**Preface to "Allergic Rhinosinusitis and Airway Diseases"**

The concept of united airway disease interactions comprises allergic rhinosinusitis, including allergic rhinitis, eosinophilic chronic rhinosinusitis, and other upper or lower airway disorders such as obstructive sleep apnea, bronchial hyperresponsiveness and allergic asthma. It embodies a coherent pathophysiology and a comprehensive approach to the treatment of upper and lower airway disorders. The treatment of chronic allergic rhinosinusitis may reduce obstructive sleep apnea symptoms, chronic cough, or the dose of inhaled corticosteroids necessary to treat asthma, and vice versa.

Many objectives in the interaction concept between allergic rhinosinusitis and airway disease management should be achieved in the near future for the reliable control of each disease. More awareness of allergic rhinosinusitis and its comorbidity with other airway diseases must be emphasized in patients' management programs. Progress in diagnosis, with the help of the advanced biomarkers and relevant imagery techniques associated with the accurate treatment of allergic rhinosinusitis and airway diseases, should be developed by scientists to drive the indication and follow-up of target treatment with biologic therapies. Finally, more research on the interaction between allergic rhinosinusitis and airway diseases considered comorbidities or modifiable cofactors should be reconsidered by physicians in the next decade.

This Book covers different interesting topics to give readers an overview of healthcare equality, advanced biomarkers, accurate diagnosis and treatment, occupational exposure-induced upper airway allergy and neoplastic disease mimicking chronic rhinosinusitis.

> **Sy Duong-Quy** *Editor*

## *Editorial* **Allergic Rhinosinusitis and Airway Diseases**

**Sy Duong-Quy 1,2,3,4**


The concept of united airway disease interaction, which comprises chronic rhinosinusitis and other lower airway disorders such as asthma, has been recognized for over a decade. This concept furthers deeper comprehension on the pathophysiology and management of upper and lower airway diseases. In this Special Issue, entitled "Allergic Rhinosinusitis and Airway Diseases", there are nine published papers which cover different interesting topics to give readers an overview of healthcare equality, advanced biomarkers, accurate diagnosis and treatment, occupational exposure-induced upper airway allergy and neoplastic disease mimicking chronic rhinosinusitis.

The equity and equality between races of patients with chronic rhinosinusitis should be considered by physicians. In fact, this issue has previously drawn the attention of the World Health Organization (WHO) [1], and was the focus of a systemic review by Weaver et al. in the Special Issue of *Sinusitis* entitled "Promoting Equity When Using the SNOT-22 Score: A Scoping Review and Literature Review" [2]. In this study, Weaver et al. [2] demonstrated the use of quality-of-life (QoL) tools to assist clinical decision-making by using SNOT-22 in patients with chronic rhinosinusitis to promote equality across diverse populations. The authors emphasized the effects of ethnicity and race on SNOT-22 scores and tried to improve equity. Based on PubMed and MEDLINE searches with appropriate keywords to find papers for a scoping review, Weaver' study revealed, for the first time, that ethnic differences appear to exist in acute sinusitis symptomatology, and ethnic differences also exist with regard to QoL tools. Thus, the authors suggest that the evidence implies that some form of correction to QoL scores could help to promote equity for non-white patients.

Although the main theme of this Special Issue is "*Allergic Rhinosinusitis and Airway Diseases*", currently, the large number of patients who have had the sequelae of COVID-19 within olfactory disorders during the post-COVID-19 phase is also a crucial healthcare problem for ENT (ear–nose–throat) physicians [3]. Therefore, in this Special Issue, Araújo et al. [4] have taken great efforts to successfully summarize the main mechanism and clinical management of anosmia in post-COVID-19 patients. This narrative review describes that olfactory disorder is one of the most common symptoms in patients with acute COVID-19 infection, and most of them recover normal neurosensory function in a short time. However, the authors emphasized that approximately 10% of patients have reported a long-term smell dysfunction which significantly impacts their quality of life. It is clear that inflammation and cellular damage can play a key role in the pathogenesis of olfactory dysfunctions. Based on this pathogenesis, the appropriate management of smell disturbances in post-COVID-19 patients should focus on the underlying mechanisms in combination with adequate smell training.

