The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Comorbidities in Patients With All-Positive Symptoms on Sinonasal Outcomes Test Quality-of-Life Instrument Alexander Caten, MD; Christopher Johnson, PharmD, BS; David Jang, MD; Jose Gurrola, MD; Stilianos Kountakis, MD, PhD Objectives/Hypothesis: The Sinonasal Outcomes Test-20 (SNOT-20) is a validated tool to assess treatment outcomes in patients with chronic rhinosinusitis (CRS). In the clinic, we observed that patients who responded with a positive score on all 20 items of the SNOT-20 questionnaire (pan-positive patients) often did not have evidence of CRS upon workup. Many of these patients had other underlying diseases contributing to their complaints. Methods: Analysis of prospectively collected data was performed to identify SNOT-20 pan-positive patients and compare them to 100 consecutive non–pan-positive patients who served as the control group. The following parameters were compared between the two patient groups: presence or absence of chronic diseases such as obstructive sleep apnea, depression, anxiety, fibromyalgia, chronic pain, headaches, temporomandibular joint disease, and arthritis—in addition to sinus computed-tomography Lund-McKay scores and nasal endoscopy Lund-Kennedy scores. We also reviewed the medication list of each patient to look for the possible presence of mental illness. Statistical analysis was performed using the chi-squared and Student t test. Results: One hundred twenty-two pan-positive patients were identified in our database collected from 2003 to 2011. Pan-positive patients had higher incidence of depression, fibromyalgia, anxiety, pain, headache, and use of depression medications—and they also had higher SNOT-20 and endoscopy scores when compared to controls (P < 0.05). Pan-positive patients were more likely female (P < 0.05), but age and race differences did not reach statistical significance. Conclusion: The SNOT-20 questionnaire assists clinicians to monitor outcomes in patients treated for CRS. However, clinicians should suspect other underlying chronic conditions in SNOT-20 pan-positive patients. Key Words: Chronic rhinosinusitis, comorbidities, depression, anxiety, obstructive sleep apnea, chronic pain, sinonasal outcomes test. Level of Evidence: 3B. Laryngoscope, 125:2648–2652, 2015
INTRODUCTION Chronic rhinosinusitis (CRS) is among the most common chronic health conditions in the United States. Most recent data indicates that approximately 12% of the adult population, equal to 28.5 million people, suffer from CRS.1 Treatment of CRS is common among the primary care community, but frequent otolaryngology referral results in over 250,000 sinus surgeries performed in the United States annually, making it one of the most frequently performed surgeries in the United States.2 Diagnosis and treatment often rely on objective findings from computed tomography (CT) scan and nasal
From the Department of Otolaryngology Head and Neck Surgery, Georgia Regents University (A.C., C.J., S.K.), Augusta, Georgia; the Division of Otolaryngology Head and Neck Surgery, Duke University (D.J.), Durham, North Carolina; and the Department of Otolaryngology Head and Neck Surgery, University of Virginia (J.G.), Charlottesville, Virginia, U.S.A. Editor’s Note: This Manuscript was accepted for publication June 1, 2015. Presented at the Triological Society Combined Sections Meeting, Coronado Island, California, U.S.A., January 22–24, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Alex Caten, MD, Department of Otolaryngology Head and Neck Surgery, Georgia Regents University, 1120, 15th St. BP 4109, Augusta, GA 30912. E-mail: [email protected]. DOI: 10.1002/lary.25456
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endoscopy results, as well as patient-reported symptoms. Recently, there is increased reliance on validated patient-reported outcomes measures (PROMs) such as the 20-Item Sinonasal Outcomes Test (SNOT-20). However, subjective symptom scores often do not correlate with objective findings on CT and endoscopy, indicating that there are confounding factors contributing to the symptoms of these patients.3–5 Previous studies indicate higher preoperative, diseasespecific, quality-of-life (QOL) symptom scores, with the Rhinosinusitis Disability Index and Chronic Sinusitis Survey identified in patients suffering from depression, as indicated by the Patient Health Questionnaire (PHQ)-9 questionnaire. However, patients with CRS suffering from depression had an improvement in postoperative symptom scores equal to the CRS patients without depression.6,7 In addition, depression and anxiety are known to have altered perception of stimuli. It was noted that patients with these conditions have increased activity in the anterior cingulate cortex and insula, which correlate with both mood and pain perception.8 There is a prevalence of major depressive disorder and generalized anxiety disorder of approximately 30% of patients with all chronic illnesses, including CRS.9 Not surprising, multiple studies showed that PROM scores also have a strong correlation with gender and with comorbidities such as depression and anxiety.7,10–12 Caten et al.: Comorbidities Pan-Positive SNOT-20 Patients
TABLE I. SNOT-20, Endoscopy, and CT scores for Pan-Positive and Control Groups. Pan-Positive Group
Fig. 1. Demographic (gender) data. Pan-positive patients (blue) and control patients (orange). Females more prominent in panpositive group, whereas gender was equal in the control group. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
In our clinical practice, we use the SNOT-20 outcomes instrument to follow our patients’ progress before and after medical or surgical intervention. We noticed over the years that some patients mark all 20 symptoms as positive without exception and often at a severe level. We hypothesize that these patients with pan-positive symptoms are more likely to have confounding factors in addition to CRS that contribute to their disease burden. The goal of our study is to confirm our clinical observation that pan-positive patients were more likely to have certain underlying chronic illnesses such as depression, anxiety, fibromyalgia, temporomandibular disorder (TMJ), primary headaches, obstructive sleep apnea (OSA), chronic pain, and arthritis than the general population presenting to a rhinology subspecialty office.
