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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 4  |  Page : 346-351

Quality of life in patients with fungal infection of nose and paranasal sinuses: A study from North India


1 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Department of ENT, Government Medical College and Hospital, Chandigarh, India
3 Department of Microbiology, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication17-Nov-2017

Correspondence Address:
Tanuja Kaushal
Indian Express Complex, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.218607

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  Abstract 

Background: Fungal infections of nose and paranasal sinuses have a protracted course with frequent relapses and recurrences. Quality of life (QOL) of such patients is severely affected. Materials and Methods: The aim of this study was to assess QOL of patients with fungal infection of nose and paranasal sinuses. The objective was to assess disease specific QOL, health-related QOL, and global QOL. Cross sectional assessment was carried out on thirty patients with the diagnosis of fungal infection of nose and paranasal sinuses. Results: The total Sino Nasal Outcome Test score was indicative of “moderate degree of problem.” Regarding generic QOL, as assessed using WHOQOL-Bref, the sample had overall moderate QOL in all domains. On the contrary, on the Short Form-36, highest scores were obtained on the individual domains of “physical functioning” and “pain” with lowest scores on the domains of “general health” and “role limitation due to physical health.” Conclusion: It can be concluded that Indian patients with fungal infection of paranasal sinuses report moderate degree of QOL on both disease specific (SNOT-20) and global (WHOQOL-Bref) scales with mild to moderate limitation on health-related QOL scale (SF-36).

Keywords: Quality of life, paranasal sinuses, generic, disease-specific, psychological


How to cite this article:
Kaushal T, Gupta N, Rushi, Singhal S, Chander J, Chavan B S. Quality of life in patients with fungal infection of nose and paranasal sinuses: A study from North India. Indian J Soc Psychiatry 2017;33:346-51

How to cite this URL:
Kaushal T, Gupta N, Rushi, Singhal S, Chander J, Chavan B S. Quality of life in patients with fungal infection of nose and paranasal sinuses: A study from North India. Indian J Soc Psychiatry [serial online] 2017 [cited 2022 Jan 26];33:346-51. Available from: https://www.indjsp.org/text.asp?2017/33/4/346/218607


  Introduction Top


Fungal sinusitis is a common specific infectious disease with an increasing incidence and is being increasingly recognized to occur in all age groups.[1] It has been reported that fungal infection of nose and paranasal sinuses (i.e., fungal rhinosinusitis) can affect about 20% of the population at any given time during their lives.[2] Additionally, fungal infections of nose and paranasal sinuses generally have a protracted course with frequent relapses and recurrences.

Quality of life (QOL) evaluation has emerged as an important outcome measure for chronic disease management. There is a considerable amount of literature showing reduced QOL in chronic rhinosinusitis.[3],[4] Hence, logically QOL is likely to be affected in fungal infections of the nose and paranasal sinuses. However to the best of our knowledge, there is no published literature on QOL in fungal infection of nose and paranasal sinuses from India.

Hence, the present study aimed to prospectively assess generic and disease-specific QOL in patients suffering with fungal infection of nose and paranasal sinuses.


  Materials and Methods Top


A total of 30 patients, aged >18 years, with the diagnosis of fungal infection of nose and paranasal sinus, and giving written informed consent were recruited for the study from the Rhinology Clinic of the outpatient department of ear, nose, and throat (ENT).

The time gap between intervention and assessment was kept at least 6 weeks for patients who had undergone surgical intervention and at least 2 weeks if the patient had undergone medical intervention. It was a cross sectional, prospective study which attempted to systematically evaluate the QOL of patients with fungal infection of nose and paranasal sinuses.

These patients were administered the following instruments:

