eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Allergy
Asthma and Sinusitis
Updated: Jun 15, 2009
Introduction
Background
In the United States, 35 million people have sinus problems, and 20 million people have asthma. Physicians know that a sinus infection can substantially contribute to the frequency and severity of asthma attacks. This article outlines the factors common to both conditions and discusses how best to improve these conditions.
Asthma and sinusitis are both recognized in ancient literature. In the 1940s and 1950s, a considerable number of sinus surgeries were performed to help people with asthma. Purulent diseased tissue was removed, the nasal airway was opened, and excellent results were achieved in some patients. In the 1960s, improvements after sinus surgery were thought to be related more to the stress reaction than to the surgical technique; therefore, sinus surgery became less popular as a principle of asthma management.
Septal deviation with concha bullosa. CT scan shows the bony anatomy, including the important structures of the maxillary frontal and sphenoid ostia. The cribriform plate, the anatomic position of which is a critical factor in any surgery, is depicted. The surgeon looks for depression at this area and dehiscence. On the image, the septum is deviated to the left, and the concha bullosa is right of the middle turbinate.
With the introduction of CT scanning in the 1970s, accurately pinpointing the location and extent of the sinus pathology became possible. A return to corrective surgery for individuals with sinusitis and for individuals with asthma has occurred, thanks to the studies of Rachelefsky,1 Spector,2 and many others showing the benefits of clearing sinus pathology. In the 1980s, functional endoscopic sinus surgery (FESS) and the ability to physiologically improve sinus function became available.
In the 1990s, as CT scanning enhanced the visualization of the sinus and as endoscopic surgery, especially with the computer-assisted techniques, advanced the ability to improve sinus function, physicians returned to sinus treatment as an aid to asthma management. Further aids to treatment have included newer antibiotics and an emphasis on cilia function. Newer medications, such as the corticosteroids sprays, have given new directions for treatment. Many allergists now emphasize the role of these drugs in treating sinusitis.
Asthma and sinusitis are increasing in frequency and morbidity, despite the advances made in understanding and treating these conditions. The overuse of antibiotics in childhood may alter the normal inflammatory response to change to an allergic-type response. A current theory suggests that a hypersensitivity reaction replaces the normal disease reaction when antibiotics are overused. This theory notes a high incidence of disease in families in the upper income brackets. These individuals have full access to medical care, cleanliness, and dust proofing. The body's immune system is designed to fight parasites and infections; if antibiotics are administered at the first sign of illness, the normal immunity may not develop, and alternate systems are produced (eg, asthma, poor resistance to infection). One suggestion is that the early antibiotics kill the good flora of the intestinal tract, which may lead to the aberrant/allergic reaction to inflammation.
For further reading, please see the following asthma resources from Medscape and eMedicine:
Pathophysiology
The physiology of mucus in individuals with asthma is similar to that of nasal mucus in healthy individuals. Mucociliary clearance (MCC) involves the cilia and the layers of mucus on the ciliated epithelium and refers to their ability to promote maximum health by moving particles along a desired path. In the upper respiratory tract, cilia propel mucus, bacteria, and the particles trapped in mucus to the nasopharynx, where the mucus drops to the hypopharynx and is swallowed. Stomach acid then disposes of the unwanted invaders. In the lower respiratory tract, the cilia that line the trachea and bronchial tree similarly move the mucus blanket up the trachea and into the hypopharynx for swallowing.
Rheologists investigate the makeup of this liquid and study its viscosity and elasticity. Two layers of mucus are present over the ciliated cell; an outer thick, viscoelastic, semisolid mucus layer, which the cilia do not directly strike, is found over a layer of watery serous fluid. Because of the low viscosity of the layer of watery serous fluid, the cilia can beat normally and move the watery lower layer, affecting movement of the upper thick layer. Changes in these properties affect movement of the mucus blanket and play a major role in pulmonary and sinus disease. If the movement of the blanket is slowed, bacteria can multiply as the mucus thickens and stagnates.
Approximately 100,000 small seromucous glands in nasal mucosa produce nasal mucus, a secretory substance. Nasal mucus has a viscosity lower than that of sputum and contains sulfate, sugars, proteins (including albumin), protective enzymes, and phagocytes.
MCC is the function of moving bacteria, contaminants, and carcinogens away. Ciliary beat frequency refers to the number of full, whiplike movements of the cilia per second (normally 16) and involves the coordination of these movements.
