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Published byVincent Holland Modified over 8 years ago
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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“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.
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