|ORIGINAL RESEARCH REPORT
|Year : 2022 | Volume
| Issue : 4 | Page : 130-135
Correlation between Lund-Mackay CT scan score and Sinonasal Outcome Test-20 symptoms score in the evaluation of chronic rhinosinusitis
Yakubu Bababa Shirama1, Auwal Adamu2, Kufre Robert Iseh3, Sa'idu Sule Ahmed4, Sule Muhammad Baba4, Sadisu Muhammad Ma'aji4
1 Department of Radiology, Abubakar Tafawa Balewa University Teaching Hospital, Abubakar Tafawa Balewa University, Bauchi, Nigeria
2 Department of Otorhinolaryngology, Head and Neck Surgery, Abubakar Tafawa Balewa University Teaching Hospital, Abubakar Tafawa Balewa University, Bauchi, Nigeria
3 Department of Otorhinolaryngology, Usman Danfodiyo University Teaching Hospital, Usman Danfodiyo University, Sokoto, Nigeria
4 Department of Radiology, Usman Danfodiyo University Teaching Hospital, Usman Danfodiyo University, Sokoto, Nigeria
|Date of Submission||08-Jul-2022|
|Date of Acceptance||13-Oct-2022|
|Date of Web Publication||09-Nov-2022|
Dr. Auwal Adamu
Department of Otorhinolaryngology, Head and Neck Surgery, Abubakar Tafawa Balewa University Teaching Hospital, Abubakar Tafawa Balewa University, Bauchi
Source of Support: None, Conflict of Interest: None
Background: Computed tomographic (CT) scan is important in the evaluation of chronic rhinosinusitis (CRS). The usefulness of CT scan in predicting the severity of symptoms is still debatable. The aim of this study is to determine the correlation between a CT scan scoring and the severity of clinical symptoms in patients with CRS. Methods: A cross-sectional study of patients with clinically diagnosed CRS. Their symptoms severity was assessed using the Sinonasal Outcome Test-20 (SNOT-20) scoring system. All eligible patients had CT scans using BrightSpeed (GE) computed tomographic scanner. The CT scan findings of each subject were scored according to the Lund-Mackay scoring system. The correlation between the CT score and the SNOT-20 symptom score was determined. Results: There were 120 participants comprised 70 (58.3%) males and 50 (41.7%) females with male: female ratio of 1.4:1. The mean and standard deviation of SNOT-20 were 38.9 ± 17.5 (range: 6–81) and that of Lund-Mackay score were 9.8 ± 5.5 (range: 0–24). There was statistical significant correlation between Lund-Mackay score and SNOT-20 score (r = 0.653 P = 0.000). The correlation was strongest in relation to nasal symptom domain (r = 0.746, P = 0.000), but it was weak with the facial symptom domain (r = 0.225, P = 0.013). Conclusion: This study found a strong positive correlation between the Lund-Mackay score and SNOT-20 symptoms score among patients with CRS.
Keywords: CT scan, Lund-Mackay score, rhinosinusitis, Sinonasal Outcome Test-20 score, symptom score
|How to cite this article:|
Shirama YB, Adamu A, Iseh KR, Ahmed SS, Baba SM, Ma'aji SM. Correlation between Lund-Mackay CT scan score and Sinonasal Outcome Test-20 symptoms score in the evaluation of chronic rhinosinusitis. J Clin Sci 2022;19:130-5
|How to cite this URL:|
Shirama YB, Adamu A, Iseh KR, Ahmed SS, Baba SM, Ma'aji SM. Correlation between Lund-Mackay CT scan score and Sinonasal Outcome Test-20 symptoms score in the evaluation of chronic rhinosinusitis. J Clin Sci [serial online] 2022 [cited 2023 Mar 21];19:130-5. Available from: https://www.jcsjournal.org/text.asp?2022/19/4/130/360623
| Introduction|| |
Rhinosinusitis is an inflammatory process involving the mucosa of the nose and one or more of the paranasal sinuses.,, Rhinosinusitis may be classified by duration as acute (<4 weeks), subacute (4–12 weeks), or chronic (more than 12 weeks with or without acute exacerbation). Chronic rhinosinusitis (CRS) is defined as the presence of two or more symptoms one of which should be nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip) with or without facial pain and pressure, with or without reduction or loss of smell >12 weeks.
