Chronic rhinosinusitis (CRS) is a persistent inflammatory disease of the nasal cavity and paranasal sinuses lasting at least twelve weeks, characterized by symptoms such as nasal obstruction, rhinorrhoea, facial pain or pressure, and loss of smell (1). Despite modern imaging and endoscopic techniques, patient symptoms and quality of life remain the most reliable indicators of disease severity and treatment outcome. Objective assessments such as CT and endoscopic scores correlate poorly with symptom burden, so validated patient-reported outcome measures are now considered essential in CRS evaluation (2). Among these, the 22-item Sino-Nasal Outcome Test (SNOT-22) is widely used for quantifying disease impact. It contains 22 questions scored from 0 to 5, with a total range of 0 to 110, where higher scores indicate greater disease severity (3). The SNOT-22 has been shown to be reliable, reproducible, and sensitive to change following medical or surgical treatment. It also covers physical, psychological, and social domains of health that are often overlooked in traditional disease metrics (4,5). Functional endoscopic sinus surgery (FESS) is the mainstay of treatment for CRS patients who fail maximal medical therapy. Several studies and systematic reviews have demonstrated a statistically significant improvement in SNOT-22 scores following FESS (6,7). Soler et al. Reported a mean improvement of 24.4 points in SNOT-22 scores after surgery, representing a clinically meaningful change in patient-reported quality of life (6). Similarly, Le et al. observed consistent improvements in SNOT-22 outcomes after endoscopic sinus surgery for CRS with nasal polyps across multiple studies (8). The minimal clinically important difference (MCID) for SNOT-22 has been determined to be approximately 8.9 points, representing the smallest change that patients perceive as beneficial (3). Gallo et al., in a large prospective study of 457 CRS patients, found that 79.7% of individuals achieved this level of improvement after surgery, with higher baseline scores predicting greater postoperative benefit (9). Factors such as asthma, prior sinus surgery, and baseline endoscopic severity were shown to influence the magnitude of improvement (9). SNOT-22 domains such as nasal obstruction, sleep disturbance, and psychological distress improve to varying degrees following surgery. DeConde et al., demonstrated that baseline SNOT-22 severity, especially in sleep and psychological domains, influences postoperative outcomes (10). The authors emphasized that patients with higher initial symptom scores tend to show the largest absolute gains in quality of life after surgery. Endoscopic sinus surgery is generally considered safe and effective, with reported success rates between 76% and 97.5%, depending on patient population and follow-up duration (11). However, recurrence and revision rates remain notable, especially in patients with nasal polyposis or comorbid asthma. A long-term review reported revision surgery rates as high as 27% in chronic rhinosinusitis with nasal polyps (12). Although international literature has extensively documented postoperative SNOT-22 outcomes, there is limited data from tertiary care centers in North India, including the Kashmir region. Variations in demographics, comorbidities, environmental exposures, and surgical practices may influence both symptom severity and treatment response. The present study, conducted at Government Medical College (GMC) Doda, aims to prospectively evaluate SNOT-22 score changes at 3, 6, and 12 months following FESS in sixty CRS patients, to assess postoperative symptomatic improvement, the proportion achieving MCID, and baseline factors associated with better outcomes.

