Evaluation of the Quality of Life of Patients Suffering from Chronic Rhinosinusitis in a Hospital Setting in Kinshasa ()
1. Introduction
Chronic Rhinosinusitis (CRS) is an inflammatory disease of the naso-sinusal mucosa characterised by the persistence of at least two major symptoms such as nasal obstruction, anterior and/or posterior nasal discharge, facial pain and loss of smell for at least 12 weeks [1] [2] [3] . This common condition affects around 5% - 12% of the world’s population [2] [4] . The prevalence of CRS varies from region to region, affecting 5.2% of the population in Canada [3] [5] , 11.9% in the United States of America (USA) [6] , 10.9% in Europe [7] , 7% in South Korea [8] , 8% in China [9] and 5.5% in Sao Paulo (Brazil) [10] . In Africa, there are very few studies on the prevalence of CRS, with an estimated rate of 25.3% in Egypt [11] , 1.6% in north-west Nigeria [12] and 1.1% in Tanzania [13] . In the Democratic Republic of Congo (DRC), data on the prevalence of CRS in the general population are not available. However, a study carried out at the Kinshasa University Hospital revealed an estimated in-hospital incidence of Rhinosinusitis of 13.2% [14] .
Moreover, CRS remains a disabling condition with a negative impact on patients’ quality of life (QoL) and a heavy economic burden [3] [4] [15] . To date, a number of studies on QoL have assessed the patient’s state of health, the severity of the disease, therapeutic methods and the socio-economic consequences of CRS [2] [16] [17] . The World Health Organisation (WHO) defines quality of life as “the individual’s perception of his or her place in life, in the context of the culture and value system in which he or she lives, and in relation to his or her goals, expectations, norms and concerns” [18] [19] . The direct impact of CRS on QoL is currently measured by several instruments, including the Sino-Nasal Outcome Test 22 (SNOT-22), the Rhinosinusitis Disability Index (RSDI) and the Rhinosinusitis Quality of Life survey (RhinoQoL) [1] [2] [16] [20] .
Numerous studies have shown that the deterioration in QoL is more significant in patients suffering from CRS, with a higher mean SNOT-22 score than in subjects without CRS [21] [22] [23] [24] . Indeed, Kosugi et al. in Brazil [25] , Hopkins et al. in the United Kingdom [26] and Idugboe et al. in Nigeria [27] respectively revealed a mean SNOT-22 score of 62.4, 41.7 and 38.7. However, in the DRC, to our knowledge, there is no work on the QoL associated with CRS; hence the interest of our study aimed at evaluating the QoL of patients suffering from CRS in a hospital setting in Kinshasa.
2. Methodology
2.1. Patients
A cross-sectional analytical study was conducted in Kinshasa in the ENT services of two medical institutions, namely the Kinshasa University Hospital and the Monkole Hospital Center, over a period from June 2020 to May 2021. These two hospitals were chosen for the study because their ENT services are well used in Kinshasa.
Based on a sample of convenience, our sample consisted of all patients suffering from CRS with or without nasal polyposis who attended the above-mentioned services during the study period. Patients at least 18 years of age with CRS diagnosed according to the clinical criteria of the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) [1] [2] [4] were included in this study. Patients had to present two or more major symptoms for at least 12 weeks, including nasal obstruction, anterior and/or posterior rhinorrhoea (seromucous or purulent), facial pain and loss of smell. In addition, signs of inflammation of the nasal mucosa had to be demonstrated by anterior rhinoscopy or nasal endoscopy and/or CT scan. All patients gave written or verbal consent.
Patients suffering from CRS associated with a tumour, granulomatous disease, uncontrolled cardiovascular or endocrine pathology and pregnancy were excluded from our study.
The control group consisted of subjects who accompanied patients to consultations, were at least 18 years old, had no ENT pathology and had given their informed consent.
Our study was registered by the Ethics Committee of the School of Public Health of the University of Kinshasa under number ESP/CE/192/2020.
