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The Laryngoscope Lippincott Williams & Wilkins, Inc. © 2003 The American Laryngological, Rhinological and Otological Society, Inc.

The Epidemiology of Chronic Rhinosinusitis in Canadians Yue Chen, MD, PhD; Robert Dales, MD, MSc; Mei Lin, MD, MSc

Objective: To study the prevalence of chronic rhinosinusitis and its risk factors among Canadians. Study Design: Complex survey design incorporating stratification, multiple stages of selection, and unequal probabilities of selection of respondents. Methods: We used the cross-sectional data from 73,364 subjects (34,241 male and 39,123 female subjects) 12 years of age or older who participated in the second cycle of the National Population Health Survey, which was conducted from 1996 to 1997. All these individuals were asked whether they had certain chronic health conditions that had lasted or were expected to last 6 months or longer, including rhinosinusitis. Results: The prevalence of rhinosinusitis was higher in female (5.7%) than in male (3.4%) subjects. The sex difference was consistent across age groups. The prevalence increased with age and leveled off after the age of 60 years. In female but not in male subjects, the prevalence was slightly higher among those living the eastern region or among native Canadians as compared with those living in the central or western regions or immigrants. Cigarette smoking and low income were associated with a higher prevalence of rhinosinusitis in both sexes. The smoking effect was modified by allergy history in male subjects. Rhinosinusitis was more common among subjects with allergy history, asthma, or chronic obstructive pulmonary disease. The prevalence of rhinosinusitis was similar in subjects with or without reporting regular alcohol drinking and exercise. Conclusion: Previous data indicating an increased susceptibility of women to asthma and chronic obstructive pulmonary disease, together with the similar finding for rhinosinusitis, suggest that women have a general increase in susceptibility to respiratory tract disease. Key Words: Allergy, epidemiology, risk factor, rhinosinusitis, smoking. Laryngoscope, 113:1199 –1205, 2003

From the Departments of Epidemiology and Community Medicine (Y.C., M.L.) and Medicine (R.D.), Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Dr. Chen is a Canadian Institutes of Health Research Investigator Award recipient. Editor’s Note: This Manuscript was accepted for publication March 12, 2003. Send Correspondence Yue Chen, MD, PhD, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada K1H 8M5. E-mail: ychen@uottawa.ca

Laryngoscope 113: July 2003

INTRODUCTION Chronic rhinosinusitis, an inflammatory disease of the facial sinuses, is a common disease and can be either “infectious” or “noninfectious,” with significant morbidity and health care costs.1–3 A recent review reported an estimated prevalence in the United States of 14% with 73 million restricted activity days and direct medical costs of 2.4 billion U.S. dollars annually.4 In addition, rhinosinusitis is considered as an important hidden factor that exacerbates asthma and other chronic lung diseases5,6 and has impacts on other health outcomes such as fatigue.7,8 Chronic rhinosinusitis is also an important predictor of maxillary sinus cancer.9,10 Although chronic rhinosinusitis is a common diagnosis, its epidemiology has not been well studied, which contrasts with abundant information on microbiology, diagnosis, and treatment of the condition.11 We used the National Population Health Survey (NPHS) data to study the prevalence and potential risk factors for chronic rhinosinusitis among Canadian 12 years of age or older.

MATERIALS AND METHODS The present analysis was based on the cross-sectional data from the second cycle of the NPHS, conducted by Statistics Canada (Ottawa, Ontario, Canada) from 1996 to 1997. The design and execution of the baseline survey have been detailed elsewhere.12,13 In brief, the target population included household residents in all 10 provinces, excluding Indian reserves, Canadian military bases, and some remote areas of Quebec and Ontario. The NPHS used a multistage, stratified sampling design to draw a representative sample of 95,466 households, including supplementary buy-in subsamples from Ontario, Manitoba, and Alberta, and 78,751 households participated in the survey, with a national response rate of 82%. In all provinces except Quebec, the Labor Force Survey design was used to draw the sample. In Quebec, the Enqueˆte sociale et de sante´ conducted by Sante´ Quebec from 1992 to 1993, with a two-stage design similar to that of the Labor Force Survey, was used. In each household, all members were asked to complete a short general questionnaire, and one person was randomly selected for a more in-depth interview. The survey included questions related to the determinants of health, health status, and use of health services.13 Each subject 12 years of age or older was asked if he or she had certain chronic health conditions, which were explained as “long-term conditions” that had lasted or were expected to last 6 months or longer. Respondents who answered the following question affirmatively were considered to have rhinosinusitis: “Do you

