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Sinusitis & Asthma

  INTRODUCTION Section 1 of 9   | Next Section  >>

Background: In the US, there are 35 million persons with sinus problems and 15 million persons with asthma. Clinically, physicians know that a sinus infection can contribute significantly to the frequency and severity of asthma attacks. The purpose of this chapter is to outline the factors common to both conditions and to note how best to improve these conditions.

Asthma and sinusitis both have been recognized in ancient literature. In the 1940s and 1950s, considerable sinus surgery was performed to help people with asthma. Purulent diseased tissue was removed, the nasal airway was opened, and excellent results were achieved for some of these patients. Then, in the 1960s, the improvements following sinus surgery were thought to be more related to the stress reaction than from the surgical technique; therefore, sinus surgery became less popular as a principle of asthma management.

With the introduction of the CT scanning technique 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 individuals with asthma has occurred, thanks to the studies of Rachelevsky, Spector, and many others showing the benefits of clearing sinus pathology. Then, in the 1980s, functional endoscopic sinus surgery (FESS) and the ability to physiologically improve sinus function became available.

In the 1990s, as the CT scan’s ability has enhanced the view of the sinus and as endoscopic surgery, especially with the computer-assisted techniques, has improved the ability to improve sinus function, physicians are returning to sinus treatment as an aid to asthma management. Further aids to treatment have included newer antibiotics and emphasis on cilia function. Newer medications, such as the corticosteroids sprays, have given new directions for treatment. Indeed, many allergists now emphasize their role in treating sinusitis.

Pathophysiology: The physiology of mucus in individuals with asthma is similar to that of nasal mucus. Mucociliary clearance (MCC) involves cilia and the layers of mucus on the ciliated epithelium and refers to the movement of particles along a desired path for maximum health. In the upper respiratory tract, cilia propel the mucus and its trapped bacteria and particles to the nasopharynx, where it drops to the hypopharynx and is swallowed. The 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.

The science of rheology investigates the makeup of this liquid and studies 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 strike directly, is found over a layer of watery serous fluid. Because of the lowered viscosity of the layer of watery serous fluid, the cilia are able to beat normally and to move the watery lower layer, thereby, affecting movement of the upper thick layer. Changes of 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 are able to multiply as the mucus thickens and stagnates.

Nasal mucus is a secretory substance produced by 100,000 small seromucous glands in nasal mucosa. Nasal mucus has a lower viscosity than sputum and contains sulfate, sugars, proteins (including albumin), and protective enzymes and phagocytes.

MCC refers to 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.

Remarkably, the ciliary movement is 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 towards the nasopharynx. Thus, 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 larger surface area for greater effect. Protection from infection is achieved by the presence of lysozymes, immunoglobulins, and phagocytes in the mucus solution. Movement of the bacteria by mucus flow reduces opportunity for penetration of the cell. Dilution of bacterial products makes them less toxic. Whatever thins the nasal mucus or stimulates it (eg, proteolytic enzymes, mucolytics) helps theasthmatic chest mucus. Measuring cilia in the chest is quite difficult; measurement requires biopsy or special radioactive gasses. Measuring the nasal cilia, as by a saccharin test, is easy and is a useful reflection of the chest cilia.

Frequency:

  • In the US: Asthma and sinusitis are both increasing in frequency. Fifteen million individuals with asthma and 35 million persons with sinusitis live in the US. No doubt, overlapping of the conditions occurs.
  • Internationally: An increased incidence is reported in all countries. The incidence of sinusitis is higher in Japan, Indonesia, and Europe than in the US. An increased incidence of both sinusitis and asthma occurring together is reported internationally as well as in the US. Certain areas have special conditions causing an increased sinusitis incidence (eg, the fires of Kuwait and Indonesia, the chromium content of the sands of Saudi Arabia). Asthma-free areas have been noted in certain sub-Saharan areas where hookworm is endemic. The parasite system (eg, eosinophiles) is fully engaged.

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.

  • In poverty situations, the incidence of asthma and allergy is higher. This increased incidence is partially based on poor environmental control. Cockroaches and dust are known to be causes of asthma. In poverty situations, pets often are prevalent in close quarters, and air filtering and dust proofing often are not performed. Asthma is a disease that requires maximum cooperation of the family. Often, the 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 also is a major factor contributing to the high rate of poorly controlled asthma and sinusitis in these patients. Often, the only primary and follow-up care for this population of patients is in the busy emergency room.
  • Sinusitis, fortunately, 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 are 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 make up 50% of office visits and are involved in a large percentage of medical costs.

