In this study, we evaluated the relationship between rhinosinusitis to the severity of asthma in asthmatic patients.

This cross-sectional study was conducted on 90 patients with asthma referring to Imam Khomeini Hospital in Ardabil city. Asthma control stepping method was used for staging of

asthma severity. Patients' clinical signs and paraclinical findings were individually evaluated and compared with particular attention to the presence or absence of rhinosinusitis. Chi square and t-test were used to analyze the data in SPSS15 software.

Rhinosinusitis was found in 66 (73%) of the 90 patients. The Forced Expiratory Volume in 1 second (FEV1) was significantly lower in the patients who also had rhinosinusitis(P=0.002).Comparing severity of asthma, most of the patients with rhinosinusitis were in stage3 (42.4%) but most of the patients without rhinosinusitis were in stage1(41.6%)(p=0.002).

The results of this study confirm the correlation between asthma severity and rhinosinusitis in asthmatic patients. Therefore,in diagnosing asthma in patients, the

possibility of the rhinosinusitis should be determined and treated

اعظمی, احد

اناری, حسن

حبیب زاده, الهام

شرقی, افشان

غفرانی, محسن

English

ArUMS Digital Repository (سامانه اطلاعات زیست پزشکی و سلامت)

Copyright© 2009, IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY. All rights reserved.                  199
ORIGINAL ARTICLE
Iran J Allergy Asthma Immunol
December 2009; 8(4): 199- 203
Rhinosinusitis Predispose Asthmatic Patients to Severe Bronchial Asthma
Ahad Aazami1, Afshan Sharghi2, Mohsen Ghofrani3, Hassan Anari4, and Elham Habibzadeh5
1 Department of Internal Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
2 Department of Community Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
3 Private Clinic (Radiology), California, USA
4 Department of Radiology, Ardabil University of Medical Sciences, Ardabil, Iran
5 Medical School, Ardabil University of Medical Sciences, Ardabil, Iran
Received:  12 August 2009; Received in revised form:  7 November 2009; Accepted:  15 November 2009
ABSTRACT
In this study, we evaluated the relationship between rhinosinusitis to the severity of 
asthma in asthmatic patients.
This cross-sectional study was conducted on 90 patients with asthma referring to Imam 
Khomeini Hospital in Ardabil city. Asthma control stepping method was used for staging of 
asthma severity. Patients' clinical signs and paraclinical findings were individually evaluated 
and compared with particular attention to the presence or absence of rhinosinusitis. Chi 
square and t-test were used to analyze the data in SPSS15 software.
Rhinosinusitis was found in 66 (73%) of the 90 patients. The Forced Expiratory Volume 
in 1 second (FEV1) was significantly lower in the patients who also had rhinosinusitis 
(P=0.002).Comparing severity of asthma, most of the patients with rhinosinusitis were in
stage3 (42.4%) but most of the patients without rhinosinusitis were in stage1 (41.6%) 
(p=0.002).
The results of this study confirm the correlation between asthma severity and 
rhinosinusitis in asthmatic patients. Therefore, in diagnosing asthma in patients, the 
possibility of the rhinosinusitis should be determined and treated.
Key words: Asthma; Correlation; Rhinosinusitis; Severity
INTRODUCTION
Asthma is a chronic inflammatory disease of the 
bronchial airways, which physiologically appears as 
diffuse narrowing of airways, and clinically as 
periodical attacks of dyspnea, cough and wheezing.1
Corresponding Author: Afshan Sharghi, MD;
Department of Community Medicine, Medical School, Ardabil 
University of Medical Sciences, Ardabil, Iran. Tel: (+98 914) 4526
802, Fax: (+98 451) 5510 057, E-mail: a.sharghi@arums.ac.ir
The prevalence of asthma is increasing, especially 
in the young and developing countries, and it is 
estimated that by 2020, 10 million people will die from 
asthma, 90% of whom are living in developing 
countries.2
According to a world–wide report on asthma
published in 2003, the prevalence of asthma in ran is
estimated to be about 5.5 percent.3 Allergenic particles, 
pharmacologic stimulators, environmental pollution, 
occupational factors, infections, exercise, and 
psychological stress are stimulators that result in an 
A. Aazami, et al.
200/ IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY                 Vol. 8, No. 4, December 2009
acute asthma attack.1 In addition, allergic rhinitis and 
sinusitis are recurrently related to asthma attacks,4 25% 
of patients afflicted by chronic rhinosinusitis have 
asthma, and 70% of asthmatics have concomitant
sinusitis.5
