Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 2 Issue: 3

The Role of Atopy and Asthma Status in Chronic Rhinosinusitis in Adults

Mahdi A. Shkoukani1,2* and John H. Krouse2
1Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, MI, USA
2Department of Otolaryngology-Head and Neck Surgery, Temple University, Philadelphia, PA, USA
Corresponding author : Mahdi A. Shkoukani
Wayne State University, 4201 St. Antoine, 5E UHC, Detroit, MI 48201
Tel: 313-577-0805, Fax: 313-577-8555
E-mail: [email protected], [email protected]
Received: February 13, 2013 Accepted: June 21, 2013 Published: July 02, 2013
Citation: Shkoukani MA, Krouse JH (2013) The Role of Atopy and Asthma Status in Chronic Rhinosinusitis in Adults. J Otol Rhinol 2:3. doi:10.4172/2324-8785.1000122

Abstract

The Role of Atopy and Asthma Status in Chronic Rhinosinusitis in Adults

Background: Chronic rhinosinusitis (CRS) is a prevalent chronic disease. Allergy and asthma in CRS patients have been discussed extensively in the literature. Epidemiologic studies support the connection between allergy and CRS although a direct causal link has not been established. The aim of this study was to assess the role of atopy and asthma status in predicting both the outcome of surgically treated chronic rhinosinusitis (CRS) and the severity of disease as assessed by radiologic findings.

Methods: Medical records of adults with CRS who failed medical therapy and underwent functional endoscopic sinus surgery (FESS) in 5 consecutive years were reviewed. All patients were included who had complete documentation for specific inclusion criteria: gender, age, asthma status, allergy status, surgical revision rate, Lund-Mackay score, presence/absence of polyposis, and disease recurrence within the first year following FESS.

Results: Fifty-three patients met the inclusion criteria. Positive inhalant allergy skin tests were noted in 79% of patients. Both atopic patients and asthmatic patients had statistically significantly higher Lund-Mackay scores than their non-atopic/non-asthmatic counterparts. There were no significant differences between atopic/asthmatic and non-atopic/non-asthmatic patients in one-year surgical outcome and surgical revision rate.

Conclusions: Adults with CRS who require surgical intervention have higher rates of atopy when compared with the general popu-lation. Atopy and asthma are good predictors of more severe radio-logic findings. Neither atopic status nor asthma, however, predicts surgical outcome or revision rate. These findings support the uni-fied airway model of generalized airway inflammation.

Keywords: Lund-Mackay scores, polyposis, FESS, modified quantitative esting, intradermal dilutional testing, unified airway model, CRS ecurrence

Keywords

Lund-Mackay scores; polyposis; FESS; modified quantitative testing; intradermal dilutional testing; unified airway model; CRS recurrence

Introduction

Chronic Rhinosinusitis (CRS) is a prevalent chronic disease that affects more than 30 million Americans [1]. In addition to causing significant physical symptoms, CRS exerts a negative influence on quality-of-life (QOL). There has historically been variability in the literature regarding diagnostic criteria for CRS, although diagnosis is generally based on clinical presentation, physical exam, nasal endoscopy and sinus computed tomography scans (CT) [2]. CRS represents a dynamic spectrum of inflammatory and infectious processes in the nose and sinuses [3].
Allergy and asthma in CRS patients have been discussed extensively in the literature. Epidemiologic studies support the connection between allergy and CRS although a direct causal link has not been established [4]. The term “one airway, one disease” refers to the fact that there are similarities and linkages between asthma and rhinitis [5].
The objective of the present study was to assess the role of atopy and asthma status in predicting both the outcome of surgically treated chronic rhinosinusitis (CRS) and the severity of disease as assessed by radiologic findings. We hypothesize that CRS patients with asthma and / or atopy will have poorer clinical outcomes and worse radiologic findings than their non-atopic, non-asthmatic counterparts.

Materials and Methods

Sample
An approval from the Institutional Review Board (IRB) at Wayne State University (Detroit, Michigan) was obtained to conduct this retrospective chart review study. Five hundred and seventy-five patients were identified to have had allergy testing (IDT or MQT) by the senior author at the Otolaryngology Department of the Wayne State University School of Medicine in 5 consecutive years. Patients who were diagnosed with CRS (using standard AAO-HNS guidelines) and who failed medical therapy and required functional endoscopic sinus surgery (FESS) were included in the study. Fiftynine (24 males and 35 females) patients met the inclusion criteria. Charts for six patients were missing and they were excluded from the study. Fifty-three patients (22 males and 31 females) were included in the analysis. The other 516 were not included because they didn’t meet the inclusion criteria (i.e., CRS responding to medical therapy, allergic rhinitis without CRS, and allergic fungal sinusitis).
Procedure
The following variables were collected from patient medical records: gender, age, asthma status, allergy status, revision rate, Lund-Mackay (LM) score, polyposis, and disease recurrence within 1 yr status post FESS. Asthmatic status was obtained from patient’s history. Modified quantitative testing (MQT) and intradermal dilutional testing (IDT) were used as skin testing techniques to evaluate for allergic status. The revision rate was determined based on the number of sinus surgeries for CRS the patient underwent in the year after the first procedure, and was recorded as a continuous variable. LM scoring was performed by the first author, who was blind to patient identity at the time of scoring. The status of polyposis was determined by physical exam in the office or intraoperatively. Recurrence was defined as recurrence of pre-operative symptoms that necessitated administration of antibiotics or oral steroids.
Analysis
Chi-square analysis was used to evaluate pair-wise comparisons between the following variables: allergy status, asthma status, LM score, disease recurrence, revision rate and polyposis. To convert LM scores to categorical data, LM score of <=8 was considered “low” and a score of greater than 8 was considered “high”. To convert revision rate to categorical data, a revision rate of 1 or greater was considered “positive” and a revision rate of 0 was considered “negative”. P values lower than 0.05 were considered statistically significant. Sigma Statversion 3.5 (Systat Software Inc., San Jose, California) was used to perform statistical analysis.

