BY Dr.Khaled Helmy

BY Dr.Khaled Helmy

Rhinosinusitis &

Asthma

Rhinosinusitis &

Asthma

Al Maamora Chest HospitalAl Maamora Chest Hospital

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.

Rhinosinusitis

"The nose is the gatekeeper of the lung.“

The link between rhinitis- sinusitis

and asthma has been recognized

since the second century AD, when

Galen drew an association between

the large number of individuals who

suffered from both wheezing and

nasal discharge.

pathophysiologic, and clinical

data confirmed the strong

comorbidity.

Patients with allergic rhinitis and no clinical

evidence of asthma frequently exhibit

bronchial hyperresponsiveness to

bronchoconstrictor agents such as

methacholine or histamine.

Bronchial hyperreactivity may represent an

intermediate phase between nasal allergy and

symptomatic asthma.

Appropriate treatment of allergic rhinitis

results in improvements in asthma symptoms

and lower airway function.

"The nose is the gatekeeper of the lung.“

100

50

10088

0

20

40

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80

100

All.Rhinitis Vs Asthma

AsthmaAll Rhinitis

9399

0

50

100

incidence of All.Rhinitis in Atopic asthma

All.Rh.adultsAll.Rh.adolecent

Incidence of Allergic Rhinitis in Allergic Asthma

25%

75%

Without Allergy With Allergy

1.cetirizine

1.e

What is interrelationship of Rhinosinusitis and asthma?

The Questions ??

What are the mechanisms of this interrelationship ?

What are the suggestions for optimal treatment of both?

Objectives

To identify the indicators of rhinosinusitis and asthma.

To understand the various pathophysiologic mechanisms responsible for the concomitant occurrence of rhinosinusitis and asthma.

To recognize the importance of identification and treatment of upper airway disease in management of chronic asthma .

Anatomy of the Sinuses

The sinuses have small orifices (ostia) that open into recesses in the nasal cavities called meati.  The meati are covered by the turbinates (also called conchae) which consist of  bony shelves surrounded by erectile soft tissue

Functions of the paranasal sinuses

Air conditioning.

Pressure damping.

Reduction of skull weight.

Heat insulatio .

Flotation of skull in water.

Increasing the olfactory area.

Vocal resonance and diminution

of auditory feedback. Nitric Oxide

Nitric Oxide secretion.

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

Cellular pathway

Pulmonary aspiration of nasal contents

Humoral pathway

when methacholine administered

into the nose of rabbits causes acute

bronchial hyperresponsiveness,

Which completely blocked if nose

pretreated with phenylephrine

The upper airway inflammation

probably augments nonspecific

bronchial responsiveness

by mean of aspiration of nasal

discharge.

Same airway = Same disease

Rhinitis and asthma are two manifestations of allergic respiratory disease.

Pathogenic events are triggered by exposure to aeroallergens.

The histology of these diseases shows chronic, eosinophilic inflammation .

Rhinitis and asthma represent global allergic involvement of the airways.

Mouth breathing is associated with nasal obstruction resulting in worsening of exercise- induced bronchospasm, whereas exclusive nasal breathing significantly reduced asthma after exercise.

Improvements in asthma associated with nasal breathing may be the result of superior humidification and warming of inspired air before it reaches the lower airways.

Mouth Breathing

X

Since the second century AD Galen was observed that purging nasal secretions offered relief to persons with pulmonary disease.

In 1919, Sluder hypothesized the existence of a sinopulmonary reflex thought to be responsible for that phenomenon.

In 1928, the French physiologist Kratchmer used noxious agents to stimulate nasal mucosa in animals, and acute bronchial hyperresponsiveness resulted.

Nasal - bronchial reflexSinopulmonary reflex

In 1969, Kaufman and Wright applied

silica particles onto the nasal mucosa

of individuals 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 nerve and

systemic administration of atropine.

Nasal - bronchial reflexSinopulmonary reflex

All these studies suggest the presence

of a reflex involving irritant receptors in

the upper airway and cholinergic nerves

in the lower airway ie .Neural pathway.

