Bronchiectasis and chronic rhinosinusitis
Article Outline
Summary
A patient with post-traumatic rhinosinusitis for 10 years developed recurrent chest infections. Computed tomographic scanning demonstrated diffuse bronchiectasis. The bronchiectasis appeared to have developed as a complication of persistent upper airway sepsis.
Key words: Bronchiectasis, Rhinosinusitis, Trauma
Introduction
A prominent feature of bronchiectasis is upper respiratory involvement primarily rhinosinusitis. The mechanism for this association is generally not well understood. This report describes bronchiectasis occurring as a probable complication of persistent upper respiratory tract sepsis.
Case report
A 36 year-old man presented for assessment of recurrent chest infections. He had been very healthy as a child with no respiratory illnesses or relevant family history. At the age of 19 he was involved in a major motor car accident where he sustained facial fractures. Over the next 5 years he had a series of operations on his nose principally to correct cosmetic deformities including Septo–Rhinoplasty and bone grafting. In this period he developed symptoms of rhinosinusitis with persistent nasal discharge and post-nasal drip. He also described exacerbations occurring every 2–3 months with purulent nasal discharge, pain over frontal sinuses, fever and constitutional upset. These symptoms persisted with no response to further surgery and partial relief with antibiotics.
Ten years after the onset of his upper respiratory tract symptoms he described developing a significant chest infection with fevers and pleuritic chest pain. This episode responded well to oral antibiotics. Over the next 7 years he had another four lower respiratory tract infections with chest X-rays demonstrating patchy lower lobe consolidation on two occasions. He worked as motor mechanic with no obvious effect on his symptoms and was light smoker (approximately five cigarettes a day for 10 years).
His current major complaints were his ongoing severe post-nasal drip and upper airway symptoms and dissatisfaction with his previous nasal surgery. On examination he was a well-looking man who had tenderness over his maxillary sinuses and scattered bi-basal crackles. Screening of his immune function including full blood examination, immunoglobulin levels, cystic fibrosis (CF) mutations, allergic bronchopulmonary aspergillosis (skin test reaction, IgE and precipitins) alpha-1 antitrypsin levels, lymphocyte and neutrophil function was normal. Spirometry demonstrated a borderline low FEV1 of 74% of predicted with the FEV1/FVC ratio of 0.73 and no significant bronchodilator effect. Lung diffusing capacity was in the normal range. A sinus CT scan showed bilateral inflammatory changes with occlusion of the ostiomeatal complex and mucosal thickening of mucosal and ethmoid sinuses. A high resolution CT scan of his lungs demonstrated discrete areas of bronchiectasis involving segments of his right middle lobe, right lower lobe and left lower lobe. These areas of bronchiectasis had associated fibrosis.
Discussion
Non-CF bronchiectasis is associated with upper respiratory tract disease with studies reporting an incidence of 30–70% of rhinosinusitis in this condition.1, 2, 3, 4, 5 Why many patients with bronchiectasis have upper and lower respiratory disease in combination is generally not known. Primary ciliary dyskinesia impairs function throughout the respiratory tract and is a classic but uncommon cause of bronchiectasis.6 It is possible that this combination may reflect a susceptibility of the entire respiratory tract to infection. An alternative explanation in some patients is that infection may have started in one area of the respiratory tract and then spread. The incidence of upper respiratory tract symptoms in chronic obstructive pulmonary disease patients with chronic bronchitis is generally very low though.
In this case the patient appeared to have normal immune function with no history of respiratory tract disease until he developed post-traumatic rhinosinusitis. There was no evidence of another underlying cause for his bronchiectasis. Nor did he have any evidence of another respiratory condition or was there any history of respiratory illnesses in childhood. He had worked as a motor mechanic for the past 15 years with no association with his cough. There was no history of overseas travel or relevant family history. Following a 10-year history of significant recurrent upper respiratory tract sepsis he then developed lower respiratory tract infections with bronchiectasis. The suggestion from this case is that bronchiectasis may occur as a complication of rhinosinusitis and this association has not been clearly described previously.
Conflict of interest statement
The author has no conflict of interest in this work.
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PII: S1755-0017(08)00044-4
doi:10.1016/j.rmedc.2008.05.003
© 2008 Elsevier Ltd. All rights reserved.
