Many people who have asthma suffer from nasal and sinus problems as well. Asthma patients can have inflammation or swelling of the tissues of the nose and sinuses, also called rhinitis and sinusitis.
Rhinitis and sinusitis are key factors in people with asthma.
There seems to be a temporal sequence or progressive manifestations of a common disease process in these patients called the Allergic March, and it may include eczema in infants.
Logically, treating rhinitis and sinusitis in asthma patients seems to allow for better control of their asthma, but there are some patient groups such as those with sinus disease that need to undergo surgery, and aspirin intolerance tends to do better.
The theory of decreasing inflammation in the upper airway leads to decreasing inflammation in the lower airway appears to have merit, but there are still many unanswered questions.
It may be that there is impairment of both the upper and lower airway function in patients with allergic rhinitis and sensitization to certain allergens such as dust mites.
Rhinosinusitis is the term used when asthma patients have problems with both. Rhinitis can happen without sinusitis, but sinusitis is almost always with rhinitis.
Nasal and sinus problems are the most common additional complaint in those patients with asthma. Sinusitis may not be dangerous in the average asthma sufferer, but it certainly must be addressed so that it never becomes serious.
How are the nose, sinuses, and asthma related?
Nasal and sinus problems and asthma are likely part of the same disease process. It has been shown that controlling nasal and sinus problems is important for both the development of asthma and the control of asthma symptoms.
At this point, we know that the treatment of nasal problems in patients with asthma has an impact on lower airway obstruction, but it has not yet been clearly defined. Still, the co-existence of nasal symptoms in asthma patients has been recognized for centuries.
The sinuses may play a special role in asthma patients. Some patients with severe chronic sinus problems are at risk of never adequately being able to control their asthma because of persistent chronic sinusitis, sinus and nasal polyps, and overall poor sinus function.
The association between the upper and lower airways has always been a mystery, but recently there are more clues as to whether the problems begin in the nose and sinuses first or in the lungs.
What is the “Allergic March”?
In recent clinical studies, it had been discovered that childhood allergic rhinitis was significantly associated with the presence of asthma. There was a three-fold higher incidence of asthma in those patients with allergic nasal symptoms such as nasal stuffiness and runny nose.
The presence of allergic rhinitis before seven years of age was used in these studies to predict whether the child would subsequently develop asthma. Thus, healthcare providers coined the term “Allergic March,” meaning that the child starts with an allergic disease of the nose and sinuses, and the disease “marches” down into the lower airways and lungs.
Furthermore, in some infants with dry skin conditions called eczema, the disease begins with dry skin and progresses to nasal symptoms, and finally affects the lungs with asthma symptoms.
In these patients, there is additional support for the Allergic March, which may begin with the infant’s skin. It is postulated that instead of there being separate disease processes, the Allergic March is a progressive manifestation of allergy in children.
It is not yet known whether beginning treatment early for a child’s dry skin or subsequent nasal and sinus problems will either prevent the development of asthma or halt its progression in every child.
What is the significance of upper airway inflammation (rhinitis or sinusitis) in asthma patients?
It is thought that either nasal or sinus disease are manifestations of the same progressive disease with asthma or the Allergic March, as described above.
Alternately, nasal or sinus disease and asthma are separate diseases that can afflict a susceptible population.
Most clinicians believe the former explanation that there is a common disease process because of the following reasons.
Those asthma patients have somewhat different nasal or sinus diseases than that experienced by children who do not have asthma. For example, asthma patients with chronic sinusitis and polyps tend to be more difficult to treat.
The inflammatory processes in the upper and lower airways in patients with asthma tend to be similar.
The severity of the disease tends to be similar in both the upper and lower airways in asthma patients.
Those asthma patients who have chronic sinusitis are more likely to fail intensive medical therapy, require multiple sinus surgeries, and require continual allergy immunotherapy.
Does treatment of allergic rhinitis or sinusitis affect the severity of asthma?
The short answer is maybe. If treatment of nasal or sinus problems lessened the severity of asthma symptoms in every case, it would have a profound impact on these children and young adults in improving asthma control.
Logically, it would seem that treating the nose and sinuses would decrease the overall inflammation in the lungs. Most clinical studies are showing this association to be the case, but it has been hard to prove. Unfortunately, it seems only certain groups of asthma patients with nasal or sinus disease seem to respond to treatment.
Those patients who tend to do better in controlling their asthma include:
- Those asthma patients who undergo sinus surgery, especially those who have nasal polyps.
- Those patients have a history of aspirin-intolerant asthma.
- Those patients with specific allergies such as sensitivity to dust and dust mites are treated for allergies.
The combination of allergy treatment and sinus surgery may be most beneficial in select groups of asthma patients.