ORIGINAL ARTICLE

COPD

Rhinosinusitis without nasal polyps in

COPD
Marte Rystad Øie 1,2, Sarah Bettina Dahlslett1,2, Malcolm Sue-Chu3,4,
Anne-S. Helvik1,5, Sverre Karmhus Steinsvåg6,7 and
Wenche Moe Thorstensen1,2

Affiliations: 1Dept of Otolaryngology, Head and Neck Surgery, St. Olavs University Hospital, Trondheim,
Norway. 2Dept of Neuromedicine and Movement Science, Norwegian University of Science and Technology
(NTNU), Trondheim, Norway. 3Dept of Circulation and Medical Imaging, Norwegian University of Science and
Technology, Trondheim, Norway. 4Dept of Thoracic Medicine, St. Olavs University Hospital, Trondheim,
Norway. 5Dept of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim,
Norway. 6Dept of Otolaryngology, Head and Neck Surgery, Sørlandet Hospital, Kristiansand, Norway.
7
Haukeland University Hospital, Bergen, Norway.

Correspondence: Marte Rystad Øie, Dept of Otolaryngology, Head and Neck Surgery, St. Olavs University
Hospital, 3250 Torgarden, 7006 Trondheim, Norway. E-mail: marte.oie@gmail.com

ABSTRACT The validity of the united airway disease concept for rhinosinusitis (RS) and chronic
obstructive pulmonary disease (COPD) has been questioned because of methodological limitations in
previous studies. In this study we investigated the prevalence of RS without nasal polyps (RSsNP) and the
severity of sinonasal symptoms in COPD and a corresponding control group. We also evaluated the
diagnostic accuracy of these symptoms for RSsNP in COPD. 90 COPD patients and 93 controls were
included in an observational cross-sectional study where globally accepted diagnostic criteria of RS and
COPD (EPOS 2012 and GOLD) were incorporated; symptomatic and endoscopic criteria for the diagnosis
of RS, and spirometry with reversibility for diagnosis of COPD. RS symptoms were identified by responses
to the sinonasal outcome test (SNOT-22), nasal endoscopy identified signs of sinonasal disease and
discriminated between RS with and without nasal polyps, and visual analogue scales (VAS) rated the
severity of sinonasal symptoms. We found RSsNP in 51% of our COPD patients which is threefold greater
than in the control group ( p<0.001). Nasal discharge (72%) and nasal obstruction (62%) were the two
most frequently reported symptoms in COPD. The diagnostic accuracy for RSsNP is better for the
composite VAS for rhinological symptoms than for facial symptoms. We conclude that RSsNP is present
in 51% of our COPD patients, which is significantly more prevalent compared to a corresponding control
group. These results suggest that COPD is associated with RS.

@ERSpublications
Rhinosinusitis is associated with COPD and is significantly more prevalent (51%) compared to
controls https://bit.ly/2YrIsmm

Cite this article as: Øie MR, Dahlslett SB, Sue-Chu M, et al. Rhinosinusitis without nasal polyps in
COPD. ERJ Open Res 2020; 6: 00015-2020 [https://doi.org/10.1183/23120541.00015-2020].

Received: 13 Jan 2020 | Accepted after revision: 28 April 2020

Copyright ©ERS 2020. This article is open access and distributed under the terms of the Creative Commons Attribution
Non-Commercial Licence 4.0.

https://doi.org/10.1183/23120541.00015-2020 ERJ Open Res 2020; 6: 00015-2020

 COPD | M.R. ØIE ET AL.

