Asthma linked with rhinosinusitis: An extensive review

Sinus inflammation and chronic rhinosinusitis are associated with a diagnosis of new onset asthma in the following year

BACKGROUND

Chronic rhinosinusitis (CRS) and asthma commonly co-occur. No studies have leveraged large samples needed to formally address whether preexisting CRS is associated with new onset asthma over time.

METHODS

We evaluated whether prevalent CRS [identified in two ways: validated text algorithm applied to sinus computerized tomography (CT) scan or two diagnoses] was associated with new onset adult asthma in the following year. We used electronic health record data from Geisinger from 2008 to 2019. For each year we removed persons with any evidence of asthma through the end of the year, then identified those with new diagnosis of asthma in the following year. Complementary log-log regression was used to adjust for confounding variables (e.g., sociodemographic, contact with the health system, comorbidities), and hazard ratios (HRs) and 95% confidence intervals (CI) were calculated.

RESULTS

A total of 35,441 persons were diagnosed with new onset asthma and were compared to 890,956 persons who did not develop asthma. Persons with new onset asthma tended to be female (69.6%) and younger (mean [SD] age 45.9 [17.0] years). Both CRS definitions were associated (HR, 95% CI) with new onset asthma, with 2.21 (1.93, 2.54) and 1.48 (1.38, 1.59) for CRS based on sinus CT scan and two diagnoses, respectively. New onset asthma was uncommonly observed in persons with a history of sinus surgery.

CONCLUSION

Prevalent CRS identified with two complementary approaches was associated with a diagnosis of new onset asthma in the following year. The findings may have clinical implications for the prevention of asthma.

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.

Autonomic nervous system dysfunction and sinonasal symptoms

Background

The autonomic nervous system (ANS) richly innervates the nose and paranasal sinuses, and has a significant role in lower airway diseases, e.g., asthma. Nonetheless, its contribution to sinonasal symptoms is poorly understood. This review aimed to explore the complex relationship between the ANS and sinonasal symptoms, with reference to systemic diseases and triggers of ANS dysfunction.

Methods

A review of articles published in English was conducted by searching medical literature databases with the key words “autonomic nervous system” and (“sinusitis” or “nose” or “otolaryngology”). All identified abstracts were reviewed, and, from these, relevant published whole articles were selected.

Results

The ANS has a significant role in the pathophysiologic mechanisms that produce sinonasal symptoms. There was limited evidence that describes the relationship of the ANS in sinonasal disease with systemic conditions, e.g. hypertension. There was some evidence to support mechanisms related to physical and psychological stressors in this relationship.

Conclusion

The role of ANS dysfunction in sinonasal disease is highly complex. The ANS sits within a web of multiple factors, including personality and psychological distress, that contribute to sinonasal symptoms. Further research will help to clarify the etiology of ANS dysfunction and its contribution to common systemic conditions.

Sino-Nasal 5 Questionnaire is Associated with Poor Asthma Control in Children with Asthma

Up to 80% of asthmatic children may experience upper airway symptoms which are often perceived as coming from the lower airways. Currently, there are no validated questionnaires to assess upper airway contribution to pediatric asthma symptoms. The Sino-Nasal 5 (SN-5) questionnaire was previously validated for identifying radiographic confirmed sinus disease in children. In this study, we hypothesize that significant SN-5 scores (≥3.5) are associated with abnormal National Asthma Education and Prevention Program (NAEPP) based asthma impairment and control in asthmatic children. Retrospective data collected on children with asthma referred for pulmonary evaluation included age, gender, ethnicity, NAEPP asthma severity, asthma control (Test for Respiratory and Asthma Control in Kids (TRACK) < 5 years, Asthma Control Test (ACT) 5 years) and pulmonary function testing. Associations between SN-5 scores and asthma impairment and control were identified. Seventy-six children were evaluated; 38% were female with a mean age of 6.9 years. Significant SN-5 scores were associated with decreased control of daytime symptoms (odds ratio (OR): 0.16 (95% confidence interval (CI): 0.06–0.44)), night time awakenings (0.09 (0.03–0.29)), activity interference (0.2 (0.06–0.68)), NAEPP defined asthma control (0.32 (0.12–0.85)) and poor asthma control based on TRACK (p < 0.001) and ACT (p < 0.001). This suggests upper airways may play a larger role in perceived lower airway symptoms, and SN-5 may be beneficial in assessing the contribution of upper airway conditions on asthma control.