There is some evidence regarding the relationship 
between rhinosinusitis and asthma, but it has not been 
clear whether rhinosinusitis is a directly triggering or 
underlying factor for asthma,6 or else these are different 
manifestations of the same pathological process.7
Evidence shows the role of rhinosinositis in triggering 
an asthma attack and the observation that remission of 
asthma symptoms follows medical or surgical treatment
of rhinosinusitis.8-10 Besides, patients with allergic 
rhinitis demonstrate a high prevalence of asthma 
compared to the normal population in a 20-years
follow-up.11
In this study, we evaluated the relationship between 
rhinosinusitis to the severity of asthma in asthmatic 
patients.
PATIENTS AND METHODS
This cross-sectional study was conducted on 
patients in Imam Khomeini Hospital, Ardabil city from
November 2007 to May 2008. Asthma was diagnosed
in these patients by spirometry, with and without 
bronchodilator. Paranasal sinus radiographs were used 
to diagnose rhinosinusitis. Data which were collected 
from the hospital were divided into three categories, 
which was documented in each patient's questionnaire:
1. Demographic data including age  and gender, 
allergic history ,asthma history , history of using anti –
asthmatic medication   and history of the number of 
hospital admission times for treatment of asthma 
2. Asthma and rhinosinusitis clinical signs and 
symptoms including respiratory distress, cyanosis and 
pulsus paradoxus.
3. Paraclinical results from chest radiography, 
paranasal sinus radiograph and spirometry.
To determine asthma severity in each patient, the 
asthma control staging method was used. According to 
this, as shown in table 1, severity of asthma in patients 
depended on the number of times of signs (coughing, 
dyspnea, wheezing) occurring during one day or night,
week or month or based on the amount of FEV1
(Forced Expiratory Volume in 1 second). Patients were 
divided into four stages: mild intermittent, mild
persistent, moderate persistent, and severe persistent.1,12
According to these groupings, patients who showed
disease signs twice in one week  or two nights in a 
month had mild asthma and were grouped as stage 1 or 
2 . Patients who showed it daily or for more than one 
night per week had moderate asthma and were grouped 
as stage 3. And at the end, patients who showed the 
signs everyday continuously and all over nights had
severe asthma were grouped as stage 4 .Also according 
to the amount of FEV1, patients who their the FEV1 
was about 80% or more had mild asthma (first and 
second stage), if it was between 60% and 80%, they 
had moderate asthma (third stage) and if it was less 
than 60%, they had severe asthma (forth stage).
All radiographs of patients were read and reported
by a single radiologist conforming to the blind method 
of assessment.
After collecting the data and staging the asthma 
severity, patients clinical signs and paraclinical results 
were individually evaluated and compared based on the 
presence or absence of rhinosinusitis. Chi square and t-
test were used to analyze the data in SPSS15 software.
RESULTS
Ninety patients with bronchial asthma were 
included in the study. The patients' mean age was 47.9 
±13.6, half being male.
Characteristics of patients without rhinosinusitis
were as under: 
Twenty-four patients (27%) had bronchial asthma 
without rhinosinusitis, 15 of them (62%) were female, 
with a mean age of 50 + 9.13. On chest radiograph, 9 
patients (37.5%) showed lung hyperinflation, and 1 
patient (4%) showed cardiomegaly.
The average of FEV1 in these patients was 
83.1%±14 %, therefore regarding this average they 
were in the first or second stage (or mild asthma).
Among them 17 patients (70.8%) had about 80 % 
FEV1 or more, amount of FEV1 for 6 patients (25%) 
was about 60 % to 80%, 1 patient (4.1%) had FEV1 of 
about 60 % or less.  
Twenty-two patients (91.7%) used anti-asthmatic 
medications, 21 of them used beta-adrenergics, twelve 
patients used anti-cholinergic, and four used 
inhalational steroids. None of the patients without 
Rhinosinusitis used neither oral nor inhalational 
steroids. These patients had an average of 12.4 + 10.5 
years of asthma history, and only 20% of them reported 
Rhinosinusitis and the Severity of Asthma
Vol. 8, No. 4, December 2009             IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY /201
being admitted to a hospital for treatment of asthma.
Characteristics of patients with rhinosinusitis were as:
Based on clinical signs and radiographic findings of 
the sinuses, 66 out of 90 patients (73%) had 
concomitant rhinosinusitis. The mean age of these 
