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.
|1||Small polyps restricted to the middle meatus; do not extend below the lower border of the middle turbinate.|
|2||Polyps extend below the lower border of the middle turbinate.|
|3||Large polyps extend down to the lower border of the inferior turbinate, or polyps are medial to the middle turbinate.|
|4||Large polyps that result in complete obstruction of the nasal cavity.|
22-Item Sino-Nasal Outcome Test (SNOT-22)1,6
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
- Runny nose
- Post nasal discharge
- Thick nasal discharge
- Ear fullness
- Ear pain
- Facial pain/pressure
- Difficulty falling asleep
- Waking up at night
- Lack of good night’s sleep
- Waking up tired
- Reduced productivity
- Reduced concentration
- Sense of taste/smell
- Blockage/congestion of nose
Lund-Mackay CT Scoring System1,4,5
The Lund-Mackay scoring system is used in conjunction with CT for scanning of nasal polyps.
|Sinus System||Possible Score*||Grading|
|Maxillary||0, 1, or 2||0 = no mucosal thickening
1 = partial opacification
2 = total opacification
|Anterior ethmoid||0, 1, or 2|
|Posterior ethmoid||0, 1, or 2|
|Sphenoid||0, 1, or 2|
|Frontal||0, 1, or 2|
|Osteomeatal complex||0 or 2 only|
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.
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.
- 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
|Normosmia||Normal sense of smell|
|Hyposmia||Decreased sense of smell|
|Hyperosmia||Increased sense of smell|
|Anosmia||Total loss of smell|
|Specific anosmia||Inability to identify a certain odor|
|Parosmia||Aberrant perception of odor|
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.
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).
Updates in the Guidelines 20199
Response For Treatment
*European Forum for Research and Education in Allergy and Airway diseases
Updates in the Guidelines 202010
|Evidence of Type 2 Inflammation||Tissue eos ≥ 10/hpf, OR blood eos ≥ 250, OR total IgE ≥100|
|Need for systemic corticosteroids or contraindication to systemic steroids||≥ 2 courses per yr, OR long term (>3 months) low dose steroids|
|Significantly impaired quality of life||SNOT-22 ≥ 40|
|Significant loss of smell||Anosmic on smell test (score depending on test)|
|Diagnosis of comorbid asthma||Asthma needing regular inhaled corticosteroids|
Response For Treatment
Defining response to biological treatment in CRSwNP
*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
*unless having a medical contraindication/rejected by the patient
ESS, Endoscopic Sinus Surgery; INCS, Inhaled Corticosteroid; NCS, Nasal Congestion Score; NPS, Nasal Polyp Score; SNOT-22, 22-item Sino-Nasal Outcome Test; VAS, Visual Analog Scale.
- 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.
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