Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors

The link between allergic rhinitis and chronic rhinosinusitis

PURPOSE OF REVIEW

Allergic rhinitis and chronic rhinosinusitis (CRS) are common disorders affecting millions of people worldwide. Although allergic rhinitis and CRS are distinct clinical entities, certain CRS endotypes share similar pathological mechanisms as those seen in patients with allergic rhinitis. This review assesses the literature behind the similarities and differences seen in patients with CRS and allergic rhinitis, and the role atopy might play in the pathophysiology of CRS.

RECENT FINDINGS

In examining the associations between allergic rhinitis and CRS, most studies have focused primarily on CRS with nasal polyps and type 2 inflammation in CRS. Recent studies have demonstrated the similarities and differences in pathologic mechanisms behind allergic rhinitis and CRS, with an emphasis on patient endotypes, genetics, and the nasoepithelial immunologic barrier. Related immunopathology shared by allergic rhinitis and type 2 inflammation in CRS has allowed for therapeutic overlap with biologic treatments.

SUMMARY

Allergic rhinitis and CRS often present as comorbid conditions, and understanding the relationship between allergic rhinitis and CRS is important when considering treatment options. Advances in understanding the genetics and immunology, as well as biologic and immunotherapeutic treatments have improved outcomes in patients with CRS, especially in the setting of atopy.

Association of allergic rhinitis with hypothyroidism, asthma, and chronic sinusitis: clinical and radiological features

Background

Allergic rhinitis (AR) is characterized by mucosal inflammation that leads to a variety of symptoms, such as nasal congestion, rhinorrhea, and sneezing. This rhinitis is triggered by inhalation of allergens, such as pollen, and this condition has a negative impact on the quality of life. AR was shown to be associated with a number of co-morbidities, including hypothyroidism, asthma, and chronic sinusitis.

Objective

This study aimed to assess AR-associated comorbidities in patients presenting symptoms and paranasal sinus computed tomography (CT) scan findings in Taif City, Saudi Arabia.

Methods

This cross-sectional study evaluated medical and radiological records of AR patients retrospectively from the period of December 2018 to September 2019 in Al-Hada Armed Forces Military Hospital, Taif City, Saudi Arabia.

Results

A total of 103 AR patients with a mean age of 39.0 ± 15.6 years with 55.3% males and 44.7% females. The three most common associated comorbidities in allergic rhinitis patients were chronic sinusitis (28.2%), hypothyroidism (21.4%), and asthma (8.7%). Nasal obstruction (30.1%) was the symptom most frequently presented by all patients. Mucosal thickening occurred most frequently in patients with associated chronic sinusitis, while bilateral osteomeatal complex obliteration was observed mostly in asthmatic patients, and bony boundary thinning was more prevalent among patients with associated hypothyroidism.

Conclusion

The gender distribution of AR was 10% more common among males; however, the most common three comorbidites in allergic rhinitis patients were chronic sinusitis, hypothyroidism, and asthma, and most of those patients were females. Hypothyroidism can be a hidden predisposing factor for AR, while chronic sinusitis can be caused by AR due to secretion stasis or immune system activation.

Low Molecular Weight Heparin Improves the Inflammatory State of Acute Sinusitis Rats Through Inhibiting the TLR4-MyD88-NF-κB Signaling Pathway

Introduction: Low molecular weight heparin (LMWH), a natural sulfated glycosaminoglycan with an affinity for proangiogenic factors, is produced by chemical or enzymatic depolymerization of unfractionated heparin (UFH). Known for its anticoagulant effects, LMWH has recently been reported to have a strong anti-inflammatory effect on colitis, myocarditis, and airway inflammation. However, as a newly-developed drug, its anti-inflammatory mechanism in upper respiratory tract inflammation has not been well-studied.

Methods: SD rats were randomly divided into control and experimental groups. The experimental group was established by building an acute nasal sinusitis model with expansion sponges mixed with Streptococcus pneumoniae. Then the experimental group rats were subcutaneously injected with different concentrations of LMWH. After seven consecutive days of injection, some rats were sacrificed, and blood and nasal mucosa samples were taken to determine their inflammation status. The remaining acute sinusitis rats were randomly selected for a week of nasal irrigation with normal saline or saline mixed with different concentrations of LMWH. One week later, rats were sacrificed, and samples of blood and nasal mucosa were taken to determine the inflammation status.

Results: Rat nasal mucosa in the model group had obvious inflammation. The degree of nasal mucosa inflammation damage in the experimental group was lower than in the experimental control group, proving that LMWH has a protective effect on the nasal mucosa and that the effect correlates with dosage. Irrigation of the nose with saline mixed with LMWH can improve the anti-inflammatory effect. Protein related to the TLR4-MyD88-NF-κB signaling pathway was activated in the acute sinusitis rat model, and LMWH can significantly inhibit its expression.

Conclusion: This is the first report of the anti-inflammatory effect of LMWH in acute upper respiratory tract inflammation, together with an explanation of its anti-inflammatory mechanism. The findings contribute a theoretical basis for its potential anti-tumor effect.

The association between allergy and sinusitis: a cross-sectional study based on NHANES 2005–2006

Background

The relationship between allergies and sinusitis, though extensively studied, remains poorly defined. While several studies proposed a cause-and-effect relationship between allergy and chronic sinusitis, several others reported the lack of any existing association. This study aimed to investigate the relationship between allergy and sinusitis.

Methods

We conducted a cross-sectional study using a representative sample of the US population from the National Health and Nutrition Examination Survey 2005‒2006 (n  = 7244). A self-reported allergy questionnaire and total and allergen-specific IgE levels were used for analysis. Participants were divided into positive and negative allergy symptoms groups (PAS, NAS, respectively) to eliminate the influence of allergy symptoms on the apparent incidence of sinusitis. Pearson’s chi-square test and the linear regression analysis using Durbin Watson test were used for statistical analysis.

