Methacholine bronchial hyperresponsiveness in chronic sinusitis

Relationship between Olfactory Acuity and Peak Expiratory Flow during Postoperative Follow-up in Chronic Rhinosinusitis Associated with Asthma

Objectives

The link between nasal and bronchial disease has been studied extensively for chronic rhinosinusitis and asthma. The concept of “united airway allergy” has become widely accepted in the past decade. We evaluated the relationship between the upper and lower airways during follow-up after endoscopic sinus surgery by monitoring sinonasal and pulmonary functions.

Methods

Thirty-nine subjects with chronic rhinosinusitis associated with bronchial asthma were entered in this study. A self smell test using stick-type odorant materials was carried out daily to evaluate postoperative recurrence of sinonasal disease. Each patient was assessed for peak expiratory flow (PEF) 3 times daily.

Results

The average (±SD) scores of initial symptoms were 8.3 ± 2.2, which was significantly decreased to 1.5 ± 1.4 by 3 months after operation. During postoperative follow-up, 25 of 39 patients showed no decrease in PEF, whereas the other 14 patients had at least 1 episode of a significant decline in PEF. In the postoperative course, with respect to the self smell test, 24 patients showed no aggravation of smell, but 15 patients had episode(s) of decreased olfaction. Twelve patients demonstrated worsening on the smell test concomitant with a decreased PEF. A discrepancy between olfactory acuity and pulmonary function was recognized in 5 patients. There were 22 patients with a good prognosis of parameters of both the upper and lower airways.

Conclusions

Daily monitoring of both upper and lower respiratory tract functions clearly revealed dual relationships, indicating that worsening of sinusitis accompanies asthma exacerbation. Appropriate measures of the upper and lower airways following endoscopic sinus surgery can be used to predict patient outcome.

Objective Assessment of Lower Airway Involvement in Chronic Rhinosinusitis

Background

When associated with lower airway involvement, the morbidity and the cost of chronic rhinosinusitis (CRS) can increase. The aim of this prospective study was to assess the clinical and radiological characteristics of the upper airways in CRS patients scheduled for functional endoscopic sinus surgery and to correlate these findings with the functional changes of the lower airways.

Methods

Twenty-five adult patients with CRS were subjected to clinical and endoscopic assessments, computed tomography scan, and allergic assessments using validated scoring systems. Lower airways were assessed by clinical history, pulmonary function test, histamine bronchial provocation test, and chest x rays.

Results

Sixty percent of CRS patients were shown to have associated lower airway involvement, i.e., 24% had asthma and 36% had small airway disease (SAD). Nasal congestion and nasal polyps were the most common clinical findings in both of these subgroups of patients. In addition, there was a negative correlation between computed tomography scan findings of the sinuses and the obstructive parameters on pulmonary function test in SAD but not in the asthma subgroup.

Conclusion

These results showed that different kinds of lower airway involvement frequently could be associated with CRS. Some are manifest such as asthma and some are hidden such as SAD and histamine bronchial hyperresponsiveness.

The Lung Function Impairment in Non-Atopic Patients With Chronic Rhinosinusitis and Its Correlation Analysis

Objectives

Chronic rhinosinusitis (CRS) is common disease in otorhinolaryngology and will lead to lower airway abnormality. However, the only lung function in CRS patients and associated factors have not been much studied.

Methods

One hundred patients with CRS with nasal polyps (CRSwNP group), 40 patients with CRS without nasal polyps (CRSsNP group), and 100 patients without CRS were enrolled. The difference in lung function was compared. Meanwhile, CRSwNP and CRSsNP group were required to undergo a bronchial provocation or dilation test. Additionally, subjective and objective outcomes were measured by the visual analogue scale (VAS), 20-item Sino-Nasal Outcome Test (SNOT-20), Lund-Mackay score, Lund-Kennedy endoscopic score. The correlation and regression methods were used to analyze the relationship between their lung function and the above parameters.

Results

The forced expiratory volume in 1 second (FEV₁) and forced expiratory flow between 25% and 75% of forced vital capacity (FEF_25-75) of CRSwNP group were significantly lower than other groups (P<0.05). On peak expiratory flow, there was no difference between three groups. In CRSwNP group, FEV₁ was negatively correlated with peripheral blood eosinophil count (PBEC) and duration of disease (r=–0.348, P=0.013 and r=–0.344, P=0.014, respectively), FEF_25-75 negatively with VAS, SNOT-20 (r=–0.490, P=0.028 and r=–0.478, P=0.033, respectively) in CRSsNP group. The incidence of positive bronchial provocation and dilation test was lower in CRSwNP group (10% and 0%, respectively), with both 0% in CRSsNP group. The multiple linear regression analysis indicated that change ratio of FEV₁ before and after bronchial provocation or dilation test were correlated with PBEC in CRSwNP group (β=0.403, P=0.006).

