Radiological Abnormalities of
Paranasal Sinuses in Asthmatics
with Rhinitis
Mrinal Sircar, M.D., D.N.B.,* Rajesh K. Karol, D.V.D.,* and Promila Bhatia, M.D.t
ABSTRACT
A total of 114 patients with asthma and coexisting rhinitis
were screened radiologically for abnormalities suggestive of
paranasal sinus (PNS) disease. Wefound such radiological ab-
normalities in 87 (76.3%) patients. Of these, 79 (90.8%) had
involvement of maxillary sinuses, 29 (33.3%) offrontal sinuses,
and 8 (9.2%) of sphenoidal sinuses. Sixteen (18.4%) patients
had single sinus involvement, none being that of sphenoidal si-
nuses. Wefound erect occipito-mental (Water's) view most use-
ful for the radiological screening of the PNS. Significance of
these findings and possible clinical implications are reviewed.
Radiological evaluation of the PNS is suggested to select pa-
tients requiring evaluation for sinusitis. (AmericanJournal of
Rhinology9, 99-101, 1995)
Radiological abnormalities of the paranasal sinuses
(PNS) have been observed in both asthma and rhini-
tiS.1-3 Some of these are thought to be caused by sinusitis,
which has been implicated in exacerbations of asthma.4
Because rhinitis is an important precipitating factor of si-
nusitis,5 we evaluated patients with asthma and coexist-
ing rhinitis for radiological abnormalities suggestive of
sinusitis.
Routine radiological evaluation of the PNS is often
limited to obtaining erect occipito-mental (Water's) view.
However, this does not visualize the posterior group of si-
nuses. In this study we assessed the contribution of lateral
view that visualizes the posterior group of sinuses in the
overall assessment of PNS abnormalities in our patients.
From the Departments of *Medicine and tRadiology, Indira
Gandhi £SI Hospital, Delhi, India
Address correspondence and reprint requests to Mrinal Sircar,
M.D., D.N.S., £-347, Nirman VihaT,New Delhi 110-092, India
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MATERIAL AND METHODS
he study population was comprised of 114 patients
T with asthma and coexisting rhinitis who attended the
Indira Gandhi ESI Hospital during one calendar year. All
the patients were nonsmokers and did not have any evi-
dence suggestive of occupational or drug induced asthma/
rhinitis or significant deviated nasal septum. Patients with
rhinitis of less than 1 month's duration were not included
in order to exclude cases of the common cold.
Complete blood counts, chest radiograph CPAview),
and radiographs of the PNS (erect occipito-mental and lat-
eral views) were obtained in all patients. Anteroposterior
(Caldwell) view was not obtained. All radiographs were
read independently by a radiologist and a physician. In
case of any disagreement, radiographs were read by both
together to arrive at a consensus. Presence of sinus mu-
cosal thickening >8 mm, sinus opacification, or air-fluid
level suggestive of sinus inflammation were recorded.6
RESULTS
he clinical and laboratory features of the 114 patients
Tare summarised in Table I. Chest radiographs did not
reveal any abnormalities other than those consistent with
asthma. The radiological abnormalities of the PNS were
observed in 87 of 114 (76.3%) patients studied (Table II).
Of these 87 patients, 79 (90.8%) had involvement of
maxillary sinuses, 29 (33.3%) of frontal sinuses, and 8
(9.2%) of sphenoidal sinuses. Single sinus was involved
in 16 (18.4%) patients. In eight patients a lateral view
demonstrated sphenoidal sinus involvement. However, all
eight patients also had concomitant involvement of the
anterior group of sinuses.
DISCUSSION
n this study 87 of 114 patients (76.3%) had mucosal
I thickening, opacification, or air-fluid level in the radi-
99
 TABLE I mains the same irrespective of the sinus involved,9 detec-
tion of sphenoidal sinus involvement in patients with
Clinical and Laboratory features of 114 Patients with maxillary or frontal sinusitis has no clinical significance.
