S F Ahsan, S Jumans*, D A Nunez
Department of Otolaryngology, Aberdeen Royal Infirmary, Aberdeen
*Department of Otolaryngology, Port of Spain General Hospital, Port-Of-Spain Trinidad
Correspondence to: D A Nunez, Consultant & Clinical Senior Lecturer, Dept. of Otolaryngology Southmead Hospital, Bristol BS10 5NB SMJ 2004 49(4): 130-133
A comparative study of the occurrence of chronic rhinosinusitis in clinics in the North of Scotland and Southern Caribbean was performed, to
test the hypothesis that patients with chronic rhinosinusitis present more commonly in temperate climates than tropical climates. The data was collected prospectively over two month periods from outpatient clinics at both sites. A higher surgical trainee or consultant otolaryngologist made the diagnosis of chronic rhinosinusitis. Eight-hundred-and-seventy-two otolaryngology outpatients were studied 311 were from Trinidad and 561 from Aberdeen. The proportion of patients presenting with chronic rhinosinusitis in both samples is similar, 54(9.6%) patients in Aberdeen and 29(9.3%) in Trinidad. The proportion of chronic rhinosinusitis patients with a history of allergy is greater in Trinidad 79.3%(23) than in the Aberdeen sample 50%(27). Patients with chronic rhinosinusitis were seen as commonly in otolaryngology clinics in a tropical setting as in a temperate setting.
Key words: Rhinosinusitis, temperate and tropical climates, allergy.
Sinusitis is a term widely used by the general population and clinicians alike and while anecdotally there is little disagreement concerning the general site of pathology few share an agreed definition. The need for an agreed definition in order to advance research and treatment of this common inflammatory disease led to the establishment of the Rhinosinusitis Task force in 1996 which has developed consensus working definitions.1 The term sinusitis has been replaced by Rhinosinusitis for reasons of accuracy, clarity and education. The mucous membranes of the nose and the sinuses are contiguous, subject to the same disease processes and it is rare for sinusitis to develop in the absence of preceding or concurrent rhinitis. Rhinosinusitis persisting more than 12 weeks is defined as chronic. Chronic rhinosinusitis is diagnosed by the presence of two or more of the following major factors; facial pain/pressure, facial congestion/fullness, nasal obstruction, nasal discharge/discoloured postnasal drainage, hyposmia/ anosmia, purulent discharge in the nose on clinical examination or one major and two of the following minor factors; headache, fever, halitosis, fatigue, dental pain, cough, ear pressure/fullness or; the finding of nasal purulence on examination.1,2
The prevalence in a United States sample was 11% in males and 12.3% in females based on household interviews of the civilian non-institutionalised population.3 The disease causes much morbidity and the prevalence is estimated to be increasing.4 The aetiology is multifactorial. The most common cause of rhino-sinusitis is a viral upper respiratory infection, with oedema or inflammation of the nasal lining and the production of thick mucus that obstruct the paranasal sinuses leading to secondary bacterial infection.5 An increased incidence of upper respiratory infections in winter is established, and low outdoor temperature is the highest climatic correlate in Britain.6 The majority of attacks of rhino-sinusitis are self-limiting. Chronic Rhinosinusitis develops more commonly in patients with allergic disease or immuno-compromise primary or secondary. Anatomical factors including nasal septal deviations, concha bullosae and accessory sinus ostia are believed to play a contributory role. Nasal polyps lead to obstruction of the sinus ostia and often cause secondary sinusitis. On their own they are considered by many authorities to represent a form of chronic non infectious hyperplastic sinusitis when extensive and not associated with signs of infection.
Diseases affecting mucous production or transport such as cystic fibrosis and ciliary dyskinesia are rare causes of chronic rhinosinusitis.7 House dust mites are a ubiquitous and important cause of allergic disease with higher levels of sensitisation found in populations living in humid and coastal areas.8 House dust mite levels in the British Isles are known to be high and increase in winter.9 The potentiating affects of allergic upper respiratory tract disease and frequent viral infections in relation to low outdoor temperatures would be expected to lead to a higher level of chronic rhinosinusitis in a northern temperate environment compared to the Caribbean. The proportion of patients presenting with chronic Rhinosinusitis in outpatient otolaryngology clinics in a tropical setting and in a northern European setting were compared to determine if there was a difference in occurrence.
The diagnostic and demographic details of outpatient otolaryngology clinic attendees at two hospitals providing secondary care to the 250,000 population of Aberdeen and tertiary care to a population of 700,000 in north-eastern Scotland were recorded prospectively. The identical methodology was employed by the same research worker at two hospitals providing secondary care to the 750,000 populations of Port-of-Spain and northeastern Trinidad and tertiary care to a population of 1.5 million. The data was collected over a two-month period at both sites, July- August 1999 in Aberdeen and September-October 1999 in Trinidad. The hospitals studied were teaching hospitals of the Universities of Aberdeen and the West Indies. The Aberdeen outpatient attendances were all publicly funded through the National Health Service with no fee at the point of delivery of the service to the patient. In the Trinidad sample the outpatient attendances at one of the hospitals (Portof- Spain General) was similarly funded but the outpatients at the Eric William’s Medical Complex were required to pay a subsidised fee for service.
A standardised proforma was used to record the study data, which included the physical signs in patients who presented with nasal/sinus problems and the presence of a history of asthma/allergic disease. Patients who had a history of asthma were classified as asthmatic, while those who had history of hay fever or positive allergy testing were classified as allergic.
