Prevalence of CRS among re-attendees at the MRRH ENT clinic
The prevalence of CRS among patients re-attending the ENT clinic in a resource limited setting was 39%. Our study results are generalizable to studies that have enrolled patients re-attending the ENT clinic in resource limited settings. However, very few studies have been done to measure CRS in this population, and not only in resource limited setting but globally. When compared to the prevalence of CRS in the general population surveys, the results are stunningly different. For instance a cross sectional survey of 19 European countries by the GA2LEN network of excellence showed variable prevalence of CRS ranging from 6.9% (95% CI 5.8–8.2%) to 27.1% (95% CI 25.0–29.3%) in Germany [
2], the maximum prevalence measured was 27.1%which is still be lower than that in our study. In an African setting, Iseh and Makusidi recruited all new patients with the diagnosis of rhinosinusitis over a 2-year period and found a prevalence of CRS of 7.3% at a teaching hospital in north western Nigeria among patients attending an ENT clinic [
16].
Clearly, the high prevalence in our study is because the respondents in our study were re-attendees, a high-risk group of patients with chronic ailments of which CRS is one. Secondly, we recruited patients at a large government health facility that attracts patients from a mostly low socioeconomic status because of free services. This category of patients is known to be at high risk for CRS [
17] and our data also confirms this. The ENT clinic at our facility also serves a larger population than most Regional Referral Hospitals in Uganda. We serve patients from 10 districts of South Western Uganda and neighboring countries of Rwanda, Burundi, Southern Tanzania and The Democratic Republic of Congo. This might further explain the high prevalence we found in comparison to the studies reviewed [
2‐
4].
Proportion of patients with poor HRQoL among those with and without CRS
Generally, CRS patients have poorer QoL compared to healthy individuals [
18‐
20]. Our study showed the same as patients with CRS had poorer Health Related Quality of life, compared to those without CRS. The domain with the highest mean score among CRS patients was the nasal symptom domain. This might be because the aspects of QoL assessed in this domain relate to the mucosal inflammatory and ostial obstructive mechanisms within CRS. We found that the psychological domain had the second highest mean score among the CRS patients and attribute this to possibly unexplored sources of psychological stress such as financial struggles in this low socio-economic setting.. Browne et al., found the highest mean score in CRS patients in the nasal symptom domain, followed closely by the mean psychological score [
14], a finding similar to that in our study.
Non-CRS patients scored highest in the ear/ facial symptom domain. We attribute this to the fact that the majority of patients seen in the MRRH otolaryngology clinic have ear related conditions from a review of the OPD records. This likely resulted in the majority of our non-CRS respondents having ear related complaints, thus reporting poorer quality of life scores in the ear symptom domain. Mean scores and trends in the SNOT 22 domains for non- CRS groups is variable across studies possibly because there is wide diversity in the non-CRS groups recruited [
14,
21,
22].
Overall, both the total and mean domain scores were higher in the CRS patients compared to respondents without CRS and this is in keeping with results from studies done elsewhere. There is however little similarity in the scores from the non-CRS population between our study and studies done elsewhere.
Factors associated with poor quality of life scores
From the bivariate analysis, poor quality of life scores were generally significantly associated with the endonasal factors except septal deviation. Having a secondary education and a monthly income of over USD 15 appeared to confer protection from poor quality of life in CRS.
We expected to find a significant association between female gender and poor quality of life but this was not true. Males tend to seek health care when they have worse symptom scores compared to females and males were also more likely to be smokers. Although females tend to report poorer QoL [
23], one may argue that male health seeking behavior and smoking may have wiped out the difference. However, this may not be entirely true since we adjusted for these differences. Ference et al., reviewed six studies on gender differences in self-reported quality of life among CRS patients. They concluded that the influence of gender on quality of life seems to be restricted primarily to the general aspects of quality of life, whereas the disease-specific health-related quality of life is not different between genders [
23].
The lack of association between GERD symptoms and both CRS and quality of life on the SNOT 22 in our study is not supported by previous findings. Patients with GERD symptoms have been shown to have a reduced nose and sinus-related quality of life [
24] and having GERD symptoms increases the mean SNOT-22 score in patients with CRS by 15.7 (95% CI, 6.5–24.9) [
25]. We suspect that this discrepancy in findings may be because only 8 respondents in our study had GERD symptoms, with 4 of them having a poor quality of life.
Our study revealed that having a formal education was protective in CRS related quality of life. A study by Kilty et al., found that having a post-secondary education was significantly associated with low self-reported sinus symptom scores in CRS patients [
26]. It is possible that for our population, patients with a formal education possibly understand prescription instructions better than those without a formal education and medical personnel find more ease in explaining disease processes to formally educated persons. This means that an educated patient might have realistic health expectations during the course of their treatment and are psychologically better equipped to manage their CRS symptoms.
Patients with a monthly income of over USD 15 were less likely to have poor quality of life. Also CRS occurred less frequently among patients with a monthly income. USD 15 is averagely sufficient to purchase a month’s supply of CRS medication with some left over to cater to other basic needs of a patient in this population. Although we could not find studies that evaluated income level and quality of life in CRS patients, Pilan et al., found that CRS was significantly more prevalent in low-income groups [
17]. The ability to purchase prescribed medication that would relieve CRS symptoms and thus result in better quality of sleep and psychological wellbeing may account for this relationship.
Because endonasal abnormalities result in persistent symptoms, they may have contributed greatly to increased nasal symptom and sleep disturbance scores for our patients. Nasal discharge is a major symptom of CRS, therefore it would seem imperative that it be associated with a poor Health Related Quality of Life in our patient sample.
In the multivariate analysis, only CRS and nasal discharge were found to be significantly associated with poor health related quality of life. Persons with CRS were almost nine times more likely to have poor quality of life compared to persons without CRS. The results agree with findings from other studies using SNOT22 among CRS patients [
18‐
20].
Our study has some limitations. First, the SNOT-22 questionnaire has not been validated in any of the indigenous languages of Uganda, however, has been used elsewhere in Africa with similar cultural setting as Uganda. We used professional translation and hence language minimally affected the validity of the results obtained from the Quality of life assessment.
Second, the lack of CT scans limited our ability to accurately diagnose CRS. However we are confident that the symptoms and endoscopic findings were adequate to make a diagnosis of CRS as per the definition by Rosenfeld and Cornelius [
3,
27].
Our study has some strength. Most quality of life studies have been done in regions that have significant seasonal variations compared to southwestern Uganda. The strength of our study is that it provides data from a region with less seasonal variation, such as sub Saharan Africa, for which information on quality of life in CRS is scarce.