Ciliary movement is remarkably coordinated so that an effective wave propels the mucus in a specific direction. Sinus cilia beat toward the natural sinus opening in the middle meatus, even after an antrostomy or artificial opening is created in the inferior meatus. Nasal cilia beat backward toward the nasopharynx. Therefore, nasal mucus is propelled into the nasopharynx and is swallowed for disposal into the stomach. In the child, this course directs the mucus with its bacteria, debris, and foreign matter over the adenoids, where lymphocytic defenses can act. The deep crypts and rugae of the adenoids create a large surface area for enhanced effect.
Lysozymes, immunoglobulins, and phagocytes in the mucus solution provide protection from infection. Movement of the bacteria by mucus flow reduces the opportunity for penetration of the cell. Dilution of bacterial products decreases their toxicity. Anything that thins the nasal mucus or stimulates it (eg, proteolytic enzymes, mucolytics) helps the asthmatic chest mucus. Measuring cilia in the chest is difficult; measurement requires biopsy or use of special radioactive gasses. Measuring the nasal cilia (eg, with a saccharin test) is easy, and the findings are a useful reflection of the chest cilia.
Frequency
United States
Asthma and sinusitis are both increasing in frequency. About 20 million individuals have asthma, and 35 million have sinusitis. The conditions undoubtedly overlap. The number of children with asthma is increasing at an alarming rate and not only in developed countries.
The incidence of asthma and allergy increases with poverty. This increased incidence is partially based on poor environmental control. Cockroaches and dust are known causes of asthma. In areas with lower socioeconomic status, pets are often prevalent in close quarters, and air filtering and dust proofing are often not performed. Asthma is a disease that requires maximum cooperation of the patient and family. Parents must oversee a complicated regimen of inhalers, pills, and breathing exercises; this type of supervision and assistance may not be available in poverty situations. Poor medical service is another major contributor to the high rate of poorly controlled asthma and sinusitis in impoverished patients. The source of primary and follow-up care for this population is often provided by the busy emergency department.
International
An increased incidence of sinus disease has been reported in all countries. The incidence of sinusitis is higher in Japan, Indonesia, and Europe than in the United States. An increasing incidence of both sinusitis and asthma that occur together has been reported internationally, as well as in the United States. Special conditions (eg, fires in Kuwait and Indonesia, chromium content of the sands of Saudi Arabia) increase the incidence of sinusitis. Asthma-free areas are present in certain sub-Saharan areas, where hookworm disease is endemic. The parasitic system (eg, eosinophiles) is fully engaged. In Somalia, which has a high incidence of hookworm disease, the reported incidence of asthma is low.
Mortality/Morbidity
Despite the availability of effective antiasthmatic drugs, asthma is responsible for more than 100 million days of restricted activity and 470,000 hospitalizations annually. The most common disease of early childhood, asthma exacts a particularly high toll among persons who are economically disadvantaged.
- Sinusitis has a low death rate. Death can occur in young children when the condition is unrecognized. In infants, the maxillary sinuses are well developed but often unrecognized as a source of possible lethal infection. In adults, fatalities occur primarily as a result of complications of sinus infection to the brain, meninges, and the cavernous sinus.
- Problems with sinusitis and rhinitis can account for 50% of office visits and are involved in a large percentage of medical costs.
Race
In Alaska, the incidence of sinusitis is high partly because of the decreased robustness of the ciliary system among Native Americans. This high rate is also associated with a high incidence of ear disease and the many hours that the population spends indoors with open fires, dry air, damp walls, and stale dust.
Sex
The incidence of sinusitis appears to be equal between the sexes.
Age
Asthma and sinusitis can occur in young children. Sinusitis in young children is not appreciated because the maxillary and ethmoid sinuses are not always recognized. After children start nursery school, the incidence of sinus and chest infections dramatically increases.
The asthma rate is increasing among children. In a recent survey in Massachusetts, 9.5% of pre–high school students had asthma. In 2004, the Centers for Disease Control and Prevention reported that 7.6% of children aged 14 years or younger had asthma.
