Chronic rhinosinusitis (CRS) is common disease in otorhinolaryngology and will lead to lower airway abnormality. However, the only lung function in CRS patients and associated factors have not been much studied.
One hundred patients with CRS with nasal polyps (CRSwNP group), 40 patients with CRS without nasal polyps (CRSsNP group), and 100 patients without CRS were enrolled. The difference in lung function was compared. Meanwhile, CRSwNP and CRSsNP group were required to undergo a bronchial provocation or dilation test. Additionally, subjective and objective outcomes were measured by the visual analogue scale (VAS), 20-item Sino-Nasal Outcome Test (SNOT-20), Lund-Mackay score, Lund-Kennedy endoscopic score. The correlation and regression methods were used to analyze the relationship between their lung function and the above parameters.
The forced expiratory volume in 1 second (FEV1) and forced expiratory flow between 25% and 75% of forced vital capacity (FEF25-75) of CRSwNP group were significantly lower than other groups (
CRS leading to impaired maximum ventilation and small airway is associated with the existence of nasal polyp. Lung function impairments can be reflected by PBEC, duration, VAS, and SNOT-20. In CRSwNP patients, PBEC is independent predictor of FEV1 change ratio.
Chronic rhinosinusitis (CRS) is a group of diseases with two or more symptoms persisting for more than 12 weeks. Symptoms include facial pain/pressure, purulent nasal discharge, nasal obstruction, and decreased sense of smell in the setting of chronic inflammation confirmed through endoscopy or radiographic studies [
This prospective study was performed on patients undergoing surgical therapy in Department of Otolaryngology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China from March 2012 to 2015. This study was approved by the Research Ethics Committee of First Affiliated Hospital of Wenzhou Medical University, and informed consents were then received from all participants. The criteria excluded patients diagnosed with pregnant, severe heart, lung, liver, kidney, blood system disease, upper respiratory infections, pulmonary diseases like asthma and took regular medication such as hormone, antihistamine drug, and bronchodilator. Finally, those who did not complete lung function test as well as subjective and objective measurements were also excluded. Patients were classified into three groups: CRS with nasal polyps (CRSwNP group), CRS without nasal polyps (CRSsNP group), and control group.
Demographic and clinical characteristics were recorded, including the gender, age, smoking, atopy, peripheral blood eosinophil count (PBEC), X-ray of chest for three groups, and duration of disease, sinus surgery number for CRSwNP and CRSsNP group.
Each patient underwent skin-prick test by intradermal prick-puncture of Dermatophagoides farinae, house-dust mites, cockroach, cat hair, dog hair, feathers, white birch, phoenix tree, cotton fibre and so on. The largest diameter of the wheal of each particular test is measured, a positive being a wheal of ≥3 mm [
Conventional ventilation function test in three groups was performed using a computerized, pneumotachograph spirometer (MasterScreen Diff; Jaeger, Hoechberg, Germany). Recorded parameters were forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF), forced expiratory flow between 25% and 75% of forced vital capacity (FEF25-75) of predicted value.
In control group, patients were given the above test and record. However, in CRSwNP and CRSsNP group, patients were given the above same test and record, and then bronchial provocation or dilation test based on final result of FEV1 of predicted value. They were given bronchial provocation test when FEV1 ≥80% of predicated value, bronchial dilation test when FEV1 <80% of predicated value. In bronchial provocation test, patients were required to inhale increasing methacholine by a quantitative pulverization machine (4 mg/mL, 0.06 mg; 4 mg/mL, 0.07 mg; 32 mg/mL, 0.42 mg; 32 mg/mL, 0.55 mg; 32 mg/mL, 0.65 mg; 32 mg/mL, 0.75 mg; respectively), with 0.9% sodium chloride solution as control. Ventilation function test was performed every 2 minutes. The total dose of methacholine was as high as 2.5 mg. PD20-FEV1 (provoking dose needed when FEV1 decreased by 20% of predicated value) ≤2.5 mg was considered an indication of positive bronchial provocation test. The increasing ratio of FEV1 ≥15% and absolute increasing value ≥200 mL after inhaling 400 μmol was considered an indication of positive bronchial dilation test. FEV1 of predicted value was again recorded when bronchial provocation or dilation test was completed. The change ratio of FEV1 before and after bronchial provocation or dilation test was calculated by the equation: difference of FEV1 of predicted value before and after bronchial provocation or dilation test/FEV1 of predicted value before bronchial provocation or dilation test.
