Chronic sinusitis in severe asthma is related to sputum eosinophilia

A multivariate analysis of risk factors for the air-trapping asthmatic phenotype as measured by quantitative CT analysis

BACKGROUND

Patients with severe asthma have increased physiologically measured air trapping; however, a study using CT measures of air trapping has not been performed. This study was designed to address two hypotheses: (1) air trapping measured by multidetector CT (MDCT) quantitative methodology would be a predictor of a more severe asthma phenotype; and (2) historical, clinical, allergic, or inflammatory risk factors could be identified via multivariate analysis.

METHODS

MDCT scanning of a subset of Severe Asthma Research Program subjects was performed at functional residual capacity. Air trapping was defined as >or= 9.66% of the lung tissue < - 850 Hounsfield units (HU). Subjects classified as having air trapping were then compared to subjects without air trapping on clinical and demographic factors using both univariate and multivariate statistical analyses.

RESULTS

Subjects with air trapping were significantly more likely to have a history of asthma-related hospitalizations, ICU visits, and/or mechanical ventilation. Duration of asthma (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.08 to 1.87), history of pneumonia (OR, 8.55; 95% CI, 2.07 to 35.26), high levels of airway neutrophils (OR, 8.67; 95% CI, 2.05 to 36.57), airflow obstruction (FEV(1)/FVC) [OR, 1.61; 95% CI, 1.21 to 2.14], and atopy (OR, 11.54; 95% CI, 1.97 to 67.70) were identified as independent risk factors associated with the air-trapping phenotype.

CONCLUSIONS

Quantitative CT-determined air trapping in asthmatic subjects identifies a group of individuals at high risk for severe disease. Several independent risk factors for the presence of this phenotype were identified: perhaps most interestingly, history of pneumonia, neutrophilic inflammation, and atopy.

Cyclooxygenases and the pathogenesis of chronic rhinosinusitis and nasal polyposis

Cyclooxygenase (COX) enzymes catalyze the rate-limiting steps in prostaglandin synthesis. Prostaglandins have an important role in several physiological processes such as maintenance of gastrointestinal integrity and pathological processes such as inflammation and neoplasia. Several mechanisms have been proposed for the development of chronic rhinosinusitis, but the common final pathway seems to be an integrated process involving the mucosal epithelium, matrix, and inflammatory cells and mediators. Upper and lower airway pathologies coexist and share common etiopathogenic mechanisms, and nasal polyposis is often associated with asthma and aspirin sensitivity. The cellular source of COX activity in acute and chronic inflammation, as in chronic rhinosinusitis, is poorly understood. COX theory postulated that inhibition of COX broke down biochemical reactions that lead to the development of asthma attacks. This article focuses on COX in the pathogenesis of chronic rhinosinusitis and nasal polyposis.

Asthma outcomes after endoscopic sinus surgery in aspirin-tolerant versus aspirin-induced asthmatic patients

BACKGROUND

Certain diseases affect both upper and lower airways. Aspirin-induced asthma (AIA) is a clinical entity characterized by asthma, nasal polyposis, and aspirin intolerance. To understand the response of the lower airway to surgical treatment of the sinuses, we examined asthma outcomes in AIA compared with a second group of aspirin-tolerant asthmatic (ATA) patients to establish if there were any differences between the two groups after endoscopic sinus surgery (ESS).

METHODS

A retrospective record review was performed of 91 asthmatic subjects with chronic rhinosinusitis. Forty-one subjects had AIA and 50 subjects had ATA. Subjective and objective asthma outcome parameters were used to compare between the two groups at three time points: immediately before ESS and 6 and 12 months after ESS.

RESULTS

Preoperatively, AIA patients had significantly higher asthma severity (p<0.0001) and lower forced expiratory volume in 1 second values (p=0.04). At 12 months after ESS, a statistically significant difference between the two groups with better results in AIA patients was seen in asthma severity improvement (p=0.010) and in the decrease of ICS doses (p<0.0001), without significant differences between the two groups in other asthma outcome parameters.

CONCLUSION

AIA patients usually present with more severe asthma. The asthmatic complaints of AIA and ATA patients continue to improve significantly over 6 and 12 month after ESS. Although ESS helped both groups of patients, AIA had statistically significant better results compared with ATA patients in asthma severity scores and decreased need for ICS.

Important research questions in allergy and related diseases: nonallergic rhinitis: a GA2LEN paper

Nonallergic rhinitis (NAR) can be defined as a chronic nasal inflammation which is not caused by systemic IgE-dependent mechanisms. It is common and probably affects far more than 200 million people worldwide. Both children and adults are affected. However, its exact prevalence is unknown and its phenotypes need to be evaluated using appropriate methods to better understand its pathophysiology, diagnosis and management. It is important to differentiate between infectious rhinitis, allergic/NAR and chronic rhinosinusitis, as management differs for each of these cases. Characterization of the phenotype, mechanisms and management of NAR represents one of the major unmet needs in allergic and nonallergic diseases. Studies on children and adults are required in order to appreciate the prevalence, phenotype, severity and co-morbidities of NAR. These studies should compare allergic and NAR and consider different age group populations including elderly subjects. Mechanistic studies should be carried out to better understand the disease(s) and risk factors and to guide towards an improved diagnosis and therapy. These studies need to take the heterogeneity of NAR into account. It is likely that neuronal mechanisms, T cells, innate immunity and possibly auto-immune responses all play a role in NAR and may also contribute to the symptoms of allergic rhinitis.

Blood and sputum eosinophil levels in asthma and their relationship to sinus computed tomographic findings

OBJECTIVE

To investigate the relationship among blood and sputum eosinophil levels, sinus mucosal thickening, and osteitis in patients with asthma.

PATIENTS AND METHODS

We conducted an observational study of 201 patients with asthma who underwent sinus computed tomographic (CT) imaging and induced sputum analysis at Mayo Clinic's site in Rochester, MN, from November 1, 2000, through December 31, 2005. Sinus CT scans were reviewed by an investigator blinded to patients' identity and chart information (J.B.H.) to assess for mucosal thickening. Each scan was assigned a CT score based on the Lund-Mackay staging scale. Approximately 20% of the scans were reviewed at random by a radiologist (N.G.C.) to ensure quality control. Bone changes consistent with osteitis were ascertained from radiology reports. Lung function was measured, and sputum was analyzed by conventional methods.

RESULTS

Sinus CT scans revealed abnormalities in 136 (68%) of the 201 study patients. Severe mucosal thickening (CT score, > or = 12) was found in 60 patients (30%) and osteitis in 18 patients (9%). There was a positive correlation between CT scores and eosinophil levels in both peripheral blood (rho=0.45; 95% confidence interval, 0.33-0.56; P<.001) and induced sputum (rho=0.46; 95% confidence interval, 0.34-0.57; P<.001). Further, elevated blood and sputum eosinophil levels were associated with the presence of osteitis on CT scan and previous sinus surgery.