2.2. Measuring Quality of Life
The QoL of patients and healthy subjects was assessed using the SNOT-22 questionnaire. It comprises a total of 22 items rated from 0 (no problem) to 5 (very severe problem). They represent health problems that have occurred in the last two weeks and are grouped into four domains [16] [28] [29] . These are the rhinological domain, comprising 8 items corresponding to the main rhinosinus symptoms (need to blow the nose, sneezing, anterior rhinorrhoea, coughing, posterior rhinorrhoea, thick nasal discharge, disturbance of smell and/or taste and nasal obstruction), the otological and facial domain, comprising 4 items corresponding to the complementary rhinosinus symptoms (sensation of blocked ears, dizziness, pressure in the ear and facial pain), the sleep domain, comprising 4 items corresponding to signs of repercussions on sleep (difficulty falling asleep, waking up in the middle of the night, poor quality of sleep and tiredness on waking) and the psychological domain, comprising 6 items corresponding to repercussions on the psychological aspect (tiredness during the day, reduced productivity, reduced concentration, frustration or agitation, reduced morale or sadness and discomfort).
The summation of item scores gives a score for each domain as well as a total or maximum score for the questionnaire ranging from 0 to 110.
The SNOT-22 questionnaire also enabled us to classify participants according to the degree of impairment of their QoL. Thus, QoL was slightly impaired if SNOT-22 score < 20 and severely impaired if SNOT-22 score ≥ 20 [30] .
2.3. Data Analysis
The data were analysed in SPSS version 26.0. Qualitative variables were summarised as frequency and percentage, while quantitative variables were summarised as median, mean and standard deviation. The information was presented in the form of tables and graphs. Student’s t-test and Mann-Whitney U-test were used to compare means and medians respectively. The relationship between two categorical variables was assessed using the Chi-square test. The significance level was p < 0.05.
3. Results
3.1. Socio-Demographic and Clinical Characteristics of Participants
We included 113 patients with CRS and 100 healthy subjects or controls in the control group. The socio-demographic characteristics and comorbidities of the participants are shown in Table 1. The mean age was 41.0 ± 14.7 years in the patients and 39.1 ± 12.6 years in the controls. More than half of the participants were university graduates. Among comorbidities, arterial hypertension and controlled diabetes mellitus were more common in patients than in controls.
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Table 1. Socio-demographic characteristics and co-morbidities of participants.
3.2. Assessment of Quality of Life
Compare the total SNOT-22 scores between the patient and control groups, Figure 1 shows that the distribution of scores in the patient group was symmetrical with a median SNOT-22 score of 44 and extremes of 14 and 78. In the control group, the distribution was asymmetrical, with a median SNOT-22 score of 7 and extremes of 1 and 40. The difference in scores between the two groups was statistically more significant (p < 0.001).
In addition, patients with CRS had significantly higher scores in all four SNOT-22 symptom domains compared with controls; especially in the rhinological domain (Figure 2).
Considering the degree of impairment, Table 2 shows that QoL was severely impaired in almost all patients with CRS compared with subjects without CRS (20.0%). This difference was statistically more significant.
Table 3 shows that patients with CRS had a statistically significant higher score than controls in the rhinological and psychological domains, regardless of the degree of QoL impairment. However, the otological and facial domains showed a non-significant difference between the two groups with slightly impaired (p = 0.129) or severely impaired (p = 0.090) QOL. Furthermore, the difference in sleep scores between the two groups was not significant in the case of mildly impaired QoL (p = 0.093).
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Table 2. Degree of impairment of participants’ quality of life.
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Table 3. SNOT-22 symptom domains according to degree of QoL impairment.
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Figure 1. Changes in quality of life as a function of SNOT-22 total scores.
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Figure 2. Average scores for SNOT-22 symptom domains.
4. Discussion
In our study, the mean age of our patients was 41.0 ± 14.7 years. This result is similar to those found by Marambaia et al. in 2013 in Brazil (40.7 ± 13.5 years) [22] and Njifou et al. in 2018 in Cameroon (37.1 ± 17.2 years) [31] . Younger adults were more affected than older subjects. More than half of the CRS patients and controls were university graduates, which shows that our patients had an acceptable intellectual level to understand the QoL questionnaire and answer it correctly.
We found that the median SNOT-22 score of patients with CRS (score = 44) was significantly higher than that of subjects without CRS (score = 7). This difference between the two groups was statistically more significant, confirming the negative impact of CRS on the QoL of these patients. Indeed, the median score of our patients was superposable to the mean scores observed by Bewick et al. [32] in 2018 (43.8 ± 22.4), and Philpott et al. [33] in 2016 (45.0 ± 21.4) in the UK. However, it was well above the mean scores found by Lange et al. [21] in Denmark in 2013 (28.1), Hoehle et al. [34] in the USA in 2016 (36.2 ± 23.1), and Nyaiteera et al. [24] in Uganda in 2018 (31.4). This disparity in results is thought to be linked to the culture and lifestyle of each population, as well as to differences in methodology.