Recently, the idea of measuring the levels of fractional exhaled nitric oxide (FENO) during the COVID-19 pandemic and in patients with long-COVID has been published [5,6]. This idea might open a new field of research in the use of FENO to screen post-COVID-19

**Citation:** Duong-Quy, S. Allergic Rhinosinusitis and Airway Diseases. *Sinusitis* **2022**, *6*, 21–25. https:// doi.org/10.3390/sinusitis6010003

Received: 5 May 2022 Accepted: 12 May 2022 Published: 14 May 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

patients with anosmia in clinical practice. Although the measurement of FENO in patients with asthma has been described in recent decades, its use in patients with allergic rhinitis (AR) remains a new area for ENT physicians [7]. In this Special Issue, Duong-Quy et al. have contributed original research on the role of nasal FENO in children with allergic rhinitis [8] to evaluate the correlations between nasal FENO and anthropometric, clinical and functional characteristics, and to determine the cut-off of nasal FENO for diagnosis of AR in the symptomatic children. This study showed that nasal FENO levels in AR patients were significantly higher than control subjects, and nasal FENO was significantly correlated with AR symptoms and nasal inspiratory/expiratory peak flows. Interestingly, the cut-off of nasal FENO for positive AR diagnosis had a very high specificity and sensitivity in AR diagnosis. These authors also concluded that the use of nasal FENO as a biomarker of AR could represent a useful tool and an additional armamentarium in the management of disease (Figure 1). lergic rhinitis (AR) remains a new area for ENT physicians [7]. In this Special Issue, Duong-Quy et al. have contributed original research on the role of nasal FENO in children with allergic rhinitis [8] to evaluate the correlations between nasal FENO and anthropometric, clinical and functional characteristics, and to determine the cut-off of nasal FENO for diagnosis of AR in the symptomatic children. This study showed that nasal FENO levels in AR patients were significantly higher than control subjects, and nasal FENO was significantly correlated with AR symptoms and nasal inspiratory/expiratory peak flows. Interestingly, the cut-off of nasal FENO for positive AR diagnosis had a very high specificity and sensitivity in AR diagnosis. These authors also concluded that the use of nasal FENO as a biomarker of AR could represent a useful tool and an additional armamentarium in the management of disease (Figure 1).

COVID-19 patients with anosmia in clinical practice. Although the measurement of FENO in patients with asthma has been described in recent decades, its use in patients with al-

*Sinusitis* **2022**, *6*, x FOR PEER REVIEW 2 of 5

**Figure 1.** Principle of nasal FENO measurement in subjects with AR. AR: allergic rhinitis; FENO: fractional exhaled nitric oxide; NOS: nitric oxide synthase.

**Figure 1.** Principle of nasal FENO measurement in subjects with AR. AR: allergic rhinitis; FENO: fractional exhaled nitric oxide; NOS: nitric oxide synthase. The use of FENO in management of asthma has been approved by many countries and international guidelines [9]; however, nasal FENO has not been approved unanimously in the management of AR. Therefore, other biomarkers used in the management of AR, such as circulating specific non-coding microRNAs (miRNAs), have been presented in another review in this Special Issue: "Allergic Rhinosinusitis and Airway Diseases". This review, entitled "*Immunological and microRNA Features of Allergic Rhinitis in the Context of United Airway Disease*" and written by Naydenova et al. [10], focused on the theory involving inflammation of the upper respiratory tract in patients with AR might contribute to lower respiratory airway inflammation. These authors suggested that Thelper 17 (Th17) cells and related cytokines are also involved in the immunological mechanism of AR along with classical Th2 cells, leading to Th17-induced neutrophilic inflam-The use of FENO in management of asthma has been approved by many countries and international guidelines [9]; however, nasal FENO has not been approved unanimously in the management of AR. Therefore, other biomarkers used in the management of AR, such as circulating specific non-coding microRNAs (miRNAs), have been presented in another review in this Special Issue: "Allergic Rhinosinusitis and Airway Diseases". This review, entitled "*Immunological and microRNA Features of Allergic Rhinitis in the Context of United Airway Disease*" and written by Naydenova et al. [10], focused on the theory involving inflammation of the upper respiratory tract in patients with AR might contribute to lower respiratory airway inflammation. These authors suggested that T-helper 17 (Th17) cells and related cytokines are also involved in the immunological mechanism of AR along with classical Th2 cells, leading to Th17-induced neutrophilic inflammation in the lungs. Definitely, the regulators of this inflammatory process could be modulated by circulating specific miRNAs, which are distinctively expressed in AR and asthmatic patients. Hence, this pathway could be considered a promising target treatment for the therapy of patients with concomitant AR and asthma.

