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Correlation of Rhinosinusitis with Bronchial
Asthma
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Dr. Nemer Al-Khtoum,
MD
Department of Otolaryngology, Royal
Medical Services.
Dr. Amin Al-Qudeh
Department of Medicine, Royal Medical
Services.
Dr. Nemer Al-khtoum
Department of ENT, RMS, Jordan Armed
Forces
Amman, Jordan
PO Box Sweileh 1834
Email: nemer72@gmail.com
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ABSTRACT
Objective:
To evaluate the predisposition of
sinus involvement in asthmatic patients.
Patients and Methods:
One hundred cases of bronchial
asthma patients of either sex were
studied. Age of patients ranged from
18-60 years with mean age of 33.67
years. CT scan of paranasal sinus
was performed for all patients.
Results: 58 (58%)
patients had symptoms and signs suggestive
of sinusitis. The most common symptom
was nasal congestion found in 52 (52%)
patients. CT Scan PNS showed evidence
of sinusitis in 78 (78%) patients
whereas 22 (22%) patients had no evidence
of sinusitis. Maxillary sinusitis
was found in 78 (78%) patient, and
52 (52%) patients had frontal sinusitis.
Ethmoid sinusitis was seen in 22 (22%)
patients and 8 (8%) patients had sphenoid
sinusitis. Maxillary polyp was found
in 22 (22%) patients and ostiomeatal
complex block in 54 (54%) patients.
Among one hundred patients of bronchial
asthma, clinically 58 (58%) patients
had evidence of sinusitis whereas
CT scan detected sinusitis in 78 (78%)
patients.
Conclusion:
The association of sinusitis and
asthma seems to be more than an epiphenomenon.
All asthmatics need to be examined
for evidence of sinusitis preferably
by CT scan.
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The association between sinusitis
and asthma has long been appreciated. The
incidence of sinusitis in asthmatic subjects
is generally stated to range from 40% to
75%.1-7Although these studies strongly suggest
that sinusitis triggers or worsens asthma,
it could be argued that they merely coexist
and represent different end products of
the same process (inflammation) occurring
in different organ systems.
Perhaps the most direct evidence of a cause-and-effect
relationship has been provided by studies
that show that appropriate treatment of
sinusitis by medical intervention can result
in significant improvement of asthma symptoms.[8-10]
Additionally, sinus surgery in patients
with asthma has been shown to bring about
improvement in lower airway disease, although
adequate controls have not been incorporated
in most studies.
Hypotheses are forwarded that
upper and lower airways need to be considered
as different stages of unique entity influenced
by common mechanisms in the inflammatory
process. Sinusitis and asthma therefore,
are considered as manifestations of one
disease process.
The aim of the present study
was to know the incidence of sinusitis in
asthmatic populations, and to compare the
relevant findings pertaining to sinus involvement
obtained by clinical and radiological studies.
The sample of this study was
conducted in the period from March 2003
to April 2005, in the Department of Medicine,
royal medical services (Amman-Jordan).
After institutional ethical
committee clearance and written informed
consent one hundred cases of bronchial asthma
patients of either sex were studied. Age
of patients ranged from 18-60 years with
the mean age of 33.67 years.
Asthmatic patients were selected
as per the guidelines advocated by the American
Thoracic Society in 1995. [11] All these
asthmatic patients underwent a detailed
history taking and a through general examination,
systemic examination and were screened for
clinical and radiological evidence of sinusitis.
CT scan of paranasal sinus was performed
for all patients.
The clinical
criteria for diagnosing sinusitis were the
presence of: [12]
- Nasal congestion/stuffiness
- purulent rhinorrhoea
- postnasal drainage
- Local pain and tenderness
overlying the sinuses
- Night cough
- Unpleasant smell, or taste
(Fetor oris)
CT criteria
for the diagnosis of sinusitis was the presence
of: [13]
- Mucosal thickening >
6 mm in children and > 8 mm in adults,
- Indistinct
bony margins,
- Erosion
of mucoperiosteum,
- Obstruction of ostiomeatal
complex.
