Olfactory Impairment in Chronic Rhinosinusitis Using Threshold, Discrimination, and Identification Scores.

Differences in testing modalities and cut-points used to define olfactory dysfunction contribute to the wide variability in estimating the prevalence of olfactory dysfunction in chronic rhinosinusitis (CRS). The aim of this study is to report the prevalence of olfactory impairment using each component of the Sniffin' Sticks test (threshold, discrimination, identification, and total score) with age-adjusted and ideal cut-points from normative populations. Patients meeting diagnostic criteria for CRS were enrolled from rhinology clinics at a tertiary academic center. Olfaction was assessed using the Sniffin' Sticks test. The study population consisted of 110 patients. The prevalence of normosmia, hyposmia, and anosmia using total Sniffin' Sticks score was 41.8%, 20.0%, and 38.2% using age-appropriate cut-points and 20.9%, 40.9%, and 38.2% using ideal cut-points. Olfactory impairment estimates for each dimension mirrored these findings, with threshold yielding the highest values. Threshold, discrimination, and identification were also found to be significantly correlated to each other ( P < 0.001). In addition, computed tomography scores, asthma, allergy, and diabetes were found to be associated with olfactory dysfunction. In conclusion, the prevalence of olfactory dysfunction is dependent upon olfactory dimension and if age-adjusted cut-points are used. The method of olfactory testing should be chosen based upon specific clinical and research goals.

Objective sleep measures after endoscopic sinus surgery in patients with chronic rhinosinusitis.

BACKGROUND: Poor sleep quality is common in chronic rhinosinusitis (CRS). Prior studies have demonstrated improvements in patient-reported measures of sleep quality following endoscopic sinus surgery (ESS). The purpose of this study was to evaluate the effect of ESS on objective sleep parameters and identify any associations between specific objective measures and patient characteristics, comorbidities, and patient-reported outcome measures (PROMs). METHODS: Adults with CRS undergoing ESS were prospectively enrolled from 4 centers across North America. Any subject previously diagnosed with a known primary sleep disorder was excluded. Objective sleep indices were recorded using a portable sleep diagnostic device preoperatively and postoperatively. Patient-reported outcome instruments were completed including the Pittsburgh Sleep Quality Index (PSQI) and the 22-item Sino-Nasal Outcome Test (SNOT-22). RESULTS: Thirty-six patients (mean age 47 years, 56% male) completed baseline and postoperative sleep studies with mean ± standard deviation (SD) follow-up 9.6 ± 7.7 months. Mean PSQI and SNOT-22 before and after ESS was 10.2 ± 3.9 vs 7.8 ± 4.4 (p = 0.001); and 54.6 ± 14.6 vs 28.5 ± 15.3 (p < 0.001), respectively. Total sleep time, sleep latency, and awakenings after sleep onset did not change following ESS (all p > 0.5) despite improvements in PSQI and SNOT-22. Changes in PSQI did not correlate with comorbidities or objective sleep indices (all p > 0.1). CONCLUSION: In this multicenter prospective cohort, objective sleep indices were not improved following ESS for CRS despite significant improvements in patient-reported sleep quality and CRS-specific QOL.

Disease control after surgery for chronic rhinosinusitis: prospective, multi-institutional validation of the Sinus Control Test.

BACKGROUND: The Sinus Control Test (SCT) is a 4-question, patient-reported questionnaire that assesses disease control in chronic rhinosinusitis (CRS). This prospective, multicenter study examines SCT outcomes following endoscopic sinus surgery (ESS), further validating its use as a control instrument for CRS. METHODS: Adults with CRS undergoing ESS were prospectively enrolled from 5 centers across North America. The SCT was administered at baseline and once 6 months after surgery. Quality of life and disease burden were evaluated using the 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy endoscopy scores. Linear regression was used to determine whether specific demographic, comorbidity, or disease severity measures were independently associated with changes in SCT scores postoperatively. RESULTS: A total of 218 patients, 111 females (50.9%) and 107 males (49.1%), were enrolled, with mean ± standard deviation age of 50.1 ± 15.6 years. Mean SCT score improved from 8.9 ± 3.5 to 4.3 ± 3.7 postoperatively (p < 0.001). Preoperatively, 21.6% were uncontrolled, 71.5% partially controlled, and 6.9% controlled. Postoperatively, 6.0% were uncontrolled, 42.6% partially controlled, and 51.4% controlled (p < 0.001). Change in SCT score correlated independently with change in SNOT-22 (r = 0.500, p < 0.001) and endoscopy scores (r = 0.310, p < 0.001). Endoscopy scores did not correlate with control status among patients with CRS without nasal polyposis (CRSsNP) nor between uncontrolled and partially controlled patients. Demographics and comorbidities were not associated with changes in SCT. CONCLUSION: Improvement in disease control following ESS as measured by the SCT correlated with improvements in SNOT-22 and endoscopy scores. The SCT is an easily administered instrument that provides information complementary to existing patient-reported and objective measures of disease severity.