Results

Sinusitis incidence in the PAS group (22.4%; 521/2327) was significantly higher than that in the NAS group (7.1%; 348/4917) [odds ratios (OR)  = 3.788, 95% confidence interval (CI) 3.272‒4.384, P  < 0.001]. sinusitis incidence in non-sensitized and sensitized groups was not statistically different. After controlling for allergy symptoms, there was a negative correlation between sensitization status and the occurrence of sinusitis in the PAS group (OR  = 1.407, 95% CI 1.156‒1.711, P  < 0.01). Increase in serum total IgE levels correlated with decrease in incidence of sinusitis in both PAS and NAS groups. sinusitis incidence was significantly reduced in the PAS group in participants sensitized to allergens such as cockroaches, ragweed, ryegrass, Bermuda grass, oak, birch, and thistle.

Conclusion

Allergy is related to sinusitis incidence. It is likely that sensitization status could reduce the incidence of sinusitis, albeit in an antigen-specific manner.

[Optimization of treatment of patients with acute bacterial rhinosinusitis with relating allergic rhinitis]

The article considers the problem of acute rhinosinusitis and its multifactorial relationship with allergic rhinitis. Data on a higher incidence of acute rhinosinusitis in patients with an allergic background is given, which is primarily associated with a deterioration in the state of the respiratory tract mucous membrane barrier function. It is shown that local allergic inflammation causes a more severe course of acute rhinosinusitis. A review of the combined course of these pathological processes is carried out and options for their treatment are considered. A study of the clinical use of the complex preparation Frinosol is described, which, thanks to the combination of a nasal decongestant and an antihistamine in its composition, effectively alleviates the symptoms of acute rhinosinusitis in patients with allergic rhinitis. It has been shown that the use of Frinosol in the complex treatment of adult patients with acute bacterial rhinosinusitis, combined with allergic rhinitis is safe and effective.

The Role of Allergic Rhinitis in Chronic Rhinosinusitis

This literature review collates and summarizes recent literature to explore the relationship between chronic rhinosinusitis (CRS) and allergy. The relationship between CRS and allergy is not fully understood. However, current evidence suggests a relationship between allergy and specific endotypes of CRS with nasal polyposis, including allergic fungal rhinosinusitis and central compartment atopic disease. Specific endotypes of CRS with nasal polyps seem to have an association with allergy. More evidence is necessary to better characterize this relationship. Level of evidence: 5.

Chronic Rhinosinusitis: Does Allergy Play a Role?

A few chronic rhinosinusitis (CRS) variants have demonstrated a strong association with environmental allergy, including allergic fungal rhinosinusitis (AFRS) and central compartment atopic disease (CCAD). However, the overall relationship between CRS and allergy remains poorly defined. The goal of this review is to evaluate the relationship between CRS and allergy with a focus on specific CRS variants.

The relationship between allergy and chronic rhinosinusitis

OBJECTIVE

To summarize the current evidence regarding a relationship between chronic rhinosinusitis (CRS) and allergy.

METHODS

Literature review.

RESULTS

Despite frequent assumption of an association between CRS and allergy the relationship between these entities remains poorly defined. Certain CRS entities, however, have demonstrated a strong association with allergy-namely allergic fungal rhinosinusitis and central compartment atopic disease.

CONCLUSION

Studies are heterogeneous and largely retrospective in design with inconclusive evidence for an association between CRS and allergy. Knowledge of CRS endotypes is important in order to understand which entities may or may not be associated with allergy. Level of Evidence: 5.

Allergy accelerates the disease progression of chronic rhinosinusitis

BACKGROUND

The role of allergy in the development of chronic rhinosinusitis (CRS) in East Asians is not clear.

AIMS/OBJECTIVES

The aim was to investigate the impact of allergies in the clinical characteristics of chronic rhinosinusitis.

MATERIAL AND METHODS

A total of 138 CRS patients who underwent endoscopic sinus surgery were included. A brief history of rhinosinusitis symptoms, blood eosinophil count, blood-specific allergen tests, computed tomography (CT) scan findings, Lund-Mackay (LM) CT scores, and Sino-Nasal Outcome Test (SNOT-22) Questionnaire scores, and sinoscopy findings at 3 and 6 months postoperatively.

RESULTS

The ImmunoCAP test was positive in 71(51%) patients and negative in 67(49%) patients. The mean age of those who received endoscopic sinus surgery was 7-years younger in the allergic group compared with the non-allergic group (p = .008). The peripheral eosinophil count in the allergic group was higher than that of the non-allergic group (p = .008). The LM scores and SNOT-22 scores were not significantly different between the two groups. The recurrence rate of nasal polyps in the allergic group was higher but without statistical significance.

CONCLUSIONS AND SIGNIFICANCE

Allergy may accelerate the disease progression of CRS. The presence of the serum-specific IgE was correlated with peripheral eosinophil percentage, especially in the CRSwNP patients.

The Role of BPIFA1 in Upper Airway Microbial Infections and Correlated Diseases

The mucosa is part of the first line of immune defense against pathogen exposure in humans and prevents viral and bacterial infection of the soft palate, lungs, uvula, and nasal cavity that comprise the ear-nose-throat (ENT) region. Bactericidal/permeability-increasing fold containing family A, member 1 (BPIFA1) is a secretory protein found in human upper aerodigestive tract mucosa. This innate material is secreted in mucosal fluid or found in submucosal tissue in the human soft palate, lung, uvula, and nasal cavity. BPIFA1 is a critical component of the innate immune response that prevents upper airway diseases. This review will provide a brief introduction of the roles of BPIFA1 in the upper airway (with a focus on the nasal cavity, sinus, and middle ear), specifically its history, identification, distribution in various human tissues, function, and diagnostic value in various upper airway infectious diseases.

