The Unified Airway: Do We Fully Appreciate Its Impact in Otolaryngology?

Effect of Treatment of the Respiratory Tract as a Functional Unit

The impact of these findings is only now starting to bear fruit from a clinical point of view. Increasingly, studies are beginning to show the beneficial impact of treating the respiratory tract as a whole. Multiple studies have shown the impact that controlling chronic sinusitis has on the management of asthma. When taken in aggregate, successful management of chronic rhinosinusitis results in decreased asthma medication, improved pulmonary function, and fewer exacerbations.13 Similarly, treatment of allergic rhinitis has an impact on asthma, as demonstrated in a cohort of patients with concurrent allergic rhinitis and asthma. As an example of this observation, patients in this study who were treated with nasal steroids enjoyed an improvement in pulmonary symptoms after 12 weeks of therapy over disease-matched controls.14

Some of the treatment modalities currently available to patients may even possess the capability to alter host cellular responses to inflammatory triggers responsible for some aspects of chronic respiratory disease. In 1999, Durham et al.15 demonstrated the effect of antigen-specific immunotherapy on CD4 function. Over the course of therapy, cutaneous CD4 lymphocytes obtained from patients treated with subcutaneous immunotherapy for a period of at least three years revealed a change in cytokine expression suggestive of a shift from Th2 to Th1 compartmentalization. Findings such as these illustrate the potential impact of treatments such as allergen-specific immunotherapy to reach beyond simply that of symptomatic control of allergic rhinitis.

Impact on the Practice of Otolaryngology

So while the exact mechanism by which a patient may describe the relationship among asthma, allergy, and rhinosinusitis may remain in question, the general observation appears reasonably sound and supportable by current literature. The notion of the unified airway concept offers both a challenge and an opportunity to the practice of otolaryngology. On one hand, common and interrelated inflammatory disease of the respiratory tract requires treating physicians to be aware of common comorbidities. Successful treatment of nasal polyposis fails to matter if an unrecognized asthma threatens a patient’s activity or life. On the other hand, this concept offers hope that comprehensive recognition and management may lead to improved overall patient outcomes.

The relevance of the unified airway concept is now becoming increasingly recognized by professional organizations within otolaryngology. Otolaryngologists treating patients with allergic rhinitis are beginning to identify, monitor, and manage patients with concurrent asthma. Otolaryngologists who treat chronic rhinosinusitis are beginning to incorporate allergy evaluation and treatment into their operative and nonoperative management schemes. The end result is the potential for improved patient care.