The Role of Home Fungal Exposure in Allergic Fungal Rhinosinusitis.

BACKGROUND: Allergic fungal rhinosinusitis (AFRS) is disproportionately identified in patients of low socioeconomic status living in warm, humid climates, and is thought to occur in response to environmental fungal species. OBJECTIVE: We hypothesized that micro-geographic differences in fungal exposure contribute to the pathogenesis of AFRS, and compared home fungal exposure of patients with AFRS to normative data and controls. METHODS: Comprehensive prospective enrollment and data capture was completed in 70 patients. Patients with AFRS were compared to a control population with chronic rhinosinusitis with nasal polyposis (CRSwNP) and comorbid atopy. Comprehensive demographics, 22-item sino-nasal outcomes test (SNOT-22) questionnaires, and endoscopy scores were compiled. Using a test strip collection system, a home fungal assessment was completed for each patient, along with detailed questions related to home condition. RESULTS: Patients with AFRS were more likely to be younger (p<.001), African American (p<.001), from a lower income bracket (p < .012), and less likely to own their home (p < .001). There were no differences in prior surgeries (p=.432), endoscopy scores (p = .409) or SNOT-22 scores (p = .110) between the groups. There were no differences in overall fungal counts between patients with AFRS and controls (p = .981). AFRS patients had a higher prevalence of Basidiospores than controls (p = .034). CONCLUSION: This study failed to detect differences in total home fungal exposure levels between those with AFRS and atopic CRSwNP, despite differences in socioeconomic status. This suggests that absolute fungal levels may not be the primary driver in development of AFRS, or that the fungal detection strategies utilized were not representative of patients' overall fungal exposure.

Factors impacting revision surgery in patients with chronic rhinosinusitis with nasal polyposis.

BACKGROUND: Surgical treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP) has evolved over the last decade as rhinologists have increasingly used topical steroid therapies and altered surgical techniques. It is important to understand the changes in success rates of surgery and frequency of revision endoscopic sinus surgery (ESS) in CRSwNP. The aim of this study was to retrospectively review the revision surgical rate of CRSwNP patients by evaluating outcomes in a cohort from the Medical University of South Carolina (MUSC). METHODS: Retrospective review of CRSwNP patients operated upon at the MUSC between 2002 and 2019 by a single surgeon was performed. Assessed factors included demographics, comorbidities, CRSwNP subtype, extent of surgery, and steroid rinse compliance. Logistic regression was performed to identify factors associated with revision surgery. RESULTS: Among 338 patients with at least 6 months of follow-up, 24.9% had revision surgery, with a mean follow-up of 52.6 months. In patients with any person-time measure, the revision rate was 5.58 per 100 person-years. Independent risk factors associated with increased odds ratio (OR) for revision surgery were: younger age (OR, 1.1); prior surgery (OR, 3.3); longer follow-up (OR, 1.1); and surgery before 2009 (OR, 2.4) (p < 0.05 for all). CONCLUSION: The revision surgery rate for CRSwNP was 24.9% among those with at least 6 months of follow-up. Risk factors for higher revision rates included younger age, previous surgery, longer follow-up, and surgery at the MUSC prior to 2009. As we enter an era of personalized medicine, it is important to consider patient- and surgeon-specific factors, which impact revision surgery rates.

