SAN ANTONIA, TEX—A clear association exists between the upper and lower airways; there is no doubt that the nose and sinus influence the health of the lungs, said Michael A. Kaliner, MD, during a multispeaker session on rhinosinusitis at the 60th annual meeting of the American College of Asthma, Allergy and Immunology in San Antonio, Texas.[1] Dr. Kaliner, Clinical Professor of Medicine at the George Washington University School of Medicine in Washington, DC, presented epidemiologic, physiologic, and clinical data to support a “unified airways” hypothesis. This hypothesis suggests, among other things, that the presence of rhinitis predisposes patients toward asthma and that treating one condition often leads to improvement in both.

The epidemiologic data included the seminal 23-year study by Greisner et al[2] of more than 700 Brown University students. In that study, allergic rhinitis was observed in 85.7% of asthma patients; asthma occurred in 21.3% of the students with rhinitis. These findings are consistent with the results of other studies that suggest that 25% to 90% of asthma patients have concomitant rhinitis, while about one quarter of rhinitis sufferers also have asthma. Sinusitis is present in approximately two thirds of patients with severe asthma, research has also shown.

In clinical studies, rhinitis treatments, including oral antihistamines and topical and inhaled nasal corticosteroids, have demonstrated the ability to improve lung function or reduce airway hyperreactivity. Surprisingly, these agents worked as well as or better than traditional asthma therapies in some asthma patients. Dr. Kaliner mentioned that in at least one study, fexofenadine or desloratidine had as much effect on asthma as did montelukast. It is also true, he added, that treating asthma often improves rhinitis.

In addition, extensive evidence has documented that surgical treatment of sinusitis can significantly improve asthma. Furthermore, medical management of sinusitis often makes asthma easier to treat.

Immunotherapy has also shown a statistically significant effect on both asthma and rhinitis. “In our office, asthma is the number one indication [for immunotherapy],” said Dr. Kaliner, explaining that he has seen a much more profound response to such therapy in asthma patients than in rhinitis patients.

ASPIRIN, ANTIBIOTICS, AND SINUSITIS

Physicians should ask patients with chronic inflammatory sinusitis about aspirin sensitivity or perform aspirin challenges to detect such sensitivity, advised Mark S. Dykewicz, MD. “We may be missing patients who have some degree of aspirin sensitivity that could be aggravating their upper airway,” cautioned Dr. Dykewicz, Director of the Training Program in Allergy and Immunology at the St. Louis University School of Medicine.

Aspirin desensitization may benefit these patients, suggest the findings of Stevenson et al.[3] “The upshot [of their study] is that with aspirin desensitization, patients who have rhinosinusitis and asthma have decreased numbers of sinus infections, improvement in olfaction, and also some decrease in the number of sinus and polyp operations per year,” Dr. Dykewicz related.

Recent data raise the possibility that macrolide antibiotics may also be useful in the management of chronic inflammatory sinusitis, even though bacteria do not cause the condition. In an open-label study involving patients with stable chronic sinusitis and persistent maxillary sinus inflammation, clarithromycin produced a broad anti-inflammatory effect marked by reductions in eosinophil counts, levels of a variety of cytokines, and edema of the maxillary sinus mucosa.[4]

Furthermore, improvement occurred in all clinical signs and symptoms of chronic sinusitis for up to 14 days after the end of treatment. Importantly, none of the patients met the criteria for bacterial sinusitis, and they had all tested negative for Chlamydia pneumoniae before treatment was initiated.

Sinus surgery is generally effective for chronic inflammatory sinusitis but not for chronic hyperplastic eosinophilic sinusitis, stated Dr. Dykewicz. In patients with nasal polyps, sinus surgery often reduces nasal secretions and obstruction, but it is unlikely to improve anosmia, he noted.

By inducing eosinophil apoptosis, antileukotriene medications could have a positive impact on chronic hyperplastic eosinophilic sinusitis. Few randomized, double-blind, placebo-controlled clinical trials have assessed this treatment, but the available data suggest that the antileukotriene zileuton may significantly improve forced expiratory volume in one second, peak expiratory flow, rhinorrhea, and anosmia in aspirin-sensitive asthma patients with hyperplastic eosinophilic sinusitis.

Surprisingly, eosinophilic inflammation does not appear to be a prerequisite for intranasal corticosteroid therapy in patients with perennial nonallergic rhinitis. Webb et al[5] showed that intranasal fluticasone relieves that form of rhinitis whether or not eosinophils are present. Thus, “nasal steroids are worth a shot in your patients with nonallergic rhinitis,” Dr. Dykewicz concluded.

SINUSITIS: A ROLE FOR INTRANASAL STEROIDS?

Intranasal corticosteroids clearly have a place in sinusitis treatment, suggest data presented by Eli O. Meltzer, MD, Clinical Professor of Pediatrics at the University of California, San Diego. For example, researchers recently reported better, more rapid, and longer lasting improvement in acute sinusitis symptoms when several weeks of intranasal fluticasone were added to oral antibiotic therapy than when a placebo was administered in conjunction with such therapy.

In the largest clinical trial to date of intranasal corticosteroids for acute sinusitis, Dr. Meltzer and colleagues found that several weeks of intranasal mometasone were significantly more effective than placebo when added to oral antibiotic therapy for acute sinusitis.[6] The investigators had expected any mometasone-related benefits they detected to be limited to patients with allergy, but their subgroup analysis revealed that the drug reduced symptoms equally in nonallergic patients.

Moreover, computed tomographic (CT) evidence of maxillary sinus and posterior ethmoid abnormalities showed greater improvement in the mometasone group than in the placebo cohort. However, “the vast majority of patients still had abnormalities on their CT after the relatively short three-week course of treatment,” Dr. Meltzer acknowledged.

Other studies have shown that patients with acute sinusitis who are treated with intranasal corticosteroids have a significantly lower risk of recurrence during the next six to 12 months than do placebo-treated patients. There is a significantly longer time to recurrence of acute sinusitis with intranasal corticosteroids, as well. Furthermore, in a study of chronic sinusitis, one month of intranasal corticosteroid therapy, when given in conjunction with antibiotics, topical decongestants, and nasal lavage, has been associated with a reduction in symptoms and only a 6% chance of requiring sinus surgery in the two years after treatment.[7]

Allergic fungal sinusitis calls for surgical removal of mucin and oral corticosteroids, alone or with intranasal corticosteroids. “If you reduce the eosinophil count to less than 400 per microliter, you often have disease control,” Dr. Meltzer said.

—Timothy Begany