patients was 47+13.4 years, and 45% of them were 
male. The most common clinical symptoms which the 
patients reported were: nasal congestion in 26 patients 
(39.4%), facial pain and pressure in 22 patients 
(33.3%), postnasal drip in 20 patients (30.3%), 
recurrent flu symptoms in 12 patients (18.1%), 
recurrent sneezing in 10 patients (15.2%), nasal drip in 
9 patients (13.6%), nasal polyp in 4 patients (6.1%), 
and nasal itching in 2 patients (3%).A total of 27 
patients (41%) simultaneously had two or fewer signs 
and 39 patients (59%) had more than 2 clinical signs.
When these patients were referred to the hospital,
23 patients (34.8%) had dyspnea, 3 patients (4.5%) had 
cyanosis, and 2 patients (3%) had pulsus paradoxus.
All 66 patients had positive findings on the 
paranasal sinus radiographs. In terms of sinus disease, 
48 patients (72.7%) had bilateral maxillary sinus 
disease, 14 patients (21.3%) unilateral maxillary sinus 
disease, 15 patients (22.7%) bilateral frontal sinus 
disease, 6 patients (9.1%) unilateral frontal sinus 
disease, and 1 patient (1.5%) had ethmoid sinus 
disease. Other reported findings on the paranasal sinus 
radiographs were as follows: conchal edema in 4 
patients (6.1%), nasal polyp in 3 patients (4.5%), and 
mucusal retention cyst and septal deviation each in 2 
patients.
On chest radiographs, 30 patients (45.5%) had lung 
hyperinflation, 1 patient had cardiomegaly, and 1 
patient had evidence of pulmonary hypertension.
The average of  FEV1 in these patients was 70.5% 
±17.3 % ,thus regarding this average they were in the 
third stage (or moderate asthma) .Among them 22 
patients (33.3%) had about 80% FEV1 or more , 
amount of FEV1 for 30 patients (45%) was about 60% 
to 80% and 14 patients (21.2%) had FEV1 about 60% 
or less. Among the above 66 patients, 57 cases (86.4%) 
used anti-asthmatic medications, of which 54 patients 
(81.8%) used beta-adrenergics, 38 (57.6%) used 
anticholinergics, 24 (36.4%) used inhalational steroids, 
7 (10.6%) used periodic oral steroids, 10 (15.2%) had a 
history of steroid injection during an asthma attack, and 
11 (16.7%) used other medications such as 
theophylline. The average history of asthma in these 
patients was 11.4 + 7.51 years, and 54.5 % of patients 
had a history of hospital admission.
Comparison of allergic history in patients: 
Among 66 asthmatic patients with rhinosinusitis, 39 
(59.1%) had allergy history and among 24 patients 
without rhinosinusitis, 10 patients (41.7%) had it .There
was not a significant difference between both groups
(p = 0.1).
Comparison of asthma severity in two groups:
Classification of the asthma severity according to 
clinical signs and FEV1 in both groups is being shown
(Table 2). Among 24 patients of asthma without 
rhinosinusitis, 17 subjects (70.8%) were in stage 1 and 
2 (mild asthma), while only 22 patients (33 .3 %) of 66 
patients afflicted by asthma with rhinosinusitis were in 
first and second stage. 
Table 1. Classification of asthma severity based on clinical features or PEFR or FEV1.
Classify Severity: Clinical Features Before Treatment or Adequate Control Symptoms
PEFR or FEV1
(PEFR Variability)
Symptoms*          
NightDay
≥80%
(<20%)
≤2nights/month≤2days/WeekStep 1: mild intermittent
≥80%
(20-30%)
≤2nights/month≤2days/Week
But <1per Day
Step 2:mild persistent
>60% -<80%
(>30%)
>1night/weekDailyStep  3:moderate persistent
≤60%
(>30%)
FrequentContinualStep 4: Severe Persistent
PEFR: Peak Expiratory Flow Rate; FEV1:, Forced Expiretory Volume in 1 s.   
*Symptoms include: cough, dyspnea , wheezing        
Source: Modified from National Ashma Education and Preventive Program
A. Aazami, et al.
202/ IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY                 Vol. 8, No. 4, December 2009
Table 2. Staging asthma severity in patients with and without rhinosinusitis.
Based on spirometry resultsBased on clinical symptomsStage of Asthma
Patients with
rhinosinusitis
Patients without 
rhinosinusitis
Patients with
rhinosinusitis
Patients 
without 
rhinosinusitis
22
(33.3%)
17
(70.8%)
9
(13.6%)
10
(41.6%)
Stage 1: mild intermittent 
FEV1≥80% 
15
(22.7%)
7
(29.1%)
Stage 2: mild persistent
FEV1≥ 80%
30
(45.5%)
6
(25%)
28
(42.4%)
6
(25%)
Stage 3: moderate persistent
60%<FEV1 <80%
14
(21.2%)
1
(4.1%)
14
(21.2%)
1
(4.1%)
Stage 4: severe persistent
FEV1≤60%
FEV1: Forced Expiretory Volume in 1 s.
Also in patients without rhinosinusitis, 6 patients
(25%) had moderate asthma and one patient had severe 
asthma; while patients who suffered from asthma with
rhinosinusitis, 30 patients (45.5%) had moderate 
