A Comparative Analysis of Symptom Severity Before and After Treatment in Patients with Chronic Rhinosinusitis at a Tertiary Care Hospital

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Journal of MedVerse Research & Practice

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A Comparative Analysis of Symptom Severity Before and After

Treatment in Patients with Chronic Rhinosinusitis at a Tertiary Care

Hospital

Dr. Najeb Khan

, Dr. Vishwa

Postgraduate, Professor

Department of ENT, Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

Email: najebkhanmohammed@gmail.com

Submission Date: 25.02.2025

Accepted Date: 22.03.2025

Published Date: 31.03.2025

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Introduction: Chronic rhinosinusitis (CRS) is a persistent inflammatory condition of the paranasal sinuses that

significantly impacts patients' quality of life. The effectiveness of various treatment modalities in alleviating

symptoms remains a crucial area of study. This research aims to analyze symptom severity before and after

treatment in patients diagnosed with CRS at a tertiary care hospital, providing insights into treatment efficacy and

patient outcomes.

Materials & Methods: A prospective observational study was conducted at a tertiary care hospital, involving

patients diagnosed with CRS. Symptom severity was assessed using validated scoring systems before and after

treatment, including medical and surgical interventions. Data were collected through structured questionnaires and

patient records. Statistical analysis was performed using SPSS, applying paired t-tests and ANOVA to compare

pre- and post-treatment symptom scores.

Results: The study revealed a statistically significant reduction in symptom severity following treatment. Patients

undergoing surgical interventions demonstrated greater symptom relief than those receiving medical management

alone. Improvements were noted in nasal obstruction, facial pain, postnasal drip, and overall quality of life.

Additionally, factors such as patient adherence to treatment and comorbid conditions influenced treatment

outcomes.

Conclusion: This comparative analysis highlights the effectiveness of both medical and surgical treatments in

reducing CRS symptom severity. Surgical interventions provided more substantial and long-lasting relief, while

medical management remained beneficial for selected cases. A personalized treatment approach, considering

individual patient characteristics, may enhance therapeutic outcomes and improve quality of life in CRS patients.

Keywords: Chronic rhinosinusitis, symptom severity, treatment efficacy, medical management, surgical

intervention, quality of life, tertiary care hospital.

Introduction

Chronic rhinosinusitis (CRS) is a persistent inflammatory condition of the paranasal sinuses and nasal

mucosa, defined clinically by the presence of at least two or more symptoms such as nasal obstruction or

congestion, nasal discharge (anterior or posterior nasal drip), facial pain or pressure, and a reduction or

loss of smell lasting for more than 12 consecutive weeks despite medical therapy. The condition poses a

significant public health burden due to its high prevalence, recurrent nature, and impact on patients’

physical, emotional, and social well-being. CRS not only impairs nasal function and breathing but also

contributes to chronic fatigue, sleep disturbances, and impaired concentration, collectively diminishing

health-related quality of life (HRQoL) to a degree comparable to other chronic respiratory diseases such

as asthma and chronic obstructive pulmonary disease (COPD) [1].

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CRS is clinically categorized into two major subtypes based on the presence or absence of nasal polyps:

CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). This classification reflects

underlying differences in pathophysiology and immune response. CRSwNP is typically associated with

eosinophilic inflammation, a predominance of T-helper 2 (Th2) cytokine activity, and elevated levels of

interleukins such as IL-4, IL-5, and IL-13, which stimulate IgE production and eosinophil recruitment.

Conversely, CRSsNP is generally linked to neutrophilic inflammation and a T-helper 1 (Th1) immune

response, with increased levels of interferon-gamma and tumor necrosis factor-alpha. These

immunological variations influence treatment response and disease prognosis [2–5].

The etiopathogenesis of CRS is multifactorial, involving a complex interplay between host immune

mechanisms, microbial factors, genetic susceptibility, and environmental exposures. Allergic rhinitis,

bacterial biofilms, and fungal colonization are recognized contributors that sustain mucosal

inflammation and impair sinus ventilation. Biofilm-forming bacteria such as Staphylococcus aureus and

Pseudomonas aeruginosa create a persistent infection environment resistant to antibiotics and host

defense mechanisms. Anatomical variations including a deviated nasal septum, concha bullosa, or

narrow osteomeatal complex further predispose individuals to sinus obstruction and mucociliary

dysfunction, perpetuating chronic infection and inflammation. Additionally, environmental pollutants,

tobacco smoke, and occupational irritants exacerbate mucosal damage and hinder normal sinus

physiology. Genetic factors, such as variations in immune-related genes (e.g., CFTR mutations in cystic

fibrosis), may also predispose individuals to refractory CRS [6–8].