Asthma in ear, nose, and throat primary care patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory disorder associated with asthma. This association is well described in patients with CRSwNP undergoing endoscopic sinus surgery (ESS); however, some patients are never referred for surgery, and the frequency of asthma in this group is largely unknown.

OBJECTIVE

To determine the frequency of asthma in patients with CRSwNP treated in a primary care (PC) setting who have never been referred for surgery and to compare this with ESS patients.

METHODS

Fifty-seven patients with CRSwNP who had never undergone ESS were prospectively recruited from nine PC ear, nose, and throat clinics in the Copenhagen area. CRSwNP was diagnosed according to the European Position Paper on Chronic Rhinosinusitis and Nasal Polyps; severity was assessed by using a visual analog scale. Allergy, lung function, and asthma tests (reversibility to β2-agonist, peak expiratory flow variability, and mannitol challenge) were performed. Findings were compared with our previously published data from patients with CRSwNP referred for surgery.

RESULTS

Asthma was diagnosed in 25 patients (44%) based on respiratory symptoms and a positive asthma test; of these, 12 (48%) had undiagnosed asthma prior to study onset. Furthermore, when using the same methods, we found a lower frequency of asthma in PC patients compared with ESS patients (44% versus 65%, p = 0.04).

CONCLUSION

A high prevalence of asthma in PC patients with CRSwNP was found. Frequently, asthma was undiagnosed. However, asthma was significantly less prevalent in PC patients compared with patients referred for ESS. The frequent concomitance of asthma, i.e., united airways disease, in PC patients calls for closer collaboration between ear, nose, and throat specialists, and asthma specialists.

Risk Factors and Comorbidities in Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a heterogeneous disorder that creates a significant burden on the healthcare system. It is caused by a combination of inflammatory, environmental, and host factors; however, the precise mechanism of how each factor leads to CRS continues to be a source of debate. Previous data regarding this topic is often inconsistent or of lower quality. In this article, we review the recent literature on the risk factors and comorbidities in CRS. Large population-based studies have helped establish smoking as a significant risk factor for CRS. The focus has now shifted towards smoking and its effect on long-term outcomes after endoscopic sinus surgery (ESS). Ciliary dyskinesia, both primary and secondary, can affect both the sinonasal cavity and lower airways simultaneously by decreasing the beat frequency of cilia and inducing mucostasis. The effects of secondary dyskinesia may be reversible and there is some evidence to suggest the use of topical mucolytics in patients with CRS. Allergy and variants of sinonasal anatomy have been hypothesized to increase the risk of developing CRS by inducing chronic inflammation and obstructing the sinus ostia. Nevertheless, emerging data regarding these topics continue to produce inconclusive results. Inflammation of the upper and lower airways can occur simultaneously as seen in patients with asthma and aspirin sensitivity. The connection between these pro-inflammatory disease states has been known for many years. Newer evidence include large population-based studies and studies that correlate objective tests, such as computer tomography scans to pulmonary function tests. However, the treatment of CRS and its effects on obstructive airway disease continues to be a topic of debate. More large prospective studies are needed in order to continue refining our knowledge of the disease processes in CRS.

Heat shock protein 70 and anti-heat shock protein 70 antibodies in nasal secretions of patients with chronic rhinosinusitis

BACKGROUND

The issue of heat shock protein (HSP) 70 and anti-HSP70 antibodies in chronic rhinosinusitis (CRS) has never been explored.