Central compartment atopic disease

BACKGROUND

Isolated polypoid changes of the middle turbinate were recently reported as having a high association with inhalant allergy. A more advanced manifestation of this association may present as polypoid changes of the entire central sinonasal compartment (i.e., the middle and superior turbinates, and the posterosuperior nasal septum), while the lateral sinus mucosa remains relatively normal.

OBJECTIVE

To introduce and describe this newly recognized variant of chronic rhinosinusitis (CRS), termed central compartment atopic disease (CCAD).

METHODS

A case series of 15 patients from two institutions who presented with sinonasal symptoms and demonstrated central compartment polypoid mucosal changes on computed tomography (CT). The endoscopic appearance of central compartment edema was assessed. Allergy status was determined by skin or serum in vitro testing.

RESULTS

The mean ± standard deviation patient age was 42.4 ± 14.8 years, and 47% of the patients were women. All 15 patients had a diagnosis of allergic rhinitis symptomatically, and those who underwent allergy assessment (14/15) tested positive. All the patients had central compartment polypoid edema on endoscopy and central nasal soft-tissue thickening with peripheral clearing on CT. Even with more severe sinus disease, a central focus of inflammatory change existed.

CONCLUSION

CCAD may represent a local inhalant allergy process that affects the central nasal structures of ethmoid origin. Although inhalant allergy changes mainly appear within the nasal cavity, medial-to-lateral progression to involve the sinuses can occur as a simple obstructive phenomenon. This is a pattern of CRS distinct from the more diffuse sinonasal inflammatory disease and likely requires allergy management as a core component.

Diagnostic Accuracy of Symptoms, Endoscopy, and Imaging Signs of Chronic Rhinosinusitis Without Nasal Polyps Compared to Allergic Rhinitis

Objectives The diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) and distinguishing it from allergic rhinitis is difficult. Yet, early detection of CRSsNP is important to prevent progressive and severe chronic rhinosinusitis. Our aim was to compare diagnostic accuracy of symptoms, endoscopy, and imaging signs of CRSsNP and allergic rhinitis -only phenotypes. Setting Prospective controlled follow-up study. Participants Forty-two nonsmoking patients visiting tertiary care due to CRSsNP and 19 nonsmoking volunteer controls with allergic rhinitis filled a symptoms questionnaire and underwent nasal endoscopy off-seasonally. All CRSsNP patients underwent computed tomography scans of paranasal sinuses. All the allergic rhinitis control subjects and 14 of the CRSsNP patients underwent sinus magnetic resonance imaging. Results Radiologic Lund-Mackay score, duration of symptoms, visual analogue scale scores of symptoms, and Sinonasal Outcome Test 22 were significantly higher in the CRSsNP group compared to allergic rhinitis control group. These factors also correlated in part with each other. Endoscopic score did not correlate with other factors, nor did it differ between CRSsNP and allergic rhinitis groups. The highest area under curve value was demonstrated for visual analogue scale score of facial pain/pressure (0.93) and score ≥4/10 showed 60% sensitivity and 95% specificity for detecting CRSsNP group ( P < .001). Radiologic sign of obstructed osteomeatal complex showed 100% specificity and 38% sensitivity for detecting CRSsNP group ( P < .001). Conclusions CRSsNP phenotype could be primarily distinguished from allergic rhinitis by higher facial pain/pressure score and secondarily by radiologic sings of obstructed ostiomeatal complex and higher Lund-Mackay score. Endoscopic score has limited value in distinguishing CRSsNP from allergic rhinitis.

Allergic phenotype of chronic rhinosinusitis based on radiologic pattern of disease

OBJECTIVES/HYPOTHESIS

Polypoid edema of the middle turbinate is a marker of inhalant allergy. Extensive edematous changes may result in limited central nasal and sinus disease, which has been called central compartment atopic disease (CCAD). Radiologically, this is seen as soft tissue thickening in the central portion of the sinonasal cavity with or without paranasal sinus involvement. When the sinuses are involved, the soft tissue thickening spares the sinus roof or lateral wall (centrally limited). This centrally limited radiological pattern was assessed among chronic rhinosinusitis (CRS) patients and compared to allergy status.

STUDY DESIGN

Diagnostic cross-sectional study.

METHODS

This study included consecutive CRS patients without prior sinus surgery. Computed tomography (CT) scans of the paranasal sinuses were blindly assessed and allergy status was confirmed by serum or skin testing. Individual sinus cavities were defined as either centrally limited or diffuse disease. The radiological pattern that may predict allergy was determined, and its diagnostic accuracy was calculated.

RESULTS

One hundred twelve patients diagnosed to have CRS, representing 224 sides, were assessed (age 46.31 ± 13.57 years, 38.39% female, 41.07% asthma, Lund-Mackay CT score 15.88 ± 4.35, 56.25% atopic). The radiological pattern defined by centrally limited changes in all of the paranasal sinuses was associated with allergy status (73.53% vs. 53.16%, P = .03). This predicted atopy with 90.82% specificity, 73.53% positive predictive value, likelihood positive ratios of 2.16, and diagnostic odds ratio of 4.59.

CONCLUSIONS

A central radiological pattern of mucosal disease is associated with inhalant allergen sensitization. This group may represent a CCAD subgroup of patients with mainly allergic etiology.

LEVEL OF EVIDENCE

3b Laryngoscope, 128:2015-2021, 2018.

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.