mation in the lungs. Definitely, the regulators of this inflammatory process could be modulated by circulating specific miRNAs, which are distinctively expressed in AR and This Special Issue has been supplemented with the study realized by Nair et al. [11] on the efficacy of saffron extract in an ovalbumin-induced airway model of allergic asthma. This study, using a very-well-known animal model to induce allergic asthma via introducing ovalbumin (OVA) into the nose, again confirmed the unification of the upper and lower airway inflammatory pathways in AR and asthma [12]. In this study, the authors used saffron (*C. sativus*) extract (CSE), a product which exerts anti-inflammatory, anti-allergic

and immunomodulatory properties, to investigate its efficacy in combination with salbutamol in the treatment of OVA-induced asthma in rats. The main results of this study demonstrated that the treatment with CSE and salbutamol significantly attenuated OVAinduced Th2 cytokine levels (TNF-α, IL-1β, IL-4, IL-13) in the bloodstream and lung tissue by ameliorating OVA-induced inflammatory influx and ultrastructural aberrations. The authors suggested that the combination of CSE and short-acting beta 2-agonist could be considered a new therapeutic strategy for the management of asthma.

Saffron has been considered as one of the most valuable spices for centuries, and it has been used in daily foods for promoting good health and a positive mood status. Therefore, the results of Nadir's study could develop the current concept related to the use of diet in the treatment of patients with respiratory allergic diseases who did not respond to pharmacological therapy [13]. In the same scope, Calatayud-Sáez et al. [14] have published their results from the study entitled "*Effects of the Traditional Mediterranean Diet in Childhood Recurrent Acute Rhinosinusitis*" in this Special Issue. This study was conducted in a young population (1–5 years old children) who had three or more acute rhinosinusitis episodes in the period of one year from the program "*Learning to Eat from the Mediterranean*" in Spain. The main outcomes of this study showed that more than 50% of study subjects did not have any episode of acute rhinosinusitis, and KIDMED (Mediterranean Diet Quality Index) scores increased significantly. These authors stated that adoption of the traditional Mediterranean diet might have a promising effect on the prevention and treatment of recurrent acute and chronic rhinosinusitis in early ages of life.

An appropriate diet, such as the traditional Mediterranean diet, may be useful for subjects who are allergic with airborne and/or food allergens. For these subjects, skin prick tests (SPT) have been considered as a relevant examination technique to detect respiratory or food allergens, although the level of specificity remains a challenge for the treatment with specific desensibilization [15]. Therefore, the atopic status assessment with SPT or specific immunoglobulin (sIgE) in subjects with asthma or AR is always a milestone in identifying potential risk factors and triggers provoking loss of disease control. A recent study in asthmatic children published by Lazova et al. [16] demonstrated that there was a moderate to strong correlation between multiscreen ImmunoCAP Phadiatop/fx5 and Euroimmun sIgE titers against aero-allergens—cats, mites, tree mix and food allergens—soy, wheat, rice, apple and peanut. This study also showed that good sensitivity and specificity were observed for EUROIMMUN Pediatric (food allergens) compared with the gold standard ImmunoCap/fx5. The authors of this study suggested that the immunoblotting technique is an easily applicable, cost-effective and reliable alternative to ImmunoCAP Phadiatop/fx5 in diagnosing atopic children.

