**2. Sinusitis related asthma**

Asthma is a chronic disorder that involves airflow obstruction, an underlying inflammation and bronchial hyper responsiveness. Asthma is complicated disorder that not only involves larger airways but also small airways. Sino nasal disorders are most commonly diagnosed with the asthma. For centuries the continuous existence of these pathological conditions has been known. However the link between upper airways and lower airways has been not clearly understood. Rhinitis and sinusitis are two wide spectrum disorders agonizing the upper airways which are closely related to asthma [23].

#### **2.1 Prevalence, risk factors and causes**

Allergic rhinitis and sinusitis are one of the risk factor for asthma. Inherited differences in asthma prevalence, asthma attacks, constructive and appropriate asthma management, thorough education and regular visit to medical health care of patients with asthma associated with sinusitis and rhinitis may lead to effectively control of asthma and also reduce the risk factor for more prevalence.

Clinical trials on the sino nasal pathological conditions has been conducted and it was reported that sinusitis and allergic rhinitis of childhood was severely associated with asthma among them 42% of the patients had asthma with sinusitis whereas 12.9% of the patients only suffered with asthma. Before the age of 7 years if sinusitis is present then it would subsequently lead to asthma. If the sinusitis or allergic rhinitis occurred at the age of seven then the chances of developing asthma increases three fold. The term "The Allergic March" is used to show the progression of the disease from the nose and sinuses to the airways of the lungs [24].

The progression of sino nasal allergic march may proceed before the development of sinusitis. In children and infants atopic eczema may leads to sinusitis and subsequently to asthma. Comparatively in infants with non-atopic eczema, no sinusitis would develop. This confirms that eczema is risk factor for the development of sinusitis and asthma as well. Which further strengthen the concept of an "Allergic March" that sinusitis, allergic rhinitis and asthma are different diseases but still the progressively enhance by allergy [25]. The effect of the first line treatment for eczema on the progression and development of sinusitis is still unknown in patients with sino nasal disorder. Clinical trials have shown that smoking increased three folds the risk of asthma in patients already having sinusitis. Recent publications have shown that obesity is also one of the risk factor for asthma however obesity is not involved in sino nasal disorders as both obesity related asthma and sinusitis related asthma follows different pathway and mechanism [26].

These clinical trials and studies verify that the sinusitis and allergic rhinitis are contributing factors in asthma progression. If sinusitis can be intervene than the development of asthma can be prevented. Another important environmental factor that is smoking elevate asthma can be controlled by quitting tobacco [27] (**Figure 1**).

#### **2.2 Difference between sino nasal disease in asthmatics and non-asthmatics**

Sino nasal disease may appear differently in asthmatics then that of general population. Literature survey showed that the patients showing nasal symptoms and undergo to examine the clinical feature of lower airway disease then it is found that most of the patients suffering with the chronic sinusitis and allergic rhinitis along with asthma as compared to non-allergic rhinitis. Asthmatic patients associated with sinusitis progress to nasal polyps and are in much complications of sino nasal disease comparing to non-asthmatics. Sinusitis related asthmatics have more severe and persistent disease and they need multiple of surgeries as well [28].

Studies revealed that sinusitis may develop asthma progressively but there is a difference in between sinusitis related asthma and general population. This is strongly supported by data.

**31**

*Sinusitis, Asthma and Headache*

population.

**Figure 1.**

air ways [29, 30].

**2.3 Upper and lower air way inflammation**

*DOI: http://dx.doi.org/10.5772/intechopen.90210*

1.In asthmatics upper air way disease appear differently as compared to general

*Risk factors for the development of sinusitis and rhinitis which leads toward asthma.*

2.Inflammation in upper and lower air ways in both population would be alike.

3.Increasing severity in the upper air ways going parallel to the severity in lower

In asthmatic patients the inflammation in nose and sinuses shows there is disease in the lungs. For instance if patient having nasal polyposis inflammation its clinical identification feature shows antibody IgE production and eosinophilic inflammation. Common inflammatory mediators are release from upper and lower air ways, due to which it is difficult to assess pathways that cause Sino nasal inflammation in asthmatics and non-asthmatics [31]. Further clinical studies have performed in which gene expression of patient with sinus mucosa polyposis and aspirin sensitive asthma was compared with chronic sinusitis and no difference in gene expression was found. Further clinical studies on gene assays that is based on testing of lower air way helps us to understand how sinusitis is different in asthma patient than non-asthmatics [26].

