Chronic sinusitis in severe asthma is related to sputum eosinophilia

Comorbidities are associated with different features of severe asthma

Background

According to ATS/ERS document on severe asthma (SA), the management of these patients requires the identification and proper treatment of comorbidities, which can influence the control of asthma.

Methods

The aim of this study was to assess the independent effect of different comorbidities on clinical, functional and biologic features of SA. Seventy-two patients with SA according to GINA guidelines were examined. We collected demographic data, smoking habit, asthma history, and assessment of comorbidities. Pulmonary function, inflammatory biomarkers, upper airway disease evaluation, asthma control and quality of life were carefully assessed.

Results

The mean age of patients was 59.1 years (65.3% female, 5.6% current smokers). Comorbidities with higher prevalence were: chronic rhinosinusitis with or without nasal polyps (CRSwNP or CRSsNP), obesity and gastro-esophageal reflux (GERD), with some overlapping among them. In an univariate analysis comparing patients with single comorbidities with the other ones, asthmatics with CRSwNP had lower lung function and higher sputum eosinophilia; obese asthmatics had worse asthma control and quality of life, and tended to have lower sputum eosinophils; asthmatics with GERD showed worse quality of life. In multivariate analysis, obesity was the only independent factor associated with poor asthma control (OR 4.9), while CRSwNP was the only independent factor associated with airway eosinophilia (OR 16.2). Lower lung function was associated with the male gender and longer duration of asthma (OR 3.9 and 5.1, respectively) and showed a trend for the association with nasal polyps (OR 2.9, p = 0.06).

Conclusion

Our study suggests that coexisting comorbidities are associated with different features of SA.

Electronic supplementary material

The online version of this article (10.1186/s12948-018-0103-x) contains supplementary material, which is available to authorized users.

New-Onset Asthma in Adults: What Does the Trigger History Tell Us?

BACKGROUND

Adult-onset asthma is an important asthma phenotype and, in contrast to childhood asthma, is often associated with specific triggers of onset. It is unknown whether these triggers correspond with specific phenotypic characteristics or predict a specific asthma outcome.

OBJECTIVE

To compare clinical, functional, and inflammatory characteristics between patients with different triggers of asthma onset, and relate these triggers to asthma outcome.

METHODS

Two hundred adults with recently diagnosed (<1 year) asthma were prospectively followed for 5 years. The trigger of asthma onset was patient reported and defined by the question: "What, in your opinion, elicited your asthma?" Asthma remission was defined as no asthma symptoms and no asthma medication use for ≥1 year. Kruskal-Wallis and Fisher's exact test were used to compare categories containing >10 patients.

RESULTS

Ten categories of triggers were identified, of which 5 contained >10 patients. Clinical and inflammatory characteristics and remission rates differed significantly between categories. "New allergic sensitization" (11%) was associated with mild atopic asthma and a relatively young age at onset; "pneumonia" (8%) with previous smoking, low IgE, and the highest remission rates (one third); "upper respiratory symptoms" (22%) with high exhaled NO and eosinophilia; "no trigger identified" (38%) did not show any specific characteristics; and "stressful life event" (7%) with high medication usage, low type 2 markers, and no disease remission.

CONCLUSIONS

Patients with adult-onset asthma can be characterized by the trigger that seemingly incited their asthma. These triggers might represent underlying mechanisms and may be important to phenotype patients and predict disease outcome.

Immunological mechanisms underlying chronic rhinosinusitis with nasal polyps

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common and quality-of-life impacting disorder, with an underlying immunological mechanism similar to other conditions such as eosinophilic asthma or atopic eczema. Areas covered: This review article summarizes the most recent evidence on the main immunological mechanisms involved in the pathogenesis and the perpetuation of CRSwNP, with a particular focus on the key role of epithelium-derived inflammation as a consequence of the interaction with the airborne environment. Expert commentary: The increase in knowledge of the immunology of CRSwNP leads to the development of therapeutical strategies based upon the use of biologic agents that, according to a personalized and precision medicine approach, will provide each single patient with the most suitable immunological treatment.

Serum Periostin as a Biomarker for Comorbid Chronic Rhinosinusitis in Patients with Asthma

RATIONALE

Periostin is a matricellular protein that is involved in the pathophysiology of allergic rhinitis, chronic rhinosinusitis, and asthma. Associations of serum periostin with systemic and airway eosinophilic inflammation and comorbid chronic rhinosinusitis in patients with asthma have been demonstrated. Although serum periostin is positioned as a marker of helper T cell 2 immune responses, its implication regarding the presence of comorbid upper airway diseases in patients with asthma remains unclear.

OBJECTIVES

To investigate the utility of serum periostin as a diagnostic biomarker for upper airway disease in patients with asthma.

METHODS

We prospectively enrolled 65 patients with stable asthma, 20 without upper airway disease, 22 with rhinitis, and 23 with chronic rhinosinusitis (13 with nasal polyps, 10 without). Serum periostin, eotaxin, total IgE, fractional exhaled nitric oxide, and blood and sputum eosinophil levels were measured and compared between upper airway disease subtypes. We evaluated the utility of each biomarker in detecting upper airway disease, associations among the biomarkers, and severity of upper airway disease as measured by the Lund-Mackay score for sinus computed tomography.

RESULTS

Serum periostin levels were higher in patients with asthma who had chronic rhinosinusitis (109.6 ± 47.4 ng/ml) than in those without upper airway disease (83.2 ± 22.9 ng/ml) (P = 0.04). Serum periostin levels in patients with asthma who had chronic rhinosinusitis and nasal polyps were significantly higher (130.0 ± 46.6 ng/ml) than in those without nasal polyps (87.9 ± 37.7 ng/ml) (P  =  0.001). Serum periostin levels were not associated with the presence or the severity of rhinitis. In contrast, receiver operating characteristic curve analyses showed moderate diagnostic accuracy for detecting chronic rhinosinusitis (area under the curve, 0.71; P = 0.01) and high accuracy for chronic rhinosinusitis with nasal polyps (area under the curve, 0.86; P = 0.0002). When we compared patients with asthma who had comorbid chronic rhinosinusitis and nasal polyps with patients with asthma without these comorbidities, we found serum periostin to be the sole biomarker among those tested for detecting the presence of nasal polyps. Serum periostin was also the sole biomarker that significantly correlated with Lund-Mackay score in patients with chronic rhinosinusitis (r = 0.44; P = 0.04).

CONCLUSIONS

Serum periostin is useful for detecting chronic rhinosinusitis with nasal polyps and predicting radiological chronic rhinosinusitis severity in patients with asthma. Clinical trial registered with the UMIN Clinical Trials Registry (UMIN000017533).

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma ('difficult asthma') should undergo systematic assessment, in order to differentiate between true severe asthma, and 'difficult-to-treat' patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Optimal control of asthma improved eosinophilic otitis media

Background

Eosinophilic otitis media (EOM) is often associated with comorbid asthma. The middle ear cavity is part of the upper airway. Therefore, EOM and asthma can be considered to be a crucial part of the “one airway, one disease” phenomenon. Based on the concept of one airway, one disease in the context of allergic rhinitis and asthma, optimal level of inhalation therapy for better asthma control leads to improvement in allergic rhinitis.

