Interpretation of Tonsillectomy Outcome Inventory-14 scores: a prospective matched cohort study.

PURPOSE: Knowledge of disease-specific instruments enables the evaluation of health- related quality-of-life (QoL) change associated with chronic and recurrent tonsillitis in adults. The main objective was to explore the interpretation of scores according to the throat-related QoL instrument, Tonsillectomy Outcome Inventory-14 (TOI-14), by determining the typical scores in healthy subjects and patients and define the minimum important change (MIC). METHODS: We performed a prospective matched cohort study in a secondary care area of Oulu University Hospital. The surgical cohort consisted of 42 patients referred to tonsillectomy due to recurrent or chronic tonsillitis. The control cohort consisted of 42 age- and sex-matched healthy controls obtained from the escorts of patients in the same hospital. We translated and validated the Finnish TOI-14 instrument and collected TOI-14 scores at entry and at 6 months and compared results to the anchor question. RESULTS: At entry, the mean TOI-14 scores were significantly higher in the surgical cohort than in the control cohort [mean (95% confidence interval)] 33.0 (27.0-39.1) vs. 5.0 (3.6-6.4), respectively. At 6 months follow-up, the mean TOI-14 scores had improved markedly after tonsillectomy to the level of the control cohort. In the healthy population, the score was in most cases under 15.0 points. In patients, a score of about 20.0 indicated mild symptoms, 30.0 moderate symptoms and 40.0 or higher intense symptoms. The MIC value was 10.0 points. CONCLUSIONS: These results enable the more accurate interpretation of the scores of the only disease-specific QoL instrument for adult throat-related diseases.

Inflammatory Biomarkers During Bacterial Acute Rhinosinusitis.

PURPOSE OF REVIEW: Diagnosis of bacterial acute rhinosinusitis is difficult. Several attempts have been made to clarify the diagnostic criteria. Inflammatory biomarkers are easily obtainable variables that could shed light on both the pathophysiology and diagnosis of bacterial acute rhinosinusitis. The purpose of this review article is to assess literature concerning the course of inflammatory biomarkers during acute rhinosinusitis and the use of inflammatory biomarkers in diagnosing bacterial acute rhinosinusitis. RECENT FINDINGS: We included C-reactive protein, erythrocyte sedimentation rate, white blood cell counts, procalcitonin, and nasal nitric oxide in this review and found that especially elevated C-reactive protein and erythrocyte sedimentation rate are related to a higher probability of a bacterial cause of acute rhinosinusitis. Still, normal levels of these two biomarkers are quite common as well, or the levels can be heightened even during viral respiratory infection without suspicion of bacterial involvement. Elevated levels of C-reactive protein or erythrocyte sedimentation rate support diagnosis of bacterial acute rhinosinusitis, but due to a lack of sensitivity, they should not be used to screen patients for bacterial acute rhinosinusitis.

Predictive factors of a beneficial quality of life outcome in patients undergoing primary sinonasal surgery: a population-based prospective cohort study.

PURPOSE: To assess predictive factors of a beneficial quality of life (QoL) outcome after primary sinonasal surgery. METHODS: A population-based prospective cohort study among 160 adult patients undergoing primary sinonasal surgery (76 septoplasties, SP; 84 endoscopic sinus surgeries, ESS) was conducted. We collected QoL data using the Sinonasal Outcome Test-22 (SNOT-22) before and after surgery. A beneficial QoL outcome was defined as a SNOT-22 score change ≥ 9 points 12 months after surgery. Various demographic, clinical and symptom-related factors predicting a beneficial QoL outcome were sought using binary logistic regression analysis. RESULTS: The mean age of the patients was 39 years (range 18-61) and 82 (51%) were males. The SNOT-22 score change varied markedly after SP (range - 17 to + 80) and ESS (range - 20 to + 58), but on average it improved (median + 15 after SP and + 16 after ESS). 41 patients (64%) achieved beneficial QoL outcome after SP and 46 (66%) after ESS. In a multivariate analysis, poor QoL before surgery (preoperative SNOT-22 ≥ 20 points) predicted a beneficial QoL outcome after SP and ESS (adjusted odds ratio 10; 95% confidence interval 1.6-64 and 12; 2.5-55, respectively) and a senior surgeon operating after SP (9.9; 1.5-67). On receiver operating characteristic curve analysis, the integer threshold value for the preoperative SNOT-22 score that gave the highest sensitivity (74%) and specificity (70%) was 30. CONCLUSIONS: QoL change after primary SP and ESS varies. A preoperative SNOT-22 score of at least 30 best predicted a beneficial QoL outcome after both procedures.

