Indian J Otolaryngol Head Neck Surg
https://doi.org/10.1007/s12070-018-1333-4
ORIGINAL ARTICLE
Correlation Between Objective Evaluation Result of Nasal
Congestion and Life Quality in Patients with Acute Rhinosinusitis
Steward Keneddy Mengko1 • Roestiniadi Djoko Soemantri1 • Sri Herawati Juniati1
Received: 19 February 2018 / Accepted: 28 March 2018
Ó Association of Otolaryngologists of India 2018
Abstract Rhinosinusitis is an inflammatory process
involving the nasal mucosa and paranasal sinuses. Rhinitis
and sinusitis generally occur simultaneously and thus the
current terminology used is rhinosinusitis. The blind nose
can negatively affect the overall quality of life including
the physical or emotional condition of the sufferer and
disruption to work or school (reduced productivity and
difficulty in concentrating). To analyse correlation between
objective evaluation results of nasal congestion through
NIPF and life quality based on sinonasal outcome Test-20
score in patients with acute rhinosinusitis. The study was
conducted at Otolaryngology Outpatient Clinic at Dr.
Soetomo General Hospital Surabaya. The time of study
began in July 2011 until the minimum sample size was
met. The sample of the study was patients diagnosed with
acute rhinosinusitis treated at Otolaryngology Outpa-
tient Clinic at Dr. Soetomo General Hospital Surabaya and
meet the research criteria. Based on statistical analysis with
Spearman rank correlation test, correlation between NIPF
value and SNOT-20 score on 16 samples got correlation
coefficient—0.310 and p = 0.243. The scatter diagram
showed the NIPF value variables and the SNOT-20 scores
being scattered in uneven spots and erratic patterns. This
indicated that an objective evaluation of nasal congestion
& Sri Herawati Juniati
sriherawati@outlook.com
Steward Keneddy Mengko
stewardkeneddy@yahoo.co.id
Roestiniadi Djoko Soemantri
thtkl_unair@yahoo.com
1 nasal sinus, complex ostiomeatal disorder (COD) and
Department of Otolaryngology, Faculty of Medicine,
Universitas Airlangga-Dr. Soetomo General Hospital,
Surabaya, Indonesia
based on NIPF and subjective assessment of quality of life
based on SNOT-20 score was not obtained correlation
(p [ 0.05). The results of the objective nasal obstruction
examination based on Nasal Inspiratory Peak Flow have no
correlation with subjective subjective assessment of quality
of life based on Sino-Nasal Outcome Test-20 score in
patients with acute rhinosinusitis.
Keywords Rhinitis
Sinusitis

Nasal inspiratory peak flow
Introduction
Rhinosinusitis is an inflammatory process involving the
nasal mucosa and paranasal sinuses. Rhinitis and sinusitis
generally occur together so that the current terminology
used is rhinosinusitis [1, 2]. Rhinosinusitis is generally
categorized into acute and chronic with a time limit of less
than 12 weeks for acute rhinosinusitis and more than
12 weeks for chronic rhinosinusitis. Rhinosinusitis is clo-
sely related to infections that can cause mucosal thickening
and accumulation of secretions in the paranasal sinus
cavity [2, 3]. Data from Electronic Medical Record (EMR)
of Dr. Soetomo General Hospital Surabaya based on
International Classification of Diseases-10 (ICD-10) in
2009 reported 586 cases of acute maxillary sinusitis, 543
cases of chronic maxillary sinusitis (Medical records of
otolaryngology outpatient clinic at Dr. Soetomo General
Hospital Surabaya).
The inflammatory process that occurs in acute rhinosi-
nusitis causes the oedema in the nasal mucosa and para-
eventually manifests in various symptoms such as pain
123

around the face or sinuses, runny nose or secretions flowing
into the throat, loss or loss [4–7].
Nasal congestion can negatively affect the overall
quality of life including the physical or emotional condition
of the sufferer, disruption to work or school (reduced
productivity and difficulty of concentration), reduced time
or quality of rest causing easily drowsiness and tiredness,
can be a trigger factor of stress and significant medical
expense burden [8, 9]. There are various types of objective
checks to assess nasal impasse such as rhinomanometry,
acoustic rhinometry and Nasal inspiratory peak flow
(NIPF).
The advantages of the NIPF method compared to rhi-
nomanometry are it is easier to use, less expensive, small,
lightweight, easy-to-interpret results, could be carried by
patients of allergic rhinitis or rhinosinusitis for monitoring
at home or elsewhere [10–12]. The objective examination
of nasal airway obstruction reported in Indonesia by pre-
vious investigators using anterior rhinomanometry in 80
patients with allergic rhinitis (AR) and 40 normal indi-
viduals showed significant (p \ 0.05) increase in nasal
airflow in patients with AR (52.50%), higher than normal
people group (15%) [13].
