BY Dr.Khaled Helmy BY Dr.Khaled Helmy Rhinosinusitis & Asthma Rhinosinusitis & Asthma Al 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. “

Asthma All Rhinitis

1.c e t i r i z i n e 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 histologically by 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 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. Nasal - bronchial reflex Sinopulmonary 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 H 1 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 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.

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.