Introduction
Rhinosinusitis (RS) is a major upper airway disease with an overall prevalence of 10.9% in Europe, and has
a significant socioeconomic impact [1]. The European position paper on rhinosinusitis and nasal polyps
(EPOS) defines RS in adults as an inflammation of the nose and paranasal sinuses, and diagnosis requires
the presence of symptomatic and either endoscopic or radiologic criteria. The symptomatic criteria are the
presence of at least two of the following symptoms: nasal obstruction, nasal discharge (anterior/posterior
nasal drip), reduction/loss of smell and facial pain/pressure, whereof one should be nasal obstruction or
nasal discharge [2]. Confirmation of sinus disease using endoscopic or radiological criteria is a
requirement, as symptoms are nonspecific and can be manifestations of other diseases, such as upper
respiratory tract infection, allergic rhinitis and migraine [3]. The nasal endoscopic criteria are the presence
in one or both nasal cavities of nasal polyps, and/or mucopurulent discharge and/or oedema or mucosal
obstruction primarily in the middle nasal cavity. The radiological criteria are mucosal changes within the
ostiomeatal complex or sinuses on computed tomography examination. Of the two clinical phenotypes of
RS, without nasal polyps (RSsNP) is twice as prevalent as with nasal polyps (RSwNP) [4].
The united airway disease (UAD) concept is based on epidemiological and clinical studies that have
reported an association of sinonasal diseases, such as allergic rhinitis and RS, with obstructive airway
diseases. According to this concept, the upper and lower airways should be considered as a single airway,
as disease processes in the lower airway such as inflammation, may affect the upper airway and vice versa
[5, 6]. Moreover, optimal management of lower airway disease requires that upper airway disease should
be assessed and treated appropriately, as exemplified in asthma by the need to assess for and treat
coexisting allergic rhinitis and polyps [7].
Chronic obstructive pulmonary disease (COPD) is an inflammatory, progressive lower airway disease with
persistent airflow limitation [8]. The main risk factor is exposure to cigarette smoke in developed countries
and to biomass smoke in poorly ventilated homes in developing countries [9]. Several epidemiological and
clinical studies have suggested an association of COPD with sinonasal symptoms; 40–88% of COPD
patients report either current, recurrent or permanent symptoms, such as rhinorrhoea/nasal discharge,
nasal obstruction and/or sneezing [10–14]. However, in a recent review on sinonasal disease and
inflammation in COPD, the validity of this association was questioned as the reviewed studies had
methodological limitations, such as the absence of a control population, self-reported COPD diagnosis and
use of nonstandardised criteria for the diagnosis of RS and COPD [15].
In this study, we investigated the prevalence of RSsNP in COPD and a corresponding control group with
respect to age and sex, applying EPOS 2012 and Global Initiative for Chronic Obstructive Lung Disease
(GOLD) criteria for the clinical diagnosis of RS and COPD, respectively. We also investigated the severity
of sinonasal symptoms and evaluated the diagnostic accuracy of these symptoms for RS in COPD.

Material and methods

Study design and subjects
The study was conducted as an observational cross-sectional study between February 2016 and December
2017 at St. Olavs University Hospital, Trondheim, Norway. COPD patients were recruited from the
respiratory outpatient and physical therapy clinics at St. Olavs University Hospital, a private pulmonology
practice and several general practitioner offices in Trondheim. Controls were recruited from the general

Study sample
n=206

COPD Controls

Spirometry: n=103 n=103

Spirometry:
Positive reversibility: n=7 Positive reversibility: n=8
Restrictive: n=3
188
n=93 n=95
Nasal endoscopy: Nasal endoscopy:
Nasal polyps: n=3 Nasal polyps: n=2
183
n=90 n=93

FIGURE 1 Overview of the study sample showing excluded subjects in each group with positive reversibility
test and nasal polyps.

https://doi.org/10.1183/23120541.00015-2020 2
 COPD | M.R. ØIE ET AL.

population, via invitation to different workplaces in Trondheim, multiple retirement associations, and
posters in various shopping malls and on the hospital’s social media page. Inclusion criteria were age
40–80 years and no history of sinonasal surgery in both groups, no known lower airway disease in the
control group and a post-bronchodilator forced expiratory volume in 1 s (FEV1) to forced vital capacity
(FVC) ratio of <0.7 with a negative bronchodilator reversibility test in the COPD group. For both groups,
exclusion criteria were any of the following: known underlying systemic diseases that could potentially
affect the nose, such as eosinophilic polyangiitis (EGPA) and granulomatous polyangiitis (GPA), cystic
fibrosis, primary ciliary dyskinesia/Kartagener syndrome and sarcoidosis, nasal tumours, asthma, current
treatment for malignancy, symptoms of common cold within the previous 2 weeks, use of long-term
oxygen therapy, a positive bronchodilator reversibility test, presence of nasal polyps on endoscopy, COPD
exacerbation within the last 6 weeks. An overview of the study sample is presented in figure 1.
All subjects gave oral and written consent for participation in the study. The study was approved by the
National Ethical Committee of Norway (reference number 2015/2017), and investigations were performed
in accordance with the principles of the Declaration of Helsinki/Hong Kong.

