© Borgis - New Medicine 3/1999, s. 8-9
Mieczysław Chmielik, Beata Zając
Sinobronchial syndrome
Department of Pediatric Otorhinolaryngology, Warsaw Medical School, Poland
Head: Prof. Mieczysław Chmielik M.D.
Summary
Sinobronchial syndrome occurs in some cases of paranasal sinus disease. The clinical picture of sinobronchial syndrome is based on the evacuation of exudate from sinuses to nasopharynx, larynx, and to the lower respiratory tract. Causes leading to the development of this condition are discussed. The authors, based on their own experience and data from literature, present the pathogenesis, diagnostic methods, and treatment of sinobronchial syndrome.
Introduction
In Nelson´s Texbook of Pediatrics we find the following definition of sinobronchial syndrome; „The term sinobronchitis is occasionally used to designate the relationship between sinus and lower respiratory tract symptoms; children with this condition may have reactive airways, cystic fibrosis, immunodeficiency, or dyskinetic cilia as the underlying disease” (2).
The term sinobronchial syndrome is occasionally used in current literature. Symptoms of sinobronchial syndrome are usually described as the symptoms of chronic sinusitis. But chronic sinusitis and sinobronchial syndrome are not the same disease. Jan Danielewicz was one of the first Polish writers who pointed out that sinobronchial syndrome was a separate form of sinusitis in children. Inflammation processes taking place in sinuses in children can not be included among chronic diseases, in his opinion, in spite of the fact that these processes usually return during a few succeeding years in autumn and winter. Sinus mucous membrane changes developing in children suffering from sinusitis are reversible, and the disease retreats spontaneously during pubescence. These cases, on Jan Danielewicz´s theory, are said to be against the chronic character of sinusitis in the pediatric group (4).
The typical clinical view of sinobronchial syndrome has promped many authors to propose the hypothesis that abnormal defensive mechanism of respiratory tract mucous membrane, and the incomplete response of the immunological system in children, are underlying pathological mechanisms.
Pathology
The normal physiological function of the paranasal sinuses depends on 3 main factors: structure and function of mucous membrane, mucus drainage, and ventilation. Mucociliary transport plays the main role in the local defensive mechanism of mucous membrane. The predominant immunoglobulin in mucous is IgA, produced by plasma cells in the submucosa. IgG penetrates from blood vessels by a passive diffusion mechanism (8).
The immunological system achieves complete efficiency in children at 10-12 years old. That is why infections of the respiratory tract in children follow a different course than in adults. During the first years of life a relative immunodeficiency is observed in children compared to adults. Levels of IgG reach adult values at approximately 3 years of age and IgA levels at 7 to 8 years. Children also have 6 to 7 viral infections per year. Frequent viral infections may influence the immunological response and lead to an abnormal immunological reaction. Recurrent viral infection could also impair mucociliary transport (5).
In some children with sinobronchial syndrome, adenoid hypertrophy or septal deviation are diagnosed (10). These pathological circumstances impair the normal ventilation of the sinuses and lead to prolongation of the inflammation process.
The pathological process of sinobronchial syndrome, regardless of the initiating event or predisposing conditions, leads to a local inflammation process. Inflammatory cells and their mediators become resident in the submucosa. Inflammation alters the ciliated epithelium and composition of mucus. Mucociliary transport dysfunction causes an impairment of sinus drainage, with the resultant pooling of secretions. Secretions filling sinuses may become infected, leading to persistence of inflammation (2).
Studies of immunological processes in recurrent sinusitis in children, carried out in recent years, confirm the hypothesis about an abnormal immunological response. In a group of children with sinobronchial syndrome, immunoglobulin A level in serum was found to be reduced to the lower limit of the norm for the patient´s age (9).
Shapiro and others showed abnormal results of immunological studies, in 34 of 61 children with chronic sinusitis. Depressed IgG levels and poor response to pneumococcal and Haemophilus influenzae antigens were found. Twenty-two patients had positive prick tests. These findings, sugges an allergic component in the pathogenesis of sinusitis in this group of children (11).
Baroody and coworkers compared the structure of mucosa from the sinuses of children suffering from chronic sinusitis with that obtained from the sphenoid sinuses of healthy adults. There were significantly more eosinophils in the tissues of children with chronic sinusitis. Allergy status did not affect the degree of tissue eosinophilia (1).
Driscoll and others, in an investigation carried out in the same way, showed significantly more CD4+ cells in the sinus mucosa of children with chronic sinusitis than in normal sinus mucosa. The number of CD8+ cells was not significantly different in either group. This contrasts with published results on adults with chronic sinusitis, in whom CD8+cells predominate in nasal polyps and submucosa. Authors suggest that this possibly reflects a difference in the immunologic response of children and adults (5).
Predicted these studies explain only a few immunological mechanisms taking place in sinusitis in children. Further investigations should be carried out to elucitade the immunological processes.