Chen et al.: Chronic Rhinosinusitis

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have sinusitis diagnosed by a health professional?” In the present analysis, we excluded subjects who did not answer this question. The present analysis was then based on 73,364 subjects (34,241 male and 39,123 female subjects). Current smokers were respondents who reported smoking cigarettes every day at the time of the survey. Former smokers were those who reported smoking cigarettes daily in the past but were not smoking at the time of the survey. Otherwise, subjects were classified as nonsmokers. Subjects were classified into low-, middle-, and high-income groups based on total household income adjusted for number of household members.14 A positive history of allergy was defined by an affirmative response to either of the following questions: “Do you have any food allergies diagnosed by a health professional?” or “Do you have other allergies diagnosed by a health professional?” Other variables included in the analysis were region (eastern, central, or western), age (12–19, 20 –29, 39 –39, 40 – 49, 0 –59, 60 – 69, or ⱖ70 y), immigrant (yes or no), household size (1, 2, 3, or ⱖ4 people), number of bedrooms (⬍3 or ⱖ3), education (low or high level), regular drinking (yes or no), regular exercise (yes or no), asthma (yes or no) and chronic obstructive pulmonary disease (COPD) (yes or no). Subjects in the low-level-education category did not proceed beyond secondary school; the high-level-education category included subjects admitted to college or university, as well as those with a postsecondary school certificate or diploma. A regular drinker was defined as a person who drank alcoholic beverages at least once a month. A regular exerciser was defined as a person who engaged in physical activities that lasted more than 15 minutes at least 12 times a month. We calculated the prevalence of rhinosinusitis and corresponding 95% confidence intervals according to individual characteristics in male and female subjects separately. Logistic regression models were used to evaluate the associations, taking covariates into consideration. Model parameters were estimated by using the method of maximum likelihood and were tested for significance by using the Wald statistic. The NPHS used a complex survey design incorporating stratification, multiple stages of selection, and unequal probabilities of selection of respondents. The effect of the complex survey design on variance estimates is represented by the design effect, defined as the ratio of the estimated variance taking into account the nature of the survey design to a comparable estimate of variance based on a simple random sample of the target population.15,16 In the present analysis, the Rao-Wu bootstrap method17,18 was used for variance estimation to take both the population weights and design effects into consideration. First, bootstrap weights were calculated by using the Rao-Wu bootstrap approach provided to us by Statistics Canada. In each stratum, clusters were used as the resampling units, including all observations within each cluster. Within stratum h, nh ⫺ 1 of nh clusters were randomly selected with replacement, and the bootstrap weight w*hik ⫽ [nh/(nh ⫺ 1)] m*hi whik was calculated, where m*h denotes the number of times that the hith cluster was selected, and whik denotes the original survey weight. If a cluster was not selected (m*hi ⫽ 0), then the bootstrap weight (w*hik) of the observations in the cluster was zero. A total of 500 bootstrap samples were provided for the 1994 to 1996 longitudinal panel, permitting calculation of 500-point estimates of each parameter of interest. The SE of each parameter estimate was then given by an SD of the values for the 500 bootstrap replications. SAS software macros for the bootstrap approach were developed by Statistics Canada, and the statistical analyses were conducted by using SAS software, release 6.12.19

RESULTS The prevalence of rhinosinusitis was higher in female than in male subjects 12 years of age or older: 5.7% (95% Laryngoscope 113: July 2003

