Rhinosinusitis

Introduction

RS affects about 31 million subjects in the US per year and is about midway between rhinitis and asthma in frequency. The annual costs are about the same as for asthma, making RS one of the 10 most costly conditions. The underlying causes of RS are shown in Table 1. Allergic rhinitis and non-allergic rhinopathy are the most common underlying causes, but anatomical abnormalities, sensitivity to nonsteroidal anti-inflammatory drugs (NSAID’s) and immune deficiencies are also frequently found.

Symptoms and Severity 

The most common symptoms of acute and chronic RS are shown in Table 5. Patients complaining about these symptoms who are found to have purulent drainage in the nasal cavities or pharynx should be considered as possibly having RS. In most cases, a good history and physical examination, possibly including a rhinoscopic examination, leads the discerning physician to consider RS and initiate empiric treatment. A Computerized Tomography (CT) scan of the sinuses is the “gold standard” for confirming the diagnosis of RS.

The evaluation of RS is quite similar to the approach taken for rhinitis: determining whether the symptoms are acute or chronic; whether the disease involves the nose alone or both the nose and sinuses; whether the patient is allergic or not; whether there is an active infection or an on-going immune inflammatory response; whether to treat empirically or to take cultures from the nose, perform rhinoscopy, order a CT scan, do an immune evaluation, or consult with a surgeon about the need for sinus surgery. These complex evaluations are standard for allergists/ immunologists and are the type of analytic decisions for which the allergist is specifically trained.

Therapeutic Considerations

 If the conclusion is that the patient does have chronic or recurrent RS, the overwhelming majority of patients do very well with careful medical management. The principles of management include medically reducing swelling in the nose, sinus irrigation, topical corticosteroids in the nose and sinuses, appropriate antibiotics, and careful education about the chronic nature of the disease and need for on-going treatment. 

In many instances, medical treatment is chronic and on-going, and aimed at controlling symptoms, but is not curative. Thus, some patients prefer the option of a surgical procedure that might eliminate an anatomical obstruction that could be the cause of RS, in the hope of a definitive cure. The current surgical  approach to RS is functional endoscopic sinus surgery where the functional ostia which drain the sinuses are identified and enlarged. This approach has an impressive 1-2 year incidence of symptom improvement. However, patients with predisposing diseases that originally led to RS still suffer from these processes and often develop RS again at a later date. Medical management is usually required for on-going symptom relief.

Severity of Allergic Rhinitis

The severity and duration of symptoms of AR varies in different patients. The classification of AR into mild and moderate/ severe is useful for therapeutic purposes. Severe persistent rhinitis sufferers are those patients whose symptoms are inadequately controlled despite adequate (i.e., effective, safe, and acceptable) pharmacologic treatment based on guidelines. 

Bousquet et al have reported that current treatment and allergy diagnosis have no effect on the patient’s assessment of rhinitis severity and that the severity, rather than the duration, had a greater impact on Visual Analogue Scale levels. Therefore, we should consider control of the disease as the main target of management. It is likely that a large proportion of this group of patients may benefit from allergen specific immunotherapy

The Burden of Allergic Rhinitis

AR has a significant socio-economic impact on the patient, the patient’s family and society. It affects multiple parameters including quality of life, physical, psychological and social functioning and has financial consequences.

Physical Symptoms: Allergies in America, a survey conducted by telephone involving 2,500 adults with AR, showed that the most common symptoms are congestion, rhinorrhea, nasal and ocular itching, tearing, sneezing, headache, facial and ear pain

Psychological effects: Fatigue, irritability, anxiety, depression, frustration, self-consciousness and lower energy, motivation, alertness, and ability to concentrate, are commonly present in patients with AR 

Decreased quality of life: Investigators have used health status questionnaires to assess the quality of life of patients with asthma or rhinitis. While physical functioning was slightly higher in patients with AR compared with patients with asthma, social functioning was lower in the AR group.

Sleep disturbances: Nasal congestion is often associated with sleep-disordered breathing. Up to 57% of adult patients and up to 88% of children with AR have sleep problems, including micro-arousals, leading to daytime fatigue and somnolence, and decreased cognitive functioning. These are accompanied by disorders of learning performance, behaviour and attention in children.