CONCLUSION

Blood and sputum eosinophil levels in patients with asthma are directly correlated with sinus mucosal thickening and are associated with osteitis, lending further support to the hypothesis that asthma and chronic rhinosinusitis are mediated by similar inflammatory processes.

Role of hypoxia in inflammatory upper airway disease

PURPOSE OF REVIEW

Hypoxia is a potent stimulus for inflammation and remodeling. Hypoxia develops in chronic sinusitis as shown via tissue oxygen concentrations and colonization with obligate anaerobes. This hypoxia reflects occlusion of the sinus ostia and thereby failure of transepithelial oxygenation, nonvascularized exudates, and the tendency of inflammatory hyperplasia to exceed neovascularization.

RECENT FINDINGS

Hypoxia-induced transcription factors are responsible for transcription of numerous inflammatory cytokines and growth factors, including vascular endothelial growth factor, CXCL8, CCL11, transforming growth factor-beta, inducible nitric oxide synthase, as well as matrix remodeling proteins such as procollagen and matrix metalloproteinases.

SUMMARY

Many diseases, such as asthma, share the tendency to afflict respiratory epithelium of the lower (bronchi) and upper (sinus) airway. Although the histopathology and inflammation of asthma and its associated sinusitis share many features, aggressive fibrosis, polyp formation and intense hyperplasia are not features of asthma, a disease seldom associated with significant chronic hypoxia. In contrast, fibrosis is a cardinal feature of hypoxic diseases of the lungs such as interstitial lung diseases and primary pulmonary hypertension. Arguably, chronic sinusitis can be viewed as reflecting both 'asthma' and 'primary pulmonary hypertension' of the upper airway.

Allergic rhinitis and rhinosinusitis

A relationship between allergic rhinitis and acute and chronic rhinosinusitis has been postulated for many years. Epidemiologic evidence suggests that such a relationship is likely. In addition, evidence of a common pathophysiologic mechanism linking these diseases is compelling and continues to evolve. Although a clear and definitive causal relationship remains to be elucidated, an increasing number of studies support the plausibility of this link. The current paradigm of the "unified airway" and evidence to support this model further strengthen this link. This article reviews the literature relating allergic rhinitis and acute and chronic rhinosinusitis.

Chronic rhinosinusitis and asthma

Based on considerations of the underlying epidemiology, pathophysiology, histopathology, clinical relationships and treatment outcomes, the links between rhinosinusitis and asthma become evident supporting the unified airway concept.

Mucosal remodeling in chronic rhinosinusitis

BACKGROUND

Despite pathophysiologic similarities, mucosal remodeling is well described in asthma but not chronic rhinosinusitis (CRS).

OBJECTIVE

This study attempts to identify mucosal remodeling in CRS and correlate it with clinical information.

METHODS

Charts and histopathology from 53 CRS patients who underwent functional endoscopic sinus surgery were reviewed. Clinical data and basement membrane (BM) thickness were recorded. BM thickness was graded as 0 (no thickening), 1 (mild thickening), 2 (moderate thickening), or 3 (marked thickening). Control mucosae from ten patients without CRS were analyzed for comparison.

RESULTS

Duration of CRS symptoms positively correlated with BM thickness (p = 0.007). Also, patients with a markedly thickened BM (score of 3) had a significantly greater duration of CRS symptoms (120 months) compared to patients with a thinner BM (score < or =2) (33 months) (p = 0.010). Markedly thickened BM was associated with increased coincidence of asthma (p = 0.019) and aspirin sensitivity (p = 0.003). No correlation was found between BM thickness and preoperative Lund-MacKay score. There was no statistically significant difference between markedly thickened BM and thinner BM with respect to coincidence of polyps, course of preoperative systemic steroids, estimated blood loss at surgery, and number of prior surgeries.

CONCLUSION

Increased BM thickness is correlated with prolonged duration of symptoms and the coincidence of asthma. This may indicate paranasal sinus remodeling akin to that which occurs in the bronchioles of persistent asthmatic sufferers.

Common characteristics of upper and lower airways in rhinitis and asthma: ARIA update, in collaboration with GA(2)LEN

This update aimed to review the new evidence available to support or refute prior Allergic Rhinitis and its Impact on Asthma (ARIA) statements. A Medline search of publications between 2000 and 2005 was conducted, with articles selected by experts. New evidence supports previous ARIA statements, such as: (i) allergic rhinitis (AR) is a risk factor for asthma; (ii) patients with persistent rhinitis should be evaluated for asthma; (iii) most patients with asthma have rhinitis; (iv) a combined strategy should be used to treat the airways and (v) in low- to middle-income countries, a different strategy may be needed. The increased risk of asthma has also been found among sufferers from non-AR. Recent reports show AR is a global problem. Many studies demonstrated parallel increasing prevalence of asthma and rhinitis, but in regions of highest prevalence, it may be reaching a plateau. Factors associated with a reduced risk of asthma and AR have been identified, confirming previous findings of protection related to exposure to infections. Treatment of rhinitis with intranasal glucocorticosteroids, antihistamines, leukotriene antagonists or immunotherapy may reduce morbidity because of asthma. To take advantage of the paradigm of unified airways, there is a need to rationalize diagnosis and treatment to optimize management.

Nasobronchial interaction mechanisms in allergic airways disease

PURPOSE OF REVIEW

During the past few decades, the incidence of sensitization to inhaled allergens as well as allergic airways disease has grown steadily. Genetic and environmental factors are recognized as etiologic factors in the development of allergic airway disease, with allergic rhinitis often preceding the development of asthma. Allergic rhinitis is considered a risk factor for the development of asthma, and almost all allergic asthmatic patients have rhinitis. Insight into the risk factors responsible for allergic airways disease and the interaction between the involved organs results in a better diagnostic and therapeutic approach in global airway allergy syndrome.

RECENT FINDINGS

Recent studies have shown that local tissue factors, such as microbial stimuli and systemic inflammatory mechanisms, play a role in the clinical expression of the allergic airway syndrome. In addition, impaired nasal function affects the lower airways of asthmatic patients via different pathways. To date, most human and animal data point towards a systemic pathway linking the upper and lower airways, involving both bloodstream and bone marrow. Recent clinical trials and current guidelines underline the importance of an integrated treatment strategy involving both ends of the respiratory tract.

SUMMARY

This review provides an overview of recent epidemiological and immunopathologic evidence concerning the link between upper and lower airways in allergic disease and its therapeutic implications.