CRS is one of the most common diseases encountered in otolaryngology practice., According to a study, the prevalence of CRS was found to be 7.3%. However, in Europe, the overall prevalence of CRS was 10.9% with marked geographical variations (6.9–27.1). The period prevalence was approximately 2% per decade, and the peak age of occurrence ranged between the ages of 20–59 years., CRS is more common in females and is accompanied by nasal polyps in about 19% to 36% of the patients. CRS has significant socioeconomic implications and the patients have substantial negative health impacts due to their disease, which adversely affects mood, physical, and social functioning. CRS is a common disease affecting over 30 million individuals globally each year, with more than 200,000 people annually requiring surgical intervention.
CRS is diagnosed clinically based on two major symptoms or one major symptom and two minor symptoms., According to the rhinosinusitis taskforce's definition, major symptoms and signs include facial pain/pressure, facial congestion/fullness, nasal obstruction/blockage (continuous or intermittent), nasal discharge/purulence, hyposmia/anosmia, and fever (for acute rhinosinusitis only). The minor symptoms and signs include headache, halitosis, fatigue, dental pain, cough, and ear pain/pressure/fullness., Distant symptoms are pharyngeal, laryngeal, and tracheal irritation causing sore throat, dysphonia, and cough, whereas general symptoms include drowsiness, malaise, and tiredness.
The clinical practice guidelines of the American Academy of Otolaryngology recommended imaging for only recurrent rhinosinusitis and CRS. Four imaging modalities have been used for evaluating patients with rhinosinusitis.These include computed tomography (CT) scan, magnetic resonance imaging, plain radiograph, and ultrasonography.
CT scan is the most preferred and “gold standard” imaging modality in recurrent and CRS.,,, CT scan is perfect for demonstrating the complex bony paranasal sinus anatomy with its variants as well as localization and extent of soft tissue masses.,,, CT scan led to improved visualization of frontal recess, orbital content, and brain anatomy. Coronal CT imaging is the preferred initial procedure, however, multisection CT has replaced coronal CT because it shows air spaces, opacification of sinuses, and detailed bony anatomy better and more clearly., It also allows objective assessment of the patency of intercommunicating passages, and shows how anatomical variants or disease processes affect the patency of the nasal cavity and the parasinuses. CT scan of the paranasal sinuses has become mandatory for patients undergoing FESS. This is because it depicts the anatomical complexities of osteomeatal complex (OMC) in a much simpler way and acts as a road map for endoscopic sinus surgery.,, In a study to test the reliability of CT scan in the assessment of CRS, it was found that CT scan is reliable and findings remain over time. CT scan was also found to decrease the incidence of morbidity and mortality from rhinosinogenic intracranial abscesses if it is done and detected early. The characteristic features of CRS in CT images include mucosal thickening, air-fluid level, and opacification of the normally air-filled sinuses.
There are several CT staging for the evaluation of CRS. However, the American Academy of Otolaryngology has recommended the Lund-Mackay scoring system as the preferred method for staging CRS.,, Previous studies have attempted to evaluate the significance of the Lund-Mackay scoring system. Bhattacharyya and Fried proposed the Lund-Mackay score cutoff point that is clinically useful in separating patients with and without CRS based on radiographic criteria. They also reported that for patients with a Lund-Mackay score of 0 or 1, it is very unlikely to have CRS and thus could be considered “negative” for CRS. Scores equal to or above 4 were considered to be indicative of CRS. A score of 2 or 3 was equivocal, and they suggested that additional weight be placed on clinical or endoscopic criteria for the diagnosis of CRS. Therefore, clinical symptomatology is still relevant in the diagnosis and assessment of the severity of CRS.
There are several symptom scoring methods which include the Sinonasal Outcome Test-20 (SNOT-20), Chronic Sinusitis Survey, Sinonasal Assessment Questionnaire, Visual Analog Scale (VAS), Rhinosinusitis Symptoms Inventory, and Rhinosinusitis Disability Index. However, SNOT-20 is the most commonly used and validated instrument for the assessment of CRS.,
This study was designed to evaluate the correlation between the Lund-Mackay score and SNOT-20 symptoms score among patients with CRS. The study will help the clinician to accurately predict the severity of symptoms based on CT scan scores. It will also help to identify patients with severe symptoms of CRS and plan for urgent treatment.