Correlation of mucus inflammatory proteins and olfaction in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is one of the most common causes of olfactory loss, but the pathophysiology underlying olfactory dysfunction in CRS has not been fully elucidated. Previous studies found correlations between olfactory cleft (OC) inflammatory cytokines/chemokines and olfaction in CRS. The purpose of this study was to evaluate the relationship between OC mucus inflammatory proteins and olfaction in a multi-institutional cohort. METHODS: Adults with CRS were prospectively recruited. Demographics, comorbidities, olfactory assessment (Sniffin' Sticks), computed tomography (CT), and OC mucus for protein analysis were collected. Statistical analysis was performed to determine associations between olfactory function, OC mucus protein concentrations, and CT opacification. RESULTS: Sixty-two patients were enrolled in the study, with an average age of 48.2 (standard deviation, 16.2) years, and 56.5% were female and 59.7% were classified as CRS with nasal polyps (CRSwNP). Ten of 26 OC mucus proteins were significantly correlated with threshold, discrimination, and identification (TDI) scores and OC opacification. Subgroup analysis by polyp status revealed that, within the CRSwNP group, C-C motif ligand 2 (CCL2), interleukin-5 (IL-5), IL-6, IL-13, IL-10, IL-9, tumor necrosis factor-α (TNF-α), CCL5, and CCL11 were significantly correlated with olfaction. For CRS without nasal polyps (CRSsNP), only C-X-C ligand 5 (CXCL5) showed a correlation. In CRSwNP, IL-6, IL-10, vascular endothelial growth factor-A, and immunoglobulin E (IgE) correlated with OC opacification, whereas, in CRSsNP, only CXCL5 showed a correlation. OC mucus proteins and Lund-Mackay score correlated only in the CRSsNP group (CXCL5, IL-5, IL-13, IgE). CONCLUSION: Several OC mucus proteins have been found to correlate with olfactory function and OC opacification. The profile of OC mucus proteins differs between CRSsNP and CRSwNP subgroups, suggesting different mechanisms between groups, but further study is required.

A Community-Based Study on the Prevalence of Olfactory Dysfunction.

BACKGROUND: Olfactory dysfunction (OD) is common, affecting an estimated 13 million adults in the United States. Prior studies may underestimate OD prevalence due to use of brief smell identification tests or age-adjusted cutoff values, which concede that it is acceptable for older people to have a decreased sense of smell. OBJECTIVE: To determine OD prevalence in the healthy community when the goal and expectation is ideal olfactory function, rather than age-based population norms. Secondary goals were to explore factors associated with OD. METHODS: Subjects without otolaryngic complaints were recruited from the community surrounding the Medical University of South Carolina. Olfactory-specific information was collected, and olfactory function was assessed using the Sniffin' Sticks test (Burghardt, Wedel, Germany) to measure threshold, discrimination, and identification (TDI). OD was defined as a TDI score < 31. Bivariate analysis and linear regression were used to determine factors associated with OD. RESULTS: In total, 176 subjects were included with mean age of 52 years (range: 20-93), 111 (63%) female, and 127 (72%) white. Mean TDI score was 28.8 (6.9) and OD was present in 94 (53%) subjects. Multivariate linear regression revealed that TDI decreased an average of 1 point every 5 years. TDI was also associated with Mini-Mental Status Examination (MMSE) score, asthma, and gastroesophageal reflux disease. Threshold was associated with age, heart problems, and gastroesophageal reflux disease. Discrimination was associated with age and MMSE scores. Identification was associated with age, heart problems, and anxiety. CONCLUSIONS: In a community-based sample, OD affects greater than 50% of subjects. Aging impacts all aspects of olfaction, while the effects of factors such as asthma, MMSE scores, gastroesophageal reflux disease, heart problems, and anxiety may only be evident in specific olfactory subtests.

