Conditions Associated With Exacerbations Of Asthma

Several clinical conditions are closely associated with and may worsen asthma by diverse mechanisms.

Sinusitis

An association between asthma and concomitant sinus disease has been recognized since the early part of the century and has been reconfirmed repeatedly both in children and adults. It is estimated that 60-75% of severe asthmatics have concomitant sinusitis and that 20-30% of sinusitis patients have asthma. Slavin treated 33 adults with asthma and concomitant sinusitis medically or surgically. After therapy, 28 of 33 subjects believed their asthma was improved, and 15 of 18 reduced their steroid requirement by 85%. Anecdotal observations suggest that the difficulty of treating asthmatics with sinusitis is proportional to the degree of sinusitis present. Physicians treating asthmatics should be alert to the possibilities that sinusitis frequently coexists in their patients and that the severity of the sinusitis may influence the course of the bronchial asthma. Although the precise mechanism by which sinusitis worsens asthma is not known with certainty, there is substantial evidence that a naso-sino-bronchial reflex exists which increases airway irritability and airflow obstruction.

In both children and adults, symptoms from acute sinusitis include purulent nasal discharge, persistent coughing (especially at night), and the presence of purulent mucus in the nasal vault and pharynx. Facial pain, headache, and fever occur less frequently. Most acute episodes of sinusitis follow upper respiratory infections, while some then develop into chronic or recurrent problems. Chronic sinusitis is associated with persistent or recurrent purulent nasal discharge, cough, headache or facial pressure, hyposmia, fetor oris, occasion temperatures, and worsening of asthma.

The physician should consider diagnostic studies for sinusitis whenever symptoms of upper respiratory infection or rhinitis are more protracted than expected, the patient has dull to intense throbbing pain over the involved sinus area, the patient's asthma is not responding appropriately to medications, or the patient has prolonged or persistent bronchitis that has failed to respond to appropriate therapy. On physical examination, edema and discoloration below the eyes may occasionally be observed. The nasal mucosa is inflamed, and a purulent discharge frequently is seen on the floor of the nose, beneath the middle turbinate, or draining down the throat.

Generally, roentgenograms with the findings of opacification, noticeable membrane thickening, or air-fluid levels within one or more sinuses confirm the suspicion of sinusitis. Computed tomography scans are much more sensitive than X-rays, provide better images, and are the currently recommended diagnostic procedure of choice.

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