Effects of Surgical Treatment for Allergic Rhinitis on Sleep and Mental Health in Adolescents
Round 1
Reviewer 1 Report
This paper is important since the impact of surgical treatments for allergic rhinitis (AR) on sleep and mental disorders in adolescents is not fully understood. This is why the authors should be commended for this paper. Surgical methods are clearly explained, outcomes are SNOT-22 scores. Using appropriate statistical methods, the authors demonstrate the efficacy of surgical treatment not only on AR symptoms but also on sleep and mental disorders.
Author Response
We appreciate your review of our manuscript and positive comments on it.
Reviewer 2 Report
This is an interesting study about effects of surgical treatment for allergic rhinitis on sleep and mental health in adolescents.
The paper is well written. However, several issues remain.
The type of surgical procedure must be reported in the abstract.
The authors did not use validated scores, but created themselves new SNOT-22 subscores. This represents an important bias for the study and must be discussed. Moreover, the authors must explain why they did not use validated questionnaires for this study.
Including patients who underwent septoplasty represents another bias. I think that these patients should be excluded to avoid bias.
How many cases without complete SNOT-22 results were excluded? This is may be another bias.
In the materials and methods, the authors must describe how allergies were tested and report previous medical treatments with drugs and doses.
No objective findings were described. There were any surgical complications? How many patients did not achieve turbinate volume reduction after surgery?
Results should be analyzed according to allergy type (perennial versus seasonal). Concerning seasonal allergies, 6 months after surgery may coincide with a time period without allergens. This represents an important bias.
The Discussion section is too short with a few data from literature.
Author Response
The type of surgical procedure must be reported in the abstract.
We appreciate your review of our manuscript and valuable comments on it. We have described surgical procedures in the abstract.
The authors did not use validated scores, but created themselves new SNOT-22 subscores. This represents an important bias for the study and must be discussed. Moreover, the authors must explain why they did not use validated questionnaires for this study.
As mentioned by the reviewer, there are several scores for validation of symptoms for allergic rhinitis. In the current study, we have tried to utilize SNOT-22 Japanese version, which was established by co-authors, for validation of surgical effects on allergic rhinitis-associated symptoms, because SNOT-22 has widely been used to assess sinonasal symptoms in a variety of sinonasal diseases including sinonasal malignancies (Bhenswala et al., 2019. DOI: 10.1002/alr.22398). In this study, we used 14 items of SNOT-22, including four items associated with allergic rhinitis, nasal to blow nose, nasal blockage, sneezing, and runny nose. These symptoms are included in validated scores for allergic rhinitis. Hence, we consider that use of these sub-scores of SNOT-22 may not be a serious bias. The present study also showed the utility of SNOT-22 for the estimation of QOL in adolescents with allergic rhinitis.
Including patients who underwent septoplasty represents another bias. I think that these patients should be excluded to avoid bias.
As mentioned by the reviewer, septoplasty can be a bias for the validation of surgical effects. We then performed additional analyses to examine the effects of septoplasty on outcomes. We compared the data between patients with septoplasty and those without septoplasty. As results, septoplasty caused no significant differences in all validated items as shown in Tables 1-3 in the revised version.
How many cases without complete SNOT-22 results were excluded? This is may be another bias.
In 12 cases, postoperative SNOT-22 scores (6 months after surgery) were not recorded. We excluded these cases from present analyses, which has been stated in 2.3. Outcomes measured in Methods.
In the materials and methods, the authors must describe how allergies were tested and report previous medical treatments with drugs and doses.
We used the immunoglobulin E radioimmunosorbent test to determine allergens. Surgical indications at our institute include the presence of symptoms refractory to oral antihistamines and topical steroids. We have stated these issues in 2.1. Subjects of Methods.
No objective findings were described. There were any surgical complications? How many patients did not achieve turbinate volume reduction after surgery?
Surgical complications were not recorded in all cases, which is described in 3.1. Total subjects in Results. There are no objective measurements for the size of inferior turbinates, which is the weakness of this study.
Results should be analyzed according to allergy type (perennial versus seasonal). Concerning seasonal allergies, 6 months after surgery may coincide with a time period without allergens. This represents an important bias.
