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

Current Approaches in the Multimodal Management of Asthma in Adolescents-From Pharmacology to Personalized Therapy

Asthma and adolescence are two sensitive points and are difficult to manage when they coexist. The first is a chronic respiratory condition, with frequent onset in early childhood (between 3 and 5 years), which can improve or worsen with age. Adolescence is the period between childhood and adulthood (12-19 years), marked by various internal and external conflicts and a limited capacity to understand and accept any aspect that is delimited by the pattern of the social circle (of the entourage) frequented by the individual. Therefore, the clinician is faced with multiple attempts regarding the management of asthma encountered during the adolescent period, starting from the individualization of the therapy to the control of compliance (which depends equally on the adverse reactions, quality of life offered and support of the close circle) and the social integration of the subject, communication probably having a more important role in the monitoring and evolution of the condition than the preference for a certain therapeutic scheme. Current statistics draw attention to the increase in morbidity and mortality among children with bronchial asthma, an aspect demonstrated by the numerous hospitalizations recorded, due either to an escalation in the severity of this pathology or to faulty management. The purpose of this article is to review the delicate aspects in terms of controlling symptoms and maintaining a high quality of life among teenagers.

STAT6 Blockade Abrogates Aspergillus-Induced Eosinophilic Chronic Rhinosinusitis and Asthma, A Model of Unified Airway Disease

Unified airway disease, including concurrent asthma and chronic rhinosinusitis (CRS), is a common, but poorly understood disorder with no curative treatment options. To establish a murine model of chronic unified eosinophilic airway inflammation, mice were challenged with Aspergillus niger, and sinonasal mucosa and lung tissue were evaluated by immunohistochemistry, flow cytometry, and gene expression. Inhalation of A niger conidia resulted in a Th2-biased lung and sinus inflammation that typifies allergic asthma and CRS. Gene network and pathway analysis correlated with human disease with upregulation of not only the JAK-STAT and helper T-cell pathways, but also less expected pathways governing the spliceosome, osteoclast differentiation, and coagulation pathways. Utilizing a specific inhibitor and gene-deficient mice, we demonstrate that STAT6 is required for mycosis-induced sinus inflammation. These findings confirm the relevance of this new model and portend future studies that further extend our understanding of the immunopathologic basis of airway mycosis and unified airway disease.

Fungi in Mucoobstructive Airway Diseases

Asthma, chronic rhinosinusitis, and related incurable allergic afflictions of the upper and lower airways are medically important because of their association with the disabling symptom of dyspnea and, at least for asthma, the potential to cause fatal asphyxiation. Extensive research over the past two decades has uncovered both the physiological basis of airway obstruction in asthma and key governing molecular pathways. Exaggerated airway constriction in response to diverse provocative stimuli, termed airway hyperresponsiveness, is mediated through the cytokines interleukin 4 (IL-4) and IL-13 and the transcription factor signal transducer and activator of transcription 6 (STAT6). Overproduction of mucus has long been known to be an essential second component of airway obstruction and is also mediated in part through the IL-4/IL-13/STAT6 pathway. In this review, we discuss a second major signaling pathway which underlies mucus production that is mediated through proteinase-cleaved fibrinogen signaling through Toll-like receptor 4. Unexpectedly, our analysis of human sputum and paranasal sinus fluid indicates that in most cases of severe allergic airway disease, a unique type of airway fungal infection, termed airway mycosis, is pathogenically linked to these conditions. We further discuss how fungal and endogenous proteinases mediate the fibrinogenolysis that is essential to both Toll-like receptor 4 signaling and fibrin deposition that, together with mucus, contribute to airway obstruction.