  1. Sociodemographic Profile Sheet: This was adapted from the sociodemographic sheet routinely used in the Department of Psychiatry. It was used to elicit the background information and record the relevant sociodemographic data.
  2. Clinical Profile Sheet: It was specifically developed for this study and was used to record the clinical details about nasal fungal infection like duration of illness, severity of illness, comorbid illnesses, past history of interventions etc.
  3. Sino-Nasal Outcome Test-20 (SNOT-20): SNOT is one of the most widely used quality-of-life instruments for sinonasal conditions.[5] The SNOT-20 is a self-administered multiple-choice 20-item test. The test retest scores are highly correlated (r = 0.9). The scale has adequate reliability (P<0.002). In this study, SNOT-20 was used as a disease-specific QOL scale.
  4. Short Form -36 (SF-36):[6],[7] The SF-36 is one of the most widely used health-related generic QOL measures with superior psychometric properties. It has adequate Test-Retest reliability (Cronbach's alpha: PCS = 0.92; MCS = 0.91) with adequate criterion validity. The SF-36 questionnaire consists of 36 questions (items) measuring physical and mental health.
  5. WHO Quality of Life Scale-Bref (WHOQOL-Bref):[8] WHOQOL-Bref is a 26 items self-administered psychometrically sound cross-cultural instrument.[8] The scale has satisfactory to good reliability (Cronbach alpha ranging from 0.66 to 0.80 for all domains).[9] Discriminant validity and content validity are also good (Coefficients have been found to range from 0.58 to 0.90).[10]


Procedure: The Consultant from ENT department made the clinical diagnosis of nasal fungal infection, which was confirmed using microbiological tests by the Consultant Microbiologist. Thereafter, the Consultant ENT directed the patient to the principal investigator for administration of tests within the ENT department. The principal investigator explained the nature of study and obtained written informed consent from the patient. Thereafter, sociodemographic profile sheet and clinical profile sheet were administered on the patient. this was followed by administration of other instruments: SNOT-20 (disease specific QOL scale); WHOQOL Bref and SF-36 (generic QOL scales) which were administered in a language which could be easily understood by the patient. The examiner would ask the question and mark answers as per patient's reporting.

Statistical analysis was carried out using the SPSS Statistics version 16.[11] Whole sample was subjected to descriptive statistics [mean, standard deviation (SD), frequency, percentages, range].


  Results Top


As per the study design, 30 patients with chronic fungal infection of nose and paranasal sinuses were enrolled. Majority were males (67%); married (63%), unemployed (60%), educated below matriculation (57%). The mean age of the sample was 37.00 (15.88) years.

The mean duration of illness was 65.30 (SD = 66.79) months. Recurrence was seen in 46.70% patients, with mean duration of current episode being 15.90 (SD = 29.27) months. Comorbid illness (most commonly associated with diabetes mellitus, hypertension, asthma, and nasal polyps) was seen in 40% patients. Majority of the patients (23/30; 77%) had undergone surgical intervention prior to induction into the study. The average time gap between intervention and assessment was 4.35 (4.90) months. Severity of illness as measured using the Lund and Mackay CT Staging System was 7.33 (3.95) and 7.87 (3.74) for left and right side respectively; subjective severity [using visual analog scale (VAS) on scale score of 0-10] at time of assessment was 3.83 (2.65).


  Discussion Top


[Table 1] shows the sub-scale wise and total scores obtained for SNOT for the whole sample. The scores obtained in each sub-scale were on the lower side of the possible range i.e. less than 25% of the maximum possible score for each sub-scale. The total score obtained was also very low out of the maximum possible score of 100.
Table 1: Subscale wise and total scores obtained for SNOT for the whole sample.

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[Table 2] shows the five most important items on SNOT reported by the whole sample. The frequency ranged from 13%-40% for whole sample.
Table 2: Five most important items as rated by respondents on SNOT-20 (n = 30).

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[Table 3] shows the domain wise and total scores obtained for the whole sample on WHOQOL-Bref.
Table 3: Domain-wise and total scores obtained for the whole sample on WHOQOL-BREF

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[Table 4] shows the domain wise score obtained on SF-36 for the whole sample. The lowest scores were for the domain of 'General Health' and highest for domains of 'Pain' and 'Physical Functioning'.
Table 4: Domain scores on SF-36 for whole sample (n = 30).

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At the outset, it will be pertinent to clarify that this report is part of a larger study wherein other psychological variables (dysfunction, coping, psychological morbidity) were also studied. This study, however, discusses only QOL in patients of rhinitis and sinusitis which are common medical conditions causing significant morbidity and huge treatment costs resulting in decreased quality of life, reduced workplace productivity and missed school days.[2],[12] The average duration of illness for the sample was nearly 5 and half years, which is indicative of its chronicity; in principle, such a chronic illness can force upon an individual many potentially stressful lifestyle changes, such as giving up cherished activities, adapting to new physical limitations and special needs, and paying for what can be expensive medications and treatment services.[13] In the present study, majority of the patients had moderate severity of illness using objective scale of assessment (Lund and Mackay CT system of scoring);[14] however, the subjective severity of illness was in milder range as assessed on VAS. This difference could possibly be explained on the basis of “adaptation” of the patients to the long duration of their illness.