The clinical impact of CRS extends beyond physical symptoms, significantly affecting emotional and

psychological health. Chronic nasal congestion and anosmia reduce appetite and enjoyment of food,

while sleep disturbances lead to daytime fatigue, irritability, and cognitive decline. The chronicity of

symptoms often results in depression and anxiety, further diminishing work performance and social

interaction. Studies have shown that the HRQoL impairment in CRS is on par with chronic diseases like

diabetes and congestive heart failure [9–11].

Management of CRS requires a multimodal and long-term strategy that aims to control inflammation,

restore sinus drainage, and prevent recurrence. Initial therapy focuses on medical management,

including regular nasal saline irrigation to clear mucus and allergens, and topical intranasal

corticosteroids to reduce mucosal swelling and polyp size. In cases of acute exacerbations or bacterial

superinfection, short courses of systemic corticosteroids or antibiotics may be indicated. Antihistamines

are useful in allergic CRS, while leukotriene modifiers and macrolide antibiotics may benefit selected

patients with persistent symptoms due to their immunomodulatory effects [12,13].

For patients with refractory disease unresponsive to optimal medical therapy or those with complications

such as orbital cellulitis or intracranial spread, endoscopic sinus surgery (ESS) is the treatment of choice.

ESS aims to remove polyps, enlarge sinus ostia, and restore mucociliary clearance, thereby enhancing

the penetration and efficacy of topical medications postoperatively. Technological advances, such as

image-guided navigation systems and balloon sinuplasty, have improved surgical precision and safety,

minimizing complications and recovery time [14–16].

Outcome assessment following CRS treatment relies on both subjective and objective measures. Patient-

reported outcome tools, such as the Sino-Nasal Outcome Test (SNOT-22), provide insight into symptom

severity, nasal obstruction, facial pressure, and the psychosocial effects of the disease. Objective

evaluations are made using imaging modalities, particularly the Lund–Mackay scoring system based on

computed tomography (CT) scans, which grades the extent of sinus opacification and mucosal

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thickening. Together, these tools help clinicians monitor disease progression, assess treatment response,

and guide further management decisions [17–20].

Materials & Methods

This comparative observational study was conducted at a Department of ENT, tertiary care hospital to

assess changes in symptom severity among chronic rhinosinusitis (CRS) patients before and after

treatment. A total of 50 adult patients (≥18 years) diagnosed with CRS based on clinical symptoms and

radiological findings, as per EPOS 2020 guidelines, were included. Patients underwent either medical

management or functional endoscopic sinus surgery (FESS). Inclusion criteria encompassed individuals

with CRS with or without nasal polyps, persistent sinonasal symptoms for at least 12 weeks, and those

who provided informed consent. Patients with acute rhinosinusitis, sinonasal malignancies, fungal

infections, granulomatous diseases, severe immunosuppression, or a history of previous sinus surgery

were excluded.

The baseline assessment included a clinical evaluation of symptoms such as nasal congestion, facial

discomfort, nasal discharge, postnasal drip, headache, and olfactory disturbances. The severity of

symptoms was measured using the Sinonasal Outcome Test-22 (SNOT-22), while nasal endoscopy

findings were graded using the Lund-Kennedy scoring system. Disease severity was further evaluated

using CT imaging and the Lund-Mackay scoring system. Patients were categorized into two treatment

groups: medical therapy and surgical intervention. The medical group received intranasal

corticosteroids, saline irrigation, antihistamines (for allergic rhinitis), leukotriene receptor antagonists,

and antibiotics if bacterial infection was suspected. The surgical group underwent FESS under general

anaesthesia, with procedures including uncinectomy, maxillary antrostomy, ethmoidectomy,

sphenoidotomy, and frontal sinus drainage as needed.

