Does sinus disease cause serious lung disease?
Published: March 18, 2022
Bronchiectasis is a chronic irreversible disease of the airways characterized by permanent dilatation of small- and medium-sized airways accompanied by cycles of inflammation and infection. Its pathophysiology involves mucus production, recurrent infection, and persistent inflammation with consequent damage to the integrity of airway structural components. It commonly occurs in patients with cystic fibrosis, asthma, immunodeficiency disorders, and ciliary disorders. Many prior studies have noted that chronic rhinosinusitis (CRS) and bronchiectasis are present in the same patients, but these studies were not designed to evaluate which condition preceded the other and whether the connection could be causal. CRS is more common than most of these other risk factors for bronchiectasis. Most prior studies were from tertiary referral centers of patients likely at the more severe end of the disease spectrums. It is thought that the post-nasal drip of CRS could seed the lungs with purulent aspiration particles,
Schwartz, et al., reporting in The Journal of Allergy and Clinical Immunology (JACI), used electronic health records from Geisinger from over one million patients in 37 counties in central and northeastern Pennsylvania representing the general population of the region. The authors hypothesized that CRS could cause bronchiectasis and designed three case-control analyses to evaluate that hypothesis. Subjects were between 18 and 80 years of age and records were used from 2010 to 2019. CRS and bronchiectasis were identified with diagnoses, procedure orders, and/or specific text in sinus or chest computerized tomography scans. Bronchiectasis case finding used three complementary definitions (diagnoses, procedures, or text) and CRS used five (diagnoses, procedures, or text, with the last all CRS, CRS with nasal polyps, and CRS without nasal polyps). Controls never had any indication of bronchiectasis and were frequency-matched to the three bronchiectasis groups on age, sex, and encounter year. There were 5,329 unique persons with bronchiectasis and 33,363 without in the three analyses, one for each bronchiectasis case definition. Important co-occurring conditions were identified with diagnoses, medication orders, and encounter types, including asthma, allergic rhinitis, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and pneumonia. The analysis first confirmed that CRS preceded the occurrence of bronchiectasis, then evaluated whether CRS was associated with bronchiectasis while excluding (e.g., cystic fibrosis, ciliary disorders) or adjusting (e.g., for asthma, GERD, COPD, pneumonia) for important confounding variables.
The average age of study subjects was 65 years and 52% were women. Most study subjects had over 10 years of contact with the health system. Cases were more likely than controls to be current or former users of tobacco, and to have CRS, prevalent asthma, asthma exacerbations, COPD, episodes of pneumonia, OSA, allergic rhinitis, and GERD. Asthma, COPD, pneumonia, allergic rhinitis, and GERD were all strongly associated with bronchiectasis, with some strong associations (e.g., odds ratios exceeding 5.0). CRS was consistently and strongly associated with all three bronchiectasis definitions. Associations (odds ratio, 95% confidence interval) were strongest for CRS based on sinus CT scan text and were generally stronger for CRS without nasal polyps (e.g., OR = 4.46 [2.09, 9.51] for diagnosis-based bronchiectasis). On average, CRS was identified over six years before bronchiectasis.
Even after adjustment for known risk factors for bronchiectasis, Schwartz et al. found that CRS, identified on average six years before, was strongly and consistently associated with bronchiectasis. The study used complementary methods to find CRS and bronchiectasis, including diagnoses, procedures, and CT scan images, and associations were present for almost all methods of case finding for both conditions. The findings are the first to suggest that CRS increases the risk of subsequent development of bronchiectasis, and in consideration of mechanistic evidence, that the relation may be causal. The findings have clinical implications, as they imply that early treatment of sinonasal disease may offer therapeutic strategies for prevention of bronchiectasis.
The Journal of Allergy and Clinical Immunology (JACI) is an official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.
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