Physical comorbidity was present in 40% of the sample and the most common medical disorders were diabetes mellitus, hypertension, asthma, and nasal polyps. Comorbidity as a concept is relevant as it is associated with worse health outcomes, more complex clinical management, and increased health care costs.[15] Three-fourth of the sample underwent surgical intervention which could be indicative of the resistant nature of the illness as surgery is reserved for patients who fail medical management.[16] The average time gap between intervention and assessment was 4.35 months; hence, it is expected that a person would have reasonably stabilized from the after-effects of the intervention (especially surgical) that they have undergone. Hence, the results obtained for the QOL variables would be minimally affected by the acute and/or direct effects of the intervention that was carried out.

Sino Nasal Outcome Test-20 (SNOT-20): SNOT-20 was utilized for the evaluation of symptom scores and is used to describe patient burden and clinical effectiveness in sinonasal disease.[19] We are not going into the details of the advantages of using SNOT, as they have been covered in detail elsewhere.[17] Additionally, we followed the subscales as developed by Browne et al[18] and confirmed later by Pynnonen et al.[19] The mean scores obtained on the various subscales [Table 1] viz., “Rhinological” = 5.87 (5.82); “Ear and Facial” = 1.87 (3.00); “Sleep” = 2.60 (3.70); and “Psychological” = 6.70 (6.11) were on the lower side in view of the range for each subscale (i.e., between 9.35% and 23.48%); lowest being for “Ear and Facial” and highest for “Rhinological.” The total SNOT score was 17.57 (14.08) which was indicative of “moderate degree of problem.”[20] We are unable to compare these with data from previous research as none is available specifically looking at this subscale construct in fungal rhinosinusitis. However, Browne et al[18] in their study of 489 subjects undergoing surgery for chronic rhinosinusitis reported higher preoperative and postoperative subscale scores ranging from 34.5% to 42% (lowest for “Sleep” and highest for “Rhinological”) and 23.5%–31% (lowest for “Sleep” and highest for “Rhinological”) respectively. The total preoperative and postoperative SNOT score was 38.4 (19.2) and 28.6 (20.5) respectively indicative of “moderate degree of problem” on both occasions. Hence it can be seen that subjects in our study had lower total SNOT score and scores on all domains compared with the study by Browne et al.[18] Interestingly, the highest domain scores were obtained in the “Rhinological” domain across both studies, which is a logical reflection of the basic nature of the disease (in being associated with inflammation of the nasal mucosa), and thereby, of the distinct construct of this particular domain.[18] However, this comparison of results needs to be interpreted with the caveat that our study was on a small number of patients suffering with fungal rhinosinusitis and in a different sociocultural set-up.

As can be seen in [Table 2], the subjects were also asked to indicate any five items on SNOT which were most important to them. The five symptoms which were reported most commonly by the subjects were “Need to blow nose” (41.37%); “Sneezing” (21.42%); “Running nose” (19.23%); “Cough” (16%); “Frustrated/restless/irritable” (20.83%); the commonest being “Need to blow nose,” and least common being “Cough”. Of these five most important items/symptoms, three were from the “Rhinological” subscale (need to blow nose, sneezing, running nose), one from “Psychological” subscale (frustrated/restless/irritable) and one was “undefined item.” Piccirillo et al,[21] during the course of development of SNOT-20 in their study of 102 patients with chronic rhinosinusitis, reported the five most important items to be- lack of good sleep, postnasal discharge, wake up tired, fatigue, thick nasal discharge. Of these, two were from the “Rhinological” subscale (postnasal discharge, thick nasal discharge), one from “Psychological” subscale (fatigue), one from “Sleep” subscale (lack of good sleep), and one was “Undefined item”. In a more recent study on the Portugese adaptation of SNOT-20, Bezerra et al[22] reported the following six (as the last three items were reported with equal frequency) most important SNOT items amongst 38 patients with chronic rhinosinusitis viz., need to blow nose, sneezing, post nasal discharge, thick nasal discharge, difficulty falling asleep, wake up tired. Of these, four were from the “Rhinological” sub-scale (need to blow nose, sneezing, post nasal discharge, thick nasal discharge), one from “sleep” subscale (difficulty falling asleep), and one was “undefined item”. Although it is difficult to make a direct comparison with previous studies due to an etiologically different sample of this study but, in broad conceptual disease-related terms, previous studies and this study were carried out on patients with rhinosinusitis. Comparing the results across all the studies, the common theme that can be seen to emerge is that amongst the five most important items, the highest proportion was from the “Rhinological” subscale which is what one would expect on a conceptual basis i.e., patients reporting those symptoms of the illness from which they are suffering with. Concurrently, no items were reported from the “facial and ear” subscale. This thereby also lends credence to the construct validity of SNOT-20.[3]