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confidence interval [CI]: 5.2, 6.1%) versus 3.4% (95% CI: 3.0, 3.9%). As shown in Table I, the sex difference was consistent across age groups. The prevalence increased with age and leveled off in the old age groups. In female but not in male subjects, the prevalence was slightly higher among those living in the eastern region or among native Canadians as compared with those living in the central or western regions or immigrants. Cigarette smoking and low income were associated with a higher prevalence of rhinosinusitis in both sexes. Rhinosinusitis was more common among those with allergy history, asthma, or COPD. The prevalence of rhinosinusitis was similar in subjects with or without reporting regular alcohol drinking and exercise. A multiple logistic regression model was used to assess the independent effects of risk factors on the prevalence of rhinosinusitis after controlling for other covariates. Asthma and COPD were first excluded from the models because those diseases share common risk factors. The age pattern was similar before and after adjusting covariates; so were the differences associated with region and immigrant status. The adjusted odds ratio for the low-income group versus the high-income group was 2.1 (95% CI: 1.3, 3.3%) for male and 1.4 (95% CI: 1.1, 1.8%) for female subjects. The effect of allergy history was similar in male and female subjects with an odds ratio of more than threefold. However, smoking was only significantly associated with rhinosinusitis in female but not in male subjects. The association between smoking and rhinosinusitis was further examined among subjects with and without allergy history. As shown in Table II , in female subjects the crude prevalence of rhinosinusitis was higher in smokers versus nonsmokers regardless of allergic status. Such a difference was not observed in male subjects with allergy history. As shown in Table III, allergy history did not modify the effect of smoking on rhinosinusitis in female subjects after adjusting for region, age, immigrant status, size of household, number of bedrooms, educational level, income adequacy, alcohol drinking, and exercise. However, in male subjects, smoking was positively associated with rhinosinusitis only in subjects without allergy history. The odds ratio for rhinosinusitis in relation to asthma was 1.94 (95% CI: 1.24, 3.03%) for male subjects and 1.73 (95% CI: 1.36, 2.20%) for female subjects after adjusting for region, age, immigrant status, size of household, number of bedrooms, educational level, income adequacy, smoking, alcohol drinking, exercise, and history of allergy.

DISCUSSION The prevalence of self-reported rhinosinusitis among adults in our study is much lower than that reported for 1996 in the United States by the National Center for Health Statistics.20 In Canada, the prevalence was approximately 3% in the 20- to 40-year-old age group, compared with 14.5% in the 18- to 44-year-old age group in the United States. This may in part be due to differences in the wording of the question asked. It may also be related to geographic differences. The prevalence of reported rhiChen et al.: Chronic Rhinosinusitis


TABLE I. Prevalence (%) and 95% Confidence Intervals (CIs) of Rhinosinusitis According to Individual Characteristics Among Canadians 12 Years of Age or Older. Males

Cases

Percent

95% CI

No.