From the literature review it is noted that increase in severity of sino nasal disease goes parallel with the lower airways. Recent publication shows that patients having severe sinusitis have severe asthma series. This study suggests that sinusitis, rhinitis and asthma all are common progression of a single systematic disease [32]. Which ids further confirm by more clinical research in which severity in inflammation of lungs is same as in sinuses, nose and systematic inflammation which is measured by circulating eosinophilia, hence the severity in sinusitis or sino nasal disease is parallel to asthma and also same implies that lymphocyte and eosinophil are characteristic feature of upper and lower air way inflammation if upper air way

go worse than lower air way also get affected in same way [33] (**Figure 2**).

*Sino-Nasal and Olfactory System Disorders*

**2.1 Prevalence, risk factors and causes**

related to asthma [23].

that not only involves larger airways but also small airways. Sino nasal disorders are most commonly diagnosed with the asthma. For centuries the continuous existence of these pathological conditions has been known. However the link between upper airways and lower airways has been not clearly understood. Rhinitis and sinusitis are two wide spectrum disorders agonizing the upper airways which are closely

Allergic rhinitis and sinusitis are one of the risk factor for asthma. Inherited differences in asthma prevalence, asthma attacks, constructive and appropriate asthma management, thorough education and regular visit to medical health care of patients with asthma associated with sinusitis and rhinitis may lead to effectively

Clinical trials on the sino nasal pathological conditions has been conducted and it was reported that sinusitis and allergic rhinitis of childhood was severely associated with asthma among them 42% of the patients had asthma with sinusitis whereas 12.9% of the patients only suffered with asthma. Before the age of 7 years if sinusitis is present then it would subsequently lead to asthma. If the sinusitis or allergic rhinitis occurred at the age of seven then the chances of developing asthma increases three fold. The term "The Allergic March" is used to show the progression

The progression of sino nasal allergic march may proceed before the development of sinusitis. In children and infants atopic eczema may leads to sinusitis and subsequently to asthma. Comparatively in infants with non-atopic eczema, no sinusitis would develop. This confirms that eczema is risk factor for the development of sinusitis and asthma as well. Which further strengthen the concept of an "Allergic March" that sinusitis, allergic rhinitis and asthma are different diseases but still the progressively enhance by allergy [25]. The effect of the first line treatment for eczema on the progression and development of sinusitis is still unknown in patients with sino nasal disorder. Clinical trials have shown that smoking increased three folds the risk of asthma in patients already having sinusitis. Recent publications have shown that obesity is also one of the risk factor for asthma however obesity is not involved in sino nasal disorders as both obesity related asthma and

control of asthma and also reduce the risk factor for more prevalence.

of the disease from the nose and sinuses to the airways of the lungs [24].

sinusitis related asthma follows different pathway and mechanism [26].

These clinical trials and studies verify that the sinusitis and allergic rhinitis are contributing factors in asthma progression. If sinusitis can be intervene than the development of asthma can be prevented. Another important environmental factor that is smoking elevate asthma can be controlled by quitting tobacco [27] (**Figure 1**).

**2.2 Difference between sino nasal disease in asthmatics and non-asthmatics**

Sino nasal disease may appear differently in asthmatics then that of general population. Literature survey showed that the patients showing nasal symptoms and undergo to examine the clinical feature of lower airway disease then it is found that most of the patients suffering with the chronic sinusitis and allergic rhinitis along with asthma as compared to non-allergic rhinitis. Asthmatic patients associated with sinusitis progress to nasal polyps and are in much complications of sino nasal disease comparing to non-asthmatics. Sinusitis related asthmatics have more severe and persistent disease and they need multiple of surgeries as well [28]. Studies revealed that sinusitis may develop asthma progressively but there is a difference in between sinusitis related asthma and general population. This is

**30**

strongly supported by data.

**Figure 1.** *Risk factors for the development of sinusitis and rhinitis which leads toward asthma.*


In asthmatic patients the inflammation in nose and sinuses shows there is disease in the lungs. For instance if patient having nasal polyposis inflammation its clinical identification feature shows antibody IgE production and eosinophilic inflammation. Common inflammatory mediators are release from upper and lower air ways, due to which it is difficult to assess pathways that cause Sino nasal inflammation in asthmatics and non-asthmatics [31]. Further clinical studies have performed in which gene expression of patient with sinus mucosa polyposis and aspirin sensitive asthma was compared with chronic sinusitis and no difference in gene expression was found. Further clinical studies on gene assays that is based on testing of lower air way helps us to understand how sinusitis is different in asthma patient than non-asthmatics [26].

