Is the sinonasal questionnaire a useful screening instrument for chronic sinonasal diseases in pulmonary clinics?

Abstract

Dixon and coworkers (Dixon AE, Sugar EA, Zinreich SJ, et al. Criteria to screen for chronic sinonasal disease. Chest 2009; 136: 1324–1332.) recently developed a five-item questionnaire for diagnosing chronic sinonasal disease in patients with asthma. Our study was designed to determine how frequently patients attending pulmonary clinics have chronic sinonasal disease and the relationship between questionnaire results and a history of sinus disease and current treatment for sinus disease. The participants were patients in pulmonary clinics at Texas Tech University Health Science Center, who answered the sinonasal questionnaire (SNQ). Additional information included a history of sinus disease or sinus/nasal surgery, smoking status, and current relevant medications. The participants included 28 men and 51 women. Patient ages ranged from 38 to 94 years (mean 62.2 years). Of all the patients, 28 patients (35.4%) had prior sinus disease, 10 (12.7%) had history of sinus or nasal surgery, 24 (30.4%) had history of asthma, and 10 (12.7%) were current smokers. Of them, 14 patients (17.7%) used nasal steroids, 12 (15.2%) used antihistamines, four (5.1%) used decongestants, nine (11.4%) used leukotriene inhibitors, 13 (16.5%) used oral corticosteroids, and two (2.5%) used combinations. The SNQ identified 39 patients (49.4%) as having chronic sinonasal diseases. Therefore, 14% of the participants had sinonasal symptoms but no prior diagnosis of sinus disease. Patients with prior sinus disease and nasal steroid use were more likely to have positive questionnaire result (p < 0.001 and p < 0.032, respectively). The SNQ can identify patients with chronic sinonasal disease in pulmonary clinics. However, the significance of sinonasal disease and its treatment in these patients needs more study.

Introduction

Rhinitis occurs in up to 25% of the general population and in up to 90% of patients with asthma.^1,2 A total of 30% of patients with asthma have sinusitis. ¹ There is also an association between upper airway pathology and chronic obstructive pulmonary disease (COPD). Montnemery et al. ³ conducted a questionnaire based study on a random sample of the Swedish population; 33% of the respondents had recurrent or persistent nasal symptoms and 40% of the subjects with self-reported COPD had these symptoms. Roberts et al. reported that 75% of patients with COPD confirmed by spirometry had nasal symptoms, ⁴ and Hurst et al. noted that 88% of patients with COPD had nasal symptoms, using the 20-item sinonasal outcome test. ⁵ These epidemiologic and clinical studies suggest that there is an association between upper and lower airway diseases, often called the “united airway” hypothesis.^6–9 However, concomitant upper airway symptoms or sinonasal disease is often underdiagnosed and undertreated in patients with lower airway diseases, and it is possible that treating upper airway diseases in these patients will improve their lower airway symptoms.

Dixon and coworkers recently developed a five-item questionnaire for diagnosing chronic sinonasal disease. They studied patients with and without asthma and used an expert panel to diagnose chronic sinonasal disease based on symptoms, CT scans, and endoscopic findings. They found that this brief questionnaire was highly sensitive and specific at a cut point of 1 (experiencing each symptom an average of 1–4 times per month).1 Our study was designed to determine how frequently patients attending pulmonary clinics have chronic sinonasal disease based on this five-item questionnaire. We also collected additional information to identify the relationships between questionnaire results and a history of sinus disease and current treatment for sinus disease.

Methods

Study subjects

This pilot study was performed in several general pulmonary clinics at Texas Tech University Health Sciences Center in Lubbock, Texas, between April and June 2010 as a quality improvement project. We used a convenience sample of patients who were willing to complete the sinonasal questionnaire (SNQ). The following data were also collected from the medical chart: age, sex, a history of sinus disease or sinus/nasal surgery, current asthma diagnosis, smoking status, and current medications (nasal steroids, antihistamines, decongestants, combinations of antihistamines/decongestants, leukotriene inhibitors, and oral corticosteroids). We did not focus on any particular clinical diagnoses, and we did not record the number of patients who declined to participate.