Clinical
History
Individuals with asthma often have a childhood history of allergy. Patients present with wheezing and coughing, and they report sleepless nights. These patients benefit from the use of an inhaler. Associated findings are symptoms of frequent sinus infections, heavy pus, or drainage of the thick mucus into the chest. Whenever individuals with asthma have a sinus infection, the asthma worsens. When accompanied by a sinus infection, the asthma does not clear with simple treatment. If the nose is obstructed, these individuals breathe with their mouth open, a practice that precipitates an asthma attack.
Patients with asthma have a dry mouth all the time and are bothered by thick nasal phlegm dripping into their throat. The thick phlegm causes patients to cough and constantly try to clear the throat. With a sinus infection, additional time is required to clear the asthma.
- Obtain a history about the frequency of nasal obstruction, purulent discharge, localized sinus pain, drainage, and fever.
- Acute sinusitis refers to a single episode, which may be severe and even last 6 weeks despite treatment.
- Nonchronic sinusitis is characterized by about 1-2 attacks per year that clear with treatment. One or 2 such attacks per year are not chronic sinusitis.
- Chronic sinusitis is defined as 4-5 episodes of sinusitis per year, in which the episodes last about 4 weeks each. Often, the episodes do not clear until antibiotics are administered.
- A history of 4 episodes of sinusitis over the last 6 months, which each cleared with the required antibiotics, suggests a persistent single infection.
- If an antibiotic is stopped, a still-present infection might gradually return. In this case, irrigation is needed; local treatment or a course of antibiotics longer than the previous course are also possibly needed. The usual physiologic process is that the antibiotic killed the bacteria, but the cilia did not return to function. Several of the following scenarios are possible:
- The antibiotic did not kill the pathogen.
- The antibiotic killed the pathogen, but the cilia did not return to function and because the mucus was not moved out, a new infection occurred. This is common in the patient whose infection responded to treatment and was clear 2 weeks ago but who now returns with yellow discharge, sneezing, blockage, and feeling sick.
- The eosinophilic attack deposited major basic protein (MBP) in the mucus, and the MBP is inhibiting the return of cilia function.
- Obtaining a family history is important in cases of asthma and allergies. A family history of sinusitis does not generally increase the incidence of sinusitis.
- An essential aid to preventing sinus or lung infection in patients with AIDS is moisturizing the respiratory tract and encouraging cilia function. The following 2 factors cause a high incidence of sinusitis in patients with AIDS:
- A lowered immune system that allows bacterial growth
- Thickened mucus exudate that becomes stagnant and allows bacterial growth
- Failure of the normal mucociliary flow system accounts for an extremely high incidence of sinus disease in patients with cystic fibrosis.
- The pathology here is that the mucus, because of high salt content, is too thick for proper mucociliary flow; therefore, bacteria can multiply and enter the body.
- Dr Terrance Davidson of the University of California at San Diego has pioneered sinus treatment in cystic fibrosis by using pulsatile irrigation to remove and thin thick mucus.
Physical
In susceptible individuals, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli.
- Physical examination
- Determine whether sinus infection precedes or follows an asthma attack.
- Determine the frequency of sinusitis and the results of antibiotic therapy.
- Examine the patient's eyes, ears, nose, throat, and larynx. Look for lymphoid hyperplasia, hypertrophic turbinates, or both. Determine if they are inflammatory or allergic in appearance. In patients with allergy, hyperplasia of the postpharyngeal wall is pale, and the mucus is clear. In those with chronic sinusitis, the hyperplasia is red, and the mucus is colored.
- Determine if the septum is obstructive. On laryngoscopy, look for signs of irritation of the posterior larynx that indicate gastroesophageal reflux disease (GERD).
- Look for a history of eustachian-tube dysfunction. Are the ears affected when the patient gets a sinus infection? Heavy nose blowing often causes this effect. Do their ears become blocked when they fly?
- Look for signs of adenoid hypertrophy or mass. Enlarged adenoids are common in children with sinusitis but uncommon in adults. A suspected adenoid mass in the adult must be examined to rule out malignancy. A unilateral mass is highly suspect. A unilateral adenoid mass with bleeding is presumptively diagnosed as a malignancy until proven otherwise. A unilateral blocked ear may be a sign of an adenoid mass.
- Hypertrophic posterior turbinates may best be observed by means of nasopharyngeal examination with a mirror. These turbinates can impair breathing and block the eustachian tube. Although this pathology was common in the past, it is now uncommon, perhaps because of improvement in antihistamine therapy.