MATERIALS AND METHODS Approval for this study was granted by the Georgia Regents University Institutional Review Board. A review of the senior author’s (S.K.) prospectively gathered data collected from 2003 to 2011, totaling 3,547 patient visits, was performed. Each individual responding with a positive score (equal to or greater than 1) to all 20 symptoms of the SNOT-20 questionnaire (pan-positive) was identified. This patient group included both patients at their initial visit and at subsequent follow-up appointments. Ninety-nine consecutive patients who did not fulfill the pan-positive criteria were isolated and used as a control. The total SNOT-20 scores, Lund-Kennedy endoscopy scores, Lund-MacKay CT scores, and demographics were collected for each of the pan-positive and the control groups. The electronic medical record (PowerChart, Cerner Corporation, Kansas City, MO) was then reviewed for each subject, specifically identifying those with headaches, OSA, chronic pain, anxiety, depression, arthritis, TMJ disease, and fibromyalgia. Because some individuals fail to divulge a chronic illness such as psychiatric disease during the medical intake, the medication lists were further reviewed to identify those subjects taking antidepressants, anxiolytics, and medications for chronic pain. All data was collected in a Microsoft Excel (Redmond, WA) database. Because all variables were presented as frequencies, statistical analysis was performed using the chi-squared (v2) test.
RESULTS Demographics Upon review of the database, 121 individuals were identified as meeting the pan-positive criteria. Eightyone (67%) of the pan-positive patients were females as Laryngoscope 125: December 2015
Control Group
P Value
Number
122
99
Total SNOT 20
43.2
21.5
2.4 3 10230
2.9 5.0
1.9 3.8
0.044 0.595
Endoscopy CT
SNOT-20 score and endoscopy scores were significantly higher in the pan-positive group. CT scores were higher in our pan-positive group, but not reaching statistical significance. CT 5computed tomography; SNOT 5 Sinonasal Outcomes Test.
compared to 50 (50%) in the control group (P 5 0.013, Fig. 1). There was no significant difference in age between the control group (average age: 47.1 years old) and the pan-positive group (average age: 49.8).
Objective Data Average total SNOT-20 scores were higher in the pan-positive group (43.2) than in the control group (21.5) (P 5 2.4 3 10230) (Table I). The average Lund-Kennedy endoscopy scores were higher in the pan-positive group (2.9) than in the control group (1.9) (P 5 0.044). The Lund-MacKay CT scores were not significantly different between the pan-positive (5.0) and the control group (3.8). Eleven patients in the pan-positive group had a CT scan, whereas nine patients in the control group had a CT scan.
Comorbidities Anxiety, depression, chronic pain, and headaches were all significantly (P < 0.05) more common in the pan-positive group (Table II). Depression was found in 41 (33.9%) of the pan-positive patients as compared to only
Fig. 2. Comorbidities. Depression, anxiety, headaches, and chronic pain significantly more common in the pan-positive (blue) group. Obstructive sleep apnea (OSA) and arthritis were more common in the pan-positive group but did not reach statistical significance. Fibromyalgia was significantly more common in the control group (orange). TMJ was more common in the control group but did not reach statistical significance. OSA 5 obstructive sleep apnea; TMJ 5 temporomandibular disorder. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
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TABLE II. Comorbidity Data With Associated P Values. Comorbidities
Pan-Positive Group (number)
Pan-Positive Group (percentage)
Control Group (number)
Control Group (percentage)
Depression
41
33.9%
15
15.1%
0.002
6.7
Anxiety Chronic pain
26 45
21.4% 37.2%
10 15
10.1% 12.4%
0.023 0.0003
5.2 13.3
P Value
v2
Primary headache
27
22.3%
10
10.1%
0.016
OSA Arthritis
34 23
28.1% 19%
17 12
14% 12.1%
0.056 0.165
3.65 1.93
Fibromyalgia
5
4.1%
5
5.1%
0.735
5.2
TMJ
5
4.1%
6
6%
0.514
Depression, anxiety, chronic pain, and headaches were significantly more commonly present in our pan-positive group. Obstructive sleep apnea and arthritis were more common in our pan-positive group, but did not reach statistical significance. Fibromyalgia and TMJ were more common in the control group. OSA 5 obstructive sleep apnea; TMJ 5 temporomandibular disorder.