The sinonasal questionnaire

This questionnaire asks about runny nose, postnasal drip, need to blow the nose, facial pain or pressure, and nasal obstruction. Possible answers include never (zero points), 1–4 times per month (1 point), 2–6 times per week (2 points), and daily (3 points). The number of points is then averaged. The optimal cut point for the SNQ based on the frequency of symptoms is 1, which is equivalent to symptoms occurring on average 1–4 times per month, and these subjects were classified as abnormal. ¹ Using the cut point of 1, the SNQ is highly sensitive (0.90; 95% confidence interval (CI) 0.77–0.97) and specific (0.94; 95% CI 0.71–1.00) for identifying the presence or absence of upper airway disease in asthmatics. ¹

Statistical analysis

Continuous variables are reported as means and SDs. The categorical variables are reported as percentages of total subjects. The Pearson’s Chi-Square was used to determine the relationship between the results of SNQ and other clinical data. A p < 0.05 was considered statistically significant. The data were analyzed using SPSS software version 13.0.

Results

This study included 28 men and 51 women. The mean age was 62.2 years (SD 11.9, range 38–94). Of all the patients, 28 patients (35.4%) had prior sinus disease, 10 patients (12.7%) had a history of sinus or nasal surgery, and 24 patients (30.4%) had a history of asthma and 10 (12.7%) were current smokers. Current medications in these patients included nasal steroids (17.7%), antihistamines (15.2%), decongestants (5.1%), combinations antihistamines/decongestants (2.5%), leukotriene inhibitors (11.4%), and oral corticosteroids (16.5%).

The SNQ identified 39 patients (49.4%) as having chronic sinonasal diseases when using the cut point of 1. These patients reported needing to blow the nose with a mean score 1.59 (SD 1.30), as the most common symptom. Runny nose had a mean score of 1.50 (SD 1.25), postnasal drip had a mean score of 1.06 (SD 1.20), and nasal obstruction had a mean score of 0.71 (SD 1.09). The least frequent symptom reported by our patients was facial pain or pressure with a mean score at 0.66 (SD 1.10).

We found a significant correlation between the questionnaire results and prior sinus disease (p < 0.001); there were no significant associations between the questionnaire results and history of asthma, history of sinus or nasal surgery, or smoking status. We also found that the patients who used nasal steroids were more likely to have positive questionnaire results (p < 0.032). Other current treatments, including antihistamines, decongestants, leukotriene inhibitors, oral corticosteroids, and combinations of antihistamines/decongestants were not significantly associated with the questionnaire results (Table 1).

Table 1.

Results of Sinonasal questionnaire and the relationship between the results and history of sinus disease and current medication.

Items	Positive response (n = 79) (%)	p Valuea
History of sinus disease	28 (35.4)	0.001
History of surgery	10 (12.7)	0.115
Asthma	24 (30.4)	0.234
Prior smoker	10 (12.7)	0.111
Nasal steroid	14 (17.7)	0.032
Antihistamine	12 (15.2)	0.084
Decongestant	4 (5.1)	0.538
Combination	2 (2.5)	0.711
Leukotriene inhibitor	9 (11.4)	0.089
Oral corticosteroid	13 (16.5)	0.166

^ap values are calculated using the Pearson’s Chi-Square.

Discussion

Previous studies have reported an association between sinonasal disease and asthma, and recent studies have documented frequent upper airway involvement in COPD patients. These associations have led to the suggestion that upper and lower airway symptoms represent a single airway disease.^6–9 Possible mechanisms for the association between the upper and lower airways in COPD include impaired nasal conditioning and filtering, neural interactions between the upper and lower airways, called nasobronchial neuronal reflexes, aspiration of nasal secretion, systemic propagation of nasal inflammation to the bronchial mucosa, and concomitant systemic inflammation with airway inflammation.^6,9,10 Hurst and coworker reported that the upper airway symptoms are more frequent in patients with confirmed COPD and that these symptoms reduced their quality of life. ⁵ Effectively treating chronic sinonasal disease might decrease the pulmonary aspiration of rhinonasal secretions containing microorganisms, inflammatory cells, and cytokines. This possibility would be particularly important if upper airway disease contributed to COPD exacerbations.

