What is the appropriate management for an adult patient with chronic nasal and sinus symptoms, as indicated by a high Sino-Nasal Outcome Test (SNOT) 22 score?

Management of Chronic Rhinosinusitis Based on High SNOT-22 Scores

A high SNOT-22 score (>21) indicates clinically significant chronic rhinosinusitis requiring treatment with intranasal corticosteroids as first-line therapy, with consideration for endoscopic sinus surgery if medical management fails after appropriate trial duration. 1

Understanding SNOT-22 Scoring

The SNOT-22 is a validated 22-item patient questionnaire scored from 0-110, where higher scores indicate worse disease-specific quality of life 1. The minimally important difference (MID) is 8.9-12 points, meaning changes of this magnitude represent clinically meaningful improvement or worsening 1.

Key diagnostic thresholds:

• SNOT-22 >21: Optimal cutoff for identifying CRS in adults, with 76% sensitivity and 61% specificity 2
• MID of 8.9 points: Represents patient-important improvement in quality of life 1
• Scores correlate with disease severity but do not differentiate CRS from non-CRS conditions alone 3

First-Line Medical Management

Intranasal corticosteroids represent the cornerstone of initial therapy for all patients with high SNOT-22 scores and confirmed CRS 1, 4, 5. The evidence demonstrates a standardized mean difference in nasal symptoms of -0.63 (95% CI: -0.89 to -0.37) and SNOT-22 improvement of -5.46 points (95% CI: -8.08 to -2.84) 5.

Specific Medical Therapy Regimen:

• Intranasal corticosteroids: Use daily as primary therapy 1, 4, 6

  • Fluticasone propionate: 2 sprays per nostril once daily for adults (ages ≥12); 1 spray per nostril once daily for children ages 4-11 6
  • Maximum duration before reassessment: 6 months for adults, 2 months per year for children 6
  • Relief typically begins within the first day, with full effectiveness after several days of regular use 6

• Nasal saline irrigation: Use as adjunctive therapy 5

  • High-volume irrigation (240 mL) once daily shows benefit 1
  • Can be enhanced with xylitol (12g in 240mL water) for additional SNOT-22 improvement 1

• Short-course oral corticosteroids: Reserve for acute exacerbations 4, 5

Important Considerations for Medical Therapy:

There is no "one-size-fits-all" regimen or mandatory duration of medical therapy required before considering surgery 1. The term "appropriate" has replaced "maximal" medical therapy, as consensus on what constitutes maximal therapy is lacking 1. Treatment decisions should be based on disease subtype, tolerability, and expected effectiveness rather than arbitrary time periods 1.

Indications for Surgical Intervention

Endoscopic sinus surgery is indicated when appropriate medical therapy fails to achieve adequate and sustained symptom improvement 1, 4, 5. Surgery improves individual symptoms, overall symptom scores, and quality of life 5.

Specific surgical criteria:

• Persistent symptoms with SNOT-22 >5 on VAS scale despite appropriate medical treatment 1
• Severe nasal polyposis with obstruction 4
• Uncontrolled disease defined as requiring rescue medication with ongoing symptoms 1

Disease Severity Assessment Beyond SNOT-22

While SNOT-22 provides symptom severity, comprehensive assessment requires:

• Nasal endoscopy: Lund-Kennedy scoring for polyps, edema, discharge, scarring, and crusting 1
• CT imaging: Lund-Mackay scoring (0-24 scale) 1, 7
  • Scores ≥5 have excellent positive predictive value for true disease 7
  • Scores ≤2 have excellent negative predictive value 7
  • Only olfaction correlates significantly with CT scores among symptoms 7

Advanced Therapies for Refractory Disease

For severe refractory CRS with nasal polyposis unresponsive to medical and surgical management, biological agents are indicated 5. This represents difficult-to-treat rhinosinusitis, defined as persistent symptoms despite adequate surgery, intranasal corticosteroids, and up to two short courses of antibiotics or systemic corticosteroids in the past year 1.

Critical Pitfalls to Avoid

• Do not use SNOT-22 alone for diagnosis: While useful for severity assessment, SNOT-22 is a poor differentiator between CRS and non-CRS conditions 3. Diagnosis requires combination of symptoms, endoscopy, and imaging 1, 5

• Do not mandate arbitrary medical therapy duration: Requiring predetermined regimens or durations before surgery is not evidence-based 1

• Do not share nasal spray bottles: This spreads germs through nozzle contamination 6

• Monitor growth in children: Intranasal corticosteroids may slow growth rate in some children, necessitating physician consultation if use exceeds 2 months per year 6

• Avoid long-term use without reassessment: Adults using intranasal steroids for >6 months and children using >2 months per year require physician evaluation 6

Treatment Algorithm Summary

1. Confirm CRS diagnosis: SNOT-22 >21 plus endoscopic findings and/or imaging 1, 2
2. Initiate intranasal corticosteroids: Daily use with nasal saline irrigation 4, 6, 5
3. Reassess at appropriate intervals: Monitor SNOT-22 scores for MID improvement of ≥8.9 points 1
4. Consider surgery: If symptoms remain uncontrolled (VAS >5) despite appropriate medical therapy 1, 4
5. Evaluate for biologics: In severe refractory disease with nasal polyposis after failed medical and surgical management 5