15 (2.4%) of the control subjects (P 5 0.002). Anxiety was present in 26 (21.4%) of the pan-positive patients and only in 10 (10.1 %) of the control subjects (P 5 0.01). Chronic pain was identified in 45 (37.1%) of the panpositive patients and in 15 (12.4%) of the control subjects (P 5 0.0003). Primary headaches were identified in 27 of the pan-positive patients (22.3%) and in 10 (10.1%) of the control subjects (P 5 0.016). Obstructive sleep apnea was found in 34 (28.1%) of the pan-positive patients and in 17 (14%) of the control subjects (P 5 0.056). Arthritis was identified in 23 (19%) of the pan-positive patients and in 12 (12.1%) of the control subjects (P 5 0.165). Fibromyalgia was identified in five (4.1%) of the pan-positive patients and in five (4.1%) of the control subjects (P 5 0.735). Temporomandibular disorder was identified in five of the pan-positive patients (4.1%) and in six (6%) of the control subjects (P 5 0.514). Chronic rhinosinusitis was diagnosed in 34 (28%) of the pan-positive patients while present in 28 (29%) of the control subjects.
Medications A review of the medications taken revealed that antidepressant medications were significantly more commonly used by pan-positive patients (P 5 0.036) (Table III). Pain medications were more commonly used among the pan-positive patients but did not reach statistical significance (P 5 0.104). Anxiety medications
were more commonly used among the control group but did not reach statistical significance (P 5 0.683).
DISCUSSION Anxiety, depression, chronic pain, and headaches were all significantly more common in the pan-positive group. This is consistent with multiple reports indicating that patients with chronic psychiatric conditions such as depression and anxiety have poorer scores on CRSspecific symptom assessments. However, no previous study has isolated a specific subgroup of rhinology patients identifiable by PROMs with a greater preponderance for chronic conditions such as ours. Our previous studies have indicated that patients with primary headaches score higher on SNOT-20 scores than patients with headaches associated with CRS.13 Further review revealed patients undergoing surgery for CRS had significant improvement in headache-specific scores following surgery.14 It comes as no surprise that primary headaches are more likely to be present within our group of pan-positive patients. Comorbidities not reaching statistical significance that were more common in our pan-positive patients included OSA and arthritis. Our previous studies have confirmed increased SNOT-20 scores in patients with OSA and CRS.15 Our current data is in agreement with this report because OSA was more common in our panpositive patients, with a near significant P value of 0.056. Many symptoms on the SNOT-20 form relate to
TABLE III. Medication Data. Medication
Pan-Positive Patients (number)
Pan-Positive Patients (percentage)
Control Patients (number)
Control Patients (percentage)
P Value
Depression
52
42.9%
29
29.3%
0.036
Anxiety
16
13.2%
15
15.2%
0.683
Pain
29
23.9%
15
15.2%
0.104
Depression medications were significantly more likely to be taken by pan-positive patients (P value 5 0.036). Pain medications were more common in pan-positive patients, which did not reach statistical significance (P value 5 0.104). Anxiety medications were more commonly taken by control patients, which did not reach statistical significance (P value 5 0.683).
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Caten et al.: Comorbidities Pan-Positive SNOT-20 Patients
quality of sleep, which confounds the underlying CRS data but remains important for overall QOL assessment. Arthritis was more common in the pan-positive group but did not reach statistical significance. No previous studies have evaluated the association of arthritis with increased PROM scores. A 2006 study noted that 22.3% of patients with rheumatoid arthritis had visited a physician for sinusitis in a 6-month period, with a lifetime prevalence of 42.9% with sinus disease,16 which is significantly higher than the average population and could be an interesting area for further investigation. Surprisingly, patients with fibromyalgia were more common in the control group than in the pan-positive group. However, the overall prevalence of fibromyalgia was low, creating difficulty reaching statistical power. Temporomandibular disorder disorders were more common in the control group but did not reach statistical significance. Furthermore, TMJ disorders are often associated with headaches and facial pressure, which are prominent symptoms present on the SNOT-20 questionnaire. A review of the patients’ medication lists revealed that our pan-positive patients were more likely to be taking antidepressants and chronic pain medications. On the other hand, the control group was more likely to be taking anxiolytics. When reviewing the number of patients on antidepressants, 52 of our pan-positive cohort were found to have antidepressants on their medication list. Meanwhile, only 41 of our patients had depression listed in their past medical history. It appears that 11 patients did not report a history of depression despite previous treatment with antidepressants. Similar discrepancies were identified among patients in the control group who were taking anxiolytics. The anxiolytics and antidepressants are commonly used for comorbidities other than anxiety and depression, such as migraine headaches. Furthermore, the discrepancy could indicate that the patient’s history of depression or anxiety has resolved and they are no longer taking these medications. Alternatively, it could indicate failure to obtain this