Objective

We conducted a pilot study to determine whether appropriate strengthening of inhalation therapy for asthma is effective for EOM.

Methods

Fifteen patients with EOM and comorbid asthma were enrolled in this study. Eight patients were randomly selected and administered appropriately strengthened inhalation therapy for asthma (strengthened group). The effect of the therapy on EOM was assessed by comparing a questionnaire for ear symptoms, clinical characteristic score, pure tone audiometry, blood tests and temporal bone computed tomography (CT) examination before and after the therapy. Seven other EOM + asthma patients without the above mentioned therapy were included as controls.

Results

In the strengthened group, the score of ear symptoms, clinical characteristics score, peripheral blood eosinophil count, CT score, and air conduction hearing level improved significantly after strengthening the inhalation therapy, but not in the control group. The lung function tests (forced vital capacity [%predicted], forced expiratory volume in 1 second [FEV₁] [L], and FEV₁ [%predicted]) significantly increased in the strengthened group after the therapy, but not in the control group.

Conclusion

In this study we demonstrated that EOM improved along with improved lung function when appropriately optimal inhalation therapy was implemented in patients with EOM and asthma. Administration of optimizing therapy for asthma might be effective for concomitant EOM.

Asthma onset pattern and patient outcomes in a chronic rhinosinusitis population

BACKGROUND

Chronic rhinosinusitis (CRS) is strongly associated with comorbid asthma. This study compares early-onset and late-onset asthma in a CRS population using patient-reported and clinical characteristics.

METHODS

At enrollment into a clinical registry, CRS patients completed the 22-item Sino-Nasal Outcome Test (SNOT-22), Asthma Control Test (ACT), mini-Asthma Quality of Life Questionnaire (miniAQLQ), the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29), and medication use questionnaires. Patients also reported comorbid asthma and age at first asthma diagnosis. Early-onset (<18 years) and late-onset (>18 years) asthma groups were defined. Analysis of variance (ANOVA), chi-square, and Kruskal-Wallis tests were used to compare patient responses.

RESULTS

A total of 199 non-asthmatic (56.1%), 71 early-onset asthmatic (20.0%), and 85 late-onset asthmatic (23.9%) CRS patients completed the survey. Body mass index (BMI) was significantly higher in late-onset asthmatic (p = 0.046) while age, gender, race, and smoking history did not differ with time of asthma onset. SNOT-22, ACT, and miniAQLQ were not different between asthma groups, but late-onset asthmatics had significantly lower physical function than non-asthmatics (p = 0.008). Compared to non-asthmatics, late-onset asthmatics showed increased rates of nasal polyps (p < 0.001), higher Lund-Mackay scores (p = 0.005), and had received more oral steroid courses (p < 0.001) and endoscopic surgeries (p = 0.008) for CRS management. Late-onset asthmatics compared to early-onset asthmatics showed increased nasal polyposis (p = 0.011) and oral steroid courses for CRS (p = 0.003).

CONCLUSION

While CRS-specific and asthma-specific patient-reported outcome measures (PROMs) were not significantly different among groups, CRS patients with late-onset asthma had poorer physical function, more frequent nasal polyposis, and required increased treatment for CRS. Late-onset asthma may predict more severe disease in CRS.

Chronic Rhinosinusitis and Aspirin-Exacerbated Respiratory Disease

Patients with severe asthma and concomitant chronic rhinosinusitis often have severe, refractory upper and lower airway inflammation. This inflammation has been proposed to be similar throughout the upper and lower airways leading to the unified airways concept. This article reviews chronic rhinosinusitis with and without nasal polyps, and the subgroup with aspirin-exacerbated respiratory disease, while focusing on the relationship with asthma. Additionally, diagnosis and treatment with current and newer therapies are discussed.

Manifestations of Inhalant Allergies Beyond the Nose

The upper and lower airways are linked epidemiologically and pathophysiologically. The upper and lower airways are considered a single, functional unit characterized by shared immunologic mechanisms, often referred to as the unified airway. Upper and lower airway inflammatory disease frequently coexist in the same patient. Allergic rhinitis and rhinosinusitis are associated with asthma. Treatment of both diseases impacts asthma outcomes. The otolaryngologist may be the first physician to suspect and diagnose asthma in patients with upper airway complaints. A thorough understanding of the relationship between allergic rhinitis, rhinosinusitis, and asthma will facilitate early identification of asthma and improve patient outcomes.

Anti-IgE and Anti-IL5 Biologic Therapy in the Treatment of Nasal Polyposis: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the role of biologic therapy on sinonasal symptoms and objective outcomes in chronic rhinosinusitis with nasal polyposis (CRSwNP).

METHODS

PubMed, OVID MEDLINE, and Cochrane Central were reviewed from 2000 to 2015. Inclusion criteria included English-language studies containing original data on biologic therapy in CRSwNP patients with reported outcome measures. Two investigators independently reviewed all manuscripts and performed quality assessment and quantitative meta-analysis using validated tools.

RESULTS

Of 495 abstracts identified, 7 studies fulfilled eligibility: 4 randomized control trials (RCT), 1 case-control, and 2 case series. Outcome measures included nasal polyp score (NPS,6), computer tomography score (5), and symptom scores (5). Meta-analysis was performed on 5 studies: Anti-IL5 therapy (mepolizumab/reslizumab) and anti-IgE therapy (omalizumab) demonstrated a standard mean difference of NPS improvement of -0.66 (95% CI, -1.24 to -0.08) and -0.75 (95% CI, -1.93 to 0.44), respectively, between biologic therapy and placebo. Quality assessment indicated a low to moderate risk of bias for the RCTs.

CONCLUSION

Biologic therapies may prove beneficial in the treatment of recalcitrant nasal polyposis in select populations. In meta-analysis, anti-IL5 therapy demonstrates a reduction in nasal polyp score. Anti-IgE therapy reduces nasal polyp score in patients with severe comorbid asthma. Additional high-level evidence is needed to assess clinical efficacy.

Could Eosinophilia predict clinical severity in nasal polyps?

Background

Although nasal polyps are one of the most frequent diseases, their etiopathogenesis remains unclear.Since eosinophils are the main inflammatory cells in the substantial proportion of nasal polyp tissues, they are considered potentially responsible for the etiopathogenesis and prognosis of the disease. Aim of this study was to investigate the relation between mucosal and peripheral eosinophilia and their relation with disease severity in nasal polyps.

Methods

The study included 53 patients with nasal polyps who underwent endoscopic sinus surgery. Preoperative Lund-MacKay computed tomography (CT) scores and the Lund-Kennedy endoscopic scores of the patients were recorded. Nasal polyp tissues were stained with hematoxylin and eosin, eosinophil counts were performed using high-power field (HPF, 400×) under the light microscope, and the patients were grouped as those with high mucosal eosinophil count and those with low mucosal eosinophil count.

Results

The mean Lund-MacKay CT score and the mean Lund-Kennedy endoscopic score were higher in the patients with high mucosal eosinophil count than in those with low mucosal eosinophil count. Likewise, the mean Lund-MacKay CT score and the mean Lund-Kennedy endoscopic scores were significantly higher in the patients with high peripheral eosinophil count than in those with low peripheral eosinophil count (p < 0.05 for both). Moreover, the mean peripheral eosinophil count was significantly higher in the patients with high mucosal eosinophil count than in those with low mucosal eosinophil count (p < 0.05).

