Imane Ammouze 1, Jure Urbančič 2
Characteristics of Patients with nasal
Complaints who do not Fulfil the Criteria
for Primary Chronic rhinosinusitis
Značilnosti bolnikov z nosnimi težavami, ki ne dosegajo meril
za primarni kronični rinosinuzitis
aBstraCt
KEY WORDS: primary chronic rhinosinusitis, quality of life, EPOS, diagnosis
BACKGROUNDS. Chronic rhinosinusitis (CRS) is a common chronic disease of the sinu-
ses and the nasal mucosa. The diagnosis is confirmed when all the clinical and endos-
copic criteria are fulfilled. In real-life situations, patients presenting similar symptoms
sometimes do not fulfil the proposed criteria for chronic rhinosinusitis. METHODS. In
our study, we compared patients who failed to fulfil all of the criteria for primary CRS
during the diagnostics and were enrolled from the clinical database updated from 2015
to the present time into the control group, which had no nasal issues. We analyzed their
clinical characteristics, number of previous nasal surgeries, the results from Sino-nasal
Outcome Test-22 (SNOT-22) Questionnaire, Visual Analogue Scale for total nasal pro-
blems, objective and subjective smell report and respective computer tomography (CT),
and endoscopic scores. RESULTS. 97 patients and 21 controls with no nasal pathology
met all inclusion and exclusion criteria of the study. We found no difference in age distri-
bution, number of outpatient visits and number of previous surgeries. However, we found
a statistically significant difference in objective smell score, visual analog and SNOT-22
score, Lund-Mackay and Kennedy-Lund score. DISCUSSION. The measured olfactory func-
tion combined with the quality of life assessment and reasonable clinical assessment might
help to identify the subgroup of patients with mild nasal problems. Nevertheless, we can-
not be sure whether this is the final presentation of their disease or whether some will
develop primary chronic rhinosinusitis in the future as there is no current test to pre-
dict the progress of such symptoms.
1 Imane Ammouze, štud. med., Faculty of Medicine and Pharmacy of Rabat, Imp. Souissi, 10100 Rabat, Morocco
2 Asist. Jure Urbančič, dr. med., Klinika za otorinolaringologijo in cervikofacialno kirurgijo, Univerzitetni klinični center
Ljubljana, Zaloška cesta 2, 1000 Ljubljana; Katedra za otorinolaringologijo, Medicinska fakulteta, Univerza v Ljubljani,
Zaloška cesta 2, 1000 Ljubljana
377Med Razgl. 2022; 61 Suppl 2: 377–382
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 377
characteristics of patients not fulfilling the
EPOS 2020 criteria for primary CRS and of
those not having any nasal issues. The aut-
hors believe that patients in our group
may be clinically closer to patients without
nasal problems (5). Therefore, we hypothe-
size that the difference in clinical attribu-
tes should not be significant.
MetHoDs
The study was performed at the University
Medical Centre Ljubljana, Department for
Otorhinolaryngology and Cervicofacial
Surgery, from August 1, 2021, to August 27,
2021. Patients were enrolled from the clini-
cal database, which had been continuously
updated since 2015 to the present time. At
the start of our study, the database compri-
sed of more than 1,300 patients, all of whom
had signed an institutional approval for col-
lecting the data. We were searching for
cases initially entered as probable CRS but
which failed to fulfil all of the criteria for pri-
378 Imane Ammouze, Jure Urbančič Characteristics of Patients with nasal Complaints who do not …
iZvleČek
KLJUČNE BESEDE: primarni kronični rinosinuzitis, kakovost življenja, EPOS, diagnostika
IZHODIŠČA. Kronični rinosinuzitis je pogosta bolezen sluznice nosu in obnosnih votlin.