Exhaled nitric oxide in persistent rhinitis with or without lower airway involvement: a review of the literature

The link between upper and lower respiratory airways has been investigated in the past decade leading to the concept of united airways disease. This hypothesis was suggested by several epidemiological observations, which had shown the high prevalence of rhinitis and sinusitis in patients with asthma, and indirectly, by observing the effects of drugs used for rhinitis on asthma symptoms. A broad spectrum of airway involvement severity can be associated with rhinitis or rhinosinusitis: from a subclinical/asymptomatic inflammatory involvement with an increase in eosinophils in induced sputum cell count, to asthma-like symptoms without functional features of asthma with or without extrathoracic airway hyperresponsiveness, to respiratory symptoms with clinical and functional criteria of asthma. The aim of this paper is to review the literature about the role of breath analysis in the relationship between nose and lung, focusing on exhaled nitric oxide (FE(NO)) measurement, a non-invasive marker of inflammation, in rhinitis and in chronic rhinosinusitis in patients complaining or not of asthma symptoms.

Difficult asthma: possible association with rhinosinusitis

Difficult asthma is rare in childhood; when child's asthma is difficult to control, review of the diagnosis and evaluation of the different risk factors for exacerbations are recommended. The relationship between rhinosinusitis and bronchial asthma is provided by epidemiologic data. Doubts persist as to whether rhinosinusitis worsens asthma, or whether these are manifestations in different parts of the respiratory tract of the same underlying disease process. However, nasal sinus disease may contribute to less control in asthma, and patients with severe asthma appear to have the most prominent abnormalities on computed tomography scanning of the paranasal sinuses. From a pathogenetic point of view, many inflammatory mediators and the cellular infiltrate are often the same in the two entities, with a relevant role probably played by eosinophils. Antibiotic treatment of chronic sinus disease in asthmatic children may improve subjective asthmatic symptoms, lung function, and decrease bronchial hyperreactivity. Scientific evidence confirms that there may be an association between asthma and sinusitis even in childhood asthma: this could be relevant for diagnostic and therapeutic purposes.

Asthma and the unified airway

Inflammatory processes of the upper and lower airway commonly co-exist. Patients with upper respiratory illnesses such as allergic rhinitis and acute and chronic rhinosinusitis often present to both otolaryngologists and primary care physicians for treatment of their symptoms of nasal and sinus disease. These patients often have concurrent lower respiratory illnesses such as asthma that may be contributing to their overall symptoms and quality of life. Unfortunately, asthma frequently remains undiagnosed in this population. It was the objective of this paper to examine the relationship between upper respiratory illnesses such as rhinitis and rhinosinusitis and lower respiratory illnesses such as asthma, and to provide a framework for primary care and specialty physicians to approach these illnesses as a spectrum of inflammatory disease. The present manuscript was developed by a multidisciplinary workgroup sponsored by the American Academy of Otolaryngic Allergy. Health care providers in various specialties contributed to the manuscript through preparation of written materials and through participation in a panel discussion held in August 2006. Each author was tasked with reviewing a specific content area and preparing a written summary for inclusion in this final document. Respiratory inflammation commonly affects both the upper and lower respiratory tracts, often concurrently. Physicians who are treating patients with symptoms of allergic rhinitis and rhinosinusitis must be vigilant to the presence of asthma among these patients. Appropriate diagnostic methods should be used to identify individuals with concurrent respiratory illnesses, and comprehensive treatment should be instituted to reduce symptoms and improve quality of life.

Inflammatory mechanisms and remodeling in chronic rhinosinusitis and nasal polyps

Chronic rhinosinusitis (CRS) is presently classified into two subgroups: CRS without and CRS with nasal polyps. A variety of inflammatory mediators, including cytokines and chemokines, as well as adhesion molecules and matrix metalloproteinases, are upregulated in both subgroups of CRS; remodeling is also observed in both. However, there are also characteristic differences. Whereas CRS without nasal polyps has more neutrophilic infiltration, in CRS with nasal polyps (especially when associated with allergy/asthma) eosinophil infiltration is strikingly increased. Although several features of remodeling (eg, squamous metaplasia, basement membrane thickening, collagen deposition, hyperplasia of mucous glands, and goblet cells) are features seen in both subgroups of CRS, epithelial shedding as observed in asthma is not seen in either subgroup. Furthermore, pseudocyst formation seen in CRS with nasal polyps is not seen in CRS without nasal polyps.

The impact of comorbid atopic disease on asthma: clinical expression and treatment

Clinically, asthma and allergic rhinitis involve separate regions of the respiratory tract while representing a common underlying inflammatory syndrome. Much evidence supports an epidemiologic association between the diseases, paranasal sinus involvement in both conditions, and parallel relationship in severity and treatment outcomes. Pathophysiologic mechanisms, including immunoglobulin E (IgE)- mediated inflammation, are also shared. Blocking IgE with the recombinant humanized monoclonal antibody omalizumab demonstrated clinical efficacy in patients with upper and lower airway diseases. IgE blockade, leukotriene modulation, and B-cell depletion therapy have all exhibited success in chronic inflammation, reinforcing and expanding the beneficial role of immunomodulation of global mediators.

Lower airway inflammation before and after house dust mite nasal challenge: an age and allergen exposure-related phenomenon

BACKGROUND

Upper and lower airways allergic disease is currently considered unitarily. Allergic inflammation in one site can extend to other sites of the respiratory tract.

OBJECTIVE

To evaluate bronchial inflammation before and after allergen-specific nasal challenge (ASNC) in rhinitic and asthmatic children, considering the different levels of allergen exposure, i.e. summer (low) and winter (high).

METHODS

Fourteen children with rhinitis and 15 with rhinitis and asthma, all monosensitized to mites and 10 healthy controls were studied. Nasal IgE were measured before ASNC in summer and in winter season. Nasal clinical score, eosinophil cationic protein (ECP), nasal tryptase, bronchial clinical score, FEV(1), PEF, sputum ECP, sputum tryptase and exhaled nitric oxide (eNO) were evaluated before and after ASNC in summer and winter season.

RESULTS

Nasal scores significantly increased after ASNC in rhinitic and asthmatic children in both seasons. Nasal IgE were significantly higher in summer compared to winter. Bronchial symptoms, FEV(1) and PEF showed no mean differences in rhinitic and asthmatic children after ASNC, with an increase of bronchial symptoms and a decrease of FEV(1) and PEF occurring in 3/15 asthmatic children. In both groups nasal tryptase and ECP after ASNC significantly increased in summer and winter, while sputum tryptase was undetectable before or after ASNC in both groups. Sputum ECP and eNO at baseline were significantly higher in patients than in controls (summer P=0.002, winter P=0.001). Sputum ECP significantly increased after ASNC in 3/15 asthmatics in summer and in 11/15 in winter, as well as in 3/14 rhinitics in summer and in 4/14 in winter. eNO significantly increased after ASNC in 3/15 asthmatics in summer and in 10/15 in winter, and in 1/14 rhinitics in summer and in 4/14 in winter. A significant median increase of sputum ECP (P=0.0007) and eNO (P=0.0012) after ASNC in asthmatic and of eNO (P=0.013) in rhinitic children was also found in winter.