Airway mycosis in allergic airway disease

The allergic airway diseases, including chronic rhinosinusitis (CRS), asthma, allergic bronchopulmonary mycosis (ABPM) and many others, comprise a heterogeneous collection of inflammatory disorders affecting the upper and lower airways and lung parenchyma that represent the most common chronic diseases of humanity. In addition to their shared tissue tropism, the allergic airway diseases are characterized by a distinct pattern of inflammation involving the accumulation of eosinophils, type 2 macrophages, innate lymphoid cells type 2 (ILC2), IgE-secreting B cells, and T helper type 2 (Th2) cells in airway tissues, and the prominent production of type 2 cytokines including interleukin (IL-) 33, IL-4, IL-5, IL-13, and many others. These factors and related inflammatory molecules induce characteristic remodeling and other changes of the airways that include goblet cell metaplasia, enhanced mucus secretion, smooth muscle hypertrophy, tissue swelling and polyp formation that account for the major clinical manifestations of nasal obstruction, headache, hyposmia, cough, shortness of breath, chest pain, wheezing, and, in the most severe cases of lower airway disease, death due to respiratory failure or disseminated, systemic disease. The syndromic nature of the allergic airway diseases that now include many physiological variants or endotypes suggests that distinct endogenous or environmental factors underlie their expression. However, findings from different perspectives now collectively link these disorders to a single infectious source, the fungi, and a molecular pathogenesis that involves the local production of airway proteinases by these organisms. In this review, we discuss the evidence linking fungi and their proteinases to the surprisingly wide variety of chronic airway and systemic disorders and the immune pathogenesis of these conditions as they relate to environmental fungi. We further discuss the important implications these new findings have for the diagnosis and future therapy of these common conditions.

Pediatric rhinosinusitis and asthma

Both asthma and rhinosinusitis are complex and heterogeneous diseases and, importantly, they often coexist: these diseases can be concomitant in 35-65% of affected children, according to different studies. Thus, evaluating this comorbidity in the clinical practice should be paramount. In this review, we focused our discussion on the multiple pathophysiological aspects that may link rhinosinusitis and asthma in the pediatric population. Although rhinosinusitis may exacerbate asthma through several mechanisms occurring by contiguity, actually this aspect seems to be only one component of the complex interplay between upper and lower airways. In particular, the onset of an important and persistent Th2-driven inflammatory process dominated by eosinophils presence at one site of the airways, may release into the bloodstream several cytokines; in their turn, those can lead to the stimulation of the bone marrow, which may function as a systemic amplifier of such an eosinophilic inflammation.

Association between Asthma and Chronic Rhinosinusitis Severity in the Context of Asthma Control

Objective Comorbid asthma is associated with decreased quality of life (QOL) in chronic rhinosinusitis (CRS). It is unclear whether this association is independent of the patients' clinical asthma status. We therefore sought to determine if asthma is associated with lower QOL in CRS, independent of asthma control. Study Design Cross-sectional cohort study of 350 patients with CRS. Setting Tertiary academic rhinology clinic. Subjects and Methods In total, 350 participants with CRS were recruited and 28.3% were asthmatic. CRS-specific QOL was measured using the 22-item Sinonasal Outcome Test (SNOT-22). Asthma control was assessed with the Asthma Control Test (ACT). General health-related QOL was assessed with the EuroQoL 5-dimensional general health-related quality of life survey visual analog scale (EQ-5D VAS). Associations were sought between SNOT-22 and EQ-5D VAS (dependent variables) and asthma (independent variable), while controlling for ACT. ACT score for patients with CRS without asthma was set at 25 (indicating completely controlled, asymptomatic asthma). Results Comorbid asthma was associated with SNOT-22 (β = 11.8; 95% confidence interval [CI], 6.2-17.3; P < .001) and EQ-5D VAS (β = -6.2; 95% CI, -11.2 to -1.3; P = .014). After controlling for ACT, asthma was no longer associated with SNOT-22 ( P = .147) or EQ-5D VAS ( P = .994). Instead, ACT score was associated with SNOT-22 (β = -2.1; 95% CI, -3.2 to -1.1; P < .001) and EQ-5D VAS (β = 2.1; 95% CI, 1.1 to 3.0; P < .001). ACT score completely drove the association between asthma and worse QOL. Conclusion Comorbid asthma is not necessarily reflective of decreased QOL in CRS. The association of comorbid asthma with lower QOL in CRS is related to the clinical status (eg, control) of asthma.

Association of Allergic Rhinitis and Sinusitis with Childhood Asthma

OBJECTIVE

To study the point prevalence of allergic rhinitis and sinusitis in childhood asthma and to examine the relationship among them.

METHODS

In 250 children (age <13 y) with mild-to-moderte asthma, allergic rhinitis was diagnosed by clinical plus nasal eosinophilia criteria, and sinusitis was diagnosed clinically plus confirmation by computerized tomography scan.