Methods
Subjects were instructed to discontinue the use of systemic antihistamine and corticosteroids at 4 days and
nasal decongestants at 12 h prior to the inclusion visit. Nasal corticosteroids were not discontinued. COPD
patients were instructed not to take their morning inhaled medication.
Weight and height were recorded for calculation of body mass index (BMI), and spirometry with
reversibility test and skin-prick test (SPT) were performed. Subjects completed self-administered
questionnaires on smoking habits, symptoms of allergy affecting the airways and sinonasal symptoms. The
presence and severity of the latter were evaluated by the sinonasal outcome test-22 (SNOT-22) [16], which
is a 22-item questionnaire on nasal and non-nasal symptoms and is a widely recognised and validated tool
for RS [2, 16, 17], and visual analogue scales (VAS), as recommended by EPOS 2012 [2]. An interview and
clinical examination with nasal endoscopy were performed by one of three otolaryngologists committed to
the study.

Spirometry with reversibility test

Pulmonary function tests were performed before and after administration of 0.4 mg salbutamol aerosol by
spacer and in accordance with European Respiratory Society (ERS) guidelines for spirometry [18].
Predicted reference values of CRAPO et al. [19] were used.

Skin-prick test
SPT was performed with an allergen panel consisting of birch, grass and mugwort pollen, cladosporium,
house dust mite (Dermatophagoides pteronyssinus), and horse, dog and cat epithelia, together with positive
and negative controls (Soluprick SQ, ALK-Abello, Horsholm, Denmark). A positive result was defined as a
wheal ⩾3 mm in diameter 15 min after application [20].

Allergy status
Allergic rhinitis was diagnosed based on self-reported symptoms characteristic for rhinoconjunctivitis on
exposure to the specific allergen(s) found positive on SPT. The self-reported symptoms must have been
present within the last 12 months.

Smoking status
Pack-year exposure was calculated, and subjects were categorised into current, former and never-smokers.

Nasal endoscopy
Nasal endoscopy was performed with a 2.7 mm, 0° True View II endoscope (Olympus, Japan), and the
mucosa in each nasal cavity was evaluated for oedema and mucopurulent discharge. A positive nasal
endoscopy was defined as unilateral or bilateral presence of oedema in the middle meatus and/or
mucopurulent discharge primarily in the middle nasal cavity [2].

COPD diagnosis confirmation

The COPD diagnosis was confirmed by the presence of airflow obstruction, defined as an increase of less
than 12% and 200 mL in FEV1 after administration of salbutamol by inhalation and a post-bronchodilator
FEV1/FVC ratio of <0.7 [8]. Severity of airflow obstruction was graded according to the GOLD 2014
criteria [8].

https://doi.org/10.1183/23120541.00015-2020 3
 COPD | M.R. ØIE ET AL.

Symptomatic criteria of rhinosinusitis

The symptomatic criteria defined by EPOS were considered present if the respondent had at least two of
the four symptoms, of which one was nasal obstruction or nasal discharge. This was determined by
dichotomisation of responses to the following items in the SNOT-22 questionnaire: item 4, nasal
obstruction; at least one of the following items, nasal discharge (anterior/posterior nasal drip): item 1
(need to blow nose), item 3 (runny nose), item 7 ( post-nasal discharge), item 8 (thick nasal discharge);
item 5 (loss of taste and smell), reduction/loss of smell; item 12, facial pain/pressure. The response range
for each item is 0–5; with 0, no problem and 5, problem as bad as it could be. A response of 0–1 and 2–5
was defined as “symptom not present” and “symptom present”, respectively [21].

Diagnosis of rhinosinusitis without nasal polyps

The clinical diagnosis of RSsNP was defined as the presence of symptomatic criteria of RS and a positive
nasal endoscopy.