Quality of life before and after sinonasal surgery: a population-based matched cohort study.

A population-based matched cohort study was conducted to explore how the quality of life (QoL) changes in patients with septal deviation or recurrent/chronic rhinosinusitis after septoplasty (SP) and endoscopic sinus surgery (ESS). We also compared the QoL of the surgical cohort with that of a concurrently collected healthy cohort. We collected data on QoL in a population-based surgical cohort of 160 patients residing in one health care district (population 405,000) in Northern Finland, and in a control cohort comprised of 206 age- and sex-matched randomly selected subjects residing in Finland (population 5,470,000). QoL was assessed at entry and 12 months later with the Sino-Nasal Outcome Test-22 (SNOT-22) and the RAND-36 generic instruments. Seventy-six SP and 84 ESS patients and 206 controls were enrolled. At entry, the mean SNOT-22 scores of the SP and ESS groups were similar (34.9 and 35.1, respectively) and both were significantly worse than the control group (17.7). At 12 months, the mean SNOT-22 score had improved after SP [change 15.7, 95 % confidence interval (CI) 11.4-19.9] and ESS (change 18.0, 95 % CI 12.4-20.9) and almost reached that of the control group, which remained unchanged. The benefit was similar regardless of the surgical indication. At 12 months, mean RAND-36 scores had improved in most domains in both patient groups and remained unchanged in the controls. After appropriate surgical criteria, both SP and ESS are effective in enhancing QoL on the population level, and postoperative QoL almost reaches the level of the control population.

Short-term outcomes of tonsillectomy in adult patients with recurrent pharyngitis: a randomized controlled trial.

BACKGROUND: Limited evidence exists as to the benefit of tonsillectomy in adult patients. We sought to determine the short-term efficacy of tonsillectomy for recurrent pharyngitis in adults. METHODS: We conducted a randomized, controlled, parallel-group trial at a tertiary care ear, throat and nose centre in Oulu, Finland, between October 2007 and December 2010. Adult patients with recurrent pharyngitis were randomly assigned to the control group (watchful waiting) or the tonsillectomy group. Our primary outcome was the difference in the proportion of patients with severe pharyngitis (severe symptoms and C-reactive protein level > 40 mg/L) within 5 months. Our secondary outcomes included differences between groups in proportions of patients who had episodes of pharyngitis with or without medical consultation, rates of pharyngitis and numbers of days with symptoms. RESULTS: Of 260 patients referred for tonsillectomy because of recurrent pharyngitis, we recruited 86 participants for our study. Of these, 40 patients were randomly allocated to the control group, and 46 were randomly allocated to the tonsillectomy group. One patient in the control group and no patients in the tonsillectomy group had a severe episode of pharyngitis (difference 3%, 95% confidence interval [CI] -2% to 7%). Seventeen patients in the control group (43%) and 2 patients in the tonsillectomy group (4%) consulted a physician for pharyngitis (difference 38%, 95% CI 22% to 55%). Overall, 32 patients in the control group (80%) and 18 patients in the tonsillectomy group (39%) had an episode of pharyngitis during the 5-month follow-up (difference 41%, 95% CI 22% to 60%). The rate of pharyngitis and number of symptomatic days were significantly lower in the tonsillectomy group than in the control group. INTERPRETATION: There was no significant difference in the number of episodes of severe pharyngitis between the control and treatment groups, and episodes were rare. However, tonsillectomy resulted in fewer symptoms of pharyngitis, consequently decreasing the number of medical visits and days absent from school or work. For this reason, surgery may benefit some patients. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT00547391.