Management of allergic rhinitis in the era of effective over-the-counter treatments

Allergic rhinitis (AR) may be regarded as a trivial issue unworthy of the doctor's time, and with the availability of many different over-the-counter (OTC) treatments, up to two thirds of patients self-manage AR before seeking medical care. Yet, AR can have a significant impact on health-related quality of life and is associated with a greater detriment to work productivity than other chronic diseases such as diabetes and hypertension. For many patients, the impact on quality of life is greater than suggested by reported symptoms and should also be a focus of treatment. Although many patients can effectively manage AR symptoms independently, a significant percentage will need direction from a physician to obtain optimal results. The availability of several different classes of treatment - including decongestants, sedating and non-sedating antihistamines, and more recently intranasal corticosteroids (INS) - has increased the complexity of self-management, leaving patients confused about the best approach to treatment. Treatment guidelines universally classify INS as the most effective medical agents available for use in the OTC and primary care settings. Many patients are unaware that INS are available OTC and that they are more effective than other therapies. Patients may have negative perceptions about the safety of INS and may have experienced unpleasant taste, scent, and feel with nasal sprays. Unless a patient volunteers the information, healthcare professionals (HCPs) may be unaware that the patient has significant AR and is using one or more OTC AR therapies. To address this gap in communication, HCPs must be proactive in identifying, assessing, and advising patients with AR, including best strategies to assess allergen trigger symptoms, which treatments are appropriate, and when and how to use them. Proper use of delivery devices is especially important. This article reviews the primary care management of AR in the context of the availability of effective OTC medicines.

The association of allergic sensitization with radiographic sinus opacification

BACKGROUND

The relationship between allergic sensitization and radiographic sinus inflammation remains unclear.

OBJECTIVES

To determine whether specific allergen sensitization is correlated with sinonasal radiographic opacification.

METHODS

Patients with chronic sinonasal symptoms were selected and included if they had allergy testing and a computed tomography (CT) of the paranasal sinuses. Data regarding demographic characteristics, in vitro allergy test results, and comorbidities were collected. CTs were reviewed, and an overall Lund-Mackay score (LMS) was calculated for each patient. A two-sample t-test was used to compare mean LMS between patients who were sensitized and patients who were not sensitized. A multiple linear regression model was used to determine whether a relationship existed among LMS and allergy results, asthma, nasal polyps, immunoglobulin E (IgE) level, medication usage, in-season versus out-of-season CTs, age, and sex. Significance was determined at an alpha level of 0.05.

RESULTS

There were 437 patients included, of whom, 251 had positive specific allergen test results and 186 had negative test results. A total of 282 patients had allergic rhinitis symptoms without a documented diagnosis of sinusitis, and 155 carried a diagnosis of chronic rhinosinusitis. The mean LMS did not differ between patients who were sensitized and patients who were not sensitized (5.56 versus 5.28; p = 0.61). Linear regression demonstrated an increase in LMS in patients with asthma (p = 0.02), male sex (p < 0.01), elevated IgE (p < 0.01), a history of anaphylaxis (p = 0.03), and nasal polyps (p < 0.01). There was a statistically significant decrease in LMS in patients with an in-season CT (p = 0.02).

CONCLUSIONS

Patients with a positive specific in vitro allergen test result did not have higher overall rates of radiographic sinus inflammation. Asthma, male sex, polyps, elevated IgE, and a history of anaphylaxis were associated with higher LMS.

[The use of intranasal glucocorticosteroids in the treatment of rhinosinusitis: Focus on mometasone furoate]

The authors discuss the mechanism of action, effectiveness, and safety of intranasal glucocorticosteroids (inGCS) used to treat acute, recurrent and chronic rhinosinusitis (RS). The last version of the European guidelines concerning the application of inGCS assigns the highest level of evidence-Ia and the highest strength of recommendations-A to these medications when applied for the treatment of acute and polypoid rhinosinusitis. Moreover, they acquire the status of the agents of choice for the therapy of chronic RS without polyps. Mometasone furoate is one of the best explored preparations of this group of medicines. It is possessed of favourable pharmacodynamic and pharmacokinetic properties when prescribed for local application. The new mometasone furoate preparation in the form of an intranasal spray Dezrinit produced by "Teva" Ltd. was registered in the Russian Federation. In a comparative randomized clinical trial (RCT), the preparation was shown to be an equivalent to the Nasonex spray.

Problem-based learning discussion: Medical treatment of pediatric chronic rhinosinusitis

This problem-based learning case focused on the approach to evaluation and management of a 5-year old girl who was "always sick" with sinus infections. The discussion unfolds in a "real life" scenario, i.e., based on information available to the clinician initially and after the acquisition of laboratory data, and, ultimately, after sinus surgery. Emphasis is placed on the differential diagnosis of the patient's symptoms, discussion of the initial management strategy for chronic rhinosinusitis (CRS), evolution from acute rhinosinusitis to CRS, the prevalence of and differential diagnosis of nasal polyps in children, treatment considerations specific for CRS with nasal polyps, the significance of Pseudomonas aeruginosa sinus infection, the significance of an abnormal sweat chloride test in a young child with nasal polyposis, special considerations in children with CRS who have cystic fibrosis, treatment considerations after endoscopic sinus surgery, and, finally, prognostic factors that impact the outcomes of endoscopic sinus surgery. This problem-based learning case highlights many facets of managing refractory CRS in children.

Burden of Respiratory Disease in Korea: An Observational Study on Allergic Rhinitis, Asthma, COPD, and Rhinosinusitis

PURPOSE

The Asia-Pacific Burden of Respiratory Diseases (APBORD) study is a cross-sectional, observational one which has used a standard protocol to examine the disease and economic burden of allergic rhinitis (AR), asthma, chronic obstructive pulmonary disorder (COPD), and rhinosinusitis across the Asia-Pacific region. Here, we report on symptoms, healthcare resource use, work impairment, and associated costs in Korea.

METHODS

Consecutive participants aged ≥18 years with a primary diagnosis of asthma, AR, COPD, or rhinosinusitis were enrolled. Participants and their treating physician completed a survey detailing respiratory symptoms, healthcare resource use, and work productivity and activity impairment. Costs included direct medical cost and indirect cost associated with lost work productivity.