Conclusion

Mucosal and peripheral eosinophilia can be used as a marker to predict disease severity in nasal polyps.

Chronic rhinosinusitis phenotypes

OBJECTIVE

To review the current knowledge surrounding different chronic rhinosinusitis (CRS) presentations and the relative roles of nasal polyps, eosinophilia, and allergies in discerning phenotypes.

DATA SOURCES

PubMed literature review.

STUDY SELECTIONS

Articles discussing the various phenotypes of CRS with emphasis on pathologic and immune mechanistic studies that distinguish disease.

RESULTS

Current guidelines primarily separate CRS based on the presence or absence of nasal polyps. This is largely driven by the tendency of eosinophilic disease to present with nasal polyps (NPs) in contrast to noneosinophilic presentations, which less often lead to the development NPs. Further separations have been proposed based on expression of aeroallergen sensitization.

CONCLUSION

The presence of NPs may only poorly predict the presence of an underlying eosinophilic process and as such may have poor utility in forming the basis for recommending eosinophil-target therapies. Similarly, there is little evidence to support a significant role for aeroallergen exposure in contributing to the presence, severity, or natural history of CRS. Appropriate separation of CRS into specific phenotypes will allow therapeutic approaches to be individualized to each distinct presentation.

Lack of Efficacy of Symptoms and Medical History in Distinguishing the Degree of Eosinophilia in Nasal Polyps

BACKGROUND

Distinguishing eosinophilic nasal polyps (NP) from noneosinophilic NP will impact prognosis and therapeutic responsiveness.

OBJECTIVE

To investigate the ability of clinical history and biomarkers to distinguish these conditions.

METHODS

A total of 74 consecutive patients undergoing surgery for NP were enrolled. Clinical presentations were evaluated using the 22-item sinonasal outcome test (SNOT-22). Biomarkers included absolute eosinophil count, IgE, and extent of tissue hyperplasia on sinus computed tomography scan. Tissue eosinophilia was quantified in 10 random hpf and data analyzed addressing both peak and average results.

RESULTS

No component of the SNOT-22 was predictive of tissue eosinophilia. Similarly, a medical history of allergic rhinitis, asthma, or aspirin-exacerbated respiratory disease was not predictive. An absolute eosinophil count of more than 300 was associated with NP tissue eosinophilia. In contrast, neither IgE nor extent of sinus computed tomography hyperplasia was predictive.

CONCLUSIONS

The ability to individualize therapies for NP is dependent on identifying clinical features or biomarkers of eosinophilia. However, with the exception of circulating eosinophilia, we could not identify a clinical feature or biomarker that robustly predicted the presence of tissue eosinophilia. Even more problematic, even the seeming "criterion standard" determination of tissue pathology was of limited value, as our cohort displayed a continuous spectrum of tissue eosinophil expression, making arbitrary any definitive cutoff distinguishing these conditions.

Radiographic Evidence of Sinonasal Inflammation in Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome: An Underrecognized Association

BACKGROUND

Sinonasal inflammation on both clinical examinations and imaging significantly impacts both asthma and chronic obstructive pulmonary disease (COPD).

OBJECTIVE

The objective of this study was to examine the association between sinonasal inflammation and asthma-COPD overlap syndrome (ACOS).

METHODS

A total of 112 patients with a ratio of forced expiratory volume in 1 s to forced vital capacity of less than 70% were enrolled. COPD, asthma, and ACOS were clinically diagnosed according to the 2014 Global Initiative for Asthma and Global Initiative for Chronic Obstructive Lung Disease guidelines. Sinonasal inflammatory condition was evaluated using sinus computed tomography, and its severity was assessed according to the Lund-Mackay staging (LMS) system. Ethmoid sinus-dominant shadow was defined as the presence of greater LMS scores for the anterior and posterior ethmoid sinuses than for the maxillary sinus.

RESULTS

COPD, asthma, and ACOS were diagnosed in 55 (49.1%), 39 (34.8%), and 18 patients (16.1%), respectively. The frequency of radiographic evidence of sinonasal inflammation in patients with COPD, asthma, ACOS was 60.0%, 94.9%, and 72.2%, respectively. Patients with ACOS and COPD had only mild radiographic evidence of sinonasal inflammation (LMS score, 1-7), whereas moderate (LMS score, 8-11) and severe (LMS score, ≥12) radiographic evidence of sinonasal inflammation were detected only in patients with asthma. Furthermore, the frequency of ethmoid sinus-dominant shadow was significantly higher in patients with asthma than in those with COPD and ACOS.

CONCLUSIONS

Radiographic evidence of sinonasal inflammation was a common comorbidity in ACOS. Future studies are required to examine the role of sinonasal inflammation in ACOS.

Impact of chronic rhinosinusitis on severe asthma patients

Coexistence of chronic rhinosinusitis (CRS) with asthma appears to impair asthma control. Type-2 innate lymphoid cells (ILC2s) respond to the cytokines of thymic stromal lymphopoietin (TSLP), interleukin (IL)-25 and IL-33, thus contributing to airway diseases such as CRS and asthma. We investigate whether the augmented Th2-cytokines in CRS might be related to sinonasal tract ILC2s corresponding to enhanced IL-25, IL-33 and TSLP release in severe asthmatics, and be involved in asthma control. Twenty-eight asthmatics (12 non-severe and 16 severe) with CRS receiving nasal surgery were enrolled. The predicted FEV1 inversely associated with CRS severity of CT or endoscopy scores. Higher expression of Th2-driven cytokines (IL-4, IL-5, IL-9, and IL-13), TSLP, IL-25 and IL-33 in nasal tissues was observed in severe asthma. Severe asthmatics had higher ILC2 cell counts in their nasal tissues. ILC2 counts were positively correlated with Th2-cytokines. Nasal surgery significantly improved asthma control and lung function decline in severe asthma and CRS. The higher expression of IL-33/ILC2 axis-directed type 2 immune responses in nasal tissue of CRS brought the greater decline of lung function in severe asthma. ILC2-induced the upregulated activity of Th2-related cytokines in asthmatics with CRS may contribute to a recalcitrant status of asthma control.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Relationships among allergic rhinitis, asthma, and chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a common disease in the United States. There are a significant number of patients with CRS who are refractory to standard medical and surgical therapy. Many of these patients also have comorbid allergic rhinitis (AR) and asthma, although the underlying pathophysiology that connects these three conditions remains unclear.

OBJECTIVE

The goal of this article is to review the relationships among CRS, AR and asthma.

METHODS

Scientific literature that addresses the prevalence of AR and asthma in CRS populations, the effect of AR and asthma on CRS disease severity, and whether treatment of AR and asthma can affect CRS outcomes was reviewed.

RESULTS

The literature supports the relationship between AR and CRS, but there is no direct evidence of causality the between the two conditions. There is a high prevalence of CRS in patients with asthma and the presence of CRS is associated with worse asthma outcomes. There is weak evidence that treatment of CRS may improve asthma outcomes. Targeting type 2 inflammation via biologics is being investigated in the treatment of asthma and CRS.

CONCLUSION

AR, asthma, and CRS are closed related and understanding the associations among these comorbid diseases will have significant clinical implication.

Current complications and treatment of aspirin-exacerbated respiratory disease

INTRODUCTION

Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.