The visual analogue scale (VAS), 20-item Sino-Nasal Outcome Test (SNOT-20), Lund-Mackay score (LMS) and Lund-Kennedy endoscopic score (LKS) was used for subjective and objective assessment of CRS. The VAS and SNOT-20 were finished by patients with CRS, LMS, and LKS by professional otolaryngologist.
The VAS was performed by CRS patients to indicate severity of their symptoms by choosing a segment on one line according to the subjective feeling. The possible range for each symptom was 0 to 10. “Mild” was defined as being 0 to 3 inclusive, “moderate” as >3 to 7 inclusive and “severe” >7 to 10 inclusive [
The coronal computed tomography (CT) scans of paranasal sinus were all completed in First Affiliated Hospital of Wenzhou Medical University. The LMS was used to rank the subjective appearance of CT scan. The sinuses involved included the maxillary, anterior ethmoidal, posterior ethmoidal, sphenoidal, and frontal sinuses. The possible score for each side ranged from 0 to 12, and the total score from 0 to 24 [
Statistical analysis was performed using SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA). Descriptive data was presented as mean and standard deviation for parametric data, median and range for nonparametric data. Chi-square test was used to compare categorical variables, while comparisons among three groups were performed using
Two hundred and forty patients undergoing surgical therapy in First Affiliated Hospital of Wenzhou Medical University during the study period were included. There was no significant difference among the three groups in terms of gender, smoking, atopy, PBEC and PEF (
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A multiple linear regression analysis was constructed of change ratio of FEV1 before and after bronchial provocation or dilation test, and it was found that PBEC was independent variable predicting change ratio of FEV1 before and after bronchial provocation or dilation test in CRSwNP group (β=0.403,
A multiple linear regression analysis indicated that none were independent variables predicting change ratio of FEV1 before and after bronchial provocation or dilation test in CRSsNP group (
We defined PBEC <0.3×109/L as low level, 0.3–0.7×109/L as moderate level and >0.7×109/L as high level. A total of 78 patients (78%) were classified into low level, 16 patients (16%) were moderate level and the other six patients (6%) were high level in CRSwNP group. FEV1 and FEF25-75 were significantly lower in high PBEC group compared to moderate and low level groups. However, there was no significant difference among the three groups in PEF (
Meanwhile, FEV1, FEF25-75 and PEF showed no significant difference between moderate (six subjects) and low level groups (34 subjects) in CRSsNP patients. Nobody was classified into high level (
Nowadays, there have been proposed mechanisms of association of upper and lower airway diseases as follows: (1) inflammatory secretion of nasal cavity or allergen that stimulate the lower airway; (2) nasobronchial and pharyngobronchial reflex; (3) similar histologic characteristics and mucosal susceptibility of the upper and lower airway; (4) the systemic amplification [
In the present study, FEV1 and FEF25-75 were significantly lower in CRSwNP patients compared to CRSsNP and non-CRS patients. However, these two parameters were no significantly different between CRSsNP and control group. FEV1 was a key parameter that reflected the maximum ventilation function, and FEF25-75 could exactly reflected the situation of airway obstruction, especially small airway abnormality. This suggested CRS could cause impairments of maximum ventilation function and small airway, which was mainly related to the existence of nasal polyps. Williamson et al. [
In CRSwNP group, FEV1 was negatively correlated with PBEC and duration of disease. It indicated that PBEC and duration of disease can reflect impairment degree of lung function of CRSwNP patients. Ciprandi et al. [
In CRSsNP group, FEF25-75 had negative correlation with VAS and SNOT-22. It showed that FEF25-75 maybe can respond to patients’ subjective sensation. However, FEV1 failed to correlated with PBEC and duration of disease, indicating PBEC just can be used to evaluate lung function in CRSwNP patients.
