INTRODUCTION: Chronic rhinosinusitis (CRS) is one of the most widespread chronic
diseases affecting about 10% of the world population. It is an inflammatory disease which
affects the paranasal sinuses (ethmoid, sphenoidal, maxillary and frontal) and the nasal cavity.
The anatomy, physiology and pathophysiology of this area is very complex and encompasses
various osseous, cartilaginous, nervous and vascular structures. The general loss of human
productivity due to CRS and absenteeism from work or school represent a major economic
factor on a global scale. The direct cost of treating chronic rhinosinusitis is well documented,
and in the United States of America, for example, the cost amounts to around $12.8 billion
annually. Patients with CRS are not at risk of mortality due to their disease, but their quality of
life is significantly impaired.
Rhinosinusitis in adults is defined according to EPOS 2012 guidelines (European Position
Paper on Rhinosinusitis and Nasal Polyps) as an inflammation of the nose and the paranasal
sinuses characterized by at least two or more specific symptoms. One symptom must be either
nasal obstruction or nasal discharge, while the other two are facial pain and/or reduced sense of
smell. In order to confirm the diagnosis, endoscopic signs (nasal polyps, oedema, mucopurulent
discharge) and/or CT changes in the nose and paranasal sinuses should be visible. According to
its duration, rhinosinusitis is classified as acute and chronic rhinosinusitis. If the disease lasts
for up to 12 weeks, it is called acute, whereas if it lasts for longer than 3 months, it is regarded
The aetiology of CRS can be odontogenic or non-odontogenic. Chronic non-odontogenic
rhinosinusitis (CnORS) is caused by allergies, biofilm formation, anatomical variations, ciliary
disfunction and others. Chronic odontogenic rhinosinusitis (CORS) is caused by pathological
processes of the teeth and the surrounding tissue including oroantral fistulas, periapical
processes, maxillary cysts, foreign bodies in paranasal sinuses, and complications after tooth
extraction. The diagnostic criteria for CORS are the same as for CnORS, however, CORS must
have a clear odontogenic cause in addition to all the criteria.
Approximately 10% of all CRS have odontogenic origins. The incidence of CORS is increasing
worldwide, mostly due to the neglect of dental health of those who cannot afford dental
treatments. A part of the increase can be attributed to the increased number of procedures in
complex reconstructive dentistry, i.e. procedures such as dental implant surgery and bone
grafting. Despite its frequency, CORS is disproportionately underrepresented in the literature
and there are still many questions regarding exact incidence, onset, diagnosis, differential
diagnosis and treatment of the disease.
CRS symptoms can be assessed by using subjective questionnaires. The most common
questionnaire is the Sino-Nasal Outcome Test (SNOT-22). SNOT-22 has been widely adopted
in clinical practice due to its simplicity, encompassing 22 symptoms reflecting health burden
for patients with rhinologic disorders. Each item quantifies symptoms severity from 0 (no
problem) to 5 (the worst symptom). The sum of all items amounts to the maximum score of
110. High score indicates poor outcome. The SNOT-22 is a validated questionnaire with disease
specific and quality of life related measures of the sinonasal function. It demonstrates good
reliability, validity, and responsiveness. The visual analogue scale (VAS) symptom score is also
a psychometric instrument widely used in the field of rhinology to subjectively quantify a
patient’s symptom severity. It consists of 16 symptoms.
Although there are a variety of radiological tests available, computerised tomography (CT) is
accepted as the gold standard for the anatomical pathology evaluation of paranasal sinus
diseases including CRS. The Lund-Mackay score (LMS) was developed to evaluate the severity
of the paranasal sinus disease. LMS is a widely used method for the radiologic staging of
chronic rhinosinusitis and involves scoring six bilateral areas from 0 to 2, for a possible range
of scores between 0 and 24.
AIM: To compare the differences between the intensity of the symptoms and the disease
severity observed on CT scans in patients with CnORS and CORS, and to correlate the
symptoms with the CT scan findings.