Reducing the airflow waveform distortions from breathing style and body position with improved calibration of respiratory effort belts.

BACKGROUND: Respiratory effort belt measurement is a widely used method to monitor respiration. Signal waveforms of respiratory volume and flow may indicate pathological signs of several diseases and, thus, it would be highly desirable to predict them accurately. Calibrated effort belts are sufficiently accurate for estimating respiratory rate, but the respiratory volume and flow prediction accuracies degrade considerably with changes in the subject's body position and breathing style. METHODS: An improved calibration method of respiratory effort belts is presented in this paper. It is based on an optimally trained FIR (Finite Impulse Response) filter bank constructed as a MISO system (Multiple-Input Single-Output) between respiratory effort belt signals and the spirometer in order to reduce waveform errors. Ten healthy adult volunteers were recruited. Breathing was varied between the following styles: metronome-guided controlled breathing rate of 0.1 Hz, 0.15 Hz, 0.25 Hz and 0.33 Hz, and a free rate that was felt normal by each subject. Body position was varied between supine, sitting and standing. The proposed calibration method was tested against these variations and compared with the state-of-the-art methods from the literature. RESULTS: Relative waveform error decreased 60-70% when predicting airflow under changing breathing styles. The coefficient of determination R2 varied between 0.88-0.95 and 0.65-0.79 with the proposed and the standard method, respectively. Standard deviation of respiratory volume error decreased even 80%. The proposed method outperformed other methods. CONCLUSIONS: Results show that not only the respiratory volume can be computed more precisely from the predicted airflow, but also the flow waveforms are very accurate with the proposed method. The method is robust to breathing style changes and body position changes improving greatly the accuracy of the calibration of respiratory effort belts over the standard method. The enhanced accuracy of the belt calibration offers interesting opportunities, e.g. in pulmonary and critical care medicine when objective measurements are required.

Diagnostic prediction models for CT-confirmed and bacterial rhinosinusitis in primary care: individual participant data meta-analysis.

BACKGROUND: Antibiotics are overused in patients with acute rhinosinusitis (ARS) as it is difficult to identify those who benefit from antibiotic treatment. AIM: To develop prediction models for computed tomography (CT)-confirmed ARS and culture-confirmed acute bacterial rhinosinusitis (ABRS) in adults presenting to primary care with symptoms suggestive of ARS. DESIGN AND SETTING: This was a systematic review and individual participant data meta-analysis. METHOD: CT-confirmed ARS was defined as the presence of fluid level or total opacification in any maxillary sinuses, whereas culture-confirmed ABRS was defined by culture of fluid from antral puncture. Prediction models were derived using logistic regression modelling. RESULTS: Among 426 patients from three studies, 140 patients (32.9%) had CT-confirmed ARS. A model consisting of seven variables: previous diagnosis of ARS, preceding upper respiratory tract infection, anosmia, double sickening, purulent nasal discharge on examination, need for antibiotics as judged by a physician, and C-reactive protein (CRP) showed an optimism-corrected c-statistic of 0.73 (95% confidence interval [CI] = 0.69 to 0.78) and a calibration slope of 0.99 (95% CI = 0.72 to 1.19). Among 225 patients from two studies, 68 patients (30.2%) had culture-confirmed ABRS. A model consisting of three variables: pain in teeth, purulent nasal discharge, and CRP showed an optimism-corrected c-statistic of 0.70 (95% CI = 0.63 to 0.77) and a calibration slope of 1.00 (95% CI = 0.66 to 1.52). Clinical utility analysis showed that both models could be useful to rule out the target condition. CONCLUSION: Simple prediction models for CT-confirmed ARS and culture-confirmed ABRS can be useful to safely reduce antibiotic use in adults with ARS in high-prescribing countries.

