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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Fatigue improvement following endoscopic sinus surgery: a systematic review and meta-analysis

AC Chester, R Sindwani, TL Smith, and N Bhattacharyya.

Review published: 2008.

CRD summary

This study assessed whether endoscopic sinus surgery improved fatigue levels associated with chronic rhinosinusitis. The authors concluded that there was a notable improvement in patients with chronic rhinosinusitis-related fatigue following surgery. However, given some methodological shortcomings the findings may be compromised.

Authors' objectives

To assess whether endoscopic sinus surgery improved fatigue levels associated with chronic rhinosinusitis.


MEDLINE, EMBASE, Web of Science, Cochrane databases and web-based sources such as Google Scholar and open-access journal sites were searched from January 1980 to the end of July 2007 with no language restrictions. Search terms were reported. References of selected articles and related reviews were searched and a handsearch of the American Journal of Rhinology was undertaken for the period 1987 to 1997. Unpublished studies were sought through ISI Proceedings and through contacts with investigators.

Study selection

All study designs of more than 10 adult patients measuring fatigue, vitality, energy or malaise following endoscopic sinus surgery were eligible for inclusion. Included studies comprised randomised controlled trials, controlled clinical trials, clinical trials, cohort studies and record review and retrospective reviews. Studies in patients with substantial comorbidities, surgery limited to the turbinates or septum or radical surgery were excluded. Included studies were in adult patients (mean age 33.5 to 52.9 years). Length of follow-up ranged from 0.5 to 42.5 months (median study duration 12.0 months). The proportion of women varied from 28 per cent to 74 per cent. All included studies compared measurements of fatigue before and after endoscopic sinus surgery using within-subject comparisons.

Two reviewers independently selected studies for inclusion in the review.

Assessment of study quality

The authors did not state that they assessed validity.

Data extraction

Mean differences (standardised mean difference: Cohen’s d) were extracted for continuous and ordinal outcomes using the exact sample size before and after surgery. Effect sizes for dichotomous outcomes were defined as the difference (with odds ratio) in the proportion of patients reporting fatigue or malaise before and after surgery. For studies using repeated-measures the repeated standardised mean difference was calculated using appropriate formulas using exact correlation coefficient (r), which was obtained through correspondence with authors. Authors were contacted for clarification or missing data.

Study characteristics were independently extracted by two reviewers.

Methods of synthesis

Odds ratios or standardised mean differences were combined using both fixed- and random-effects models. Where studies reported results for separate groups, scores were weighted based on sample size. A priori subgroup analyses were undertaken for studies that reported vitality domain scores, symptom rating scores and dichotomous outcomes. Follow-up was classed as short (within one year) and long (>1 year). Heterogeneity was assessed using the I2 test, where 25 per cent was low heterogeneity, 50 per cent moderate and 75 per cent high.

Publication bias was assessed using a funnel plot and by using the Kendall rank correlation coefficient.

Results of the review

Twenty-eight studies were included in the review (n=3,427, range 19 to 1,240), although three were excluded from the analysis due to disproportionately large effect sizes. Most were prospective cohort studies of consecutive patients.

There was a significant improvement in fatigue following endoscopic sinus surgery 0.77 (95% confidence interval (CI): 0.59, 0.95, p<0.001) (25 studies), but there was a high level of between-study heterogeneity (I2=90%).

Subgroup analyses for 11 studies yielded a moderate combined effect change in vitality scores of 0.47 (95% CI: 0.38, 0.56) with no heterogeneity (I2=0%). No publication bias was evident. Sensitivity analysis showed that the combined effect size for these studies was robust. Subgroup analyses for studies reporting by symptom rating yielded a combined effect of 0.97 (95% CI: 0.65, 1.29) with substantial heterogeneity (I2=95%). Results by visual analog scale (VAS) scores yielded a combined effect of 0.82 (95% CI: 0.68, 0.96) with low heterogeneity (I2=36%).

Authors' conclusions

There was a notable improvement in patients with chronic rhinosinusitis-related fatigue following endoscopic sinus surgery.

CRD commentary

This review addressed a clear question and undertook a comprehensive search for studies with no restriction placed on language. A search for unpublished studies was performed. A formal assessment of publication bias revealed that none was present. Appropriate methods were used for study selection and data extraction, both of which were undertaken in duplicate. There was no assessment of the methodological quality of the included studies. There was marked diversity among the included studies and statistically significant heterogeneity was detected for the full sample of selected papers. It was, therefore, unclear whether it was appropriate to pool the studies statistically and the legitimacy of the pooled results was questionable. The conclusions were based largely on limited evidence, including observational studies which were not quality assessed. Some subgroup analyses addressed the heterogeneity and would appear to provide more reliable results, but the overall conclusions based on the full sample of selected papers should be treated with caution.

Implications of the review for practice and research

The authors did not state any implications for practice or further research.


Not stated.

Bibliographic details

Chester A C, Sindwani R, Smith T L, Bhattacharyya N. Fatigue improvement following endoscopic sinus surgery: a systematic review and meta-analysis. Laryngoscope 2008; 118(4): 730-739. [PubMed: 18216743]

Indexing Status

Subject indexing assigned by NLM


Adult; Chronic Disease; Databases as Topic; Endoscopy; Fatigue /therapy; Humans; Rhinitis /surgery; Sinusitis /surgery



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18216743


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