CONCLUSIONS

Basal sputum ECP and eNO values, significantly higher before ASNC in rhinitic patients compared to control subjects, confirm the inflammatory link of upper and lower airways. The more frequent detection of inflammatory changes induced by ASNC in winter suggests that allergen exposure favours the transfer of nasal inflammation to lower airways.

The role of fungi in the airway of chronic rhinosinusitis patients

PURPOSE OF REVIEW

To analyze the role of fungi in the upper and lower airway in chronic rhinosinusitis patients.

RECENT FINDINGS

Recently, the involvement of the lower airway (as asthma, small airway disease and bronchial hyperresponsiveness) in chronic rhinosinusitis patients had been documented. Fungal spores after inhalation are submerged in the aqueous lining layers of the airway. The site depends on the size of the inhaled spores. The process of inhalation, retention and clearance of fungal spores may explain the positive culture results in both normal subjects and in most chronic rhinosinusitis patients. Fungal culture of different parts of the upper and lower airway in chronic rhinosinusitis patients had no correlation with cellular changes (local eosinophilia) and other clinical parameters. In chronic rhinosinusitis, with persistence of the chronic inflammatory process, the cells may be activated nonspecifically.

SUMMARY

The role played by fungi in most chronic rhinosinusitis patients as the target antigen of initiation of such chronic inflammation is still debated. With the presence of chronic eosinophilic inflammation in chronic rhinosinusitis, an exaggerated reaction to various inhaled antigens is anticipated. The role of fungi will be confirmed only when T cells within the sinuses are shown to be actively responding to fungal antigens cultured from the sinus and with the demonstration that their elimination will stop the disease.

[Allergic inflammatory diseases of the upper airways and their impact on asthma--following on from a case report]

The authors present a case report of a patient referred to physician for "difficult-to-treat asthma". Clinical evaluation concluded that severe chronic inflammatory upper airway disease was an asthma worsening factor. Patient demonstrated improvement in asthma control, after surgery. In the context of the clinical study, the authors present a review of the most common allergic inflammatory diseases of the upper airways (allergic rhinitis, chronic sinusitis and nasal polyposis) and reflect on their impact on asthma.

Severe asthma: lessons from the Severe Asthma Research Program

Severe asthma affects only a small percentage of the asthma population. However, these patients remain poorly understood and difficult to treat. Because the numbers are relatively small (10% or less of the asthma population), a network approach with shared protocols, samples, and data provides a unique opportunity to recruit the numbers of subjects necessary to perform adequately powered studies. The Severe Asthma Network (Severe Asthma Research Program) was established by the National Heart, Lung, and Blood Institute in 2001 to advance collectively the study of severe asthma to determine factors that differentiated these patients or subjects from those with milder asthma. Nearly 800 subjects have been recruited in less than 4 years to begin to address these differences. Future studies will specifically evaluate the role of inflammatory/oxidative processes, infection, genetics, and the distal lung in the pathogenesis of severe asthma.

Diagnostic classification of persistent rhinitis and its relationship to exhaled nitric oxide and asthma: a clinical study of a consecutive series of patients

BACKGROUND

Rhinitis and asthma represent the manifestation of one syndrome. Our hypothesis is that in patients with symptoms of persistent rhinitis, lower airway inflammation, lower respiratory symptoms, and lung function abnormalities compatible with asthma are more frequently associated with the diagnosis of allergic rhinitis (AR) and chronic rhinosinusitis (CRS) than with nonallergic rhinitis (NAR).

METHODS

One hundred eight of 590 consecutive patients referred in 1 year for rhinitis were enrolled on the basis of nasal symptoms lasting > 4 weeks. Asthma was diagnosed on the basis of symptoms and a positive bronchodilation testing result and/or methacholine hyperresponsiveness. Exhaled nitric oxide (Feno) was measured with the single exhalation method at 50 mL/s.

RESULTS

AR was diagnosed in 39%, NAR in 21%, and CRS in 40%. The prevalence of asthma was significantly higher in AR patients (33%) and CRS patients (42%) than in NAR patients (8.7%) [p = 0.036 and p = 0.005, respectively]. Feno was significantly higher in patients with AR and CRS compared to patients with NAR (44.3 parts per billion [ppb]; 95% confidence interval [CI], 34 to 54 ppb; and 53 ppb; 95% CI, 42 to 64 ppb; vs 22 ppb; 95% CI, 18 to 27 ppb; p = 0.002 and p = 0.001, respectively). Patients with asthma had Feno values significantly higher than patients without asthma (64 ppb; 95% CI, 51 to 77 ppb; vs 33.3 ppb; 95% CI, 28 to 39 ppb; p < 0.001).

CONCLUSIONS

The diagnostic classification of persistent rhinitis helps to predict lower airway inflammation (increased Feno) and prevalence of asthma: AR and CRS are associated with higher mean Feno values and higher prevalence of asthma than NAR.

The relationship between rhinosinusitis and asthma sinusitis

Chronic sinusitis comprises numerous disorders characterized by inflammation, mucous gland hyperplasia, and remodeling. Chronic hyperplastic eosinophilic sinusitis (CHES) is characterized by unrestrained proliferation of eosinophils, Th2-like lymphocytes, fibroblasts, goblet cells, and mast cells. The pathology of CHES is similar to that of asthma, and it is frequently diagnosed in association with asthma. It has been reported that exacerbations of CHES occur temporally with worsening of asthma; however, in the absence of well-controlled studies, this linkage remains unproven. In this article, the potential mechanisms linking these two diseases are examined.

Nasal symptoms, airway obstruction and disease severity in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by inflammation of the lung in association with airflow obstruction. There is increasing evidence of upper airway involvement in COPD and we have reported that this nasal inflammation is proportional to that in the lung. Given recognized relationships between lower airway inflammation and spirometric indices such as the Forced Expiratory Volume in one second (FEV(1)), we hypothesized that there may be a relationship between nasal obstruction and FEV(1) in COPD. We also sought to investigate relationships between nasal symptoms and nasal patency in COPD.

METHODS

We assessed the nasal and pulmonary airways, using acoustic rhinometry and spirometry respectively, in 51 patients with COPD.

RESULTS

The presence of chronic nasal symptoms in COPD was associated with reduced nasal patency (6.04 cm(2) symptoms vs. 9.55 cm(2) no symptoms, at the second minimum cross-sectional area, P = 0.049). Nasal patency in COPD was inversely proportional to pulmonary airflow obstruction, and therefore to COPD disease severity (e.g. FEV(1)% predicted vs. second minimum cross-sectional area, r = 0.36, P = 0.009).