RESULTS

The point prevalence of allergic rhinitis was 13.6%, and of sinusitis was 2%. On multivariate analysis, allergic rhinitis, sinusitis, and family history were significantly associated with asthma severity.

CONCLUSION

Allergic rhinitis is common in childhood asthama, but sinusitis is rare.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Chronic rhinosinusitis and age: is the pathogenesis different?

Chronic rhinosinusitis (CRS) is a common disease with a significant impact on quality of life, which is seen across all age groups. There are differences in symptomatology, histopathology and associated diseases when comparing pediatric versus adult patients with CRS. Nasal polyposis tends to be less commonly seen in pediatric CRS compared with adults except in children with cystic fibrosis or allergic fungal rhinosinusitis. The differences in histopathology of CRS in different age groups include higher cellularity and more prominent lymphocytic infiltration in children compared with adults who tend to have a stronger eosinophilic infiltration and more prominent glandular hyperplasia. There are data supporting a stronger association of gastroesophageal reflux disease and otitis media with CRS in children compared with adults. Adenoids may play a role in pediatric, but not adult CRS. Immunodeficiencies and asthma are strongly associated with CRS in all age groups. There is a paucity of data on pathophysiology of disease on elderly CRS.

A systematic review and meta-analysis of asthma outcomes following endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Patients suffering from both chronic rhinosinusitis (CRS) and asthma demonstrate improved asthma outcomes when upper airway inflammation is controlled with medications. It is unclear if similar benefits exist when the upper airway is treated surgically. This study presents a systematic review and meta-analysis to assess the effects of endoscopic sinus surgery (ESS) on asthma outcomes.

METHODS

Ovid MEDLINE and the Cochrane databases were searched to identify studies examining asthma outcomes in patients with CRS following ESS. Included studies involved a cohort of at least 5 patients and reported at least 1 postoperative asthma outcome.

RESULTS

Twenty-two studies involving a total of 891 patients were identified. Mean follow-up across all studies was 26.4 months. Patients reported improved overall asthma control in 76.1% (95% confidence interval [CI], 71.9% to 80.3%) of cases. The frequency of asthma attacks decreased in 84.8% (95% CI, 76.6% to 93.0%) of patients and the number of hospitalizations decreased in 64.4% (95% CI, 53.3% to 75.6%). Decreased use of oral corticosteroids was seen in 72.8% (95% CI, 67.5% to 78.1%) of patients; inhaled corticosteroid use decreased in 28.5% (95% CI, 22.6% to 34.5%) and bronchodilator use decreased in 36.3% (95% CI, 28.9% to 43.7%) of patients. Mean improvement in predicted forced expiratory volume at 1 second (FEV1 ) was 1.62%, but was not statistically significant (p = 0.877).

CONCLUSION

ESS in patients with concomitant bronchial asthma improves clinical asthma outcome measures, but not lung function testing. Difficulty conducting controlled clinical trials of ESS limits the strength of conclusions which can be reached.

Diagnosis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a rather common disease in children, but its symptoms are often subtle and non-specific and this may result in overlooking a correct diagnosis. In turn, a missed diagnosis of CRS prevents a correct management to be performed and is associated with uneffective investigations and improper treatments. Actually, when CRS symptoms, which are mainly nasal congestion and obstruction, nasal discharge, facial pain, cough, and halitosis, are correctly assessed, the clinical diagnosis of CRS may be achieved, and confirmation may be obtained by imaging criteria or nasal fibroendoscopy. In imaging, computed tomography (CT) is the first choice technique for the evaluation of CRS and is able to provide an anatomic road map when surgery is required. Magnetic resonance imaging (MRI) of the sinuses, orbits, and brain should be performed whenever extensive or multiple complications of sinusitis are suspected. Also for middle ear disorders, CT is the first choice because it detects opacification of the middle ear cavity and mastoid cells, presence of fluids or debris, and allows the ossicular chain and the cortical bone of the mastoid to be evaluated. Another important diagnostic issue is the need to look for disorders that are frequently associated with CRS, such as obstructive sleep apnea syndrome (OSAS), that has some recognized risk factors in adenotonsillar hypertrophy, craniofacial anomalies, obesity, and neuromuscular disorders. Other associated disorders requiring investigation are recurrent or persistent otitis media and difficult asthma.