In addition to airborne and food allergens, some evaporated chemical products used in industry could be the cause of airway allergies in workers [17]. This crucial problem has been clarified by the study realized by Kashyap et al., published in this Special Issue of *Sinusitis* [18]. This study included tannery workers of Kanpur city in India who were frequently exposed to chromium during the leather tanning process. The authors found that the severity of nasal and sinus allergies increased with age and work duration in the tannery, and workers with occupational exposure were more likely to develop sinus problems than those without exposure. The authors suggest that this high risk of occupational factors could be eliminated by improving the overall working conditions and ensuring necessary protective regulations for the tannery workers to reduce upper airway allergies and other carcinogenic factors.

This Special Issue, "Allergic Rhinosinusitis and Airway Diseases", concludes with the ninth paper presenting an interesting clinical case, entitled "*Low-Grade B Cell Lymphoproliferative Disorder Masquerading as Chronic Rhinosinusitis*", reported by Chen et al. [19]. In this case report, a 72-year-old man was referred by his general practitioner for symptoms mimicking chronic rhinosinusitis unresponsive to local corticosteroid treatment and antibiotics. Although the histopathology result taken from the middle turbinate biopsy revealed chronic non-specific inflammatory changes with mixed microbial flora, the patient

was consequently referred to hematology specialists, as recommended previously [20]. Then, a combination of serum and radiological findings (chest CT scan: mediastinal and hilar lymphadenopathy; Figure 2) was used to perform the clinical diagnosis of B-cell lymphoproliferative disorder. The authors of this case report recommend that patients with chronic rhinosinusitis who present with atypical clinical features such as nasal crusting and treatment resistant organisms may have underlying immunosuppression. ously [20]. Then, a combination of serum and radiological findings (chest CT scan: mediastinal and hilar lymphadenopathy; Figure 2) was used to perform the clinical diagnosis of B-cell lymphoproliferative disorder. The authors of this case report recommend that patients with chronic rhinosinusitis who present with atypical clinical features such as nasal crusting and treatment resistant organisms may have underlying immunosuppression.

necessary protective regulations for the tannery workers to reduce upper airway allergies

This Special Issue, "Allergic Rhinosinusitis and Airway Diseases", concludes with the ninth paper presenting an interesting clinical case, entitled "*Low-Grade B Cell Lymphoproliferative Disorder Masquerading as Chronic Rhinosinusitis*", reported by Chen et al. [19]. In this case report, a 72-year-old man was referred by his general practitioner for symptoms mimicking chronic rhinosinusitis unresponsive to local corticosteroid treatment and antibiotics. Although the histopathology result taken from the middle turbinate biopsy revealed chronic non-specific inflammatory changes with mixed microbial flora, the patient was consequently referred to hematology specialists, as recommended previ-

*Sinusitis* **2022**, *6*, x FOR PEER REVIEW 4 of 5

and other carcinogenic factors.

**Figure 2.** Transverse CT chest image with arrows indicating mediastinal and hilar lymphadenopathy. Coronal CT sinus image depicting disease affecting the ethmoid bullae and ostio-meatal com-**Figure 2.** Transverse CT chest image with arrows indicating mediastinal and hilar lymphadenopathy. Coronal CT sinus image depicting disease affecting the ethmoid bullae and ostio-meatal complex [19].

In conclusion, this Special Issue, entitled "Allergic Rhinosinusitis and Airway Diseases", successfully raises more awareness of rhinosinusitis and its comorbidity with other airway diseases. Hence, the concept of united airway disease interaction comprising upper and lower airway diseases should be recognized in patient management programs. Progress in diagnosis, with the use of the advanced biomarkers and relevant imagery techniques associated with accurate treatment of chronic rhinosinusitis and lower airway dis-In conclusion, this Special Issue, entitled "Allergic Rhinosinusitis and Airway Diseases", successfully raises more awareness of rhinosinusitis and its comorbidity with other airway diseases. Hence, the concept of united airway disease interaction comprising upper and lower airway diseases should be recognized in patient management programs. Progress in diagnosis, with the use of the advanced biomarkers and relevant imagery techniques associated with accurate treatment of chronic rhinosinusitis and lower airway diseases, should continue to be developed in the future.

eases, should continue to be developed in the future. **Funding:** This research received no external funding.