information during the initial intake, thereby making our medication and medical history data unreliable for accurate analysis. Ultimately, this reinforces the importance of having a high clinical index of suspicion for active depression or anxiety among all patients who present with these signs and symptoms. Identifying the pan-positive SNOT-20 patient may help detect patients who would benefit from psychiatric treatment or control of other chronic medical illnesses. Interestingly, the pan-positive patients had higher Lund-Kennedy endoscopy scores, consistent with worsened disease. This is likely due to the inclusion of all patients and not correcting for severity of CRS. It has been established that patients with simultaneous depression and CRS have poorer scores on outcomes measures.7,10 Causal debate remains whether depression worsens symptoms of CRS or CRS worsens symptoms of depression. In addition, it reinforces the importance of ruling out CRS in all patients, including pan-positive patients. However, there was no significant difference in Lund-Mackay CT scores between the pan-positive and control groups. Not all patients included in this study had a CT to evaluate, and CT scans were only obtained
when indicated. This data is in congruence with previous studies that have identified a disagreement between the reporting of patient symptoms and objective data.4 Our data is consistent with previous studies indicating that women score higher on sinus-specific PROMs because our pan-positive patients were composed of 66.9% females and our control group was 50% females. This relationship between sex and increased symptom outcomes scores has been well established and is believed to be due to multiple factors. Depression is known to be more common in females and is considered the underlying etiology of the poorer scores.17 Although the SNOT-20 is a QOL outcomes test designed to measure improvement in symptoms following treatment, previous studies have validated the use of the SNOT-20 as an assessment tool in which it was able to discriminate between individuals with CRS and healthy patients.18 Our study has multiple limitations associated with a retrospective review of a database. We relied heavily on the medical record to identify the presence of comorbidities. By using the medical record to identify patients with comorbidities, we understand that not all patients presenting give an accurate medical history. Therefore, both the pan-positive group and the control group will include patients with a history of comorbidities that we failed to identify. However, we were able to identify a large number of patients, thereby decreasing the error from using the medical record to identify these patients with comorbidities. Furthermore, we chose to include the patient’s medication list as a method to identify patients not reporting comorbidities at presentation. Using medication history introduces further difficulties because medications, especially antidepressants, can be used for alternative reasons such as OCD, smoking cessation, premenstrual disorders, pain, and headaches. We did not include pre- and posttreatment SNOT-20 scores because this was not the goal of our study. In addition, our study lacks general QOL scores such as the 36-item short form (SF-36) health survey or the mental health-specific PHQ-9, which would reinforce our findings of comorbidities affecting reporting on the SNOT-20 questionnaire and allow for further characterization of the severity of the comorbidity. Furthermore, inclusion of the PHQ-9 questionnaire for panpositive patients may further elucidate an underlying mental health disorder not previously identified.
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Caten et al.: Comorbidities Pan-Positive SNOT-20 Patients
CONCLUSION We have observed that patients who report all symptoms on SNOT-20 QOL instrument as positive are more likely to have underlying depression, anxiety, headaches, and chronic pain than patients who mark at least one symptom as zero on the form. When we manage pan-positive patients in our practices, we must ensure that their underlying comorbidities are optimally addressed in addition to treating their CRS symptoms.
Acknowledgment Work was completed at Georgia Regents University.
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BIBLIOGRAPHY 1. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. Vital Health Stat 10 2014;1–161. 2. Bhattacharyya N. Ambulatory sinus and nasal surgery in the United States: demographics and perioperative outcomes. Laryngoscope 2010; 120:635–638. 3. Zheng Y, Zhao Y, Lv D, Liu Y, Qiao X, An P, Wang D. Correlation between computed tomography staging and quality of life instruments in patients with chronic rhinosinusitis. Am J Rhinol Allergy 2010;24:e41–e45. 4. Wabnitz DA, Nair S, Wormald PJ. Correlation between preoperative symptom scores, quality-of-life questionnaires, and staging with computed tomography in patients with chronic rhinosinusitis. Am J Rhinol 2005; 19:91–96. 5. Hopkins C. Patient reported outcome measures in rhinology. Rhinology 2009;47:10–17. 6. Davis GE, Yueh B, Walker E, Katon W, Koepsell TD, Weymuller EA. Psychiatric distress amplifies symptoms after surgery for chronic rhinosinusitis. Otolaryngol Head Neck Surg 2005;132:189 –196. 7. Brandsted R, Sindwani R. Impact of depression on disease-specific symptoms and quality of life in patients with chronic rhinosinusitis. Am J Rhinol 2007;21:50–54. 8. Zubieta JK, Ketter TA, Bueller JA, et al. Regulation of the Human Affective Responses by Anterior Cingulate and Limbic Muopiod Neurotransmission. Arch Gen Psychiatry 2003;60:1145–1153.