RESULTS

The study enrolled 999 patients. Patients were often diagnosed with multiple respiratory disorders (42.8%), with asthma/AR and AR/rhinosinusitis the most frequently diagnosed combinations. Cough or coughing up phlegm was the primary reason for the medical visit in patients with a primary diagnosis of asthma and COPD, whereas nasal symptoms (watery runny nose, blocked nose, and congestion) were the main reasons in those with AR and rhinosinusitis. The mean annual cost for patients with a respiratory disease was US$8,853 (SD 11,245) per patient. Lost productivity due to presenteeism was the biggest contributor to costs.

CONCLUSIONS

Respiratory disease has a significant impact on disease burden in Korea. Treatment strategies for preventing lost work productivity could greatly reduce the economic burden of respiratory disease.

Management of Allergic Rhinitisand Sinusitis

Allergic rhinitis and sinusitis are chronic conditions of the airway and cause significant morbidity. Both can require pharmacotherapy with nonprescription products to relieve symptoms or with prescription products to treat the underlying pathophysiology. Because these diseases are prevalent conditions, the pharmacist is in the unique position of being the first health professional contact for many patients. The pharmacist can assist the patient in selection of nonprescription antihistamines, decongestants, and nasal saline sprays as well as provide instruction on the use of steam therapy, aromatic vapors, and warm compresses for the relief of symptoms. Equally important, the pharmacist can encourage patients to seek care from a physician when treatment with intranasal corticosteroids, antibiotics, and nonsedating antihistamines are needed.

Nasal Colonization with Staphylococcus Aureus is not Associated with the Severity of Symptoms or the Extent of the Disease in Chronic Rhinosinusitis

OBJECTIVES: There is an increasing knowledge that the severity of perennial allergic rhinitis is associated with nasal carriage of Staphylococcus aureus (S. aureus). The aim of this study was to evaluate the rate of bacterial colonization with S. aureus in the nose of subjects with and without chronic rhinosinusitis (CRS) and to correlate these findings with the severity of symptoms and the extent of the disease.

STUDY DESIGN AND SETTING: Open, prospective controlled trial.

METHODS: 190 subjects with CRS and 42 subjects with septal deviation without sinusitis (control subjects) were included in this study. Swabs were taken endoscopically from the middle meatus and bacteria were cultured and identified. Airway symptoms were assessed by subjects in standardized questionnaires and frequencies of respiratory tract infections were noted. The rhinosinusitis extent was graded by CT scan assessment. Analysis of variance, chi-square test, and Pearson's correlation test were applied for statistical analyses.

RESULTS: The S. aureus carriage rate was 25.5% in CRS and 31.4% in control subjects. Further facultative pathogens were cultured in 20.6% of subjects with CRS and in 8.5% of controls. 73.8% of S. aureus were ampicillin-resistant, multiresistant strains were cultured in 5.8%. Most airway symptoms and the frequencies of respiratory tract infections were significantly higher in the CRS group compared with control subjects. In post hoc comparison between the subgroups with and without S. aureus colonization, no significant differences were found between the extent of rhinosinusitis and the severity of airway symptoms.

CONCLUSIONS: Facultative pathogens were detected in more than 40% of CRS patients without acute respiratory tract infections. In contrast to the findings in atopic dermatitis and perennial allergic rhinitis, the colonization rate with S. aureus is not increased and S. aureus carriage is not a risk factor for the severity or the extent of rhinosinusitis.

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.

Obstructive Sleep Apnea and the Subsequent Risk of Chronic Rhinosinusitis: A Population-Based Study

The relationship between obstructive sleep apnea (OSA) and chronic rhinosinusitis (CRS) still remains unclear. This retrospective cohort study aimed to investigate the relationship between OSA and subsequent CRS using a population-based dataset. The study used data from the Taiwan Longitudinal Health Insurance Database 2005. We selected 971 patients with OSA for the study cohort and 4855 patients without OSA for the comparison cohort. Each patient was tracked for 5 years to determine those who were subsequently diagnosed with CRS. Stratified Cox proportional hazard regression analyses were performed to examine the association of OSA with subsequent CRS. The results revealed that 161 (2.76%) of the total sampled patients were subsequently diagnosed with CRS. Subsequent incidences of CRS were found in 64 (6.59%) patients with OSA and 97 (2.00%) patients without OSA. The adjusted hazard ratio (HR) of subsequent CRS for patients with OSA was 3.18 (95% confidence interval: 2.27~4.45) compared to those without OSA. Furthermore, the HR for CRS was similar for subjects with OSA for both genders (with an adjusted HR of 3.44 for males and 2.63 for females). We concluded that patients with OSA had a higher risk of subsequent CRS compared to patients without OSA regardless of sex.

Clinical practice guideline (update): adult sinusitis

OBJECTIVE

This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

Mouse allergen exposure and decreased risk of allergic rhinitis in school-aged children

BACKGROUND

Little is known about exposure to mouse allergen (Mus m 1) and allergic rhinitis (AR).

OBJECTIVE

To evaluate the association between mouse allergen exposure and AR in children.

METHODS

We examined the relation between mouse allergen level in house dust and AR in 511 children aged 6 to 14 years in San Juan, Puerto Rico. Study participants were chosen from randomly selected households using a multistage probability sample design. The study protocol included questionnaires, allergy skin testing, and collection of blood and dust samples. AR was defined as current rhinitis symptoms and skin test reactivity to at least one allergen.

RESULTS

In the multivariate analyses, mouse allergen level was associated with a 25% decreased odds of AR in participating children (95% confidence interval, 0.62-0.92). Although endotoxin and mouse allergen levels were significantly correlated (r = 0.184, P < .001), the observed inverse association between Mus m 1 and AR was not explained by levels of endotoxin or other markers of microbial or fungal exposure (peptidoglycan and glucan).