Assessment of symptom severity and diagnostic accuracy of sinonasal symptoms

Subscales for rhinological and ear/facial symptoms were constructed by summation of responses to item
1–5, 7 and 8 and item 9–12, respectively, in the SNOT-22 questionnaire [16].
The severity of each of the following symptoms was self-assessed on VAS from 0 to 100 mm, with 0
representing “not troublesome” and 100 “worst thinkable troublesome” [22]: nasal obstruction, nasal
discharge (anterior/posterior nasal drip), reduced sense of smell, facial pain, sinus pressure, mouth
breathing, sneezing and headache. VAS responses to the first three symptoms were summated to obtain a
composite VAS for rhinological symptoms and responses to the following two were summated to obtain a
composite VAS for facial symptoms.
The diagnostic accuracy of VAS responses [23] for a diagnosis of RSsNP was evaluated by construction of
receiver operating characteristics (ROC) curves of the composite VAS for rhinological and facial symptoms
for both groups.

Statistical analysis
SPSS version 25 (Statistical Packages for the Social Sciences, for Windows, USA) was used for statistical
analysis. Continuous variables with a positively skewed distribution were rescaled and log10 transformed to
obtain a normal distribution prior to analysis. Comparative analyses between groups were performed with
t-tests for continuous variables and the Chi-squared statistic, with Fisher’s exact test when appropriate, for
categorical variables. Group comparisons with adjustments for age and sex were also performed using
linear regression for continuous variables and logistic regression for categorical variables. The results of the
regression analyses did not deviate from the results of the Chi-squared and t-tests, thus results are
presented as mean±SD and frequencies and percentages, respectively. Area under the ROC curve with 95%
confidence intervals were computed for composite VAS for rhinological and facial symptoms to compare
the diagnostic accuracy, and a value >0.8 has a good diagnostic accuracy [24]. Independent group area
difference under the ROC curve was used for tests of statistical significance between COPD and control
groups. The level of significance was set at the standard two-sided level of 5%.

Results
Subject characteristics
In the studied sample, the mean age of 90 subjects with COPD and 93 control subjects were 66.2 and
63.7 years, respectively. Sex and BMI were evenly distributed in the two groups. The prevalence of allergic
rhinitis was almost three times higher in control subjects than in COPD subjects (table 1). Airflow
limitation was moderate (GOLD2) in 44% and severe (GOLD3) in 37% of COPD subjects (table 2).

Symptoms and diagnostic criteria of RS

The prevalence of three of the four symptoms of RS were significantly greater in the COPD group than in
the control group (figure 2a). In both groups, nasal discharge was the most prevalent, followed in
decreasing order by nasal obstruction, impaired taste and smell and facial pain/pressure.
The prevalence of symptomatic criteria for RS in COPD subjects was twice the prevalence in controls, (57
(63%) versus 28 (30%), p<0.001) and the endoscopic criteria was 1.5-fold more prevalent in COPD than in
controls (63 (70%) versus 42 (45%), p=0.003) (figure 3).

Prevalence of RSsNP
The prevalence of RSsNP in the COPD group was 51% (n=46) and over threefold higher than in the
control group (n=15, p<0.001) (figure 3). When subjects with allergic rhinitis were excluded, the diagnosis

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 COPD | M.R. ØIE ET AL.

TABLE 1 Subject characteristics

COPD Control p-value

Subjects n 90 93
Males 49 (54.4) 51 (54.8) 0.96
Age years 66.2±8.7 63.7±8.7 0.051
Smoking status
Current 17 (18.9) 7 (7.5) <0.001
Former 68 (75.6) 47 (50.5)
Never 5 (5.6) 39 (41.9)
Pack-years# 28.6±20.9 6.6±10.8 <0.001
BMI kg·m2 27.0±5.4 27.3±4.7 0.7
Allergic rhinitis 5 (5.6) 14 (15.1) 0.035
Nasal corticosteroids 4 (4.4) 4 (4.3) 1.0
Pulmonary function¶
FEV1 L 1.6±0.7 3.0±0.9 <0.001
FEV1 % pred 53.1±18.7 94.6±12.2 <0.001
FVC L 3.0±1.0 3.7±1.0 <0.001
FVC % pred 75.8±18.0 93.8±13.0 <0.001
FEV1/FVC 0.53±0.12 0.78±0.05 <0.001