Aspirin-exacerbated respiratory disease: Prevalence, diagnosis, treatment, and considerations for the future

Aspirin-exacerbated respiratory disease (AERD) is a late onset condition characterized by the Samter triad (aspirin sensitivity [as well as sensitivity to any nonselective cyclooxygenase inhibitor], nasal polyps, asthma) and additional features, including eosinophilic chronic rhinosinusitis, hypereosinophilia, anosmia, frequent absence of atopy, and, intolerance to ingestion of red wine and other alcoholic beverages. The diagnosis is rare, and, because of this, it is also often missed by physicians. However, it is highly overexpressed in patients with severe asthma (and severe chronic rhinosinusitis with nasal polyps), which makes its recognition essential. For this review, we considered mechanisms involved in the pathogenesis of this disease and discussed the clinical symptoms of AERD. We also discussed the role of aspirin desensitization in the treatment of AERD. Also, we considered medications (e.g, leukotriene modifiers) and surgical interventions that have a role in the treatment of AERD.

Determinants of Incomplete Asthma Control in Patients with Allergic Rhinitis and Asthma

BACKGROUND

Characterizing associations between the upper and lower airways is important for asthma management.

OBJECTIVES

This study aimed to assess the determinants of incomplete asthma control in patients with allergic rhinitis (AR) and asthma.

METHODS

Multiple factors including age, sex, atopy, smoking history, medication use, Asthma Control Questionnaire (ACQ) score, FEV₁, fraction of exhaled nitric oxide (Feno), and rhinitis questionnaire score were examined. AR was defined by rhinitis symptoms and the sensitization to inhaled allergens. ACQ was used to dichotomize the subjects into the incompletely controlled group (ACQ score ≥0.75) and the well-controlled group. The factors that contribute to incomplete asthma control were assessed by a multivariate analysis.

RESULTS

A total of 260 patients with AR and asthma were enrolled and 108 patients (42%) were classified as incomplete asthma control. The incompletely controlled group was older (P < .05), and had more airflow limitation, more airway inflammation, and more severe rhinitis symptoms (all P < .001). In contrast, the well-controlled group was more likely to be taking nasal corticosteroids (NCSs) (P < .01). In a multivariate model adjusted by age, asthma treatment, airflow limitation, and Feno, persistence and severity of rhinitis (odds ratio [OR], 2.57; 95% CI, 1.41-4.70, and OR, 2.00; 95% CI, 1.10-3.65) and nonuse of NCSs (OR, 3.83; 95% CI, 1.50-9.81) were independently associated with incomplete asthma control.

CONCLUSIONS

The persistence and severity of AR and the use of NCSs were associated with the level of asthma control in patients with AR and asthma. Further studies are required to determine whether appropriate treatment of rhinitis would improve asthma control.

Co-morbidities and cognitive status in a cohort of teenagers with asthma

BACKGROUND

There is limited data regarding co-morbidities and cognitive status of asthma during childhood and adolescence. The aim of the current study was to explore the presence of co-morbidities and cognitive status in a large cohort of teenagers with asthma.

METHODS

The medical records of 314,897 consecutive 17-year-old males, undergoing comprehensive medical and cognitive evaluation prior to recruitment for military service, were reviewed. The prevalence of co-morbidities and a cognitive assessment in subjects with asthma were compared to those without asthma. Both a univariate and multivariate logistic regression analysis were performed.

RESULTS

Active asthma was documented in 21,728 (6.9%) subjects: 3.3% were diagnosed with mild intermittent asthma, and 3.6% with persistent asthma. A significant positive correlation between a higher cognitive score and prevalence of asthma was found (P < 0.001), with a 55% increased prevalence of asthma in the subjects with the highest cognitive score compared to those with the lowest score. The following co-morbidities were significantly more prevalent in asthmatics compared to non-asthmatics: chronic rhinitis (35% vs. 5%), atopic dermatitis (2% vs. 0.4%), urticaria (1% vs. 0.3%), anaphylaxis (0.4% vs. 0.1%), chronic sinusitis (0.4% vs. 0.1%), overweight with body mass index (BMI) above 25 kg/m(2) (20% vs. 17%) and underweight with BMI less than 17 kg/m(2) (3.2% vs. 2.8%), irritable bowel syndrome (IBS) (1% vs. 0.5%), and thyroid disorders(0.4% vs. 0.2%). Chronic rhinitis and sinusitis, atopic dermatitis, IBS, and thyroid disorders were all significantly more prevalent in persistent compared to intermittent asthma (P < 0.001).

CONCLUSIONS

In adolescence, a higher cognitive status was associated with a higher rate of asthma. Chronic rhinitis was the most prevalent co-morbidity and was found in one third of adolescent asthmatics. Other allergic diseases, chronic sinusitis, over and underweight, IBS, and thyroid disorders were also more prevalent in asthmatics. Pediatr Pulmonol. 2016; 51:901-907. © 2016 Wiley Periodicals, Inc.

[How to consider triggers and comorbid conditions in severe asthma in adults]

Triggers and precipitating factors as well as comorbid conditions are associated with asthma and severe asthma. They interfere with the potential to control the disease and represent an additional burden for the patients. Allergen exposure is well known to induce loss of control and exacerbations. Comorbid conditions belong to various fields of medicines including cardiovascular diseases, osteoporosis, obesity and sleep apneas and GERD. They should be diagnosed and treated for themselves according to the best state of the art. Their precise role et their contribution to severe asthma pathophysiology is largely unknown and longitudinal cohort studies are needed to better understand and treat the patients with severe asthma.

Asthma associated with chronic rhinosinusitis: a population-based study

BACKGROUND

Few studies have investigated the relationship between asthma and chronic rhinosinusitis (CRS). The present study investigated the association between asthma and the risk of CRS in a large national sample.

METHODS

Patients newly diagnosed with asthma (International Classification of Diseases, Ninth Revision [ICD-9], Clinical Modification code 493) between 2000 and 2008 were identified from the Taiwan National Health Insurance Research Database. The cases were compared with sex-, age-, residence-, and insurance premium-matched controls, and both groups were followed until the end of 2009 for incidences of CRS with or without nasal polyps (CRSwNP or CRSsNP, respectively). Competing risk-adjusted Cox regression analyses were performed after adjustment for sex, age, residence, insurance premium, steroid use, hyperlipidemia, diabetes, hypertension, coronary artery disease, Charlson comorbidity index score, and mortality. We also performed a case-control study to determine the association between asthma and CRS.

RESULTS

The cohort study analysis examined 81,462 patients with a mean ± standard deviation (SD) follow-up period of 5.8 ± 2.4 years. Asthma was an independent predictor of CRSsNP (hazard ratio = 2.58; 95% confidence interval [CI], 2.20 to 3.03; p < 0.001) in the fully adjusted models. In the case-control analysis, both CRSwNP and CRSsNP were associated with asthma in the fully adjusted models.

CONCLUSION

Asthma was associated with increased risks of CRSwNP and CRSsNP, independent of several potential confounding factors.

Occupational and environmental risk factors for chronic rhinosinusitis in China: a multicentre cross-sectional study

Background

Chronic rhinosinusitis (CRS) is defined as a condition of inflammation in the paranasal sinus mucosa persisting for more than 12 weeks. We previously reported that the prevalence of CRS was about 8 % in China. Here, we aim to investigate the occupational and environmental risk factors associated with CRS.

