© Borgis - New Medicine 3/1999, s. 8-9
Mieczysław Chmielik, Beata Zając
Department of Pediatric Otorhinolaryngology, Warsaw Medical School, Poland
Head: Prof. Mieczysław Chmielik M.D.
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.
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.
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).
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