N-PASS Follow Up Form
Date
Medical History
Patient Name
No.
Number of Weeks on Biologics
Clinical Evaluation on VAS (0-10)
Not troublesome
Troublesome
*(Mild > 0 to 3), (Moderate >3 to 7), or (Severe >7 to 10).
Nasal congestion/obstruction
Nasal discharge (Anterior/Posterior nasal drip)
Reduction/Loss sense of smell
Facial pain/Pressure
Sleep disturbance or Fatigue
Rescue treatment needed
OCS use
Yes
No
Surgery
Yes
No
When
Improvement in Relevant Comorbidities
SNOT-226,7
8-20 inclusive (Mild)
>20-50 (Moderate)
>50 (Severe)
NPS (Endoscopic Nasal Polyp Score)1,3
| Right Nostril |
0
|
1
|
2
|
3
|
4
|
| Left Nostril |
0
|
1
|
2
|
3
|
4
|
Total score
*The maximum score is 8 (4 points per nasal cavity).
Treatment Decision
Biological treatment continuation
Change biological treatment
Surgery
Other
Possible Side Effects
- Bachert C, Mannent L Naclerio RM, et al. Effect of Subcutaneous Dupilumab on Nasal Polyp Burden in Patients With Chronic Sinusitis and Nasal Polyposis: A Randomized Clinical Trial. JAMA. 2016 Feb 2;315(5):469-79.
- Fokkens W, Lund V, Mullol J, et al European Position Paper on Rhinosinusitis and Nasal Polyps group. European position paper on rhinosinusitis and nasal polyps 2007. Rhinol Suppl. 2007;(20):1-136.
- Sino-Nasal Outcome Test (SNOT-22). St Louis, MO: Washington University; 2006.
- Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology. 1993;3 l (4): 183-184.
- Bhattacharyya N. Test-retest reliability of CT in the assessment of chronic rhinosinusitis. Laryngoscope. 1999; l 09(7 Pl l): l 055-l 058.
- Hopkins C, Gillett S, Slack R, et al. Psychometric validity of the 22-item Sinonasal Outcome Test. Clin Otolaryngol. 2009;34(5):447-454.
-
Toma S, Hopkins C. Stratification of SNOT-22 scores into mild, moderate or severe and relationship with other subjective instruments. Rhinology. 2016 Jun 1;54(2):129-33.
MAT-BH-2200294/ V1/MARCH2022