General illness and psychological factors in patients with
chronic nasal symptoms
A. C. Yao
J. A. Wilson
ENT Department, County Durham &
Darlington NHS Foundation Trust,
ENT Department, Stockport NHS
Foundation Trust, Stockport, UK
Institute of Cellular Medicine, Newcastle
Upon Tyne Hospitals NHS Foundation
Trust, Newcastle University, Newcastle
upon Tyne, UK
Psychology Department, Northumbria
University, Newcastle upon Tyne, UK
ENT Department, Institute of Health and
Society, Newcastle Upon Tyne Hospitals
NHS Foundation Trust, Newcastle
University, Newcastle upon Tyne, UK
Naveed Kara, ENT Department, County
Durham & Darlington NHS Foundation
Trust, Darlington, UK.
Sunderland Head & Neck Charitable Fund
Objectives: Only a minority of patients referred to specialists with sinonasal symp-
toms have clear evidence of chronic rhinosinusitis (CRS). This study aims to estimate
the prevalence of and associations between (i) general illness factors (fatigue, auto-
nomic dysfunction) and (ii) psychological factors (anxiety, depression, somatisation,
personality traits) in patients presenting with sinonasal symptoms.
Design: The following validated questionnaires were administered to patients: the Sino-
Nasal Outcome Test-22 (SNOT-22) identifying symptom burden, Composite Autonomic
Symptom Score-31 (COMPASS-31) measuring autonomic function, Chalder Fatigue
Questionnaire, Patient Health Questionnaire-15 (PHQ-15) addressing somatisation
symptoms, Hospital Anxiety and Depression Scale (HADS), and the International Person-
ality Item Pool-50 (IPIP-50). Comparisons were made with normative and general popu-
lation data, and relationships were analysed using nonparametric correlation.
Setting: Secondary care ENT outpatients.
Participants: Adults referred with chronic sinonasal symptoms.
Main outcome measures: SNOT-22, COMPASS-31, Chalder, PHQ-15, HADS, and
IPIP-50 questionnaire scores.
Results: Sixty-one patients were included. There was a high prevalence of all gen-
eral and psychological factors assessed compared with controls. Total SNOT-22
scores showed significant correlation with Chalder fatigue scores, total autonomic
dysfunction score, anxiety, depression, somatisation tendencies and the emotionally
unstable personality trait. Emotional instability and psychological dysfunction corre-
lated significantly with sleep and psychological subscales of SNOT-22 but not the
rhinological or ear/facial subscales.
Conclusion: Patients with sinonasal symptoms demonstrate high prevalence and
complex associations of general illness factors, psychological distress and certain
personality traits. The SNOT-22 is a valuable tool, but its utility is limited by correla-
tions with these confounding factors (eg psychological factors) that may exaggerate
the total score. The use of the SNOT-22 component subscales is likely to provide
more clinically meaningful and discriminant information.
There is poor correlation between self-reported chronic sinonasal
symptoms and clinical findings, and as a result, sinogenic facial pain
is often incorrectly diagnosed.
This is partially due to the many
influences on symptom reporting as seen in patients suffering from
psychiatric distress who report increased symptom burden in chronic
This is of particular concern as chronic nasal condi-
tions such as chronic rhinosinusitis (CRS) are responsible for a signifi-
cant proportion of primary care workload.
Epidemiological data cite
Accepted: 11 November 2017
Clinical Otolaryngology. 2018;43:609–616. wileyonlinelibrary.com/journal/coa © 2017 John Wiley & Sons Ltd