Asthma and Rhinitis Further, the maxillary sinuses are the most frequently in-
Sex No. (%) Males 42 (36.8) volved sinuses. Hence erect occipito-mental (Water's)
Females 72 (63.2) view is most useful for detecting clinically significant
Age (Years) 30.6 ± 11.5 sinus involvement in asthmatics with coexisting rhinitis,
(Range 13-65 yrs) and routine lateral view has little to contribute.3,JO
Family hlo atopy No. (%) Present 57 (50.0) There are several controversies regarding the signifi-
Absent 57 (50.0) cance of the sinus radiographic findings. Fascenelli has
Duration of rhinitis (years) 6.1 ± 9.2 reported radiological abnormalities of the PNS in 26 per-
(Range 1 mth-50 yrs) cent of normal asymptomatic adults. I I On the other hand,
Duration of asthma (years) 4.6 ± 6.8 positive bacterial cultures of sinus punctures, or wash-
(Range 1 mth-30 yrs) ings, have been reported in 6 to 20 percent of s1'mpto-
Eosinophilia No. (%) Present 26 (22.8) matic patients with normal sinus radiographs.12•l Thus,
Absent 88 (77 .2) sinus radiographic findings have high levels of false pos-
itive and false negative results.
In general, radiological evidence of sinusitis (sinus in-
ographs of their PNS. Previous studies have reported 27.1 fection) in unselected patients bears a hi¥h degree of cor-
to 53.0 percent sinus abnormalities in asthmatics with or relation with positive puncture findings. 4,15 However, in
without coexisting rhinitis.1-3 asthmatics, with or without rhinitis, such direct correla-
A preponderance of maxillary sinus involvement (79 of tion has not yet been established. Further, only some of
87 (90.8%)) was observed in our patients. Similar obser- the asthmatics with radiological abnormalities of the PNS
vations have been reported by other workers as weltl,3 appear to have sinus infection, as they show mixed re-
This is most likely due to the anatomical position and sponse to treatment with antimicrobials, ranging from
antigravity drainage of the maxillary sinuses.6 complete radiological clearance, throu~hfartial clear-
Only eight (9.2%) patients had involvement of the ance, to no radiological improvement. ],4, 6,]
sphenoidal sinuses, and no ethmoidal sinus involvement Pelikan and Pelikan have radiologically demonstrated
was seen in the radiographs taken. Such low prevalence both immediate and late phase allergic response of the
14
could be due to several reasons. Ethmoidal sinuses are sinus mucosa after nasal challenge with allergens. They
multiple and dispersed one behind the other. Hence in- coined the term allergic sinusopathy to describe sinus
volvement of some of these may produce minimal hazi- pathology caused by allergy as distinct from sinusitis due
ness that is difficult to detect on plain radiographsY For to sinus infection. However, such chronic allergic pro-
similar reasons, unilateral sphenoidal sinus opacification cesses can lead to stagnation of secretions in the PNS,
may be missed on a lateral film.7 Further, concomitant which can become sec0!1darily infected.5
swollen nasal turbinates due to rhinitis frequently ob- Thus, both infection and allergy could independently
scure the ethmoidal sinuses, and at times the sphenoidal produce the observed radiological abnormalities of the
sinuses as well.7 Thus the apparent lack of ethmoidal PNS and could also coexist in the same patient. It has
sinus involvement and low rate of sphenoidal sinus in- been suggested that air-fluid level and sinus opacification
volvement is perhaps due to the inherent inadequacy of indicate infection of the PNS, whereas isolated mucosal
occipito-mental and lateral views. thickening merely represents chronic allergic process.l,2
In our study all eight patients with sphenoidal sinus in- We conclude that there is a high prevalence of radio-
volvement also had involvement of the anterior group of logical abnormalities of the PNS in patients of asthma
sinuses. Because medical management of sinusitis re- with coexisting rhinitis. These can be attributed to allergy

TABLE II

Analysis of the Radiological Data of 87 Patients with Abnormal Sinus Radiographs

Frontal Maxillary Sphenoidal Ethmoidal
Side/Site No. (%) No. (%) No. (%) No. (%)
(a) Unilateral 14 (16.1) 28 (32.2) 0(0)
Right 7 (8.0) 12 (13.8) 0(0)
Left 7 (8.0) 16 (18.4) 0(0)
(b) Bilateral 15 (17.2) 51 (58.6) 8 (9.2) 0(0)
(c) Total 29 (33.3) 79 (90.8) 8 (9.2) 0(0)

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 (i.e. allergic sinusopathy), sinus infection (i.e. sinusitis),
both simultaneously, and nonallergic inflammatory mech-
anisms. Since rhinitis can precipitate sinusitis5 and the
latter can aggravate asthma,4 the evaluation for sinusitis
in asthmatics with coexisting rhinitis should be consid-
ered if the asthma is difficult to control. Some clinicians
have suggested computerized tomography (CT) imaging
of the sinuses as an alternative to radiographs because of
CT enhanced sensitivity. However, the equipment for CT
imaging is expensive and not available in many clinics.