OBJECTIVE

To determine the nasal secretion (NS) levels of HSP70 and anti-HSP70 antibodies in patients with CRS with nasal polyps (CRSwNP) and patients with CRS without nasal polyps (CRSsNP), and to evaluate their associations with CRS clinical severity and correlation with NS interleukin (IL), IL-5 and interferon λ.

METHODS

CRS severity was determined by Lund-Mackay scores. Levels of immunoglobulin E (IgE), IL-4, IL-5, interferon λ, HSP70, and anti-HSP70 antibody levels in NS were measured by enzyme-linked immunosorbent assay.

RESULTS

Forty-six patients with CRSsNP (25 women [54.3%] and 21 men [45.7%], mean [standard deviation {SD}]) age, 34.1 ± 12.3 years; 54 patients with CRSwNP (24 women [44.4%] and 30 men [55.6%], mean [SD] age, 37.9 ± 17.5 years). A group of 40 healthy subjects served as controls. Compared with the controls (with a mean [SD] NS HSP70 level of 0.05 ± 0.03 μg/mL), mean [SD] NS HSP70 levels in both the CRSsNP group (0.16 ± 0.07 μg/mL) and CRSwNP group (0.21 ± 0.10 μg/mL) were increased (p < 0.001). Similarly, the mean (SD) NS anti-HSP70 antibody levels were significantly higher in patients with CRSwNP (0.25 ± 0.09 optical density value [ODV]) compared with CRSsNP (0.13 ± 0.04 ODV) (p < 0.001) and healthy controls (0.14 ± 0.02 ODV) (p < 0.001). NS HSP70 in subjects with CRSwNP showed a significant positive correlation with the Lund-Mackay score (r = 0.31; p < 0.05). NS levels of either HSP70 or anti-HSP70 antibodies were strongly correlated with NS IL-4 in the CRSwNP group (r = 0.62, p < 0.001; and r = 0.69, p < 0.001, respectively).

CONCLUSION

NS concentrations of HSP70 and secretory IgA anti HSP70 antibodies are increased in CRSwNP (but not in CRSsNP) and correlate positively with the Lund-Mackay score, NS IL-4, and NS IL-5.

Management of chronic rhinosinusitis with nasal polyps and coexisting asthma: A systematic review

BACKGROUND

Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and asthma are strongly associated, and patients suffering from both diseases are often difficult to treat. However, no guidelines about the management of patients with CRS and coexisting asthma exist.

OBJECTIVE

The purpose of this systematic review was to evaluate the management of CRSwNP and coexisting asthma.

METHODS

We systematically searched electronic databases and included clinical trials in which the clinical outcomes after medical or surgical treatment of patients with CRSwNP and asthma were assessed. The strength of the evidence for each outcome was graded on the basis of study quality and consistency in findings.

RESULTS

We included seven trials in which the effect of montelukast, omalizumab, erythromycin, and functional endoscopic sinus surgery (FESS) were studied in 317 adults with CRSwNP and asthma. All the interventions improved the majority of subjective and objective nasal outcomes significantly. However, few studies found significant effects on pulmonary function tests. The strength of the evidence was low overall.

CONCLUSION

Both FESS and medical interventions with systemic anti-inflammatory drugs improved nasal outcomes, although their efficacy in relation to the lower airways remains unclear. A low number of studies met inclusion criteria for this systematic review, which emphasizes the need for high-quality trials to explore the treatment of patients with CRSwNP and coexisting asthma.

A population-based study investigating chronic rhinosinusitis and the incidence of asthma

OBJECTIVES/HYPOTHESIS

Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses, associated with reduced health-related quality of life and increased utilization of healthcare services. Chronic upper and lower respiratory diseases often coexist, although the extent to which CRS is associated with developing asthma remains unclear. To investigate the effect of CRS on receiving a subsequent diagnosis of asthma, we used data from a previously conducted national, longitudinal survey.

