Original Article J

Indian J Pediatr 1996; 63 : 549-552 ul

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Sine-Bronchial Syndrome in Children with Asthma S. Rajajee, S. Geetha and S. lanani The Child's Trust Hospital and The Child's Tm~st Medical Research Foundation, Madras

Abstract. Thirty children in the age group of 2 to 12 years were brought with a history of recurrent non-seasonal moderate to severe wheezy episodes associated with symptoms of nasal congestion, sneezing and occasional headache. All of them had maxillary or pan sinusitis with 26 having associated right, left or bilateral lower lobe pneumonitis or bronchiectasis. Serum immunoglobulins were normal in 22 and was not done in eight. There was positive (2 to 4 + above negative control) skin test response to dust and dust mite in 15 of the 22 children tested. Throat swabs/sputum or nasal secretions grew B-hemolytic streptococcus or streptococcus pneumoniae in twenty seven. All the children were put on bactericidal drugs for 6 to 8 weeks arid bronchodilators were used when needed. At the end of 6 to 8 weeks follow-up X-ray of sinuses and chest showed significant clearing of the lesions which coincided with marked clinical improvement. Sinus X-ray should be considered in bronchial asthma resistant to medical management s~nce untreated bacterial sinusitis can be an underlying cause of chronic poorly controlled asthma. (Indian J Pediatr 1996; 63 : 549-552)

Key Words : Sinusitis; Asthma

The ethmoid and maxillary sinuses are ap- Of the 67 consecutive cases referred as parent by third to fourth month of intra- bronchial asthma, 30 children between 2 to uterine life and are thus present at birth 1. 12 years (mean 4.5 years) with the sympSinusitis is often neither recognised nor tom complex of non-seasonal recurrent treated appropriately as many physicians wheezing, chronic cough (night and day), believe that the paranasal sinuses are not nasal stuffiness, post-nasal drip, headache sufficiently developed in infants to be of and facial pain were taken for the present clinical importance. Chronic sinusitis study. The duration of symptoms was be(disease present for more than 3 weeks) tween 6 months to 5 years (mean 1.5 years). Investigations included X-ray films of may be the cause of poorly controlled asththe sinuses (waters) and chest; blood eosima. The" aim of this study was to assess nophil count and cultures of nasal secreprospectively the role of sinusitis in poorly tions, throat swab and s p u t u m for aerobic controlled asthma and the effect of organisms. Serum immunoglobulin profile treatment with a prolonged course of was done in 22 children. Each child was evaluated for presence of allergy by deantibiotics on the severity of asthma. tailed history taking and physical examinaMATERIALAND METHODS tion followed by skin prick tests with Curewell allergens. Based on the culture reports, the chilReprint requests: Dr. Sarala Rajajee 19, 2nd dren were treated with appropriate antibiMain Road, C.LT.Colony, Madras-600 004.

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CLINICAL FEATURES

RADIOLOGICAL FEATURES

Fig. 1. otics for a period of 6 to 8 weeks d e p e n d i n g on clinical i m p r o v e m e n t . X-ray films of the sinuses a n d chest were repeated at the end of this period. Clinical r e s p o n s e w a s recorded as excellent if there were no further w h e e z i n g e p i s o d e s at the e n d of 1 y e a r of follow up, good w h e n there was mild occasiot~aI wheeze and poor, if there was no imp rovement.

RESULTS

All the 30 children had s y m p t o m s of chronic c o u g h a n d nasal stuffhaess ha addition to wheeze. T w o (6%) children h a d facial p a i n and five (16%) had headache. X-rays of the sinuses s h o w e d evidence of bilateral m a x i l l a r y sinusitis in 20 children, unilateral m a x i l l a r y sinusitis in 4 a n d

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.551

Response to Treatment (by Clinical Features)

R e s p o n s e to T r e a t m e n t

(Radiologieal improvement)