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9. Dersh J, Gatchel R, Polatin P, Mayer T. Prevelance of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability. J Occup Environ Med 2002;44: 459–468. 10. Nanayakkara JP, Igwe C, Roberts D, Hopkins C. The impact of mental health on chronic rhinosinusitis symptom scores. Eur Arch Otorhinolaryngol 2013;270:1361–1364. 11. Mace J, Michael YL, Carlson NE, Litvack JR, Smith TL. Effects of depression on quality of life improvement after endoscopic sinus surgery. Laryngoscope 2008;118:528–534. 12. Wasan A, Fernandez E, Jamison RN, Bhattacharyya N. Association of anxiety and depression with reported disease severity in patients undergoing evaluation for chronic rhinosinusitis. Ann Otol Rhinol Laryngol 2007;116:491–497. 13. Perry B, Login IS, Kountakis SE. Nonrhinologic headache in a tertiary rhinology practice. Otolaryngol Head Neck Surg 2004;130:449–452. 14. Moretz WH, Kountakis SE. Subjective headache before and after endoscopic sinus surgery. Am J Rhinol 2006;20:305–307. 15. Lachanas VA, Woodward TD, Antisdel JL, Kountakis SE. Sino-nasal outcome test tool in patients with chronic rhinosinusitis and obstructive sleep apnea. ORL J Otorhinolaryngol Relat Spec 2012;74:286–289. 16. Michaud K, Wolfe F. The association of rheumatoid arthritis and its treatment with sinus disease. J Rheumatol 2006;33:2412–2415. 17. Mendolia-Loffredo S, Luad PW, Sparapani R, Loehrl T, Smith TL. Sex differences in outcomes of sinus surgery. Laryngoscope 2006;116:1199–1203. 18. Morley AD, Sharp HR. A review of sinonasal outcome scoring systemswhich is best?. Clin Otolaryngol 2006;31:103–109.
Caten et al.: Comorbidities Pan-Positive SNOT-20 Patients
Rhinological and Otological Society, Inc.
Comorbidities in Patients With All-Positive Symptoms on Sinonasal Outcomes Test Quality-of-Life Instrument Alexander Caten, MD; Christopher Johnson, PharmD, BS; David Jang, MD; Jose Gurrola, MD; Stilianos Kountakis, MD, PhD Objectives/Hypothesis: The Sinonasal Outcomes Test-20 (SNOT-20) is a validated tool to assess treatment outcomes in patients with chronic rhinosinusitis (CRS). In the clinic, we observed that patients who responded with a positive score on all 20 items of the SNOT-20 questionnaire (pan-positive patients) often did not have evidence of CRS upon workup. Many of these patients had other underlying diseases contributing to their complaints. Methods: Analysis of prospectively collected data was performed to identify SNOT-20 pan-positive patients and compare them to 100 consecutive non–pan-positive patients who served as the control group. The following parameters were compared between the two patient groups: presence or absence of chronic diseases such as obstructive sleep apnea, depression, anxiety, fibromyalgia, chronic pain, headaches, temporomandibular joint disease, and arthritis—in addition to sinus computed-tomography Lund-McKay scores and nasal endoscopy Lund-Kennedy scores. We also reviewed the medication list of each patient to look for the possible presence of mental illness. Statistical analysis was performed using the chi-squared and Student t test. Results: One hundred twenty-two pan-positive patients were identified in our database collected from 2003 to 2011. Pan-positive patients had higher incidence of depression, fibromyalgia, anxiety, pain, headache, and use of depression medications—and they also had higher SNOT-20 and endoscopy scores when compared to controls (P < 0.05). Pan-positive patients were more likely female (P < 0.05), but age and race differences did not reach statistical significance. Conclusion: The SNOT-20 questionnaire assists clinicians to monitor outcomes in patients treated for CRS. However, clinicians should suspect other underlying chronic conditions in SNOT-20 pan-positive patients. Key Words: Chronic rhinosinusitis, comorbidities, depression, anxiety, obstructive sleep apnea, chronic pain, sinonasal outcomes test. Level of Evidence: 3B. Laryngoscope, 125:2648–2652, 2015
INTRODUCTION Chronic rhinosinusitis (CRS) is among the most common chronic health conditions in the United States. Most recent data indicates that approximately 12% of the adult population, equal to 28.5 million people, suffer from CRS.1 Treatment of CRS is common among the primary care community, but frequent otolaryngology referral results in over 250,000 sinus surgeries performed in the United States annually, making it one of the most frequently performed surgeries in the United States.2 Diagnosis and treatment often rely on objective findings from computed tomography (CT) scan and nasal
From the Department of Otolaryngology Head and Neck Surgery, Georgia Regents University (A.C., C.J., S.K.), Augusta, Georgia; the Division of Otolaryngology Head and Neck Surgery, Duke University (D.J.), Durham, North Carolina; and the Department of Otolaryngology Head and Neck Surgery, University of Virginia (J.G.), Charlottesville, Virginia, U.S.A. Editor’s Note: This Manuscript was accepted for publication June 1, 2015. Presented at the Triological Society Combined Sections Meeting, Coronado Island, California, U.S.A., January 22–24, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Alex Caten, MD, Department of Otolaryngology Head and Neck Surgery, Georgia Regents University, 1120, 15th St. BP 4109, Augusta, GA 30912. E-mail: [email protected]. DOI: 10.1002/lary.25456