**Funding:** This research received no external funding. **Conflicts of Interest:** The authors declare no conflicts of interest. **Conflicts of Interest:** The author declares no conflict of interest.

#### **References**

**References** 1. Available online: https://www.who.int/data/health-equity (accessed on 2 May 2022).

plex [19].


**Abigail Weaver 1,2 and Andrew Wood 2,3,4,\***


**Abstract:** It is established that non-white people experience worse health outcomes than white people within the same population. Equity addresses differences between patient subgroups, allowing needs-based distribution of resources. The use of quality-of-life (QoL) tools to assist clinical decision making such as the SNOT-22 for chronic rhinosinusitis promotes equality, not equity, as qualityof-life (QoL) tools provide the same criteria of symptom scoring across diverse populations. We considered the effects of ethnicity and race on SNOT-22 scores and whether these scores should be adjusted to improve equity. PubMed and MEDLINE provided papers for a scoping review. A combination of the following search terms was used: patient-reported outcome measures (PROM) (OR) quality of life; (AND) race (OR) ethnicity (OR) disparities; (AND) otolaryngology (OR) SNOT-22 (OR) sinusitis. The first study identified no evidence of ethnic variability in SNOT-22 scores. However, the study did not represent the local population, including 86% white people. Other studies identified baseline SNOT-22 disparities with respect to population demographics, gender, and age. Ethnic differences appear to exist in acute sinusitis symptomatology. In other fields both within and outside of otorhinolaryngology, ethnic differences exist with regard to QoL tools. This scoping review identified a paucity of data in rhinology. However, evidence implies some form of correction to QoL scores could help promote equity for non-white patients.

**Keywords:** otolaryngology; sinusitis; ethnic groups; patient-reported outcome measures; quality of life; social justice

#### **1. Introduction**

The importance of equity is increasingly recognized and discussed within healthcare generally and within rhinology in particular [1]. Equity in healthcare is defined as "the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically" [2]. The World Health Organization (WHO) explains equity as overcoming and avoiding disparities that infringe on justice and fairness. While equity and equality both target fairness, equality is based on the equal distribution of a commodity within a population, whereas equity is based on unequal distribution to accommodate for differences in need. Therefore, they are fundamentally different principles, potentially at odds with each other. The use of qualityof-life (QoL) tools to facilitate clinical decision making promotes equality, i.e., treating everyone the same. However, if QoL tools do not sufficiently represent different patient groups, their use may prove a potential impediment to equity.

While noting that race and ethnicity are related terms, one's race is the inherited phenotypic attribute of a person. In contrast, one's ethnicity relates to the cultural factors, from a particular group, with which an individual identifies [3].

We have identified, within our New Zealand population, that non-white, minority ethnicities are underrepresented in Public Hospital Rhinology clinics and operating lists [4,5].

**Citation:** Weaver, A.; Wood, A. Promoting Equity When Using the SNOT-22 Score: A Scoping Review and Literature Review. *Sinusitis* **2022**, *6*, 15–20. https://doi.org/10.3390/ sinusitis6010002

Academic Editor: Sy Duong-Quy

Received: 30 November 2021 Accepted: 13 January 2022 Published: 16 January 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

This is despite data indicating that non-white populations appear to have a higher burden of rhinologic diseases. While the reasons for this are likely to be multi-factorial [4], we aimed to consider whether the processes that we as rhinologists use, might be contributing to this apparent inequity, and if so, how this might be addressed.