Effects of endoscopic sinus surgery on objective and subjective measures of cognitive dysfunction in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common condition that has been associated with cognitive dysfunction. The purpose of this study was to evaluate the effect of endoscopic sinus surgery (ESS) on the subjective and objective measures of cognitive dysfunction and related quality-of-life measures in CRS. METHODS: Thirty-five adults with CRS refractory to medical therapy were prospectively enrolled. Preoperatively and postoperatively (≥4 months), subjects completed objective neurocognitive evaluation with the Automated Neuropsychological Assessment Metrics (ANAM) platform and multiple questionnaires, including the Cognitive Failures Questionnaire (CFQ), a modified World Health Organization Health and Work Performance Questionnaire (ctHPQ), 22-item Sino-Nasal Outcomes Test (SNOT-22), Sinus Control Test (SCT), Questionnaire of Olfactory Disorders (QOD), Beck Depression Inventory-second edition (BDI-II), Pittsburgh Sleep Quality Index (PSQI), and Fatigue Severity Scale (FSS). RESULTS: Thirty-three of 35 patients satisfactorily completed the study. Postsurgical improvement in the CFQ was 46.7 ± 18.4 to 31.9 ± 17.8 (p < 0.001). Neurocognitive testing revealed significant improvements in mathematical processing (p = 0.003) and matching to sample (p = 0.023), as well as a significant decline in simple reaction time (p = 0.026). In addition, improvements were noted for SNOT-22 (54.8 ± 21.4 to 24.8 ± 21.1, p < 0.001), SCT (9.3 ± 2.6 to 3.9 ± 3.8, p < 0.001), PSQI (10.7 ± 4.5 to 6.9 ± 4.0, p < 0.001), BDI-II (14.0 ± 9.9 to 8.9 ± 9.0, p < 0.001), QOD (17.6 ± 13.4 to 9.9 ± 12.3, p = 0.001), and FSS (4.6 ± 1.4 to 3.1 ± 1.5, p < 0.001). There was significant improvement in overall presenteeism (7.3 ± 1.4 to 8.4 ± 1.3, p = 0.029). Analysis by polyp status revealed significant improvement in mathematical processing and matching to sample in only CRS patients without polyps. CONCLUSION: ESS is associated with improvement in subjective and some aspects of objective cognition.

Endoscopic repair of spontaneous skull base defects decreases the incidence rate of intracranial complications.

BACKGROUND: Spontaneous skull base defects can result in life-threatening intracranial complications (ICCs), including meningitis and pneumocephalus. Endoscopic skull base reconstruction (ESBR) has traditionally been the treatment of choice, but its impact upon ICCs is not known. In this study, we aimed to describe the incidence rate of preoperative ICCs in patients with spontaneous skull base defects, risk factors associated with ICC development, and the impact of surgical repair on the incidence rate of ICCs. METHODS: A retrospective review was performed of all spontaneous skull base defects undergoing ESBR from 2005 to 2019 at 2 academic tertiary care medical centers. The incidence rate of ICCs and the demographics information and risk factors were collected. RESULTS: In 222 spontaneous skull base defects, preoperative ICCs occurred in 46 subjects (20.7%) with an incidence rate of 22.7 per 100 person-years. Factors significantly associated with preoperative ICCs included symptom duration, reduced body mass index (BMI), resolved cerebrospinal fluid rhinorrhea, and location in the frontal or lateral sphenoid sinuses. Endoscopic repair was successful in 97.2% of subjects and the postoperative ICC incidence rate was significantly reduced at 0.8 per 100 person-years (p < 0.001). CONCLUSION: Spontaneous skull base defects pose significant risk for life-threatening ICCs. Our findings reveal significantly elevated odds of ICC development associated with resolved CSF rhinorrhea, lower BMI, longer duration of symptoms, and defect location. Endoscopic repair is highly successful with low morbidity and significantly reduces the incidence rate of intracranial complications.

Impaired eating-related quality of life in chronic rhinosinusitis.

BACKGROUND: Despite the tremendous burden of smell and taste dysfunction in patients with chronic rhinosinusitis (CRS), objective measures of smell and taste fail to fully account for eating-related disruptions in CRS patient quality of life (QOL). In this study we sought to investigate the driving force behind impaired eating-related QOL in CRS patients. METHODS: Adult CRS patients were prospectively enrolled and answered a series of surveys relating to smell, taste, overall sinus-specific QOL, and depression. Patients with both smell-related and taste-related eating complaints were considered to have impaired eating-related QOL. Clinical demographics, objective chemosensory scores, and endoscopy scores were collected. RESULTS: Seventy patients were enrolled and 23% showed impaired eating-related QOL. In multivariable analyses, patients with aspirin-exacerbated respiratory disease (AERD) showed 10.7 times higher odds of impaired eating-related QOL (odds ratio [OR] 10.72; 95% confidence interval [CI], 1.09 to 105.09; p = 0.042); meanwhile, for every 1-point increase in depression scores, the odds of impaired eating-related QOL increased by 1.3 (OR 1.31; 95% CI, 1.10 to 1.57; p = 0.003). For every 1-point decrease in orthonasal olfactory threshold, the odds of impaired eating-related QOL increased by 1.9 times (OR 1.85; 95% CI, 1.14 to 3.00; p = 0.013). Symptom scores, polyp status, endoscopic scores, and other olfactory measures did not remain significant after adjusting for other variables in forward-selection multivariable modeling. CONCLUSION: Disruptions in eating-related QOL cannot be fully explained by objective smell or taste testing alone. We identified AERD and depression as independent risk factors for greater odds of impaired eating-related QOL in CRS. Improved orthonasal threshold scores were independently associated with better eating-related QOL.