| Methods|| |
A prospective cross-sectional study of adult patients with clinically diagnosed CRS attending the otorhinolaryngology clinic of our institution. Ethical approval was obtained from the Health Research Ethics Committee of Usmanu Danfodiyo University Teaching Hospital, Sokoto. Informed consent was also obtained from each of the participants before enrolment into the study. Consecutive patients seen at the otorhinolaryngology clinic of the center with a clinical diagnosis of CRS who satisfied the inclusion criteria were recruited. The inclusion criteria was any patient (≥16 years) with a clinical diagnosis of CRS who presented during the study period. The clinical diagnosis was made according to the Multidisciplinary Rhinosinusitis Task Force of the American Academy of Otolaryngology–Head and Neck Surgery. Participants who had nasal or paranasal sinus surgery in the past were excluded from the study.
A profoma was used to collect the relevant clinical information. SNOT-20 was used to assess the severity of the symptom. SNOT-20 comprised 20 symptoms grouped into five categories as follows: (1) nasal symptoms, (2) oropharyngeal symptoms, (3) facial symptoms, (4) sleep-related symptoms, and (5) systemic symptoms. Each symptom was scored based on a six-point Likert scale: 0 (no problem), 1 (very mild problem), 2 (mild problem), 3 (moderate problem), 4 (severe problem), and 5 (very severe problem). The total score ranges from 0 to 100, and it has been categorized into four groups: 0–10 (mild symptom score), 11–40 (moderate symptom score), 41–69 (moderately symptom score), and 70–100 (severe symptom score).
All the recruited patients were sent to the radiology department of the same institution and had CT scan done using four slices Bright Speed (GE) CT scanner. Contiguous axial 2.5 mm slices were obtained from the vertex to the base of the skull in pre- and postintravenous contrast series. Images were reformatted in coronal and sagittal sections. These were stored in the memory of the CT scanner and copied on LG CD recordable discs. Images were retrieved from the memory of the CT scanner/CDs in the CT suite. The CT scan images were reported by the investigators, and the findings were scored according to the Lund-Mackay scoring system.,, When reading the Lund-Mackay scoring system, the paranasal sinuses were grouped as: frontal, maxillary, sphenoid, anterior ethmoidal cells, posterior ethmoidal cells, and OMC. For each of the paranasal sinus groups, right and left sides were scored separately. The score of 0 shows no abnormality; score 1 designates partial opacification and score 2 indicates total opacification. OMCs were scored either 0 (not obstructed) or 2 (obstructed). The total CT score ranged from 0 to 24.,
The data collected was cross-checked for accuracy and filtered using Microsoft Excel and analyzed using Statistical Products and Service Solution (SPSS) version 20 for Windows (IBM Inc. Chicago, Illinois, USA). Analysis began with descriptive statistics using mean and standard deviation (SD) for quantitative data and frequency as well as percentages for qualitative data. This was followed by inferential statistics; the Chi-square test was used to determine associations between categorical variables while Pearson's correlation test was used for continuous variables. The results were presented in the form of tables and charts. The level of statistical significance was set at P < 0.05.
| Results|| |
The participants constituted 70 (58.3%) males and 50 (41.7%) females with male: female ratio of 1.4:1 [Table 1]. The mean age and SD of the patients were 34.4 ± 9.8 (range: 17–60). The total SNOT-20 symptom score ranged from 6 to 81 with a mean and SD of 38.9 ± 17.5. [Table 2] showed the frequency, mean, and range of each symptom domain. There were 6 (5.0%) patients with mild symptoms, 69 (57.5%) with moderate symptoms, 37 (30.8%) with moderately severe symptoms, and 8 (6.7%) had severe symptoms [Figure 1].
|Figure 1: The distribution of SNOT-20 symptom severity. SNOT-20: Sinonasal Outcome Test-20|
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The total CT scores of the participants ranged from 0 to 24 with a mean of 9.8 ± 5.5. [Figure 2] and [Figure 3] showed CT scan findings in some of the patients we studied. The correlation between the Lund-Mackay CT score and the SNOT-20 score was determined, and there was a strong positive correlation (r = 0.653, P = 0.001) between the two scores [Table 3]. It was also found that the Lund-Mackay scores correlated very well with symptom domains [Table 4]. The correlation was strongest in relation to nasal symptom domain (r = 0.746, P = 0.000), whereas the correlation was very weak in relation to facial symptom domain (r = 0.225, P = 0.013).