Data presented as n (%) or mean±SD, unless otherwise stated. The p-values refer to data comparison
between COPD and controls. COPD: chronic obstructive pulmonary disease; BMI: body mass index; FEV1:
forced expiratory volume in 1 s; % pred: % predicted; FVC: forced vital capacity. #: Missing data in four
controls and three COPD; ¶: pre-bronchodilator values in two controls and one COPD. Otherwise,
pulmonary function parameters are based on post-bronchodilator measurements.

of RSsNP remained significantly greater in the COPD group than in controls (41 (48%) versus 12 (15%),
p<0.001).
RSsNP was diagnosed in 47% (32 of 68) former and 65% (11 of 17) current smokers in the COPD group
and in 19% (9 of 47) former and 29% (2 of 7) current smokers in the control group ( p=0.35).
In the COPD group, RSsNP was diagnosed in 27 (59%) males and 19 (41%) females ( p=0.41) and in 2
(29%), 18 (45%), 19 (58%) and 7 (70%) subjects with mild, moderate, severe and very severe airflow
limitation (GOLD 1–4), respectively.

Severity of sinonasal symptoms

The total SNOT-22 score was significantly higher in the COPD group than in controls (29.8±18.8 versus
16.6±15.5, p<0.001). SNOT subscale scores of rhinological and ear/facial symptoms were significantly
higher in the COPD group than in the control group (figure 2b).
VAS for nasal obstruction, reduced sense of smell, mouth breathing, and sneezing were significantly
greater in the COPD group than in the control group (table 3), while nasal discharge, facial pain and sinus
pressure were not. The composite VAS score was significantly higher for rhinological symptoms in the
COPD group than in the control group and was not significantly different for facial symptoms between
the two groups (table 3).

TABLE 2 Grade of airflow limitation in COPD subjects

Post-bronchodilator FEV1, mean±SD

GOLD classification n (%) L % pred

GOLD 1 Mild 7 (7.8) 2.7±0.8 85.7±4.2

GOLD 2 Moderate 40 (44.4) 1.9±0.6 65.5±8.1
GOLD 3 Severe 33 (36.7) 1.2±0.3 40.0±5.3
GOLD 4 Very severe 10 (11.1) 0.7±0.2 24.4±3.6

GOLD: Global Initiative for Chronic Obstructive Lung Disease; FEV1: forced expiratory volume in 1 s;
% pred: % predicted.

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 COPD | M.R. ØIE ET AL.

a) 100 b) 20
p<0.001
90 COPD 18 COPD
80 p<0.001 Control 16 Control
70 p<0.001 14
72
Prevalence %

60 12
62

Score
p=0.02
50 10
p=0.001
40 45 8
30 37 6
33 p=0.16
20 4
10 15 17 2
10
0 0
Nasal obstruction Nasal discharge Impaired taste Facial pain/ Rhinological Ear/facial
and smell pressure SNOT subscales

FIGURE 2 a) Prevalence of symptoms of rhinosinusitis (European position paper on rhinosinusitis and nasal polyps (EPOS) criteria). Data derived
from sinonasal outcome test (SNOT)-22. b) Rhinological and ear/facial SNOT subscales. Data are presented as mean±SD.

Diagnostic accuracy of sinonasal symptoms for RSsNP

The area under the curve (95% CI) of the ROC curve for the composite rhinological VAS was not
significantly different in the COPD and control groups (0.82 (0.73–0.90) versus 0.85 (0.76–0.95), p=0.56).
The cut-off composite rhinological VAS score was 56 and 36.5 for COPD and controls, respectively. The
ROC curve values for the composite facial VAS were 0.63 (0.51–0.74) versus 0.82 (0.68–0.95), p=0.03
(figure 4).

