Sinusitis connection: Chronic UAI, AD improve with surgery

Key Points

AD afflicts up to 20 percent of children in the United States. An estimated 10 percent of cases are in the moderate-to-severe range. For these patients, AD is a lifelong disease that often requires hospitalization and systemic immunosuppressive therapy.

A variety of coexisting infections have been recognized as triggering and exacerbating AD, and there is anecdotal evidence that upper airway infections, such as rhinosinusitis and adenotonsillitis, can exacerbate AD, though their precise role is not fully known.

With a goal of determining whether surgical treatment of UAI improves severity of AD in children, the researchers retrospectively reviewed the records of 10 pediatric patients with severe refractory AD.

Patients were treated with systemic immunosuppressive therapy at the time they were being surgically treated for recurring adenotonsillitis and/or rhinosinusitis between October 2004 and October 2007.

The researchers defined improvement as patients being able to discontinue systemic immunosuppressive therapy after surgical treatment for UAI.

Five patients had chronic rhinosinusitis (CRS). One underwent adenoidectomy alone, and four were treated with adenoidectomy and endoscopic sinus surgery.

Two patients with chronic adenotonsillitis (CAT) were treated with tonsillectomy and adenoidectomy (T&A). Three patients had both CRS and CAT; one was treated with T&A alone, while two underwent T&A as well as endoscopic sinus surgery.

Results

The researchers found that nine of the 10 patients were able to discontinue systemic immunosuppressive therapy for AD within three months after their surgery.

According to the researchers, this is the first study to report improvement in AD with treatment of UAI, thus supporting anecdotal evidence of an exacerbating link between UAI and severe refractory AD.

This recognition may have a significant impact on the treatment course and management of patients with severe AD.

Case study

Dr. Siegfried says she became aware of the possibility of a link between UAI and AD two years ago when she was treating Annie, a 4-year-old patient with severe eczema that was not well controlled on cyclosporine plus methotrexate.

"Annie's mother had a history of severe sinusitis and sinus headaches that had responded well to sinus surgery," Dr. Siegfried tells Dermatology Times.

"Her mother suspected that Annie had sinus headaches and asked me about the possibility. Annie had no other obvious sinus symptoms, except snoring - a symptom her mother did not mention and that I only recognized in retrospect.

"I referred her to Dr. Donovan, a pediatric otolaryngologist.

"Within a month of her sinus surgery, Annie's skin cleared and remained clear after discontinuing cyclosporine methotrexate and topical corticosteroids. Her eczema has been well-controlled since then," Dr. Siegfried says.

Symptoms

Following her experience with Annie, Dr. Siegfried learned of the subtle symptoms that mark occult sinus disease in children - snoring, nocturnal cough, bad breath and irritability that could mean headaches.

"I started asking about these symptoms, as well as a family history of chronic sinusitis, and I found that these were quite common among children with severe eczema," Dr. Siegfried says.

"Many otolaryngologists are unwilling to consider surgery in very young children, for a variety of reasons. Dr. Donovan was very willing to evaluate this special population of children and be a little bit more surgically aggressive because of the potential for improving their severe skin disease," she says.

Conclusions

According to the study's conclusions, it is possible that the immune system is influenced by chronic UAI, thus contributing to the exacerbation of AD.

For example, children with chronic adenotonsillitis reportedly have high levels of CD19+ B-lymphocytes, increased circulating immune complexes and impaired neutrophil chemotactic function. These factors also are known to figure in the development of AD.

It is possible, according to the study, that adenoidectomy and tonsillectomy in these patients removed factors that lead to the development and persistence of AD - thus, the patients reviewed in the study showed marked improvement in their AD.

The study also suggests the possibility that chronic rhinosinusitis (CRS) activates the immune system, and that treatment of CRS leads to concurrent improvement in AD.

Dr. Siegfried notes that the majority of children with AD have no evidence of chronic UAI. In such cases, UAI surgical treatments are out of the question.

"No one would do surgery on a patient without evidence of chronic UAI," she says. "I would not suspect improvement in a subset of kids with eczema who do not have UAI, because this is not a relevant trigger for them."

The study notes that additional prospective studies are needed to determine the exact relationship among these factors.

Dr. Siegfried says she hopes such studies will "further establish the link between microbial colonization/infection as one of the important triggers for the inflammation that drives atopic dermatitis. There are other microbial links as well - gut and skin colonizers, for example."

Disclosure: Dr. Siegfried reports no relevant financial interests.