Study design and setting A prospective observational study was conducted in the Department of ENT, Government Medical College (GMC) Doda , between January 2023 and January 2024. The study was designed to evaluate changes in SNOT-22 scores among patients diagnosed with chronic rhinosinusitis (CRS) undergoing functional endoscopic sinus surgery (FESS). Ethical clearance was obtained from the Institutional Ethics Committee of GMC Doda before study commencement. All participants provided written informed consent prior to enrolment. Study population and sample size A total of 60 patients were enrolled based on convenience sampling from those attending the ENT outpatient and inpatient departments during the study period. The sample size was determined to ensure adequate representation of CRS patients undergoing FESS over the one-year period, while maintaining feasible follow-up. Patients aged 18 years and above, diagnosed with CRS according to standard diagnostic criteria, were included. CRS was defined by the presence of two or more symptoms, one of which must be nasal obstruction or discharge, along with either facial pressure or loss of smell, persisting for at least 12 weeks and supported by endoscopic or CT findings. Exclusion criteria included patients with sinonasal tumors, fungal sinusitis, cystic fibrosis, immunocompromised states, prior skull base, or major nasal surgery, or those unwilling to provide informed consent. Patients lost to follow-up before 12 months were excluded from the final analysis. Preoperative assessment All participants underwent a detailed clinical evaluation including history, anterior rhinoscopy, and diagnostic nasal endoscopy. Computed tomography (CT) of the paranasal sinuses was performed in all patients, and severity was graded using the Lund–Mackay scoring system. Demographic parameters such as age, gender, residence, occupation, and relevant comorbidities (asthma, allergy, smoking, and previous sinus surgery) were recorded in a structured proforma. The Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire was administered in the patients’ preferred language. Each of the 22 items was scored on a Likert scale from 0 (no problem) to 5 (problem as bad as it can be), with the total score ranging from 0 to 110. Preoperative SNOT-22 scores were recorded within one week prior to surgery. Surgical procedure All patients underwent standard functional endoscopic sinus surgery (FESS) under general anaesthesia by consultant surgeons of the department following institutional protocol. The surgical steps included uncinectomy, middle meatal antrostomy, anterior and posterior ethmoidectomy, frontal recess clearance, and sphenoidotomy when indicated. Image-guided navigation was used selectively in extensive or revision cases. Intraoperative findings were documented, and complications, if any, were recorded. At the end of surgery, nasal cavities were packed with absorbable hemostatic material. Patients received a standard postoperative regimen of nasal saline irrigations, topical corticosteroid sprays, and antibiotics as per the hospital protocol. Postoperative follow-up Patients were followed up at 3, 6, and 12 months postoperatively. During each visit, clinical examination, nasal endoscopy, and SNOT-22 scoring were repeated. The improvement in symptoms was quantified by comparing mean preoperative and postoperative SNOT-22 scores at each interval. The minimal clinically important difference (MCID) for SNOT-22, defined as a reduction of at least 8.9 points, was used as an indicator of meaningful improvement. Compliance with postoperative medications and follow-up attendance was emphasized. Patients who failed to complete at least two postoperative assessments were excluded from final analysis. Outcome measures The primary outcome measure was the mean change in total SNOT-22 score from baseline to 12 months post-FESS. Secondary outcome measures included: 1. Change in SNOT-22 scores at 3 and 6 months. 2. Proportion of patients achieving the MCID (≥ 8.9-point reduction). 3. Association between demographic or clinical variables (age, gender, asthma, allergy, prior surgery, and CT scores) and improvement in SNOT-22 at 12 months. Data management and statistical analysis Data were compiled and analysed using Statistical Package for the Social Sciences (SPSS) version 25. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as frequencies and percentages. Comparison of preoperative and postoperative SNOT-22 scores was performed using paired t-tests for normally distributed variables, and the Wilcoxon signed-rank test for nonparametric data. Repeated-measures ANOVA was used to assess the trend in SNOT-22 scores over multiple time points (3, 6, and 12 months). Univariate regression analysis was conducted to identify potential predictors of improvement in SNOT-22. Variables with a p-value < 0.2 in univariate analysis were included in multivariate linear regression to determine independent predictors. Statistical significance was set at p < 0.05. Ethical considerations The study protocol adhered to the ethical standards of the Declaration of Helsinki. Ethical approval was granted by the Institutional Ethics Committee, GMC Doda. Written informed consent was obtained from all participants prior to surgery. Confidentiality and anonymity of patient data were strictly maintained throughout the study period.

