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Indian Pediatr 2017;54: 21-24 |
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Association of Allergic
Rhinitis and Sinusitis with Childhood Asthma
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Selva Kumar Chinnakkannan, Meenu Singh,
#Rashmi Ranjan Das, Joseph L Mathew
and
*Akshay Kumar Saxena
From Departments of Pediatrics and *Radiology, Post
Graduate Institute of Medical Education & Research, Chandigarh; and
#Department of Pediatrics, All India Institute of Medical Sciences,
Bhubaneswar; India.
Correspondence to: Dr Meenu Singh, Professor,
Department of Pediatrics, PGIMER, Chandigarh 160 012, India.
Email: [email protected]
Received: October 14, 2015;
Initial review: January 11, 2016;
Accepted: November 03, 2016.
Published online: November 05, 2016.
PII:S097475591600023
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Objective: To study the point prevalence of allergic rhinitis
and sinusitis in childhood asthma and to examine the relationship among
them. Methods: In 250 children (age <13 y) with mild-to-moderte
asthma, allergic rhinitis was diagnosed by clinical plus nasal
eosinophilia criteria, and sinusitis was diagnosed clinically plus
confirmation by computerized tomography scan. Results: The
point prevalence of allergic rhinitis was 13.6%, and of sinusitis was
2%. On multivariate analysis, allergic rhinitis, sinusitis, and family
history were significantly associated with asthma severity.
Conclusions: Allergic rhinitis is common in childhood asthama,
but sinusitis is rare.
Keywords: Atopy, Bronchial asthma, Nasal allergy, , Nasal
eosinophilia.
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T he terms ‘allergic
rhino-bronchitis’, and ‘united airway diseases’, denote contiguous
allergic inflammation of the airways, and to treat both the conditions
simultaneously even if one (either upper or lower airway allergy) does
not manifest clearly [1]. The epidemiological associations among asthma,
rhinitis, and sinusitis have been observed since a long time [2]. Most
of the studies have been done in Western countries which involved
children of different ethnicity, where the incidence of atopy and
allergic conditions are high, and children usually have intrinsic type
of asthma which is different from extrinsic type of asthma commonly seen
in Indian children. We determined the prevalence of allergic rhinitis
(AR) and sinusitis in Indian children with asthma along with their
effect on asthma severity.
Methods
This observational study was conducted over a
one-year period in the pediatric allergy and asthma clinic of a
tertiary-care hospital in Chandigarh, India. Children (age<13 y) with
asthma, presenting first time to the clinic, were eligible for
inclusion. Some were already talking treatment from outside, but not on
a regular basis. No child was using inhaled medications (steroids or
others). Those with underlying chronic diseases or congenital
malformations including those of upper airways (e.g., cleft lip
and cleft palate) were excluded. The study was approved by the Institute
Ethics Committee.
Parents/guardians were provided detailed information
about the study, and consent (along with assent in children >7 year old)
was obtained prior to recruitment of children into the study. Asthma
severity of each participant was classified as per National Asthma
Education and Prevention program II (updated 2002) [3]. Parents were
enquired about the age of child, presenting symptoms, number of
episodes, diurnal and seasonal variation of symptoms, family history,
and other pertinent history about AR and sinusitis.
AR was diagnosed clinically, if
³2 of the symptoms
(recurrent sneezing, nasal discharge, nasal itching, nasal blockage)
were present for >1 hr on most days, along with nasal mucosa changes
(pale or bluish, boggy with swelling and watery discharge). Clinically,
sinusitis was considered if ³2
of the symptoms (nasal congestion, facial pain, headache, thick
yellow-green nasal discharge, hyposmia, dental pain) were present for
>12 weeks along with mild erythema and swelling of nasal mucosa with or
without sinus tenderness. Nasal smear for eosinophils was done in
children suspected to be having AR. Nasal smear was obtained by gentle
scraping of the lateral nasal wall and then using the Hansan’s
technique. The of eosinophils against total leucocytes was calculated
and presence of ³4
eosinophils was considered to be positive. Computed tomography (CT) scan
of sinuses was performed in children suspected to be having sinusitis,
to look for the presence of opacification, mucosal thickening, or
air-fluid level.
Statistical analysis: The data were analyzed
using SPSS version 16.0. Multiple logistic regression was used to
explore the association between demography, symptoms/signs, family
history, presence of AR and sinusitis, with the asthma severity. Factors
identified with univariate analysis (P<0.1) and the ones which
were thought to be clinically important were considered for the multiple
regression analysis.
Results
We included 250 children with physician-diagnosed
asthma (Fig. 1). The mean (SD) age was 6.7 (3.11) years,
with male preponderance (M:F=2.6:1). Asthma was mild intermittent in
28%, mild persistent in 41%, and moderate persistent in 31%. None had
severe persistent asthma.
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Fig. 1 Flow of study participants.
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The most common symptoms of AR were nasal discharge
and sneezing, and most common signs were allergic salute and allergic
crease. AR was suspected in 90 (36%) children (M:F=2.4:1), and
clinically diagnosed in 51, of which 34 (67%) had proven AR (nasal smear
eosinophils ³4%).