Seeking common pathophysiology in asthma, atopy and sinusitis

Asthma and chronic sinusitis are inexplicably common airway diseases that are linked to atopy and allergic inflammation. T helper type 2 (Th2) cells and the associated cytokines are believed to play crucial pathogenic roles in asthma, but the environmental factors that instigate allergic airway disease remain poorly understood. Environmental proteinases are highly allergenic and are candidate inducers of airway Th2 responses. Determining the proteinases and their sources that are relevant to airway disease, however, remains challenging. In this Opinion, we summarize the evidence that implicates fungi as both a relevant source of allergenic proteinases and a potential cause of asthma, atopy and chronic sinusitis through airway infection. Clarification of the extrinsic causes of these processes will markedly improve diagnosis, prognosis and therapy.

[Diagnosis and treatment guidelines for difficult-to-control asthma in children]

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.

Current Thinking on the Relationship Between Rhinosinusitis and Asthma

An observation made initially on clinical grounds and epidemiologic evidence, i.e., that rhinosinusitis and asthma are closely linked diseases is now supported by a growing body of scientific evidence. Most recent evidence supports the characterization of rhinosinusitis and asthma as two compartmental expressions of a common mucosal susceptibility to exogenous stimuli. In addition, there is evidence that the compartmental processes can affect and amplify each other via a systemic intermediary. The bone marrow is involved in this process, and IL-5 may be a key cytokine for orchestrating the systemic interaction. These facts argue that rhinosinusitis and asthma are not simply localized disease processes but part of a systemic inflammatory disease affecting the respiratory tract. They also provide a compelling rationale for combined treatment strategies with consideration of the treatment of rhinosinusitis as a means of improving asthma control and monitoring for signs of bronchial involvement in those with rhinosinusitis.

Rhinosinusitis in children and asthma severity

PURPOSE OF REVIEW

Rhinosinusitis is a common condition in children. The association between rhinosinusitis and asthma is supported by strong epidemiological and pathogenic evidence. Moreover, a close relationship between sinusitis and asthma severity has also been reported. This study shows the new findings in this strong relationship.

RECENT FINDINGS

The profile of inflammatory cells and inflammatory mediators seen in both conditions bears considerable similarity, especially in both diseases with a relevant role played by eosinophils.

SUMMARY

Severe asthma is uncommon in childhood, but there is compelling evidence showing that the most severe asthma is closely associated to upper respiratory illness, especially rhinosinusitis. Treatment of chronic rhinosinusitis, medical or surgical or both, benefits concomitant asthma and has been shown to reduce the severity of asthma.

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.

Survey of outcome of asthmatic children referred to outpatient clinic of Tabriz University of Medical Sciences

This study was designed to follow patients regarding to achieving control, identify disease exacerbations and discover relation between exacerbation and risk factors. In a cross sectional-analytic study, 400 asthmatic patients in the range of 2-14 years old who were visited at the specialized outpatient clinic of Tabriz University of Medical Sciences were divided and studied on the base of disease severity. At the end (at least one year treatment), patients were categorized based on level of disease control and one year after this stage, cases of exacerbation were identified and studied. By excluding patients with poor adherence, 342 patients continued treatment as intermittent, mild persistent, moderate persistent and severe persistent asthma (38, 235, 61 and 8 patients, respectively). After a period of one year treatment, the patients were divided as well controlled, partly controlled and uncontrolled (68, 30 and 2%, respectively). Cases of disease exacerbations were more if sinusitis, familial asthma history and poor adherence were present (p < 0.01, p < 0.001 and p < 0.05, respectively). There is meaningful association between poor adherence, sinusitis and positive family history of asthma with disease exacerbation.

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.

The future of asthma therapy: integrating clinical and experimental studies

Asthma is one of the most common, and now most heavily investigated, of modern diseases. Research along two fronts, involving experimental models of asthma and human clinical trials, proceeds in parallel, often with investigators unaware of their counterpart's findings. Here, we review the unique immunological insights into asthma pathogenesis and therapy that may be gained from comparison of human clinical trial results and analogous experimental studies. The pitfalls and benefits of animal models of asthma are discussed, and we briefly review ongoing asthma clinical studies that are based on immunological principals. Finally, we use new insights from human and animal studies to construct a refined immunopathologic disease model that may be of use in designing future experimental and therapeutic studies.

