Literature Reading

Rhinology and Allergy

UNIFIED AIRWAY
Presentant: Achmad P

Supervisor:

dr. Arif Dermawan, M.Kes., Sp.T.H.T.K.L.(K)

D E PA R T M E N T O F O T O R H I N O L A R Y N G O L O G Y- H E A D & N E C K S U R G E R Y

FA C U LT Y O F M E D I C I N E PA D J A D J A R A N U N I V E R S I T Y

H A S A N S A D I K I N G E N E R A L H O S P I TAL

BANDUNG

2017
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 INTRODUCTION
The respiratory tract is considered to be an
integrated system and to behave as an
organized, functional unit

Worsening of disease in one part of the

airway negatively impacts other parts of
the airway
Effectively managing disease in one part
of the airway seems to improve disease in
other parts of the airway
Justice.J.M, Orlandi R. The Unified Airway. Head & Neck Surgery - Otolaryngology. Lippincot Williams & Wilkins. 5 th edition.
p550-555. Philadelphia.2014 2
 INTRODUCTION
The concept of unified airway has
solidified the need for
multidisciplinary care for these
patients involving primary care
physicians, otolaryngologist,
allergists, immunologists, and
pulmonologists

Justice.J.M, Orlandi R. The Unified Airway. Head & Neck Surgery - Otolaryngology. Lippincot Williams & Wilkins. 5 th edition.
p550-555. Philadelphia.2014 3
 Unified Airway Disease

Krouse JH. 2008. The Unified Airway-Conceptual Framework. Department of Otolaryngology Wayne
State University 4
 Unified airway

5
Pawankar R. Overview on the pathomechanism of allergic rhinitis. Asian pac allergy.2011
 Three Criteria in support of the
theory unified airway
1. Patients with upper airway disease should
have a higher prevalence of lower
respiratory diseases
2. Interrelated pathophysiologic mechanisms
between upper and lower airway diseases
should exist to explain the interaction of
these two disease processes.
3. Treatment of one portion of the unified
airway should improve symptoms in a
separate portion of the respiratory system
Justice.J.M, Orlandi R. The Unified Airway. Head & Neck Surgery - Otolaryngology. Lippincot Williams & Wilkins. 5 th edition.
Philadelphia.2014 6
 Phatogenesis :

Wheatley, Togias . Allergic Rhinitis. The New England Journal of Medicine. N Engl J Med
2015; 372:456-63
7
Wheatley, Togias . Allergic Rhinitis. The New England Journal of Medicine. N Engl J Med 8
2015; 372:456-63.
 Allergic Rhinitis and
Rhinosinusitis-Asthma

9
 Pathophysiological
mechanisms
1. The nasobronchial reflex
2. The loss of nasal protection of the
lower airway
3. Shared inflammation throughout the
respiratory tract

Krouse JH. 2008. The Unified Airway-Conceptual Framework. Department of Otolaryngology Wayne
State University 10
 Osteomeatal Complex

James A.Hadley,Mani S.Kavuru,Jack B.Anon,Lily C.Pien,Diagnosis and Management Rhinitis and 11

Rhinosinusitiis,Third edition,2005.
Pathophysiology of Rhinosinusitis

Benson B, Riauba L, Davidoff TQ, et al. Sinusitis, acute. Emedicine from WebMD
Website.http://emedicine.medscape.com/article/232670-overview. (28/2/2015) 13
PATHOPHYSIOLOGY AR-RHINOSINUSITIS

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PATHOPHYSIOLOGY AR-RHINOSINUSITIS
(Contd)

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 PATHOPHYSIOLOGY

American Academy of Allergy Asthma & Immunology,Journal of Allergy and Clinical 16