CONCLUSIONS

The degree of nasal airway obstruction in COPD reflects the impairment to pulmonary airflow, and is greater in the presence of chronic nasal symptoms. This study provides further evidence of pan-airway involvement in COPD.

Allergic rhinitis and sinusitis in asthma: differential effects on symptoms and pulmonary function

BACKGROUND

Allergic rhinitis and sinusitis are frequently associated with asthma. The purpose of this study was to determine the impact of self-reported allergic rhinitis and sinusitis on lower airway disease in a large cohort of participants with well-characterized asthma.

METHODS

A cohort study of participants in two trials of the American Lung Association-Asthma Clinical Research Centers: 2,031 asthmatics in the Safety of Inactivated Influenza Vaccine in Asthma in Adults and Children (SIIVA) trial and 488 asthmatics in the Effectiveness of Low Dose Theophylline as Add-on Treatment in Asthma (LODO) trial. At baseline, participants reported the presence of allergic rhinitis and sinusitis, and then lung function and asthma control were measured. During the trials, participants were monitored for asthma exacerbations.

RESULTS

More than 70% of participants reported either allergic rhinitis or sinusitis. Sinusitis was more common in female patients (odds ratio, 1.46 [SIIVA]), those with gastroesophageal reflux disease (odds ratio, 2.21 [SIIVA]), and those of white race (odds ratio, 1.53 [SIIVA]). Similar associations were seen for allergic rhinitis. LODO participants with allergic rhinitis and sinusitis had increased asthma symptoms and a trend toward more sleep disturbance. Participants with allergic rhinitis had higher baseline lung function than those without allergic rhinitis measured by peak flow (91.2% vs 95.8% in the SIIVA trial). Participants with sinusitis had similar lung function to those without sinusitis. Participants with and without allergic rhinitis had similar exacerbation rates. In the LODO trial only, participants with sinusitis had increased asthma exacerbations (5.68 per patient per year vs 3.72 per patient per year).

CONCLUSION

Allergic rhinitis and sinusitis are associated with more severe asthmatic symptoms and, in patients with poorly controlled asthma, more exacerbations but are not associated with low lung function.

The role of sinus disease in asthma

PURPOSE OF REVIEW

Some time ago, a link between upper and lower respiratory disease was described, which gave rise to the concept of 'united airways disease'. This concept primarily refers to the well established link between allergic rhinitis and asthma, but it also covers a possible link between sinus disease and asthma (allergic or nonallergic) and other lower airway disease.

RECENT FINDINGS

The current classification of chronic rhinosinusitis (CRS) includes disease without and with nasal polyps, which are considered subgroups of CRS. Different patterns of inflammatory and regulatory cytokines (involving distinguishable T-helper lymphocyte populations) and of remodelling markers, however, were recently described to differentiate nasal polyposis from CRS, yielding two discrete entities. These patterns resemble those of lower airway diseases, such as asthma and chronic obstructive pulmonary disease, and suggest a common aetiological/pathogenetic background. Whereas the link between nasal polyps and asthma is well established (indeed, asthma improves after medical or surgical treatment of sinus disease), that between CRS and lower airway disease is not well understood. Recently, Staphylococcus aureus enterotoxins, acting as superantigens, were identified as a possible link between nasal polyps and asthma, resulting in severe disease manifestations in both upper and lower airways.

SUMMARY

The role played by sinus disease in asthma is only partially understood, largely because of deficits in the clinical classification and in basic knowledge of pathophysiological pathways. Recent research into upper airway and sinus inflammation and remodelling may reveal new perspectives and lead to a classification of sinus disease, which will facilitate appropriate clinical and epidemiological studies.

Rinite, sinusite e asma: indissociáveis?

Este estudo tem como objetivo rever a literatura ressaltando aspectos epidemiológicos e fisiopatológicos relacionados à abordagem unificada de rinossinusite alérgica e da asma, com as respectivas implicações terapêuticas. O levantamento bibliográfico foi realizado a partir das informações disponibilizadas pelas bases de dados Medline, MD Consult, Highwire, Medscape, LILACS e por pesquisa direta, dos últimos trinta anos, utilizando-se os termos allergic rhinitis e asthma. Foram selecionados 55 artigos originais em revisão não sistemática abordando a questão da associação clínica entre rinossinusite alérgica e asma. Verifica-se que nos últimos anos, com o uso de medicamentos tópicos, para as vias aéreas superiores ou para as vias aéreas inferiores, a abordagem terapêutica tem sido distinta. Entretanto, inúmeros inquéritos epidemiológicos, estudos de imunopatologia e clínicos demonstram a inter-relação entre asma e rinossinusite alérgica evidenciados por: i) a rinite alérgica encontra-se associada à asma e constitui-se em fator de risco independente para o seu aparecimento; ii)as características imunopatológicas da rinite alérgica e da asma são semelhantes; iii)a rinite alérgica e a asma são manifestações de uma enfermidade sistêmica; iv)o controle da rinite favorece o controle da asma. A estreita associação entre a rinite alérgica e a asma requer a integração das abordagens diagnóstica, terapêutica e profilática dessas enfermidades. Opções terapêuticas que permitam o controle simultâneo de ambas oferecem vantagens relacionadas ao custo e à tolerabilidade.

Is rhinosinusitis a cause of asthma?

There is a great deal of evidence of an association between rhinosinusitis and asthma. However, it is less clear whether rhinosinusitis is a direct trigger for asthma or the two conditions are simply manifestations of a common underlying process. Evidence for a role for rhinosinusitis as a trigger for asthma includes many examples of improvement in asthma once concomitant rhinosinusitis is treated medically or surgically. Possible mechanisms for this relationship include naso-pharyngo-bronchial reflexes, postnasal drip, abnormal breathing, and the local production of inflammatory mediators that trigger pulmonary inflammation via the bone marrow. On the other hand, evidence exists that rhinosinusitis and asthma are manifestations of a common process. For example, there are similarities between the histopathological changes in the epithelium in chronic rhinosinusitis and asthma. The bone marrow may provide the link between the upper and lower airways in creating a common disease. A second possible mechanism for a common disease is response to staphylococcal enterotoxins. Although evidence exists to suggest that rhinosinusitis either triggers asthma or represents a local manifestation of a shared disorder, the key to reconciling this apparent controversy is to consider that rhinosinusitis is not just a single, uniform disease. Current evidence suggests that rhinosinusitis with neither polyps nor eosinophilic inflammation acts as a direct trigger for asthma, whereas rhinosinusitis with both polyps and eosinophilic inflammation shares underlying mechanisms with asthma. Clearly, however, there is considerable overlap between the different, complex mechanisms that link rhinosinusitis to asthma.