Cases

Percent

95% CI

1595 19286 13360

66 739 426

3.76 3.39 3.47

2.53, 4.99 2.76, 4.02 2.68, 4.26

1912 22227 14984

169 1537 851

8.28 5.35 5.66

6.52, 10.04 4.80, 5.90 4.75, 6.56

3530 5329 7653 6065 4435 3655 3574

42 127 247 270 217 157 171

1.0 2.3 3.6 4.8 4.5 4.2 4.1

0.5, 1.6 1.6, 3.0 2.2, 4.9 3.6, 5.9 3.2, 5.7 2.9, 5.4 2.5, 5.6

3435 6180 8217 6229 4947 4328 5787

63 222 524 503 472 367 406

2.1 3.2 6.6 6.9 8.6 6.8 5.4

1.2, 2.9 2.3, 4.2 5.4, 7.7 5.7, 8.0 7.0, 10.1 5.5, 8.0 4.4, 6.4

5371 28713 157

166 1063 2

3.28 3.50 0.45

1.80, 4.76 3.07, 3.92 —

6258 32726 139

353 2202 2

4.23 6.03 1.97

3.40, 5.06 5.51, 6.54 —

6679 11144 5862 10556

298 426 206 301

3.6 4.3 3.0 3.0

2.7, 4.5 3.5, 5.1 2.3, 3.8 2.1, 3.9

9338 12202 6532 11051

820 878 361 498

7.7 6.9 5.5 4.1

6.7, 8.7 6.0, 7.8 4.4, 6.6 3.5, 4.7

10312 23244 685

423 786 22

3.87 3.29 3.48

3.12, 4.63 2.73, 3.85 1.63, 5.34

13163 25092 868

998 1502 57

6.36 5.38 6.18

5.62, 7.09 4.82, 5.94 3.77, 8.59

16181 17685 375

531 693 7

2.96 3.88 1.99

2.46, 3.47 3.10, 4.65 0.03, 3.94

18487 20288 348

1044 1493 20

4.79 6.47 6.13

4.23, 5.34 5.78, 7.16 2.72, 9.54

3549 7834 15715 7143

171 303 550 207

5.4 3.2 3.4 2.7

3.6, 7.2 2.5, 3.9 2.6, 4.1 2.0, 3.3

6311 9492 14716 8604

531 628 923 475

7.8 4.7 5.9 4.6

6.5, 9.2 4.0, 5.4 5.1, 6.8 3.9, 5.3

6944 27297

564 667

7.0 2.5

5.8, 8.2 2.0, 3.0

11584 27539

1474 1083

10.9 3.5

9.7, 12.1 3.1, 3.9

No.

Region Eastern Central Western Age (y) 12–19 20–29 30–39 40–49 50–59 60–69 ⱖ70 Immigrant Yes No Unknown Size of household 1 2 3 ⱖ4 No. of bedrooms ⬍3 ⱖ3 Unknown Educational level Low High Unknown Income adequacy Low Middle High Unknown Any allergies Yes No

nosinusitis in the northeastern region of United States is approximately half that of the southern region. A survey of otolaryngological practices found that the proportion of endoscopic procedures for allergic fungal rhinosinusitis was several-fold higher in the southern compared with the northern United States.21 Lower prevalences in Canada would be consistent with and support the notion of a north–south gradient in North America. The 1-year prevalence among individuals at least 15 years of age in Nottingham, UK, was 13.7% defined as a report of at least two of three features, congestion including rhinorrhea, and Laryngoscope 113: July 2003

Females

sneezing, in excess of 2 weeks.22 However, a nationwide survey in Korea of 10,000 people reported a prevalence of 1.0%.23 Female subjects were twice as likely as male subjects to report rhinosinusitis in Canada, a sex difference similar in direction to the 50% increase reported by the National Center for Health Statistics.3,20 We can only speculate on the increased susceptibility among women. Perhaps female subjects have smaller ostia making them more susceptible to obstruction and subsequent infection. There is evidence that women are more likely than men to develop Chen et al.: Chronic Rhinosinusitis

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TABLE I.—CONTINUED Prevalence (%) and 95% Confidence Intervals (CIs) of Rhinosinusitis According to Individual Characteristics Among Canadians 12 Years of Age or Older. Males

No.

Smoking status Nonsmoker Former smoker Current smoker Unknown Regular drinking Yes No Unknown Regular exercise Yes No Unknown Asthma Yes No Unknown COPD Yes No Unknown

Cases

Percent

Females

95% CI

No.

Cases

Percent

95% CI

15937 9287 8884 133

476 406 347 2

3.0 3.5 4.2 —

2.3, 3.8 2.8, 4.1 3.3, 5.2

22163 8209 8579 172

1243 651 654 9

4.6 6.8 7.6 —

4.1, 5.1 5.7, 7.8 6.3, 8.9

21428 12415 398

736 484 11

3.51 3.39 1.30

2.84, 4.17 16541 2.75, 4.03 22159 0.30, 2.29 423

1084 1460 13

5.91 5.57 1.94

5.23, 6.58 4.99, 6.15 0.54, 3.33

19490 13501 1250

698 493 40

3.41 3.53 3.00

2.91, 3.92 23036 2.64, 4.42 15315 0.52, 5.48 772

1462 1070 25

5.85 5.56 3.11

5.28, 6.42 4.84, 6.28 1.12, 5.10

2087 32142 12

188 1040 3

7.4 3.2 —

5.4, 9.4 2.7, 3.7

3374 35734 15

499 2055 3

11.5 5.1 —

9.7, 13.3 4.7, 5.6

917 33316 8

139 1092 0

14.1 3.2 —

10.2, 18.1 1510 2.7, 3.7 37600 13

356 2195 6

22.5 5.1 —

17.9, 27.1 4.7, 5.5

COPD ⫽ chronic obstructive pulmonary disease.

