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Campus
Campus

N-Pass Tool

Medical History
Patient Name
No.
Clinical Evaluation on VAS (0-10)
Not troublesome
Troublesome
*The scale above is used to self-rate individual symptoms given below,
severity of symptoms (0 corresponds to not troublesome and 10 to worst thinkable troublesome)
Rhinosinusitis disease was graded as (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
History of presenting symptoms:
Number of years since diagnosis of Nasal Polyps:
ESS Surgery
No
Yes, how many
Date of last surgery
Courses of Systemic Corticosteroid Use in the Past Year
Number:
Duration:
Relevant Comorbidities
Asthma
NSAID-ERD/AERD
Allergic Fungal Rhino-Sinusitis
Atopic Dermatitis
Eosinophilic Esophagitis
Evaluation & Investigations
Blood Eosinophils:
Total IgE:
(IU/ML)
Tissue EOS (Optional)
HPF
Blood eosinophils can be influenced by use of systemic steroids
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).
Polyp size / location
Anatomical description No polyp. Presence of small polyps in the middle meatus not reaching below the inferior border of the middle turbinate. Polyps reaching below the inferior border of the middle turbinate Large polyps reaching the lower border of the inferior turbinate or polyps medial to the middle turbinate. Large polyps causing complete obstruction of the inferior nasal cavity.
Lund-Mackay CT Scoring System1,4,5
OPTIONAL
Sinus system Left Right Total score
Maxillary
Anterior ethmoidal
Posterior ethmoidal
Sphenoidal
Frontal
Osteomeatal complex
Total score
GRADING
0 = Absence (No mucosal thickening)
1 = Partial opacification
2 = Complete opacification
The Osteomeatal Complex (OC) is graded separately as 0 = not occluded or 2 = occluded, deriving a maximum score of 12 per side.
SNOT-226,7
8-20 inclusive (Mild)
>20-50 (Moderate)
>50 (Severe)
*The range of the SNOT-22 score is 0 to 110, where lower scores indicate less impact.
To see the full SNOT-22 questionnaire, go to https://www.canvasc.ca/pdf/SNOT22.pdf
Treatment Decision
Appropriate medical therapy
Surgery
Initiate biologic
Please use the PASS follow up sheet after 16 week.
Print this form
Click for the N-PASS follow up form

MAT-BH-2200294/ V1/MARCH2022