Original article

Sinus disease in children with respiratory allergy☆

Background: Chronic rhinosinusitis (CRS) in children is a relatively common entity with significant negative effect on quality of life and significant utilization of health care resources.

Methods: This textbook chapter is an exhaustive up-to-date review of CRS in children including latest information about pathophysiologic factors, associated comorbidities, and medical and surgical management.

Results: CRS in children is an inflammatory disease with an increase in eosinophils, neutrophils, and lymphocytes in the sinus mucosa. Bacterial infection probably contributes to the pathophysiology of the disease, and there is emerging evidence to support the contribution of bacterial biofilms. Unlike adult CRS, the adenoids play an important role in children and probably act as a bacterial reservoir that contributes to CRS. Several comorbidities are associated with CRS to different extents, and they include allergic rhinitis, immune deficiencies, primary ciliary dyskinesia, cystic fibrosis, and allergic fungal sinusitis. Mainstay of therapy is medical and includes nasal saline irrigations, intranasal steroids, and antibiotics. Surgical therapy is reserved to medical failures and includes adenoidectomy, sinus irrigation, and functional endoscopic sinus surgery.

Conclusions: CRS is encountered by pediatricians, allergists, otolaryngologists, and infectious disease specialists. We present a comprehensive review of clinical disease and an evidence-based review of diagnosis, and medical and surgical management strategies.

Upper airway disease, including chronic rhinitis and rhinosinusitis, affect most children with asthma. Over the past two decades, our understanding of the connection between the nose, paranasal sinuses, and lungs has evolved significantly. A growing body of population-based studies has established that allergic rhinitis in children acts as a critical independent risk factor for the development of asthma and that specific allergen immunotherapy has been shown to reduce the risk for developing asthma by approximately 50%. A number of physiologic mechanisms underlie the apparent connection between the upper and lower airways, particularly the systemic spread of inflammation from the nose and sinuses to the lungs. A large number of studies have examined the effect of nasal and sinus therapy, including both medical and surgical treatments, on subjective and objective parameters of asthma. While there is a paucity of randomized, blinded studies, the existing data do suggest that treatment of rhinitis and sinusitis have a beneficial effect on asthma symptoms, pulmonary function, and bronchial hyperresponsiveness.

The effect of cinnamaldehyde on the treatment of allergic rhinitis (AR) was investigated in rat model.

Twenty-eight female Wistar albino rats were randomly divided into four groups: Group 1 (control) (C), Group 2 (AR with no treatment) (AR + NoTr), Group 3 (AR + Azelastine HCl) (AR + Aze), and Group 4 (AR + cinnamaldehyde) (AR + Cin). At day 21, AR + Aze rats were given an Azelastine HCl drop, and AR + Cin rats were given cinnamaldehyde intranasally. In all groups, allergic symptoms histopathological results were evaluated.

The AR + NoTr group showed the worst allergic symptoms, cilia loss and greater inflammation. In the AR + Aze and AR + Cin groups, allergic symptom scores were higher than those in the control group. However, between AR + Aze and AR + Cin groups, there were no significant differences in the allergic symptom scores Histopathological analysis revealed vascular congestion and an increase in goblet cell numbers in the AR + Cin group. However, AR + Cin rat nasal mucosa had less plasma cell infiltration compared with the AR + NoTr group. In rats from the AR + Aze group, analysis of the nasal mucosa revealed less eosinophil infiltration than that seen in the AR + NoTr group. A lower score for mast cell (MC) infiltration was observed in the nasal mucosa of rats treated with Azelastine HCl compared with cinnamaldehyde.

In this study we observed that both Azelastine HCl and cinnamaldehyde reduced allergic symptoms in an AR rat model. Cinnamaldehyde decreased vascular congestion as well as plasma cell, eosinophil, and inflammatory cell infiltration into the lamina propria.

Nasal irrigation has been used as adjunctive therapy for sinonasal disease but is under-researched in children. The study aim was to evaluate the effectiveness of nasal irrigation with normal saline in the management of acute sinusitis in atopic children.

We enrolled 60 atopic children with acute sinusitis, of whom 29 received nasal irrigation with normal saline and 31 did not receive nasal irrigation. All participants underwent a nasal peak expiratory flow rate (nPEFR) test, a nasal smear examination, and radiography (Water's projection) and were requested to complete a Pediatric Rhinoconjunctivitis Quality-of-Life Questionnaire (PRQLQ) during the baseline visit. All participants were requested to record symptoms in a daily diary and were followed up at 1-week intervals. A physical examination, nasal smear, and nPEFR were performed at each visit, and all daily diaries were collected. At the final visit (after 3 weeks), the symptom diaries were reviewed and participants were requested to complete the PRQLQ again. nPEFR, radiography, and a nasal smear were also repeated.

There were significant improvements in mean PRQLQ and nPEFR values (p < 0.05) for the irrigation compared to the non-irrigation group. There was no significant difference in radiographic findings between the groups (p > 0.05). The irrigation group recorded significant improvements in eye congestion, rhinorrhea, nasal itching, sneezing, and cough symptoms compared with the non-irrigation group.

Nasal irrigation is an effective adjunctive treatment for acute sinusitis in atopic children.