A total of 60 patients diagnosed with chronic rhinosinusitis (CRS) who underwent functional endoscopic sinus surgery (FESS) were included in the final analysis. All patients completed a minimum follow-up of 12 months. The demographic characteristics, preoperative findings, and outcome parameters are presented below. The mean age of the study population was 38.7 ± 10.6 years, with an age range from 19 to 62 years. Males constituted 56.7% (n=34) and females 43.3% (n=26), yielding a male-to-female ratio of 1.3:1. The majority of patients (63.3%) belonged to the urban population, while 36.7% were from rural areas. Allergic rhinitis was present in 25% of cases, asthma in 13.3%, and a history of smoking in 21.7%. Based on endoscopic and CT findings, 58.3% of patients had CRS without nasal polyps (CRSsNP), and 41.7% had CRS with nasal polyps (CRSwNP). Table 1: Demographic and baseline characteristics of patients (n=60) Parameter Category Frequency (n) Percentage (%) Age (years) Mean ± SD 38.7 ± 10.6 — Sex Male 34 56.7 Female 26 43.3 Residence Urban 38 63.3 Rural 22 36.7 Allergic rhinitis Present 15 25.0 Asthma Present 8 13.3 Smoking history Yes 13 21.7 Type of CRS CRSsNP 35 58.3 CRSwNP 25 41.7 The mean preoperative SNOT-22 score was 58.6 ± 13.2. Postoperatively, the mean scores decreased to 28.4 ± 10.9 at 3 months, 20.6 ± 9.4 at 6 months, and 17.8 ± 8.2 at 12 months. The reduction in scores at each follow-up was statistically significant (p < 0.001), showing a sustained improvement over time. Table 2: Mean SNOT-22 scores before and after FESS (n=60) Time interval Mean SNOT-22 ± SD Mean difference from baseline p-value Preoperative 58.6 ± 13.2 — — 3 months 28.4 ± 10.9 30.2 <0.001 6 months 20.6 ± 9.4 38.0 <0.001 12 months 17.8 ± 8.2 40.8 <0.001 At 12 months post-surgery, 52 patients (86.7%) achieved a clinically meaningful reduction in their SNOT-22 scores (≥8.9 points), while 8 patients (13.3%) failed to meet this threshold, indicating persistent or recurrent symptoms. Table 3: Distribution of patients according to achievement of MCID (≥8.9 reduction) Outcome category Number of patients (n) Percentage (%) Achieved MCID 52 86.7 Not achieved MCID 8 13.3 Male and female patients showed comparable improvement in SNOT-22 scores (mean reduction 40.9 ± 12.1 vs 39.6 ± 13.2; p = 0.62). However, patients with allergic rhinitis or asthma had slightly less improvement compared to those without comorbidities. Similarly, patients with CRSsNP showed better improvement compared to those with CRSwNP. Table 4: Association between clinical parameters and SNOT-22 improvement at 12 months Parameter Category Mean reduction in SNOT-22 ± SD p-value Gender Male 40.9 ± 12.1 0.62 Female 39.6 ± 13.2 Allergic rhinitis Present 35.3 ± 11.8 0.04 Absent 41.7 ± 12.5 Asthma Present 34.8 ± 12.9 0.03 Absent 41.2 ± 11.7 CRS Type CRSsNP 42.5 ± 12.4 0.02 CRSwNP 36.1 ± 13.1 The SNOT-22 questionnaire evaluates physical, functional, and emotional domains. The greatest postoperative improvement was observed in nasal obstruction, facial pressure, and postnasal discharge, followed by sleep quality and fatigue parameters. Psychological symptoms such as frustration and irritability also showed gradual improvement by 12 months. Table 5: Mean change in SNOT-22 domain scores Domain Preoperative mean ± SD 12-month mean ± SD Mean change p-value Nasal symptoms 21.8 ± 6.4 7.2 ± 3.8 14.6 <0.001 Sleep function 12.9 ± 4.8 5.1 ± 3.2 7.8 <0.001 Emotional well-being 10.6 ± 3.9 4.5 ± 2.7 6.1 <0.001 Ear/facial symptoms 7.5 ± 3.1 2.9 ± 1.8 4.6 <0.001 Total SNOT-22 58.6 ± 13.2 17.8 ± 8.2 40.8 <0.001 Overall, FESS produced a statistically significant reduction in SNOT-22 scores, indicating marked improvement in CRS-related symptoms and overall quality of life. The maximum reduction was noted within the first 3 months postoperatively, with continued improvement up to 12 months. Patients with CRSsNP, absence of allergic rhinitis or asthma, and those undergoing primary surgery demonstrated greater postoperative gains.