The median score of the control group was in line with those found in several studies assessing QoL in adult subjects with or without CRS [22] [35] [36] [37] . Among others, we cite the work published by Lange et al. in Denmark in 2016 [35] , Yeolekar et al. in India in 2013 [36] , Gillett et al. in the United Kingdom in 2009 [37] , who each found a median score of 7, and Marambaia et al. in Brazil in 2013 [22] , who reported a score of 8. This observation proves that the SNOT-22 questionnaire is also suitable for use in our setting as an instrument for assessing quality of life in our patients, despite the differences linked to socio-cultural characteristics. The score of 7 can therefore be considered as an indicator of good QoL in our population, and can thus be used to evaluate the management of the disease.
In assessing the SNOT-22 symptom domains, we found that patients with CRS were significantly affected in all four symptom domains (rhinological, otological, sleep and psychological) compared with controls. Moreover, the rhinological domain had a higher score than the other three domains because of nasal obstruction, rhinorrhoea and the need to blow the nose, which had an impact on the psychological and sleep domains. These results are in line with those of Lange et al. in Denmark in 2013 [21] , Nyaiteera et al. in Uganda in 2018 [24] , and Idugboe et al. in Nigeria in 2019 [27] . The literature also informs us that rhinological symptoms constitute the major problem for patients with CRS, as they are the direct expression of inflammation of the naso-sinusal mucosa and are responsible for alterations in other aspects of QoL [1] [2] [3] [4] .
Our study reveals that almost all our patients had a severely impaired QoL, unlike the controls, in whom QoL was severely impaired in only 20% of cases. However, it should be noted that the deterioration in QoL observed in the controls in our study could be due to factors such as a naso-sinus inflammatory state that is clinically neglected, certain comorbidities that are ignored, the subject’s psychological state giving less interest to the questioning, as well as poor comprehension of the questionnaire for some.
By comparing the scores of the domains of the SNOT-22 as a function of impairment of QoL, we found that CRS patients had a significantly higher score than controls in the rhinological domain and the psychological domain, whether the QoL was slightly impaired or severely impaired. On the other hand, the scores observed in the otological and facial domains, although high in the patients, did not show a statistically significant difference in the two categories of QoL impairment. This observation would thus indicate a weak influence of the otological domain in the variation of the SNOT-22 score in patients suffering from CRS in our setting. However, Levy et al. unexpectedly found significantly better scores in the psychological and sleep domains in patients with CRS with low SNOT-22 scores compared with subjects without CRS [30] .
5. Strengths and Limitations of the Study
The results thus obtained could make our study a reference for future research on the evaluation of QoL, the treatment of CRS, and the economic burden in our environment. However, a number of limitations should be noted, in particular the small sample size, which only included patients seen in hospital setting, with the risk of selection bias. In addition, the measurement of quality of life depends on the subjective responses of the participant, which could expose the study to certain biases such as social desirability or simulation bias.
6. Conclusion
CRS significantly affected the QoL of our patients in all four domains of the SNOT-22, the instrument used in our study. Patients with CRS generally had poorer SNOT-22 scores than subjects without CRS. Almost all patients had a severely impaired QoL, with significant impairment in the rhinological and psychological domains. This indicates the need for better management of the disease in our setting.
Authors’ Contributions
All the authors contributed to this article from conception to submission. Hilaire Kalala Kabala: designed the study, conducted it and wrote it up. Patricia Kakobo Kitombole: contributed to the design of the study protocol and revised the manuscript. Honoré N. Yalombe: collected the study data. Lievin Mvita Kayipu: collected and interpreted the CT data. Léon Mwamba Nkashama: analysed the statistical data and revised the manuscript. Dieudonné Nyembue Tshipukane: designed the study, analysed the statistical data and revised the manuscript.
Statement on Data Availability
The raw data for this study are available and made available to the authors without reservation.
Annex
Sino-Nasal Outcome Test (SNOT-22) Questionnaire
Below you will find a list of symptoms and social/emotional consequences of your nasal disorder. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. Please assess your health problems over the last two weeks, considering the severity and frequency of the problem when it occurs. Thank you for your participation. Do not hesitate to ask for assistance if necessary.