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Year : 2021  |  Volume : 23  |  Issue : 3  |  Page : 117-122

The prevalence of chronic sinusitis symptoms among inflammatory bowel disease patients at tertiary hospital in Riyadh

1 Department of Otolaryngology, King Saud University, Riyadh, Saudi Arabia
2 Department of Otolaryngology-Head&Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Department of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
4 Department of Otolaryngology, King Fahd Central Hospital in Jizan, Jazan, Saudi Arabia

Date of Submission05-May-2021
Date of Acceptance01-Jul-2021
Date of Web Publication05-Oct-2021

Correspondence Address:
Dr. Ibrahim Sumaily
Department of Otolaryngology, King Fahd Central Hospital in Jizan, Jazan
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_22_21

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Background: The etiologies of both chronic rhinosinusitis (CRS) and inflammatory bowel disease (IBD) are not well known. Both are inflammatory diseases that are triggered by genetic and environmental factors. Existing literature lacks the evaluation of the overlap between these clinical entities. Herein, we attempt to determine the prevalence of CRS symptoms among the patients with IBD at King Khalid University Hospital. Methodology: This text presents a cross-sectional study on patients with confirmed diagnoses based on colonoscopy and histological findings. Patients were evaluated using the chronic sinusitis survey (CSS) and the rhinosinusitis disability index (RSDI). Other variables evaluated in this study include age, gender, chronic illnesses, duration of the IBD, smoking, medications, and family history. Results: Eighty-two IBD patients were enrolled in the study, and of these patients, 61 have Crohn's disease (CD) and 21 have ulcerative colitis (UC). There was no statistically significant difference in the presence of sinonasal symptoms between patients with CD and UC: 11.47% and 9.52%, respectively. CSS score was nonsignificantly higher among CD patients: 10.79 compared to 6.15 for UC patients, P = 0.125. In addition, the RSDI score was higher among CD patients: 13.11 compared to 5.14 in UC patients. However, this difference is not significant, P = 0.069. Conclusion: The prevalence of CRS symptoms among IBD patients is comparable to the general population. It was nonsignificantly less prevalent in UC patients in comparison to CD patients.

Keywords: Chronic sinusitis, Crohn's disease, inflammatory bowel disease, ulcerative colitis

How to cite this article:
Alromaih S, Abuhaimed A, Alkhowaiter S, Alkethiri K, Alfarhan O, Alkhurayji S, Alhazmi N, Sumaily I. The prevalence of chronic sinusitis symptoms among inflammatory bowel disease patients at tertiary hospital in Riyadh. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:117-22

How to cite this URL:
Alromaih S, Abuhaimed A, Alkhowaiter S, Alkethiri K, Alfarhan O, Alkhurayji S, Alhazmi N, Sumaily I. The prevalence of chronic sinusitis symptoms among inflammatory bowel disease patients at tertiary hospital in Riyadh. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Jul 2];23:117-22. Available from: https://www.sjohns.org/text.asp?2021/23/3/117/327567

  Introduction Top

Chronic rhinosinusitis (CRS) with or without nasal polyps in adults is a clinical disease defined by the persistence of symptomatic inflammation of the nasal mucosa and paranasal sinuses. Its prevalence is approximately 10% in the Western world.[1],[2] Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal tract (GIT). Clinically, IBD includes Crohn's disease (CD), ulcerative colitis (UC), and other conditions.[3] The proper diagnosis of IBD is crucial for determining the management plan, which is based on clinical, colonoscopy-related, radiologic, and histologic criteria.[4] The gold standard diagnostic measure used to investigate IBD is colonoscopy. As IBD is a systemic disease, its extraintestinal manifestations may present several years before GIT manifestations.[5] In Saudi Arabia, the association between IBD and chronic sinonasal symptoms is largely unknown. Hence, we decided to conduct this study to determine the prevalence of chronic sinonasal symptoms among IBD patient population.

  Methodology Top

Study design and participants

The research for this paper was conducted through a cross-sectional study on 82 patients with IBD from the gastrointestinal clinic at King Khalid University Hospital between March and December 2019. Our sample included patients with confirmed diagnosis of IBD by colonoscopy and biopsy, and all of the participants must have isolated IBD. Patients without a confirmed diagnosis of IBD, patients with incomplete charts and records, patients with other autoimmune diseases related to their gastrointestinal system, pediatric and child patients (under 10 years old age), patients with uncontrolled hypertension, and patients with uncontrolled diabetes mellitus were excluded from the study to minimize confounding factors that might affect results. That could be from the disease itself and the related systemic inflammation that accompanies metabolic syndrome. Furthermore, having such uncontrolled disease would affect the management decisions made by the treating physicians. Hence, we chose to exclude them. We operated according to the assumption that an average of 48% of IBD patients report chronic sinonasal diseases,[6] a confidence level of 95%, and a 5% margin of error. The final estimated sample size was 82 patients.