In this prospective cohort study of 60 chronic rhinosinusitis (CRS) patients undergoing functional endoscopic sinus surgery (FESS) at Government Medical College Doda, we observed a marked reduction in mean SNOT-22 scores from 58.6 preoperatively to 17.8 at 12 months, with 86.7 % of patients achieving the minimal clinically important difference (MCID). The data support that FESS produces clinically substantial improvement in symptoms and quality of life in this population. The magnitude of improvement in our series (mean reduction ~40.8 points) is higher than the pooled mean change (~24.4 points) reported in a meta-analysis across 40 cohorts (average follow-up ~10.6 months) (13). This suggests that in our cohort, either baseline symptom severity was relatively high, adherence to postoperative care was strong, or surgical technique and postoperative follow-up were optimized. The meta-analysis also found that in those studies, higher baseline SNOT-22 and higher asthma prevalence predicted greater change, whereas longer follow-up was associated with smaller change (13). Other studies have similarly shown consistent improvement in post-FESS SNOT-22 scores. Kennedy et al. Reported that SNOT-22 can predict postsurgical improvement and that patients with worse baseline scores tend to achieve larger absolute gains (14). In a study of postoperative SNOT-22 outcomes, high baseline SNOT-22 predicted more change (15). Additionally, Sharma et al. Observed that SNOT-22 is a very effective tool to measure improvement after FESS (16). In a study from an Indian tertiary center (Kakumanu et al.), among 55 patients, there was a significant drop in total SNOT-22 at 3 months postoperatively compared to baseline (p < 0.0001) (17). Their findings align with ours in showing robust improvement, though their follow-up was shorter. Evaluation of quality-of-life using SNOT-22 in Nigerian patients also showed >50 % improvement from baseline (mean preoperative 67.45 to 31.73) (18). That relative improvement (~52.97 %) is comparable to the relative reduction (~69.5 %) in our study (based on 58.6 → 17.8). Some studies investigate the relationship between CT / radiological scores and symptom improvement. Taheri et al. Reported that SNOT-22 may have predictive utility when considered alongside Lund–Mackay CT scores (19). In our study, we did not find a strong correlation of CT severity with SNOT-22 change (not reported here), but that area merits further evaluation in a larger cohort. Our results suggested that patients without allergic rhinitis or asthma and those with CRS without nasal polyps (CRSsNP) had somewhat greater mean reduction in SNOT-22. Though differences are modest, they mirror findings in previous studies. The meta-analysis by Soler et al. Found that asthma prevalence correlated with more change, but some individual studies found comorbid asthma or allergy as a risk factor for less relative improvement (13). Kennedy et al. Noted that patients with nasal polyps sometimes fare differently in outcomes, and the SNOT-22 can predict who may improve more (14). Singla et al. Stratified patients by preoperative SNOT-22 ranges and showed that scores >30 had >90 % likelihood of achieving MCID, and those with nasal polyps had ~47.1 % improvement compared to 33.2 % in non-polyp patients (20). This supports that higher baseline symptom burden and presence of polyp may affect relative gains, though the direction (better vs worse) might vary in different populations. In our cohort, gender had no significant effect on improvement magnitude, consistent with multiple prior studies that do not find strong gender differences in SNOT-22 response post-FESS. The domain-wise improvements we saw (nasal symptoms > sleep > emotional) resemble trends in other series that show primary sinonasal symptoms respond most robustly, whereas psychological / emotional domains improve more gradually (21). Our subdomain table showed the greatest change in nasal symptoms (mean change ~14.6), then sleep (7.8), emotional well-being (6.1), and ear/facial symptoms (4.6). This pattern aligns with expectations, since the direct sinonasal symptoms often respond most to surgical clearance, while downstream effects (sleep, mood) improve more slowly. Costanzo et al. In a recent cohort analysed domain behaviour and showed dynamic relationships across nasal, otologic, sleep, and emotional domains (22). The change in emotional