METHODS

Respondents from the Canadian National Population Health Survey from 1998/1999 to 2010/2011 were used. Data were analyzed from 11,555 (66.9%) subjects, ≥ 19 years of age and reporting no asthma at baseline. Respondents were reviewed for 12 years to determine the cumulative incidence of asthma. Logistic regression was used to estimate the effect of CRS on the development of asthma, adjusting for age, gender, body mass index, cigarette smoking, and food- or nonfood-related allergies.

RESULTS

During the 12-year study period, 6.0% (95% confidence interval [CI] [95% CI]: 5.4%-6.7%) of respondents developed asthma. Baseline CRS (odds ratio [OR]: 2.7, 95% CI: 1.9-3.9), female gender (OR: 1.4, 95% CI: 1.1-1.8), and allergies (OR: 2.6, 95% CI: 2.1 - 3.3) were significantly associated with developing asthma. After adjustment, respondents with CRS were significantly more likely to develop asthma than non-CRS counterparts (OR: 2.0, 95% CI: 1.4-2.9).

CONCLUSION

Results indicate that one in 13 individuals with CRS will be subsequently diagnosed with asthma. Given the economic burden and use of healthcare services associated with asthma, providers managing CRS may consider increased awareness and subsequent treatment for asthma.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1296-1302, 2016.

Review: Immunology of sinusitis, trauma, asthma, and sepsis

Background:

This review article is important for allergists/immunologists and otolaryngologists. It discussed chronic rhinosinusitis, epidemiology, pathogenesis, innate adaptive immunology, nuclear factor–kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma, sinusitis, elderly pathogenesis, oxidative stress, depression, seasonal variation, vitamin D, genetic susceptibility and sepsis, hereditary angioedema related to trauma and stress.

Objective:

The objective of this review is to link chronic rhinosinusitis, epidemiology, innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma and sinusitis.

Methods:

A literature search was conducted from several articles, prospective studies, recent reviews and earlier reports. A synergistic relationship develops between activation of the innate immune system and the loss of organ barrier functions. Many complex factors, such as genetics, physical agents, mediators in the development of organ failure both in asthma, sinusitis, stress, depression and trauma, leading to posttraumatic organ failure. Asthma and sepsis, a common condition encountered in hospital environments remains an important cause of death at intensive care units where allergists/immunologists and otolaryngologists are frequently consulted. The patient's immune surveillance could fail to eliminate the pathogen, allowing it to spread and there is a proinflammatory mediator release with inappropriate activation.

Conclusion:

This review discussed chronic rhinosinusitis, sinusitis related to trauma, the innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, inflammation, reactive oxygen species, asthma pathogenesis, and asthma in the elderly, oxidative stress, depression, seasonal variation and vitamin D, cytokines, genetic susceptibility related to sepsis, hereditary angioedema related to trauma and stress.

Cockroach sensitization mitigates allergic rhinoconjunctivitis symptom severity in patients allergic to house dust mites and pollen

BACKGROUND

Modifiers of symptom severity in patients with allergic rhinoconjunctivitis (AR) are imprecisely characterized. The hygiene hypothesis implicates childhood microbial exposure as a protective factor. Cockroach sensitization (C+) might be a proxy for microbial exposure.

OBJECTIVE

We sought to determine whether C+ assayed by means of skin prick tests influenced AR symptom severity in controlled and natural settings.

METHODS

Total symptom scores (TSSs) were recorded by 21 participants with house dust mite allergy (M+) in the natural setting and during repeated exposures of 3 hours per day to house dust mite allergen in an allergen challenge chamber (ACC). In M+ participants the peripheral blood and nasal cells were assayed for T-cell activation and transcriptomic profiles (by using RNA sequencing), respectively. Participants allergic to mountain cedar (n = 21), oak (n = 34), and ragweed (n = 23) recorded TSSs during separate out-of-season exposures to these pollens (any pollen sensitization [P+]) in the ACC; a subset recorded TSSs in the pollination seasons.