## **2.3 Upper and lower air way inflammation**

From the literature review it is noted that increase in severity of sino nasal disease goes parallel with the lower airways. Recent publication shows that patients having severe sinusitis have severe asthma series. This study suggests that sinusitis, rhinitis and asthma all are common progression of a single systematic disease [32]. Which ids further confirm by more clinical research in which severity in inflammation of lungs is same as in sinuses, nose and systematic inflammation which is measured by circulating eosinophilia, hence the severity in sinusitis or sino nasal disease is parallel to asthma and also same implies that lymphocyte and eosinophil are characteristic feature of upper and lower air way inflammation if upper air way go worse than lower air way also get affected in same way [33] (**Figure 2**).

**Figure 2.**

*Physiological relation between upper and lower air way: Inflammation in upper air way (nose, sinuses) develop with parallel to lower air way (lungs) in asthmatic patients.*

Sino nasal disorders may increase the risk of lower air way (lungs) diseases which can be seen from the clinical studies. It has been shown that children suffering from allergic asthma and allergic rhinitis due to the dust mites, in that patients there was increased exhalation of nitric oxide was found [34]. Studies have also shown that in patients with allergic asthma allergens can develop the release of eosinophils from bone marrow which shows that sinusitis, rhinitis and asthma could be separate diseases but affected by single systematic disease [35].

### **2.4 Sino nasal disorder associated with asthma**

Sino nasal disorders are linked with asthma is supported by the clinical research studies i.e. non asthmatic patients with allergic rhinitis have inflammation and abnormalities in lower airway. This is further supported by the fact that allergic rhinitis have an increase prevalence for the hyper bronchial activity. Another study showed that sinusitis and allergic rhinitis are associated with impaired lung functions which are significantly related to duration and exposure of sino nasal disorder to the risk factors. These findings suggest that patients with sinusitis and allergic rhinitis may have subclinical abnormalities of their intra thoracic airways and may be at risk of developing the clinical disease of asthma [36, 37] (**Figure 3**).

#### **2.5 Asthma management**

Asthma control appears worse in individuals having sino nasal disorder. Recent cross sectional, retrospective and prospective studies between the asthma symptoms and sinusitis symptoms have performed. These studies suggested that severity in sino nasal disorders increase the severity of asthma symptoms [36].

#### **2.6 Treatment outcomes**

Important parameters for the treatment outcome include 1. Early treatment of the patient suffering with sino nasal disease to prevent asthma. 2. Treatment regimen should be as effective as to treat asthma symptoms along with sinusitis and rhinitis [38].

Clinical trials are performed on 147 children treated with specific subcutaneous immunotherapy for rhinoconjuctivitis, showed that most of the children do not progress to asthma. Recently study was published in which patients treated

**33**

**Figure 3.**

*Progressive gradation of sino nasal disease.*

nasal disease [42, 43].

*Sinusitis, Asthma and Headache*

*DOI: http://dx.doi.org/10.5772/intechopen.90210*

with antihistamine and nasal corticosteroids for the treatment of allergic rhinitis and airflow obstruction investigated by FEF25–75. It was shown that air flow obstruction was treated with in 3 months [39]. Over the decades there has been much interest in finding out and establishing treatment for the sino nasal disorder which may affect the asthma. However studies were performed among which prospective study was disappointing and retrospective study was suggested that by treating sinusitis and rhinitis asthma can be prevented from progression [40, 41]. From the previous trials it was believed that by treating nasal diseases lower air way abnormalities can be controlled which can decrease systemic eosinophilic inflammation. But in the recent trials it was seen that treatment of rhinitis do not affect the lower air way inflammation in any way which was investigated by measuring exhaled (nitric oxide) NO [42]. In these double blinded systemic controlled trials almost 40 children were subjected to treat with nasal steroids along with placebo. The results of the trials suggested that sino nasal inflammation and systemic inflammation was treated, which were investigated by counting eosinophilic cationic protein but unfortunately there was no effect on lower air way inflammation (measured by exhaled by NO). These randomized trials were contraindicated with the previous trials which were carried on the adults. According to previous trials on adults lower air way inflammation was affected by measuring exhaled NO which was decreased by treating with nasal steroids. These results suggested that the effect of nasal treatment to control asthma or lower air way inflammation may vary in different patients sub groups. Not only this but also, studies have suggested that surgical treatment of nasal disease may also help in managing asthma outbreak. Despite of these clinical trials still there is a need to determine how well sino nasal treatment can help in reduction of asthma. Investigation of the patients who may have benefit from the treatment of