asthma and COPD.24,25 Perhaps this increased susceptibility is not restricted to the lower respiratory tract but also extends to the sinuses. In our data set, the gender difference could not be explained by age, socioeconomic status, smoking, allergies, and other factors studied. The sex difference persisted across age groups. In both sexes in Canada, the highest reported prevalence of chronic rhinosinusitis was in subjects between 30 and 60 years of age, a trend similar to that reported by the National Center for Health Statistics in which the prevalence was highest at 17.4% in individuals 45 to 64 years of age, compared with those under 18 years of age at 6.4%. Cigarette smoking was significantly associated with chronic rhinosinusitis in female subjects, whereas this association was less marked in male subjects. Relative small ostia in female subjects may also be a reason for the increased susceptibility to this condition in response to smoking. In addition, the smoking effect is probably modified by allergic status in male subjects. In both sexes, smoking showed a similar effect on rhinosinusitis in those without allergy history. For those with a history of allergy, a similar association was found in female but not in male subjects. It is likely that allergic individuals are more sensitive to the irritant effects of smoking and it is possible that these individuals are more likely to be nonsmokers or to give up smoking. A previous study has found that allergic status alters the relation between exposure to environmental tobacco smoke and childhood asthma.26 Laryngoscope 113: July 2003

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However, this may not explain the sex difference in modification of allergic status. Because the prevalence of allergy history was much higher in female (30%) than in male subjects (20%), under-reporting in male subjects or over-reporting in female subjects for these conditions might bias the results, in addition to the possibility of a true sex difference. Rhinosinusitis was reported twice or three times as often in subjects who reported asthma and allergies, consistent with their common underlying pathological condition, eosinophilic inflammation of the respiratory tract.27,28 A small number of uncontrolled clinical studies reported an improvement in asthma following treatment of accompanying sinus disease.29,30 These findings suggest that rhinosinusitis may aggravate asthma, but randomized clinical trials are required for confirmation. The prevalence of rhinosinusitis was threefold to fourfold higher in subjects with chronic bronchitis or emphysema. The association could not be accounted for by age, gender, socioeconomic status, or amount of tobacco smoked. There has been one previous report of this association. A French case– control study defined cases as subjects with chronic rhinosinusitis and control subjects as those with a history of an acute rhinosinusitis but no subsequent symptoms of chronic rhinosinusitis.31 The odds ratio was 6.7 (95% CI: 2.4, 18.8%) for the association between chronic bronchitis and chronic rhinosinusitis. The diagnosis of bronchitis and ascertainment of chronic Chen et al.: Chronic Rhinosinusitis


TABLE II. Adjusted Odds Ratios (ORs) and 95% Confidence Intervals (CIs) for Rhinosinusitis in Relation to Risk Factors Among Canadians 12 Years of Age or Older. Males

Risk Factors

Region Eastern Central Western Age (y) 12–19 20–29 30–39 40–49 50–59 60–69 ⱖ70 Immigrant Yes No Size of household 1 2 3 ⱖ4 No. of bedrooms ⬍3 ⱖ3 Educational level Low High Income adequacy Low Middle High Unknown Any allergy Yes No Smoking status Nonsmoker Former smoker Smoker Regular drinking Yes No Regular exercise Yes No

Females

Crude OR (95% CI)

Adjusted* OR (95% CI)

Crude OR (95% CI)