Discussion
In this study, we found that COPD is associated with RS and sinonasal symptoms have significantly
greater severity in COPD subjects than in controls. This association is supported by a clinical diagnosis of
RSsNP in 51% and the presence of symptomatic criteria of RS in over 60% of COPD subjects (figure 3).
Moreover, RSsNP is threefold and symptomatic and endoscopic criteria of RS are 1.5–2-fold more
prevalent in the COPD group than in the control group. The greater severity of sinonasal symptoms in
COPD is evident when these symptoms are assessed by SNOT-22 subscales for rhinological and ear/facial
symptoms (figure 2b), VAS for individual symptoms and composite VAS for rhinological symptoms (table
3). The latter has a superior diagnostic accuracy for RS than the composite VAS for facial symptoms
(figure 4).
The prevalence of nasal discharge, nasal obstruction and impaired taste and smell varied from 72 to 37%
in COPD subjects in this study and was significantly greater than in controls (figure 2a). Previous studies
have found that sinonasal symptoms are frequently reported by COPD patients [10–14, 25, 26]. However,
those studies had limitations, such as the lack of a control group [11, 13, 14, 27] and spirometric

Negative Positive Positive Negative

COPD Symptomatic 33 (37%) 11 (12%) 46 (51%) 17 (19%) 27 (30%) Endoscopic

(n=90) criteria criteria

p<0.001 RSsNP p=0.001

p<0.001

65 (70%) 13 (14%) 15 (16%) 27 (29%) 51 (55%)

Control Symptomatic Endoscopic
(n=93) criteria criteria

FIGURE 3 Prevalence of symptomatic and endoscopic criteria and rhinosinusitis without nasal polyps (RSsNP)
in chronic obstructive pulmonary disease (COPD) and control groups.

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TABLE 3 Visual analogue scales (VAS) (mm) for sinonasal symptoms

Sinonasal symptoms COPD (n=90) Control (n=93) p-value

Nasal obstructiona 23.4±25.9 14.1±21.2 0.007

Nasal discharge (anterior/posterior drip)b 20.5±26.3 13.4±21.1 0.12
Reduced sense of smellc 16.0±25.3 6.9±5.4 0.014
Facial paind 6.4±14.2 4.7±12.4 0.65
Sinus pressuree 9.5±20.4 6.9±16.4 0.42
Mouth breathing 24.9±28.1 11.9±20.1 0.001
Sneezing 17.8±20.8 10.8±20.1 0.002
Headache 14.6±22.1 10.9±19.6 0.25
Composite rhinological VAS (a+b+c) 59.9±61.9 34.4±51.4 0.001
Composite facial VAS (d+e) 15.9±37.7 11.5±27.0 0.4

Data are presented as mean±SD, unless otherwise stated.

confirmation of COPD diagnosis [10, 14, 26, 27], which have been addressed in our study. Moreover, we
found that almost two out of three subjects with COPD fulfilled the EPOS symptomatic criteria for RS.
This prevalence is threefold higher than that reported in a Brazilian study by CAMINHA et al. [21]. The
difference in prevalence rates is consistent with the large variability in the overall prevalence rates of
7–27% reported across 12 countries in the 2011 pan-European prevalence study [1]. Our prevalence of
63% is slightly greater than that of 53% reported by KELEMENCE et al. [14]. However, that study is not fully
eligible for comparison, as the definition of symptomatic RS included EPOS criteria as well as headache,
ear pain, halitosis and fatigue.
To our knowledge, this is the first study where EPOS endoscopic criteria were used for a diagnosis of
RSsNP in COPD and control subjects. Our finding of RSsNP in every other subject with COPD is in
accordance with the prevalence of 49% reported by YANG et al. [27]. However, there are differences
between the two studies. In Yang’s study, there was no control group; headache was included in the
symptomatic criteria and radiologic criteria were used to diagnose RS. Nasal endoscopy is the only
modality that discriminates RSsNP from RSwNP. Moreover, in our study, we also evaluated for allergic

a) 1.0 b) 1.0

0.8 0.8

0.6 0.6
Sensitivity

Sensitivity

Reference line Reference line

0.4 Controls (n/N=15/93 (16%)) 0.4 Controls (n/N=15/93 (16%))
COPD (n/N=46/90 (51%)) COPD (n/N=46/90 (51%))
Control COPD Control COPD
VAS 36.5 56 VAS 5.5 6.5
0.2 Sensitivity 73% 63% 0.2 Sensitivity 80% 52%
Specificity 80% 80% Specificity 83% 80%
AUC 0.85 0.82 AUC 0.82 0.63
95% CI 0.76–0.95 0.73–0.90 95% CI 0.68–0.95 0.51–0.74
p-value 0.56 p-value 0.03
0.0 0.0
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
1 – specificity 1 – specificity

FIGURE 4 Receiver operating characteristic curves and diagnostic accuracy of (a) composite rhinological visual analogue scale (VAS) and
(b) composite facial VAS in chronic obstructive pulmonary disease (COPD) and controls for a diagnosis of rhinosinusitis without nasal polyps
(RSsNP) using European position paper on rhinosinusitis and nasal polyps (EPOS) criteria. AUC: area under the curve; CI: confidence interval.