Nasal - bronchial reflexSinopulmonary reflex

Receptors in the nose and pharynx and,

paranasal sinuses produce afferent fibers

that form part of the trigeminal nerve,

which passes to the brain stem and connects with the

reticular formation of the dorsal vagal nucleus from the

vagal nucleus, parasympathetic efferent fibers travel in

the vagus nerve to the bronchi.

The Treatment Link

The link between rhinosinusitis and asthma ,

suggesting that when one condition is

effectively treated, the other may improve

as well.

Administering the intranasal corticosteroid

beclomethasone dipropionate to patients

with allergic rhinitis and asthma significantly

decreased bronchial hyperreactivity and

improved asthma symptoms leading to

conclude that ignoring inflammation in

the upper airway is likely to lead to

suboptimal results in asthma treatment

A reduction in nitric oxide, which is a potent

modulator of bronchial tone, may precipitate acute

bronchial hyperresponsiveness .

GERD has a role in inducing the nasal mucosal

edema and inflammation that cause obstruction of the

sinus ostia, which in turn stimulates the autonomic

nervous system. The amount of pharyngeal reflux of

gastric acid is greater in patients with chronic sinusitis

that does not respond to initial antireflux therapy.

Other associated processes

Diagnosis

History.

Symptoms.

Signs.

Investigations.

Referral.

Plan X ray paranasal sinuses

Asthma diminishes when coexistent rhinosinusitis is maximally treated by medical or surgical intervention.

Medical treatment include…. antihistamines ,topical intranasal corticosteroids , decongestants, sinopulmonary lavage and broad-spectrum antibiotic therapy (when indicated).

The role of medication in treatment is to reduce chronic inflammation associated with asthma and coexisting nose& paranasal sinus disease.

Treatment strategies

Antihistamines effectively block H1 receptors

and function as anti-inflammatory agents.

Decongestants can significantly affect ostial

blockage .

Topical intranasal corticosteroids has a

profound effect on reducing tissue edema and

inflammation in the sinuses.

Antibiotic should be used only ifthere is

infection.

Medical Treatment

Functional endoscopic sinus surgery (FESS)

FESS on 125 rhinosinusitis –asthmatic patients monitored for an average of 6.5years after FESS was performed.

About 90% of patients improved asthma symptoms.

Benefit was demonstrated by

* Less frequent use of a beta-agonist inhaler in 50% of patients.

* Fewer need of oral corticosteroid to control acute asthma exacerbations in 66% of patients.

Low Level Laser Therapy of Sinusitis

Future of allergy treatmentAnti IgE

Xolair (omalizumab) Finally approved by the FDA

for adults and teens with moderate-to-severe

allergic asthma, it's a new kind of allergy drug.

Promising agents for steroid reduction in persons with allergic asthma.

May protect against acute allergen-induced exacerbation.

Not antigen specific.

Xolair ( omalizumab)

May have uses in other allergic diseases.

Not every case of asthma is triggered by an

allergic reaction.. Exercise, cold outdoor

temperatures and other factors may be the

seminal event in susceptible individuals. While

those cases, too, are characterized by

inflammation and narrowing of the airways.

Tanox is developing a similar drug, known as

TNX-901.

Xolair ( omalizumab)

Considerable clinical and research evidence substantiates the interrelationship between

rhinosinusitis and asthma.

Optimal treatment of asthma depends on aggressive management of associated rhinosinusitis.

Rhinosinusitis is best managed by the use of antihistamines, intranasal corticosteroids, decongestants, sinus lavage to maintain adequate mucociliary clearance

Antibiotics should be used only if needed.

Anti IgE is a promising treatment for allergic diseases.

Conclusions

Given by injection once or twice a

month, it lets many patients cut

back on other asthma drugs.

A genetically engineered

antibody(Anti IgE) that blocks the

cascade of events in the body that

triggers allergic asthma .