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evaluated by the senior author (MD); items were subtracted, and wording was modified to ensure that concerns commonly raised by patients during clinical visits were addressed. Issues identified in early interviews were corrected for subsequent interviews. Whenever patients did not understand the question, the interviewer provided clarification or reformulated the question. Each participant was interviewed once. Patients were recruited until thematic saturation was achieved. All interviews were conducted by the same interviewer. Interviews were conducted either in French or in English, depending on patient preference. Analysis Data saturation was achieved after 22 interviews, which prompted us to stop the interview process. Sample size in qualitative studies is determined when data saturation is achieved [17]. This is determined during data collection, when no new information or themes are discussed during interviews [18]. Thus, there is no formula or criteria to determine sample size, but some authors propose 12 to 26 interviews as a general rule of thumb [19]. Interviews were audio-recorded and transcribed verbatim for continuous analysis. Transcripts were coded by hand and were not returned to patients for comments or corrections. No data extraction software was used. Feedback was not provided to participants. There was one coder (NS), who listened repeatedly to the recordings and reread the transcripts. A thematic approach was used to identify common patterns among the interviews. This allowed the identification, analysis and reporting of patterns found across the data set. Results The average interview time was 13.3 min (range: 8–25). The median age was 53 years old (range: 19–79) and there 14 male participants (64%). The median number previous ESS was 2 (range: 1–7). Seventeen patients had CRSwNP (77%). Many patients had severe forms of CRS, with recurring disease despite surgical intervention and maximal therapy. Patients had many comorbidities including asthma, aspirin intolerance and atopy. One patient had a concurrent diagnosis of common variable immune deficiency. Most patients were not active smokers (77%) and the majority of patients were Caucasian (90%). Demographic data and disease characteristics for interviewed participants are presented in Many patients reported nasal congestion as the most bothersome symptom. They also reported secondary sleep disturbances, as well as an impact on activities of daily living (including sports). According to them, these were consequences of the nasal congestion. Patients with diagnosed sleep apnea who were dependent on a CPAP machine reported difficulty using it because of their inability to breathe through their nose. One participant was a competitive weightlifter. The obstructive symptoms became so severe that he could not exercise anymore and had to undergo surgery only to continue training. When it was completely blocked before surgery, I could not breathe at all. At night, my mouth got very dry. If I choked on food, I could not breath from the nose. (Participant 16, male, CRSwNP) Try blocking your nose with a clothespin for 24h, I dare you. Then imagine that for years. (Participant 16, male, CRSwNP)Patients seldom described a single symptom and most often had multiple rhinologic complaints before ESS. They could usually identify a principal symptom mostly responsible for the decrease in QoL. In many cases, that symptom was the persistent and incapacitating headaches. Patients with CRSwNP were also very bothered by the severe nasal congestion. With sinusitis, it’s not only the headaches … I always feel like I’m in a box, like my head is in a box. (Participant 17, female, CRSwNP) When asked to describe what it feels like to have CRS, some patients reported symptoms which are not traditionally reported in CRS as being part of their disease, such as hypoacusis, pruritus or tinnitus. It’s itchiness on the nose, it’s an uncomfortable squeezing sensation. It’s as if someone is lifting you from the tip of your nose. (Participant 7, male, CRSwNP) Hyposmia and anosmia were rarely mentioned spontaneously as a symptom of CRS. Only with additional prompts did many patients describe anosmia, which often had a tremendous impact on their QoL. One participant was passionate about cooking and drinking wine and described anosmia as a “handicap”. Three patients also mentioned being afraid of eating leftover food because they could not tell if it was still edible without a normal sense of smell and taste. One patient also noticed an association between acute sinusitis episodes and a feeling of cacosmia. My sinusitis greatly affected my quality of life. Even working full-time was difficult. I could not eat; I could not smell. I was afraid of tasting food from fear of getting sick. I could not smell fire
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