Total or partial tonsillar resection (tonsillectomy or tonsillotomy) to change the quality of life for adults with recurrent or chronic tonsillitis: study protocol for a randomised controlled trial.

BACKGROUND: Tonsillar surgery has been used for decades to treat recurrent and chronic tonsillitis in adults. Recurrent and chronic tonsillitis result in disturbing symptoms, treatment costs, sick leave, and impaired quality of life (QoL). Theoretically, removing all or part of the altered pathological palatal lymphoid tissue alleviates the symptoms and enhances the QoL. Whether this is true with total or partial tonsillar resection (tonsillectomy (TE) and tonsillotomy (TT), respectively) has not been reported in a randomised trial yet. METHODS: We conduct a multicentre, partly blinded, randomised, 6-month, parallel-group clinical study including 285 adult participants referred to surgical treatment for chronic or recurrent tonsillitis. The participants will either have TE, TT or watchful waiting (WW). The primary outcome will be the difference between the mean disease-specific Tonsillectomy Outcome Inventory-14 (QoL questionnaire) scores at 6 months. Comparison is made firstly between the combined TE+TT and WW groups (superiority analysis), and secondly between the TE and TT groups (non-inferiority analysis). DISCUSSION: This study will add significant new information to the effects and harms of TE and TT procedures in the treatment of adults with chronic or recurrent tonsillitis. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04657549.

Endoscopic sinus surgery (ESS) to change quality of life for adults with recurrent rhinosinusitis: study protocol for a randomized controlled trial.

BACKGROUND: Endoscopic sinus surgery (ESS) has been used for decades to treat recurrent acute rhinosinusitis episodes (RARS) in adults. RARS results in infectious symptoms, antibiotic courses, sick leaves, and impaired quality of life. Theoretically, the ESS procedure, through improving the drainage of the paranasal sinuses, decreases the symptoms and enhances the quality of life of the RARS patients. Whether this is true has not been reported in a randomized trial yet. METHODS: We conduct a single-center, non-blinded, randomized, 6-month, parallel group superiority clinical study including 80 adult participants referred to surgical treatment for RARS. The participants will either have ESS or conservative medical treatment (control group). The primary outcome will be the difference between the mean disease-specific Sinonasal Outcome Test 22 (quality of life questionnaire) change scores (from baseline to 6 months) of ESS and control group. DISCUSSION: This study will add significant new information to the effect and harms of ESS procedure in the treatment of adults with RARS. TRIAL REGISTRATION: ClinicalTrials.gov NCT04241016 . Registered on 17 January 2020.

Cause-specific mortality in patients with head and neck cancer: Long-term follow-up of a population-based cohort from 1986 to 2012 accounting for competing risks.

OBJECTIVES: Recent recommendations for treating head and neck cancer (HNC) patients favor an individualized approach. Expected long-term survival - together with short-term survival - after diagnosis is the primary focus in assessing the treatment modality and follow-up scheme. "Disease-specific" survival up to five years is often used for measuring the prognosis and for assessing treatment methods. However, especially long-term survival is strongly affected by competing causes of death among HNC patients. MATERIALS AND METHODS: The long-term prognosis of patients with HNC in terms of mortality from both cancer and competing causes was analyzed according to recent methodological guidelines by examining cumulative incidence functions and models for cause-specific hazards and sub-distribution hazards in a population based cohort of 220 patients treated in a tertiary care center in Northern Finland. RESULTS: In addition to well-known tumor-related factors, mortality from HNC was associated with older age. The mortality from other causes of death was strongly dependent on age and Charlson's Comorbidity Index, but less on gender. When demonstrating the importance of individualized approach in simulated patients, the mortality was highly variable across patients with similar cancer status, but with different comorbidities or age. CONCLUSION: The overall survival pattern of HNC patients depends not only on their cancer characteristics, but also varies greatly according to their age and comorbidities. Our findings support the need for individualized treatment and follow-up protocols, and active management of comorbid diseases. Appropriate methods for analyzing competing risks should be used when presenting survival estimates of cancer patients.