Rhinosinusitis & Asthma

BY

Dr.Khaled Helmy
Al Maamora Chest Hospital

Rhinosinusitis

Reflect the inflammatory process that extends from the sinuses to the nasal mucosa, causing symptoms of nasal obstruction and nasal discharge both are the prominent features of sinusitis.

"The nose is the gatekeeper of the lung.

The link between rhinitis- sinusitis and asthma has been recogni ed since the second century !", when #alen drew an association between the large number of indi$iduals who suffered from both whee ing and nasal discharge.

pathophysiologic, and clinical data confirmed the strong comorbidity.

"The nose is the gatekeeper of the lung.

%atients with allergic rhinitis and no clinical e$idence of asthma fre&uently exhibit bronchial hyperresponsi$eness to bronchoconstrictor agents such as methacholine or histamine. 'ronchial hyperreacti$ity may represent an intermediate phase between nasal allergy and symptomatic asthma. !ppropriate treatment of allergic rhinitis results in impro$ements in asthma symptoms and lower airway function.

!ll.Rhinitis (s !sthma 100 80 60 40 20 0

Asthma All Rhinitis

88

100 50

100

incidence of !ll.Rhinitis in !topic asthma 100 93 99

50

All.Rh.adults All.Rh.adolecent

)ncidence of !llergic Rhinitis in !llergic !sthma

75% 25%
*ithout !llergy *ith !llergy

The ,uestions ++
*hat is interrelationship of Rhinosinusitis and asthma+
1.e

*hat are the mechanisms of this interrelationship + *hat are the suggestions for optimal treatment of both+
1.c e t i r i z i n e

-b.ecti$es
To identify the indicators of rhinosinusitis and asthma. To understand the $arious pathophysiologic mechanisms responsible for the concomitant occurrence of rhinosinusitis and asthma. To recogni e the importance of identification and treatment of upper airway disease in management of chronic asthma .

!natomy of the /inuses

The sinuses ha$e small orifices 0ostia1 that open into recesses in the nasal ca$ities called meati. The meati are co$ered by the turbinates 0also called conchae1 which consist of bony shel$es surrounded by erectile soft tissue

2unctions of the paranasal sinuses

!ir conditioning. %ressure damping. Reduction of skull weight. 3eat insulatio . 2lotation of skull in water. )ncreasing the olfactory area. (ocal resonance and diminution
of auditory feedback. 4itric -xide

4itric -xide secretion.

5ellular pathway

Rhinosinusitis and asthma are characteri ed by an inflammatory process that is marked histologically by tissue eosinophils, mast cells, T lymphocytes , macrophages, and epithelial cells .

%ulmonary aspiration of nasal contents

3umoral pathway
The upper airway inflammation probably augments nonspecific bronchial responsi$eness by mean of aspiration of nasal discharge. when methacholine administered into the nose of rabbits causes acute bronchial hyperresponsi$eness, *hich completely blocked if nose pretreated with phenylephrine

/ame airway 6 /ame disease

Rhinitis and asthma are two manifestations of allergic respiratory disease. %athogenic e$ents are triggered by exposure to aeroallergens. The histology of these diseases shows chronic, eosinophilic inflammation . Rhinitis and asthma represent global allergic in$ol$ement of the airways.

7outh 'reathing
7outh breathing is associated with nasal obstruction resulting in worsening of exerciseinduced bronchospasm, whereas exclusi$e nasal breathing significantly reduced asthma after exercise. )mpro$ements in asthma associated with nasal breathing may be the result of superior humidification and warming of inspired air before it reaches the lower airways.

4asal - bronchial reflex

/inopulmonary reflex
/ince the second century !" #alen was obser$ed that purging nasal secretions offered relief to persons with pulmonary disease. )n 8989, /luder hypothesi ed the existence of a sinopulmonary reflex thought to be responsible for that phenomenon. )n 89:;, the 2rench physiologist <ratchmer used noxious agents to stimulate nasal mucosa in animals, and acute bronchial hyperresponsi$eness resulted.

4asal - bronchial reflex

/inopulmonary reflex
)n 89=9, <aufman and *right applied silica particles onto the nasal mucosa of indi$iduals without lower airway disease and noted significant, immediate increases in lower airway resistance. This bronchospasm induced by nasal silica was blocked by both resection of the trigeminal ner$e and systemic administration of atropine.