The impact of medical therapy on cognitive dysfunction in chronic rhinosinusitis.

BACKGROUND: Cognitive dysfunction in chronic rhinosinusitis (CRS) is often overlooked despite potentially broad implications. Earlier work has demonstrated decreased cognitive function in CRS patients at baseline. In this study we sought to prospectively evaluate the impact of initial, appropriate medical therapy on subjective and objective cognitive function, fatigue, and workplace productivity. METHODS: Adult patients with CRS were prospectively enrolled and completed a robust battery of pretreatment quality-of-life and neurocognitive testing, before undergoing appropriate medical therapy with follow-up testing at 6 weeks. Patient-reported cognitive function was assessed using the Cognitive Failures Questionnaire (CFQ), whereas fatigue was measured with the Fatigue Severity Scale (FSS). Objective cognitive function was assessed using the Automated Neuropsychological Assessment Metrics (ANAM) platform and workplace productivity using the Clinical Trials version of the World Health Organization Health and Work Performance Questionnaire (ctHPQ). RESULTS: Twenty-seven patients were enrolled. Patients demonstrated posttreatment improvement scores on the FSS (4.32 ± 1.78 to 3.28 ± 1.65; p = 0.003), Pittsburgh Sleep Quality Index (8.62 ± 5.06 to 6.85 ± 4.11; p = 0.014), and CFQ (38.56 ± 16.40 to 33.04 ± 14.35; p = 0.046). Objective neurocognitive tests of mathematical processing and Stroop Reaction Test Block 3 improved after medical therapy (19.79 ± 5.61 to 21.3 ± 6.87; p = 0.029 and 43.06 ± 15.66 to 50.42 ± 19.34; p = 0.002, respectively). Measures of workplace productivity did not change significantly. CONCLUSION: Appropriate medical therapy improves several measures of cognitive dysfunction in patients with CRS. Sustainability of results should be evaluated with larger, prolonged studies.

Olfactory cleft mucus proteins associated with olfactory dysfunction in a cohort without chronic rhinosinusitis.

BACKGROUND: Olfactory dysfunction (OD) is a common problem, affecting up to 20% of the general population. Previous studies identified olfactory cleft mucus proteins associated with OD in chronic rhinosinusitis (CRS) but not in a healthy population. In this study we aimed to identify olfactory cleft mucus proteins associated with olfaction in individuals without sinus disease. METHODS: Subjects free of sinus disease completed medical history questionnaires that collected data regarding demographics, comorbidities, and past exposures. Olfactory testing was performed using Sniffin' Sticks, evaluating threshold, discrimination, and identification. Olfactory cleft mucus (OC) and, in select cases, inferior turbinate mucus (IT) were collected with Leukosorb paper and assays performed for 17 proteins, including growth factors, cytokines/chemokines, cell-cycle regulators, and odorant-binding protein (OBP). RESULTS: Fifty-six subjects were enrolled in the study, with an average age of 47.8 (standard deviation [SD], 17.6) years, including 33 females (58.9%). The average threshold/discrimination/identification (TDI) score was 30.3 (SD, 6.4). In localization studies, OBP concentrations were significantly higher in OC than IT mucus (p = 0.006). Cyclin-dependent kinase inhibitor 2A (CDKN2A/p16INK4a), basic fibroblast growth factor (bFGF), chemokine ligand 2 (CCL2/MCP-1), granulocyte macrophage colony-stimulating factor (GM-CSF), and chemokine ligand 20 (CCL20/MIP-3a) all inversely correlated with overall TDI (all rho ≥ -0.479, p ≤ 0.004). Stem cell factor (SCF) correlated positively with overall TDI (rho = 0.510, p = 0.002). CONCLUSION: Placement of Leukosorb paper is relatively site-specific for olfactory proteins and it is feasible to collect a variety of olfactory cleft proteins that correlate with olfactory function. Further study is required to determine mechanisms of OD in non-CRS subjects.

Variability in Retronasal Odor Identification Among Patients With Chronic Rhinosinusitis.

