Chronic Obstructive Pulmonary Disease and Rhinosinusitis

Up to 88% of patients with COPD presenting at an academic unit for respiratory disease experience nasal symptoms, most commonly rhinorrhoea.⁵⁰ Nasal symptoms in COPD patients correlate well with an overall impairment of QOL.⁵² Thus far, no further information is available on the nasobronchial interaction in COPD patients.

Treatment of Chronic Rhinosinusitis Alters the Course of Asthma

The following paragraphs will outline the benefit of rhinosinusitis treatment on asthma. This relationship strengthens the concept of a unified airway. Treatment of CRS and its exacerbations will undoubtedly benefit the overall treatment outcome of asthma. Until recently, no well-conducted clinical trials have been performed that show the beneficial effects of drug therapy for CRS on bronchial asthma. Ragab et al.⁵³ published the first randomised, prospective study comparing surgery with drug therapy in 43 patients with CRS with or without NP and asthma. Both medical and surgical treatment regimens for CRS were associated with subjective and objective improvements in asthma. No well-conducted trials on the effects of drug therapy for NP on asthma have been conducted so far.

Proposed Treatment Scheme of Chronic Rhinosinusitis for Pulmonologists

The following paragraphs will outline a proposed treatment flow chart of CRS for pulmonologists (see Figure 4).⁶⁵ For a detailed description of the various tables and level of evidence on which recommendations are made, we refer to the EP³OS document itself. Treatment of CRS depends on the presence or absence of NP. Nasal assessment of polyp presence by means of anterior rhinoscopy alone is inadequate. Nasal endoscopy is more adequate, although not always easily accessible or applicable by pulmonologists. If endoscopy is not available, referral to an ear, nose and throat (ENT) specialist should be considered. If any sinister symptoms occur (see Figure 5), an immediate referral to an ENT specialist is recommended.

Treating Rhinosinusitis without Nasal Polyps

If no NP are present, severity of rhinosinusitis should be determined. If moderate, topical steroids can be added to the initial treatment and the condition re-evaluated after 14 days. If severe, treatment with antibiotics (according to the national recommendations) in combination with topical steroids is recommended. Nasal microbiology culture with determination of resistance pattern can be considered before antibiotic therapy is started. If effective within 48 hours, treatment with topical steroids and antibiotics should be continued for seven to 14 days. If no effect is seen within 48 hours or if the disease persists after two weeks of initially successful treatment, referral to an ENT specialist for possible surgical treatment is recommended.

Treating Rhinosinusitis with Nasal Polyps

If mild or moderate NP is present, treatment with topical steroid spray or drops and nasal douches are recommended. When severe, the use of oral steroids (for no longer than three weeks) is the first choice of treatment. If, after evaluation at three months, symptoms have not been alleviated or they have increased, sinonasal surgery should be considered (referral to an ENT specialist).

Treating Exacerbations within Chronic Rhinosinusitits

Exacerbations within CRS should primarily be treated with analgaesics and decongestants for symptomatic relief (no antibiotic treatment necessary). If symptoms persist, treatment with antibiotics and/or oral corticosteroids is recommended.

Surgical Treatment of Chronic Rhinosinusitis with or without Nasal Polyps

Referral to an ENT surgeon is recommended where surgery is considered. The benefit of endoscopic sinus surgery (ESS) on asthma has been investigated. ESS for CRS has been shown to alleviate sinonasal symptoms, but also improves bronchial symptoms and reduces medication use for bronchial asthma in uncontrolled studies.^54–56 After a mean follow-up period of 6.5 years, 90% of asthmatic patients reported that their asthma was better than it had been before ESS, with a reduction in the number of asthma attacks and amount of medication used to treat asthma.¹⁴

After ESS for NP in patients with concomitant asthma, a significant improvement in lung function and a reduction of systemic steroid use was noted. This was not the case in aspirin-intolerant asthma patients.⁵⁷ In a small series of patients with NP, endoscopic sinus surgery did not affect the asthma state.⁵⁸ However, nasal breathing and QOL improved in most patients. There is no clear evidence that CRS or NP patients with asthma benefit less from sinus surgery than patients without asthma.^59–61 Nevertheless, post-operative endoscopy findings regarding healing were worse in patients with concomitant asthma than in those without asthma.^62–64 This suggests a greater need for aggressive post-operative medical treatment (such as steroids, nasal lavages or antibiotics if necessary) and revision sinus surgery where needed.

Conclusion

The EP³OS document supplies pulmonologists with a clear definition of rhinosinusitis and evidence-based guidelines for diagnosis and treatment. The unified airway concept is currently well accepted in light of airway allergy, but needs to be implemented more often in the case of CRS. In addition, more research is needed to improve the strength of evidence for efficacy of any sinonasal treatment, as several treatment regimens have not been fully investigated in properly conducted, randomised trials. Following evidence-based guidelines has proved to be beneficial for the overall outcome in treating disease.⁶⁶ In using these guidelines, an optimal treatment of rhinosinusitis is achieved, hopefully resulting in improvement and control of the pulmonological disease state. The ultimate goal of considering the whole airway in patients with upper and/or lower airway disease is to ensure optimal airway treatment.