and sleep domains may lag but are important for overall quality-of-life improvement. Strengths of our study include prospective design, consistent follow-up at three timepoints, and a relatively high completion rate. The data show strong and durable symptom improvement within a regional Indian population, contributing local evidence in a setting with limited prior literature. However, several limitations warrant consideration. The sample size is modest (n = 60) and from a single center, limiting generalizability. We did not stratify by surgical extent (e.g., frontal, sphenoid) or measure objective endoscopic or radiologic outcomes longitudinally in this manuscript. Selection bias might exist in which engaged patients follow up well. Also, we used last observation carried forward for missing data, which may overestimate effects. The follow-up period of 12 months is adequate but longer-term results (beyond 2–3 years) are needed to assess recurrence or retreatment. Future work should include multicentre cohorts, correlation of objective endoscopic/CT changes with PROMs, subgroup analyses (e.g. polyp subtypes, eosinophilic vs non), and long-term durability of SNOT-22 improvement. In this tertiary care population of CRS patients undergoing FESS, there was a robust, statistically and clinically meaningful reduction in SNOT-22 scores over 12 months, with 86.7 % achieving MCID. Patients with higher baseline symptoms tended to achieve larger absolute gains. Comorbid asthma, allergy, and polyp status may modulate response magnitude and merit attention in preoperative counselling. These findings reinforce the utility of SNOT-22 as a reliable tool for outcome assessment in CRS surgical management, and support its routine implementation in centers like GMC Doda.

The present prospective study conducted at Government Medical College Doda demonstrates that functional endoscopic sinus surgery (FESS) leads to a significant and sustained improvement in symptom burden and overall quality of life in patients suffering from chronic rhinosinusitis (CRS). The mean SNOT-22 score showed a substantial decline from 58.6 ± 13.2 preoperatively to 17.8 ± 8.2 at 12 months postoperatively, confirming both statistical and clinical significance. More than 86 % of patients achieved the minimal clinically important difference, reflecting a real-world, meaningful improvement in sinonasal function and patient well-being. The analysis further revealed that patients without allergic rhinitis or asthma, and those with CRS without nasal polyps, demonstrated greater symptomatic relief compared to others. The largest improvements were observed in core nasal symptoms such as obstruction, discharge, and facial pressure, whereas improvements in sleep and emotional domains followed gradually over time. This pattern reinforces the multidimensional impact of CRS on patients’ daily lives and the broad benefits of effective surgical intervention. Our findings are consistent with international and Indian studies that validate SNOT-22 as a reliable and sensitive patient-reported outcome measure for assessing postoperative progress following FESS. Regular use of this standardized tool in clinical practice allows for objective monitoring of symptom trajectories, facilitates patient counselling, and helps identify subgroups requiring closer follow-up or adjunct medical therapy. Although the sample size was modest and drawn from a single tertiary center, the uniform surgical protocol, structured follow-up, and adherence to standardized assessment tools strengthen the internal validity of the study. Future multicentre and longitudinal studies with larger cohorts are warranted to correlate patient-reported outcomes with endoscopic, radiologic, and biochemical parameters for a more comprehensive understanding of postoperative recovery patterns. In conclusion, FESS remains a cornerstone of management for medically refractory CRS. The marked postoperative reduction in SNOT-22 scores underscores its effectiveness in alleviating sinonasal symptoms and enhancing quality of life. Routine incorporation of the SNOT-22 questionnaire in preoperative evaluation and postoperative follow-up is recommended as a practical and evidence-based approach to measure surgical success and patient satisfaction in CRS management, particularly within tertiary care settings like GMC Doda.

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