Background Retronasal olfaction is important in flavor detection and enjoyment. The ability to identify specific individual retronasal odors may play a role in quality of life for patients with chronic rhinosinusitis (CRS). Objective To identify patterns and improve understanding of retronasal identification of individual odors in CRS patients. Methods Patients diagnosed with CRS underwent retronasal and orthonasal (Sniffin' Sticks) olfactory testing and taste testing (taste strips). Retronasal identification was tested with presentation of flavored powders on the posterior tongue. Retronasal identification for individual odors was compared with results of orthonasal and taste testing. Results Seventy participants were evaluated. Retronasal identification correlated with orthonasal identification and discrimination for most individual odors. Among all patients, cinnamon and apple were identified better retronasally and banana better orthonasally ( P < .05). Anosmics identified retronasal orange, cinnamon, mushroom, coffee, smoked ham, peach, ginger, grape, and cheese more than would be expected by chance for a forced-choice paradigm with 3 distractor items ( P < .05), and this was independent of objective taste function for most odors. Conclusion Retronasal and orthonasal identification of most odors correlate in CRS patients; however, patients with anosmia can still identify certain retronasal odors more often than expected. These odors do not appear to stimulate gustatory pathways and may involve trigeminal stimulation. Understanding preserved retronasal neural stimuli may allow providers to improve eating-related quality of life in these patients.

Retronasal olfaction in chronic rhinosinusitis.

OBJECTIVE: The goals of this study were to assess retronasal olfaction in patients with chronic rhinosinusitis (CRS) and describe clinical factors that influence retronasal olfaction. This study sought to investigate the influence of retronasal olfaction on patient-perceived outcomes and examine the relationship between retronasal and orthonasal olfaction. METHODS: Retronasal olfactory function was tested using odorized powders in the oral cavity, whereas Sniffin' Sticks test (Burghart Instruments, Wedel, Germany) were used to assess orthonasal function prospectively in 69 adult CRS patients. Endoscopic evaluation of the olfactory cleft was scored using the Olfactory Cleft Endoscopy Scale (OCES). Several quality-of-life (QOL) instruments relating to sinonasal, olfactory, and chemosensory functions were used to assess the interactions between patient-reported outcome measures and retronasal olfaction. RESULTS: There was strong correlation between retronasal and total orthonasal olfaction scores (r = 0.77, P < 0.001) as well as retronasal scores with orthonasal subscores. Retronasal scores were worse in patients with nasal polyposis (P = 0.002), asthma (P = 0.04), and aspirin-exacerbated respiratory disease (AERD) (P = 0.02), whereas OCES was the only independent predictor of retronasal olfaction (r = -0.42, P < 0.001). Significant correlation existed between retronasal olfaction and olfactory-specific QOL and chemosensory smell scores. CONCLUSION: Few studies have examined retronasal olfaction in CRS patients. In this cohort, CRS patients demonstrated deficits in retronasal olfaction, with worse scores in patients with nasal polyposis, asthma, and AERD. Retronasal olfaction scores correlate with degree of inflammation of the olfactory cleft. Retronasal olfaction correlated strongly with orthonasal olfaction and patient-reported smell and taste metrics, although orthonasal olfaction may have a stronger correlation with these metrics. LEVEL OF EVIDENCE: NA. Laryngoscope, 2437-2442, 2018.

Impact of bitter taste receptor phenotype upon clinical presentation in chronic rhinosinusitis.

BACKGROUND: Genetic variation of the bitter taste receptor T2R38 has been associated with recalcitrant chronic rhinosinusitis (CRS). Specific T2R38 polymorphisms, correlating with bitter taste sensitivity to phenylthiocarbamide (PTC), have been identified as an independent risk factor for surgical intervention in CRS patients without polyps; however, the exact role of PTC tasting ability in clinical practice remains unknown. In this investigation we characterize PTC taste sensitivity in a tertiary care rhinology practice with pertinent clinical measures of disease and quality of life (QOL). METHODS: Adult CRS patients were prospectively assessed for their ability to taste PTC and categorized as nontasters, tasters, or supertasters. Objective taste was assessed with strips for bitter, sweet, sour, and salty, whereas olfactory testing was measured with Sniffin' Sticks. Correlation was performed between PTC tasting ability and patient demographics, endoscopy scores, validated QOL surveys, and both subjective and objective measures of taste and olfaction. RESULTS: Sixty-seven patients were enrolled. Fifty-two percent were identified as nontasters, 34% as tasters, and 13% as supertasters. Nontasters were more likely to be non-Hispanic (p = 0.018), white (p = 0.027), without nasal polyposis (p = 0.004), and nonasthmatics (p = 0.019). There were no other statistical differences in patients' demographics, QOL measures, and subjective or objective olfactory and taste scores when compared with patients' oral PTC-sensing ability. CONCLUSION: Oral PTC-sensing ability may serve as a convenient marker of increased disease severity in white CRS patients without polyps and vary among regional populations. PTC tasting ability appears to provide unique phenotypic information not obtained using other subjective or objective measures of smell and taste.

