ABSTRACT
Background: Chronic rhinosinusitis (CRS) is a group of disorders characterised by inflammation of the mucosa of the nose and paranasal sinuses lasting for at least twelve (12) consecutive weeks. Even though evidence from scientific studies show that CRS has a negative impact on the health related quality of life (HRQOL) of patients, there is paucity of information in literature to establish relationship between HRQOL of patients with CRS and nasal index. Is there a relationship between CRS HRQOL and nasal index? Aim: The aim of this study was to determine the relationship between nasal index and HRQOL in adult Nigerians with CRS. Methods: This one year prospective, cross-sectional descriptive study was conducted at the ENT clinic of National Hospital, Abuja. All consecutive adult patients diagnosed with chronic rhinosinusitis, were included in this study. Data collection was done with a semi- structured questionnaire to elicit bio data, history of symptoms of CRS, frequency of symptoms and the most disturbing symptom. Then overall symptom scoring was done using a ‘10cm line’ visual analogue scale on which patients marked their symptom severity. This line was then measured to derive the quality of life (QOL) score. Nasal index was then calculated as a ratio of the nasal breadth to the nasal height expressed as a percentage. For the control group only the biodata and their nasal index were determined. Results: A total of 110 patients with CRS and 110 healthy controls were recruited into this study. Those aged 31 to 40years had the highest incidence of CRS. The quality of life score had a significant positive correlation with the nasal index of those with CRS (r= 0.269, p<0.05). There was a significant association between nasal index and the severity of symptom of CRS (p<0.05). No association existed between nasal index and frequency of
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symptoms (p>0.05). Nasal blockage was the commonest ‘most disturbing’ symptom and there was no relationship between nasal index and the ‘most disturbing’ symptom (p>0.05). Conclusion: There exists an association between nasal index and the HRQOL of patients with CRS and this can be utilised by including nasal index determination as a domain in one of the instruments for the evaluation of HRQOL of patients with CRS. Keywords: Chronic rhinosinusitis, rhinosinusitis, health related quality of life, quality of life, nasal indexq, visual analogue score, Abuja
CHAPTER ONE
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Introduction Chronic rhinosinusitis (CRS) is a group of disorders characterised by inflammation of the mucosa of the nose and paranasal sinuses lasting for at least twelve (12) consecutive weeks
. It affects individuals of all age group and is one of the common chronic conditions in medicine. It has a global incidence. The prevalence of CRS in the United States (US) is 16%
while in Europe it is 10.9 percent
. In Nigeria, a number of hospital based studies reported prevalence rates of CRS between 7.3% and 93 percent 4–8 . A number of risk factors predispose to the development and persistence of this condition, yet its aetiology remains largely unknown. The risk factors include allergy, asthma, aspirin sensitivity, immunocompromised states, genetic factors, pregnancy, endocrine factors, local host factors among others
.CRS causes local symptoms such as nasal obstruction, headaches, anosmia/hyposmia, purulent nasal discharge and post- nasal drip
. It also causes systemic symptoms such as fatigue and malaise. The European Position Paper on rhinosinusitis and nasal polyps (EPOS) classified CRS into chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP)
.CRS with or without nasal polyps causes significant physical symptoms. It has a negative impact on health related quality of life (HRQOL) and can substantially impair daily functioning 10. Various CRS HRQOL instruments (11–13) have been used to confirm this. This depicts the severity of the disease as perceived by the patient. HRQOL measurements are the best approximation of the burden of disease for the patient
. Although CRS is not a life threatening disease, it can significantly decrease patient’s HRQOL, hence it is now advocated that a global assessment of patients with CRS must
include, together with nasal symptoms, nasal endoscopy and computed tomographic (CT) Scan, a measurement of HRQOL
.HRQOL of patients can be measured using either patient reported outcome measurements (PROM) or symptom scores
. Some studies have shown that a number of conditions impact negatively on the quality of life of patients with CRS. Patients who have allergy and CRS have more severe symptoms than those who suffer from CRS alone
. Gastroesophageal reflux disease, second hand tobacco smoke exposure, post-traumatic stress disorder, immunosuppression and polymorphism in alpha-1-antitrypsin gene have all been found to correlate with more severe symptoms of CRS and hence lowers their HRQOL 17–20 . Other chronic illnesses that have been associated with a poor HRQOL in patients with CRS include depression, olfactory dysfunction, fatigue, sleep disturbance and sexual dysfunction 21.