Interference with social interaction: Social isolation, activity limitations, limited visits to friends and family, and an inability to visit open spaces such as parks and closed spaces (restaurants, cinemas), are frequent consequences of AR. Patients are forced to carry handkerchiefs or tissues, and need to rub and blow the nose repeatedly

Use of medications: On average, patients with AR usually use two or more medicines to treat their AR. Self-medication with over the counter sedating antihistamines results in drowsiness and further impairment of cognitive and motor functions.

Financial burden: It has been demonstrated that patients with AR support two-fold increases in medication costs and 1.8 times the number of visits to health practitioners when compared with matched controls. Expenses for AR include direct and indirect costs 

In the United States of America, direct costs for AR increased from $ 2.7 billion in 1995 to $7.3 billion in 2002. Indirect costs in 2002 were estimated at $4.28 billion, with a total amount of $11.58 billion for that year. Additionally 3.5 million lost work days and 2 million lost school-days occur annually. On any given day, about ten thousand children are absent from school in the USA because of AR.

The burden of allergic diseases

Allergic Rhinitis

Key statements 

• Allergic rhinitis (AR) results from an IgE-mediated inflammation of the nasal mucosa. 

• The disease currently affects between 10% and 30 % of the population. 

• Studies indicate that prevalence rates are increasing worldwide. 

• The classification proposed in the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines is useful for the implementation of treatment. 

• AR is a risk factor for asthma. 

• Other co-morbidities of AR include: sinusitis, nasal polyposis, conjunctivitis, otitis media with effusion, upper respiratory infections, breathing through the mouth, and sleep disorders. 

• AR has a significant impact on patients based on the degree of the severity of their symptoms. It has psychological effects, interferes with social interactions, and creates an economic burden not only for the affected subject, but for the family and for the society at large. 

• Management is based on patient education, environmental control measures, pharmacotherapy and specific immunotherapy

Introduction

Allergic rhinitis is defined by the presence of nasal congestion, anterior and posterior rhinorrhea, sneezing, and nasal itching secondary to IgE-mediated inflammation of the nasal mucosa. It must be differentiated from other non allergic forms of rhinitis with a similar clinical picture

Risk factors for the development of AR include a family history of atopic diseases, increased total serum IgE before 6 years of age, higher socio-economic class, and the presence of positive immediate-type hypersensitivity skin tests. The most common causative allergens include pollens, dust mites, molds, and insects.

Atopic subjects inherit a predisposition to produce specific IgE antibodies that bind to high-affinity receptors on mast cells. In the nose, IgE-bound mast cells recognize the allergen and degranulate, releasing preformed mediators (histamine, tryptase, chymase, kininogenase, heparin, and other enzymes). Newly formed mediators including prostaglandin D2 and cysteinyl leukotrienes are released by mast cells, eosinophils, basophils, and macrophages and produce edema, rhinorrhea, mucosal hypertrophy, mucus secretion, and vasodilation leading to nasal obstruction. Stimulation of sensory nerves results in nasal itch, sneezing, and increased congestion. This early allergic response is followed by a late-phase response starting 4 - 8 hours after allergen exposure, which is characterized by congestion, postnasal mucous discharge, hyposmia, and nasal hyperreactivity to non specific environmental stimuli. Repeated mucosal exposure to allergens results in a priming mechanism by which the amount of allergen required to induce an immediate response decreases as a consequence of the influx of inflammatory cells

Prevalence

Allergic rhinitis is the most common form of non-infectious rhinitis, affecting between 10% and 30% of all adults and as many as 40% of children. Epidemiologic studies show that the prevalence of AR continues to increase worldwide. The World Health Organization has estimated that 400 million people in the world suffer from AR, and 300 million from asthma.

In the United States of America, the prevalence of AR ranges from 3% to 19%. According to the Centers for Disease Control and Prevention, 23.7 million cases were reported in 1996. Overall, it affects 30 to 60 million individuals annually. In childhood, affected boys outnumber girls, but the sex ratio is about equal in adults. AR develops before the age of 20 years in 80% of cases. Increased prevalence is observed in non whites, in some polluted urban areas, and in first-born children. AR accounts for 16.7 million physician office visits annually.