Taste impairment in chronic rhinosinusitis.

BACKGROUND: Though many patients with chronic rhinosinusitis (CRS) describe disturbances in smell and taste, there have been no studies specifically assessing taste impairment in CRS. This study sought to objectively assess taste dysfunction in CRS patients and determine whether taste impairment correlates with olfactory dysfunction. Additionally, this investigation sought to determine the impact of taste dysfunction on quality of life (QOL) in CRS and identify the clinical factors that influence taste. METHODS: Sixty-eight CRS patients were prospectively enrolled and completed several QOL surveys in relation to taste, smell, overall sinus-specific QOL, and depression. Validated taste strips were used to determine gustatory dysfunction pertaining to sweet, sour, salty, and bitter. Olfactory testing was assessed using the Sniffin' Sticks Test while both Lund-Kennedy and Olfactory Cleft Endoscopy Scoring (OCES) systems were used for endoscopic evaluation. RESULTS: The overall prevalence of dysgeusia was 28%, with scores significantly lower for sour compared to other subgroups. No correlation was observed between taste scores and objective olfactory metrics including olfaction tests and OCES. Taste scores were better in younger patients (r = 0.28, p = 0.02), female patients (p = 0.004), and never smokers compared to former smokers (p = 0.01). Taste scores did not correlate with patient-reported outcome measures or CRS disease severity metrics. CONCLUSION: Taste dysfunction is a common complaint in CRS. This cohort shows prevalence of gustatory loss to be about 28% using ideal normative values. This dysfunction correlated with male gender, smoking history, and older age. Taste dysfunction did not correlate with measured olfactory outcomes.

Understanding the relationship between olfactory-specific quality of life, objective olfactory loss, and patient factors in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) significantly impacts olfaction. However, the relationship between objective olfaction and patient-reported olfactory-specific quality of life (QOL) is not well understood. Furthermore, objective olfactory testing can be time consuming, so we sought to determine if patient-reported olfactory QOL can be used as screening tool for olfactory dysfunction. METHODS: Olfactory dysfunction was evaluated in 109 patients with CRS using the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) and the Sniffin' Sticks Test, assessing for olfactory threshold, discrimination, identification, and overall composite scores (TDI; composite score of threshold, discrimination, and identification). Regression analysis was performed to correlate olfactory metrics and patient and disease-specific factors with QOD-NS scores. Optimal QOD-NS scores to classify patients based upon objective olfactory function were established. RESULTS: Bivariate and multivariate regression analyses of QOD-NS and CRS-associated comorbidities, objective measures of disease, demographics, and CRS-specific QOL were performed. Non-white race, depression, and worse 22-item Sino-Nasal Outcome Test (SNOT-22) scores correlated with worse QOD-NS scores (p < 0.005). Worse TDI scores correlated with worse QOD-NS scores, and discrimination had the strongest correlation (p < 0.001). Mean ± standard deviation (SD) QOD-NS scores for normosmia, hyposmia, and anosmia were 44 ± 7.2, 35.7 ± 12.8, and 31.6 ± 10.7, respectively. Receiver operating characteristic curve analysis revealed an area under the curve of 0.770 (p < 0.001), and a QOD-NS cutoff of 38.5 to have maximal Youden's index to define normal vs abnormal TDI score. CONCLUSION: In CRS, QOD-NS correlates with non-white race, depression, SNOT-22, and TDI score, with discrimination having the strongest correlation. The QOD-NS also appears to be a feasible tool for olfaction screening.

Sleep quality outcomes after medical and surgical management of chronic rhinosinusitis.