A rational approach to the management of severe refractory asthma

Severe refractory asthma is a heterogeneous condition with different patterns of severity and different reasons for loss of asthma control. The three main patterns include asthma with frequent exacerbations, asthma with irreversible airway obstruction, and asthma with reduced sensitivity or resistance to corticosteroids. Each of these patterns has distinct risk factors. The assessment of patients with severe asthma requires a systematic, diagnostic and management protocol. The majority of patients will benefit from thorough analysis and treatment of aggravating factors. In some patients with severe refractory asthma, in particular those with concomitant chronic rhinosinusitis, long-term administration of systemic corticosteroids may be necessary. In these patients all efforts should be directed towards reducing the dose of corticosteroids as much as possible. Although several corticosteroid-sparing agents and immunosuppressants have been proposed in the literature, none of these has gained complete acceptance in clinical practice, either because of limited efficacy or unacceptable adverse effects. Novel potent anti-inflammatory therapies aimed at reducing the need for systemic corticosteroids in patients with severe, refractory asthma are urgently needed.

Aspirin sensitivity and severity of asthma: Evidence for irreversible airway obstruction in patients with severe or difficult-to-treat asthma

BACKGROUND

Patients with aspirin sensitivity experience hyperplastic sinusitis and nasal polyposis. We speculated that similar mechanisms could be acting in the lower airway and that these individuals would demonstrate more severe asthma and irreversible loss of lung function.

OBJECTIVE

We sought to investigate the role of aspirin-exacerbated respiratory disease (AERD) as a risk factor for the development of irreversible airway obstruction.

METHODS

The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study is a multicenter observational study of subjects with severe or difficult-to-treat asthma. Data were compared between subjects who reported asthma exacerbation after aspirin ingestion and those who did not. The primary measure of bronchodilator-resistant obstruction (possible remodeling) was the maximally achieved postbronchodilator spirometry averaged over the 3-year duration of the study.

RESULTS

Adult subjects (>/=18 years) with AERD (n = 459) were compared with subjects with non-aspirin-sensitive asthma (n = 2848). Subjects with AERD had significantly lower mean postbronchodilator percent predicted FEV(1) compared with subjects with non-aspirin-sensitive asthma (75.3% vs 79.9%, P < .001). Differences in spirometry between the 2 cohorts persisted after controlling for potential confounding variables. In addition, subjects with AERD were more likely to have severe asthma by means of physician assessment (66% vs 49%, P < .001), to have been intubated (20% vs 11%, P < .001), to have a steroid burst in the previous 3 months (56% vs 46%, P < .001), and to have required high-dose inhaled corticosteroids (34% vs 26%, P < .001).

CONCLUSIONS

These data suggest that aspirin sensitivity is associated with increased asthma severity and possible remodeling of both the upper and lower airways.

Alterações tomográficas de seios paranasais em pacientes adultos com rinite alérgica

OBJETIVO: Determinar, através de análise de tomografia computadorizada, a freqüência de envolvimento dos seios paranasais em pacientes com rinite alérgica. MÉTODOS: Foram selecionados 60 pacientes ambulatoriais com diagnóstico de rinite alérgica e queixa de obstrução nasal. Os pacientes foram submetidos a rinoscopia anterior, aplicação de questionários para avaliação da intensidade dos sintomas, testes cutâneos para aeroalérgenos e tomografia computadorizada de seios paranasais. Foi utilizado o escore de Lund para caracterização do envolvimento tomográfico dos seios paranasais. RESULTADOS: Alteração tomográfica de seios paranasais ocorreu em 31 pacientes (52%). O somatório do maior diâmetro das reações cutâneas para aeroalérgenos, a intensidade dos sintomas de rinite e os achados à rinoscopia anterior não foram diferentes entre os pacientes com ou sem alteração tomográfica de seios paranasais. Todos os pacientes com envolvimento de seios paranasais apresentavam alterações em complexos osteomeatais, enquanto que apenas 11 pacientes sem envolvimento de seios paranasais apresentavam esta alteração (38%) (p < 0,01). CONCLUSÃO: A freqüência de alterações tomográficas dos seios paranasais nesta amostra de indivíduos adultos com rinite alérgica foi elevada e não se correlacionou com a intensidade dos sintomas nem com a reação cutânea a alérgenos, mas apenas com imagens de obstrução em complexo osteomeatal.

Airway inflammation in nasal polyposis: immunopathological aspects of relation to asthma

BACKGROUND

Nasal polyposis (NP) is a chronic inflammatory disorder of the upper respiratory tract, which is often coexist with asthma. However, the pathogenesis of especially in patients with NP is still a matter of debate.

OBJECTIVE

To better understand the immunopathologic mechanism involved in this relationship, we investigated the inflammatory cell profiles in bronchial and nasal tissues of patients with NP alone and with concomitant asthma.

METHODS

Seventeen patients with NP (six male, 11 female, age range: 19-63, mean age: 38.29+/-13.27 years) were selected for the study. Subjects were divided into two groups based on the presence of asthma or bronchial hyper-responsiveness (BHR). NP without BHR (Group 1) (n=8), NP and asthma or BHR (Group 2) (n=9). All patients underwent atopy evaluation including detailed history, skin prick test (SPT), total and specific IgE determination in sera. None of the subjects had taken inhaled, nasal or oral corticosteroids for at least 1 month before the study. Respiratory symptoms of asthmatic patients were controlled with only short acting beta(2)-agonist inhaler drugs as needed. NP tissue, nasal and bronchial mucosa biopsies were taken from all patients using fiberoptic endoscopy. CD3, CD8, CD16, CD68, AA1 (mast cell tryptase), human leucocyte antigen-DR (HLA-DR) and eosinophil peroxidase (EPO) expressing cells in specimens were determined by immunohistochemical methods. Positively staining inflammatory cell types were counted. Subepithelial lamina propria and periglandular areas were separately evaluated.

RESULTS

No significant difference was found in polyp tissue, nasal and bronchial CD3(+), CD8(+), CD16(+), CD68(+), AA1(+), HLA-DR(+) and EPO(+) positive cells between groups. There were significantly higher numbers of CD8(+), CD16(+), HLA-DR(+), EPO(+) cells in the polyp tissue and nasal mucosa vs. the bronchial mucosa in all groups (P<0.05). However, CD8(+) cells were significantly increased in the polyp tissue and bronchial mucosa of patients with NP alone when compared with the patients with both asthma and NP (P<0.05). CD3(+), CD68(+) and CD16(+) cell counts were tended to be higher within the nasal polyp tissue of patients with isolated NP compared with counts within nasal and bronchial mucosa of patients with NP and asthma. Also, patients with isolated NP showed more HLA-DR(+) cells in the nasal polyp tissue and nasal mucosa than those of patients with NP and asthma. Immunoreactivity for EPO(+) eosinophils within the nasal and bronchial mucosa was more prominent in patients with NP and asthma compared with patients with NP alone. The number of EPO(+) eosinophils within the polyp tissue, nasal and bronchial mucosa was higher in the skin prick test negative (SPT -ve) group than the SPT positive (SPT +ve) ones.