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Immunology,2011
Halpren RL. 2012. Allergic Rhinitis and the Unified Airway: A Therapeutic Dilemma. Center for Cosmetic and Corrective Jaw
Surgery. Newyork. Elsevier. 17
 Allergic Rhinitis and Asthma
The ciliated pseudostratified columnar
epithelium in the nasal cavity is similar
to that of the respiratory mucosa.
The inflammatory process in both
areas is similar, involve eosinophils,
lymphocytes, and mononuclear cells
as well as similar cytokines, such as IL-
4, 5, and 13, which are typical of Th2
type allergic response
Justice.J.M, Orlandi R. The Unified Airway. Head & Neck Surgery - Otolaryngology. Lippincot Williams & Wilkins. 5 th edition.
Philadelphia.2014 18
 Pathophysiology Asthma

Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic rhinitis and its impact on asthma
(ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy. 2008;
63 Suppl 86:8-160. Feng C, Miller D, Simon, R. The united allergic airway: Connections between allergic rhinitis,
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asthma, and chronic sinusitis . Am J Rhinol Allergy. 2012 (26); 187-90.
Similarities And Differences Between The
Nasal And Bronchial Inflammatory Mucosa

Tsilochristou OA et al. 2013. Pediatric Allergic Rhinitis and Asthma: Can the March
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be Halted?. Pediatr Drugs 15:431440
 Allergic rhinitis and
adenoid hypertrophy

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 Adenoid
The adenoid is the peripheral lymphoid
organ located in the nasopharynx that is
part of the Waldeyer ring
contributes to the development of immunity
against inhaled micro-organisms in early life
In all children, the volume of the adenoid
increases with age with a maximal volume
in the age group of 56 years, followed by a
gradual decrease in volume by the age of
89 years
Hellings, P. 2006. Allergic Rhinitis and Its Impact On Otorhinolaryngology. Department of Otorhinolaryngology, Head and
Neck Surgery Leuven Hospital University 61 : 661 23
 Immunology of the tonsils
(contd)

In contrast to lymph nodes, tonsils and

adenoids lack afferent lymph, but the
reticular crypt epithelium contains dendritic
cells (DCs) that can transport exogenous
antigens to the extrafollicular T-cell areas and
to the B-cell follicles (Table 1)

Interdigitating DCs (IDCs) function as antigen-

presenting cells (APCs) in primary immune
responses and occur abundantly in the
extrafollicular areas, often closely surrounded
by T cells
Brandtzaeg, P. 2003. Immunology of Tonsils and Adenoids : Everything the ENT Surgeon needs
26to
know. International J. of Pediatric Otorhinolaryngology 67S1, S69-S76
Allergic Rhinitis and AR-
AOM

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 Adenoids, Adenoiditis and
Otitis Media

Adenoids enlargement
promoting inflammatory
changes in their proximity
and even in the middle ear
through the release of
chemical mediators
may contribute to ET
dysfunction
causing mechanical
obstruction
ET : Eustachian Tube
Marseglia, G.L. & Poddighe, D. 2009. Role of Adenoids and Adenoiditis in Children with Allergy and Otitis Media.
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Current Allergy and Asthma Reports 9 : 460-464
 PATHOGENESIS
Mechani Functional
cal
Intraluminal
OBSTRUCTION Poor tensor Veli
Allergic Rhinitis
OF THE TUBE Palatini muscle
Viral Rhinitis
Function

Extraluminal Negative pressure Increased tubal

Adenoid Of the Middle ear compliance
Hypertrophy
Nasopharingeal Duration
tumor Magnitude

Efussion
AOM Transudation
Eksudation

OME
Bluestone,C. 2003. Eustachian Tube Function and Allergy in Otitis Media. Pediatric Otolaryngology. 61 : 758 29
Pelikan, Z. 2009. The role of nasal allergy in chronic secretory otitis media. Ann Allergy Asthma Immunol. 99 : 109
 The Link Between Adenoids,
Adenoiditis, Otitis Media, and Allergy

When a child presents with recurrent episodes of

otitis media or with symptoms indicating a possible
inflammation/ infection of the adenoids, a complete
medical evaluation should be conducted, such as :
1)Collect a detailed history of the child,
2)Investigate the allergic status of the patient,
3)Perform a nasal endoscopy to reach a more
precise diagnosis and to obtain microbiologic
findings
4)Perform such an examination for clinically
undetectable infections