1.11 0.75, 1.65 1.00 1.02 0.76, 1.38

1.04 0.70, 1.55 1.00 1.02 0.75, 1.40

1.60 1.24, 2.06 1.00 1.06 0.86, 1.30

1.51 1.00 1.02

0.82, 1.25

1.00 2.26 3.61 4.85 4.52 4.23 4.10

1.00 2.20 3.99 5.91 6.33 5.71 5.91

1.00 1.57 3.28 3.44 4.39 3.41 2.66

0.95, 2.59 2.08, 5.19 2.19, 5.42 2.79, 6.93 2.13, 5.45 1.66, 4.28

1.00 1.14 2.63 2.82 3.30 2.65 2.21

0.67, 1.92 1.62, 4.27 1.73, 4.59 2.02, 5.39 1.57, 4.50 1.29, 3.81

1.20, 4.26 1.81, 7.18 2.63, 8.94 2.46, 8.28 2.22, 8.08 2.08, 8.09

1.15, 1.99

0.94 0.59, 1.49 1.00

0.85 0.53, 1.35 1.00

0.69 0.55, 0.86 1.00

0.78 1.00

1.00 1.22 0.87, 1.72 0.85 0.58, 1.24 0.84 0.59, 1.19

1.00 1.51 1.02, 2.23 1.20 0.78, 1.86 1.32 0.87, 2.01

1.00 0.89 0.73, 1.09 0.70 0.55, 0.91 0.52 0.42, 0.64

1.00 0.99 0.80 0.68

0.80, 1.24 0.60, 1.08 0.50, 0.91

1.00 0.84 0.66, 1.09

1.00 0.96 0.71, 1.29

1.00 0.84 0.71, 0.99

1.00 1.11

0.91, 1.36

0.76 0.58, 0.99 1.00

0.88 0.68, 1.15 1.00

0.73 0.62, 0.86 1.00

0.83 1.00

0.70, 1.00

1.63 1.07, 2.50 0.94 0.69, 1.30 1.00 0.79 0.56, 1.12

2.06 1.30, 3.27 1.06 0.76, 1.47 1.00 0.92 0.63, 1.35

1.35 1.06, 1.72 0.65 0.51, 0.83 1.00 0.77 0.62, 0.95

1.37 0.88 1.00 0.95

1.05, 1.79 0.71, 1.09

2.96 2.23, 3.94 1.00

3.46 2.57, 4.65 1.00

3.38 2.84, 4.03 1.00

3.30 1.00

2.77, 3.94

1.00 1.14 0.83, 1.57 1.40 1.02, 1.93

1.00 0.82 0.59, 1.12 1.24 0.90, 1.70

1.00 1.51 1.23, 1.86 1.71 1.37, 2.14

1.00 1.24 1.57

1.04 0.78, 1.37 1.00

0.91 0.68, 1.21 1.00

1.06 0.91, 1.25 1.00

0.95 1.00

0.80, 1.13

0.97 0.72, 1.29 1.00

1.07 0.79, 1.45 1.00

1.06 0.89, 1.25 1.00

1.07 1.00

0.90, 1.28

rhinosinusitis in the control group was based on symptoms. The explanation for this association is uncertain but may reflect a general susceptibility of the respiratory tract Laryngoscope 113: July 2003

1.15, 4.23 2.04, 7.81 3.07, 11.37 3.45, 11.63 2.87, 11.38 2.88, 12.14

Adjusted* OR (95% CI)

0.62, 0.98

0.75, 1.21

0.99, 1.54 1.24, 1.99

to environmental insults. Smoking accounts for approximately 90% of chronic bronchitis and emphysema, and also is a risk factor for rhinosinusitis, both in our study Chen et al.: Chronic Rhinosinusitis

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TABLE III. Prevalence (%) and 95% Confidence Intervals (CIs) of Rhinosinusitis According to Smoking and Allergy Status Among Canadians 12 Years of Age or Older. Any Allergies Smoking Status

Males Nonsmoker Former smoker Smoker Unknown Females Nonsmoker Former smoker Smoker Unknown

No Allergies

No.

Cases

Percent

95% CI

No.