Hence, it can be seen that on a disease-specific QOL instrument (SNOT-20), patients suffering with fungal rhinosinusitis experience moderate degree of problem, with the most prominent symptoms being rhinological.

WHOQOL-Bref: WHOQOL-Bref is a generic QOL instrument available in Hindi and developed to assess the subjective QOL over a period of previous 2 weeks.[23] As can be seen in [Table 3], the mean of total score so obtained was 82.97 (17.49) indicating moderate QOL. On assessing the four domains of WHOQOL-Bref, the scores generally ranged around 70% of the maximum possible score obtainable in each domain, reflecting moderate QOL in each domain. There is no comparable data using WHOQOL-Bref in rhinosinusitis, including fungal infections of nose and paransal sinuses. However, we can compare the findings with data in other physical illnesses and psychological illnesses from the Indian setting in a similar general hospital set-up viz., QOL in acromegaly (total score = 70.7),[24] and QOL in DSM-IV diagnosed depression (total score = 66.02).[25] Hence, the QOL scores obtained in our study were marginally better than those for other physical and psychological illnesses from similar general hospital settings.

SF-36: Before discussing the results of SF-36 [Table 4] for the whole sample, it will be pertinent to mention about certain conceptual aspects related to the scoring and interpretation of SF-36. Responses to each of the SF-36 items are scored and summed according to a standardized scoring protocol [7] and expressed as a score on a 0–100 scale for each of the eight health concepts. Higher scores represent better self-perceived health. Five of the scales are ''unipolar'' (physical functioning, role limitation due to physical health, pain, social functioning, and role limitation due to emotional problems), meaning that they define health status in terms of the absence of disability. The maximum score of 100 is therefore achieved when no disability is reported. The other three scales (general health, energy, and emotional well being) are ''bipolar'' scales, covering both positive and negative health states. The maximum of 100 on these bipolar scales therefore indicates not just the absence of disability, but the presence of a positive state of health.[26] SF-36 scales are divided into two domains viz., ''Physical'' (physical functioning, role limitation due to physical health, pain, general health) and ''Mental'' (social functioning, role limitation due to emotional problems, energy, emotional well being). SF-36 results [Table 4] can be discussed using two interpretation strategies viz., content-based and construct-based.[27] Content-based interpretation uses information from items and individual domains, whereas construct-based interpretation is primarily an abstract concept which answers questions about the underlying meaning of health concepts e.g., ''unipolar-bipolar'' and ''physical-mental'' health measures.[27]