In Europe, the European Community Respiratory Health Survey established the prevalence of AR as being from 4% to 32%. The International Study on Asthma and Allergies in Childhood (ISAAC) reported the prevalence of allergic rhinitis in Latin America.

THE BURDEN OF ALLERGIC DISEASE

Allergic Rhinitis 

• Allergic rhinitis (AR) results from an IgE-mediated inflammation of the nasal mucosa. 

• The disease currently affects between 10% and 30 % of the population. 

• Studies indicate that prevalence rates are increasing worldwide. 

• The classification proposed in the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines is useful for the implementation of treatment. 

• AR is a risk factor for asthma. 

• Other co-morbidities of AR include: sinusitis, nasal polyposis, conjunctivitis, otitis media with effusion, upper respiratory infections, breathing through the mouth, and sleep disorders.

• AR has a significant impact on patients based on the degree of the severity of their symptoms. It has psychological effects, interferes with social interactions, and creates an economic burden not only for the affected subject, but for the family and for the society at large. 

• Management is based on patient education, environmental control measures, pharmacotherapy and specific immunotherapy.

Allergic Conjunctivitis 

• Allergic conjunctivitis is an increasingly prevalent allergic disease, with the same clinical gravity as allergic asthma and allergic rhinitis.

• The umbrella term “allergic conjunctivitis” includes distinct clinical entities, from mild but disturbing forms due to IgE sensitization to aeroallergens; to forms of keratoconjunctivitis where the severe allergic inflammation, with corneal involvement, is more difficult to diagnose and treat, and may lead to permanent ocular damage and even loss of vision.

Rhinosinusitis 

• Rhinosinusitis (RS) is one of the most common and expensive medical conditions. 

• RS occurs in a number of forms, the most common of which are either acute or chronic. 

• Initial treatment of RS is usually by a primary care physician (PCP) and if unsuccessful, the PCP should refer either to a surgeon or to an allergist for specialized care. 

• In the vast majority of cases, RS is controlled by proper medical management without the need for surgery. 

• Surgery should only be considered in those patients who are properly managed but in whom a number of medical treatment programs fail. 

• The Allergist, who is trained in allergy, immunology, microbiology, internal medicine and/or pediatrics combined with an expert knowledge of nasal and sinus anatomy and appropriate pharmacology, is best suited to manage RS.

Asthma 

• Asthma is a life-long chronic inflammatory disorder of the airways, associated with variable structural changes, that affects children and adults of all ages. It is associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment. 

• When uncontrolled, asthma can cause death, and can markedly interfere with normal activities, seriously impacting an individual’s quality of life.

• Because of under-diagnosis and inadequate treatment, asthma presents a serious public health problem throughout the world; especially in low and middle income countries.

• Atopy - the genetic predisposition to develop IgEmediated sensitivity to common aeroallergens, is the strongest identifiable predisposing factor to the development of asthma, especially in children.

• There was a sharp increase in the prevalence, morbidity, and mortality associated with asthma beginning in the 1960s and 1970s in the so-called “Westernized” countries of the world. 

• The prevalence of asthma in different countries varies widely, but the disparity is narrowing due to rising prevalence in low and middle income countries as they adopt a more Western-type lifestyle. It is plateauing in high income countries. 

• Inhaled corticosteroids are currently the most effective antiinflammatory medications to treat persistent asthma. 

• The monetary costs of asthma are substantial and include both direct medical costs and the indirect costs, the latter associated with time lost from work and premature deaths. 

• National efforts to tackle asthma as a public health problem, such as the program introduced in Finland, produce remarkable benefits that are reflected in dramatic reductions in deaths and hospital admissions.

• Many barriers exist to a reduction in the worldwide burden of asthma. 

• There are unmet diagnostic, therapeutic, educational and financial needs to achieve better worldwide control of asthma.

 • More effort is needed to focus on ways to improve the management of asthma by focusing on disease control rather than treating acute episodes. This concept has to be embedded in healthcare programs.