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endoscopy results, as well as patient-reported symptoms. Recently, there is increased reliance on validated patient-reported outcomes measures (PROMs) such as the 20-Item Sinonasal Outcomes Test (SNOT-20). However, subjective symptom scores often do not correlate with objective findings on CT and endoscopy, indicating that there are confounding factors contributing to the symptoms of these patients.3–5 Previous studies indicate higher preoperative, diseasespecific, quality-of-life (QOL) symptom scores, with the Rhinosinusitis Disability Index and Chronic Sinusitis Survey identified in patients suffering from depression, as indicated by the Patient Health Questionnaire (PHQ)-9 questionnaire. However, patients with CRS suffering from depression had an improvement in postoperative symptom scores equal to the CRS patients without depression.6,7 In addition, depression and anxiety are known to have altered perception of stimuli. It was noted that patients with these conditions have increased activity in the anterior cingulate cortex and insula, which correlate with both mood and pain perception.8 There is a prevalence of major depressive disorder and generalized anxiety disorder of approximately 30% of patients with all chronic illnesses, including CRS.9 Not surprising, multiple studies showed that PROM scores also have a strong correlation with gender and with comorbidities such as depression and anxiety.7,10–12 Caten et al.: Comorbidities Pan-Positive SNOT-20 Patients
TABLE I. SNOT-20, Endoscopy, and CT scores for Pan-Positive and Control Groups. Pan-Positive Group
Fig. 1. Demographic (gender) data. Pan-positive patients (blue) and control patients (orange). Females more prominent in panpositive group, whereas gender was equal in the control group. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
In our clinical practice, we use the SNOT-20 outcomes instrument to follow our patients’ progress before and after medical or surgical intervention. We noticed over the years that some patients mark all 20 symptoms as positive without exception and often at a severe level. We hypothesize that these patients with pan-positive symptoms are more likely to have confounding factors in addition to CRS that contribute to their disease burden. The goal of our study is to confirm our clinical observation that pan-positive patients were more likely to have certain underlying chronic illnesses such as depression, anxiety, fibromyalgia, temporomandibular disorder (TMJ), primary headaches, obstructive sleep apnea (OSA), chronic pain, and arthritis than the general population presenting to a rhinology subspecialty office.
MATERIALS AND METHODS Approval for this study was granted by the Georgia Regents University Institutional Review Board. A review of the senior author’s (S.K.) prospectively gathered data collected from 2003 to 2011, totaling 3,547 patient visits, was performed. Each individual responding with a positive score (equal to or greater than 1) to all 20 symptoms of the SNOT-20 questionnaire (pan-positive) was identified. This patient group included both patients at their initial visit and at subsequent follow-up appointments. Ninety-nine consecutive patients who did not fulfill the pan-positive criteria were isolated and used as a control. The total SNOT-20 scores, Lund-Kennedy endoscopy scores, Lund-MacKay CT scores, and demographics were collected for each of the pan-positive and the control groups. The electronic medical record (PowerChart, Cerner Corporation, Kansas City, MO) was then reviewed for each subject, specifically identifying those with headaches, OSA, chronic pain, anxiety, depression, arthritis, TMJ disease, and fibromyalgia. Because some individuals fail to divulge a chronic illness such as psychiatric disease during the medical intake, the medication lists were further reviewed to identify those subjects taking antidepressants, anxiolytics, and medications for chronic pain. All data was collected in a Microsoft Excel (Redmond, WA) database. Because all variables were presented as frequencies, statistical analysis was performed using the chi-squared (v2) test.
RESULTS Demographics Upon review of the database, 121 individuals were identified as meeting the pan-positive criteria. Eightyone (67%) of the pan-positive patients were females as Laryngoscope 125: December 2015
Control Group
P Value
Number
122
99
Total SNOT 20
43.2
21.5
2.4 3 10230
2.9 5.0
1.9 3.8
0.044 0.595
Endoscopy CT
SNOT-20 score and endoscopy scores were significantly higher in the pan-positive group. CT scores were higher in our pan-positive group, but not reaching statistical significance. CT 5computed tomography; SNOT 5 Sinonasal Outcomes Test.
compared to 50 (50%) in the control group (P 5 0.013, Fig. 1). There was no significant difference in age between the control group (average age: 47.1 years old) and the pan-positive group (average age: 49.8).
Objective Data Average total SNOT-20 scores were higher in the pan-positive group (43.2) than in the control group (21.5) (P 5 2.4 3 10230) (Table I). The average Lund-Kennedy endoscopy scores were higher in the pan-positive group (2.9) than in the control group (1.9) (P 5 0.044). The Lund-MacKay CT scores were not significantly different between the pan-positive (5.0) and the control group (3.8). Eleven patients in the pan-positive group had a CT scan, whereas nine patients in the control group had a CT scan.
