease was factored in, were not independently related to outcome and prognosis. However, in stage IV disease (diffuse sinonasal polyposis), asthma did worsen the prognosis. The primary assessment of extent of disease was made using radiographic and intraoperative data, and similar evaluations were used when the initial staging system was proposed.

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