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There is no known study yet on the relationship, if any, between nasal index and severity of symptoms (that is, HRQOL) of CRS patients. The shape of the nose are important in genetic counselling, reconstructive surgery and forensic investigation and also considered as a clue to racial origin 22, however its role in the HRQOL of patients with CRS is yet to be determined. The Nasal Index is a standard anthropometric parameter, determined as a ratio of the greatest breadth of the nasal aperture and the height of the nasal skeleton expressed as a percentage 23,24 .Based on the Nasal Index, nasal shape can be classified into three different types
namely: Leptorrhine or fine nosed (nasal index ≤69.9), Mesorrhine or medium nosed (nasal index 70.0 – 84.9) Platyrrhine or broad nosed (nasal index ≥ 85.0) The differences in the nasal index has been proposed to be an adaptation to climate with broad noses (platyrrhine) evolving in a warm, humid environment where there was little need
for air conditioning and narrow noses (leptorrhine) evolving in cold and dry climates where the air needed more warming 26,27 .Several studies exist on nasal indices of different populations all over the world. Most of these studies were done among races and ethnic groups and these revealed a lot of variations among the different ethnic groups and races. In Nigeria a study among the Igbo, Yoruba and Ijaw ethnic groups of southern Nigeria, showed a mean nasal index of > 85.0 for the three ethnic groups
. The Research Problem The prevalence rate of CRS in Nigeria varies from one part of the country to another. A number of studies have reported prevalence rate ranging from 7.3% in the northern part of the country to 93% in the south 4–8 . The cost of care has also been reported to be enormous in this environment
. Complications arising from this condition have been reported by various studies in this environment. A study at Sokoto reported that 14.4% of the cases had complications with orbital complications being the commonest
. In a hospital based study at Ibadan, prevalence of orbital complication was 41% and sinus wall complications was 32 percent
.Another study in the same hospital at Ibadan done 12years later, reported that 6% of the patients developed complications which include frontoethmoidal mucocoele, frontocutaneous fistula, Pott’s puffy tumor, visual loss and intracranial abscess
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among others. Although studies elsewhere have established that chronic rhinosinusitis has a negative impact on the health related QOL of patients, however there is paucity of studies addressing this in this environment. In addition, many health domains e.g. symptoms, physical activity, functional status and emotional domains, are included in the instruments used for assessment of CRS quality of life outcomes, not enough has been published on how the nasal index may
actually contribute to the severity or recurrence of this disease. Hence, there is no empirical evidence yet establishing the effect of nasal index on HRQOL of CRS patients. Research Question: Could nasal index be a factor influencing the severity of symptoms perceived by patients with chronic rhinosinusitis? Could it be a factor that has a negative impact on health related QOL of patients with this condition? Null Hypothesis: Nasal index is not a factor that impacts negatively on the health related quality of life of adult patients with chronic rhinosinusitis. Alternate Hypothesis: Nasal index is a factor that impacts negatively on the health related quality of life of adult patients with chronic rhinosinusitis. Justification for this study A number of studies in this environment have reported variations in nasal index among different ethnic groups in this environment. This, however, has not been linked to predilection of any disease entity among these ethnic groups because there is paucity of studies in that area. The HRQOL of life of patients with CRS has also been reported to vary with different disease entities, often found to be associated with CRS and among individuals. No explanation has been given to account for these variations. Could these be due to variation in nasal index? The aim of this study therefore, was to determine the relationship between nasal index and health related quality of life of patients with chronic rhinosinusitis.
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