Fig. 2. p a n s i n u s i t i s in 6 children. F e a t u r e s of sinusitis included c o m p l e t e opacity of the sin u s or u n i f o r m m u c o s a l thickening. There was c o r r e s p o n d i n g right l o w e r lobe p n e u m o n i t i s or b r o n c h i e c t a s i s in 21 patients. T h r e e had bilateral d i s e a s e a n d 3 s h o w e d

left lower lobe i n v o l v e m e n t . S e r u m i m m u n o g l o b u l i n s w e r e n o r m a l in 22 children for w h o m it was tested. 15 child r e n h a d positive skin test (2+ a b o v e n e g a tive control) to dust as well as dust mite. Bacteriological isolates w e r e s t r e p t o c o c -

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cus pnetmloniae in 20 cases a n d [~-hemolytic streptococcus in 7. After 6 to 8 weeks of a p p r o p r i a t e antibiotics therapy, 19 patients s h o w e d excellent response and 11 h a d good response. There was radiological clearing of sinus and chest in all cases. D~SCUSS~ON

The association of paranasal sinus disease and b r o n c h i a l asthma has b e e n o b s e r v e d for m a n y years 2. In 53% of children with ali~rgic r e s p i r a t o r y disease, sinus X-ray sl~ows abnormalities 3. R 0 s e n b e r g et al 4 obse~'ved that allergens d e p o s i t e d in the nostrii did not p r o d u c e changes in lung function w h e r e a s direct inhalation of the same antigen into the airways p r o d u c e d expected changes in mechanics. Associated bacterial infections of para,aasal sinuses d u e to h a e m o p h i l u s and a~neumococcus m a y be r e s p o n s i b l e for p o o r l y c o n t r o l l e d a s t h m a s. In the p r e s e n t study, streptococcus p n e u m o n i a e accounte d " f o r 66% a n d h e m o l y t i c s t r e p t o c o c c u s 24% of all the bacteriological isolates. H e a d a c h e and facial pain are infrequent s y m p t o m s of sinusitis, p r o b a b l y d u e to larger ostia in children a l l o w i n g d r a i n a g e of sinus secretionsL Apart from sinusitis 26 children h a d p a r e n c h y m a t lung disease. There w e r e c o r r e s p o n d i n g right lower lobe p n e u m o n i t i s or b r o n c h i e c t a t i c c h a n g e s in 21 children, bilateral lower lobe involvement in 3 and left lower lobe signs in 3 cases. This is probably due to post-nasal drip and bacterial seeding of the lrmgs. The p a r a n a s a l sinusitis p r o d u c e s p o o r control of asthma by causing bronchitis or

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p n e u m o n i t i s , reflex b r o n c h o s p a s m or b y e n h a n c i n g partial blockade of a d r e n e r g i c receptors 6,7. In children there is a paucity of s y m p toms a n d signs related to sinus disease. C h r o n i c c o u g h which is m o r e at n i g h t or e a r l y m o r n i n g with w h e e z i n g e p i s o d e s m a y be the only clinical presentation. It m u s t be b o r n e in m i n d that sinusitis m a y be a cause or precipitating factor of bronchial asthma, and if objective e v i d e n c e of sinusitis is present it must be treated adequately (for at least 6-8 weeks) with approp r i a t e antibiotics. For children allergic to dust, d u s t control m e a s u r e s and use of c h r o m o g l y c a t e nose d r o p s is useful in maintaining the response. REFERENCES

1. Gary S Rachelefsky, Roger MK, Sheldon CS. Chronic sinustis in the allergic child. Paed Clin N Am 1988; 35 : 1091-1101. 2. Bullen SS. Incidence of asthma in 400 cases of chronic sinusitis. ] Allergy 1932; 4 : 402. 3. Katz R. Sinusitis in children with respiratory allergy. J Allergy & Clin Immunol 1978; 61 : 190. 4. Rosenberg GL, Rosenthal RH, Norman PS. Inhalational challenge with pollen in sensitive asthmatics. J Allergy & Clin lmmunoI 1983; 71 : 302. 5. Raymond GS, Richard EC, Williams HF et aL Sinusitis and bronchial asthma. ] Allergy & hmmmoI 1980; 66 : 250-257. 6. Szentivanyi A. The ~ adrenergic theory of the atopic abnormality in bronchial asthma. J Allqy 1968; 42:203. 7. Bhibysdittur US, William WB. Respiratory infections and asthma. Med Clin N Am 1992; 76 : 895-913.