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.

The relationship between psychogenic cough and the diagnosis and misdiagnosis of asthma: a review

The differential diagnoses of persistent nonproductive cough include numerous pulmonary and nonpulmonary organic disorders as well as functional illnesses. Many diseases can cause cough, and several studies have shown asthma among the most common etiologies associated with chronic cough in adult nonsmokers, as well as children. Psychogenic cough and its relationship to asthma and other asthma-like illnesses is complex since distinct maladies with similar features may coexist individually or in combination in any given patient. While chronic cough may occur as a sole presenting manifestation of bronchial asthma in all age groups, recent findings suggest that most children with persistent cough without other respiratory symptoms do not have asthma. Since several organic, as well as functional diseases, may present with persistent cough as their sole manifestation in either adults or children, cough should not be used as a single or major determinant to diagnose and treat asthma, especially when empirically focused therapy trials fail. Given the range of illnesses causing cough, no single management guideline can be expected to be universally effective.

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.

Pediatric chronic sinusitis and asthma: a review

Rhinosinusitis and asthma are common conditions associated with significant morbidity and health care costs. Recent studies in adults have suggested that rhinosinusitis and asthma may be manifestations of an inflammatory process within a continuous airway rather than fully separate diseases that only act locally; and, in fact, the presence of upper airway disease may influence lower airway disease. Controlling upper airway infection, inflammation, and symptoms may improve signs and symptoms of asthma. Pediatric studies regarding this matter are few, but the impact of rhinosinusitis and asthma is still immense and significant in children. This article discusses several pediatric studies regarding medical or surgical management of sinusitis and asthma outcome. These studies show that aggressive treatment of sinusitis when present can significantly improve asthma symptoms and quality of life in children, indicating that sinusitis may play an important role in initiating or exacerbating asthma. These findings have important implications for the physician treating a child with chronic asthma.

An assessment of sinus quality of life and pulmonary function in children with cystic fibrosis

BACKGROUND

Treatment of patents with cystic fibrosis (CF) is primarily directed at the lungs. However, there is a growing feeling that the status of the sinuses may have a profound influence on the status of the lungs in these patients. A number of investigators have demonstrated a relationship among coexisting rhinitis, sinusitis, other upper airway conditions, and lung disease. Several studies have shown that treatment and resolution of sinusitis results in an improvement in a number of pulmonary conditions. We hypothesize that pulmonary function test scores will be lower in patients with CF with more severe sinusitis.

METHODS

Consecutive CF patients were asked to complete a sinus-specific quality-of-life instrument, the 16-item Sino-Nasal Outcome Test (SNOT-16), and these scores, were compared to FEV, scores.

RESULTS

Univariate analysis revealed a significant correlation between SNOT-16 and FEV1 in patients under the age of 12. There was a trend toward significance in the older children and evaluation of the raw data shows that children with the highest FEV, had the lowest SNOT-16.

CONCLUSION

This study indicates that the severity of sinus disease correlates with the severity of pulmonary disease in CF patients under the age of 12. We plan to use the SNOT-16 to assess sinus interventions on pulmonary status.

Long-Term Follow-Up for Children Treated With Surgical Intervention for Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

The goal of this study is to retrospectively compare the long-term, 10 year, outcomes of surgical versus medical management of young children with chronic rhinosinusitis.

STUDY DESIGN

This is a retrospective, age-matched, cohort outcome study performed at a tertiary-care hospital.

METHODS

Two groups of young children (2-5 yr old) with chronic rhinosinusitis were treated with endoscopic sinus surgery or medically managed and evaluated 10 years after their initial therapy. Of the 131 eligible patients, 67 could be located and consented to participate in the study. Six symptoms (day cough, night cough, irritability or crankiness, headaches, nasal airway obstruction, and purulent rhinorrhea) were used to assess the outcome of their treatment.

