The ‘‘single airway’’ concept  The upper respiratory tract -nose and paranasal sinuses- has the same mucosal lining as the lower airways  Both compartments are involved together in health and disease  In asthma, allergic rhinitis and nasal polyposis  Similarly useful in chronic infective respiratory conditions

Mucociliary clearance - Important first-line defence of both upper & lower respiratory tracts - Trap inhaled matter and propel it to the nasopharynx  Impaired sinonasal clearance  Stasis of secretions  Prone to bacterial infection  Chronic rhinosinusitis  Other important host defences - Immunoglobulins, defensins - Aantibacterial components of the mucus such as lysozyme

 Same aetiology and pathophysiology  Sinonasal disease may directly influence the bronchial condition  Rarely considered together & Little literature on the treatment of sinonasal disease in bronchiectasis This article  Review sinonasal disease in bronchiectasis and cystic fibrosis  Addresses the possible interactions between the health and disease of the upper and lower airways Bronchiectasis and cystic fibrosis Sinonasal disease

 Rhinosinusitis - Inflammation of the nose and paranasal sinuses - Nasal obstruction/congestion or anterior/posterior rhinorrhoea - Anosmia and facial pain or pressure  Acute rhinosinusitis ; Sx. < 12 weeks Nasal polyposis  Chronic rhinosinusitis ; Nasal polyposis - Chronic inflammatory disease of the nose and sinus mucosa - Frequently associated with asthma, cystic fibrosis (CF), primary ciliary dyskinesia (PCD) and aspirin sensitivity

 2.7% 6.6%  2.7% and 6.6% of the population have chronic rhinosinusitis  Increased incidence in patients with chronic inflammatory lower respiratory disease  Chronic rhinosinusitis can impact heavily on quality of life with significant impairments on health status instruments  Patients with chronic rhinosinusitis had more general body pain and worse social functioning than those with COPD or heart failure -The health impact of chronic sinusitis in patients seeking otolaryngologic care -The health impact of chronic sinusitis in patients seeking otolaryngologic care Otolaryngol Head Neck Surg 1995 Otolaryngol Head Neck Surg 1995

 Abnormal dilation of the bronchi due to the loss of elastic and muscular components of the wall due to destruction by enzymes such as collagenase and elastase from neutrophils - Excess mucus production - Recurrent lower respiratory tract infections  End result of several different aetiologies  It is almost universal, and often more severe, when the sinusitis and bronchiectasis share a common aetiology

 Autosomal recessive condition whereby ciliary motility is absent or severely impaired leading to sinusitis, otitis media, glue ear, chronic bronchitis, bronchiectasis and male infertility  Kartagener’s syndrome ; association of situs inversus characterises  Patients have congested noses from birth and often have difficulty breast feeding due to the inability to nose breathe  Need for cilia investigation

 Characterised by bronchiectasis, chronic rhinosinusistis and male infertility  Ciliary function is found to be normal and clearance is impaired because the mucus is viscous  Association with mercury poisoning in childhood from teething powders and treatment of worm infections  Diagnosis is made on exclusion of CF and PCD

 Autosomal recessive condition characterised by a defect in the CF transmembrane conductance regulator gene product that leads to abnormalities of ion flux at the epithelial surface  The increased sodium absorption leads to periciliary liquid depletion and abnormal mucus movement  Clinically, patients progress to chronic respiratory failure caused by bacterial infections and have pancreatic insufficiency

 Nasal mucociliary clearance ; small saccharin particle is placed on the medial side of the inferior turbinate and the time taken to experience the taste recorded, with abnormal values typically > 20 min - Use of colloid particles labelled with technetium-99  Nasal brush biopsy - Structure and function of the cilia is assessed following a - Cyto logy brush; scrape epithelial cells from the inferior turbinate  Expired nitric oxide levels - Useful in the assessment of a patient with bronchiectasis - Screening tool for PCD Assessment of mucociliary clearance

 Review of the symptoms an assessment of their severity  Review of the symptoms & an assessment of their severity - The amount and type of discharge - Any facial pain or smell disturbance - The degree of nasal obstruction  Rhinomanometry  Anterior rhinoscopy & Endoscopy  Radiography of the sinuses  CT Assessment of upper airway Failure of treatment Failure of treatment Preoperatively Preoperatively For complications For complications

 Japanese study  Japanese study ; 45% of patients with idiopathic bronchiectasis  UK study  UK study ; 84% of patients with idiopathic bronchiectasis 50% of those with postinfective bronchiectasis  Anterior and posterior rhinorrhoea, anosmia and nasal obstruction  Nasal polyps occur in up to 40%  S. aureus, CNS, GNB & Anaerobic  Universal in PCD and Young’s syndrome

 Almost patient with CF has nasal and paranasal sinus disease  < 10% of patients with CF typically report significant symptoms  S. aureus, H. influenzae prevalent in the younger age group  P. aeruginosa important in older patients  Anaerobes and fungi (1/3 of CF patients)  The different sinonasal manifestations and severity of CF  No associations  Complications of sinonasal disease (eg, mucoceles) in CF  Much rarer than in the general population

 Initial therapy should be medical with the aim to relieve symptoms, improve quality of life and avoid disease complications  Chronic rhinosinusitis often responds incompletely to treatment, which is usually continued long term

 Improved drainage › Saline irrigation ; clear secretions and nasal crustings › Saline nasal spray (eg, Sterimar) or Douching (eg, Sinu-rinse) › Topical decongestants  Steroids Topical nasal steroids › Improvements in both symptoms and objective measures › Reduce nasal polyp size and symptoms Medical treatment

 Antibiotics  Topical ointments (eg, Bactroban, Naseptin)Macrolides › Reduce inflammatory cytokines(eg, IL-8, TNF-α), inflammatory cell recruitment and free radical production › Improve ciliary motility and reduce biofilm production › Not studied in patients with CF or bronchiectasis  Other agents › Topical mucolytic, N-acetylcysteine › Antileukotrienes, antihistamines

 Surgery › Performed endoscopically with the aim of improving drainage Endoscopic sinus surgery Endoscopic sinus surgery - Reserved for patients who do not respond to medical treatment - Well tolerated in patients with CF Surgical treatment

 Sinonasal disease › Significant morbidity in patients with chronic respiratory disease › It can also significantly impact on lower respiratory health › It should not be considered in isolation  Asthma, Children with CF  Bronchiectasis › Migration of organisms from the upper respiratory tract › Acting as a ‘‘sump’’ for reinfection › Early detection of colonization and aggressive management › P. aeruginosa eradication protocols

“Single airway” model Common aetiology and pathophysiology of sinonasal and respiratory disease Improve lower respiratory health Improve lower respiratory health Reduce infection & inflammation Reduce infection & inflammation in the bronchiectatic airway in the bronchiectatic airway Appreciation & treatment of of Concomitant sinonasal dis.