Comorbidities Anxiety, depression, chronic pain, and headaches were all significantly (P < 0.05) more common in the pan-positive group (Table II). Depression was found in 41 (33.9%) of the pan-positive patients as compared to only
Fig. 2. Comorbidities. Depression, anxiety, headaches, and chronic pain significantly more common in the pan-positive (blue) group. Obstructive sleep apnea (OSA) and arthritis were more common in the pan-positive group but did not reach statistical significance. Fibromyalgia was significantly more common in the control group (orange). TMJ was more common in the control group but did not reach statistical significance. OSA 5 obstructive sleep apnea; TMJ 5 temporomandibular disorder. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
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TABLE II. Comorbidity Data With Associated P Values. Comorbidities
Pan-Positive Group (number)
Pan-Positive Group (percentage)
Control Group (number)
Control Group (percentage)
Depression
41
33.9%
15
15.1%
0.002
6.7
Anxiety Chronic pain
26 45
21.4% 37.2%
10 15
10.1% 12.4%
0.023 0.0003
5.2 13.3
P Value
v2
Primary headache
27
22.3%
10
10.1%
0.016
OSA Arthritis
34 23
28.1% 19%
17 12
14% 12.1%
0.056 0.165
3.65 1.93
Fibromyalgia
5
4.1%
5
5.1%
0.735
5.2
TMJ
5
4.1%
6
6%
0.514
Depression, anxiety, chronic pain, and headaches were significantly more commonly present in our pan-positive group. Obstructive sleep apnea and arthritis were more common in our pan-positive group, but did not reach statistical significance. Fibromyalgia and TMJ were more common in the control group. OSA 5 obstructive sleep apnea; TMJ 5 temporomandibular disorder.
15 (2.4%) of the control subjects (P 5 0.002). Anxiety was present in 26 (21.4%) of the pan-positive patients and only in 10 (10.1 %) of the control subjects (P 5 0.01). Chronic pain was identified in 45 (37.1%) of the panpositive patients and in 15 (12.4%) of the control subjects (P 5 0.0003). Primary headaches were identified in 27 of the pan-positive patients (22.3%) and in 10 (10.1%) of the control subjects (P 5 0.016). Obstructive sleep apnea was found in 34 (28.1%) of the pan-positive patients and in 17 (14%) of the control subjects (P 5 0.056). Arthritis was identified in 23 (19%) of the pan-positive patients and in 12 (12.1%) of the control subjects (P 5 0.165). Fibromyalgia was identified in five (4.1%) of the pan-positive patients and in five (4.1%) of the control subjects (P 5 0.735). Temporomandibular disorder was identified in five of the pan-positive patients (4.1%) and in six (6%) of the control subjects (P 5 0.514). Chronic rhinosinusitis was diagnosed in 34 (28%) of the pan-positive patients while present in 28 (29%) of the control subjects.
Medications A review of the medications taken revealed that antidepressant medications were significantly more commonly used by pan-positive patients (P 5 0.036) (Table III). Pain medications were more commonly used among the pan-positive patients but did not reach statistical significance (P 5 0.104). Anxiety medications
were more commonly used among the control group but did not reach statistical significance (P 5 0.683).
DISCUSSION Anxiety, depression, chronic pain, and headaches were all significantly more common in the pan-positive group. This is consistent with multiple reports indicating that patients with chronic psychiatric conditions such as depression and anxiety have poorer scores on CRSspecific symptom assessments. However, no previous study has isolated a specific subgroup of rhinology patients identifiable by PROMs with a greater preponderance for chronic conditions such as ours. Our previous studies have indicated that patients with primary headaches score higher on SNOT-20 scores than patients with headaches associated with CRS.13 Further review revealed patients undergoing surgery for CRS had significant improvement in headache-specific scores following surgery.14 It comes as no surprise that primary headaches are more likely to be present within our group of pan-positive patients. Comorbidities not reaching statistical significance that were more common in our pan-positive patients included OSA and arthritis. Our previous studies have confirmed increased SNOT-20 scores in patients with OSA and CRS.15 Our current data is in agreement with this report because OSA was more common in our panpositive patients, with a near significant P value of 0.056. Many symptoms on the SNOT-20 form relate to
TABLE III. Medication Data. Medication
Pan-Positive Patients (number)
Pan-Positive Patients (percentage)
Control Patients (number)
Control Patients (percentage)
P Value
Depression
52
42.9%
29
29.3%
0.036
Anxiety
16
13.2%
15
15.2%
0.683
Pain
29
23.9%
15
15.2%
0.104
Depression medications were significantly more likely to be taken by pan-positive patients (P value 5 0.036). Pain medications were more common in pan-positive patients, which did not reach statistical significance (P value 5 0.104). Anxiety medications were more commonly taken by control patients, which did not reach statistical significance (P value 5 0.683).