Marseglia, G.L. & Poddighe, D. 2009. Role of Adenoids and Adenoiditis in Children with Allergy and Otitis Media. 30
Current Allergy and Asthma Reports 9 : 460-464
 The Link Between Adenoids, Adenoiditis,
Otitis Media, and Allergy (contd)

OME frequency vary according to the endoscopic

pattern, especially in younger age classes.
Children
Children Children with
with
with adenoiditis and
rhinosinusit
adenoiditis rhinosinusitis
is
Among 2-5 years 50% 17% 42%
old
Among 6-11 older than
In patients 62% 8%
11 years of 58%
age, there was no
years old trend. These epidemiologic and clinical data
similar
seem to suggest a role for adenoid disease in the
development of OME.

Marseglia, G.L. & Poddighe, D. 2009. Role of Adenoids and Adenoiditis in Children with Allergy and Otitis Media. 31
Current Allergy and Asthma Reports 9 : 460-464
The Link Between Adenoids, Adenoiditis,
Otitis Media, and Allergy (contd)

Breakdown of the population

evaluated in the study by
Marseglia et al.
The total number of patients
presenting with otitis media
with effusion (OME) was 53:
11% (n = 23) of those with
acute rhinosinusitis (ARS),
50% (n = 10) of those with
adenoiditis, and
40% (n = 20) of those with
ARS and adenoiditis.

Marseglia, G.L. & Poddighe, D. 2009. Role of Adenoids and Adenoiditis in Children with Allergy and Otitis Media. 32
Current Allergy and Asthma Reports 9 : 460-464
Allergic Rhinitis and Sleep-Disordered
Breathing & Dentofacial Abnormalities

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 Nasal congestion is the most
common and bothersome symptom,
and is often associated with sleep-
disordered breathing
Decrease in quality of life and
productivity and an increase in
daytime sleepiness

Sardana N, Craig TJ. 2011. Congestion and Sleep Impairment in Allergic Rhinitis. Asian Pac J
Allergy Immunol:297-306 34
Symptom Of Patients With Allergic Rhinitis

Soose RJ. Role of Allergy in Sleep-Disordered Breathing. 2012; 625-635

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Allergic Rhinitis Patients And The Subjective
Impact Of Nasal Congestion On Sleep

Soose RJ. Role of Allergy in Sleep-Disordered Breathing. 2012; 625-635

36
Sardana N, Craig TJ. 2011. Congestion and Sleep Impairment in Allergic Rhinitis. Asian Pac J
Allergy Immunol:297-306 37
Sardana N, Craig TJ. 2011. Congestion and Sleep Impairment in Allergic Rhinitis. Asian Pac J
Allergy Immunol:297-306 38
Allergic rhinitis and
Laryngitis

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 Laryngeal Involvement In The
Unified Airway
1. Direct effects of airway
inflammation in the laryngeal
structures
2. Manifestations of the trafficking of
materials through this anatomic
region
3. The development of secondary
edema (particularly in the
interarytenoid area as well as the
vocal process of the arytenoids) as a
Krouse JH et al. Rhinogenic Laryngitis, Cough, and the Unified Airway. Department of Otorhinolaryngology-Head and Neck
Surgery. Temple University: 2010. 40
Krouse JH et al. Rhinogenic Laryngitis, Cough, and the Unified Airway. Department of Otorhinolaryngology-Head and Neck
Surgery. Temple University: 2010. 41
 HIGHLIGHTS
The upper and lower airways function
as a single unit, the unified airway
Because of the shared inflammation
between the upper and lower
airways, patients with upper airway
disease have a higher risk of
concurrently having or subsequently
developing lower airway disease

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 HIGHLIGHTS
Through appreciating the
relationships that exist among
disease such as otitis media, allergic
rhinitis, acute and chronic
rhinosinusitis, and asthma,
physicians can be more thorough in
their diagnosis and treatment of
patients who have airway disorders

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 HIGHLIGHTS
An understanding of the concept of
the unified airway and the ability to
translate its principles into successful
diagnostic and treatment strategies
can enhance the practice of
otolaryngology and can lead to
improved patient outcomes and
quality of life

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THANK YOU

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