METHODS: The research was conducted from October 2019 to May 2020 at the Clinic of
Otorhinolaryngology and Head and Neck Surgery of University Medical Centre Sestre
Milosrdnice, the Clinical Department of Diagnostic and Interventional Radiology of University
Medical Centre Sestre Milosrdnice and the Department of Oral Surgery of Univesity Hospital
Dubrava. The study included 64 adult patients, 32 with CnORS in the first group and 32 patients
with CnORS in the second group. Patient data were collected according to the principle of
matching pairs between the two groups, according to age (+/- five years) and gender. The
diagnosis of CRS was made according to the diagnostic criteria of the EPOS 2012 guidelines.
Since the finding of inflammatory changes on a CT scan was mandatory for the patient to be
included in the study, the endoscopy finding was not necessary for the diagnosis of CRS and
was used to visually exclude the presence of nasal polyps.
CT scan was performed as a diagnostic or preoperative procedure carried out by an
otorhinolaryngology specialist, after which the patient gave informed consent and was
subsequently included in the study. The patient then completed two health-related quality of
life questionnaires, SNOT-22 and VAS. VAS included additional questions regarding the
presence of asthma, acetylsalicylic acid (ASA) intolerance, allergic rhinitis, smoking, previous
sinus surgery, nasal corticosteroid use, as well as antihistaminic and antibiotic use. The CT scan
was reviewed and scored (according to the LMS) exclusively by a radiology specialist - a
neuroradiology subspecialist. Patients were assigned to a certain group only after they had
undergone a detailed clinical examination by an otorhinolaryngologist and an oral surgeon, and
after the CT scan had been evaluated by a radiologist. For the disease to be declared
odontogenic, the CT findings had to show pathology related to the teeth of the upper jaw or the
surrounding structures, which necessarily implies the involvement of the Schneiderian
membrane. The following patients were excluded from the participation in the study: patients
under the age of eighteen, patients with nasal and sinus polyposis, patients with a previous sinus
injury or a sinus tumour process, pregnant women, and patients with cystic fibrosis,
granulomatosis with polyangiitis and primary ciliary dyskinesia. Patients with a nasal septum
deviation angle greater than 10 degrees diagnosed by an imaging test and patients whose CT
scan was of poor quality (e.g. artifacts) were also excluded from the study.
The case-control matching procedure between the two groups (CnORS and CORS) was used
to randomly match patients according to gender and age (+/−five years). The normality of data
distribution for continuous data has been checked with Kolmogorov-Smirnov's test and due to
the test results an appropriate non-parametric data analysis has been used in the following
analyses. Fisher's exact test has been used to assess differences in categorical clinical variables
between the investigated groups. The Mann-Whitney U test was used for differences in
quantitative clinical variables (specific VAS symptoms, SNOT-22, and LMS) between the study
groups. Spearman’s Rho correlation coefficients were calculated to compare the association
between the individual VAS and SNOT-22 symptoms with the LMS for the individual study
groups. All P values below 0.05 were considered significant.
RESULTS: Patients with CORS and CnORS matched by age and gender in this study did not
show a statistically significant difference in any of the following: acetylsalicylic acid
intolerance, allergic rhinitis, smoking, previous sinus surgery, use of nasal corticosteroids,
antihistamines and antibiotics. The most common cause of CORS is the first molar disease, and
the most common cause of odontogenic pathology is the periapical process. A statistically
significant difference in individual symptoms was observed. CORS patients had a statistically
significant higher self-reported values of thick nasal discharge, halitosis and temperature
compared to CnORS patients. There was no statistically significant difference in other
symptoms or in the overall SNOT-22 score. Furthermore, no statistically significant difference
was found when the LMS was compared. A positive correlation between the LMS and thick
nasal secretion and frustration levels was present in the CORS patients. The CnORS group
showed a positive correlation between the runny nose, the loss of smell/taste and the LMSs.
The overall SNOT-22 score did not show a correlation with the LMS in either of the two groups.
CONCLUSION: Thick nasal secretion, halitosis and fever are more intense in patients with
CORS, which is valuable information for the everyday clinical practice. The LMS is not
statistically significantly different between the two groups and is not a good predictor of a
chronic odontogenic disease. Individual symptoms show a positive correlation between the
LMS in both groups, specifically between runny nose and loss of smell/taste in the CnORS
group, and thick nasal secretions and frustration levels in the CORS group.