Improving the quality of life of the patient (Quality of
Life—QoL) is the overall goal for treatment, in addition to
reducing symptoms and functional disorders. The subjec-
tive assessment of the quality of life of rhinosinusitis
patients includes Rhinosinusitis Outcome Measurement
(RSOM-31), Rhinosinusitis Disability Index (RSDI), Sino-
Nasal Outcome Test-16 (SNOT-16), SNOT-20, Chronic
Sinusitis Survey (CSS), RhinoQol, Sinusitis Outcomes
Questionnaire (SOQ).
However, the specific QOL instrument is mostly used to
assess the effectiveness of interventions only in patients
with chronic rhinosinusitis [12]. The ever published study
was the QOL assessment by modification of SNOT-16 to
acute rhinosinusitis patients after receiving antibiotic
therapy in 166 adults at 10 physician doctors’ practice in
St. Louis, Missouri during November 2006–May 2009 [9].
Assessment of the specific life quality of patients with
rhinosinusitis progresses through the SNOT-20 instrument
[14–17]. SNOT-20 contains 20 modification questions
from Rhino-Sinusitis Outcome Measure 31 (RSOM-31)
questions. This instrument is very popular and is often used
to assess patients and the clinical effectiveness of sinonasal
diseases. SNOT-20 includes various health-related quality
of life including physical, functional and emotional limi-
tations [14].
Several studies have compared measurements of nasal
peak flowmeter, rhinomanometry and Visual Analog Scale
(VAS) in determining nasal congestion with conflicting
results. Clarke et al. found nasal peak flow as a relatively
insensitive measure compared to rhinomanometry. Jones
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Indian J Otolaryngol Head Neck Surg
et al. and Fairley et al. found a strong correlation of nasal
airway barrier examination using NIPF with anterior
anomaly and subjective sensation of the nose, and therefore
it was concluded that NIPF is a good objective examination
for nasal congestion as measured by rhinomanometry [11].
The correlation of nasal congestion assessed with NIPF and
quality of life based on the SNOT-20 score in acute rhi-
nosinusitis patients has not been reported. Based on the
above description, the authors were encouraged to find out
the correlation between the results of objective evaluation
for nasal congestion through NIPF with subjective evalu-
ation results of life quality based on SNOT-20 score in
patients with acute rhinosinusitis.
Methods
This is an observational analytical study with cross-sec-
tional design. This study was conducted in the outpatient
unit of ENT-HN Dr. Soetomo General Hospital Surabaya
from July 2011 until the minimum number of sample was
achieved. The sample of the study was patients diagnosed
with acute rhinosinusitis treated at otolaryngology outpa-
tient clinic at Dr. Soetomo General Hospital Surabaya and
met the research criteria.
Adapun the inclusion criteria in this study were patients
with acute rhinosinusitis based on the criteria of European
Position Paper on Rhinosinusitis and Nasal polyps 2007
(EP3OS), patients aged 15–55 years who have not received
antibiotic treatment, patients who were cooperative and
willing to participate in the study. The exclusion criteria
were heavy smokers, in long-term nasal drop medication,
having abnormalities or diseases in the nasal cavity such as
polyps, sinecia or heavy deviation septum, having a history
of previous nasal or sinus surgery, patients with atrophic
rhinitis, diabetes mellitus, and renal failure to autoimmune
diseases.
Consecutive sampling technique was used in this study.
The study began with anamnesis and physical examination
of each sample with anterior rhinoscopy. They were then
diagnosed with acute rhinosinusitis according to EP3OS
2007 criteria. Samples who met the research criteria were
asked to sign the informed consent to participate in the
research and to fill out the SNOT-20 questionnaire. They
then underwent Nasal Inspiratory Peak Flow (NIPF)
examination.
All collected data were arranged in data collection
sheets in the form of tables and were processed statistically
using Spearman correlation test. Data were analyzed using
SPSS software (SPSS Inc., Chicago, IL).
