Childhood illnesses associated with risks for chronic rhinosinusitis in middle age
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Key takeaways:
- Researchers identified three subtypes of chronic rhinosinusitis and trajectories of asthma and allergy with chronic rhinosinusitis.
- Comorbidity prevalence increased with chronic rhinosinusitis severity.
Children with asthma, frequent head colds and tonsilitis at age 7 years face greater risks for chronic rhinosinusitis in middle age and may benefit from closer monitoring and proactive management, according to a study published in Allergy.
These associations manifested across three trajectories of asthma and allergy from ages 7 to 53 years, Jennifer Perret, MBBS, FRACP, PhD, physician-trained respiratory and sleep epidemiologist, allergy and lung health unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, and colleagues wrote.
The population-based Tasmanian Longitudinal Health Study (TAHS) followed 3,364 patients (male, n = 1,649).
“Our TAHS study was started in 1968 as an asthma study so participants were followed to observe the natural history of this lung condition that affects the lower airways,” Perret told Healio.
Given the volume of information from the participants’ childhoods, Perret said that she and her colleagues wanted to know what factors from these childhoods and over these lifetimes could be associated with chronic rhinosinusitis (CRS) later in life as an upper airway condition of the nose and sinuses.
“We also wanted to know how closely asthma and allergies were associated, especially among those who had current CRS symptoms and had been diagnosed by a doctor,” Perret said.
Study results
Perret said that she and her colleagues only knew of one other long-term study that examined childhood risk factors for CRS in adults, but the adults in that study were in their 30s.
“Our study of middle-aged adults in their early 50s found that frequent upper respiratory infections in childhood, namely head colds and tonsillitis, predisposed to doctor-diagnosed CRS in mid-adult life,” she said. “This was important new knowledge and made sense, as CRS affects the upper airways.”
The three subtypes of CRS severity that researchers identified in the cohort included 2.5% (95% CI, 2%-3%) with CRS diagnosed by a doctor and current symptoms, 3.4% (95% CI, 2.8%-4.1%) with current CRS symptoms but no doctor diagnosis and 4.3% (95% CI, 3.7%-5.1%) with a past CRS diagnosis only.
Prevalence of facial pain/pressure among patients with current symptoms included 87.9% (95% CI, 79%-94%) for those with doctor diagnosis and 62.8% (95% CI, 53%-71%) for those who did not have a doctor diagnosis.
Multiple comorbidities related to CRS increased in severity across the three subtypes of CRS severity, such as lower airways diseases, gastro-esophageal reflux disorder, obesity, snoring and mental health disorders.
The researchers also noted increases in prevalence of concurrent doctor-diagnosed asthma regardless of positive skin prick testing across the subtypes of CRS severity. For example, 37.8% of those patients with doctor-diagnosed symptomatic CRS and 12.7% of the full cohort had current doctor-diagnosed asthma.
There were increases in concurrent clinical asthma symptoms, symptomatic COPD and pre-bronchodilator and post-bronchodilator airflow obstruction but not in current smoking across the CRS subtypes as well.
Additionally, fewer patients with symptomatic CRS and a past diagnosis of sinusitis were employed in middle age compared with patients who did not have CRS or sinusitis. Similarly, there was less full-time employment among patients with a past diagnosis regardless of symptoms, compared with those with no CRS or sinusitis.
There also were differences between the adult CRS subtypes in the prevalence of frequent childhood head colds, maternal smoking and other parental factors, the researchers said, such as a predominance of women among those with a past doctor diagnosis whether or not they had current symptoms.
Frequent childhood head colds and tonsillitis and current childhood asthma had significant associations with the most severe subtype of symptomatic doctor-diagnosed CRS in middle age, the researchers said, both before and after adjustment for parental smoking.
Frequent childhood head colds doubled the odds for symptomatic doctor-diagnosed CRS in middle age (multinominal OR [mOR] = 2.04; 95% CI, 1.24-3.37), which further increased with asthma in middle age (mOR = 3.47; 95% CI, 1.47-8.17).
Odds for symptomatic doctor-diagnosed CRS in middle age increased by a factor of 1.61 (95% CI, 1-2.59) with frequent childhood tonsilitis and by a factor of 2.23 (95% CI, 1.25-3.98) with current childhood asthma.