Content-based Interpretation: Highest scores were obtained on the individual domains of ''Physical functioning'' and ''Pain'' (81.00 each) with lowest scores on the domains of ''General health'' (54.58) and ''Role limitation due to physical health'' (62.50). The range of scores so obtained for all eight domains was spread over approximately 26 points (54.58-81.00) indicating not too wide a scatter. The high scores on domains of ''physical functioning'' and ''pain'' indicated that patients perceived a good state of physical health. On the contrary, low scores on ''General health'' and ''Role limitation due to physical health'' indicate that the illness had impacted on the functioning and perception of the person about his/her health status. Overall, all the domains had scores of 54-81 indicating that the limitation experienced in various domains was ranging from mild to moderate. Comparing our results with previous literature, SF-36 has been used in intervention studies on chronic rhinosinusitis (not specifically fungal), wherein low scores were reported with improvement following intervention.[28],[29],[30],[31] In fact, Alobid et al[29] studied 78 patients with severe nasal polyps and reported that the patient population scored worse on all domains of SF-36 except for that of “Physical functioning”. Specific studies on fungal rhinosinusitis have been few in number. Hox et al[32] investigated correlations between individual subjective and objective parameters of stable nasal polyposis disease in 65 patients on VAS and questionnaires (SNOT-22 and SF-36), and found that VAS scores for nasal blockage correlated with the SF-36 scores. Videler et al[33] studied the efficacy of medical (azithromycin) and surgical (endoscopic sinus surgery) using SF-36 as one of the assessment parameters. However, all these three studies had not reported results for each of the domains, due to which a direct comparison is not possible. Additionally, it would be pertinent to mention the results from a recent study of 184 adults in Mumbai,[34] of whom 52 suffered with a physical illness. The 52 people suffered with different physical illnesses (musculoskeletal, hypertension, diabetes mellitus, others) and on SF-36, their individual domain scores ranged from as low as 61.06 (role limitation due to physical health) to as high as 85.09 (social functioning). This range was reasonably comparable to the range seen in our study. Although the disease population studied by Sinha et al[34] was heterogenous, nonclinic based and non-ENT based, yet it is important to discuss as it is probably the study to translate the SF-36 for Indian population and evaluate its psychometric properties.

Construct-based Interpretation: The mean scores obtained on the ''Physical Health'' and ''Mental Health'' construct were 70 (range = 54-81) and 74 (range = 65-80) respectively, thereby reflecting comparable scores across both constructs though the range was more widespread with the ''Physical health'' construct. Additionally, it can be seen that the health status for both constructs was reasonable. Unfortunately, there are no comparable data available in literature related to fungal rhinosinusitis to undertake a direct comparison for these constructs. In an Indian study which involved a population having heterogenous physical illnesses, the ''Physical Health'' construct score (Mean value = 69.06; Range = 61.06-82.60) was less than the ''Mental Health'' construct score (Mean value = 76.89; Range = 70.22-85.09).[34]

This brings us to an important methodological and conceptual issue related to the use of SF-36 in the Indian population. Despite it being a widely used and very popular generic QOL instrument, being part of over 10 studies on rhinosinusitis,[3] and also being used to assess QOL in various physical disorders in the Indian population,[34] there is only one study which has attempted to translate and assess the psychometric properties of SF-36.[34] However, there is still no literature available related to norms specific for the nondiseased Indian population and also in various physical disorders (especially in relation to age and gender). Psychometrically, usage of SF-36 data and its interpretation is dependent on the norms available; these norms ideally being generated and computed on the normative and diseased population in which the SF-36 was developed or translated.[35],[36] Although Sinha et al[34] did not attempt to strictly develop norms for the Indian population, but the scores obtained can be used as a rough guide as working terms of reference for the Indian norms for SF-36. Hence, on extrapolating the comparative data between our study and that from Sinha et al,[34] it can be seen that our sample scored lower on all domains for the nondiseased population (n = 132). On the contrary, when comparing our results with the diseased population (n = 52) in the study by Sinha et al,[34] the scores obtained for our sample in majority of the domains of the ''Mental Health'' construct were lower, whereas they were more comparable in the domains of the ''Physical Health'' construct. The reasons for these findings are unclear and difficult to interpret due to the methodological and conceptual issues as outlined above.

Overall, SF-36 is an instrument that has generated more questions than answers in this study and should be subject to further in-depth analysis for various methodological issues; especially regarding its use in diseases of the nose and paranasal sinuses.

This study had some limitations viz., it was conducted on a small outpatient tertiary care hospital sample, with a cross-sectional design, and lack of longitudinal data; thereby limiting generalizability. Additionally, this specific report is limited to only discussing QOL and not focusing on other relevant variables (coping strategies, life events, daily hassles, personality, specific psychiatric/psychological morbidity, etc.)

Nevertheless, we can conclude that in our sample of patients with a chronic disease like rhinosinusistis, moderate degree of QOL was reported on both disease specific (SNOT-20) and generic (WHOQOL-Bref) scales with mild to moderate limitation (SF-36). This being the kind of such study from India, there is a need for more information on this illness and its impact on QOL in order to be able to develop improved and holistic care by the primary clinicians (ENT) in conjunction with the mental health professionals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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