BACKGROUND: Endoscopic sinus surgery (ESS) has been shown to improve sleep in patients with chronic rhinosinusitis (CRS). However, it is unknown how this improvement compares with non-CRS control subjects' sleep, and medically treated CRS patients. METHODS: Patients meeting diagnostic criteria for CRS and controls from the same reference population were recruited from 4 academic centers. Patients chose either medical or surgical treatment. The Pittsburgh Sleep Quality Index (PSQI) was administered to patients before treatment and after 6 months, whereas controls received the PSQI at enrollment. RESULTS: The study population consisted of 187 cases (64 medical and 123 surgical) and 101 controls. Baseline PSQI scores for CRS patients (9.27 ± 4.76) were worse than for controls (5.78 ± 3.25), even after controlling for potential confounding factors such as asthma and allergy (p < 0.001). There was no significant difference in baseline PSQI between patients choosing medical vs surgical treatment. The PSQI score in surgical patients improved from 8.36 ± 5.05 to 7.44 ± 5.09 (p = 0.020). The PSQI score in medical patients demonstrated a nonsignificant increase with treatment from 8.71 ± 4.48 to 9.06 ± 4.80 (p = 0.640). After controlling for allergy and asthma, 6-month PSQI scores in medical patients remained significantly higher than in controls (p = 0.001), whereas a significant difference could not be demonstrated between surgical patients and controls (p > 0.05). PSQI subdomain analysis mirrored the overall findings. CONCLUSION: Patients with CRS report worse sleep compared with controls. Surgically treated CRS patients show significant improvement in PSQI scores, whereas those continuing with medical management fail to improve and remain worse than controls.

Association of olfactory dysfunction in chronic rhinosinusitis with economic productivity and medication usage.

BACKGROUND: Chronic rhinosinusitis (CRS) has significant impacts upon productivity, economic metrics, and medication usage; however, factors that are associated with these economic outcomes are unknown. METHODS: We evaluated olfactory dysfunction in 221 patients with CRS using the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) and the 40-item Smell Identification Test (SIT) and assessed whether an association existed between these olfactory metrics and healthcare utilization, productivity, and medication usage over the preceding 90 days. RESULTS: After adjusting for CRS-associated comorbidities, objective measures of disease, demographics, and CRS-specific quality of life (QOL), patients with lower QOD-NS scores (worse patient-reported olfaction) had more missed days of normal productivity and employment, worse productivity levels, more hours of missed employment due to physician visits, more time caring for sinuses, greater distance traveled to medical appointment, more days of oral steroid use, and higher odds of being on disability insurance. Clinical olfaction, as measured by SIT, was associated with greater distance traveled to medical appointment and higher odds of being on disability insurance, but did not correlate with other productivity measures. CONCLUSION: Impaired olfactory-specific QOL is associated with significantly worse economic and productivity metrics and increased medication usage even after adjusting for CRS-specific comorbidities, objective measures of disease, demographics, and severity of CRS-specific QOL. Future studies are warranted to determine if targeting the impaired olfactory-specific QOL noted in patients with CRS results in improved productivity and economic outcomes.

Twenty-two-item Sino-Nasal Outcome Test in a control population: a cross-sectional study and systematic review.

BACKGROUND: The 22-item Sino-Nasal Outcome Test (SNOT-22) is a commonly utilized outcome measure for chronic rhinosinusitis (CRS). However, what constitutes a normal score remains poorly defined. The goal of this study was to evaluate SNOT-22 scores in a control population without CRS and perform a systematic review and meta-analysis of "normal" values. METHODS: Ninety-nine subjects without CRS were enrolled, with 95 fully completing the SNOT-22 questionnaire. Multivariable linear regression was used to determine whether demographic factors or medical comorbidities influence SNOT-22 scores in a population without CRS. A systematic literature search was performed, identifying studies that evaluated the SNOT-22 in a non-CRS population and estimates for SNOT-22 values were pooled. RESULTS: Thirty-six males and 59 females were included in the primary analysis with a mean age of 53.4 ± 17.3 years (range, 18-88 years). The mean SNOT-22 score was 16.4 ± 15.2. Asthma (p = 0.003) and depression (p = 0.002) were found to be independent predictors of higher SNOT-22 scores. Thirteen articles were identified in the literature search and 1 was provided via author correspondence, with 10 reporting sufficient data to be included in the meta-analysis. Weighted mean SNOT-22 score was 11 ± 9.4 (n = 1517). Our data differed significantly from published data (mean difference = 5.4; 95% confidence interval [CI], 3.4 to 7.5; p < 0.0001) likely owing to differences in comorbidities. CONCLUSION: SNOT-22 scores vary in non-CRS populations depending upon the group queried. Asthma and depression are associated with higher SNOT-22 scores and should be considered when determining what constitutes a normal value.