Indian J Otolaryngol Head Neck Surg

Results Table 2 Classification of NIPF value results and SNOT-20 score

Variable Subject N = 16
Basic data
NIPF 89.37 ± 22.27
Data distribution for age was obtained from data analysis, None 1 (6.25%)
with the youngest sample being 16 and the oldest 49. The Mild 9 (56.35%)
age mean was 30.18 years old. In gender distribution there Moderate 6 (37.5%)
were 11 female samples (68.8%) and 5 male samples Severe –
(31.2%). The level of education of the patients in this study SNOT-20 41.56 ± 17.41
consisted of 1 sample of junior high school (6.25%), 10 None-mild 8 (50%)
samples of senior high school (62.5%), 3 samples of Mild-moderate 6 (37.5%)
Diploma (18.75%) and 2 samples of College (12.5%). The Moderate-severe 2 (12.5%)
samples’ occupations were 5 samples of students (junior- Severe –
senior high school and college students) (31.25%), 3
samples of government employees (18.75%), 7 samples of
private employees (43.75%) and one sample of housewife
(6.25%) (Table 1). score of 50–80 L/s was categorized as moderate nasal
congestion and 6 samples with it were found in this study
NIPF examination results and SNOT-20 score (37.5%) with the mean of 68.33 ± 14.72. NIPF score of
81–120 L/s was categorized as mild nasal congestion and 9
The assessment included an objective evaluation of nasal samples were found (56.25%) with the mean of
congestion based on NIPF and subjective evaluation of 98.88 ± 12.44. NIPF value of more than 120 L/s indicated
quality of life based on the results of the questionnaire. The no nasal congestion objectively, with one sample was
total score of SNOT-20 showed that the mean value (SD) found (6.25%) with the mean of 130. The overall mean of
of NIPF was 89.37 (22.27), while the mean value of (SD) NIPF value was 89.37 ± 22.27 (Table 2).
SNOT-20 total score was 41.56 (17.41). The minimum Based on the criteria of total modification score SNOT-
value of NIPF was 50 and its maximum value was 130, 20 showed the degree of impaired life quality in patients
while the minimum score of SNOT-20 was 16 and its with acute rhinosinusitis. The score of 0–39 was catego-
maximum value was 73 (Table 2). rized as none-mild with 8 samples (50%). In this category,
The level of nasal congestion could be objectively the mean of SNOT-20 total score was 26.5 ± 6.84. The
determined based on NIPF examination results. The NIPF score of 40–59 was categorized as moderate with 6 samples
value of less than 50 L/s was categorized as severe nose (37.5%). In this category, the mean of SNOT-20 total score
congestion in which none were found in this study. NIPF was 52.16 ± 4.35. The score of 40–59 was categorized as
moderate with 2 samples (12.5%). In this category, the
Table 1 Subjects’ characteristic
mean of SNOT-20 total score was 70 ± 4.24. No sample
was included in severe category (with the score of 80–100)
Characteristic Subject N = 16 in this study. The overall mean of SNOT-20 total score was
Age 30.18 ± 11.36 41.56 ± 17.41) (Table 2).
Gender
Male 5 (31.2%) Correlation between NIPF value results and SNOT-
Female 11 (68.8%) 20 score
Education level
Junior high school 1 (6.25%) The statistical analysis using Spearman rank correlation
Senior high school 10 (62.5%)
test between NIPF value and SNOT-20 score showed the
Diploma 3 (18.75%)
correlation coefficient value of 0.310 and p of 0.243
(Table 3, Fig. 1). The scatter diagram showed that the
College 2 (12.5%)
NIPF value variables and the SNOT-20 scores were scat-
Occupation
tered in uneven spots and erratic patterns. This suggested
Student 5 (31.25%)
that no correlation was obtained in objective evaluation of
Government employee 3 (18.75%)
nasal congestion based on NIPF and subjective assessment
Private employee 7 (43.75%)
of quality of life based on SNOT-20 score was not obtained
Housewife 1 (6.25%)
correlation (p [ 0.05).

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Table 3 Correlation between NIPF value and SNOT-20 score
Correlation Result
Correlation coefficient - 0.310
p 0.243
N 16
Discussion
The exact prevalence of acute rhinosinusitis was difficult to
obtain because not all patients sought further treatment and
due to the variations in the terminology of rhinosinusitis
[8, 18, 19]. Acute rhinosinusitis can occur in all ages. In
general, children were more likely to experience acute
episodes than adults, averagely 6–10 times per year
whereas adults had 3–4 times episode per year [20].
The prevalence of acute rhinosinusitis in female was
higher than in male. It commonly occurred in women aged
of 25–64 [18]. A research data in 1999 in Netherlands
reported approximately 8.4% of the population with acute
rhinosinusitis [8]. In the epidemiological study of the
Global Allergy and Asthma European Network (Ga2len)
survey of some THT-KL departments from Belgium, the
UK and the Netherlands, in some city dwellers in Europe,
54.1% women and 45.9% men were diagnosed with acute
rhinosinusitis based on EP3OS criteria, with the median
age of 45 years old [21].