CONCLUSION

Mouse allergen exposure is associated with decreased odds of AR in Puerto Rican school-aged children.

Development of a questionnaire for the assessment of quality of life in korean children with allergic rhinitis

Purpose

Korean children have their own unique lifestyle based on their living environment and culture. This study aimed to develop a questionnaire to evaluate the quality of life in Korean children with allergic rhinitis.

Methods

After a preliminary survey, an initial questionnaire was developed. Questions were modified to be easily understood by young children aged 6 to 7 years. The modified questionnaire was tested on children aged 6 to 12 years old. Item scores, defined as the proportion of children whose answer score was 1 point or higher was multiplied by the average answer score of each question, were used to identify questions that have practical application to the quality of life in Korean children with allergic rhinitis. Differences in answer scores between children with allergic rhinitis and those who were healthy were assessed by a Wilcoxon rank-sum test. The relationship between nasal index scores and quality of life scores was determined by a Spearman rank order test.

Results

An initial questionnaire was composed of 21 items. We identified 19 questions with item scores above 0.5 in children with allergic rhinitis, many of which were related to nasal symptoms and 10 questions that were different between the allergic rhinitis group and the control group. The final questionnaire included the 10 questions that had both high item scores and a significant difference in the answer scores between the two groups.

Conclusions

The developed questionnaire is essential and practical for assessing discomfort related to the symptoms felt by Korean children with allergic rhinitis.

Macrophage Infiltrate Is Elevated in CRSwNP Sinonasal Tissue Regardless of Atopic Status

Objective

Macrophages are major producers of inflammatory cytokines; however, their role in chronic rhinosinusitis (CRS) has not been clearly defined. The aim of this study was to quantify macrophages in sinus tissue of patients with various subtypes of CRS and determine the impact of atopic status on macrophage infiltrate.

Study Design

Prospective immunohistochemical study of human sinonasal tissue.

Setting

Academic medical center.

Subjects and Methods

Human sinonasal tissue was taken from patients with CRS with nasal polyposis (CRSwNP, n = 8), CRS without nasal polyposis (CRSsNP, n = 8), and controls (n = 8) undergoing surgery for CSF leak repair or endoscopic excision of non-secreting pituitary tumor. Samples were immunohistochemically stained for macrophage/monocyte markers Mac387 and CD68.

Results

CRSwNP patients had significantly increased numbers of Mac387 and CD68 cells compared to control patients ( P < .05) or CRSsNP patients ( P < .01). CRSsNP had significantly increased number of cells staining for CD68 compared to controls ( P < .05). The increased presence of macrophages measured by either marker in CRSwNP was independent of atopic status.

Conclusion

Macrophages are increased in CSRwNP patients regardless of atopic status and may contribute to the immunopathology of CRS.

Histological Characteristics of Chronic Rhinosinusitis with Nasal Polyps: Recent 10-Year Experience of a Single Center in Daegu, Korea

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) has various histological patterns and the immunologic characteristics differ between eastern and western patients. This study assessed the histological pattern of Korean NPs and determined whether Korean NP patterns have become westernized.

Methods

Three hundred forty-nine CRSwNP patients were enrolled in this study in 2001 (n = 107), 2006 (n = 111), and 2011 (n = 131). Histological type was categorized as eosinophilic, neutrophilic, seromucinous gland hyperplasia, and stromal atypia types. Medical records were reviewed for their atopic status, olfactory function, and computed tomography (CT) score.

Results

The eosinophilic type was significantly increased in 2011 (62.6%) when compared with 2001 (52.3%) and 2006 7.7%). The incidence of atopic NPs was significantly higher in 2006 (18.9%) and 2011 (21.5%) than in 2001 (14.0%). Although atopic status and CT score were not significantly different among three NP types, anosmia was more common in eosinophilic NPs.

Conclusion

The prevalence of NPs with atopy and eosinophilic NPs has continuously increased in Korea, indicative that the sinonasal disease pattern is becoming similar with western countries.

Eosinophilic inflammation of chronic rhinosinusitis with nasal polyps is related to OX40 ligand expression

The aims of this study were to investigate OX40 ligand expression in sinus tissue from patients with nasal polyposis compared with patients with chronic rhinosinusitis without nasal polyps (NPs), and to determine if OX40 ligand expression is related to eosinophilic sinus infiltration. Twenty patients with chronic rhinosinusitis (11 with and nine without NPs) and seven controls were enrolled in the study. The mRNA expression of OX40 ligand and thymic stromal lymphopoietin and its receptor were analyzed. The immunoreactivity score for OX40 ligand and the eosinophil count were obtained. The mRNA expression and immunoreactivity score of OX40 ligand were higher in patients with nasal polyposis than in patients without NPs, as well as healthy controls. The mRNA expression of thymic stromal lymphopoietin and its receptor was significantly higher in nasal polyposis than in the control, but not significantly higher than in chronic rhinosinusitis without NPs. A correlation between the number of OX40 ligand-positive cells and the number of eosinophils in sinus biopsies was found only in patients with nasal polyposis. In conclusion, the thymic stromal lymphopoietin/OX40 ligand axis is up-regulated in nasal polyposis and is related to the intensity of eosinophilic inflammation.

Sinusitis, Rhinitis, Asthma, and the Single Airway Hypothesis

The one airway, one disease hypothesis proposes that the upper and lower airways share the same physiology and histomorphology. Epidemiological clinical studies support a link between rhinosinusitis and asthma. The relationship can occur in both directions, with nasal allergen challenge leading to inflammatory changes in the lower airway and bronchoprovocation studies of the lower airway leading to inflammatory changes in the upper airway. In addition, both similarities and differences exist in the pathogenesis of nasal polyps and asthma. The mechanism for the connection between the upper and lower airways is a matter of great debate. It has been proposed that inflammatory changes in the lower airway may lead to systemic inflammatory effects that play a role in increased bronchial hyperresponsiveness. Similarly, lower airway inflammatory changes may affect nasal airway patency via systemic effects. Moreover, nasopharyngeal-bronchial reflexes may play a non-immunologic role in the interaction between the lower and upper airways. An example of the connection between the upper and lower airways is found in aspirin-exacerbated respiratory disease whereby leukotrienes play a role in the pathology of chronic rhinosinusitis with polyps and asthma. It is also been observed that the treatment of asthma is hindered by untreated rhinosinusitis.