Study tools

The study protocol was divided into two major phases: a review of the patients' electronic records and two standardized, Arabic version, validated, and disease-specific quality-of-life tools – the Rhinosinusitis disability index (RSDI) and the chronic sinusitis survey (CSS).[7] Patients' demographic data and their information on IBD type, site, behavior, disease duration in months, age of diagnosis in years, family history of IBD, smoking status, medications used for IBD management, nasal disease in the system, and the previous nasal surgery in the system were collected retrospectively according to the patients' electronic records.

The RSDI was developed in 1997 by Benninger and Senior.[8] It consists of a 30-item questionnaire with three subscale domains that measure the physical (11 items), functional (9 items), and emotional (10 items) impact of sinus disease on patients. Patients were asked to provide categorical responses to each question, which were then converted into numerical scores from 0 to 4, with 4 implying the greatest level of impact (score range: 0–120).[9] Higher RSDI totals and subscale scores represent a higher impact. On the other hand, CSS was developed in 1995 by Gliklich and Metson.[8] It is a duration-based, six-question survey that measures sinusitis-specific symptoms and medication used to control sinonasal symptoms during the preceding 8 weeks (score range: 0–100).[10] The surveys had one language option (Arabic), which was prepared through the translation of the English RSDI and CSS. Data were collected through a patient-administered written questionnaire.

Statistical methods

A statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 24.0 software (SPSS Inc., Chicago, IL, USA). We calculated the frequencies and percentages of all nominal variables and the mean, standard deviation, median, and range (minimum-maximum) of measurable variables. We used a Kolmogorov–Smirnov test to check whether or not the measurable variables were normally distributed and a nonparametric Mann–Whitney U test to compare the measurable variables (total scores of physically, psychologically, and functional points of view) with respect to the type of IBD, nasal disease, previous nasal surgery, and family history of IBD. In addition, we used a Chi-squared test and Fisher's exact test to compare the type of IBD (CD and UC) with respect to all nominal variables (demographic characteristics, nasal disease, previous nasal surgery, and family history of IBD). The results were considered a significant for P values below 0.05 (P < 0.05).

Ethical considerations

This study was approved by the King Saud University College of Medicine Research Center institutional review board on March 5, 2019 (No. E-18-3552). Patients were informed about the purpose of the study and gave their consent. Participation in this study was voluntary, and patients had the right to refuse to answer the questions or withdraw from the study at any time. We guaranteed participants' confidentiality by assigning each patient a code for the analysis. No financial aid awards were given to the participants.

  Results Top

The total mean score of the RSDI was 11.07 (±15.26), which was found to be nonsignificantly higher among CD patients: 13.11 (±16.65) compared to 5.14 (7.81) in UC patients, with a P value of 0.06. On the other hand, the score was statistically significantly higher among those with nasal disease: 21.11 (±13.26) compared to 9.83 (±15.10) in those with no nasal disease, with a P value of 0.007. Similarly, those with the previous nasal surgery had high scores, but the difference was nonsignificant: 19.0 (±14.35) compared to 10.56 (±15.26), with a P value: 0.18

Based on their diagnosis, according to sinonasal symptoms, participants with positive nasal disease history received statistically significantly higher physical and functional scores: 14.22 (±9.19) and 4.67 (±5.27) compared to 5.30 (±7.93) and 2.41 (±4.60) for those with no nasal disease, with P values of 0.003 and 0.034, respectively. In contrast, the emotional scores did not differ significantly between the two groups.

CD participants demonstrated statistically nonsignificant (P > 0.05) higher mean scores in the physical, functional, and emotional domains: 7.47 (±9.21), 3.11 (±5.25), and 2.52 (±4.25) compared to 2.89 (±4.53), 1.33 (±2.03), and 1.0 (±1.92) in the UC group, respectively.

No significant association was found between the medications being used and the RSDI score.