Cases

Percent

95% CI

3603 1750 1577 14

269 161 134 0

6.8 7.4 7.1 —

5.3, 8.3 4.8, 10.1 4.8, 9.4

12334 7537 7307 119

207 245 213 2

1.8 2.5 3.6 —

1.0, 2.6 2.0, 3.1 2.5, 4.6

6391 2610 2544 39

725 378 362 9

8.9 12.5 14.8 —

7.5, 10.2 9.9, 15.1 11.3, 18.3

15772 5599 6035 133

518 273 292 0

2.8 4.3 4.6 —

2.4, 3.3 3.3, 5.3 3.6, 5.7

and in previous reports. If susceptibility to the damaging effects of cigarette smoke is shared by both the upper and lower respiratory tract, then those developing rhinosinusitis would also be more likely to develop COPD. The association between lower household income and the presence of chronic rhinosinusitis is consistent with the observation of a higher prevalence of other chronic respiratory diseases, asthma and COPD, in individuals with a lower social status. This effect was partially explained by the increase in cigarette smoking and other risk-factor exposures among those of lower social status. Although education level is another indicator of socioeconomic status, it is not a good measure when children and young adults are included. The present study has an advantage of a large sample size, and the sample represents the Canadian population. It provided insight into the epidemiology of rhinosinusitis, which has been understudied in this country as well as others. However, the present study is based on questionnaire data only, and the accuracy of self-reported chronic rhinosinusitis is not known. Sokol,32 mentioning four studies in support, argued that “the primary care practitioner’s overall assessment of the likelihood of rhi-

nosinusitis performs well compared with ultrasound, radiography, or sinus puncture.” However, Stankiewicz and Chow33 recently studied a group of 78 patients meeting the symptom-based definition of chronic rhinosinusitis and found that 45% of them had no evidence of rhinosinusitis on computed tomography (CT) scan or nasal endoscopy. The physician-diagnosed chronic rhinosinusitis may or may not have objective evidence that the patient truly had the condition. There is a possibility that increased health care–seeking behavior or subjective sensitivity to symptoms is one reason for the increased prevalence of rhinosinusitis in women, which requires more studies. In addition, we cannot assume causality for the risk factors studied because of the nature of crosssectional data.

CONCLUSION Chronic rhinosinusitis was reported in 5% of Canadian adults, more commonly in women, older adults, smokers, lower-income families, and individuals with chronic lower respiratory tract diseases. The advantage of the present study is the large number of unselected subjects whose results are representative of the Canadian

TABLE IV. Odds Ratios (ORs) and 95% Confidence Intervals (CIs) for Prevalence of Rhinosinusitis in Relation to Smoking Status, Sex, and Allergy History. Any Allergy

Smoking Status

Males Nonsmoker Former smoker Smoker Females Nonsmoker Former smoker Smoker

No Allergies

Crude OR (95% CI)

Adjusted* OR (95% CI)

Crude OR (95% CI)

Adjusted* OR (95% CI)

1.00 1.10 (0.69, 1.74) 1.04 (0.67, 1.60)

1.00 0.68 (0.42, 1.10) 0.81 (0.51, 1.27)

1.00 1.39 (0.84, 2.28) 1.99 (1.23, 3.23)

1.00 0.95 (0.61, 1.47) 1.65 (1.11, 2.43)

1.00 1.47 (1.10, 1.97) 1.78 (1.28, 2.47)

1.00 1.20 (0.90, 1.60) 1.67 (1.18, 2.37)

1.00 1.56 (1.15, 2.11) 1.68 (1.25, 2.26)

1.00 1.24 (0.91, 1.69) 1.41 (1.02, 1.96)

*Adjusted for resident area, age, place of birth, size of household, and income adequacy.

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Chen et al.: Chronic Rhinosinusitis


population. The disadvantage is that its size precluded radiological confirmation of rhinosinusitis. Random misclassification of chronic rhinosinusitis resulting from diagnostic error would lead to an underestimation of the associations we found but would not be expected to create artifactual associations.

Acknowledgments The authors thank Colette Koeune of Statistics Canada for her assistance in remote access to the NPHS data.

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