Conclusion

CRS leading to impaired maximum ventilation and small airway is associated with the existence of nasal polyp. Lung function impairments can be reflected by PBEC, duration, VAS, and SNOT-20. In CRSwNP patients, PBEC is independent predictor of FEV₁ change ratio.

Bronchial hyperresponsiveness

BACKGROUND

Bronchial hyperresponsiveness (BHR) is often regarded as a 'hallmark' of asthma and bronchoprovocation testing is frequently performed to support a diagnosis of asthma. However, BHR is also found in a spectrum of other lung diseases and can be provoked by a variety of specific stimuli.

AIMS

To review the pathophysiology of BHR, discuss various methods of testing for BHR and describe the epidemiology of BHR in a variety of previously studied populations.

METHODS

We performed a systematic review of references identified using Medline and hand searches of identified articles. Because of space limitations, we have included those reports that seem most representative of the overall BHR literature.

RESULTS

BHR can be induced by a variety of stimuli that trigger a number of different but overlapping physiological mechanisms. Bronchoprovocation testing can be performed using a variety of stimuli, various protocols and differing test criteria, yielding results that may be discordant. Elevated rates of BHR have been reported in studies of smokers, chronic obstructive pulmonary disease patients, atopics, athletes, exposed workers and the general population.

CONCLUSIONS

Due to the prevalence of BHR in a spectrum of clinical patients and working populations, clinicians should be aware that BHR is not specific for asthma. When performed correctly, the greatest clinical value of BHR testing is to rule out suspected asthma in patients in whom testing is negative. Assessment of BHR also provides insights into the pathological mechanisms of airway disease.

Association and management of eosinophilic inflammation in upper and lower airways

This review discussed the contribution of eosinophilic upper airway inflammation includes allergic rhinitis (AR) and chronic rhinosinusitis (CRS) to the pathophysiology and course of asthma, the representative counterpart in the lower airway. The presence of concomitant AR can affect the severity of asthma in patients who have both diseases; however, it is still debatable whether the presence of asthma affects the severity of AR. Hypersensitivity, obstruction and/or inflammation in the lower airway can be detected in patients with AR without awareness or diagnosis of asthma, and AR is known as a risk factor for the new onset of wheeze and asthma both in children and adults. Allergen immunotherapy, pharmacotherapy and surgery for AR can contribute to asthma control; however, a clear preventive effect on the new onset of asthma has been demonstrated only for immunotherapy. Pathological similarities such as epithelial shedding are also seen between asthma and CRS, especially eosinophilic CRS. Abnormal sinus findings on computed tomography are seen in the majority of asthmatic patients, and asthmatic patients with CRS show a significant impairment in Quality of Life (QOL) and pulmonary function as compared to those without CRS. Conversely, lower airway inflammation and dysfunction are seen in non-asthmatic patients with CRS. Treatments for CRS that include pharmacotherapy such as anti-leukotrienes, surgery, and aspirin desensitization show a beneficial effect on concomitant asthma. Acting as a gatekeeper of the united airways, the control of inflammation in the nose is crucial for improvement of the QOL of patients with co-existing AR/CRS and asthma.

Rhinosinusitis and asthma: a very long engagement

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

Analysis of the comorbidity of bronchial asthma and allergic rhinitis by questionnaire in 10,009 patients

BACKGROUND

Bronchial asthma (BA) and allergic rhinitis (AR) are thought to share a common pathogenesis. However, reports concerning the comorbidity of the two diseases in a large-scaled population are rare in Japan. In the present study, we performed an analysis on the two diseases using questionnaires that addressed the diagnosis, symptoms and period of occurrence in more than 10,000 patients with BA or AR.

METHODS

Patients with BA (adult: n = 2,781, childhood: n = 3,283) and AR (n = 3,945) were enrolled in the present study during the 3 months from August 1, 2006 to October 31, 2006.

RESULTS

Sixty one percent of the patients with adult BA showed symptoms of AR. Among them, 68% of the patients were diagnosed with AR. Among the patients with childhood BA, 68% showed AR symptoms and 60% were diagnosed with AR. On the other hand, 49% of AR patients showed BA symptoms and 35% of them were diagnosed with BA. The symptoms of both BA and AR in the BA and AR patients were frequent in two seasons, March and April, and September and October. In addition, BA and AR symptoms often co-occurred in the patients with BA and AR.