Methods

Data were collected from seven Chinese cities: Urumqi, Changchun, Beijing, Wuhan, Chengdu, Huaian and Guangzhou. CRS was diagnosed according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EP³OS) document. Participants were asked to complete a standardized questionnaire, which was developed by the Global Allergy and Asthma European Network (GA²LEN) project and covered sociodemographic characteristics, CRS-related symptoms and occupational and environmental exposures. We evaluated the association between CRS and various occupational and environmental factors using odds ratios (ORs) and 95 % confidence intervals (95 % CIs).

Results

The total study population consisted of 10,633 subjects, 850 (7.99 %) of whom were defined as having CRS according to the EP³OS criteria. We found that there were significant associations between occupational and environmental factors and CRS. Specifically, having a clearance-related job, occupational exposure to dust, occupational exposure to poisonous gas, a pet at home or carpet at home or at the workplace were risk factors for CRS. Additionally, the method used to keep warm in winter, the duration of time spent using air conditioning in summer and the frequency of exposure to mouldy or damp environments were significantly different in subjects with and without CRS.

Conclusions

Our data showed that some occupational and environmental exposures are strongly associated with CRS, which aids in understanding the epidemiology of CRS.

Occurrence and impact of sinusitis in patients with asthma and/or allergic rhinitis

OBJECTIVE

The occurrence of radiological sinusitis in patients with asthma without any obvious nasal symptoms could possibly increase the severity of asthma. We investigated the occurrence and impact of sinusitis on computed tomography of the paranasal sinuses (CT-PNS) in patients with asthma and/or allergic rhinitis. Effect of sinusitis on the quality of life (QoL) was also assessed.

METHODS

All subjects underwent spirometry with reversibility, CT-PNS, intradermal test against common aeroallergens and responded to Symptom Severity Score and Rhinosinusitis Disability Index (RSDI). Of the 216 consecutive patients, 27 had asthma without nasal symptoms (Group 1), 58 had asthma with allergic rhinitis (Group 2) and 131 had allergic rhinitis (Group 3). Thirty normal healthy controls without atopy were also included (Group 4).

RESULTS

20/27 (74%) patients in Group 1 had sinusitis on CT-PNS. 48/58 (82%) patients in Group 2 and 88/131 (67%) patients in Group 3 had chronic rhinosinusitis (CRS) as confirmed on CT-PNS. 6/30 (20%) healthy controls in Group 4 had mucosal thickening. Asthmatics with radiological sinusitis in Group 1 and with CRS in Group 2 had significantly lower FEV1, FEV1/FVC ratio, were more symptomatic and had a greater impairment of QoL. The mean sinus severity score was significantly higher in Group 2. In Group 3, sinusitis occurred significantly higher in "blockers" than "sneezers-runners" (41/79 versus 47/52, p = 0.045).

CONCLUSIONS

Occurrence of radiological sinusitis on CT-PNS in asthmatics without nasal symptoms and CRS in allergic rhinitis with or without asthma increases the severity of the disease and affects the QoL.

Prevalence of confirmed asthma varies in chronic rhinosinusitis subtypes

BACKGROUND

Chronic rhinosinusitis (CRS) and asthma describe inflammation of the upper and lower airway, respectively. Not surprisingly, the prevalence of CRS and asthma has been linked, with up to 50% asthma prevalence in CRS with nasal polyposis (CRSwNP) patients. However, these prevalence rates do not address subtypes of CRSwNP including allergic fungal rhinosinusitis (AFRS). This study sets out to objectively determine asthma prevalence in CRS subtypes prospectively.

METHODS

A prospective prevalence study of adult CRS patients was conducted over a 1-year period at a tertiary care center. Patients were grouped into CRSwNP, CRS without nasal polyposis (CRSsNP), or AFRS. Patients were administered the Asthma Screening Questionnaire (ASQ) and asthma was confirmed by pulmonary function testing (PFT) if positive on the ASQ. Chi square analysis was performed to compare the asthma prevalence among the CRS subtypes.

RESULTS

A total of 410 patients (age 48.1 ± 16.4; 53.5% male) were included. Of these, 178 (43.4%) had CRSwNP, 166 (40.5%) had CRSsNP, and 66 (16.1%) met criteria for AFRS. Analysis revealed that 48.3% of CRSwNP patients, 16.5% of CRSsNP patients, and 23.6% of AFRS patients had asthma confirmed by PFTs. Chi square analysis showed a significant difference in asthma prevalence between CRSwNP and AFRS (p = 0.0016) and CRSwNP and CRSsNP (p = 0.0000), but no significant difference between CRSsNP and AFRS (p = 0.2380).

CONCLUSION

There is a significant difference in the prevalence of asthma between CRSwNP and AFRS, suggesting a fundamental distinction in their etiologies despite similar immunologic profiles. Further efforts to delineate these biological disparities are underway.

Comorbidity has no impact on eosinophil inflammation in the upper airways or on severity of the sinonasal disease in patients with nasal polyps

OBJECTIVE

The study was designed to determine whether there is an association between the comorbidity as atopy, bronchial asthma, aspirin intolerance and eosinophil infiltration of the upper airways, severity of the sinonasal disease and rate of revision sinus surgery in patients with nasal polyps.

MATERIAL AND METHODS

One hundred and fifty patients were enrolled in the prospective study. Differences in CT score, rate of revision surgery, concentration of eotaxin and eosinophil cationic protein in nasal lavage fluid (NALF) and distribution of eosinophils in NALF and nasal tissue in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), chronic rhinosinusitis without nasal polyps (CRSsNP) and control group were investigated. We focused on the relationship between presence of comorbidity (atopy, bronchial asthma and aspirin intolerance) and severity of the disease, the need of revision surgery and markers of eosinophil inflammation in upper airways in patients with CRSwNP.

RESULTS

Patients with CRSwNP had more severe form of the sinonasal disease, higher rate of revision FESS and significant higher presence of markers of eosinophil inflammation in NALF and nasal tissue than patients with CRSsNP (P < 0.05). Atopic and non-atopic asthma as well as aspirin sensitivity significantly more often coexisted with CRSwNP. Comorbidity did not influence eosinophil infiltration or severity of the disease in patients with CRSwNP.

CONCLUSION

Presence of comorbidity (atopy, bronchial asthma and aspirin intolerance) has no impact on severity of the disease or eosinophil content in the upper airways in patients with CRSwNP.

Phenotypes, Risk Factors, and Mechanisms of Adult-Onset Asthma

Asthma is a heterogeneous disease with many phenotypes, and age at disease onset is an important factor in separating the phenotypes. Genetic factors, atopy, and early respiratory tract infections are well-recognized factors predisposing to childhood-onset asthma. Adult-onset asthma is more often associated with obesity, smoking, depression, or other life-style or environmental factors, even though genetic factors and respiratory tract infections may also play a role in adult-onset disease. Adult-onset asthma is characterized by absence of atopy and is often severe requiring treatment with high dose of inhaled and/or oral steroids. Variety of risk factors and nonatopic nature of adult-onset disease suggest that variety of mechanisms is involved in the disease pathogenesis and that these mechanisms differ from the pathobiology of childhood-onset asthma with prevailing Th2 airway inflammation. Recognition of the mechanisms and mediators that drive the adult-onset disease helps to develop novel strategies for the treatment. The aim of this review was to summarize the current knowledge on the pathogenesis of adult-onset asthma and to concentrate on the mechanisms and mediators involved in establishing adult-onset asthma in response to specific risk factors. We also discuss the involvement of these mechanisms in the currently recognized phenotypes of adult-onset asthma.