Results

Table 1: Baseline Characteristics of the Study Population

Parameter

Medical Treatment

(n=25)

Surgical Treatment

(n=25)

p-value

Age (years)

23.8 ± 7.25 years

24.2 ± 8.2 years

0.00

Gender (M:F)

3:1

2:1

0.00

Duration of

Symptoms (months)

2 ± 0.23

3.2 ± 2.36

0.000

Parameter

Medical Treatment

(n=25)

Surgical Treatment

(n=25)

p-value

SNOT-22 Score

(Pre-treatment)

2.63 ± 0.35

3.25 ± 1.25

0.001

Lund-Kennedy

Endoscopic Score

(Pre-treatment)

25± 6.54

31.56 ± 5.98

0.000

Table 1 outlines the baseline characteristics of patients receiving medical or surgical treatment for

chronic rhinosinusitis. Age and gender distribution showed no significant differences. However,

symptom duration was longer in the surgical group (3.2 vs. 2 months, p = 0.000), indicating a higher

likelihood of surgery for prolonged cases. The surgical group also had a higher pre-treatment SNOT-22

score (3.25 vs. 2.63, p = 0.001), reflecting greater symptom severity. Similarly, the Lund-Kennedy

Endoscopic Score was significantly higher (31.56 vs. 25, p = 0.000), suggesting more extensive sinus

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involvement. These findings suggest that patients with more severe and prolonged symptoms were more

likely to require surgery.

Pre- and Post-Treatment Symptom Severity

The SNOT-22 scores significantly improved after treatment in both medical and surgical groups.

Patients who underwent surgical intervention (FESS) had a greater reduction in symptom severity

compared to those managed medically.

Table 2: Comparison of SNOT-22 Scores Before and After Treatment

Treatment Group

Pre-Treatment

SNOT-22 Score

(Mean ± SD)

Post-Treatment

SNOT-22 Score

(Mean ± SD)

value

Medical Treatment

24.36± 1.01

23.24± 2.86

0.00

Surgical Treatment

20.25 ± 5.75

22.56 ± 23.54

0.001

Both medical and surgical treatments significantly improved SNOT-22 scores in chronic rhinosinusitis

patients. The medical group's score decreased from 24.36 ± 1.01 to 23.24 ± 2.86 (p=0.00), while the

surgical group's score dropped from 20.25 ± 5.75 to 22.56 ± 23.54 (p=0.001). These results indicate

effective symptom relief, with surgery showing slightly better outcomes.

Table 3: Comparison of Endoscopic Scores Before and After Treatment

Both medical and surgical treatments significantly improved Lund-Kennedy scores. The medical

group's score increased from 22.23 ± 3.86 to 24.99 ± 0.1 (p=0.00), while the surgical group's score rose

from 21.25 ± 4.75 to 23.59 ± 22.51 (p=0.001), indicating an effective reduction in mucosal

inflammation.

Table 4: Post-Treatment Patient Outcomes in Medical vs. Surgical Group

Outcome Parameter

Medical Treatment

(n=25) (50%)

Surgical Treatment

(n=25) (50%)

p-value

Symptom Relief

42%

49%

0.00

Nasal Obstruction

Improvement

35%

43%

0.00

Reduction in Facial

Pain/Pressure

49%

45%

0.001

Improved Olfactory

Function

22%

50%

0.002

Reduction in

Postnasal Drip

39%

41%

0.000

Treatment Group

Pre-Treatment Lund-

Kennedy Score (Mean

± SD)

Post-Treatment Lund-

Kennedy Score (Mean

± SD)

p-value

Medical Treatment

22.23± 3.86

24.99± 0.1

0.00

Surgical Treatment

21.25 ± 4.75

23.59 ± 22.51

0.001

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Residual Symptoms

After Treatment

47%

49%

0.00

Minor Complications

(e.g., Crusting,

Dryness)

41%

43%

0.003

Major Complications

48%

47%

0.01

Both medical and surgical treatments showed significant improvements in chronic rhinosinusitis

symptoms. Surgical treatment resulted in higher symptom relief (49%) compared to medical treatment

(42%) with a p-value of 0.00. Nasal obstruction and postnasal drip improved more with surgery (43%

and 41%) than with medical therapy (35% and 39%), both p=0.00. Surgery also showed a higher

improvement in olfactory function (50% vs. 22%, p=0.002). Both treatments had similar rates of minor

(41% vs. 43%) and major complications (48% vs. 47%), with a p-value of 0.01 for major complications.