Environmental allergies and respiratory morbidities in cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is characterized by recurrent respiratory infections and progressive lung disease. Although environmental factors account for 50% of the variation in CF lung function, few specific exposures have been identified. Studies using small study samples focusing on environmental allergies in CF have had inconsistent results. Our objective was to examine the role of environmental allergies in upper and lower respiratory tract morbidities in CF.

METHODS

A total of 1,321 subjects with CF were recruited through the U.S. CF Twin-Sibling Study. Questionnaires were used to determine the presence/absence of environmental allergies. Questionnaires, chart review, and U.S. CF Foundation Patient Registry data were used to track outcomes.

RESULTS

Within the study sample 14% reported environmental allergies. Environmental allergies were associated with a higher risk of sinus disease (adjusted OR: 2.68; P < 0.001) and nasal polyps (adjusted OR: 1.74; P = 0.003). Environmental allergies were also associated with a more rapid decline in lung function (additional -1.1%/year; P = 0.001). However, allergies were associated with a later median age of acquisition of Pseudomonas aeruginosa (6.6 years vs. 4.4 years; log rank P = 0.027). The reported use of common allergy medications, anti-histamines and leukotriene inhibitors, did not alter the frequency of respiratory morbidities.

CONCLUSIONS

Environmental allergies are associated with an increased risk of sinus disease and nasal polyps and a more rapid decline in CF lung function, but may have a protective effect against the acquisition of P. aeruginosa. Prospective studies are needed to confirm these associations which have implications for more aggressive management of allergies.

Complement defects in patients with chronic rhinosinusitis

The complement system is an important part of our immune system, and complement defects lead generally to increased susceptibility to infections and autoimmune diseases. We have studied the role of complement activity in relation with chronic rhinosinusitis (CRS), and more specifically studied whether complement defects collectively predispose individuals for CRS or affect CRS severity. The participants comprised 87 CRS patients randomly selected from the general population, and a control group of 150 healthy blood donors. The CRS patients were diagnosed according to the European Position Paper on Rhinosinusitis and nasal Polyps criteria, and severity was evaluated by the Sino-nasal Outcome Test-22. Serum samples were analysed by ELISA for activity of the respective pathways of complement, and subsequently for serum levels of relevant components. We found that the frequency of complement defects was significantly higher among CRS patients than among healthy control subjects. A majority of Mannan-binding lectin deficient CRS patients was observed. The presence of complement defects had no influence on the severity of subjective symptoms. Our studies show that defects in the complement system collectively may play an immunological role related to the development of CRS. However, an association between severity of symptoms and presence of complement defects could not be demonstrated.

Clinical severity and epithelial endotypes in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous disease defined by epithelial inflammation. The link between measures of traditional disease severity and markers of epithelial inflammation is poorly understood as prior research has focused on presence of polyps or degree of eosinophilia. The expression of 3 epithelial derived cytokines implicated in initiation of T-helper 2 (Th2) inflammation and an eosinophil chemoattractant were compared with clinical measures used in CRS.

METHODS

Sinus mucosal samples from CRS patients undergoing sinus surgery were analyzed for interleukin-25 (IL-25), IL-33, thymic stromal lymphopoietin (TSLP), and eotaxin-3 messenger RNA (mRNA) expression by quantitative polymerase chain reaction (PCR). Tumor patients undergoing surgery transnasally with normal sinus mucosa were controls. Gene expression was compared with symptom, radiology, and endoscopy scores, serological markers, presence of reactive airways disease (RAD), and atopy.

RESULTS

Thirty-seven patients (38% female, mean age 48 ± 15 years), 12 CRS with nasal polyps (CRSwNP), 18 CRS without nasal polyps (CRSsNP), and 7 controls were recruited. CRSwNP phenotype predicted elevated IL-25, IL-33, and eotaxin-3 levels. Increased eotaxin-3 correlated with poorer computed tomography (CT) (p = 0.004) and endoscopic scores (p = 0.049). Increased IL-25 correlated with poorer CT scores (p = 0.012) and raised serum eosinophils (p = 0.006). No associations with RAD, atopy, and symptom measures were found. No associations for IL-33 and TSLP were found.

CONCLUSION

Inflammatory mediators of the epithelium in CRS has some correlation with traditional measures of disease burden. Certain epithelial profiles may predict highly dysfunctional epithelial barriers and prospective evaluation of the clinical outcomes from interventions is required. Future endotyping of the epithelium in CRS may be able to provide prognostic information.

Pathophysiology, favoring factors, and associated disorders in otorhinosinusology

The pathogenesis of rhinosinusitis (RS) is related to inflammation, caused by infections in the acute form of the disease but also by other agents in the chronic forms. Cytology allows to evaluate the defensive components, such as hair cells and muciparous cells, while the presence in the nasal mucosa of eosinophils, mast cells, bacteria and/or fungal hyphae, or spores indicates the nasal pathology. The anatomic and physiologic characteristics of the otorhinosinusal system account for the frequent concomitant involvement of the different components. The pivotal pathophysiologic sites are the ostiomeatal complex, the spheno-ethmoidal recess, and the Eustachian tube. The latter is the link with acute otitis media (AOM), which is the most common disease in infants and children and has major medical, social, and economic effects. Moreover, because of the strict relationship between upper and lower airways, nasal sinus disease may contribute to asthma and sinusitis may be considered as an independent factor associated with frequent severe asthma exacerbations. Concerning the role of allergy, the available data do not permit to attribute a central role to atopy in sinusitis and thus allergy testing should not be a routine procedure, while an allergologic evaluation may be indicated in children with OM, especially when they have concomitant rhinitis.