Management of the patient with eosinophilic asthma: a new era begins

Now that it is generally accepted that asthma is a heterogeneous condition, phenotyping of asthma patients has become a mandatory part of the diagnostic workup of all patients who do not respond satisfactorily to standard therapy with inhaled corticosteroids. Late-onset eosinophilic asthma is currently one of the most well-defined asthma phenotypes and seems to have a different underlying pathobiology to classical childhood-onset, allergic asthma. Patients with this phenotype can be identified in the clinic by typical symptoms (few allergies and dyspnoea on exertion), typical lung function abnormalities (“fixed” airflow obstruction, reduced forced vital capacity and increased residual volume), typical comorbidities (nasal polyposis) and a good response to systemic corticosteroids. The definitive diagnosis is based on evidence of eosinophilia in bronchial biopsies or induced sputum, which can be estimated with reasonable accuracy by eosinophilia in peripheral blood. Until recently, patients with eosinophilic asthma had a very poor quality of life and many suffered from frequent severe exacerbations or were dependent on oral corticosteroids. Now, for the first time, novel biologicals targeting the eosinophil have become available that have been shown to be able to provide full control of this type of refractory asthma, and to become a safe and efficacious substitute for oral corticosteroids.

Late-onset eosinophilic asthma has a distinct clinical and functional profile with treatment implicationshttp://ow.ly/MH7AH

Residual exhaled nitric oxide elevation in asthmatics is associated with eosinophilic chronic rhinosinusitis

OBJECTIVE

Eosinophilic chronic rhinosinusitis (ECRS) is as a subgroup of chronic rhinosinusitis (CRS) with nasal polyps. ECRS is a refractory disease closely related to bronchial asthma. Fractionated exhaled nitric oxide (FeNO) levels were reportedly elevated in some asthmatics with CRS after adequate treatment, suggesting that residual eosinophilic airway inflammation or ECRS might affect FeNO levels.

METHODS

To investigate the association between asthma with ECRS and FeNO levels, we examined FeNO levels in 133 asthmatics (99 with ECRS and 34 without ECRS) and 13 patients with ECRS without asthma. The severity of asthma was defined by the Global Initiative for Asthma guidelines and that of sinusitis was evaluated by the sinus CT score based on the Lund-Mackay scale.

RESULTS AND CONCLUSIONS

FeNO levels were elevated even in well-controlled asthmatics with ECRS, whereas asthmatics without ECRS and ECRS patients without asthma did not have high FeNO levels (>50 ppb). Although FeNO levels were not correlated with asthma severity, they were positively correlated with the sinus CT score. In asthmatics with ECRS, patients with higher FeNO levels had more severe ECRS and asthma. There is a possibility of having comorbid ECRS, particularly in asthmatics with high FeNO levels even after adequate treatment, including ICS, suggesting that asthma and ECRS may be closely associated as one airway disease with eosinophilic inflammation. Continual awareness of the coexistent ECRS is ideally recommended for asthmatics with high FeNO levels.

Relationship between sputum eosinophilia and sinus disease in patients with eosinophilic bronchitis

BACKGROUND

Sinus disease is commonly seen in patients with asthma, and several studies have been published describing the relationship between sinus disease and the inflammation seen in the sputum of asthmatic subjects. In this article, we expand on this knowledge by studying patients with eosinophilic bronchitis with and without asthma.

METHODS

We describe the relationship between the severity of sinus disease determined by the Lund-Mackay score and sputum eosinophilia. Comparisons with blood eosinophil and total immunoglobulin (IgE) measurements are made.

RESULTS

We have shown that the severity of sinus disease is positively correlated with sputum eosinophil counts, and the site of sinus disease affected the level of eosinophilia. There was a positive correlation between sputum eosinophils and blood eosinophils, but there was no relationship with blood total IgE levels.

CONCLUSIONS

We have confirmed that there is a link between upper and lower airway inflammation and that this is not limited to patients with asthma. The process is associated with systemic inflammation as evidenced by increased blood eosinophils but appears to be independent of IgE.

Nasal symptomatology, obstruction, and paranasal sinus opacity in patients with chronic obstructive pulmonary disease

CONCLUSION

Patients with chronic obstructive pulmonary disease (COPD) more frequently suffer from nasal symptoms as well as upper respiratory tract obstruction compared with the healthy population.

OBJECTIVE

The relationship between chronic rhinosinusitis and bronchial asthma has been studied in detail in the past. In recent years, a limited number of authors have also studied involvement of the nose and paranasal sinuses in patients with COPD.

METHODS

This was an observational cross-sectional study with subsequent prospective assessment; 42 patients with COPD were included. The control group consisted of 12 healthy subjects. All patients with a history of rhinitis or rhinosinusitis and patients with previous surgery of the nose and sinuses were excluded from the study. Clinical variables evaluated were nasal symptoms (SNAQ-11 questionnaire), nasal endoscopy, nasal patency (active rhinomanometry), and computed tomography of paranasal sinuses.

RESULTS

In the COPD group, there was a higher occurrence of nasal symptoms and pathological findings on nasal endoscopy compared with the control group. The overall nasal airflow was higher in the control group (compared with COPD patients) and the overall nasal resistance was higher in the COPD group (compared with controls). Pathological opacity of one or more sinuses was confirmed in 38% of COPD patients.

Relationship between chronic rhinosinusitis and lower airway diseases: An extensive review

Significant links between allergic rhinitis and asthma have been reported, and the united airway disease hypothesis is supported by numerous findings in epidemiologic, physiologic, pathologic, and immunologic studies. The impact of allergic rhinitis on asthma has been established. On the other hand, the relationship between chronic rhinosinusitis and lung diseases has been under investigation. Chronic rhinosinusitis is a common disease, and the high prevalence of chronic rhinosinusitis in some kinds of lung diseases has been reported. Recent studies suggest that the treatment of chronic rhinosinusitis has beneficial effects in the management of asthma. Here, we present an overview of the current research on the relationship between chronic rhinosinusitis and lower airway diseases including asthma, chronic obstructive pulmonary disease, cystic fibrosis, diffuse panbronchiolitis, primary ciliary dyskinesia, idiopathic bronchiectasis, and allergic bronchopulmonary aspergillosis.

Optimizing an Internal Airway Percussion Device for Facilitating Exhalate Diagnostics of the Human Respiratory System

PURPOSE

There is an urgent need for simple, inexpensive, noninvasive, and repeatable technique for the diagnosis of pulmonary diseases. Bronchoalveolar lavage, which is the gold standard diagnostic method for pulmonary diseases, does not meet any of these criteria. This study seeks to develop and optimize a novel technique of Internal Airway Percussion (IAP) to facilitate the collection and characterization of human respiratory system exhalates.