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 COPD | M.R. ØIE ET AL.

rhinitis at the time of inclusion, as this entity affects 10–20% of the adult population [28] and can mimic
symptoms of RS. Although allergic rhinitis was almost threefold more frequent in the control group, the
relative prevalence of RSsNP in the COPD group was unchanged, which suggests that the high prevalence
of RSsNP is not due to undiagnosed allergic rhinitis.
In addition to being more prevalent (figure 2a), the severity of RS symptoms was greater in COPD than in
controls as demonstrated by data obtained from the SNOT-22 and VAS. The SNOT subscales showed that
COPD subjects were significantly more troubled than controls by rhinological and ear/facial symptoms
(figure 2b). This suggests that altered nasal conditions secondarily may lead to increased mouth breathing
and thus inadequate protection and homeostasis of the lower airways in COPD which is in line with the
UAD concept. Future studies should investigate whether RS symptoms have an impact on quality of life in
COPD.
Further, the prevalence of RSsNP was 47% and 19% in COPD and controls former smokers respectively
and increased by almost 1.5 in current smokers in both groups, which may indicate that cigarette smoke
has a negative effect in the upper airway. Cigarette smoke has been proposed to have pathophysiological
effects on the sinonasal mucosa that can account for increased frequency of upper airway symptoms and
impairment of olfaction [29, 30].
It would be clinically beneficial to have a simple instrument to screen COPD patients for RS. This is
desirable as both patients and their physicians underrecognise sinonasal symptoms [6, 31], and RS is
independently associated with treatment failure in COPD exacerbations [32]. In the present study, three
rhinological VAS items were summated, and the resulting composite VAS score of 56 or higher had the
best diagnostic accuracy for RSsNP in COPD patients, with a sensitivity and specificity of 63% and 80%,
respectively. The composite VAS may have a potential for selecting COPD patients for further assessment
by an otolaryngologist. However, the cut-off value for a specificity of 80% was higher in COPD than in
control subjects, which may be due to differences in symptom burden in the two groups. The cut-off value
may variate depending on sample characteristics and care settings [33]. As such, it will be prudent to
validate the relationship between the composite rhinological VAS score and the diagnosis of RSsNP in
larger cohorts of COPD patients, preferably in relation to the severity of airflow limitation, and of control
subjects in primary and specialist care settings.
The strengths of this study are the relatively large sample size with almost equal sex representation,
inclusion of COPD patients across the spectrum of disease severity, inclusion of a control group similar in
age, number and from the same population area, as well as the use of globally accepted diagnostic criteria
for RS and COPD. Spirometry with reversibility testing allowed us to eliminate asthma on COPD overlap
and allergy testing permitted discrimination of RS symptoms from allergic rhinitis. There is a possibility of
a recruitment bias of subjects with sinonasal symptoms in the control group, as the protocol included
clinical examination by an otolaryngologist. This limitation may account for the higher mean subscale
score of the SNOT rhinological symptoms in our control group, compared to the control population in a
study by ERSKINE et al. [17]. Conversely, this limitation could add strength to our study as the results
would be more significant if the bias was absent. Another limitation was our inability to evaluate the
impact of RS on exacerbations of COPD, due to the lack of access to exacerbation data.

Conclusion
RSsNP is present in 51% of our COPD patients and is threefold more prevalent in the COPD group than
in controls. These results suggest that COPD is associated with RS.

Acknowledgements: We are grateful for the assistance of the Clinical Research Facility, St. Olavs Hospital, Trondheim
University Hospital and their nurses, as well as research nurse Else Bartnes, Dept of Otolaryngology, Head and Neck
Surgery, St. Olavs University Hospital.

Conflict of interest: None declared.

Support statement: The study was supported by a PhD grant provided by the Liaison Committee between the Central
Norway Regional Health Authority and the Norwegian University of Science and Technology.

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