Transcript Sinusitis and asthma - Welcome to Egyptian Doctor's Guide

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 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.
"The nose is the gatekeeper of the lung.“
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.
All.Rhinitis Vs Asthma
100
80
60
40
20
0
Asthma
All Rhinitis
incidence of All.Rhinitis in Atopic asthma
All.Rh.adults
All.Rh.adolecent
Incidence of Allergic Rhinitis
in Allergic Asthma
%
%
Without Allergy
With Allergy
The Questions ??
What is interrelationship of Rhinosinusitis
and asthma?
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What are the mechanisms of this
interrelationship ?
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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.
Cellular pathway
Rhinosinusitis and asthma are characterized by an
inflammatory process that is marked histologically
by tissue eosinophils, mast cells, T lymphocytes ,
macrophages, and epithelial cells .
Pulmonary aspiration
of nasal contents
Humoral pathway
The upper airway inflammation
probably augments nonspecific
bronchial responsiveness
by mean of aspiration of nasal
discharge.
when methacholine administered
into the nose of rabbits causes acute
bronchial hyperresponsiveness,
Which completely blocked if nose
pretreated with phenylephrine
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
Mouth breathing is associated
with nasal obstruction resulting
in worsening of exerciseinduced 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.
X
Nasal - bronchial reflex
Sinopulmonary reflex
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 reflex
Sinopulmonary 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 reflex
Sinopulmonary 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.
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
Other associated processes
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.
Diagnosis
 History.
 Symptoms.
 Signs.
 Investigations.
 Referral.
Plan X ray paranasal sinuses
Treatment strategies
Asthma diminishes when coexistent
rhinosinusitis is maximally treated by
medical or surgical intervention.
Medical treatment include….
antihistamines ,topical intranasal
corticosteroids , decongestants,
sinopulmonary lavage and broadspectrum antibiotic therapy (when
indicated).
The role of medication in treatment is
to reduce chronic inflammation
associated with asthma and coexisting
nose& paranasal sinus disease.
Medical Treatment

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.
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 treatment
Anti 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.
Xolair ( omalizumab)
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.
Conclusions
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.
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 .