A total of 82 IBD patients were recruited. The patients had a mean age of 30.74 (±9.48), and the majority of participants were males, 62.2%. Almost three-quarters (74.4%) of the participants have CD, while 25.6% have UC. The mean disease duration was 85.1 (±55.79) months, and the mean age at diagnosis was 23.67 (±9.30) years. There was a family history of IBD in 7.3% of the participants, and 23.2% were smokers. The majority, 84.1%, and 80.5%, of the patients were using infliximab and azathioprine, respectively. Almost half (51.2%) of the participants were using steroids. Our review of the patients' charts found that 11% have sinonasal symptoms, and 6.1% had undergone nasal surgery at the time of the study. As for the IBD phenotype classification, it was inflammatory in more than half (53.7%) of the participants and penetrating for 36.6%. The ilium and colon together were the most affected sites in 45.1% of the participants, followed by ilium only at 20.7%. The differences between CD and UC patients are evident in their baseline and clinical characteristics. There were no statistically significant differences between the two groups in any of the assessed sociodemographic (age, gender, family history, and smoking) or clinical characteristics (disease duration, age at diagnosis, nasal disease, or nasal surgery). The inflammatory behavior of IBD was significantly higher in UC patients (100% vs. 37.7%, P = 0.0001), while penetration behavior was significantly higher in CD patients (49.4% vs. 0.00%, P = 0.0001). The results of the current study reveal that patients with UC had a higher prevalence of family history of IBD and a higher prevalence of previous nasal surgery: 14.3% and 9.5%, respectively, compared to 4.9% and 4.9%, respectively, for CD patients. On the other hand, there was a higher prevalence of sinonasal symptoms among CD patients, at 11.5%, compared to UC patients, at 9.5%. All these differences were statistically nonsignificant [Table 1].
Table 1: Sociodemographic data

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According to the CSS, 12.2% of the participants had sinonasal headache and had experienced pain for 3 to 4 weeks, 4.9% had pain for 2 to 3 weeks, and 30.5% for 1 to 2 weeks. Discharge from the mouth and nose was reported by <30% of the participants (26.8%); 20.7% experienced this symptom for 1 to 2 weeks. A total of 21.9% of participants reported throat congestion or difficulty breathing, and among these patients, 19.5% had experienced these symptoms for 1 to 2 weeks. Only 9.8% of the participants were using antibiotics. Nasal sprays were used by only 17.1% of the participants for 1 to 2 weeks. Medications for sinonasal problems were used by 23.2% of participants. Of these patients, 15.9% used them for 1 to 2 weeks, 6.1% for 3 to 4 weeks, and 1.2% for 2 to 3 weeks [Table 2].
Table 2: The chronic sinusitis survey results

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Patients' total scores on the CSS questionnaire differed significantly according to the presence of nasal disease: a mean total score of 24.53 (±14.35) for nasal diseased patients and 7.76 (±13.47) for those with no nasal disease (P ≤ 0.0001). This difference reflects the sensitivity of the CSS in identifying the presence of sinonasal symptoms. However, this total score was not found to be significantly higher among CD: 10.79 (±15.16) for UC patients and 6.15 (±11.90) in the UC group, P = 0.125 [Table 3] and [Table 4].
Table 3: Correlation between chronic sinusitis survey scores and the presence of sinonasal symptoms

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Table 4: Correlation between chronic sinusitis survey scores and inflammatory bowel disease types

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As for the physical domain of the RSDI, the results indicate that 24.4% and 23.2% of the participants reported “usually” feeling pain or pressure and eye pain and reading difficulty, respectively. Otherwise, the majority of participants reported “never” experiencing any of the domain items. Similar results were found in the functional and emotional domains, where the vast majority reported never experiencing the two domain's items. In the functional domain, 17.1% of participants reported feeling tired, and 11% reported usually feeling restricted in their routine activities. With regard to the emotional domain, the highest reported disorder was difficulty in attention, which was found among 12.2% of the participants [Figure 1].
Figure 1: The rhinosinusitis disability index results

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  Discussion Top

The prevalence of CRS in the US has been estimated at 15%,[11] while the prevalence in Europe has been reported as 10.9%.[12] The criteria to diagnose CRS are based on the presence of at least two of the following symptoms for a minimum of 12 weeks: nasal obstruction, nasal discharge, facial pain, or olfactory dysfunction.[1] In addition, a nasal endoscopy should identify at least one of the following signs: nasal polyps, mucopurulent discharge, or edematous mucosal obstruction primarily in the middle meatus. In lieu of a nasal endoscopy, diagnostic imaging with a computed tomography scan should find mucosal changes within the ostiomeatal complex, and/or sinuses.[1] However, among the IBD patients in our study, there appeared to be a low number of patients who had been diagnosed with chronic sinonasal symptoms.