CONCLUSIONS

Comorbidity of BA and AR was high in both populations of BA and AR. The symptoms of both BA and AR co-occurred on both a daily and seasonal basis. These results suggested that BA and AR share a common immuno-pathogenesis in the airway and need to be treated as a single airway disease.

Interpretation of the "positive" methacholine challenge

BACKGROUND

A methacholine challenge may be used in confirming the diagnosis of asthma, occupational asthma, or reactive airways dysfunction syndrome (RADS) through identification of bronchial hyperreactivity (BHR). While sensitivity of the test in diagnosing clinically significant asthma is excellent, specificity of the test is poor. Since there are many conditions which have been associated with BHR, a positive test must be interpreted cautiously.

METHODS

This paper reviews potential causes of a positive methacholine challenge other than asthma or RADS which have been reported in the medical literature.

RESULTS

Factors which may be associated with a positive methacholine test include test methodology, normal variation of BHR in the general population, and numerous medical conditions.

CONCLUSIONS

In cases of inhalation exposure evaluations, alternative explanations must be considered when determining whether a causal association exists between the exposure and a positive methacholine test result.

Chronic rhinosinusitis and risk of lung cancer in the Singapore Chinese Health Study

Epidemiologic evidence suggests that chronic inflammatory conditions of the lung may increase lung cancer risk. These chronic conditions, such as chronic obstructive pulmonary disease and asthma, commonly coexist with chronic rhinosinusitis. We prospectively examined if chronic rhinitis or sinusitis was associated with lung cancer risk in the Singapore Chinese Health Study, a population-based cohort of 63,257 Singapore Chinese, who were aged 45-74 years when recruited between 1993 and 1998. Each subject completed a comprehensive interview on medical conditions, dietary and lifestyle factors at recruitment, and cancer occurrence and survival status were determined via linkage to population-based registries. As of 31 December, 2005, 954 cohort participants had developed lung cancer. Compared with subjects without such history, subjects who reported a history of physician-diagnosed rhinitis or sinusitis at baseline, whether allergic or nonallergic, had a statistically significant 59% increase in risk of lung cancer (hazard ratio [HR] = 1.59; confidence interval [CI] = 1.06-2.37). This association was significant and stronger in women (HR = 2.32; 95% CI = 1.23-4.39) compared to men, and for the adenocarcinoma cell type (HR = 1.91; 95% CI = 1.07-3.42) compared to other histologies. Overall, a history of asthma, hay fever, allergic dermatitis, food allergy or any other allergic conditions asked in a single question was not related to lung cancer risk (HR = 1.11; 95% CI = 0.90-1.36). Chronic rhinosinusitis may be a marker of pan-airway inflammation and its association with lung cancer risk provides evidence linking inflammation to lung carcinogenesis, especially among women.

Prevalence of lower airway diseases in patients with chronic rhinosinusitis

CONCLUSION

There is high prevalence of lower airway diseases in patients with chronic rhinosinusitis and frequently co-existing lower airway diseases have not been diagnosed before.

OBJECTIVES

To examine the prevalence of lower airway diseases in patients with chronic rhinosinusitis.

METHODS

Seventy-three consecutive patients with chronic rhinosinusitis were enrolled in this prospective study. With routine physical examination, spirometry and methacholine bronchial provocation test were performed and chest simple radiograph or chest computed tomography was taken.

RESULTS

Thirty patients (41.1%) had lower airway diseases. There were 8 patients with asthma, 5 with asymptomatic bronchial hyperresponsiveness, 11 with small airway disease, 2 with chronic obstructive pulmonary disease and 4 with bronchiectasis. Of these 30 patients, 21 patients (70.0%) were first diagnosed as having lower airway diseases in this study.

Nasal and sinus inflammation in chronic obstructive pulmonary disease

Epidemiologic studies suggest that as many as 75% of patients with COPD have concomitant nasal symptoms and more than 1/3 of patients with sinusitis also have lower airway symptoms of asthma or COPD. Because the inflammatory response of the upper and lower airways are similar, and both sites have a similar exposure to allergens and irritants, it is not surprising that rhinitis or sinusitis would coexist with COPD. Possible mechanisms of combined upper and lower airway dysfunction include the so-called nasal-bronchial reflex, inflammation caused by smoking, mouth breathing caused by nasal obstruction, and pulmonary aspiration of nasal contents. Patients with chronic sinusitis commonly have nonspecific bronchial hyperresponsiveness, suggesting a neural reflex. Postnasal drainage of nasal inflammatory mediators during sleep also may increase lower airway responsiveness. Therapy of nasal and sinus disease is associated with improved pulmonary function in patients with COPD.