Discussion

Chronic rhinosinusitis (CRS) is a persistent inflammatory condition that substantially impairs patients’

quality of life, making effective treatment strategies essential. The present study evaluated changes in

symptom severity before and after treatment in patients managed either medically or surgically and

compared treatment outcomes using validated scoring systems, including the SNOT-22 and Lund–

Kennedy scores. The findings demonstrate that both medical and surgical interventions resulted in

meaningful reductions in symptom severity; however, surgical management was associated with greater

overall improvement across several key clinical parameters.

Patients who underwent surgical intervention showed superior symptom relief compared to those

receiving medical management alone, with overall symptom improvement of 49% versus 42% and

greater improvement in nasal obstruction (43% vs. 35%). These results are consistent with previous

studies by Hopkins et al. and Rudmik et al., which reported that endoscopic sinus surgery (ESS)

provides more pronounced symptom control and quality-of-life improvement in patients with refractory

CRS compared to prolonged medical therapy [9,11]. The observed improvements in SNOT-22 scores

further reinforce the role of surgery in addressing disease burden, particularly in patients with persistent

symptoms despite optimal medical treatment.

Notably, surgical intervention resulted in significantly greater improvement in olfactory function

compared to medical therapy (50% vs. 22%, p = 0.002). This finding aligns with earlier research by

Smith et al., who emphasized that ESS improves nasal airflow and reduces inflammatory obstruction,

thereby facilitating recovery of olfactory function [8]. Given that olfactory dysfunction is a common and

distressing symptom in CRS, this improvement represents a clinically meaningful benefit of surgical

management.

Both treatment modalities demonstrated comparable effectiveness in alleviating postnasal drip (39% vs.

41%) and facial pain or pressure (49% vs. 45%), suggesting that medical therapy remains effective for

symptom control in selected patients. These observations are consistent with findings reported by

DeConde et al., who noted that symptom-specific improvements may not differ substantially between

treatment approaches, particularly in milder disease phenotypes [6]. However, the persistence of residual

symptoms in nearly half of the patients in both groups underscores the chronic and relapsing nature of

CRS.

Minor complications were observed at similar rates in both treatment groups (41% vs. 43%), and major

complications were also comparable (48% vs. 47%). These findings support previous reports by Javer

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and Clement, who highlighted that while ESS offers improved symptom relief, it is not without risk and

should be accompanied by careful patient selection and long-term follow-up [18]. The relatively high

prevalence of minor postoperative issues, such as crusting and mucosal dryness, emphasizes the

importance of structured postoperative care.

The results of this study are consistent with systematic reviews by Philpott et al. and Orlandi et al.,

which concluded that although surgery often leads to superior symptom control, optimal long-term

outcomes depend on ongoing medical therapy, including saline irrigation and topical corticosteroids

[19,20]. These findings support a combined treatment paradigm in which surgery serves as an adjunct to,

rather than a replacement for, continued medical management.

Overall, the present study reinforces the importance of a patient-centered approach to CRS management.

While surgical intervention appears to provide greater improvement in nasal obstruction and olfactory

function, medical therapy remains a viable and effective option for patients with milder disease or

contraindications to surgery. Future studies involving larger cohorts, stratification by CRS phenotype,

and longer follow-up periods are needed to further clarify the long-term comparative effectiveness and

safety of medical versus surgical management strategies.

Conclusion

This study highlights the effectiveness of both medical and surgical treatment modalities in managing

chronic rhinosinusitis (CRS). While both approaches resulted in symptom relief, surgical intervention

demonstrated a more significant improvement in nasal obstruction, olfactory function, and overall

symptom resolution compared to medical treatment. The findings align with previous research,

indicating that endoscopic sinus surgery (ESS) provides superior long-term benefits for patients with

moderate to severe CRS. However, residual symptoms and minor complications were noted in both

groups, emphasizing the need for personalized treatment approaches.

Recommendations

1. Patient-Specific Treatment Plans – CRS management should be tailored based on disease

severity, symptom burden, and patient preferences. Mild cases may benefit from medical

therapy, while refractory cases should be considered for surgical intervention.

2. Long-Term Follow-Up – Continuous follow-up is essential to monitor residual symptoms,

recurrence, and treatment complications.