Bronchial hyperresponsiveness (BHR) is defined as a situation in which airway is in an abnormally sensitive condition after exposure to a variety of physical, chemical and biological stimulation. BHR mostly happened in asthma, allergic rhinitis and so on. Actually, BHR was also found in CRS. BHR was measured by the bronchial provocation test. In this study, the prevalence of positive bronchial provocation test in CRSwNP and CRSsNP patients was only 10% and 0%, respectively. Nevertheless, increased lower airway responsiveness could be driven by the following situations including the nasobronchial reflex in CRS, inflammatory reaction caused by smoking, per oral breathing caused by nasal obstruction, posterior sinonasal drainage of inflammatory mediator during sleep [
In CRSwNP group, we found decreased FEV1 and FEF25-75 was more frequently observed in patients having CRSwNP with high level of PBEC than in those having CRSwNP with moderate and low level. This indicted PBEC of CRSwNP patients can reflected decreased lung function. It showed similar result according to Tanaka et al.’s research [
This study has some limitations in the interpretation of the results. First, we excluded patients diagnosed with pulmonary diseases like Asthma, but we failed to find asthma component by provocation test in 240 candidates to exclude hidden asthmatic components. Second, differences in age between the groups can represent a bias for evaluation. Patients in CRSwNP group is higher than CRSsNP group, and differences in age may affect the differences in lung function.
In conclusion, our results showed that impaired maximum ventilation and small airway in patients with CRS were related with the existence of nasal polyp. PBEC, duration and subjective outcomes can reflect impaired lung function of CRS patients. Meanwhile, PBEC was independent predictor of change ratio of FEV1 in CRSwNP patients.
▪ Impaired maximum ventilation and small airway in patients with chronic rhinosinusitis (CRS) were related with the existence of nasal polyp.
▪ Peripheral blood eosinophil count (PBEC), duration and subjective outcomes can reflect impaired lung function of CRS patients.
▪ PBEC was independent predictor of change ratio of FEV1 in CRS with nasal polyps patients.
No potential conflict of interest relevant to this article was reported.
Forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF), forced expiratory flow between 25% and 75% of forced vital capacity (FEF25-75) in CRSwNP, CRSsNP and control group. (A, C) FEV1 and FEF25-75 were significantly lower. (B) PEF was no significantly different among three groups. CRSwNP, chronic rhinosinusitis with nasal polyps; CRSsNP, chronic rhinosinusitis without nasal polyps; NS, no significance.
Demographic and clinical characteristics of three groups
Characteristic | CRSwNP (n=100) | CRSsNP (n=40) | Non-CRS (n=100) | |
---|---|---|---|---|
Sex (male:female) | 66:34 | 16:24 | 58:42 | 0.137 |
Age (yr) | 55±10 | 51±13 | 58±9 | 0.034 |
Smokers | 40 (40) | 10 (25) | 36 (36) | 0.497 |
Atopy | 10 (10) | 2 (5) | 6 (6) | 0.673 |
PBEC (109/L) | 0.28±0.43 | 0.18±0.16 | 0.21±0.17 | 0.681 |
LMS | 15.70±5.50 | 7.45±4.06 | 1.42±1.39 | <0.001 |
FEV1 (% of predicted) | 89.72±13.07 | 93.98±12.66 | 100.07±14.12 | 0.001 |
PEF (% of predicted) | 89.03±17.23 | 95.06±12.98 | 91.13±17.41 | 0.394 |
FEF25-75 (% of predicted) | 69.85±24.54 | 87.59±21.49 | 90.52±21.44 | <0.001 |
Values are presented as mean±SD or number (%).
CRSwNP, chronic rhinosinusitis with nasal polyps; CRSsNP, chronic rhinosinusitis without nasal polyps; CRS, chronic rhinosinusitis; PBEC, peripheral blood eosinophil count; LMS, Lund-Mackay score; FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow; FEF25–75, forced expiratory flow between 25% and 75% of forced vital capacity.
Correlation coefficients of FEV1, PEF, FEF25-75 in CRSwNP group
Variable | PBEC | DD | SSN | VAS | SNOT-20 | LMS | LKS |
---|---|---|---|---|---|---|---|
FEV1 | –0.348 |
–0.344 |
–0.078 | –0.127 | –0.033 | –0.067 | –0.130 |
PEF | 0.042 | –0.274 | 0.014 | –0.143 | –0.128 | –0.154 | –0.176 |
FEF25-75 | –0.149 | –0.237 | –0.056 | –0.128 | –0.180 | –0.070 | –0.135 |
FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow; FEF25–75, forced expiratory flow between 25% and 75% of forced vital capacity; CRSwNP, chronic rhinosinusitis with nasal polyps; PBEC, peripheral blood eosinophil count; DD, duration of disease; SSN, sinus surgery number; VAS, visual analogue scale; SONT-20, 20-item Sino-Nasal Outcome Test; LMS, Lund-Mackay score; LKS, Lund-Kennedy endoscopic score.