4asal - bronchial reflex

/inopulmonary reflex
!ll these studies suggest the presence of a reflex in$ol$ing irritant receptors in the upper airway and cholinergic ner$es in the lower airway ie .4eural pathway. Receptors in the nose and pharynx and, paranasal sinuses produce afferent fibers that form part of the trigeminal ner$e, which passes to the brain stem and connects with the reticular formation of the dorsal $agal nucleus from the $agal nucleus, parasympathetic efferent fibers tra$el in the $agus ner$e to the bronchi.

The Treatment >ink

The link between rhinosinusitis and asthma , suggesting that when one condition is effecti$ely treated, the other may impro$e as well. !dministering the intranasal corticosteroid beclomethasone dipropionate to patients with allergic rhinitis and asthma significantly decreased bronchial hyperreacti$ity and impro$ed asthma symptoms leading to conclude that ignoring inflammation in the upper airway is likely to lead to suboptimal results in asthma treatment

-ther associated processes

! reduction in nitric oxide, which is a potent modulator of bronchial tone, may precipitate acute bronchial hyperresponsi$eness . #?R" has a role in inducing the nasal mucosal edema and inflammation that cause obstruction of the sinus ostia, which in turn stimulates the autonomic ner$ous system. The amount of pharyngeal reflux of gastric acid is greater in patients with chronic sinusitis that does not respond to initial antireflux therapy.

"iagnosis 3istory. /ymptoms. /igns. )n$estigations. Referral.

%lan @ ray paranasal sinuses

Treatment strategies
!sthma diminishes when coexistent
rhinosinusitis is maximally treated by medical or surgical inter$ention.

7edical treatment include.

antihistamines ,topical intranasal corticosteroids , decongestants, sinopulmonary la$age and broadspectrum antibiotic therapy 0when indicated1.

The role of medication in treatment is

to reduce chronic inflammation associated with asthma and coexisting noseA paranasal sinus disease.

7edical Treatment

!ntihistamines effecti$ely block 38 receptors and function as anti-inflammatory agents. "econgestants can significantly affect ostial blockage . Topical intranasal corticosteroids has a profound effect on reducing tissue edema and inflammation in the sinuses.

!ntibiotic should be used only ifthere is infection.

2unctional endoscopic sinus surgery 02?//)

2?// on 8:B rhinosinusitis Casthmatic patients monitored for an a$erage of =.Byears after 2?// was performed. !bout 9DE of patients impro$ed asthma symptoms. 'enefit was demonstrated by

F >ess fre&uent use of a beta-agonist

inhaler in BDE of patients.

F 2ewer need of oral corticosteroid to

control acute asthma exacerbations in ==E of patients.

>ow >e$el >aser Therapy of /inusitis

2uture of allergy treatment

!nti )g?

@olair 0omali umab1 2inally appro$ed by the 2"! for adults and teens with moderate-to-se$ere allergic asthma, itGs a new kind of allergy drug.

@olair 0 omali

umab1

%romising agents for steroid reduction in

persons with allergic asthma.

7ay protect against acute allergen-induced

exacerbation.

4ot antigen specific.

@olair 0 omali

umab1

7ay ha$e uses in other allergic diseases. 4ot e$ery case of asthma is triggered by an
allergic reaction.. ?xercise, cold outdoor temperatures and other factors may be the seminal e$ent in susceptible indi$iduals. *hile those cases, too, are characteri ed by inflammation and narrowing of the airways.

Tanox is de$eloping a similar drug, known as

T4@-9D8.

5onclusions
5onsiderable clinical and research e$idence substantiates the interrelationship between rhinosinusitis and asthma. -ptimal treatment of asthma depends on aggressi$e management of associated rhinosinusitis. Rhinosinusitis is best managed by the use of antihistamines, intranasal corticosteroids, decongestants, sinus la$age to maintain ade&uate mucociliary clearance !ntibiotics should be used only if needed. !nti )g? is a promising treatment for allergic diseases.

#i$en by in.ection once or twice a month, it lets many patients cut back on other asthma drugs. ! genetically engineered antibody0!nti )g?1 that blocks the cascade of e$ents in the body that triggers allergic asthma .