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As per history and clinical
examination 58 (58%) patients had symptoms
and signs suggestive of sinusitis. The most
common symptom was nasal congestion found
in 52 (52%) patients.
CT Scan PNS showed evidence
of sinusitis in 78 (78%) patients whereas
22 (22%) patients had no evidence of sinusitis.
Maxillary sinusitis was found in 78 (78%)
patients, and 52 (52%) patients had frontal
sinusitis. Ethmoid sinusitis was seen in
22 (22%) of patients and 8 (8%) of patients
had sphenoid sinusitis. Maxillary polyp
was found in 22 (22%) of patients and ostiomeatal
complex block in 54 (54%) patients.
Among one hundred patients
of bronchial asthma, clinically 58 (58%)
patients had evidence of sinusitis whereas
CT scan detected sinusitis in 78 (78%) patients.
In our study, clinically 58
(58%) of patients out of 100 patients of
bronchial asthma had signs and symptoms
of sinusitis whereas 42 (42%) of patients
were asymptomatic for sinusitis.
On CT scan of paranasal sinus,
78 (78%) patients of bronchial asthma showed
evidence of sinusitis. All 58 patients,
who were clinically symptomatic for sinusitis,
had evidence of chronic sinusitis on CT
scan PNS.
In addition, on CT scan PNS
20 (47%) more patients were detected to
have sinusitis out of 42 clinically asymptomatic
patients. 54 (54%) of patients showed evidence
of ostiomeatal complex block. The ostiomeatal
complex is the common drainage pathway for
maxillary, frontal and anterior ethmoid
sinuses. CT scan has given newer understanding
of how the patient is affected with sinusitis.
Various mechanisms have been
proposed to explain the relationship between
sinusitis and asthma. The 5 most common
are sinonasobronchial reflex [14-25]; inhalation
of cold, dry air [26-31]; aspiration of
nasal secretions[32-38]; cellular and soluble
mediators [39-42], and diminished?-agonist
responsiveness.
In one study Weille [43] examined
500 patients with asthma, 72% of whom had
concomitant chronic sinus disease. Of 100
patients who underwent sinus surgery, 56
subsequently experienced improvements in
chest symptoms; complete resolution of asthma
occurred in 10. Twenty-three of 24 patients
with simultaneous chronic sinusitis and
asthma experienced a 75% or greater improvement
in asthma symptoms after surgical drainage
in another study.[44] This association is
supported by other researchers, including
Slavin,[45] who reported that lower airway
symptoms were significantly reduced after
nasal surgery in patients with severe asthma
that often required daily oral corticosteroid
therapy. In a follow-up of similar patients,
60% were found to have experienced improved
asthma symptoms that persisted for 5 years.
In another study of sinus
surgery in patients with asthma, 17 patients
were treated with nasal surgery because
of severe sinus disease. Fifteen of these
patients experienced improved sinus symptoms,
and 13 experienced significantly improved
asthma symptoms, postoperatively.[46] Most
of these patients underwent the Montgomery
procedure, in which the mucosal lining of
the sinuses is obliterated, and adipose
tissue from the abdomen is implanted. This
procedure promotes the formation of fibrous
tissue, which helps to reduce the recurrence
of infection. In one patient, severe asthma
symptoms that could not be controlled with
high-dose corticosteroids developed after
the procedure. When the implant was removed,
however, control of the asthma was regained.
This phenomenon supports the idea that sinus
disease and asthma exacerbations are related.
The association of sinusitis
and asthma seems to be more than an epiphenomenon.
In our study out of 100 asthmatics evidence
for sinusitis was found clinically in 58%
cases while CT Scan PNS detected sinusitis
in 78% cases. This observation assumes significant
clinical importance that all asthmatics
need to be examined for evidence of sinusitis
preferably by CT scan.
It is very pertinent to mention
that ENT specialist must look down into
the chest for evidence of bronchospasm and
chest physicians should examine asthmatic
patients for evidence of rhinosinusitis.
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