Chronic rhinosinusitis (CRS) is a non-fatal condition, the treatment of which is directed toward managing symptoms [6]. The ability to quantify symptoms through QoL tools is, therefore, of great importance in CRS management and decision making with regard to appropriate treatment options. The WHO defines QoL as "the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals" [7]. With regard to the assessment of QoL in CRS, the 22-item Sinonasal Outcome Test (SNOT-22) has become the sentinel subjective assessment of disease severity [8], with 3560 articles returned on a Google Scholar search of "SNOT-22" (search performed 4 April 2021).

Given the importance of the SNOT-22 score in surgical decision making for CRS patients and apparent inequities in the provision of treatment, we wished to investigate the effects of race and ethnicity on the SNOT-22 QoL tool and whether the total SNOT-22 score should be adjusted for patient race or ethnicity when used for clinical decision making. We hypothesize that in the context of comparable disease burden, non-white groups record lower total SNOT-22 scores.

#### **2. Methods**

A scoping review technique found peer-reviewed journal papers that met the following inclusion criteria: (1) published between 2010 and 2021; (2) written in English; (3) involved preoperative symptom reporting; (4) provided details of patient demographic; (5) specifically discussed the impact of demographic on symptom scoring in otorhinolaryngology diseases. The following bibliographic databases identified relevant documents from 2010 to 2021: MEDLINE and PubMed. Exclusion criteria included (1) studies published before 2010; (2) papers without English translation; (3) papers that did not compare demographic disparities on symptom scores in otorhinolaryngology disease. The initial search occurred in January 2021 and was repeated in August 2021 to ensure new relevant data were included. The below search strategy was created by one reviewer in collaboration with the Waikato Clinical Campus Librarian. The studies were identified using the selection criteria above.

Search Terms:


The search was followed by analyzing the title, abstract, and subject headings to identify papers that met the study criteria. Reference lists of the identified papers were scanned for similar articles, generating a further literature review. Two reviewers determined the relevance of the studies prior to inclusion into the study. To prevent biased studies influencing data outcomes, the demographics of the studies' local population were compared with the study populations. Reference number five was included as a local preprint publication.

#### **3. Results**

Following the method, PubMed identified 1444 papers without using the quality-of-life search term, and MEDLINE/OVID identified 30 papers from the above search.

There was a paucity within the literature explicitly related to PROMs and ethnic/race disparities, and even fewer for the SNOT-22 specifically. A publication on chronic rhinosinusitis identified that less than 10% of American studies provided information on minority-specific demographics when discussing ESS surgical outcomes. It also identified minority populations made up less than half the national census estimates receiving ESS [9].

(1) Results discussing ethnicity/race SNOT22 scores at the time of diagnosis of CRS

One relevant study, at a tertiary rhinology clinic in Boston, Massachusetts, indeed discussed influences of the recruited population demographics. The conclusion was made that there was no evidence identified of disparity between ethnic and racial groupings to their SNOT-22 scores. The population included 300 adult patients with CRS. The study analyzed the patients' symptom scores (SNOT-22 and EuroQol 5-dimensional visual analog scale), age, race, ethnicity, smoking status, medication usage, and comorbidities. The racial groupings for the study cohort were classified as "white" (281 patients), "Black or African American" (5 patients), or "other" (14 patients). The ethnicity groupings were classified as "non-Hispanic" (246 patients), "Hispanic" (9 patients), and "declined to respond" (45 patients). The relatively small groups meant the confidence intervals were large (and therefore reported no statistically significant difference). However, on multivariate analysis, "non-white and/or Hispanic" patients recorded a SNOT-22 score of −2.2 (−11.5 to 7.0), compared with "white, non-Hispanic" patients [10].

Further studies identified within the scoping review attempted to compare disparities in SNOT-22 scores for race and ethnicity, indicating that minority populations have increased SNOT-22 scores at the time of CRS diagnosis. Kuhar et al. (2019) reported that African American patients had higher SNOT-22 scores, compared with white patients (50.7 vs. 1.5, *p* < 0.022). It was also noted, however, that histologic measures of disease severity including eosinophils per high power field, polypoidal disease, subepithelial disease, hyperplastic/papillary changes, and fibrosis indicated a more significant disease burden within the African American population [11]. Similarly, the same pattern of increased SNOT-22 scores at the time of diagnosis was described in Hispanic patients, compared with non-Hispanic patients (55 vs. 37, *p* < 0.001), by Levine et al. (2021). Hispanics, however, also had objective evidence of more severe CRS, such as the presence of nasal polyps (RR = 2.5; 95% Cl: 1.0–5.9), neo-osteogenesis, extended procedures, and tissue eosinophilia [12].

