Chronic rhinosinusitis often mistaken for allergic rhinitis
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Key takeaways:
- 45.2% of patients who had “nasal allergies” had chronic rhinosinusitis.
- Patients with CRS tended to be older with a greater proportion of men.
- Specific symptoms were associated with a CRS diagnosis.
Patients who believe they have allergic rhinitis really might have chronic rhinosinusitis, according to a study published in Otolaryngology – Head and Neck Surgery.
These misperceptions can lead to ineffective care and worse quality of life, Ahmad R. Sedaghat, MD, PhD, director of the division of rhinology, allergy and anterior skull base surgery, University of Cincinnati College of Medicine, and colleagues wrote.
“We have seen in our clinical practices many instances where patients have believed that they have allergies for many years and have sought treatment for allergies for years,” Sedaghat said in a press release.
Yet these patients do not find relief because they have had chronic rhinosinusitis (CRS), he continued, adding that this is especially true for the Cincinnati and Ohio River valley region, where environmental allergies are highly prevalent.
“As someone who grew up in this region, I can attest to how commonly we tend to attribute sinus and nasal symptoms to ‘allergies,’” Sedaghat said.
Allergic rhinitis (AR) and CRS have overlapping symptomatology, he explained, including nasal blockage and nasal drainage.
“Both can also cause sinus pressure,” Sedaghat said. “Despite their common clinical symptoms, however, nasal allergies and CRS in many ways have different treatments.”
Study design, results
The researchers aimed to identify predictors that could guide patients who are experiencing these symptoms to seek evaluation for CRS.
The cross-sectional study comprised 219 adults (mean age, 44.3 years; 63.9% women) who presented to a tertiary care rhinology and allergy clinic with a chief complaint of “nasal allergies” between May 2019 and May 2023.
The clinic diagnosed 91.3% (n = 200) of these patients with AR and 45.2% (n = 99) with CRS, including 16 patients (16.2%) who had nasal polyps.
Also, 5.5% (n = 12) did not test positive for allergy, nor did they meet diagnostic criteria for CRS. Further, 3.2% met the diagnostic criteria for CRS but did not test positive for allergy.
Consistent medication usage among the patients with CRS included only an antihistamine (25.3%; n = 25), only an intranasal corticosteroid (4%; n = 4), an antihistamine and an intranasal corticosteroid (50.5%; n = 50), and neither an antihistamine nor an intranasal corticosteroid (20.2%; n = 20).
The patients with CRS tended to be older than the patients who did not have CRS (P = .013). Patients with vs. without CRS also had a greater proportion of men (P = .008), higher 22-item sino-nasal outcome test scores (P = .025) and higher nasal endoscopy scores (P < .001).
Odds ratios for CRS included 1.02 (95% CI, 1.01-1.04) for older age, 2.29 (95% CI, 1.3-4.04) for male sex, 2.01 (95% CI, 1.63-2.49) for higher endoscopy score and 1.02 (95% CI, 1.01-1.03) for higher SNOT-22 score.
SNOT-22 nasal items associated with a CRS diagnosis included:
- need to blow nose: OR = 1.33; 95% CI, 1.09-1.63;
- thick nasal discharge: OR = 1.3; 95% CI, 1.09-1.55;
- sense of taste/smell: OR = 1.32; 95% CI, 1.08-1.63; and
- blockage/congestion of nose: OR = 1.44; 95% CI, 1.19-1.74.
With an association between the sum of the severity of these symptoms measured using a six-point Likert scale and CRS (OR = 1.16; 95% CI, 1.08-1.25), the researchers called this sum a statistically significant predictor for having CRS (area under the curve [AUC] = 0.667; 95% CI, 0.596-0.739).
Specifically, a score of 8 or higher out of a possible total of 20, which would indicate a mean burden of at least a mild or slight problem for each of the symptoms, predicted CRS with 64.6% sensitivity and 63.3% specificity.
A combined severity score for these symptoms of 8 or higher also was significantly associated with CRS (OR = 3.16; 95% CI: 1.81-5.5), the researchers said, adding that the severities of these symptoms varied in how they predicted CRS as well.
For example, a moderate problem with blockage/congestion of nose and with thick nasal discharge predicted CRS. Similarly, a mild or slight problem with a need to blow nose and a very mild problem for sense of taste or smell also predicted CRS.
The researchers called nasal endoscopy score a statistically significant predictor of CRS as well (AUC = 0.772; 95% CI, 0.713-0.831), with scores of 1 or higher predicting CRS with 72.7% sensitivity and 74.1% specificity (OR = 8.37; 95% CI, 4.55-15.38).
Conclusions, next steps
The researchers specifically used SNOT-22 because it could simultaneously measure AR and CRS scores without the need for different questionnaires. Yet these findings and how they apply to patients are distinct from the test, Sedaghat said in the press release.
“We were able to determine that at certain sinus/nasal symptom severity thresholds, patients should consider the possibility of CRS, but these thresholds are described in lay terms that patients can easily apply to their own situation,” he said.
Noting that health literacy remains a challenge for the public, the researchers said they were not surprised that patients would seek treatment for AR instead of CRS, especially considering the marketing for overlapping medications for symptoms they have in common.
The researchers also noted that physicians can even have trouble distinguishing between AR and CRS. Yet the researchers cautioned that these mistakes may lead to ineffective treatments that prolong symptoms, decreasing quality of life and increasing costs.
Physicians should strive to educate these patients about CRS, especially in areas impacted by environmental allergies such as Cincinnati, to ensure they get the proper diagnosis and treatment, the researchers said.
Through counseling of individuals and of communities at large, patients could learn to consider CRS when their nasal obstruction or discharge symptoms reach a moderate or greater level of severity or if they lose some degree of their sense of smell, the researchers said.
“I’ve had patients who tell me that they have been treated with allergy shots for 10, 20 or more years without relief of their symptoms but who after they discovered they had CRS and we started them on appropriate treatment, achieved relief within a few months,” Sedaghat said.
Additionally, the researchers said, new research should investigate the benefits of improving health literacy pertaining to CRS among patients as well as the benefits of early diagnosis, which could improve quality of life and reduce costs.
Reference:
- UC research examines chronic sinusitis. https://www.uc.edu/news/articles/2024/02/university-of-cincinnati-research-examines-chronic-sinusitis.html. Published Feb. 26, 2024. Accessed March 20, 2024.
Perspective
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This study found that individual characteristics — such as “need to blow nose,” “thick nasal discharge” and “blockage/congestion of nose” — were all individually tied to an increased likelihood of chronic disease. The authors also found that there was an additive effect, as the sum of these individual symptoms was also indicative of chronic rhinitis.
In clinical practice, it is common for patients with chronic nasal symptoms to also have seasonal flares. So, despite having symptoms present much of the year, they present with exacerbations during typical allergy seasons, which may lead to the diagnosis of seasonal or periodic rhinitis rather than a more year-round diagnosis. And, as the authors pointed out, many patients do not realize that they have impactful symptoms most of the year.
When patients present with nasal symptoms, they provide us with an excellent opportunity to probe the duration and characteristics of their complaints a bit further and offer appropriate therapies.
Asking about the intensity of symptoms and using the key phrases outlined in this study and/or using validated questionnaires such as SNOT-22 can help us zero in on patients needing more chronic therapy options.
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