Diagnozo potrdimo z znanimi kliničnimi in endoskopskimi merili. V klinični praksi pa
večkrat najdemo bolnike, ki imajo simptome, podobne kroničnemu rinosinuzitisu, a ne
izpolnjujejo meril za diagnozo. METODE. V raziskavi smo primerjali bolnike brez izpol-
njenih meril za diagnozo kroničnega rinosinuzitisa s kontrolno skupino, ki nima nosnih
težav. Podatke smo pridobili iz baze podatkov, ki sega v leto 2015. Primerjali smo nji-
hove klinične značilnosti, število prejšnjih operacij v nosnem predelu, dosežen rezultat
pri sinonazalnem testu izida 22 (Sino-Nasal Outcome Test, SNOT-22), vizualni analogni
lestvici (Visual Analog Scale, VAS), objektivnih in subjektivnih ocenah voha in rezulta-
te računalniške tomografije in endoskopije. REZULTATI. 97 bolnikov in 21 kontrolnih pre-
iskovancev je ustrezalo merilom za vključitev. Razlik nismo našli pri starosti, številu obiskov
v ambulanti in številu predhodnih posegov. Statistično značilne razlike pa smo našli v obje-
ktivni oceni voha, oceni VAS in SNOT-22 ter v Lund-Mackayjevi in Kennedy-Lundovi oceni.
RAZPRAVA. Izmerjena vohalna funkcija, oceno kakovosti življenja in ustrezna klinična
preiskava bi lahko pomagale poiskati bolnike z milimi nosnimi težavami. Vseeno pa ne
vemo, ali je trenutno stanje teh bolnikov dokončno, Morda se bo sčasoma izkazalo, da
njihova bolezen vseeno ustreza merilom za primarni kronični rinosinuzitis, saj trenut-
no ne obstajajo preiskave, ki bi lahko napovedale razvoj simptomov.
BaCkgroUnDs
Chronic rhinosinusitis (CRS) is a common
chronic disease of the sinuses and the nasal
mucosa (1). It’s prevalence is estimated at
10.9% for the general European population
(2). The diagnosis is confirmed when all the
European Position Paper on the Primary
Care Diagnosis and Management of Rhino-
sinusitis and Nasal Polyps 2020 (EPOS
2020) criteria are fulfilled – primary crite-
ria are related to the history of the disease,
and secondary criteria can be assessed only
after an endoscopy of the nose, which is
almost inclusively available at the otola-
ryngologists’ (ear, nose and throat, ENT) out-
patient offices (1, 3). EPOS 2020 recognizes
the main differentiation between primary
CRS and secondary CRS as adapted from the
work of Grayson and colleagues (4). In real-
life situations, patients presenting similar
symptoms sometimes do not fulfil the pro-
posed criteria for CRS and fail to get a CRS
diagnosis. This study compares the clinical
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 378
resUlts
We identified 97 patients with nasal com-
plaints not diagnosed as primary CRS and
21 controls with no nasal pathology who
met all inclusion and exclusion criteria of
the study. The mean age in the first group
was 50.9 ± 16.3 years, 53 patients were
females (54.6%) and 44 males (45.4%).
Patients came to the outpatient clinic 1–3
times, with the average of 1.2 visits. 17.5%
of the patients had an allergy, 5.2% had
asthma, and 23.3% had gastroesophageal
reflux disease (GERD). The mean number
of previous surgeries was 0.2 ± 0.5. All
patients reported having an ordinary sense
of smell. In the second group, the mean age
was 48.2 ± 11.8, 10 patients were females
(47.6%) and 11 males (52.4%), all patients
came to the outpatient clinic only once and
had no previous surgeries. All patient cha-
racteristics of both groups are shown in
table 1.