(2) Demographic disparities identified in SNOT22 score—not related to ethnicity/race

A cross-sectional study in Brazil identified disparities in SNOT-22 scores for gender and age. Although these are disparities within the same ethnicity and race, this study implies that differences between subgroups may impact PROMS, irrespective of disease severity. There was a statistically significant (*p* = 0.005) difference of two points in the baseline SNOT-22 scores between genders. Men without CRS had a baseline SNOT-22 score of 7, compared with women, whose baseline score was 9. Age over 60 years also indicated a significantly lower score of 7, compared with the younger age groups scores of 8–10 [13].

(3) Ethnic variability in sinonasal symptoms

The same group in Boston has studied ethnic disparities in symptomatology and presentation in the context of acute rhinosinusitis (ARS). They performed a retrospective study of 1,632,826 visits to hospital emergency departments (EDs) where ARS was diagnosed. Compared with white patients, Black (*p* = 0.038) and Hispanic patients (*p* = 0.019) presenting to EDs were less likely to complain of typical sinonasal symptoms. Hispanic patients also reported less typical ARS symptoms such as cough, sputum production, head cold, or flu-like symptoms [14].

(4) Ethnic variation in symptom reporting in otorhinolaryngology

The literature review identified that within other otorhinolaryngology (ORL) fields, studies have identified ethnic disparities in the self-reporting of symptoms. For example, in a study of 5236 women of child-bearing age, the objective measure of hours slept was compared with self-reported trouble sleeping. Women from minorities experienced fewer nights of adequate sleep than white women. However, white women had statistically significantly increased odds of reporting trouble sleeping than minority populations, with an adjusted odds ratio (OR) of 0.47 and 0.29, compared with Black and Hispanic women, respectively. This is still evident when controlling for hours slept [15].

Ethnic/racial disparities in patient-reported outcome measures have also been noted in laryngology. After controlling for influential demographics including education, income, and health insurance, minorities' self-reported voice problems had decreased OR, compared with white Americans, with African Americans reporting an OR of 0.83 and Hispanics 0.63 and remaining minorities at 0.69, compared with white adults [16].

#### (5) Ethnic variation in symptom reporting outside of otorhinolaryngology

There are ethnic inequities in symptom reporting and QoL surveys in multiple medical fields, for instance, in HIV symptom management. The literature review identified Black non-Hispanics were significantly underreporting "fatigue, depression, muscle aches, anxiety, difficulties with memory and concentration" with compared to other ethnicities [17].

#### **4. Discussion**

It is essential to identify limitations in QoL measures with regard to whether they contribute to current health inequities. If our hypothesis is correct that minorities with CRS are under-reporting symptoms on SNOT-22 surveys, white people may be preferentially prioritized for intervention over minority populations, thus contributing to health disparities that unjustly harm minority populations. Although not directly addressing our question around race and ethnicity, it has been identified that different groups within society do report different mean SNOT-22 scores [13].

It is well established that some non-whites suffer worse health outcomes than white people. In our New Zealand population, many studies have shown worse health outcomes for the indigenous Maori population, compared with non-M ¯ aori. In a literature review, a ¯ study was identified in which Maori was significantly less likely to be offered chemotherapy ¯ than non-Maori and was more likely to experience delays within the first eight weeks ¯ before chemotherapy. Another study discussed in this review found Maori women were ¯ significantly less likely to receive pain relief during labor; furthermore, doctors of European ethnicity spent 17 % less time with Maori patients than other ethnic groups [ ¯ 18]. Recent studies in our department demonstrated a significant under-representation of minority ethnicities in rhinology clinics and operating theatres [4]. The reasons for such ethnic disparities are likely multi-factorial [4] but may include that disease burden in non-white populations is relatively under-represented when QoL is quantified.