RESULTS

Children undergoing endoscopic sinus surgery had more significant disease as noted on the computed tomography (CT) scans. Their symptom severity, however, was similar. When individual symptoms were compared, there were no statistically significant differences between the surgically and medically managed groups. When the mean was controlled for baseline symptom severity and CT severity, there was statistical improvement in nasal airway obstruction and decreased rhinorrhea. There was a trend toward improvement in cough, but this was not statistically significant. Parenteral assessment of improvement (change) in symptoms (P = .001) and their degree of satisfaction with treatment (P = .005) was significantly higher in the surgically managed group.

CONCLUSIONS

Children who have chronic rhinosinusitis improve in their symptoms of nasal airway obstruction and purulent discharge if they undergo surgery. Parents of young children with chronic rhinosinusitis appear to be more satisfied with the outcome of surgical management than medical management when assessed 10 years later.

Management of recurrent sinus disease in children with cystic fibrosis: a combined approach

OBJECTIVE

To determine whether a combined approach (CA) consisting of functional endoscopic sinus surgery (FESS), Caldwell-Luc operation, and medial maxillectomy is beneficial for children with cystic fibrosis (CF) with refractory sinonasal disease previously treated with endoscopic procedures alone.

STUDY DESIGN

Retrospective review and comparison of outcomes of CA and FESS alone for each CF patient.

OUTCOMES MEASURED

sinonasal symptoms, endoscopic findings, number of hospitalizations, antibiotic courses, and forced expiratory volume in 1 second (FEV1).

SETTING

Referral hospital.

RESULTS

Fifteen children underwent CA between 1996 and 2000 (7 males, 8 females; 13.8 years mean age; 42 months average follow-up period). Significant decrease in number of hospitalizations and intravenous antibiotic courses, with increased mean FEV1 (from 70.2% preoperation to 89.3% postoperation, P < 0.0001) were found. Marked clinical improvement persisted for several years.

CONCLUSION

Applying the CA after multiple failed endoscopic procedures in CF patients reduced morbidity and resulted in successful management of sinonasal disease. CA is suggested after multiple failed endoscopic procedures. Further studies of CA as a first-line procedure for difficult sinus cases in children with CF is recommended.

EBM RATING

C-4.

Clinical characteristics of chronic rhinosinusitis with asthma

OBJECTIVE

This study was directed at identifying clinical features of chronic rhinosinusitis with asthma, and examining the differences of the postoperative outcomes in asthmatics and nonasthmatics.

STUDY DESIGN AND SETTING

Twenty-one asthmatic and 77 nonasthmatic patients who underwent functional endoscopic sinus surgery (FESS) were entered into the study. The following six parameters were determined in asthmatic and nonasthmatic groups; the presence of allergy, previous sinus surgery, severity of preoperative rhinosinusitis symptoms, improvements in postoperative rhinosinusitis symptoms, preoperative disease extent, and postoperative endoscopic outcomes.

RESULTS

Symptom scores improved significantly in both asthmatics and nonasthmatics postoperatively, and asthmatics exhibited significantly worse postoperative endoscopic outcomes compared with nonasthmatics. No difference was found in other parameters between two groups. Multivariate analysis revealed asthma continues to be an independent predictor of success.

CONCLUSIONS

The present study found that chronic rhinosinusitis in asthmatics showed worse postoperative outcomes than in nonasthmatics, and every attempt should be made for the improvement of surgical results in these patients.

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.

Antimicrobial therapy in childhood asthma and wheezing

There is an increasing number of viral and bacterial pathogens suspected of contributing to asthma pathogenesis in childhood, making it more difficult for the practitioner to make specific therapy decisions. This review discusses the role of viruses, e.g. respiratory syncytial virus, human metapneumovirus, influenza viruses and rhinoviruses, as well as the role of the atypical bacteria Chlamydophila pneumoniae and Mycoplasma pneumoniae, as contributors to childhood asthma. Diagnosis, prevention, and therapy are discussed, including a summary of drugs, i.e. macrolide antibacterials, antivirals, and vaccine regimens already available, or at least in clinical trials. For the practitioner dealing with patients every day, drug regimens are assigned to the individual pathogens and an algorithm for the management of atypical infections in patients with asthma or recurrent wheezing is presented.