379Med Razgl. 2022; 61 Suppl 2:
mary CRS during the diagnostics (1). Mean
age, sex distribution, asthma, allergy, and
gastroesophageal reflux disease prevalence
were calculated. All patients filled out the
Slovenian Sino-nasal Outcome Test-22
(SNOT-22) Questionnaire with Visual Ana-
logue Scale (VAS) for total nasal problems and
a subjective smell report (5). Patients had also
done the Sniffin’ Sticks Screening 12 Test
(SST-12) (6). With SST-12, a score of 6 and less
is defined as anosmia, and normosmia is defi-
ned by a score of at least 11 (7). We reviewed
the number of previous nasal surgeries,
their respective computer tomography (CT)
scores and endoscopic scores (8, 9). We used
the χ2-test and multiple T-tests to compare
the groups. Statistical software Statistical
Product and Service Solutions 20 (SPSS-20,
IBM, Armonk, USA) and Prism 6 (GraphPad
Software, San Diego, USA) were used. Before
the study, we received approval from the
Slovenian national ethical committee (deci-
sion number 0120-297/2017/3).
table 1. Patient characteristics. GERD – gastroesophageal reflux disease, SNOT-22 – Sino-nasal Outcome
Test-22, SD – standard deviation.
n=118 non-primary Crs no nasal pathology p-value
Female/male 53/44 (54.6/45.4%) 10/11 (47.6/52.4%) 0.64‡
Allergy 17 (17.5%) – –
Asthma 5 (5.2%) – –
GERDa 20 (23.3%) – –
Normal smell 97 (100.0%) – –
Age (mean, min.–max., SD) 50.9 (18–81, 16.3) 48.2 (11.8) 0.61
Outpatient visits (mean, min.–max., SD) 1.2 (1–3, 0.5) 1.0 (0.0) 0.21
Sniffin’ Sticks 12b (mean, min.–max., SD) 9.3 (6–12, 1.7) 11.0 (0.4) 0.0027
Number of previous surgeriesc 0.2 (0–3, 0.5) 0.0 (0.0) 0.21
(mean, min.–max., SD)
Lund-Mackay scored (mean, min.–max., SD) 2.33 (0–9, 2.8) 0.0 (0.0) 0.0115
VAS (mean, min.–max., SD) 3.8 (0–10, 2.8) 0.2 (0.4) 0.0001
Kennedy-Lund (mean, min.–max., SD) 1.5 (0–6, 1.7) 0.0 (0.0) 0.006
Hadley score (mean, min.–max., SD) 0.3 (0–4, 0.8) 0.0 (0.0) 0.24
Total SNOT-22 scoree (mean, min.–max., SD) 19.9 (0–81, 17.15) 3.8 (3.1) 0.0039
a n= 86, b n= 50, c n= 82, d n= 48, e n= 95, ‡ χ2 test, 
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 379
In the first group, olfactory function was
assessed in 50 patients using the SST-12,
the mean result was 9.3 ± 1.7. The Lund-
Mackay score calculated in 48 patients
was 2.33±2.8. The Kennedy-Lund score was
1.5 ± 1.7, and the Hadley score was 0.3 ± 0.8.
The VAS score was 3.8 ± 2.8. The total
SNOT-22 score was 19.9 ± 17.15. 
In the control group, the SST-12 test
score was 11.0±0.4. All of the Lund-Mackay
scores, the Kennedy-Lund score and Hadley
scores were null. The VAS score was
0.2 ± 0.4. The total SNOT-22 score was
3.8 ± 3.1.
Both groups consisted of patients with
similar sex (p = 0.64) and age distribution
(p = 0.61). The number of outpatient visits
was also similar (p = 0.21). The groups
didn’t differ in the number of previous
surgeries (p = 0.21). The Hadley score sho-
wed no difference either (p=0.24). However,
the SST-12 test score was significantly
lower in the group without any nasal com-
plaints (9.3 versus 11.0, p=0.0027). Also, the
Lund-Mackay, Kennedy-Lund, and SNOT-
22 scores showed a statistically significant
difference between the two groups (p<0.05).
DisCUssion
CRS is a complex and clinically widely
diverse disease (1). Even when comparing
a group of patients not fulfilling the crite-
ria for primary CRS to the patients of the
control group not having any nasal symp-
toms, the clear-cut difference in clinical and
quality of life (QOL) parameters is hard to
anticipate. 