CONCLUSIONS

Our results demonstrate that infiltration of inflammatory cells in the nasal and the lower airways do not remarkably differ between patients with NP alone who has no evidence of BHR and asthmatic patients with NP. However, patients with SPT-ve NP reveal more intense eosinophilic inflammation in the entire respiratory mucosa.

Severe Asthma in Adults

Severe asthma remains poorly understood and frustrating to care for, partly because it is a heterogeneous disease. Patients with severe asthma disproportionately consume health care resources related to asthma. Severe asthma may develop over time, or shortly after onset of the disease. The genetic and environmental elements that may be most important in the development of severe disease are poorly understood, but likely include both allergic and nonallergic elements. Physiologically, these patients often have air trapping, airway collapsibility, and a high degree of methacholine hyperresponsiveness. Specific phenotypes of severe asthma are only beginning to be defined. However, describing severe asthma by age at onset (early- vs. late-onset) appears to describe two phenotypes that differ at immunologic, physiologic, epidemiologic, and pathologic levels. In particular, early-onset severe asthma is a more allergic-associated disease than late-onset severe asthma. In addition, patients with severe asthma can be defined on the basis of presence and type of inflammation. Severe asthma with persistent eosinophilia (of either early or late onset) is more symptomatic and has more near-fatal events. However, at least 50% of patients with severe asthma have very little identifiable inflammation. Thus, "steroid resistance" may occur at numerous levels, not all of which are caused by a lack of effect of steroids on inflammation. Treatment remains problematic, with corticosteroids remaining the most effective therapy. However, 5-lipoxygenase inhibitors, anti-IgE, and immunomodulatory drugs are also likely to have a place in treatment. Improving therapy in this disease will require a better understanding of the phenotypes involved.

Characterisation of patients with frequent exacerbation of asthma

BACKGROUND

Exacerbation is one of the most significant problems in patients with asthma. Although subpopulation of patients is more susceptible to exacerbations than others, which clinical features characterise susceptibility to exacerbation are not well understood.

METHODS

Consecutive non-smoking adult patients with asthma who had multiple exacerbations (ME) despite regular maintenance treatment were compared with those who had at most single exacerbation as control during the previous 1 year. Exacerbation of asthma is defined initiations or escalations of systemic corticosteroid as part of the management for aggravated asthma condition.

RESULTS

Patients with ME (n=32, male: 6, mean age: 46.7 years) were characterised by intensive current maintenance treatment (dose of inhaled corticosteroid; 1037.5+/-452.8 vs 621.6+/-257.3 microg, P=0.0005, proportion of oral corticosteroid users; 28.1% vs 2.7%, P=0.008), severe episodes of exacerbation (asthma-related hospitalisations; 71.9% vs 23.4%, P=0.0002, arrival on ambulance; 37.5% vs 8.1%, P=0.008), concomitant chronic sinusitis (34.4% vs 10.8%, P=0.038) and intolerance to non-steroidal anti-inflammatory drugs (NSAIDs) (34.4% vs 5.4%, P=0.006) in comparison with controls (n=37, male:11, mean age:44.4). Pulmonary function in patients with ME was characterised by persistent airflow limitation and reduced reversibility.

CONCLUSION

Patients with ME are at increased risk for severe exacerbation despite more intensive maintenance anti-inflammatory treatment. Persistent irreversible airflow limitation and complications of chronic sinusitis and/or NSAIDs intolerance are characteristics to this subpopulation.

Chronic hyperplastic eosinophilic sinusitis as a predictor of aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is a disease of intense eosinophilic inflammation that can produce fibrosis, hyperplasia, and remodeling.

OBJECTIVE

To investigate the usefulness of quantifying severity of chronic hyperplastic eosinophilic sinusitis in predicting the presence of AERD.

METHODS

Data were compared between asthmatic patients who reported exacerbations after aspirin ingestion and those who did not. The primary outcome measure was severity of sinusitis using a validated computed tomography (CT) scan-based scoring system. Indices of lower airway remodeling and other markers of inflammation were also evaluated.

RESULTS

Twenty-one patients with AERD were compared with 19 patients with aspirin-tolerant asthma (ATA). Patients were well matched for asthma severity as shown by their similar lung function as measured by postbronchodilator forced expiratory volume in 1 second. Patients with AERD were distinguished by their sinus CT scores (AERD patients: 16.9; 95% confidence interval [CI], 13.4-21.3; ATA patients: 6.2; 95% CI, 4.2-9.1; P < .001), and they were considerably more likely to have nasal polyps (AERD patients: 90%; ATA patients: 26%; P < .001). In addition, AERD patients demonstrated increased total lung capacity (AERD patients: 107.9%; 95% CI, 99.9%-117.6%; ATA patients: 98.0%; 95% CI, 93.7%-102.5%; P = .05), reflecting a trend toward increased air trapping. No significant differences occurred in diffusing capacity, exhaled nitric oxide, eosinophilia, or exhaled breath condensate pH.

CONCLUSIONS

AERD can be distinguished from ATA by the extent of hyperplasia on CT scan and the presence of nasal polyps. We hypothesize that AERD represents a remodeling process that affects both the upper and lower airways.

Rhinosinusitis and pediatric asthma

Rhinosinusitis is a common disease in patients of all age groups. Rhinosinusitis arises from a variety of infectious and inflammatory mechanisms. There is ample evidence that rhinosinusitis can directly influence asthma. There is also growing evidence that rhinosinusitis may be associated with asthma as different manifestations of the same disorder. A great deal of future research is required to fully elucidate the different mechanisms whereby rhinosinusitis influences or associates with asthma, but it is clear that rhinosinusitis needs to be considered in patients with severe or refractory asthma.

Endothelial L-selectin ligands in sinus mucosa during chronic maxillary rhinosinusitis

RATIONALE

Chronic rhinosinusitis is characterized by persistent inflammation of the nasal and paranasal mucosa with numerous emigrated leukocytes. L-selectin on leukocytes and its endothelial glycosylated ligands initiate organ-specific leukocyte infiltration into inflamed tissues.

OBJECTIVES

The purpose of this study was to evaluate the endothelial expression of functionally active endothelial L-selectin ligands, sulfated sialyl Lewis x, in maxillary sinus mucosa from patients with chronic rhinosinusitis and from normal control subjects.

