Co-morbidities of Rhinosinusitis

Asthma patients, particularly those with severe or difficult to manage asthma, often have concomitant sinusitis. In some studies as many as 65% of severe asthmatics have been found to have evidence of RS on CT. Other observations suggest a nearly universal incidence of sinusitis in patients with severe asthma. The evaluation of moderate to severe asthma should routinely involve a careful review for possible sinusitis, as treating the sinuses may ease the severity of asthma remarkably. 

About 25% of chronic RS patients develop nasal polyps, which are inflammatory growths extending from the sinuses into the nasal cavities. There are several characteristics that distinguish the chronic RS patient with polyps from those that do not develop polyps. Managing nasal polyps is complex and involves a balance between surgery designed to open the ostia and aggressive medical management with corticosteroids instilled into the nose and sinuses and judicial use of antibiotics and oral corticosteroids.

Current and Future Needs

It is evident that physicians do not recognize RS because of the subtlety in identifying the spectrum of symptoms as RS and distinguishing this condition from upper respiratory tract infections/colds or other on-going forms of rhinitis. Better teaching of PCPs, earlier referral to allergists and otolaryngologists, and more use of rhinoscopies and CT scans will enhance our recognition of this important disease.

Some leading specialists utilize liquid suspensions of corticosteroids instilled into the sinuses by lavages in treating RS. Availability of approved formulations of suspensions of corticosteroids would help with this treatment choice. As we try to understand RS better, identification of the characteristics of patients who develop RS, or who then develop nasal polyps, will become more evident and allow us to recognize those patients at higher risk. However, studies of the treatment of RS need higher priority both from governmental agencies and from the pharmaceutical industry. As it stands today, very few medications have been studied or approved for the treatment of RS or related conditions (such as polyps). 

Research Needs 

Little is known about why some patients with acute RS develop persistent inflammation of the sinuses that can persist for years or even a lifetime. Theories about persistent bacterial infections caused by biofilms, bacterial osteitis, or other conditions need to be explored and proven, or discredited. The possible role of Staphylococcus and Streptococcus in chronic RS need to be explored as does the possible role of chronic fungal infections. The role of specific immune abnormalities in patients with recurrent RS needs exploration, as do the immune mechanisms involved in the normal response to RS. Therapeutic medical and surgical approaches need careful analysis and long term assessments.

Unmet Needs 

A large percentage of the population has undiagnosed RS, or inadequately treated RS. Even after establishing the diagnosis, the appropriate guidelines for medical management have not been established and there appears to be too much surgery, performed too early in the course of the disease. Expert guidelines for the diagnosis and management of RS are needed.

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.

Symptoms and Severity

Although some symptoms are similar in all forms (itching – which is typical of allergic conjunctivitis, distinguishing it from other forms of a red eye – redness, tearing and photophobia), the pathophysiology, disease associations, and clinical presentation can differ, for example, the giant papillae in VKC and CLC. The disease severity and management are different in these phenotypes of ocular allergy (Figure 2). While SAC and PAC (very often associated with rhinitis) impair a patient’s quality of life they are mild diseases and are easily controlled by adequate anti-allergic treatment. On the other hand, VKC (occurring alone or more frequently associated with asthma, particularly in young boys before puberty and in some geographical regions with intense natural light) and AKC (typically associated with atopic eczema) are rare but severe clinical entities, in which the involvement of the cornea (vernal and atopic keratoconjunctivitis) is difficult to treat and may eventually cause impairment of visual function.

The allergist has a central role in the diagnosis of allergic conjunctivitis. Patients with bilateral red itching eyes should always be referred to the allergist not only for skin testing and IgE determination, which may be negative, particularly in some cases of VKC and AKC, but also to evaluate general and ocular clinical symptoms. The allergist can also arrange for more sophisticated tests such as the detection of eosinophils in tears, which is typical of VKC and AKC, or of SAC and PAC during the acute phase. The age of the subject, the clinical association with asthma or eczema, the presence of ocular pain or of an intense photophobia, and a poor response to common anti-allergic treatments should prompt the allergist to consult an ophthalmologist to evaluate the presence of a possible corneal involvement.

Therapeutic Considerations

 An adequate treatment of rhinitis with topical steroids, immunotherapy when indicated, systemic and topical antihistamines (or more recent molecules with a dual antihistaminic and anti-inflammatory action) may easily control SAC and PAC. The corneal involvement in VKC and AKC often requires the use of steroids, with the potential for severe iatrogenic side effects of these drugs in the eye (glaucoma, ulcers).

Future Research Needs 

Research efforts in allergic conjunctivitis should mainly be devoted to the most severe forms of ocular allergy (SOA), in an attempt to clarify their pathophysiology better, to standardize diagnosis, and to suggest new forms of treatment. 

Rhinosinusitis

Key Statements 

• 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 be considered only 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.