Chronic rhinosinusitis and age: is the pathogenesis different?

Abstract

Chronic rhinosinusitis (CRS) is a common disease with a significant impact on quality of life, which is seen across all age groups. There are differences in symptomatology, histopathology and associated diseases when comparing pediatric versus adult patients with CRS. Nasal polyposis tends to be less commonly seen in pediatric CRS compared with adults except in children with cystic fibrosis or allergic fungal rhinosinusitis. The differences in histopathology of CRS in different age groups include higher cellularity and more prominent lymphocytic infiltration in children compared with adults who tend to have a stronger eosinophilic infiltration and more prominent glandular hyperplasia. There are data supporting a stronger association of gastroesophageal reflux disease and otitis media with CRS in children compared with adults. Adenoids may play a role in pediatric, but not adult CRS. Immunodeficiencies and asthma are strongly associated with CRS in all age groups. There is a paucity of data on pathophysiology of disease on elderly CRS.

Keywords::

• adults
• bacteriology
• chronic rhinosinusitis
• elderly
• histopathology
• immunodeficiency
• nasal polyps
• pediatrics

Financial & competing interests disclosure

The authors are supported by The Ernest S Bazley Grant to Northwestern Memorial Hospital and Northwestern University. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • There are few studies directly comparing the pathogenesis, symptoms or the comorbidities associated with chronic rhinosinusitis (CRS) in children versus adults or elderly.

• • Although there are no formal studies evaluating the prevalence of nasal polyposis in pediatric CRS, it is reported that nasal polyps are rare findings in young children and if seen are mostly in the setting of other co-morbidities like cystic fibrosis (CF) or allergic fungal rhinosinusitis (AFRS). Most reports suggest that NP rarely occurs before the age of 10. For that reason, it is recommended to further investigate children with nasal polyps to rule out congenital diseases, neoplastic changes or other associated conditions.

• • There are also differences in the histopathology of CRS in adults compared with children; pediatric CRS tissue tends to have higher lymphocytes, monocyte/macrophages, neutrophils and natural killer cells, and fewer submucosal glands, thinner epithelium and less eosinophils infiltration in mucosa and submucosa when compared with adult CRS.

• • The data associating gastroesophageal reflux disease (GERD) and otitis media (OM) with CRS is stronger in pediatric patients compared with adults, which could be due to anatomical differences in different age groups. And in case of OM could also be due to the coexistence of inadequate immune function or other triggers of rhinitis including environmental allergies in these patients.

• • With regard to the discrepant findings reported in the literature, it is difficult to determine whether allergic rhinitis (AR) has a significant association with CRS in children; however most adult studies report higher prevalence of atopy in CRS than in the general population.

• • CRS is long known to be more common in patients with asthma both in children and adults. In context of the one airway theory, with all the evidence on the inflammatory and anatomical relationships between the nose, paranasal sinuses and the lower respiratory tract, it has been hypothesized that rhinosinusitis impacts bronchial asthma in all age groups which has been proven to be the case in multiple adult studies; however there are fewer studies in children.

• • At this point, it is not clear if the frequency or types of immunodeficiencies found in pediatric CRS are different from adults, but based on reviewed data it is strongly recommended to evaluate immune function in children and adults with chronic/recurrent rhinosinusitis and poor response to medical treatment, or history of other infectious diseases like recurrent pneumonia or OM.