Symptoms of sinobronchial syndrome
Sinobronchial syndrome usually recurs in a period of exacerbation and remission during a few succeding years especially in autumn and winter. A cough is the most characteristic symptom. Cough attacks usually appear one or two hours after the child falls asleep, and also in the morning. During the day the child is usually free of symptoms, related to the changing position of exudate in relation to the sinus ostia. No auscultatory pathological signs can be elicited from the bronchial tree (4). The remaining symptoms of sinobronchial syndrome are typical of other forms of sinusitis in children:
- swelling of nasal mucous membrane,
- nasal obstruction,
- nasal or/and post discharge (purulent or mucopurulent),
- headache,
- abdominal discomfort, vomiting in the morning,
- irritability, tiredness.
Differentiation
Sinobronchial syndrome should be differentiated from bronchitis and pneumonitis. In bronchitis and pneumonitis a cough is steady symptom, and there are typical auscultatory signs. Other causes of cough are:
- cough variant asthma (S. Corrao),
- cough due to foreign body in airways,
- drug-induced cough,
- psychogenic cough,
- other disorders, which stimulate a cough receptor of afferen neurones in the cough reflex arc.
Diagnosis
Diagnosis of sinobronchial syndrome is based on typical clinical symptoms (4). Sometimes we need to take X-rays of the sinuses and chest to confirm the diagnosis. In patients with frequent recurrences of sinusitis and bronchitis or pneumonitis it is necessary to exclude diseases which may appear as sinobronchial syndrome: mucoviscidosis, immotile cilia syndrome and congenital or acquired immunodeficiency. For this purpose we need to carry out diagnostic examinations such as:
- bacteriological examination of excudate from sinuses or bronchi,
- X-ray examination, CT scans,
- immunological tests,
- examination of structure and function of cilia,
- tests to exclude mucoviscidosis.
In cases where immunodeficiency, immotile cilia syndrome and mucoviscidosis have been excluded, we can accept that sinobronchial syndrome is one form of sinusitis in children, connected with abnormal defensive mechanisms in the mucous membrane and in incomplete response of the immunological system as the underlying pathology.
Treatment
Treatment of sinobronchial syndrome includes a topical or oral application of an immunomodulating preparation. Mucolytics are also recommended.
During acute exacerbation of sinobronchial syndrome symptom´s antibiotics should be administrated for 10 to 14 days.
In cases of a patient with sinobronchial syndrome, and with concominant adenoid hypertrophy or nasal septal deviation, operative treatment should be taken into concideration.
Piśmiennictwo
1. Baroody F.M.et al.: Eosinophilia in Chronic Childhood Sinusitis. Arch. Otolarygol. Head. Neck. Surg. 1995, 121:1396-1402. 2. Behrman R.E.: Podręcznik Pediatrii. Nelson, pod red. M. Sieniawskiej, Wyd. Naukowe PWN, Warszawa 1996, str 875. 3. Chazan R.: Zakażenia układu oddechowego. a-medica press, Warszawa 1998, 57-61. 4. Danielewicz J.: Klinika i patogeneza zespołu zatokowo-oskrzelowego u dzieci. Ped. Pol. 1981, 61:11-12, 1311-15. 5. Driscoll P.V. et al.: CD4 Lymphocytes Are Increased in the Sinus Mucosa of Children With Chronic Sinusitis. Arch. Otolaryngol. Head. Neck. Surg. 1996, 122:1071-76. 6.Gul E. et al.: Kilka uwag na temat zapaleń zatok przynosowych u dzieci na podstawie analizy materiału Oddziału Laryngologii Wojewódzkiego Szpitala we Wrocławiu z lat 1987-1992. Otolaryng. Pol. 1994, 48, supl., 136139. 7. Kossowska E.: Podsumowanie obrad pierwszego dnia kongresu Otolaryng. Pol. supl., I Europejski Kongres Otolaryngologii Pediatrycznej 5-7.09.1979 Warszawa, 76. 8. Krzeski A., Janczewski G.: Choroby nosa i zatok przynosowych. Sanmedia Warszawa 1997, 4849. 9. Łakota A. i wsp.: Poziom magnezu w surowicy i jego wpływ na leczenie zespołu zatokowooskrzelowego u dzieci. Otolaryng. Pol. 1994, 48, supl. 18, 125-132. 10. Nowak W. et al.: Zespół zatokowooskrzelowy u dzieci leczonych w Szpitalu Miejskim w Bytomiu w latach 1976-1978. Otolaryng. Pol. supl. I Europejski Kongres Otolaryngologii Pediatrycznej 57.09.1979 Warszawa, 50-51. 11. Shapiro G.G. et al.: Immunological Defect in Patients With Refractory Sinusitis Pediatrics 1991, 87, 3:311-16.