Results

Fifty-three adult patients met the inclusion criteria: 22 males and 31 females. The mean age for the study population was 43 ± 14 years. Positive inhalant allergy skin tests were noted in 79% of patients who had documented records of the test. Asthma was present in 50% of patients. At the time of surgery, 16 out of 48 (33%) patients had at least one previous FESS. Intraoperatively, polyposis was noted in 29 (55%) patients. The mean LM score for the 52 patients who had their sinus CT reviewed was 11.1 ± 7.3. Thirty patients had a “high” LM score whereas the other 22 patients had a “low” score. Forty patients had follow-up periods in the range of 1-60 months. Recurrence of CRS symptoms that necessitated giving antibiotics within the first year was documented in 17 patients.
Chi-square tests were performed to assess pair-wise comparisons between the variables noted in Table 1. Means and standard deviations for significant comparisons are noted in Table 2. Atopic patients had a LM score of 11.2 ± 1.2 whereas non-atopic patients had a LM score of 5.8 ± 2.1 (p = 0.031). In addition, asthmatic patients had a LM score of 13.6 ± 1.4 whereas the mean LM score was 9.2 ± 1.5 for non-asthmatics (p=0.039). Both atopic patients and asthmatic patients in the sample therefore had significantly higher LM scores than their non-atopic/ non-asthmatic counterparts. In addition, patients who were noted to have polyposis intraoperatively had significantly higher LM scores than those patients without nasal polyps (p<0.0001). There were no significant differences between atopic/asthmatic and non-atopic/non-asthmatic patients in surgical revision rate at follow-ups of up to one year.
Table 1: Chi-Square Analysis.
Table 2: Mean (SD) LM Scores for Significant Comparisons.

Discussion

Fifty-three CRS adult patients who failed medical therapy and required FESS for treatment were included in the study. About one third of the study population had at least one FESS prior to joining the study. Recurrence of disease within one year post FESS was as high as 42%. Prevalence of allergy and asthma were 79% and 50% respectively in our study population. LM scores were significantly higher among atopic and asthmatic patients compared to their non-atopic and nonasthmatic counterparts. Disease recurrence and surgical revision rate were not statistically different when comparing atopic and asthmatic patients with their non-atopic and non-asthmatic counterparts.
In the present study, allergy prevalence in CRS patients who failed medical therapy was 79%. This figure is higher than the generally accepted prevalence of allergy in the adult population, which is estimated to be between 10% and 30% [6]. This finding is consistent, however, with observations of Emanuel and Shah [7], who found that allergy tests were positive in 84% of their CRS patients whose symptoms were severe enough to necessitate a FESS. This observation emphasizes the increased prevalence of allergy among patients undergoing surgery for CRS.
CRS patients who had asthma or allergy as comorbidity tend to have more severe sinus CT changes with higher LM scores. This association was statistically significant in our present population. In 2000, Krouse [8] demonstrated similar findings among 50 atopic patients undergoing sinus surgery. In examining patient symptoms, however, Krouse8 noted that CT scan severity was not associated with symptom severity or quality of life, while presence and severity of allergy did correlate with these variables. In 2000, Smith et al. [9] also demonstrated that asthmatics had significantly higher LM scores (15.0 ± 7.7) compared to non-asthmatics (10.0 ± 5.5); however, he showed that allergy did not appear to predict the severity of sinus CT abnormalities. In 2005, McMains and Kountakis [10] studied revision FESS in CRS patients and reported higher LM scores in asthmatics compared to non-asthmatics. In 2006, Robinson et al. [11] studied CRS patients undergoing FESS, reporting an atopy prevalence of 30%. They also showed that LM scores were not significantly different between atopic and non-atopic patients. Stewart et al. [12] however, reported in 2000 that atopic patients with CRS had poorer surgical outcomes than non-allergic individuals.
Disease recurrence and surgical revision rate were not statistically different in this study when comparing atopic and asthmatic patients with their non-atopic and non-asthmatic counterparts, suggesting that the presence of allergy or asthma alone may not necessarily predict worse prognosis. Severity of disease as assessed by CT scan, however, did appear to be associated both with atopic status and the presence of asthma. The present findings support the observation that both allergy and asthma status appear to be associated with severity of sinus disease as assessed by CT scan.
The present study has several potential limitations that need to be mentioned. Symptoms were not assessed using a standardized questionnaire such as Rhinosinusitis Disability Index (RSDI) or Sino- Nasal Outcome Test (SNOT-20). In addition, this study is an uncontrolled, retrospective, observational study. Subjects were not enrolled prospectively, and the limited sample size may not be fully representative of the population of patients with CRS.

Conclusion

The present findings suggest that adults with CRS who require surgical intervention have higher rates of atopy when compared with the general population. In addition, they suggest that atopy and asthma are associated with more severe radiologic findings on CT scan. Neither atopic status nor asthma alone, however, predicts surgical outcome or revision rate. These findings support the unified airway model of generalized airway inflammation. Further prospective studies are needed to demonstrate support for these results.

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