Correlation coefficients of FEV1, PEF, FEF25-75 in CRSsNP group
Variable | PBEC | DD | SSN | VAS | SNOT-20 | LMS | LKS |
---|---|---|---|---|---|---|---|
FEV1 | –0.068 | 0.388 | 0.352 | –0.030 | –0.150 | –0.196 | 0.048 |
PEF | –0.108 | –0.108 | –0.182 | –0.034 | –0.092 | 0.218 | –0.095 |
FEF25-75 | –0.156 | –0.010 | –0.134 | –0.490 |
–0.478 |
–0.103 | –0.062 |
FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow; FEF25–75, forced expiratory flow between 25% and 75% of forced vital capacity; CRSsNP, chronic rhinosinusitis without nasal polyps; PBEC, peripheral blood eosinophil count; DD, duration of disease; SSN, sinus surgery number; VAS, visual analogue scale; SNOT-20, 20-item Sino-Nasal Outcome Test; LMS, Lund-Mackay score; LKS, Lund-Kennedy endoscopic score.
Linear regression model summary of CRSwNP group for change ratio of FEV1 before and after bronchial provocation or dilation test (
Variable | B | SE | β | |
---|---|---|---|---|
Constant | –2.459 | 5.347 | ||
Age | 0.093 | 0.069 | 0.195 | 0.184 |
PBEC | 4.439 | 1.544 | 0.403 | 0.006 |
DD | 0.007 | 0.007 | 0.158 | 0.359 |
SSN | –0.715 | 1.176 | –0.109 | 0.546 |
VAS | 0.065 | 0.147 | 0.100 | 0.662 |
SNOT-20 | 0.011 | 0.234 | 0.009 | 0.961 |
LMS | 0.211 | 0.145 | 0.243 | 0.153 |
LKS | –0.067 | 0.254 | –0.047 | 0.795 |
CRSwNP, chronic rhinosinusitis with nasal polyps; FEV1, forced expiratory volume in 1 second; SE, standard error; PBEC, peripheral blood eosinophil count; DD, duration of disease; SSN, sinus surgery number; VAS, visual analogue scale; SNOT-20, 20-item Sino-Nasal Outcome Test; LMS, Lund-Mackay score; LKS, Lund-Kennedy endoscopic score.
Linear regression model summary of CRSsNP group for change ratio of FEV1 before and after bronchial provocation or dilation test (
Variable | B | SE | β | |
---|---|---|---|---|
Constant | –6.324 | 4.812 | ||
Age | 0.083 | 0.047 | 0.384 | 0.106 |
PBEC | –4.955 | 4.321 | –0.287 | 0.276 |
DD | –1.151 | 0.014 | –0.302 | 0.319 |
SSN | –4.366 | 1.553 | –0.155 | 0.474 |
VAS | 0.350 | 0.232 | 1.151 | 0.159 |
SNOT-20 | –0.368 | 0.251 | –0.949 | 0.170 |
LMS | 0.116 | 0.307 | 0.173 | 0.712 |
LKS | 0.689 | 0.579 | 0.381 | 0.259 |
CRSsNP, chronic rhinosinusitis without nasal polyps; FEV1, forced expiratory volume in 1 second; SE, standard error; PBEC, peripheral blood eosinophil count; DD, duration of disease; SSN, sinus surgery number; VAS, visual analogue scale; SNOT-20, 20-item Sino-Nasal Outcome Test; LMS, Lund-Mackay score; LKS, Lund-Kennedy endoscopic score.
Comparison of lung function parameters and PBEC
Group | PBEC | No. | FEV1 | PEF | FEF25-75 |
---|---|---|---|---|---|
CRSwNP | Low | 78 | 92.50±12.26 | 89.02±16.26 | 72.33±23.67 |
Moderate | 16 | 83.41±8.25 | 96.38±16.88 | 71.30±23.43 | |
High | 6 | 70.47±15.00 | 69.53±21.66 | 33.73±10.40 | |
0.004 | 0.068 | 0.028 | |||
CRSsNP | Low | 36 | 95.16±12.78 | 96.36±13.53 | 89.15±20.84 |
Moderate | 6 | 87.23±11.71 | 87.67±6.20 | 78.73±27.83 | |
0.330 | 0.297 | 0.454 |
PBEC, peripheral blood eosinophil count; FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow; FEF25–75, forced expiratory flow between 25% and 75% of forced vital capacity; CRSwNP, chronic rhinosinusitis with nasal polyps; CRSsNP, chronic rhinosinusitis without nasal polyps.