Nasal polyps and the severity of asthma

BACKGROUND AND OBJECTIVES

Upper airway pathologies often accompany asthma. Because this represents a single airway, the diagnosis, follow up and treatment of both upper and lower respiratory diseases is essential. Samter Syndrome (SS) is known to be associated with more severe asthma. The presence of nasal polyps (NPs) is also associated with asthma. However, the incidence of NPs in asthma and the effect of NPs on asthma severity are not well documented.

METHODS

Three hundred and forty-two asthma patients were evaluated by endoscopic nasal examination, pulmonary function test, skin prick tests and paranasal sinus tomography.

RESULTS

Three hundred and eleven patients with asthma without NP, 19 asthma patients with NP and 12 patients with SS were included. It was found that 54.3% of patients without NPs, 63.2% with NP and 66.7% with SS were at step 3 on the Global Initiative for Asthma scale of severity, and 1.9%, 15.8% and 33.3% were at step 4, respectively.

CONCLUSIONS

The presence of NPs in asthma patients is associated with an increase in asthma severity. In patients with asthma, the possibility of NPs should be investigated and treatment planned accordingly.

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.

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 possible link between sinusitis and lower airway hypersensitivity: the role of Staphylococcal enterotoxin B

Background and aims

The prevalence of asthma has been keeping arising with unknown etiology. The cumulative evidence indicates that chronic rhinosinusitis (CRS) closely relates to asthma, but the detailed mechanisms remain unclear. The present study aimed to take insight into the role of Staphylococcus enterotoxin B (SEB) in a possible association between CRS and asthma.

Methods

38 patients with both CRS and asthma underwent functional endoscopic sinus surgery. Serum specific IgE and cytokines, clinical symptoms of CRS and asthma were evaluated before and after the surgery. Peripheral blood mononuclear cells (PBMCs) were separated from the patients and cultured. Th2 response of the cultured PBMCs in the presence or absence of specific antigens and SEB was evaluated.

Results

Besides the improvement of CRS symptoms, amelioration of asthma was also observed in the patients with both CRS and asthma after the sinus surgery. The preoperatively elevated Th2 cytokines, IL-4 and IL-5, normalized postoperatively. Th2 response was generated with separated PBMCs in the presence of specific antigens. SEB was required for maintaining Th2 response in these separated PBMCs.

Conclusion

The present results indicate that a possible link exists between CRS and lower airway hypersensitivity. Sinusitis derived SEB may play a role in sustaining Th2 responses in the low airway hypersensitivity related to sinusitis.

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.

Concomitant chronic sinusitis treatment in children with mild asthma: the effect on bronchial hyperresponsiveness

STUDY OBJECTIVE

Previous studies have suggested that aggressive treatment of sinusitis can decrease bronchial hyperresponsiveness (BHR). However, there is still too little evidence to draw this conclusion, and the concept remains controversial.

DESIGN

A prospective, open-label study.

SETTING

University children's hospital allergy and immunology center and radiologic department.

PATIENTS

Sixty-one children with mild asthma and allergic rhinitis participated in the study. Forty-one of these 61 children had sinusitis, and the remainder had no sinusitis. Ten matched, nonatopic, healthy children were used as a control group.

INTERVENTION

Children with chronic sinusitis were placed into two groups. One group was treated with amoxicillin-clavulanate for 6 weeks and then with nasal saline solution irrigation for 6 weeks. For the other group, the treatment order was reversed. Children without chronic sinusitis received nasal saline solution irrigation for 12 weeks.

MEASUREMENTS

Clinical symptoms and signs of sinusitis, FEV(1), and BHR were analyzed in the patients before and after treatment.

RESULTS

The clinical symptoms and signs of sinusitis, but not FEV(1), showed a significant improvement after antibiotic treatment. After aggressive treatment for sinusitis, it was found that the provocative concentration of methacholine causing a 20% fall in FEV(1) of children with mild asthma and sinusitis was significantly higher after treatment.

CONCLUSION

The results suggest that every asthmatic patient needs to carefully evaluate to determine whether the patient has concomitant sinusitis. Respiratory infections that meet criteria for sinusitis, even if they do not exacerbate asthma, should be treated. It is suggested that sinusitis should always be kept in mind as a possible inducible factor for BHR, and that aggressive treatment of chronic sinusitis is indicated when dealing with an asthmatic patient who shows an unpredictable response to appropriate treatment. Moreover, the findings of this study provide more evidence for an association between sinusitis and asthma with respect to BHR.