N-Pass Handbook

Bilateral Endoscopic Nasal Polyp Score (NPS)^1,3

Polyp size is assessed endoscopically to determine the nasal polyp score (NPS).

The NPS scale ranges from 0 (no polyp) to 4 (large polyps) for each nostril. These scores are tallied from each nostril for a total score ranging from 0 to 8.

22-Item Sino-Nasal Outcome Test (SNOT-22)^1,6

The 22-item sino-nasal outcome test (SNOT-22) is a validated questionnaire used to assess the impact of CRSwNP on HRQoL.

It includes questions specifically designed to measure nasal blockage, and sense of taste and smell.

• The range of the SNOT-22 score is 0 to 110.
• Lower scores indicate less impact.

Take a Closer Look: The SNOT-22

The SNOT-22 questionnaire provides a 6-point scale which is used to assess 22 symptoms and social or emotional consequences in patients with CRSwNP.

Each symptom or consequence is ranked on a 6-point scale:

• No problem (0 pts)
• Very mild problem (1 pt) 
• Mild or slight problem (2 pts)
• Moderate problem (3 pts)
• Severe problem (4 pts)
• Problem as bad as it can be (5 pts)

The following list contains the 22 symptoms and social or emotional consequences ranked in the SNOT-22:

• Need to blow nose
• Sneezing
• Runny nose
• Cough
• Post nasal discharge
• Thick nasal discharge
• Ear fullness
• Dizziness 
• Ear pain
• Facial pain/pressure
• Difficulty falling asleep
• Waking up at night
• Lack of good night’s sleep
• Waking up tired
• Fatigue
• Reduced productivity
• Reduced concentration
• Frustrated/restless/irritable
• Sad
• Embarrassed
• Sense of taste/smell
• Blockage/congestion of nose

Lund-Mackay CT Scoring System^1,4,5

The Lund-Mackay scoring system is used in conjunction with CT for scanning of nasal polyps.

CT Computed Tomography

*Calculated per side (total score of 0 to 24 across both sinuses)

This system uses a score of 0 to 2, which reflects the absence (0), partial (1), or complete (2) opacification of each sinus as well as of the vital ostiomeatal complex (0 is not obstructed and 2 is obstructed).

The maximum score possible for each side is 12 (total score of 0 to 24 across both sides), higher scores indicate worse status.

Evaluation of Nasal Symptoms and Olfactory Function¹¹

Nasal Congestion Score

The nasal congestion score (NCS) is a self-evaluation of symptoms of congestion.

The NCS is a monthly average of the patient’s own daily morning assessment of the severity of their congestion symptoms over the previous 24 hours.

The NCS is graded according to the following 4-point scale:

⁰ is equal to absent symptoms (no sign/symptom evident).

¹ is equal to mild symptoms (sign/symptom clearly present, but minimal awareness; easily tolerated).

² is equal to moderate symptoms (definite awareness of sign/symptom that is bothersome but tolerable).

³ is equal to severe symptoms (sign/symptom that is hard to tolerate; causes interference with activities of daily living and/or sleeping).

Total Rhinosinusitis Symptoms Score (TSS)^1,2

The Total Rhinosinusitis Symptoms Score (TSS) is a calculated composite score (ranging between 0 to 9) consisting of the sum of rhinosinusitis symptoms assessed each morning by the patient.

TSS assesses the following symptoms:

• Nasal congestion.
• Loss of sense of smell.
• Rhinorrhea.

Each symptom is graded on a 4-point scale (0 - 3):

⁰ indicates no symptoms.

¹ indicates mild symptoms that are easily tolerated.

² indicates awareness of symptoms that are bothersome but tolerable.

³ indicates severe symptoms that are hard to tolerate and interfere with daily activity.

Olfactory Dysfunction¹³

• Loss of smell is one of the most significant symptoms to patients, and has a substantial impact on QoL.
• In addition, the impairment of the sense of smell seems to correlate with disease severity and maybe the first sign of disease recurrence.
• However, the exact mechanism underlying impaired olfaction is still not fully understood.
• May be related to nasal airflow reduction, local edema-induced compression of olfactory nerves, as well as mucosal inflammation.

