Sleep quality assessment in chronic rhinosinusitis patients submitted to endoscopic sinus surgery: a meta-analysis

Guttemberg, Manuela Dowsley A.; Mata, Fabiana A. Figueiredo da; Nakanishi, Márcio; de Andrade, Keitty R.C.; Pereira, Maurício G.

doi:10.1016/j.bjorl.2019.06.008

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Brazilian Journal of Otorhinolaryngology

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REVIEW ARTICLE • Braz. j. otorhinolaryngol. 85 (6) • Nov-Dec 2019 • https://doi.org/10.1016/j.bjorl.2019.06.008 copy

Sleep quality assessment in chronic rhinosinusitis patients submitted to endoscopic sinus surgery: a meta-analysis^☆ ☆ Como citar este artigo: Guttemberg MD, Mata FA, Nakanishi M, Andrade KR, Pereira MG. Sleep quality assessment in chronic rhinosinusitis patients submitted to endoscopic sinus surgery: a meta-analysis. J Pediatr (Rio J). 2019;85:780–7.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Chronic rhinosinusitis can lead to poor sleep quality in affected individuals. Endoscopic nasal surgery has been indicated for patients with chronic rhinosinusitis, resulting in improved quality of life, but it is still unknown if there is a similar improvement in sleep quality after the surgical procedure.

Objective:

To estimate the sleep quality of patients with chronic rhinosinusitis after undergoing endoscopic sinus surgery.

Methods:

The literature search was conducted in the indexed databases PubMed, Embase, Lilacs, SciELO, Google Scholar, Web of Science, Scopus, Database of Thesis and Dissertations of CAPES, Cochrane Library, Clinical Trials and in the grey literature. It included studies that reported the sleep quality of patients with chronic rhinosinusitis after undergoing endoscopic sinus surgery based on questionnaires assessing quality of life. Two researchers independently conducted the study selection and extraction. The random effects model was chosen to conduct the meta-analysis that was performed using the statistical package STATA, version 11.

Results:

Overall, 4 studies and 509 subjects were included in the systematic review. Improved sleep quality was observed in 90% of the patients. There was an improvement (on average, from 57% to 67%) in each of the five symptoms related to sleep quality. The results of the meta-analysis revealed high heterogeneity.

Conclusions:

This review shows that a large percentage of patients report improved sleep quality after endoscopic sinus surgery.

Keywords
Chronic rhinosinusitis; Sleep quality; Endoscopic sinus surgery; Meta- analysis; SNOT-22

Author, year of publication	Alt et al.¹²12 Alt JA, Smith TL, Schlosser RJ, Mace JC, Soler ZM. Sleep and quality of life improvements after endoscopic sinus surgery in patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2014;4:693-701.	De Vilhena et al.²¹21 De Vilhena D, Duarte D, Lopes G. Calidad de vida postoperatoria en la rinosinusitis crónica con poliposis nasal. Rev ORL. 2016;7:17-22.	Mascarenhas et al.²²22 Mascarenhas JG, da Fonseca VM, Chen VG, Itamoto CH, Silva CA, Gregório LC, et al. Long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyps. Braz J Otorhinolaryngol. 2013;79:306-311.	Li et al.²⁰20 Li H, Zhang X, Song Y, Wang T. Effects of functional endoscopic sinus surgery on chronic rhinosinusitis resistant to medication. J Laryngol Otol. 2014;128:976-978.
Local	Oregon Helth & Sciece University (Portland, OR) Medical University of South Carolina (Charleston, SC) Stanford University (Palo Alto, CA) University of Calgary (Alberta, CA)	Hospital Pedro Hispano (Porto, Portugal).	UNIFESP-EPM (São Paulo, Brasil).	Central South University, Changsa, China.
Period of data collection	April 2011 to January 2014	September 2012 to February 2014	NR	April to October 2011
Sample characteristics	Adult patients (18 years and over) with a diagnosis of refractory CRS. Exclusion: Acute Repetitive Rhinosinusitis, sleep apnea or corticoid dependence.	Adult patients with CRS with polyps. Exclusion: Previous nasal surgery or not complete questionnaire.	Adult patients (18 years and over) with a diagnosis of CRS with or without polyps.	Adult patient's diagnosis of refractory CRS with or without polyps. Exclusion: Patients with asthma and ASA intolerance.
Type of study	Before and After	Before and After	Before and After	Before and After
Sample size (n)	219	100	38	152
Age, mean	50.7 (±14.7)	42.8 (±14.9)	46.2	35.2 (±12.3)
Female (%)	118 (53.9%)	45 (45%)	22 (57.9%)	64 (42.1%)
Sleep improvement in the sample (%)	72%	99%	92.1%	NR
Follow-up time (months)	6	3	3 e 24	3, 6 e 12
Diagnosis of CRS	2007 Adult Sinusitis Guideline (AAO-HNS)	NR	EPOS 2012	NR
Quality of Life questionnaire	SNOT-22	SNOT-22	SNOT-22	SNOT-20