|Figure 2: Axial CT scan of the paranasal sinuses showing partial opacification of the left maxillary antrum|
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|Figure 3: Coronal CT scan of the paranasal sinuses showing almost complete opacification of the nose and paranasal sinues|
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|Table 3: Correlation between Lund-Mackey score and Sinonasal Outcome Test-20 symptom score|
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Involvement of OMC was seen in 84 (70%) of the patients, in which 49 (40.8%) had unilateral disease and 35 (29%) had bilateral disease [Table 5]. The Chi-square test showed a statistically significant association between OMC involvement and severity of symptoms (P = 0.000). Among the participants we studied, none of the 6 patients with mild disease had OMC involvement, but 29 of the 37 patients with moderately severe disease, and all the 8 patients with severe disease had OMC involvement [Table 5].
|Table 5: Relationship between osteomeatal complex with severity of symptoms|
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| Discussion|| |
CRS is one of the most common diseases that pose a challenge to otorhinolaryngologists with prevalence as high as other chronic conditions such as allergy and asthma., CRS has significant socioeconomic implications and patients have substantial negative health impacts due to their disease, which adversely affects their mood as well as physical and social functioning. Although the diagnosis of CRS is based on clinical features, the use of CT scans helps in making specific diagnoses and planning for surgical treatment. This study evaluated the relationship between the patients' symptoms (according to SNOT-20) and their CT findings (based on the Lund-Mackay score).
There was a slight male preponderance with a male: female ratio of 1.4:1 in this study. This is similar to the findings of Iseh and Makusidi, Amodu et al., and Moghadasi et al., where they reported a male-to-female ratio of 1.4:1, 1.5:1, and 1.8:1, respectively. However, other workers reported female predominance in their studies., In our study, the highest frequency of CRS was found in the age group of 30–39 years. This is in agreement with the findings of previous studies in Nigeria and India.,,
In this study, we found a statistically significant correlation between the SNOT-20 symptom score and the Lund-Mackay CT scoring system (r = 653, P = 0.001). Moreover, in term of symptom domains, the strongest correlation was found in relation to the nasal symptoms (r = 0.746, P = 0.000) and sleep-related symptom domains (r = 0.598, P = 0.000). The correlation was found to be weak with facial symptom domain (r = 0.225, P = 0.013). This is in agreement with the findings of Moghadasi et al. where they found good correlation and statistical significant association between SNOT-20 score and CT score (r = 0.74, P = 0.0001). Similarly, Kenny et al. reported a significant correlation between Lund-Mackay CT scoring and symptoms such as nasal obstruction, nasal discharge, postnasal drip, and hyposmia, but headache and facial pain/pressure had no correlation. Other studies by Wabnitz et al. and Arango and Kountakis also found a statistically significant correlation between symptoms and CT scoring. In contrast, Amodu et al. found no significant correlation between the overall disease severity score and the Lund-MacKay CT score (r = 0.195, P = 0.6). The reason for that could be due to the symptom score used in their study which was a visual analog scale (VAS) with much fewer symptoms than SNOT 20. Other studies by Basu et al., Bhattacharyya et al., and Stewart et al. also found no correlation between symptoms and CT findings.
In this study, the involvement of OMC was seen in 70% of patients and there was a statistically significant association between the involvement of OMC and the severity of symptoms in patients with CRS. This was buttressed by the fact that none of the patients who had mild symptoms had OMC involvement and all those patients who had bilateral OMC involvement had severe disease. This finding agreed with that of Amodu et al. who found involvement of OMC in 70% of their patients, and about 63% of patients with OMC involvement had intermediate-to-high symptom scores. Nair in India also observed pathology in the OMC in 75.8% of their cohorts. They also found that all of their patients who had severe symptoms had OMC involvement. Other studies also emphasized the importance of OMC disease in the pathogenesis of CRS.,, Therefore, we can deduce from this study that CT findings of obstructed OMC may predict the severity of symptoms of CRS. Further studies are needed to validate this finding.
| Conclusion|| |
This study found a strong correlation between the Lund-Mackay score and SNOT-20 symptoms score among patients with CRS. The CT findings (especially the obstruction of OMC) can predict the severity of symptoms of CRS.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]