The variability of asthma

Asthma is a chronic disease of airway inflammation that affects all age groups. Despite national treatment recommendations and the availability of effective controller medications, asthma morbidity remains pervasive and currently represents a considerable socioeconomic burden. Asthma may be intermittent or persistent; persistent asthma may be mild, moderate, or severe. Many factors influence asthma severity, both on a short-term basis and over time. In individual patients, asthma severity may fluctuate because of physiologic, environmental, socioeconomic, or behavioral factors. Inhaled corticosteroids (ICSs) are safe and well tolerated, and are the preferred long-term treatment for controlling persistent asthma of all severities in adults and children. Awareness of episodic changes in asthma severity, with subsequent tailored adjustment in guideline-based ICS therapy, should enable optimal control of asthma with minimal medication requirements.

Pediatric sinusitis

Sinusitis remains one of the most prevalent but clinically challenging disease processes in pediatrics. Lack of appropriate culture evidence makes the diagnosis difficult, and increasing microbial resistance presents a therapeutic dilemma. This article examines causative factors, appropriate diagnostic measures, and effective medical and surgical treatment options for sinusitis in the pediatric population.

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.

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.

Management of unresponsive asthma

Difficult asthma is defined as asthma that is not controlled despite treatment with> 800 micro g budesonide or equivalent per day. Poor control is defined as the need for bronchodilators more than three times a week, school absence of more than five days a term, or one episode or more of wheezing each month. Common causes of poor response to treatment include; wrong diagnosis, inappropriate medications or improper inhalation technique, poor adherence to medications and co-morbidity. Steroid resistant asthma is uncommon and estimated to be 1 in 1000-10000 asthmatic patients. If there is no functional improvement to prednisolone 2 mg/kg/day for 2 weeks with adherence checked by measuring serum prednisolone and cortisol levels, a fibreoptic bronchoscopic examination with bronchoalveolar lavage and large airway biopsy should be considered. Eosinophilic inflammation identified on the biopsy in a child who is unresponsive to prednisolone may benefit from alternative anti-inflammatory treatments such as cyclosporin. Neutrophilic infiltration in biopsy may benefit with macrolide antibiotics, 5-lipogenase inhibitors or theophyllines.

MCP-1 gene regulatory region polymorphism in Chinese children with mild, moderate and near-fatal asthma

BACKGROUND

A polymorphism in the monocyte chemoattractant protein 1 (MCP-1) gene regulatory region has been associated with asthma in Caucasians. This polymorphism is possibly endemic to the Asian region, but its impact on Asian populations is unclear. In addition, the relationship of this marker with life-threatening asthma has not been clarified. The aim of this study was to test the genetic association between the MCP-1 -2518A/G polymorphism and asthma/atopy in a cohort of Chinese children, with particular emphasis on those patients who had experienced life-threatening asthma attacks.

METHODS

Forty-eight children with near-fatal asthma, 134 mild-to-moderate asthmatics, 69 allergic-disorder cases without asthma, and 107 nonasthmatic, nonatopic control children were genotyped by a polymerase chain reaction-based assay.

RESULTS

Comparison of the four groups of children (n = 358) revealed no detectable differences in genotype or allele frequencies of the MCP-1 -2518A/G polymorphism. There was no evidence of association between the polymorphism and any of the outcomes of interest including clinical severity, blood eosinophil count, atopy, total serum IgE levels, and degree of bronchial hyper-responsiveness.

CONCLUSION

These results suggest that the MCP-1 -2518A/G polymorphism is not a risk factor for near-fatal asthma. Furthermore, this polymorphism seems to play no role in the development of asthma or atopy in Chinese subjects, possibly as a result of the genetic heterogeneity between Asian and Caucasian populations with respect to regulation of MCP-1 expression. Our results underscore the necessity of accounting for ethnic background in the investigation of asthma-predisposition genes.

Nasal involvement in allergic asthma

Even since the late 19th century, a relationship has been suspected between upper airway disease and the subsequent development or aggravation of asthma symptoms. To date, it has been generally accepted that pathologic conditions of the upper airways, e.g. allergic rhinitis, chronic sinusitis and nasal polyposis, may influence the lower airways. However, the mechanisms underlying this relationship were, for a long time, poorly understood. Recently, evidence has been accumulating which indicates a systemic connection as one of the responsible mechanisms in nasobronchial crosstalk. In this review, the pathophysiologic and immunologic aspects of the interaction between upper and lower airways will be discussed.