Many clinicians will recommend antimicrobials selec-
tively on strong clinical suspicion and not confirm sinusi-
tis by imaging.3,16 If the diagnosis of sinus disease is
in doubt erect occipito-mental view alone is clinically ad-
equate to evaluate for sinus disease, especially where
only conventional radiology is available and resources
are limited.
ACKNOWLEDGMENT
The authors wish to thank Dr. Sanjay Gupta, M.D., for useful sug-
gestions for carrying out the study and for help in preparing this manu-
script.
REFERENCES
1. Rachelefsky GS, Goldberg M, Katz RM, et al. Sinus disease in
children with respiratory allergy. J Allergy Clin Immunol 61:
310-316,1978.
2. Zimmerman B, Stringer 0, Feanny S, et al. Prevalence of abnor-
malities found by sinus x-rays in childhood asthma: Lack of rela-
tion to severity of asthma. J Allergy Clin Immunol 80:268-273,
1987.
3. Schwartz HJ, Thompson JS, Sher TH, Ross RJ. Occult sinus ab-
normalities in asthmatic patients. Arch Intern Med 147:2194-
2196,1987.
4. Rachelefsky GS, Katz RM, Siegel SC. Chronic sinus disease with
AmericanbyJournal
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associated reactive airway disease in children. Pediatrics 73:526-
529,1984.
5. Slavin RG. Sinusitis in adults (symposium). J Allergy Clin Im-
munol 8] :1028-1032,1988.
6. Slavin RG. Sinusitis in adults and its relation to allergic rhinitis,
asthma, and nasal polyps. J Allergy Clin Immunol 82:950-956,
1988.
7. Andrew WK, Swart JG. Fallibility of sinus radiographs in
demonstrating ethmoid sinusitis (Jetter). S Afr Med J 72:158,
1987.
8. Som PM, Lawson W, Biller HF, Lanzieri CF. Ethmoid sinus dis-
ease: CT evaluation in 400 cases. Part I, Nonsurgical patients.
Radiology 159:591-597, 1986.
9. Friday GA, Fireman P. Sinusitis and asthma: Clinical and patho-
genic relationships. In Fick RB Jr, ed. Inflammatory disorders of
the airways. Clinics in chest medicine. vol 19, no. 4. Philadelphia:
W. B. Saunders Co., 1988, pp 557-565.
10. Hayward MWJ, Lyons K, Ennis WP, Rees J. Radiography of
paranasal sinuses-One or three views? Clin Radiol 41:163-164,
1990.
] 1. Fascenelli FW. Maxillary sinus abnormalities: Radiographic evi-
dence in an asymptomatic population. Arch Otolaryngol 90:190-
]93,1969.
12. Vuorinen P, Kauppila A, Pulkkinen K. Comparison of results of
roentgen examination and puncture and irrigation of the maxil-
lary sinuses. J Laryngol Otol 76:359-365, 1962.
13. McNeil RA. Comparison of the findings on transillumination, x-
ray, and lavage of the maxillary sinuses. J Laryngol Otol
77:1009-1013,1963.
14. Pelikan Z, Pelikan Filipek M. Role of nasal allergy in chronic
maxillary sinusitis-Diagnostic value of nasal challenge with al-
lergen. J Allergy Clin Immunol 86:484-491, 1984.
15. Slavin RG, ZiI\iox AP, Samuels LD. Allergic sinusitis: Does it
exist (abstract)? New Engl Reg Allergy Proc 9:256, 1988.
16. Rachelefsky GS, Katz RM, Siegel Sc. Chronic sinusitis in chil-
dren with respiratory allergy: The role of antimicrobials. J Al-
lergy Clin Immunol69:382-387, ]982.
17. Friedman R, Ackerman M, Wald E, et al. Asthma and bacterial
sinusitis in children. J Allergy Clin Immunol 74:185-189,
1984. 0
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