Sex: Incidence of sinusitis appears to be equal among the sexes.

Age: Asthma and sinusitis can occur in very young children. Sinusitis in very young children is not appreciated because the presence of the maxillary and ethmoid sinuses is not always recognized. Once children start nursery school, the incidence of sinus and chest infections skyrockets.

  CLINICAL Section 2 of 9   << Previous Section | Top | Next >>

History: Individuals with asthma often have a childhood history of allergy. Patients present with wheezing and coughing, and they complain of sleepless nights. These patients benefit by the use of an inhaler. Associated with these symptoms are complaints of frequent sinus infections, heavy pus, or thick mucus drainage into the chest. Whenever individuals with asthma get a sinus infection, the asthma worsens. When accompanied by a sinus infection, the asthma fails to clear with simple treatment. When the nose obstructs, these individuals breathe with the mouth open, which precipitates an asthma attack. Patients with asthma have a dry mouth all the time and are bothered by thick nasal phlegm dripping into the throat. The thick phlegm causes these patients to cough and try to clear the throat constantly. With a sinus infection, a much longer time period is required to clear the asthma. Obtain history regarding frequency of bouts of nasal obstruction, purulent discharge, localized sinus pain, drainage, and fever.

  • Frequency
    • History of frequent bouts of sinusitis is evidenced.
    • Every year, 4-5 episodes of sinusitis occur and last about 4 weeks each.
    • Often, the episodes do not clear until antibiotics are administered.
  • Not chronic sinusitis
    • A history of 4 bouts of sinusitis over the past 6 months, each of which required antibiotics and did clear, is more suggestive of the same infection hanging on.
    • When the antibiotic is stopped, the infection, still present, gradually returns.
    • In this case, irrigation is needed as well as possible local treatment or a longer course of antibiotic.
  • Family history
    • Obtaining family history is very important in cases of asthma and allergies.

    • For sinusitis, a higher incidence generally does not follow a family history of sinusitis.
  • The following 2 factors cause a very high incidence of sinusitis in patients with AIDS:
    • Lowered immune systems allow bacterial growth.
    • A thickened mucus exudate becomes stagnant and allows for bacterial growth.
  • The failure of the normal mucociliary flow system accounts for an extremely high incidence of sinus disease in patients with cystic fibrosis.

Physical: In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes usually are associated with widespread, but variable airflow obstruction that often is reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli.

  • Determine if sinus infection precedes or follows asthma attack.
  • Determine frequency of sinusitis and results of antibiotic therapy.
  • Examine eyes, ears, nose, throat, and larynx. Look for lymphoid hyperplasia and/or hypertrophic turbinates. Determine if they are inflammatory or allergic in appearance.
  • Determine if the septum is obstructive. On laryngoscopy, look for signs of irritation of the posterior larynx indicating gastroesophageal reflux disease (GERD).
  • Look for history of eustachian tube dysfunction.
  • Look for signs of adenoid hypertrophy or mass.
  • Hypertrophic posterior turbinates may best be seen via nasopharyngeal mirror exam.
  • In cases of unilateral purulent drainage from a child, especially look for a foreign body.
  • Perform nasal endoscopy to reveal patent or closed sinus ostia.
  • Visualize the maxillary, frontal, and sphenoid ostia.
  • Physical findings of asthma
    • Individuals with asthma wheeze and have impaired breathing.
    • The chest sometimes is retracted or sunken, indicating inhalation difficulty. (Barrel chest indicates emphysema.)
    • Nostrils flare.
    • Throat is often dry.
  • Physical findings of sinusitis
    • Patient breathes through the mouth and shows purulent drainage.
    • Patient may have a mild fever.
    • Local tenderness over the affected sinus is present.
    • With nasal speculum, a purulent drainage usually is observed from the middle meatus.
    • Transillumination shows decreased light passage on the affected side.
    • Purulent material may be observed in the pharynx and/or the nasopharynx