It should be noted that IBD is a systemic disease that manifests as extraintestinal symptoms. These symptoms play an important role in disease morbidity, and in some patients, they are the first clinical manifestations of IBD, sometimes preceding the onset of gastrointestinal symptoms by many years.[5] Some patients have described extraintestinal complications involving the nose and paranasal sinuses with IBD. Kinnear reported a case of a young woman with CD who developed nasal congestion and postnasal drainage. She was eventually found to have posterior nasal lesions histologically resembling CD inflammation.[13] Other reports of CD patients have described cases of nasal septal perforation,[14] nasal mucosal inflammation causing stenosis,[15] and microabscesses.[16] Some previous studies have noted the high prevalence of chronic sinonasal symptoms in IBD patients. David T et al. report a link between IBD and chronic sinonasal symptoms. They conducted a study with a net sample of 160 patients to determine the prevalence of chronic sinonasal manifestations in IBD patients. Of their study participants, 44 were diagnosed with UC, and the rest were CD patients. The researchers found that 48% of the patients with IBD reported chronic sinonasal disease symptoms, and patients with CD had a higher prevalence of sinonasal disease than patients with UC (53% vs. 32%; P, 0.02).[6] On the other hand, another study published by Yang et al. found that rhinosinusitis-derived staphylococcal enterotoxin B is possibly associated with the pathogenesis of UC. In some UC patients, these researchers found that pathogenesis may be associated with preexisting CRS by a mechanism of swallowing sinusitis-derived staphylococcal enterotoxin B.[17]

In Saudi Arabia, the connection between IBD and chronic sinonasal symptoms is still largely unknown; hence, we conducted this cross-sectional analysis of 82 IBD cases from Saudi Arabia. Our results indicate that the prevalence of nasal disease among IBD patients is low (11%), with a higher prevalence of nasal disease among CD patients compared to UC patients. This is contrary to a study conducted in the US, which found an elevated prevalence of chronic sinonasal disease in IBD patients, with chronic sinonasal disease occurring in approximately half of the patients.[6]

With regard to the RSDI, the total score was 11.07, and participants with a positive nasal disease history demonstrated higher RSDI total and subscale (physical and functional) scores, which represent greater disease impact. The total mean CSS score differed significantly between patients who were found to have nasal disease compared to those with no nasal disease.

There are many reasons for the increase in findings with regard to the association between sinonasal symptoms and IBD. For example, CD inflammation was found to involve the enhanced recruitment of leukocytes from the bloodstream, which may contribute to dysregulated mucosal inflammation in the gut.[18] Furthermore, autonomic hyperreflexia has been associated with more severe inflammation in some CD patients.[19]

Despite the strengths of this research, our study is limited by its relatively small sample size. The endoscopic and radiological assessment was done only for the patients who have been diagnosed with sinonasal symptoms; a large percentage of patients being on steroids could underestimate the CSS and RDSI scores, while smoking could increase it. Further study on larger sample size is suggested.

  Conclusion Top

Based on our findings, we conclude that the prevalence of the CRS among IBD patients is low. It is less prevalent in UC patients in comparison to CD patients. Further studies could address the prevalence of sinonasal symptoms among IBD patients in Saudi Arabia by considering a large number of patients in different regions.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Hastan D, Fokkens WJ, Bachert C, Newson RB, Bislimovska J, Bockelbrink A, et al. Chronic rhinosinusitis in Europe – An underestimated disease. A GA2LEN study. Allergy 2011;66:1216-23.  Back to cited text no. 12
Kinnear WJ. Crohn's disease affecting the nasal mucosa. J Otolaryngol 1985;14:399-400.  Back to cited text no. 13
Ulnick KM, Perkins J. Extraintestinal Crohn's disease: Case report and review of the literature. Ear Nose Throat J 2001;80:97-100.  Back to cited text no. 14
Pochon N, Dulguerov P, Widgren S. Nasal manifestations of Crohn's disease. Otolaryngol Head Neck Surg 1995;113:813-5.  Back to cited text no. 15
Kriskovich MD, Kelly SM, Jackson WD. Nasal septal perforation: A rare extraintestinal manifestation of Crohn's disease. Ear Nose Throat J 2000;79:520-3.  Back to cited text no. 16
Yang PC, Liu T, Wang BQ, Zhang TY, An ZY, Zheng PY, et al. Rhinosinusitis derived Staphylococcal enterotoxin B possibly associates with pathogenesis of ulcerative colitis. BMC Gastroenterol 2005;5:28.  Back to cited text no. 17
Fiocchi, C. Inflammatory bowel disease: Etiology and pathogenesis. Gastroenterology 1998;115:182-205.  Back to cited text no. 18
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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