Thus, the point prevalence of AR in asthma was 13.6%. Majority (85.3%)
of children with AR had moderate persistent asthma. Five (2%) children
(age, 5-12 years) had both clinical and CT findings suggestive of
sinusitis, and all of them had moderate persistent asthma. Maxillary,
sphenoid and ethmoid sinuses were commonly involved.
Risk factors for asthma severity, AR and sinusitis
are shown in Table I. In case of asthma, family history
was significantly associated with disease severity. Family history of
asthma was significantly associated with sinusitis, whereas family
history of allergy (AR and atopic drmatitis) was significantly
associated with AR.
TABLE I Univariate Analysis
of Risk Factors for Asthma Severity, Allergic Rhinitis and
Sinusitis in Asthmatic Children
Variables |
Moderate persistent
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Allergic rhinitis
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Sinusitis |
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asthma (n=77) |
(n=34) |
(n=5) |
Age of onset of symptom >5y |
1.16 (0.68-2.0)
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0.85 (0.4-1.79) |
5.8 (0.64-52.66)
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Duration of symptom ³2 y |
1.38 (0.78-2.43)
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0.73 (0.35-1.52)
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0.9 (0.15-5.5) |
Male gender
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0.71 (0.39-1.28) |
1.07 (0.47-2.42)
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0.56 (0.09-3.45) |
Family history of asthma |
2.0 (1.08-3.7)
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0.71 (0.28-1.82)
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14.85 (1.62-135.69)
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Family history of AR or AD |
3.52 (1.57-7.87)
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6.82 (2.86-16.25)
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2.02 (0.22-18.72) |
OR: Odds Values in odds ratio (95% confidence interval) AR:
Allergic rhinitis; AD: Atopic dermatitis. |
In multiple logistic regression model, for severity
determination, persistent asthma (mild and moderate) was made as one
group. Presence of AR, sinusitis, and family history of asthma were
significantly associated with asthma severity (Table II).
TABLE II Multiple Regression Analysis of Risk Factors for Severity of Asthma
Variable |
OR (95% CI) |
P value |
Age of presentation >5 y |
0.67 (0.36-1.45)
|
0.386 |
Male gender |
0.54 (0.29-1.08)
|
0.057 |
Duration of symptom >2 |
1.1 (0.56-1.98) |
0.564 |
Family history of asthma |
2.01 (1.22-4.15) |
0.013 |
Family history of AR or AD |
0.86 (0.44-2.37) |
0.634 |
Presence of AR |
3.72 (2.65-12.46) |
0.001 |
Presence of sinusitis |
10.85 (1.69-126.3) |
0.005 |
OR: Odds ratio; 95% CI: 95% Confidence interval; AR: Allergic rhinitis; AD: Atopic dermatitis.
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Discussion
In the present study, the prevalence of proven AR was
13.6%, and of sinusitis was 2% in childhood asthma. On multivariate
analysis, AR, sinusitis, and family history of asthma were associated
with increased asthma severity.
Limitations of present study was that the children
presenting only to the health facility were recruited; the actual
prevalence of AR and sinusitis may either be over-estimated (being a
tertiary-care hospital) or under-estimated (possibility of influence of
anti-asthma medications on other allergic conditions). Absence of a
control group (without asthma) also makes it difficult to interpret the
point prevalence of AR and sinusitis estimated in the study.
A previous Indian study has found a higher prevalence
of AR (28%) compared to the present study [4]. This difference may be
because of employment of both clinical and nasal smear criteria to prove
AR in the present study. In a study including 40 AR patients, 80% showed
nasal smear eosinophilia ( ³4%)
[5]. When the nasal smear eosinophilia was compared to the skin tests, a
high degree of correlation (88%) was found. On multiple regression
analysis, AR was associated with increase in asthma severity in the
present study. Similar findings have been reported by other studies
[6,7].
The prevalence of sinusitis was also low in present
study as compared to other studies. Nguyen, et al. [9] concluded
that for diagnosis of sinusitis, imaging studies should be combined with
clinical evaluation. In the present study, use of CT scan for diagnosis
of sinusitis might have lead to a lower estimate of prevalence. Children
with sinusitis had more asthma severity on multiple regression analysis.
Tsao, et al. [12] found an improvement in the asthma symptoms,
and normalization of pulmonary function after antibiotic treatment of
sinusitis. Rachelefsky, et al. [13] reported that 79% of
asthmatic cases could discontinue their bronchodilators after resolution
of sinusitis with antibiotic use.
For measurement of true prevalence of AR and
sinusitis in asthma, future studies should focus on district-or
school-level surveys from various parts of the country.
Acknowledgement: Prof Naresh Kumar Panda,
Department of Otorhinolaryngology, PGIMER, Chandigarh, India for
providing technical assistance.
Contributors: SC, MS, JLP, AS: conceived and
designed the study; SC: coordinated the study and collected data; MS,
RRD: revised the manuscript for important intellectual content, drafted
the paper, analyzed the data and helped in manuscript writing. The final
manuscript was approved by all authors
Funding: None; Competing interest: None
stated.
What this Study Adds?
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The point prevalence of allergic rhinitis in children with
asthma is 13.6%, and that of sinusitis is 2%.
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A positive family
history, allergic rhinitis, and sinusitis are associated with
higher asthma severity.
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