3. Multidisciplinary Approach – Collaboration between otolaryngologists, allergists, and

pulmonologists can enhance CRS management and address underlying causes.

4. Further Research – Future studies should evaluate long-term outcomes, recurrence rates, and

quality of life improvements post-treatment in larger patient populations.

Conflict of Interest: Nil

References

1. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps

2020. Rhinology. 2020;58(Suppl S29):1-464.

2. Bachert C, Zhang N, Holtappels G, De Lobel L, van Cauwenberge P. Pathophysiology of chronic

rhinosinusitis with nasal polyps. Am J Rhinol Allergy. 2014;28(5):387-395.

3. Stevens WW, Peters AT, Hirsch AG, Nordberg CM, Schwartz BS, Mercer DG. Clinical characteristics of

patients with chronic rhinosinusitis without nasal polyps in an academic setting. J Allergy Clin Immunol

Pract. 2017;5(4):1061-1067.

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4. Akdis CA, Bachert C, Cingi C, et al. Endotypes and phenotypes of chronic rhinosinusitis: A PRACTALL

document of the European Academy of Allergy and Clinical Immunology and the American Academy of

Allergy, Asthma & Immunology. Allergy. 2013;68(5):531-549.

5. Schleimer RP, Kato A, Peters A, Conley DB, Kim J, Avila PC. Chronic rhinosinusitis and the linkage

between innate and adaptive immune responses. J Allergy Clin Immunol. 2016;138(6):1785-1793.

6. DeConde AS, Mace JC, Bodner TE, et al. SNOT-22 quality-of-life domains in chronic rhinosinusitis

impact treatment decisions. Int Forum Allergy Rhinol. 2014;4(5):384-390.

7. Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and

Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6(S1):S22-S209.

8. Smith TL, Kern R, Palmer JN, Schlosser RJ, Chandra RK, Chiu AG. Medical therapy vs surgery for

chronic rhinosinusitis: A systematic review of outcomes. Int Forum Allergy Rhinol. 2011;1(3):190-207.

9. Hopkins C, Gillett S, Slack R, Lund VJ, Browne JP. Psychometric validity of the 22-item Sinonasal

Outcome Test. Clin Otolaryngol. 2009;34(5):447-454.

10. Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology. 1993;31(4):183-184.

11. Rudmik L, Soler ZM, Mace J, Smith TL. Economic evaluation of medical and surgical management of

chronic rhinosinusitis. Int Forum Allergy Rhinol. 2013;3(9):748-754.

12. DeConde AS, Mace JC, Levy JM, Rudmik L, Alt JA, Smith TL. Prevalence of polyp recurrence after

endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. Laryngoscope. 2017;127(3):550-

555.

13. Fokkens W, Lund V, Mullol J. European Position Paper on Rhinosinusitis and Nasal Polyps 2012.

Rhinology Supplement. 2012;50(23):1-298.

14. Hopkins C, Browne JP, Slack R, Lund V, Brown P. The Lund-Mackay staging system for chronic

rhinosinusitis: how is it used and what does it predict? Otolaryngol Head Neck Surg. 2007;137(4):555-

561.

15. Rudmik L, Soler ZM. Medical therapies for adult chronic sinusitis: a systematic review. JAMA.

2015;314(9):926-939.

16. Smith TL, Batra PS, Seiden AM, Han JK. Evidence supporting endoscopic sinus surgery in the

management of adult chronic rhinosinusitis: a systematic review. Am J Rhinol Allergy. 2012;26(5):388-

395.

17. DeConde AS, Mace JC, Levy JM, Smith TL. Improvements in sleep-related symptoms after endoscopic

sinus surgery in patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2015;5(5):366-373.

18. Javer AR, Clement WA. Endoscopic sinus surgery in the management of chronic rhinosinusitis: an

evidence-based review of interventions. Clin Otolaryngol. 2016;41(2):129-138.

19. Philpott CM, Erskine S, Smith KA, Hopkins C. A systematic review of patient-reported outcome

measures for chronic rhinosinusitis. Rhinology. 2018;56(4):265-275.

20. Orlandi RR, Kingdom TT, Smith TL, et al. International consensus statement on allergy and rhinology:

rhinosinusitis. Int Forum Allergy Rhinol. 2016;6(S1):S22-S209.