There was no clear correlation between acute rhinosi-
nusitis and sex, age, education as well as occupational level
[18]. Most patients with acute rhinosinusitis did not seek
for treatment and if any, they mostly visited general
practitioners instead of to the referral hospital [8, 21]. In
this study, there were only 16 samples with acute
Fig. 1 Scatter Diagram of Correlation
Between NIPF value and SNOT-20 Score
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Indian J Otolaryngol Head Neck Surg
rhinosinusitis. During the 7 months of data collection, most
samples came with impairment in performing activities at
work or at school. Nasal congestion was the most common
complaint and bothered the patients with rhinosinusitis
which became the reason of their visit to doctors [8, 22].
The inflammatory process of the nasal mucosa and para-
nasal sinuses in acute rhinosinusitis might cause nasal
congestion.
When the inflammatory process continued, the nasal
congestion became more severe and affected the quality of
life due to inhibition of work or school activities, sleep
disturbances, increased medical expenses and emotional
disturbance [8, 9, 22]. The samples with acute rhinosi-
nusitis sought for treatment related to the perceived dis-
comfort that interfered with their daily activities. In this
study there was no total score of SNOT-20 indicating
severe quality of life disorder (80–100) as a candidate for
possible operational intervention.
Sinonasal Outcome Test-20 was one of the instruments
to assess the quality of life specifically related to sinonasal
disease. It contained 20 questions that included health
status and showed the severity of symptoms including
physical problems, functional limitations and emotional
consequences in patients with rhinosinusitis. This instru-
ment was usually used to assess the effectiveness of ther-
apy in patients with rhinosinusitis. Validation of SNOT-20
showed a high correlation with rhinosinusitis (r = 0.9,
p \ 0.002) and significant score change (p \ 0.0002) after
therapy [23].
The data were processed statistically with Spearman
rank correlation test between NIPF value and SNOT-20
score and showed r of - 0.310 and p of 0.243. Negative
correlation indicated that a decrease in the NIPF value (an
indication of an increase in nasal congestion) might lead to
an increase in the total score of SNOT-20 (indication of an
Indian J Otolaryngol Head Neck Surg
increase in the quality of life disorder of acute rhinosi-
nusitis patient), but the statistical test results were not
significant (p [ 0.05). If logical relationship were found
between variables, then the analysis could be supported by
the graph in the form of scatter diagrams that showed
certain points. Each point showed a result rated as depen-
dent variable or independent variable.
The possibility of scatter diagram form when a corre-
lation occured between variables can be positive straight
line, negative straight line, positive curve, negative curve
[24]. This means that objective assessment of nasal con-
gestion based on NIPF and subjective assessment of quality
of life based on SNOT-20 score was not obtained corre-
lation. Based on the results of the objective examination of
the nasal congestion with NIPF no severe nose impairment
was found, whereas in the subjective evaluation of quality
of life based on the total score of SNOT-20 found no
serious quality of life disorder.
The results of NIPF measurements might vary depend-
ing on the flow meter characteristics, the techniques and
subjects’s skills in using the device, as well as the varia-
tions caused by changes in the size and shape of the airway
due to individual differences [25, 26]. The exact limitations
of normal values and nose impasse through NIPF mea-
surements were still a debate in relation to the above
variations, but it was generally stated objectively with
NIPF that the limitation of 120 L/s for the nose congestion
[26]. Nasal congestion might occur due to mucosal chan-
ges, structural changes or both. Mucosal changes can be
physiological, i.e. nasal cycles and body or pathological
position with infection, allergies, hypertrophy and atrophy
mucosa. Changes in structures that caused nasal congestion
might affect the septum (deformity, trauma, perforation,
hematoma) or new growth (nasal polyps, papillomas,
benign and malignant tumors). Other causes that could
cause nasal congestion were adenoid hypertrophy, foreign
object, koana atresia and rice-style collapse [27, 28].
Evaluation of quality of life was multidimensional
which included various things, including physical function,
emotional function, intellectual, social, life satisfaction and
feeling healthy. Operationalization of these dimensions
should show the following factors: severity and disease
course, sociodemographic factors and individual socio-
cultural factors [29].
In this study, the subjects were the population of
Indonesian people, especially from Surabaya or surround-
ing areas where cultural and personality factors that were
still tend to be closed to certain things. This might influ-
ence the subjective assessment of the patient when filling
the questionnaire, for example question on SNOT-20
questionnaire numbers 18, 19, 20 about frustration/irri-
tability, sadness, shame. It was in contrast to the applica-
tion of SNOT-20 questionnaires to assess the quality of life
of patients with synonymous disease in Western popula-
tions which showed significant results because the popu-
lation of Westerners was more legal and open and thus the
application of the questionnaire is more appropriate.
Conclusion
The results of nasal congestion objective examination
based on Nasal Inspiratory Peak Flow showed no correla-
tion with the subjective evaluation of life quality based on
Sino Nasal Outcome Test-20 scores in patients with acute
rhinosinusitis.
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