METHODS

The IAP device transmits sound waves into the respiratory tract, thereby increasing the release of aerosolized particles within exhaled breath by vibrating both lungs. Nine combinations of sound wave frequencies and amplitudes were studied to determine optimal frequency and amplitude combination for maximum aerosol particle gain in healthy human subjects.

RESULTS

Square-shaped sound waves generated at 15 Hz and 3 cm H₂O resulted in 15 times greater total mass of collected particles in the first 2 min of sampling, and 1.2 to 1.5 times increase in count median diameter of the particles.

CONCLUSIONS

IAP, optimized at the frequency of 15 Hz and the pressure amplitude of 3 cm H₂O, increased the total mass of particles exhaled from the human respiratory system. IAP has a broad range of potential clinical applications for noninvasive diagnosis of lung diseases including asthma, cystic fibrosis, pneumonia, and lung cancer, along with improvement of mucus clearance.

Influence of upper airway abnormalities on the control of severe asthma: a cross-sectional study

BACKGROUND

A better understanding of severe uncontrolled asthma (UA) in the upper airways is needed. The aims of this study were to assess the prevalence of upper airway abnormalities and their associations with UA.

METHODS

An observational study enrolled individuals with severe asthma. Sociodemographic and clinical questionnaires regarding asthma, rhinosinusitis, and laryngopharyngeal reflux (LPR) were administered. Skin-prick tests and fiber optic nasolaryngoscopies were also performed. Descriptive statistical analysis was performed, using a multiple Poisson regression model to obtain adjusted prevalence ratios (PRs) and to identify the clinical profiles associated with the highest and lowest percentages of the dependent variable, lack of asthma control.

RESULTS

The sample consisted of 64 participants who were divided into 2 groups according to asthma control. Thus, group I comprised 27 individuals with severe controlled asthma (CA), and group II consisted of 37 individuals with UA. Women represented 87.5% of the study population. The median age was 54 years, and 86% of the sample had rhinosinusitis. Relevant associations were detected between UA and hyposmia (PR = 2.04), hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) (PR = 1.45), arytenoids hyperemia (PR = 1.45), LPR (PR = 1.37), a positive family history of asthma (PR = 1.35), onset of asthma at age 10 years or older (PR = 0.59), and swelling of the vocal cords (PR = 0.54).

CONCLUSION

This study found a very high prevalence of rhinosinusitis in patients with severe asthma as well as associations between UA and hyposmia, hypersensitivity to NSAIDs, arytenoids hyperemia, and LPR. Clinical profiles prone to UA were identified.

Rhinosinusitis and asthma: a very long engagement

Upper and lower airways may be considered as a unique entity, interested by coexisting inflammatory processes that share common etiopathogenic mechanisms. Previous studies have strongly demonstrated a relationship between rhinosinusitis and asthma. This has led to the introduction of the concept of “United Airways”, which has also been included in the WHO document Allergic Rhinitis and its Impact on Asthma (ARIA); this concept has important consequences also on the treatment of these disorders. To better summarize the evident connection between upper and lower airway disease we decided to describe it as a multilayered construction, each level pointing out more deeply the relationship between these entities.

Eosinophilic otitis media is associated with asthma severity and smoking history

PURPOSE

Eosinophilic otitis media (EOM) is an intractable otitis media characterized by an accumulation of eosinophils in the middle ear and a strong association with asthma. We investigated the relationship between EOM and asthma severity, asthma risk factors, lung function, and airway structural changes assessed by high-resolution computed tomographic (HRCT) scanning.

MATERIALS AND METHODS

Forty-one asthma patients with chronic rhinosinusitis (18 men and 23 women; mean age 56 years; age range 25-82 years) were included in this study. EOM was diagnosed according to the published diagnostic criteria. Asthma severity and risk factors for asthma, such as smoking history (Brinkman index, BI), were examined. Airway wall thickness and emphysema were assessed with HRCT scanning by a blinded respiratory specialist using a validated method. Lung function was measured using standard procedures.

RESULTS

EOM was diagnosed in 34% of the patients. Asthma severity, BI and airway wall thickness were each statistically greater in patients with EOM than in patients without EOM.

CONCLUSION

There was a close relationship between EOM and asthma severity in asthma patients with chronic rhinosinusitis. Cessation of smoking might help prevent EOM by reducing airway wall thickness.

The impact of sinusitis on the long-term clinical outcomes of asthma

Background

Upper respiratory diseases have been linked with lower respiratory diseases. However, the long-term effect of sinusitis on the clinical outcomes of asthma has not been fully evaluated.

Objective

The aim of this study was to investigate the impact of sinusitis on the disease progression of asthma.

Methods

Seventy-five asthmatic patients confirmed with the methacholine bronchial provocation test or bronchodilator response were included. The study patients underwent paranasal sinus x-ray upon their asthma evaluation and they visited the hospital at least 3 years or longer. We retrospectively reviewed their medical records and compared data according to the presence of comorbid sinusitis.

Results

Among the 75 asthmatic subjects, 38 subjects (50.7%) had radiologic evidence of sinusitis. Asthmatics with sinusitis had significantly lower forced expiratory volume in 1 second (FEV₁; 79.2% vs. 88.2%) and PC₂₀ values (5.2 mg/mL vs. 8.9 mg/mL) compared to asthmatics without sinusitis at the time of diagnosis. This difference in FEV₁ disappeared (82.6% vs. 87.2%) in the 3-year follow-up, although FEV₁ was more variable (31.7% vs. 23.5%) and worst FEV₁ was also significantly lower in patients with sinusitis compared to those without (70.9% vs. 79.0%). There were no significant differences in the number of hospital visits, acute exacerbations, and scores for the asthma control test.

Conclusion

Although sinusitis was associated with lower baseline lung function and higher hyperreactivity, sinusitis was not related with significant deterioration in lung function over 3 years of follow-up. Asthmatics with sinusitis showed more variability in lung function during the follow-up period. Healthcare utilization was not different except antibiotics use.

ICON: chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a public health problem that has a significant socio-economic impact. Moreover, the complexity of this disease due to its heterogeneous nature based on the underlying pathophysiology - leading to different disease variants - further complicates our understanding and directions for the most appropriate targeted treatment strategies. Several International/national guidelines/position papers and/or consensus documents are available that present the current knowledge and treatment strategies for CRS. Yet there are many challenges to the management of CRS especially in the case of the more severe and refractory forms of disease. Therefore, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), a collaboration between EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus (ICON) on Chronic Rhinosinusitis. The purpose of this ICON on CRS is to highlight the key common messages from the existing guidelines, the differences in recommendations as well as the gaps in our current knowledge of CRS, thus providing a concise reference. In this document we discuss the definition of the disease, its relevance, pharmacoeconomics, pathophysiology, phenotypes and endotypes, genetics and risk factors, natural history and co-morbidities as well as clinical manifestations and treatment options in both adults and children comprising pharmacotherapy, surgical interventions and more recent biological approaches. Finally, we have also highlighted the unmet needs that wait to be addressed through future research.