asthma and 14 (21.2 %) had severe asthma. The 
difference statistically was significant (p <0.05). In 
addition, in staging asthma severity based on the 
presence of cough, dyspnea or wheezing during the day 
or night, 63.6% of asthmatics with rhinosinusitis (as 
opposed to the 29.2% without rhinosinusitis) were 
allocated in the moderate or severe asthma groups, 
which was a astatistically significant finding (P=0.01).
DISCUSSION
In this study, 73% of patients with asthma had 
rhinosinusitis simultaneously, nasal congestion was the 
most common symptom among them, and most patients 
had maxillary sinuses affected the most with few where
the frontal sinuses were affected. In the study by Talib 
(2002) in India, conducted on 50 asthmatics, 70% of 
patients also had rhinosinusitis, and the most common 
symptoms and most common afflicted sinus were
similar to our study. Other radiographic findings of our 
study were conchal edema (6.1%), nasal polyp (4.5%), 
and mucosal retention cyst and septal deviation (3%), 
and in comparison to the study by Talib  was less 
prevalent. It can be due to less accuracy of radiographs 
comparing to CT scan in diagnosing the above 
findings.5
In terms of medication use, the most commonly 
used medications in the two groups (in decreasing 
order) were beta-adrenergics, anti-cholinergics and 
inhalational steroids. The use of oral and intravenous 
steroid was only seen in asthmatics with concomitant
rhinosinusitis. In terms of hospital admission, 20% of 
patients with simple asthma and 54.5% of patients with 
asthma and rhinosinusitis gave such history. In 
addition, the signs of severe disease such as cyanosis 
and pulsus paradoxus were only seen in patients whom 
also had rhinosinusitis. Overall, these signs indicate 
less strict control of asthma in patients 
with concomitant rhinosinusitis.
According to conclusions by Dixon Anne et al,4
allergic rhinitis and rhinosinusitis correlate with many 
severe symptoms in asthma, and without strict control 
will lead to more severe asthma attacks.13,14 In the 
study by Ragab et al,8 there was a decrease in asthma 
signs and symptoms after treating chronic rhinosinusitis 
in asthmatic patients.
In the current study, asthmatics with rhinosinusitis 
showed a lower FEV1 compared to those with asthma
but without rhinosinusitis (83.3% compared to 70.5%, 
respectively), which is in contrast with the findings of 
the Dixon Annes study.
In the Dixons study, the groups under study patients 
were specific with limited and similar selection, such as 
groups being treated with low-dose theophylline and 
those who had received the flu vaccine. But in our 
study, the asthmatic patients of Imam did not have any 
specific criteria. In the Dixon Anne study, the FEV1 in 
Rhinosinusitis and the Severity of Asthma
Vol. 8, No. 4, December 2009             IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY /203
patients with simple bronchial asthma was not 
significantly different from those with rhinosinusitis, 
but FEV1 improvement was seen after chronic 
rhinosinusitis treatment in the Ragab study and the 
Vigac Davor study.8, 10
In our study, 14% of asthmatics with rhinosinusitis 
were in the severe stage, compared to only 4.2% of 
patients with simple asthma who were in this stage, 
which may prove less severity of asthma in patients 
without rhinosinusitis. The study by Durson et al also 
showed that 77.5% of asthmatics with rhinosinusitis 
were in the severe and moderate stages of asthma.15
In conclusion the results of this study confirm the 
correlation between asthma severity and rhinosinusitis 
in asthmatic patients. Therefore, in the case of 
diagnosing asthma in patients, the possibility of the 
rhinosinusitis should be determined and treated. In 
addition, the present cross-sectional study only shows 
the correlation between severity of asthma and 
existance of rhinosinusitis in asthmatic patients, but for 
distinguishing cause and effect relationship between 
asthma severity and rhinosinusitis , it is better to plan 
and do longitudinal studies such as a case- control or a 
cohort study. Also, because of high cost and high 
radiation dose of CT, we used plain radiography of the 
sinuses to diagnose rhinosinusitis, but CT scanning, 
which has a higher accuracy, would be better for 
diagnostic and therapeutic purposes.
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Rhinosinusitis Predispose Asthmatic Patients to Severe Bronchial Asthma

http://eprints.arums.ac.ir/1600/1/Asthma.pdf

Rhinosinusitis Predispose Asthmatic Patients to Severe Bronchial Asthma

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