Better Diagnosis, Treatment Needed for Chronic Rhinosinusitis in CF Care

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by Steve Bryson, PhD |

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Adults with cystic fibrosis (CF) who live with recurrent nose and sinus inflammation — called chronic rhinosinusitis, or CRS — have a poor health-related quality of life (HRQoL), and need improved diagnosis and treatment, a large Canadian study concluded.

These findings were especially true for patients who experienced severe nasal involvement from CRS on top of their CF symptoms.

“The more severe the [CRS] sinonasal symptoms are, the worse HRQoL was,” the researchers wrote. Specifically, these CF patients had worse scores in assessments “in the nasal, ear/facial pain and sleep subdomains.”

Given the strong correlation between CRS severity and quality of life across all assessment tools applied in this study, these data highlight the need to diagnose and manage chronic rhinosinusitis in CF care, with better treatment, the researchers recommended.

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The study, “The negative impact of chronic rhinosinusitis on the health-related quality of life among adult patients with cystic fibrosis,” was published in the Journal of Cystic Fibrosis.

Coinciding with the hallmark features of CF — the buildup of abnormally thick mucus in the lungs, liver, pancreas, and intestines — ongoing inflammation of the sinuses and nasal passages, known as chronic rhinosinusitis, is common among patients.

Major symptoms include nasal congestion, mucus discharge, facial pain and pressure, and a reduced sense of smell. CRS is different from the more common form of acute rhinosinusitis, typically caused by a temporary infection of the sinuses (common cold).

To understand the impact of CRS in cystic fibrosis, researchers based in Toronto conducted a study to first determine the condition’s prevalence in a large group of CF patients. The overall goal was to evaluate the effect of CRS on health-related quality of life (HRQoL) in people with CF. Further, the team sought to compare available CRS and HRQoL assessment tools.

Participants were recruited from the Toronto Adult Cystic Fibrosis Clinic, with 215 patients enrolling. Among them, the median age was 31 years, and about half were female. Those with two or more major CRS symptoms were considered symptomatic.

Between those with and without CRS, there were no differences in age, sex, or CF-causing mutation. Lung function, body fat content, CF-related diabetes, lung transplant status, and sputum cultures also were similar among the participants. For the final analysis, 20 individuals were excluded due to a lack of previous examinations.

Of the 195 patients evaluated, the prevalence of CRS was 42.6% based on nasal endoscopy — a thin, flexible tube with a tiny camera inserted into the sinuses.

“The prevalence of CRS is estimated to be 4.5–12% among the non-CF population,” the researchers noted.

Among the 83 individuals with symptomatic CRS and confirmed endoscopic findings, 61.4% had nasal polyps — soft, painless, non-cancerous growths that line the nose or sinuses.

The HRQoL assessment tools included SNOT-22, a CRS-specific health-related quality of life measure that gauges the severity of current symptoms. Two other validated, disease-specific tools, CFQ-R and CF-QUEST, also were used to determine HRQoL in people with CF. The generic general health measure SF-36 also was used for assessments. Except for SNOT-22, higher scores indicate better HRQoL.

Participants diagnosed with CRS had significantly higher overall SNOT-22 scores above the minimally clinically important difference of 8.9. Those scores reflect greater symptom severity and worse HRQoL than those found for patients without CRS. On measures of nasal, ear, and facial pain, as well as sleep impact, scores also were higher (worse).

Worse HRQoL scores beyond the minimally clinically important difference were seen in the physical domain of SF-36 and the lung domain of CFQ-R. Significantly lower QoL scores also were reported for the role limitation domain of CFQ-R.

For CF-QUEST, worse HRQoL for patients with CRS was indicated for most assessed domains, including global (overall), physical and treatment-related, and social and vocational.

A comparison of these assessment tools found a moderately strong correlation between the physical and mental domains of SF-36 and CF-QUEST with SNOT-22 scores, meaning a lower physical and mental quality of life with more severe CRS symptoms. A lower HRQoL related to the lung domain of CFQ showed a moderate correlation with more severe CRS in SNOT-22.

There was a strong correlation between most items from the nasal subdomain of SNOT-22 and SF-36, CF- Quest, and CFQ-R, reflecting more several nasal involvement worsened HRQoL across all measures.

Specific SNOT-22 measures significantly related to a lower HRQoL across all tools including nose blockage, a need to blow the nose, runny nose, cough, postnasal discharge, and thick nasal discharge.

Worse SNOT-22 sneezing domain scores correlated with lower CF-Quest and CFQ-R scores, and a poorer sense of smell was related to lower CF-Quest scores.

“Our study demonstrates that CRS is indeed a prevalent co-morbid [co-existent] condition in CF,” the researchers concluded. “In addition, CRS significantly reduces the HRQoL of CF patients not only in sinonasal symptoms but also within physical health domain in a “dose-response” fashion.”

“Given the strong correlation among SNOT-22, CFQ-R, CF-Quest and SF-36 in CF patients, our study highlights the importance of diagnosing and managing CRS in the care of CF patients,” the researchers added.