*Sinusitis, Asthma and Headache DOI: http://dx.doi.org/10.5772/intechopen.90210*

**Figure 3.**

*Sino-Nasal and Olfactory System Disorders*

**Figure 2.**

Sino nasal disorders may increase the risk of lower air way (lungs) diseases which can be seen from the clinical studies. It has been shown that children suffering from allergic asthma and allergic rhinitis due to the dust mites, in that patients there was increased exhalation of nitric oxide was found [34]. Studies have also shown that in patients with allergic asthma allergens can develop the release of eosinophils from bone marrow which shows that sinusitis, rhinitis and asthma could be separate diseases but affected by single systematic disease [35].

*Physiological relation between upper and lower air way: Inflammation in upper air way (nose, sinuses)* 

Sino nasal disorders are linked with asthma is supported by the clinical research studies i.e. non asthmatic patients with allergic rhinitis have inflammation and abnormalities in lower airway. This is further supported by the fact that allergic rhinitis have an increase prevalence for the hyper bronchial activity. Another study showed that sinusitis and allergic rhinitis are associated with impaired lung functions which are significantly related to duration and exposure of sino nasal disorder to the risk factors. These findings suggest that patients with sinusitis and allergic rhinitis may have subclinical abnormalities of their intra thoracic airways and may be at risk of developing the clinical disease of

Asthma control appears worse in individuals having sino nasal disorder. Recent cross sectional, retrospective and prospective studies between the asthma symptoms and sinusitis symptoms have performed. These studies suggested that severity

Important parameters for the treatment outcome include 1. Early treatment of the patient suffering with sino nasal disease to prevent asthma. 2. Treatment regimen should be as effective as to treat asthma symptoms along with sinusitis and

Clinical trials are performed on 147 children treated with specific subcutaneous immunotherapy for rhinoconjuctivitis, showed that most of the children do not progress to asthma. Recently study was published in which patients treated

in sino nasal disorders increase the severity of asthma symptoms [36].

**2.4 Sino nasal disorder associated with asthma**

*develop with parallel to lower air way (lungs) in asthmatic patients.*

asthma [36, 37] (**Figure 3**).

**2.5 Asthma management**

**2.6 Treatment outcomes**

**32**

rhinitis [38].

*Progressive gradation of sino nasal disease.*

with antihistamine and nasal corticosteroids for the treatment of allergic rhinitis and airflow obstruction investigated by FEF25–75. It was shown that air flow obstruction was treated with in 3 months [39]. Over the decades there has been much interest in finding out and establishing treatment for the sino nasal disorder which may affect the asthma. However studies were performed among which prospective study was disappointing and retrospective study was suggested that by treating sinusitis and rhinitis asthma can be prevented from progression [40, 41]. From the previous trials it was believed that by treating nasal diseases lower air way abnormalities can be controlled which can decrease systemic eosinophilic inflammation. But in the recent trials it was seen that treatment of rhinitis do not affect the lower air way inflammation in any way which was investigated by measuring exhaled (nitric oxide) NO [42]. In these double blinded systemic controlled trials almost 40 children were subjected to treat with nasal steroids along with placebo. The results of the trials suggested that sino nasal inflammation and systemic inflammation was treated, which were investigated by counting eosinophilic cationic protein but unfortunately there was no effect on lower air way inflammation (measured by exhaled by NO). These randomized trials were contraindicated with the previous trials which were carried on the adults. According to previous trials on adults lower air way inflammation was affected by measuring exhaled NO which was decreased by treating with nasal steroids. These results suggested that the effect of nasal treatment to control asthma or lower air way inflammation may vary in different patients sub groups. Not only this but also, studies have suggested that surgical treatment of nasal disease may also help in managing asthma outbreak. Despite of these clinical trials still there is a need to determine how well sino nasal treatment can help in reduction of asthma. Investigation of the patients who may have benefit from the treatment of nasal disease [42, 43].