All subjects in this study were diagnosed perennial allergic rhinitis by the immunoglobulin E radioimmunosorbent test, which has been stated in 2.1. Subjects in Methods. However, some patients with perennial allergic rhinitis were also positive for seasonal allergens, especially pollens of cedar, orchard grass and hogweed in Japan. Hence, as mentioned by the reviewer, the effect of inflammation response to seasonal allergens can affect present results.
The Discussion section is too short with a few data from literature.
According to the reviewers’ comments, we have performed additional analyses, resulting in addition of two paragraphs (2nd and 3rd paragraphs) in Discussion and an increase of eight citations.
Reviewer 3 Report
Good work. Only one point must be explained. You performed a bone resection of turbinate but in the literature often it is considered a invasive approach. Why did you use it?
About this explanation you should mention these works:
- Ortenzio P, Guzzo O, Lorusso F, Gallina S, Sireci F. Advances in the role of nasal surgery in the treatment of OSAS. Advances in Sleep Apnea: Detection, Diagnosis and Treatment, 2021, pp. 213–242
- Sireci F, Dispenza F, Zambito P et al. The minimally invasive sinus surgery technique. Advances in Health and Disease, 2021, 37, pp. 191–200
Author Response
We appreciate your review of our manuscript and positive comments on it. We have stated the reasons for the choice of surgical procedures in the second and third paragraphs in Discussion.
Reviewer 4 Report
Good idea to look at SNOT Subcategories and their relation to surgical outcome in AR;
The Abstract needs to be improved. Whats sample size? Considering the considerable - please rephrase.
How many received septoplasty, how many neurectomy? this makes a difference. Please describe these subgroups.
A table on the patients characteristics is required including the subgroups with septoplasty and without.
The MCID should be implemented in methods and results to confirm relevant improvements. See and cite
- DOI: 10.4193/Rhin21.253
How many subjects improved by 12 points on the SNOT? Were there more in the septoplasty group?
Author Response
The Abstract needs to be improved. Whats sample size? Considering the considerable - please rephrase.
We appreciate your review of our manuscript and positive comments on it. We have stated a sample number in the abstract and deleted ‘considerable’ in the revised version.
How many received septoplasty, how many neurectomy? this makes a difference. Please describe these subgroups.
We have stated the numbers of patients who underwent posterior nasal neurectomy or septoplasty in 3.1. Total subjects in Results.
A table on the patients characteristics is required including the subgroups with septoplasty and without.
According to this comment, we have added Tables 2 and 3 showing outcomes in subgroups with or without septoplasty.
The MCID should be implemented in methods and results to confirm relevant improvements. See and cite DOI: 10.4193/Rhin21.253. How many subjects improved by 12 points on the SNOT? Were there more in the septoplasty group?
We appreciate the reviewer for this valuable comment, which may increase the value of our manuscript. We cited an above-mentioned article [10], which describes that the MCID for SNOT-22 in sinusitis patients is a 12-point. Based on this, we divided total subjects into two groups, subjects with or without MCID, which is shown in Table 1 and the third paragraph of 3.1. Total subjects in Results. Methods have been revised according to this, which is shown in the second paragraph of 2.3. Outcomes measured in Methods. Septoplasty had no significant effect on MCID for SNOT-22. The proportion of subjects with MCID for SNOT-22 was also validated in subjects with sleep and mental disorders. Effects of septoplasty on outcomes in subjects with sleep and mental disorders were also examined. The results are shown in Tables 2 and 3.
Round 2
Reviewer 2 Report
The absence of objective measurements for the size of inferior turbinates, as a limit of the study, must be discussed in the Discussione section.
Author Response
According to the reviewer's comment, we have added the following description at the end of Discussion.
However, outcomes measured in this study lacked objective assessments of surgical effects. Therefore, distinct effects of our surgical modality on improvement of nasal obstruction were unclear. In future studies, effects of alterations in nasal airflow that are determined by objective assessments on sleep and mental disorders should be examined.
Reviewer 4 Report
my concerns have been addressed thank you
Author Response
We appreciate your review of this manuscript.