US minority populations also experience similar inequities. The National Health Interview Survey identified that white adults with CRS had an increased likelihood of receiving specialist appointments and intervention than minority populations [9]. A retrospective study of 1344 adults with CRS showed that African Americans who underwent operations showed greater objective severity of refractory CRS [19]. Another study of 4337 patients identified that African Americans and Hispanic patients had higher requirements for urgent operations for sinusitis (*p* = 0.003 and *p* < 0.001, respectively) [20], presumably representing lower access to elective care.

Our scoping review highlighted a paucity of data regarding the effect of race and ethnicity on SNOT-22 scores. Although the Bergmark (2018) study was commendable in its intentions, this data had significant limitations. First, considering racial groupings, 93.7% of the study population identified as white, in a city where recent census data show that 44.4% are white [21]. This implies a high risk of selection bias. Although some power calculations were performed, ethnicity and racial groupings of the size reported would appear liable to a type 2 error, noting that a non-significant trend toward lower QoL scores was reported in non-white patients. Finally, the groupings assessed—namely, white vs. non-white and Hispanic vs. non-Hispanic, cannot be considered generalizable to all ethnic and racial groupings. Based on this one study, and noting its limitations, it seems inappropriate, therefore, to generalize that ethnicity does not impact total SNOT-22 scores.

Two articles report higher total SNOT-22 scores within minority populations at presentation. However, they also identify that the disease burden was substantially higher in those groups. Thus, the comparison of SNOT-22 scores does not identify if minority populations with equivalent CRS severity under-report on total SNOT-22 scores [11,12].

Data from other fields both within and outside of ORL indicate that ethnic variabilities exist regarding self-reporting of symptom burden with symptoms relatively underrepresented by non-white populations. It seems reasonable to hypothesize, therefore, that using the SNOT-22 score or other QoL measures in rhinology contributes to inequitable treatment of non-white populations. Unfortunately, however, we are unable to prove or disprove this hypothesis.

The described study of ARS patients may be limited by an inaccurate diagnosis of ARS in the ED setting, owing to differential diagnoses such as migraine. However, it does raise the possibility that there may be ethnic and racial variation within the various SNOT-22 domains, as well as with respect to the total SNOT-22 score, meriting further study.

In summary, the literature discussed in this review identifies ethnic variability in symptom reporting. However, there are no conclusive data to prove or disprove our hypothesis. Research is required to identify ethnic variations in total SNOT-22 scores but also within the domains of the SNOT-22 score. Ideally, a large prospective study with ethnic and racial groupings representative of the local population should be performed. This would ideally be a multi-centered or even multi-national study. This study may face challenges owing to the inadequate referral of non-white patients to tertiary centers, generating selection bias. Objective measures such as the Lund-Mackay score (LMS) or endoscopic scores could be used as comparators.

#### **5. Conclusions**

While our scoping review has indicated a paucity of data in rhinology related to ethnicity and QoL tools/PROMS, evidence from other population subgroups and fields of medicine cast doubt on the effectiveness of the SNOT-22 tool to assess the severity of CRS equitably in non-white populations. Without the use of a correction, the use of QoL tools such as the SNOT-22 may contribute to white patients preferentially being offered intervention. In the pursuit of more equitable practice, further study is merited in this field.

**Author Contributions:** Conceptualization, A.W. (Andrew Wood); methodology, A.W. (Abigail Weaver); validation, A.W. (Andrew Wood) and A.W. (Abigail Weaver); data curation, A.W. (Abigail Weaver); writing—original draft preparation, A.W. (Abigail Weaver) and A.W. (Andrew Wood); writing review and editing, A.W. (Andrew Wood); visualization, A.W. (Abigail Weaver); supervision, A.W. (Andrew Wood). All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Data are available through MEDLINE and PubMed using the references below.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