The researchers did not report any clear interactions between the effects of these exposures and current allergic rhinitis or ever-smoking on CRS in middle age. The associations among nonsmokers were significant, the researchers added, but they were not significant among ever smokers.
The protective main association between doctor-diagnosed childhood pneumonia/pleurisy and past sinusitis was modest as well after adjustment for parental smoking (mOR = 0.48; 95% CI, 0.24-0.95), particularly among the three nonsmokers in this group, the researchers said.
Patients in the three CRS subtypes had similar prevalence of allergic rhinitis by age 7 years, ranging from 12.8% to 16.3% and increasing to a range of 88.9% to 94% by age 53 years, compared with the patients who did not have any CRS or sinusitis.
Patients with doctor-diagnosed symptomatic CRS in middle age experienced increases from 12.8% at age 7 years to 81.2% at age 13 years in prevalence of allergic rhinitis-ever, which the researchers called substantially greater than the increases among patients with less severe CRS subtypes in early adulthood.
Prevalence in current asthma increased between early adolescence and early adulthood across all three CRS subtypes, the researchers continued.
Trends for any skin-prick allergen across the subtypes of CRS also were significant, the researchers said (P trend = .048).
Results for Dermatophagoides pteronyssinus included 58.2% for those with doctor-diagnosed CRS and 40.2% for those who did not have sinusitis or CRS. Results for peanut were 20% and 8.1% and for cow’s milk were 10% and 3.5% for the same groups.
The researchers also identified five trajectories for asthma and allergies among 3,112 patients in the sample: minimal asthma and allergies (49%), early onset persistent asthma and allergies (5.8%), early onset remitted asthma and allergies (6.2%), late onset asthma and allergies (8.6%) and late onset hay fever without asthma (30.4%).
The groups with early onset persistent asthma and allergies, late onset asthma and allergies and late onset hay fever without asthma were associated with each CRS subtype, but the group with early onset remitted asthma and allergies, was not, compared with the group with minimal asthma and allergies, the researchers said.
The association between late onset asthma and allergies and CRS increased in strength as the severity of CRS increased, the researchers said. Associations between CRS and early-onset asthma and allergy and late-onset hay fever without asthma were similar across all the subtypes of CRS as well.
“The link between allergic asthma and CRS in the adults of our study was surprising, mainly because the association was so strong,” Perret said.
Perret called this finding significant because it can explain in part why newer biological type 2 anti-inflammatory therapies are particularly effective among patients who suffer from both conditions.
“This link between allergic asthma and CRS in adults of the general community is also important because it had not been previously mentioned in some major medical guidelines, and greater recognition would now be encouraged,” she said.
Specific mORs for symptomatic doctor-diagnosed CRS in middle age included 6.74 (95% CI, 2.76-16.4) for early onset persistent asthma and allergies, 15.9 (95% CI, 8.06-31.4) for late onset asthma and allergies and 3.02 (95% CI, 1.51-6.06) for late onset hay fever.
Conclusions, next steps
These findings represent the first time that the history of asthma and allergic rhinitis-ever have been documented within each subtype of CRS, including substantial increases in prevalence from childhood or adolescence through adulthood, the researchers said, adding that this pattern is similar to the sequence seen in the atopic march.
“Most studies on CRS have been based in hospital and specialist settings, whereas we have followed large numbers of adults from the general community between their first to sixth decade of life,” Perret said. “This makes our study unique.”
Also, the researchers said, the three trajectories of asthma and allergies between childhood and middle age linked with CRS indicate that asthma, hay fever and allergies are potentially treatable traits of CRS.
“For doctors managing children for frequent head colds and/or recurrent tonsillitis, prescribing antibiotics earlier and more often might lessen a child’s future risk for CRS from bacterial infections of the upper airway,” Perret said.
Additionally, she continued, doctors, parents and other clinicians can ensure that these children are up to date with all currently available vaccinations against respiratory infections.
“For doctors who have diagnosed and are treating middle-aged patients with CRS symptoms, they can also actively seek a history and look for signs of asthma and allergies which could be treated as well,” Perret said.
The researchers will follow up with these TAHS participants when they are in their early 60s, Perret said, and look at whether their symptoms improve with asthma therapies.
For more information:
Jennifer Perret, MBBS, FRACP, PhD, can be reached at jennifer.perret@unimelb.edu.au.