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
    • A current theory suggests that with overuse of antibiotics, the normal disease reaction is replaced by a hypersensitivity reaction.
    • This theory notes a high incidence of disease in families with upper incomes; these individuals have full access to medical care, cleanliness, and dust proofing.
    • The body’s immune system is designed to fight parasites and infections, and, if the antibiotic is given at the first sniffle, perhaps the normal immunity fails to develop and alternate systems are produced (eg, asthma, poor resistance to infection).
  • Genetics
    • When compared to sinusitis, asthma has more of a genetic etiology.
    • Incidence of asthma increases when both parents have asthma.
    • More individuals with asthma are having children.
  • Environmental factors are becoming increasingly more important and include the following:
    • 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.
    • Additionally, smog, diesel fumes, and sulfur dioxide all combine to interfere with good cilia function. Hypersensitivity reactions seem to occur when the individual gets an overwhelming exposure and fails to recover ciliary function. Unfortunately, new solvents are marketed daily and the effect on cilia function is not provided by the manufacturers. Even more unfortunate is the fact that despite the 50 million dollars spent by the Federal Drug Administration (FDA) on clinical evaluations, no drugs are evaluated as to their effect on mucociliary clearance.
    • Known industrial toxins include chlorine, sulfur dioxide, cupric compounds, and chromium dusts.
    • Fires are a known factor. When countrywide fires, such as in Kuwait or Indonesia, occur, the incidence of sinusitis and asthma increases. 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 Indonesia forest fires and excess smog experience in London. Some of the respiratory problems might be prevented by simple irrigation with Locke-Ringer type solutions.
    • Other environmental problems to be considered include pet allergens, house-dust mite allergen, cockroach allergen (most significant in patients who live in the inner city), indoor fungi and molds, and outdoor allergens (eg, trees, grass, weed pollens, seasonal mold spores).
  • Impaired mucociliary clearance: Sinusitis and asthma are inflammatory diseases and, as such, are caused or aggravated when mucociliary clearance is impaired. Factors that slow cilia include the following:
    • Cocaine
    • Antihistamines
    • Dehydration
    • Inhalation of air or steam above 40 degrees Celsius
    • Heavy load of iced drinks
    • Chilling drafts
    • Sulfur dioxide, ozone, smog
    • 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)
    • Pseudomonas species, Haemophilus influenzae, and many viral infections
    • Hyperbaric oxygen
    • Reduction of airway diameter
    • AIDS
  • In addition to the above factors, there is an increasing recognition of GERD as an irritant that brings on asthmatic symptoms, as well as throat and laryngeal complaints. When the larynx is visualized with mirror or endoscope, the arytenoids are inflamed, especially posteriorly. Standard GERD measures may be beneficial.
  • Dye or tracers placed in the sinus appear 16 hours later in the lower trachea. Thus, there is little question that bacteria from the sinuses find their way to the lower respiratory system. Bacteria then act as an inflammatory agent.
  DIFFERENTIALS Section 3 of 9  << Previous Section | Top | Next >>

Other Problems to be Considered:

Differential diagnosis of asthma includes the following:
Chronic obstructive pulmonary disease (chronic bronchitis or emphysema)
Congestive heart failure
Cough secondary to drugs (eg, angiotensin-converting enzyme inhibitors)
Laryngeal dysfunction (eg, ventricular dysphonia)
Mechanical obstruction of the airways (eg, tumors, anatomic changes)
Retrosternal thyroid
Pulmonary embolism
Pulmonary infiltration with eosinophilia
Bronchostenosis
Enlarged lymph nodes
Foreign body in trachea or bronchus
Laryngeal webs
Laryngotracheomalacia primarily in infants
Tracheal stenosis in infants
Tumor
Vascular rings
Vocal cord dysfunction
Bronchopulmonary dysplasia
Cystic fibrosis
Heart disease
Obliterative bronchiolitis
Viral bronchiolitis
Aspiration from swallowing mechanism dysfunction
Gastroesophageal reflux disease (GERD)
Recurrent cough not due to asthma
Environmental irritants
Differential diagnosis of sinusitis:
Cervical or temporal mandibular joint (TMJ) referred pain
Allergic rhinitis
Nasal polyps
Foreign body (common in children; characterized by unilateral purulent odorous drainage)
Acute common cold
Deviated nasal septum
Rhinitis medicamentosum

  WORKUP Section 4 of 9   << Previous Section | Top | Next >>

Lab Studies:

  • Pulmonary function studies indicate respiratory function.
  • Culture purulent discharge.