Because of the united airway hypothesis, some authors have recommended that physicians should consider screening for chronic sinonasal symptoms in patients with lower airway diseases and consider the possibility of lower respiratory tract disease in patients who present with chronic nasal symptoms. ⁶ We could not identify studies that compared outcomes in patients with chronic lung diseases who are appropriately diagnosed and treated for upper airway symptoms. Our pilot study demonstrates that a simple screening tool for chronic sinonasal disease is useful in pulmonary clinics. The SNQ is easy to use and has high sensitivity and specificity to detect chronic sinonasal disease without sophisticated investigation, at least in asthmatics. ¹ We found that almost 50% of the patients from our general pulmonary clinic had chronic sinonasal disease, and some of these patients probably need a more focused evaluation of these symptoms. Of the patients in our sample, 14% had sinonasal symptoms but no prior diagnosis of sinus disease. This result supports previous studies reporting chronic sinonasal disease is often underdiagnosed and undertreated. We did not record specific diagnoses and do not know if the prevalence of sinonasal symptoms is higher in particular patient groups in this outpatient clinic cohort. We think that this patient population represents the usual patients seen in general pulmonary clinics, but these results may not be generalizable.

We also collected the information about current medications use by our patients and found that nasal steroid use is significantly associated with a positive SNQ score. The interpretation of this result is uncertain and suggests that some patients have sinusitis symptoms when on therapy. However, the SNQ was originally developed to screen for the disease and not to follow symptoms after the treatment. ¹ Our results represent a cross-sectional one-time survey, and it is possible that patients with positive score while on treatment would have had a higher scores prior to treatment. Prospective treatment trials could clarify this uncertainty.

There are a limited number of studies on the association of upper airway symptoms with other pulmonary diseases. We could not find a study on the association between upper airway diseases and idiopathic pulmonary fibrosis (IPF). However, there are studies on the association between gastroesophageal reflux disease (GERD) and pulmonary fibrosis. ¹¹ Tobin and colleagues found a higher prevalence of GERD detected by ambulatory pH monitoring in the IPF patients, ¹² and Raghu et al. found a high incidence of reflux in a prospective study of 65 patients with IPF. ¹³ In a recent retrospective study of 457 patients who had lung transplantation, the group of patients who underwent fundoplication before lung transplant had a lower incidence of acute rejection and bronchiolitis obliterans syndrome and better survival than the group who did not undergo antireflux surgery. ¹⁴ This suggests that microaspiration could have a role in the pathophysiology of posttransplant bronchiolitis obliterans syndrome and supports the idea that recurrent microaspiration is a potential cause of pulmonary fibrosis. Could chronic upper airway disease have a similar effect?

Obstructive sleep apnea is a well known disorder caused by intermittent obstruction of the upper airway during sleep. Kohler et al. have suggested that chronic nasal obstruction could influence the pathogenesis of obstructive sleep apnea and snoring. ¹⁵ The most common etiologies of nasal obstruction are allergic and nonallergic rhinitis. Both these disorders can be treated, and this treatment could potentially alleviate sleep problems. ¹⁶ Previous studies on the management of upper airway symptoms in OSA patients, including surgical management of the obstruction in the patients with abnormal anatomy, nasal dilators to increase upper airway patency, and medications such as topical nasal decongestant and nasal steroids, showed only minor improvements in obstructive sleep apnea symptoms and severity. However, these studies typically had small sample sizes. ¹⁵

In summary, the SNQ is a useful screening instrument for chronic sinonasal disease. Some clinical factors in our study, such as prior nasal surgery, smoking status, and current medications except nasal steroids, did not have a statistically significant association with the test result. The questionnaire can be used in routine patients seen in pulmonary clinics to screen for chronic sinonasal disease and should be studied in more detail in certain patient groups, especially COPD patients with frequent exacerbations.