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quality of sleep, which confounds the underlying CRS data but remains important for overall QOL assessment. Arthritis was more common in the pan-positive group but did not reach statistical significance. No previous studies have evaluated the association of arthritis with increased PROM scores. A 2006 study noted that 22.3% of patients with rheumatoid arthritis had visited a physician for sinusitis in a 6-month period, with a lifetime prevalence of 42.9% with sinus disease,16 which is significantly higher than the average population and could be an interesting area for further investigation. Surprisingly, patients with fibromyalgia were more common in the control group than in the pan-positive group. However, the overall prevalence of fibromyalgia was low, creating difficulty reaching statistical power. Temporomandibular disorder disorders were more common in the control group but did not reach statistical significance. Furthermore, TMJ disorders are often associated with headaches and facial pressure, which are prominent symptoms present on the SNOT-20 questionnaire. A review of the patients’ medication lists revealed that our pan-positive patients were more likely to be taking antidepressants and chronic pain medications. On the other hand, the control group was more likely to be taking anxiolytics. When reviewing the number of patients on antidepressants, 52 of our pan-positive cohort were found to have antidepressants on their medication list. Meanwhile, only 41 of our patients had depression listed in their past medical history. It appears that 11 patients did not report a history of depression despite previous treatment with antidepressants. Similar discrepancies were identified among patients in the control group who were taking anxiolytics. The anxiolytics and antidepressants are commonly used for comorbidities other than anxiety and depression, such as migraine headaches. Furthermore, the discrepancy could indicate that the patient’s history of depression or anxiety has resolved and they are no longer taking these medications. Alternatively, it could indicate failure to obtain this information during the initial intake, thereby making our medication and medical history data unreliable for accurate analysis. Ultimately, this reinforces the importance of having a high clinical index of suspicion for active depression or anxiety among all patients who present with these signs and symptoms. Identifying the pan-positive SNOT-20 patient may help detect patients who would benefit from psychiatric treatment or control of other chronic medical illnesses. Interestingly, the pan-positive patients had higher Lund-Kennedy endoscopy scores, consistent with worsened disease. This is likely due to the inclusion of all patients and not correcting for severity of CRS. It has been established that patients with simultaneous depression and CRS have poorer scores on outcomes measures.7,10 Causal debate remains whether depression worsens symptoms of CRS or CRS worsens symptoms of depression. In addition, it reinforces the importance of ruling out CRS in all patients, including pan-positive patients. However, there was no significant difference in Lund-Mackay CT scores between the pan-positive and control groups. Not all patients included in this study had a CT to evaluate, and CT scans were only obtained
when indicated. This data is in congruence with previous studies that have identified a disagreement between the reporting of patient symptoms and objective data.4 Our data is consistent with previous studies indicating that women score higher on sinus-specific PROMs because our pan-positive patients were composed of 66.9% females and our control group was 50% females. This relationship between sex and increased symptom outcomes scores has been well established and is believed to be due to multiple factors. Depression is known to be more common in females and is considered the underlying etiology of the poorer scores.17 Although the SNOT-20 is a QOL outcomes test designed to measure improvement in symptoms following treatment, previous studies have validated the use of the SNOT-20 as an assessment tool in which it was able to discriminate between individuals with CRS and healthy patients.18 Our study has multiple limitations associated with a retrospective review of a database. We relied heavily on the medical record to identify the presence of comorbidities. By using the medical record to identify patients with comorbidities, we understand that not all patients presenting give an accurate medical history. Therefore, both the pan-positive group and the control group will include patients with a history of comorbidities that we failed to identify. However, we were able to identify a large number of patients, thereby decreasing the error from using the medical record to identify these patients with comorbidities. Furthermore, we chose to include the patient’s medication list as a method to identify patients not reporting comorbidities at presentation. Using medication history introduces further difficulties because medications, especially antidepressants, can be used for alternative reasons such as OCD, smoking cessation, premenstrual disorders, pain, and headaches. We did not include pre- and posttreatment SNOT-20 scores because this was not the goal of our study. In addition, our study lacks general QOL scores such as the 36-item short form (SF-36) health survey or the mental health-specific PHQ-9, which would reinforce our findings of comorbidities affecting reporting on the SNOT-20 questionnaire and allow for further characterization of the severity of the comorbidity. Furthermore, inclusion of the PHQ-9 questionnaire for panpositive patients may further elucidate an underlying mental health disorder not previously identified.
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CONCLUSION We have observed that patients who report all symptoms on SNOT-20 QOL instrument as positive are more likely to have underlying depression, anxiety, headaches, and chronic pain than patients who mark at least one symptom as zero on the form. When we manage pan-positive patients in our practices, we must ensure that their underlying comorbidities are optimally addressed in addition to treating their CRS symptoms.
Acknowledgment Work was completed at Georgia Regents University.
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