RESULTS

The hierarchy of TSSs (highest to lowest) among M+ participants tracked the following skin prick test sensitization statuses: M+P+C- > M+P+C+ > M+P-C- > M+P-C+. In nasal cells and peripheral blood the immune/inflammatory responses were rapidly resolved in M+P+C+ compared with M+P+C- participants. Among those allergic to pollen, C+ was associated with a lower TSS during pollen challenges and the pollination season. After aggregated analysis of all 4 ACC studies, C+ status was associated with a 2.8-fold greater likelihood of a lower TSS compared with C- status (odds ratio, 2.78; 95% CI, 1.18-6.67; P = .02).

CONCLUSIONS

C+ status is associated with mitigation of AR symptom severity in adults with AR.

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

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

Chronic rhinosinusitis: an under-researched epidemic

Background

Chronic rhinosinusitis (CRS) is a highly prevalent inflammatory disease with significant impacts on patient quality of life and daily productivity. Evaluating the volume of research on CRS, relative to similar chronic diseases, may provide insight into current disparities in research prioritization.

Methods

A systematic review was performed using Ovid MEDLINE (R) (1970 – December 31st, 2014) to define the volume of research publications for CRS, asthma, and diabetes mellitus (DM). Primary outcomes were overall volume of research publications and volume of publications per year. A subgroup analysis was performed using chi-square (χ2) omnibus test with 2×3 contingency tables to identify significant differences in the proportion of total randomized controlled trials, systematic reviews, meta-analyses, and economic evaluation publications between CRS, asthma, and DM groups.

Results

There were substantial disparities in the volume of research published over the last 45 years for CRS (n = 7,962), asthma (n = 136,652), and DM (n = 337,411). Although the volume of research for CRS in increasing, the disparities in the annual publication volumes between CRS, asthma, and DM appeared consistent over the last 45 years.

Conclusions

Outcomes from this review have demonstrated a large disparity in the volume of published research for CRS compared to asthma and DM. Given the similarities in prevalence rates, impact on quality of life and economic burden, the relative under supply of CRS research should prompt efforts to increase research prioritization for this chronic disease.

The role of dendritic cells and monocytes in the maintenance and loss of respiratory tolerance

Promoting tolerance to inhaled antigens is an active area of study with the potential to benefit the millions of Americans currently suffering from respiratory allergies and asthma. Interestingly, not all individuals with atopy are symptomatic, arguing that sensitization alone does not lead to an allergic clinical phenotype. Respiratory dendritic cells (rDCs), classically associated with inducing inflammatory responses, can actively promote tolerance. Tolerance can be broken when inflammatory stimuli, including viral infections and other environmental exposures, inhibit rDC-mediated tolerance by allowing innocuous antigen to be presented to initiate type-2 immunity. Importantly, rDCs are composed of multiple subsets, each with a unique response to an inhaled antigen that can lead to either tolerance or inflammation. In this review, we will discuss how rDC subsets actively maintain tolerance or, alternatively, break tolerance in response to environmental cues.

Pediatric chronic rhinosinusitis

Pediatric chronic rhinosinusitis is a multifactorial inflammatory and infectious disorder. It likely reflects a dysfunction at the site of the interaction between host and environmental factors in the nose and sinuses. Our limited understanding of this common childhood disease makes it difficult to diagnose and to treat effectively. This review focuses on the scope of manifestations particular to the pediatric form of the disease, diagnostic challenges, and epidemiologic data. The normal development of sinuses in children, the role of inflammation, and biofilm and immune responses in the pathophysiology of chronic rhinosinusitis in pediatric patients are discussed. Predisposing and comorbid factors contributing to this disorder or associated with it are described. The current investigational and therapeutic approaches are presented, including recommendations for imaging and medical and surgical therapy. Various aspects of the disease that are still subject of controversy are underscored. Advice for what constitutes a reason to involve a multidisciplinary collaboration in the care of a child with chronic rhinosinusitis is provided.