Patients were classified as having chronic rhinosinusitis on the basis of their presenting history and clinical findings by an experienced otolaryngologist of registrar or consultant grade. No attempt was made to determine how rigidly each clinician applied the Rhinosinusitis task force criteria in making a diagnosis of chronic rhinosinusitis. Permission for the study was obtained from both the University of Aberdeen Medical School, Scotland and the University of the West Indies Medical Faculty, St. Augustine, Trinidad and Tobago.
Chi-squared test was used for inter-group statistical analysis.
The details of 872-otolaryngology department outpatient attendances were studied, 561 from Aberdeen and 311 from Trinidad. There were 286 male patients and 275 female patients in Aberdeen sample while the Trinidad sample consisted of 132 male and 179 female patients, (Table I). Fifty-four patients (9.6% of sample population) presented with symptoms consistent with chronic rhinosinusitis in Aberdeen. 9.3%(29) of the otolaryngology outpatient clinic attenders in Trinidad were diagnosed with chronic rhinosinusitis. There was no sex predominance in either sample (Table I).
On the basis of history there was a striking difference in the incidence of asthma and allergy between patients with chronic rhinosinusitis and patients attending otolaryngology clinics with other clinical conditions. In Aberdeen 12.3%(69) and 14.3%(80) of patients without rhinosinusitis had history of asthma and allergy respectively compared to 31.5%(17) asthmatic and 50%(27) allergic patients with chronic rhinosinusitis. In Trinidad 10.6%(33) and 14.4%(45) of patients without rhinosinusitis had a history of asthma or allergy respectively; this is compared to 48.3%(14) asthmatic and 79.3%(23) allergic patients with chronic rhinosinusitis (Table II).
On statistical analysis there is no significant difference in sex distribution between rhinosinusitis samples in Trinidad and Aberdeen across all age groups. The proportion of rhinosinusitis patients with asthma is similar in Trinidad and Aberdeen while the proportion of rhinosinusitis patients with allergy is higher in Trinidad than Aberdeen (p=.009).
The hypothesis, namely that the proportion of patients presenting with chronic rhinosinusitis to otolaryngology clinics in Trinidad would be less than that for clinics in Aberdeen is disproved. A similar proportion of patients presented to each clinic with chronic rhinosinusitis, 9.3% in Trinidad and 9.6% in Aberdeen.
The criteria proposed by the Rhinosinusitis Task force are the features widely used by practicing otolaryngologist and were familiar to the otolaryngologists making the diagnosis of rhinosinusitis in the study. The data collected by the researcher was based on the clinician’s report with no attempt to record all of the symptoms reported by individual patients or which criteria were used in making the diagnosis of rhinosinusitis in an individual patient. The presence of the researcher recording patients diagnoses including rhinosinusitis is likely to have caused clinicians to apply diagnostic criteria more robustly, but we did not study the effect of the presence of the researcher on diagnoses recorded. The risk of different criteria being used to make the diagnosis of chronic rhinosinusitis was reduced by the involvement of the same researcher at both sites, study lead clinician’s at both sites trained in otolaryngology in the United Kingdom and familiar with the study’s aim. The study was conducted during the summer months in Aberdeen when the incidence of upper respiratory tract infections in the population predisposing to the development of chronic sinusitis should be low compared to the winter months.6 At the time the study was performed there was a waiting time of approximately 9 months from the general practitioner’s referral to the patient being seen in an outpatient clinic in Aberdeen. In effect patients seen in clinics in July and August had been referred from the previous winter. July and August were chosen as the recruitment months in Aberdeen, in order to maximise capturing patients referred during the previous winter months of November-February. The climate in Trinidad does not show a significant seasonal temperature change and no attempt was made to target patients presenting at a particular time of the year. The study months of September and October in Trinidad were chosen for convenience. The study was thus designed to maximise the chance of finding a difference in the proportion of patients presenting to otolaryngology departments in the areas studied if a northern European winter climate is indeed associated with a greater incidence of rhinosinusitis.
Aberdeen (and the UK) has a well-established publicly funded primary care system with good resources compared to Trinidad. In Trinidad patients referred to one of the otolaryngology outpatient departments studied were required to pay a fee for their consultation. The effect of financial factors on the proportion of patients with rhinosinusitis seen in the outpatient clinics studied is unknown.
The proportion of patients with chronic rhinosinusitis who are asthmatic is equal in Trinidad and Aberdeen on statistical analysis while the proportion of patients with allergy is higher in Trinidad than Aberdeen (p=.009). Newman et al. have shown that 78% of patients with extensive rhinosinusitis non-responsive to medical treatment are allergic while 71% are asthmatic.10 A higher proportion of chronic rhinosinusitis patients with allergy in Trinidad may be a reflection of patients presenting with more severe disease. The lack of discernable difference in the proportion of patients with a history of asthma or allergic disease in the other otolaryngology outpatient attenders at both sites suggest that allergic disease is not more common in the southern Caribbean. The reason for the apparent difference in the proportion of allergy sufferers with chronic rhinosinusitis in the two samples will require further study to elucidate the cause.
Patients with chronic rhinosinusitis constitute a similar proportion of outpatient otolaryngology clinic attendees in the north of Scotland and the north of Trinidad. Rhinosinusitis sufferers with a history of allergic disease are more commonly seen in otolaryngology clinics in Trinidad.
ACKNOWLEDGEMENTS: The otolaryngology outpatient clinical staff and patients at Mount Hope Hospital (Trinidad), Port of Spain General Hospital (Trinidad), Royal Aberdeen Children’s Hospital and Woolmanhill Hospital (Aberdeen). Mr R Moffat for data collection.
Presented in part at: The Scottish Otolaryngology Society, Winter Meeting November 2000
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