Definitions of Smell Impairment¹⁴

Loss of Smell Score (LoS)^1,2

The loss of smell score is a patient-collected assessment of the daily symptom severity of decreased or loss of smell.

The loss of smells score is graded using a 0 to 3 categorical scale, where 0 = no symptom, 1 = mild LoS, 2 = moderate LoS, 3 = severe LoS.

VAS score

Visual Analog Scale (VAS), 0 to 10.

This VAS is ideal in the classification of symptoms of rhinosinusitis into mild (VAS 0–3), moderate (>3–7), and severe (>7–10).

University of Pennsylvania Smell Identification Test (UPSIT)^7,8

• A self-administered test that uses microencapsulated odorants that are released by scratching standardized odor-impregnated test booklets
• The individual “scratches and sniffs” each odor in the booklet, then selects from four multiple-choice answers corresponding to the perceived smell
• The UPSIT score ranges from 0 to 40, where higher scores indicate better status

A particular strength of this test is that a clinician can distinguish patients:

• Normal sense of smell, normosmia score (35-40)
• Different levels of reduction; mild (score of 31), moderate (score of 26-30)
• Severe microsmia score (9-25), anosmia score (0-18)

Updates in the Guidelines 2019⁹

EUFOREA* Guidelines

Defining response to biological treatment in CRSwNP patients

Evaluation of 5 criteria

• Reduced nasal polyp size
• Reduced need for systemic corticosteroids
• Improved quality of life
• Improved sense of smell
• Reduced impact of comorbidities

Response For Treatment

EUFOREA* Consensus

Indications for biological treatment in CRSwNP patients

• Evidence of Type 2 Inflammation
• Need for systemic corticosteroids (2 or more courses in the past year)
• Significantly impaired quality of life
• Significant loss of smell
• Diagnosis of comorbid asthma

*European Forum for Research and Education in Allergy and Airway diseases

Updates in the Guidelines 2020¹⁰

EPOS** Guideline

Indications for biological treatment in CRSwNP

Presence of bilateral polyps in a patient who had ESS*

Response For Treatment

Defining response to biological treatment in CRSwNP

Evaluation of 5 criteria

• Reduced nasal polyp size
• Reduced need for systemic corticosteroids
• Improved quality of life
• Improved sense of smell
• Reduced impact of comorbidities

*Exceptional circumstances excluded (e.g., not fit for surgery)

**European Position Paper on Rhinosinusitis and Nasal Polyps

EUFOREA Expert Board Meeting on Uncontrolled Severe CRSwNP¹⁵

Evaluation of the clinical response to a biologic within 6 months of treatment: ‘‘continue or stop’’ suggestions

Selection of a biologic drug and monitoring of its effectiveness

Prediction of response in an individual patient is not possible today

Diagnosis of Uncontrolled Severe CRSwNP

Uncontrolled

Persistent or recurring CRSwNP despite long-term INCS, and having received at least one course of systemic corticosteroids* in the preceding 2 years and/or previous sinonasal surgery*

• Long-term low dose systemic corticosteroids is not recommended in CRSwNP
• One course of systemic corticosteroids refers to a minimum of 5 days of systemic corticosteroids at a dose of 0.5-1 mg/Kg/day or more
• Previous sinonasal surgery refers to any surgical procedure from the resection of polyps to conventional ESS or extended approaches

Severe

Bilaterlal CRSwNP with a NPS of ≥ 4, and persistent symptoms despite long-term INCS with the need for add-on treatment

• Bilateral polyposis (by nasal endoscopy)
• NPS ≥ 4 out of 8
• Presence of persistent symptoms assessed by:
  • Loss of smell score (0-3) ≥ 2 points
  • NCS (0-3) ≥ 2 points
  • SNOTT-22 ≥ 35 points
  • Total symptoms VAS ≥ 5 out of 10 cm

*unless having a medical contraindication/rejected by the patient

For the indication of Type 2 biologics including anti-IL4 receptor alpha (Dupilumab), anti-IgE (Omalizumab) and anti-IL5/R (Mepolizumab, Benralizumab), an underlying Type 2 inflammation should be highly likely

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