Transforming growth factor β and severe asthma: a perfect storm

Asthma is a chronic inflammatory airway disease involving complex interplay between resident and infiltrative cells, which in turn are regulated by a wide range of host mediators. Identifying useful biomarkers correlating with clinical symptoms and degree of airway obstruction remain important to effective future asthma treatments. Transforming growth factor β (TGF-β) is a major mediator involved in pro-inflammatory responses and fibrotic tissue remodeling within the asthmatic lung. Its role however, as a therapeutic target remains controversial. The aim of this review is to highlight its role in severe asthma including interactions with adaptive T-helper cells, cytokines and differentiation through regulatory T-cells. Associations between TGF-β and eosinophils will be addressed and the effects of genetic polymorphisms of the TGF-β1 gene explored in the context of asthma. We highlight TGF-β1 as a potential future therapeutic target in severe asthma including its importance in identifying emerging clinical phenotypes in asthmatic subjects who may be suitable for individualized therapy through TGF-β modulation.

Efficacy of nasal mometasone for the treatment of chronic sinonasal disease in patients with inadequately controlled asthma

BACKGROUND

Chronic sinonasal disease is common in asthmatic patients and associated with poor asthma control; however, there are no long-term trials addressing whether chronic treatment of sinonasal disease improves asthma control.

OBJECTIVE

We sought to determine whether treatment of chronic sinonasal disease with nasal corticosteroids improves asthma control, as measured by the Childhood Asthma Control Test and Asthma Control Test in children and adults, respectively.

METHODS

A 24-week multicenter, randomized, placebo-controlled, double-blind trial of placebo versus nasal mometasone in adults and children with inadequately controlled asthma was performed. Treatments were randomly assigned, with concealment of allocation.

RESULTS

Two hundred thirty-seven adults and 151 children were randomized to nasal mometasone versus placebo, and 319 participants completed the study. There was no difference in the Childhood Asthma Control Test score (difference in change with mometasone - change with placebo [ΔM - ΔP], -0.38; 95% CI, -2.19 to 1.44; P = .68; age 6-11 years) or the Asthma Control Test score (ΔM - ΔP, 0.51; 95% CI, -0.46 to 1.48; P = .30; age ≥12 years) in those assigned to mometasone versus placebo. In children and adolescents (age 6-17 years) there was no difference in asthma or sinus symptoms but a decrease in episodes of poorly controlled asthma defined by a decrease in peak flow. In adults there was a small difference in asthma symptoms measured by using the Asthma Symptom Utility Index (ΔM - ΔP, 0.06; 95% CI, 0.01 to 0.11; P < .01) and in nasal symptoms (sinus symptom score ΔM - ΔP, -3.82; 95% CI, -7.19 to -0.45; P = .03) but no difference in asthma quality of life, lung function, or episodes of poorly controlled asthma in adults assigned to mometasone versus placebo.

CONCLUSIONS

Treatment of chronic sinonasal disease with nasal corticosteroids for 24 weeks does not improve asthma control. Treatment of sinonasal disease in asthmatic patients should be determined by the need to treat sinonasal disease rather than to improve asthma control.

Influence of chronic sinusitis and nasal polyp on the lower airway of subjects without lower airway diseases

Purpose

Upper and lower respiratory tract pathologies are believed to be interrelated; however, the impact of upper airway inflammation on lung function in subjects without lung disease has not been evaluated. This study investigated the association of CT finding suggesting chronic sinusitis and lung function in healthy subjects without lung disease.

Methods

This was a retrospective study of prospectively collected data from 284 subjects who underwent a pulmonary function test, bronchial provocation test, rhinoscopy, and osteomeatal unit computed tomography offered as a private health check-up option.

Results

CT findings showed that the sinusitis group had a significantly lower FEV1/FVC ratio than subjects without sinusitis finding (78.62% vs 84.19%, P=0.019). Among the sinusitis group, subjects classified by CT findings as the extensive disease group had a slightly lower FEV1/FVC than those of the limited disease group (76.6% vs 79.5%, P=0.014) and the associations were independent of the presence of airway hyperresponsiveness. The subjects with nasal polyp had also lower FEV1 and FEV1/FVC than subjects without nasal polyp (FEV1: 100.0% vs 103.6%, P=0.045, FEV1/FVC: 77.4% vs 80.0%, P=0.005).

Conclusions

CT findings suggesting chronic sinusitis and nasal polyp were associated with subclinical lower airway flow limitation even in the absence of underlying lung disease.

Analysis of comorbidities and objective parameters in refractory chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objective of this study was to construct the clinical profile of patients with chronic rhinosinusitis (CRS) with/without polyposis undergoing revision sinus surgery and to evaluate the relationship of polyposis, asthma, acetylsalicylic acid (aspirin) (ASA) sensitivity, inhalant allergies, and previous sinus surgery on disease severity as measured by objective parameters.

STUDY DESIGN

Cross-sectional study.

METHODS

Two-hundred twenty-five patients were accrued at a tertiary care academic center. Categorical factors recorded included presence of polyps, asthma, inhalant allergy, and ASA sensitivity. Continuous variables assessed included mean number of previous sinus surgeries, Lund-Kennedy endoscopy score, Lund-Mackay computed tomography (CT) score, absolute eosinophil count (AEC), and total immunoglobulin E (tIgE) level. Statistical analysis was performed to analyze the impact of polyposis, asthma, inhalant allergy, and ASA sensitivity on objective parameters. The mean number of previous surgeries was also correlated with objective parameters.

RESULTS

The mean age was 50.1 years with a male:female ratio of 1.1:1. The overall prevalence of polyposis, asthma, inhalant allergy, and ASA sensitivity was 56.4%, 48.4%, 38.7%, and 16.0%, respectively. The mean endoscopy and CT scores were 9.0 (± 4.0) and 11.4 (± 5.8), respectively. The mean AEC and tIgE were 0.4 k/μL (± 0.4) and 161.4 IU/mL (± 251.4). The mean number of previous endoscopic sinus surgeries was 1.8. Patients with CRS with polyposis had a statistically significant increase in presence of asthma (odds ratio [OR]: 7.5, P < .0001), inhalant allergy (OR: 3.6, P < .0001), and ASA sensitivity (OR: 78.6, P < .0001). Patients with polyposis had a statistically significant increase in endoscopy score (P < .0001), CT score (P < .0001), AEC (P < .0001), and tIgE (P = .0002). Patients with asthma had a statistically significant increase in endoscopy (P < .0001) and CT scores (P < .0001), AEC (P < .0001), and tIgE (P = .0002). Patients with inhalant allergy had a statistically significant increase in endoscopy (P = .0069), CT scores (P = .0017), and tIgE (P = .0084) but not AEC (P = .1492). Patients with ASA sensitivity had a statistically significant increase in endoscopy score (P < .0001), CT score (P < .0001), and AEC (P = .003) but not tIgE level (P = .186). The number of previous surgeries had a statistically significant correlation with endoscopy (P = .006) and CT scores (P = .03) but not AEC (P = .48) or tIgE (P = .66).

CONCLUSIONS

The current analysis constructed the clinical profile of the recalcitrant CRS patient undergoing revision sinus surgery. In general, this patient group has a high prevalence of polyposis, asthma, inhalant allergy, ASA sensitivity, and elevated disease burden as measured by objective measures. The polyp phenotype signifies statistically higher prevalence of associated comorbidities and greater objective disease severity. The presence of asthma, inhalant allergy, and ASA sensitivity also predicts statistically higher disease burden. The endoscopy and CT scores statistically correlate with the number of previous surgeries.

LEVEL OF EVIDENCE

4 Laryngoscope, 123:E1-E11, 2013.