- In children with unilateral purulent drainage, look for a foreign body.
- Perform nasal endoscopy to examine for patent or closed sinus ostia (see Image 1).
- Visualize the maxillary, frontal, and sphenoid ostia.
- Physical findings of asthma
- Individuals with asthma wheeze and have impaired breathing.
- The chest is sometimes retracted or sunken, indicating inhalation difficulty. (A barrel chest indicates emphysema.)
- The nostrils flare.
- The throat is often dry.
- Physical findings of sinusitis
- The patient breathes through the mouth and has purulent drainage.
- The patient may have a mild fever.
- Local tenderness is present over the affected sinus.
- On examination with a nasal speculum, a purulent drainage is usually observed from the middle meatus.
- Transillumination shows decreased passage of light on the affected side.
- Purulent material may be observed in the pharynx, nasopharynx, or both.
Causes
Asthma and sinusitis are increasing in frequency and morbidity, despite the advances made in understanding and treating these conditions. The following theories suggest what is causing these increases:
- Overuse of antibiotics
- The overuse of antibiotics in childhood may alter the normal inflammatory response to change to an allergic-type response.
- A current theory suggests that a hypersensitivity reaction replaces the normal disease reaction when antibiotics are overused.
- This theory notes a high incidence of disease in families in the upper income brackets. These individuals have full access to medical care, cleanliness, and dust proofing.
- The body's immune system is designed to fight parasites and infections; if antibiotics are administered at the first sign of illness, the normal immunity may not develop, and alternate systems are produced (eg, asthma, poor resistance to infection).
- Genetic factors
- Asthma has more of a genetic etiology than does sinusitis.
- The incidence of asthma increases when both of the patient's parents have asthma.
- More individuals with asthma are having children now than before.
- Biofilm: This occurs when bacteria develop a colony-type integration with sticky attachment to surfaces, an enveloping shield that blocks antibiotic action, and a departmentalization of certain bacteria that causes some to go dormant and others to multiply. In addition, real channels are developed. At a certain size, these break off and seed to other surfaces. This is a major problem for catheters and certain stents but is also an increasing problem for the sinus and chest. Gentle stream irrigation may not be sufficient to remove these; pulsatile irrigation tests in orthopedic research projects have been successful.3
- Major basic protein (MBP) produced by eosinophiles against fungus: In the common "Mayo-type" fungal condition, a common fungus may cause eosinophiles to overreact and overproduce a toxic product to kill the fungus. This toxic product, called MBP, irritates and inflames the respiratory system, causing nasal congestion and secondary infection.
- Environmental factors
- These factors are becoming increasingly important.
- The major environmental irritant, other than specific occupational substances, is tobacco smoke.
- Current theory attributes the increase of sinusitis and asthma to air pollution. When the air is polluted with smog, diesel, gasoline, and other noxious products, the sun's heat and rays may combine them into dozens of products whose long-term effects are unknown at this time.
- In addition, smog, diesel fumes, and sulfur dioxide all combine to interfere with good cilia function. Hypersensitivity reactions seem to occur when the individual has an overwhelming exposure and does not recover ciliary function. Unfortunately, manufacturers are marketing new solvents daily without disclosing their effect on ciliary function. Despite the $50 million spent on clinical studies for evaluation required by the US Food and Drug Administration (FDA), no drugs have been evaluated for their effect on MCC.
- Known industrial toxins include chlorine, sulfur dioxide, cupric compounds, and chromium dusts, all of which can be toxic to respiratory functions.
- Fires are a known risk factor. When fires occur countrywide, such as in Kuwait or Indonesia, the incidence of sinusitis and asthma increases. The oil fires in Kuwait released polymelia aromatic hydrocarbons, nickel, and vanadium into the atmosphere. This contamination resulted in upper and lower respiratory infections. Similar problems have occurred with the Indonesian forest fires and with excessive smog in London. Some of the respiratory problems might have been prevented with simple irrigation by using Locke-Ringer–type solutions. Lung and sinus pathology affected teenagers in these regions a decade after these severe fires.
- Closed environments: An increase in the number of pets in closed quarters may be causing an increase in asthma and sinusitis. Closed environments may also have mold and no fresh air.
- Other environmental problems to be considered are pet allergens, house dust-mite allergen, cockroach allergen (most important for inner-city residents), indoor fungi and molds, and outdoor allergens (eg, trees, grass, weed pollens, seasonal mold spores).