Atopic profile of patients failing medical therapy for chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is an inflammatory condition of the nasal airway and paranasal sinuses that can broadly be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). The relationship between CRS and atopy to inhalant allergens remains unclear. We sought to examine the presence of atopy in patients failing medical therapy for both types of CRS. The objective of this research was to analyze the frequency and distribution of allergen sensitivity in patients failing medical therapy for CRSwNP and CRSsNP in comparison to rhinitis patients without CRS and the general population.

METHODS

A prospectively collected database of 334 consecutive CRS patients who had surgery after failing maximal medical therapy was queried to identify those who met inclusion criteria: a sinus computed tomography (CT), an endoscopy consistent with CRS, and skin-prick testing with 24 common inhalant allergens in 8 classes at our institution (n = 125). Additionally, data from these CRS patients were compared to a group of 50 patients diagnosed with rhinitis who had similar symptoms but radiologically normal CT scans, as well as published normative population skin-prick testing data obtained from the National Health and Nutrition Examination Study III (NHANES III). The relationship between atopy, as assessed by the frequency of skin test positivity, and radiological disease severity, was assessed for several allergen classes in CRSwNP, CRSsNP and rhinitis patients.

RESULTS

One or more positive skin results were observed in 103 of 125 (82.4%) CRS patients who underwent surgery--a prevalence significantly higher than that found in the NHANES III study (p < 0.05) but not different from the rhinitis control group (36/50, 72.0%). The most prevalent positive skin test results were to dust mites and ragweed in CRSwNP, CRSsNP, and rhinitis patients. Comparing these 3 patient groups, there were no significant differences in the rates of positive skin-test results to any single allergen. However, the median number of skin test–positive results was higher in CRSwNP patients compared to CRSsNP and rhinitis patients. Consistent with other studies, we found that CRSwNP patients were more likely to be male and have concurrent asthma.

CONCLUSION

In our series of patients failing medical therapy for CRS, we found higher rates of atopy compared with the general population but not compared with rhinitis patients. CRSwNP patients with medically refractory sinusitis were more likely to have multiple positive skin tests and asthma as compared to the general population or patients with either CRSsNP or rhinitis. Host barrier dysfunction may play a role in enabling multisensitization.

The united allergic airway: connections between allergic rhinitis, asthma, and chronic sinusitis

BACKGROUND

The united allergic airway is a theory that connects allergic rhinitis (AR), chronic rhinosinusitis, and asthma, in which seemingly disparate diseases, instead of being thought of separately, are instead viewed as arising from a common atopic entity.

OBJECTIVE

This article describes patients with such diseases; explores ideas suggesting a unified pathogenesis; elucidates the various treatment modalities available, emphasizing nasal corticosteroids and antihistamines; and provides an update of the literature.

METHODS

A literature review was conducted.

CONCLUSION

The aggregation of research suggests that AR, asthma, and chronic rhinosinusitis are linked by the united allergic airway, a notion that encompasses commonalities in pathophysiology, epidemiology, and treatment.

Impact of allergic rhinitis in school going children

Allergic rhinitis (AR) is the most common chronic pediatric disorder. The International Study for Asthma and Allergies in Childhood phase III found that the global average of current rhinoconjunctivitis symptoms in the 13-14 year age-group was 14.6% and the average prevalence of rhinoconjunctivitis symptoms in the 6-7 year age-group was 8.5%. In addition to classical symptoms, AR is associated with a multidimensional impact on the health related quality of life in children. AR affects the quality of sleep in children and frequently leads to day-time fatigue as well as sleepiness. It is also thought to be a risk factor for sleep disordered breathing. AR results in increased school absenteeism and distraction during class hours. These children are often embarrassed in school and have decreased social interaction which significantly hampers the process of learning and school performance. All these aspects upset the family too. Multiple co-morbidities like sinusitis, asthma, conjunctivitis, eczema, eustachian tube dysfunction and otitis media are generally associated with AR. These mostly remain undiagnosed and untreated adding to the morbidity. To compound the problems, medications have bothersome side effects which cause the children to resist therapy. Children customarily do not complain while parents and health care professionals, more often than not, fail to accord the attention that this not so trivial disease deserves. AR, especially in developing countries, continues to remain a neglected disorder.

Predisposing factors associated with chronic and recurrent rhinosinusitis in childhood

Purpose

There is currently no information regarding predisposing factors for chronic and recurrent rhinosinusitis (RS), although these are considered to be multifactorial in origin, and allergic diseases contribute to their pathogenesis. We evaluated the predisposing factors that may be associated with chronic and recurrent RS.

Methods

In this prospective study, we examined patients with RS younger than 13 years of age, diagnosed with RS at six tertiary referral hospitals in Korea between October and December, 2006. Demographic and clinical data related to RS were recorded and analyzed.

Results

In total, 296 patients were recruited. Acute RS was the most frequent type: 56.4% of the patients had acute RS. The prevalences of other types of RS, in descending order, were chronic RS (18.9%), subacute RS (13.2%), and recurrent RS (11.5%). Factors associated with recurrent RS were similar to those of chronic RS. Patients with chronic and recurrent RS were significantly older than those with acute and subacute RS. The prevalences of allergic rhinitis, atopy, and asthma were significantly higher in patients with chronic and recurrent RS than those with acute and subacute RS.

Conclusions

An association between atopy and chronic/recurrent RS, compared to acute and subacute RS, suggests a possible causal link.