METHODS

Maxillary sinus mucosa specimens (116) were obtained surgically and immunohistochemically stained with monoclonal antibodies detecting sialyl Lewis x or sulfated extended core 1 lactosamines. The severity of the inflammation was determined by intraoperative endoscopic findings, computed tomography scans, and histopathologic assessment of the specimens.

MEASUREMENTS AND MAIN RESULTS

The percentage of vessels expressing endothelial sulfated sialyl Lewis x epitopes increased during chronic rhinosinusitis compared with uninflamed control tissue, especially in patients with additional allergic rhinitis, and decreased in specimens from aspirin-intolerant patients with preoperative oral corticosteroid treatment. In addition, the expression level of endothelial sulfated sialyl Lewis x epitopes and the number of mucosal eosinophils correlated with the severity of the inflammation, and decreased in specimens taken 9 months postoperatively compared with intraoperative samples, especially in patients with intranasal corticosteroid treatment.

CONCLUSIONS

Our results suggest that functionally active L-selectin ligands might guide leukocyte traffic into maxillary sinus mucosa preferentially in patients with severe findings of chronic maxillary rhinosinusitis, thus leading to aggravation of the inflammation.

Molecular and cellular staging for the severity of chronic rhinosinusitis

OBJECTIVES

To correlate objective and subjective clinical parameters with molecular, cellular, and histologic markers and to acknowledge the importance of these basic science parameters in a severity classification system for chronic rhinosinusitis (CRS).

STUDY DESIGN

Retrospective analysis of prospectively collected data of consecutive patients undergoing endoscopic sinus surgery for CRS in an academic institution.

METHODS

The preoperative computed tomography (CT) scans of all patients with CRS scheduled for surgery were graded according to Lund and Mackay. The patients completed a Sino-Nasal Outcome Test (SNOT)-20 questionnaire and had a preoperative nasal endoscopy performed, which was graded by assigning an endoscopy score according to Lanza and Kennedy. Subjects had a medical questionnaire regarding presence of aspirin sensitivity, allergic rhinitis, asthma, and medication usage. Subjects also underwent pulmonary function testing and had skin tests for allergies. At the time of surgery, blood was drawn to determine the level of peripheral eosinophilia and the degree of polymorphisms of the leukotriene C4 synthase gene. Sinus mucosal and polyp tissue was examined pathologically for the number of eosinophils per high-powered filed (HPF) and was stained for EG2 to determine the portion of activated eosinophils. Leukotriene C4 levels (pg/g of tissue) were determined using a sensitive competitive enzyme immunoassay. Endoscopy and SNOT-20 scores were reevaluated 1 year after surgery. Data were analyzed for disease-severity correlation to recommend a severity classification system for CRS that incorporates the contribution of clinical, molecular, cellular, and histologic parameters.

RESULTS

The presence of polyps resulted in higher preoperative CT scores and higher preoperative and postoperative symptom scores. Average preoperative CT scores were significantly higher in asthmatics and allergy patients and correlated with endoscopy scores. Patients with more than five eosinophils/HPF of sinus tissue had higher frequency of polyps and asthma and higher CT and endoscopy scores than patients without sinus tissue eosinophilia (less than or equal to 5 cells/HPF sinus tissue). The subgroup of patients with eosinophilic nasal polyps (eosinophilic hyperplastic rhinosinusitis) had more severe disease by CT and endoscopy than the subgroup of patients with nasal polyps (hyperplastic rhinosinusitis) but without eosinophilia. Similarly, patients without polyps but with tissue eosinophilia had more severe disease than patients without polyps and without eosinophilia. Leukotriene C4 levels were elevated in all patient groups. Symptom scores did not correlate with any of the parameters.

CONCLUSION

We suggest the following severity classification system for CRS: 1) eosinophilic chronic hyperplastic rhinosinusitis (ECHRS): patients with polyps and sinus tissue eosinophilia; 2) noneosinophilic chronic hyperplastic rhinosinusitis (NECHRS): patients with polyps but without sinus tissue eosinophilia; 3) eosinophilic chronic rhinosinusitis (ECRS): patients without polyps but with sinus tissue eosinophilia; 4) noneosinophilic chronic rhinosinusitis (NECRS): patients without polyps and without sinus tissue eosinophilia.

An update on the asthma-rhinitis link

PURPOSE OF REVIEW

For the present article we collected and reviewed the more relevant experimental results concerning the asthma-rhinitis link in allergic diseases, published since January 2002.

RECENT FINDINGS

During the last 2 years, particular attention has been devoted to the behaviour of the immune response in the two compartments of the airways. The recent experimental data, mainly obtained with specific nasal or bronchial allergen challenges, have confirmed that the link between the nose and the bronchi is bidirectional, and that a systemic cross-talk occurs. Furthermore, the pathogenic role of paranasal sinus infections in respiratory allergy has been better elucidated. It was shown that, in sinusitis, a T helper type 2 polarization exists, which can be reverted by proper therapy. On the other hand, despite the abundant experimental evidence, our view of the united airways is still not complete, and several points need to be developed.

SUMMARY

The new findings on the asthma-rhinitis link have confirmed the current pathogenic view of respiratory allergy. These findings have important implications from a therapeutic point of view, and therefore encourage and promote the search for novel integrated treatment strategies.

How should nasal symptoms be investigated in asthma? A comparison of radiologic and endoscopic findings

BACKGROUND

To improve asthma control, the management of rhinosinusitis often leads the physician to perform sinonasal imaging and/or nasal endoscopy, but their respective contributions are still insufficiently understood.

OBJECTIVE

To evaluate the potential contribution of a symptoms questionnaire, sinus radiography (SR) and computed tomography (CT) scan to the diagnosis of nasal diseases in asthmatic patients when compared with ENT examination.

METHODS

A total of 124 patients completed a questionnaire on nasal symptoms administered by the chest physician. Then, they underwent ENT examination. On the same day, SR and CT scans were performed independently.

RESULTS

Patients (80.3%) had nasal symptoms during the month preceding the consultation. The ENT examination was normal in 8.1% (n = 10) and revealed rhinitis in 57.3% (n = 71), rhinosinusitis in 14.5% (n = 18) and nasal polyposis in 20.2% (n = 25). For rhinitis, the negative predictive value of bilateral nasal obstruction was 87.8%. Both SR and CT had low sensitivity and specificity. For rhinosinusitis, the negative predictive value of nasal symptoms varied from 85.4 to 95.2%. Sinus CT was at least as accurate as SR for the diagnosis of rhinosinusitis. In a multivariate analysis, only the CT scan (score > or =12) appeared to be significantly associated with the diagnosis of nasal polyposis.

CONCLUSION

In asthmatic patients, physicians need to enquire systematically about the existence of nasal symptoms by using this simple questionnaire which is sensitive for rhinitis, and has good negative predictive value for excluding rhinosinusitis and nasal polyposis.