Quality questions	Author, year of publication
Quality questions	Alt et al.¹²12 Alt JA, Smith TL, Schlosser RJ, Mace JC, Soler ZM. Sleep and quality of life improvements after endoscopic sinus surgery in patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2014;4:693-701.	De Vilhena et al.²¹21 De Vilhena D, Duarte D, Lopes G. Calidad de vida postoperatoria en la rinosinusitis crónica con poliposis nasal. Rev ORL. 2016;7:17-22.	Mascarenhas et al.²²22 Mascarenhas JG, da Fonseca VM, Chen VG, Itamoto CH, Silva CA, Gregório LC, et al. Long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyps. Braz J Otorhinolaryngol. 2013;79:306-311.	Li et al.²⁰20 Li H, Zhang X, Song Y, Wang T. Effects of functional endoscopic sinus surgery on chronic rhinosinusitis resistant to medication. J Laryngol Otol. 2014;128:976-978.
1. Was the study question or objective clearly stated?	YES	YES	YES	YES
2. Were eligibility/selection criteria for the study population prespecified and clearly described?	YES	YES	YES	NO
3. Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?	CD	CD	CD	CD
4. Were all eligible participants that met the prespecified entry criteria enrolled?	YES	YES	YES	CED
5. Was the sample size sufficiently large to provide confidence in the findings?	YES	CD	CD	CD
6. Was the test/service/intervention clearly described and delivered consistently across the study population?	YES	NO	NO	YES
7. Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?	YES	YES	YES	YES
8. Were the people assessing the outcomes blinded to the participants' exposures/ interventions?	NR	NR	NR	YES
9. Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?	NO / YES	NO / YES	NO / YES	NO / YES
10. Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p-values for the pre-to-post changes?	YES	YES	YES	YES
11. Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention?	NR	NR	NR	NR
12. If the intervention was conducted at a group level did the statistical analysis take into account the use of individual-level data to determine effects at the group level?	NA	NA	NA	NA
Total number of "YES"	8	6	7	6

Symptom description	% (95% CI)	p-value	I² in %
Difficulty falling asleep	67 (56-78)	< 0.01	84.1
Wake up at night	57 (19-90)	< 0.01	98.6
Lack of a good night´s sleep	65 (50-78)	< 0.01	90.4
Wake up tired	62 (40-82)	< 0.01	95.6
Fatigue	60 (32-84)	< 0.01	97.3

Author, year of publication	Item	Preoperative (SD)	Postoperative (SD)	Improvement (%)
Alt et al.¹²12 Alt JA, Smith TL, Schlosser RJ, Mace JC, Soler ZM. Sleep and quality of life improvements after endoscopic sinus surgery in patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2014;4:693-701.	Difficulty falling asleep	2.2 (1.6)	1.2 (1.4)	46.3
	Wake up at night	2.6 (1.6)	1.5 (1.4)	42.8
	Lack of a good night´s sleep	2.8 (1.6)	1.6 (1.5)	42.1
	Wake up tired	2.9 (1.5)	1.7 (1.5)	40.4
	Fatigue	2.9 (1.5)	1.6 (1.5)	42.7
	Summarized scores items	13.5 (6,9)	7.7 (6.6)	42.6^a a Only Alt et al.12 reported the summarized scores items.
	Difficulty falling asleep	2.5 (0.2)	0.9 (0.1)	64.5
	Wake up at night	2.6 (0.2)	1.3 (0.1)	51.7
De Vilhena et al.²¹21 De Vilhena D, Duarte D, Lopes G. Calidad de vida postoperatoria en la rinosinusitis crónica con poliposis nasal. Rev ORL. 2016;7:17-22.	Lack of a good night´s sleep	2.6 (0.2)	1.1 (0.1)	59.5
	Wake up tired	2.7 (0.2)	1.0 (0.1)	64.0
	Fatigue	2.6 (0.2)	1.0 (0.1)	59.8
	Difficulty falling asleep	3.6 (1,8)	0.6 (1.1)	83.3
	Wake up at night	3.7 (1.6)	1.1 (1.4)	70.3
Mascarenhas et al.²²22 Mascarenhas JG, da Fonseca VM, Chen VG, Itamoto CH, Silva CA, Gregório LC, et al. Long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyps. Braz J Otorhinolaryngol. 2013;79:306-311.	Lack of a good night´s sleep	3.6 (1.8)	0.8 (1.4)	77.8
	Wake up tired	2.9 (2.0)	0.6 (1.2)	79.3
	Fatigue	2.7 (1.9)	0.8 (1.3)	70.4
	Difficulty falling asleep	1.2 (1.0)	0.4 (0.6)	64.7
	Wake up at night	0.5 (0.6)	0.4 (0.6)	10.8
Li et al.²⁰20 Li H, Zhang X, Song Y, Wang T. Effects of functional endoscopic sinus surgery on chronic rhinosinusitis resistant to medication. J Laryngol Otol. 2014;128:976-978.	Lack of a good night´s sleep	0.9 (0.9)	0.5 (0.5)	51.1
	Wake up tired	0.7 (1.0)	0.3 (0.5)	54.2
	Fatigue	0.6 (0.9)	0.4 (0.6)	39.7

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[1] *Corresponding author. E-mail: manudowsley@yahoo.com.br (M.D. Guttemberg).