- Impaired MCC
- Sinusitis and asthma are inflammatory diseases and, as such, are caused or aggravated when MCC is impaired.4
- Factors that slow cilia include the following:
- Cocaine
- Antihistamines
- Dehydration
- Inhalation of air or steam hotter than 40°C
- Frequently drinking iced drinks
- Chilling drafts
- Sulfur dioxide, ozone, smog, and diesel fumes
- Inhalation of chromium dusts
- Cupric (copper) compounds
- Nickel dusts
- Chimney dusts
- Formaldehyde
- Late stages of allergy
- Nasal polyps
- Skydrol (a solvent used in airplane maintenance)
- Benzalkonium (a common preservative in saline sprays)
- Infections with Pseudomonas species, Haemophilus influenzae, and many viral pathogens
- Hyperbaric oxygen
- Reduction of airway diameter
- AIDS
- Gastroesophageal reflux disease
- In addition to the above factors, recognition of GERD as an irritant that brings on asthmatic symptoms, as well as throat and laryngeal symptoms, is increasing.
- When the larynx is visualized with mirror or endoscope, the arytenoids are inflamed, especially posteriorly.
- Standard GERD measures may be beneficial. Often, keeping the head of the bed elevated, avoiding spices, and not eating after 8 pm can be highly therapeutic. Trials of acid inhibitors must be started with twice-daily dosing in order to determine effectiveness.
- Bacteria
- Dye or tracers placed in the sinus appear 16 hours later in the lower trachea. Therefore, bacteria from the sinuses find their way to the lower respiratory system.
- Bacteria then act as inflammatory agents.
- Development of drug-resistant bacteria
- Fungi
- Researcher Jens Ponikau and others have discussed fungal infection as a cause of chronic sinusitis.5 They have cultured fungi from the sinuses of chronically ill patients; however, other researchers have shown that the same organisms can be cultured from healthy individuals.
- In reading the literature and especially in obtaining the patient's history, consider the term "fungal sinus infection " with caution. This term is loosely defined and used to refer to 1 of 4 of the following distinct entities:
- Overwhelming total infection that fills all the sinuses, as observed in immunocompromised patients
- Presence of fungus that is cultured in a patient with a chronic sinus condition
- Presence of fungus that is opportunistic and that results after the use of antibiotics, especially topical ones
- Presence of fungus normally observed when sinus symptoms are of other etiologies, such as migraine head pain
- Sleep apnea is commonly found in patients with asthma, especially in patients who are obese.
- A diagnosis of sleep apnea is essential.6 The following factors are used in the diagnosis of sleep apnea:
- Loud snoring that bothers the patient's partner
- Tiredness in the morning after sleeping
- Falling asleep during the day or after lunch
- Not feeling rested in the morning no matter how long one sleeps
- A reduction of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), total lung capacity, functional residual capacity, and expiratory reserve volume are associated with obesity/asthma. Obesity causes fat on the diaphragm and weakness of chest muscles and leads to obstructive sleep apnea (OSA).
- In OSA, the fall in O2 may lead to a reflex bronchoconstriction, an increase in GERD, or both. Treatment with continuous positive airway pressure (CPAP) can dramatically improve respiratory function.
- Children with asthma may also have OSA and obesity.
- People with asthma reproducing with other people with asthma
- An increase in stress levels: This could possibly lower natural immunity.
- Studies today show that many failures in asthma are due to the patient not being properly educated and/or simply not understanding or following instructions. Rechecking, at each visit, the proper use of medications, inhalers, adequate hydration, cleaning the environment, and breathing and relaxation exercises is important.7,8,9
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| Differential Diagnoses & Workup: Asthma and Sinusitis |
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| References |
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Further Reading
Keywords
asthma, sinusitis, respiratory distress, bronchitis, allergic bronchitis, sinus problems, sinus infection, postnasal drip, rhinitis, allergic rhinitis, mucociliary clearance, asthmatic, reactive airway disease, wheeze, bronchiolitis, bronchial asthma, acute asthma, allergies, bronchial airways, bronchial airway narrowing, inflammation of the bronchi, bronchial smooth muscle contraction, wheezing, dyspnea, airway narrowing, noisy breathing, difficult breathing, difficulty breathing, respiratory disease