We have compared a group of patients
with non-primary CRS and a control group
of patients with no nasal pathology. The
patients in both groups had similar age, sex
ratio, outpatient visits, the same number of
previous nasal surgeries and equal Hadley
scores. We have disregarded the information
about allergy due to a similar percentage of
affected individuals in our non-primary
CRS group as in the general public and the
lack of exact data in our control group (2).
The distribution of patients with asthma
and patients with GERD in our non-primary
CRS group was similar as reported in epi-
demiologic studies (10, 11).
An altered sense of smell might be
a significant sign of nasal disease. It is well
known that self-rated olfaction does not cor-
relate significantly to the measured olfactory
performance, consequently, self-reported
ordinary sense of smell might not be appro-
priate for evaluation (12). Therefore, we
used the SST-12 for a more objective olfac-
tory assessment, which showed signifi-
cant differences between both groups as
shown in table 1. The non-CRS group had
a mean score within the hyposmia interval.
In contrast, the no nose pathology group
had a mean score compatible with normo-
smia, well above the anosmia limit (12). Our
data suggests that there might be some
olfactory impairment associated with the
non-primary CRS group.
The Lund-Mackay CT score and Kennedy-
-Lund endoscopic score were significantly
higher in our non-primary CRS group. We
could attribute this finding to the possibi-
lity of some patients having a secondary
CRS, prolonged or post-viral acute rhino-
sinusitis (ARS) or just repetitive episodes
of ARS (1). According to the published
population estimates from Fokkens and
colleagues, this might not be a hallmark of
the whole cohort since the controls had no
CT or endoscopic signs as shown in table 1
(1). The VAS score was also significantly
higher in our non-primary CRS group,
which may reflect the same fact. According
to EPOS 2020, the mean VAS value of the
non-primary CRS group translates to »not
bothersome symptoms« (1).
The comparison of the mean score of
the SNOT-22 questionnaire, which is used
to assess the QOL of patients with CRS,
shows a significant difference between the
group of non-primary CRS and the controls
(table 1). The values for non-primary CRS
380 Imane Ammouze, Jure Urbančič Characteristics of Patients with nasal Complaints who do not …
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 380
are considered mild according to the vali-
dated Slovenian version of the SNOT-22
test (5). This means the patients from our
non-primary CRS group fall just under the
cut-off values of the CRS cohort (1, 5). The
results obtained from the data analysis
partially supported the hypothesis of the
non-primary CRS group being similar to
the controls without CRS. Both groups are
not entirely different and at the same
time not entirely the same. Other studies
of CRS signs and symptoms also do not
always find a consistency of clinical signs
in a wide range of real-life presentations.
This results in poor patient stratification,
when some symptoms and some signs are
present, but do not entirely fulfill the EPOS
2020 criteria (1). We believe the symptoms
themselves may prompt further diagno-
stics with endoscopy and CT, but the
observed changes still do not fulfil the
beforementioned criteria for primary CRS.
The objective data rejects the hypothesis,
on the other hand, the Lund-Mackay,
Kennedy-Lund or Hadley scores are not
nearly close to the values seen in patients
with primary CRS (5).
QOL results are even more interesting.
The proven difference is somewhat expec-
ted. The patients who were referred to the
tertiary outpatient institution with some
nose complaints or diagnostic signs that
would eventually impact their QOL all had
a mild severity of symptoms. They also pre-
sent values regarded as too low to offer any
treatment (1).
The main bias of our study is the fact
that we cannot be sure whether present
signs and symptoms represent the final pre-
sentation of the patients’ disease or whet-
her some of them will develop primary CRS
in the future as there is no current test to
predict the progress of such symptoms (1).
This is the first study that has explored
the characteristics of patients with nose pro-
blems not fulfilling the criteria for prima-
ry CRS diagnosis. Further studies on similar
samples of patients might give more insight
on how to better diagnose, treat and predict
the outcomes of such patients. 
The measured olfactory function com-
bined with the QOL assessment and rea-
sonable clinical investigation might help
to identify the subgroup of patients with
mild nasal problems.
381Med Razgl. 2022; 61 Suppl 2:
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