Correspondence

Nasal endoscopy to characterize sinonasal

disease
To the Editor:
The data from Dixon et al1 suggest that using 100-200 mg/d
intranasal mometasone spray does not improve asthma control
in patients who also have sinonasal disease. Pointedly, no
mention was made as to what instructions were given to patients
regarding nasal spray technique. For example, patients with nasal
polyposis and associated osteomeatal complex disease are unlikely to benefit from using a nasal spray with a technique that
results in preferential deposition to the inferior turbinates. Moreover, higher doses of intranasal mometasone (ie, 400 mg/d)
might be required to effectively treat nasal polyposis, along
with correct advice regarding directing the spray toward the osteomeatal complex area. For example, in the United Kingdom we
routinely use fluticasone propionate drops at doses of 400 to 800
mg/d for both induction and maintenance therapy for such
patients.2
The term sinonasal disease is rather vague and does not
accurately describe a clinically relevant patient phenotype in
terms of predicting response to medical therapy with topical
corticosteroids. In this regard we routinely perform rigid nasal
endoscopy on all new patients attending the Dundee Rhinology
Mega-clinic3 to assess the extent of polyp disease in addition to
excluding other conditions, such as inferior turbinate hypertrophy, septal deviation, concha bullosa, and adenoidal hypertrophy,
which might require surgical intervention. Without first making a
proper endoscopic diagnosis, one cannot make any meaningful
conclusions regarding treating the unified allergic airway with
intranasal corticosteroids, especially in terms of their effect on
concomitant asthma control. Further prospective studies are
required in more carefully characterized patients who have
uncomplicated allergic rhinitis and persistent asthma to assess
the effects of intranasal corticosteroids for the unified allergic
airway.
Brian Lipworth, MD
From the Scottish Centre for Respiratory Research, Medical Research Institute,
University of Dundee, Ninewells Hospital & Medical School, Dundee, United
Kingdom. E-mail: b.j.lipworth@dundee.ac.uk.
Disclosure of potential conflict of interest: B. Lipworth has received compensation for
board membership from Boehringer Ingelheim, Chiesi, TEVA Pharmaceuticals,
Meda, and Sandoz; his institution has received or has grants pending from Chiesi,
TEVA, Meda, Pearl, Janssen, and Roche; he has received payment for delivering lectures from TEVA and Meda; and he has received compensation for travel and other
meeting-related expenses from Boehringer Ingelheim and TEVA.
REFERENCES
1. American Lung AssociationAsthma Clinical Research Centers Writing
Committee: Dixon AE, Castro M, Cohen RI, Gerald LB, Holbrook JT, Irvin CG,
et al. Efficacy of nasal mometasone for the treatment of chronic sinonasal disease
in patients with inadequately controlled asthma. J Allergy Clin Immunol 2015;
135:701-9.e5.
2. Vaidyanathan S, Barnes M, Williamson P, Hopkinson P, Donnan PT, Lipworth B.
Treatment of chronic rhinosinusitis with nasal polyposis with oral steroids followed
by topical steroids: a randomized trial. Ann Intern Med 2011;154:293-302.
3. Lipworth BJ, White PS. Allergic inflammation in the unified airway: start with the
nose. Thorax 2000;55:878-81.
Available online May 8, 2015.
http://dx.doi.org/10.1016/j.jaci.2015.04.004

212

Reply
To the Editor:
We agree with Dr Lipworth1 that our study does not address
whether treating complex sinonasal disease documented by
endoscopy would affect asthma outcomes. This was not the
purpose of our study. The purpose of our study was to determine
whether treating chronic sinonasal disease in a diverse patient
population in a manner analogous to that widely practiced in
nontertiary care specialty practices would improve asthma
control.2
Sinonasal disease was determined by using a validated
questionnaire with high sensitivity and specificity for determining
the presence of sinonasal disease, which was superior to
endoscopy and computed tomographic imaging.3 The reason
for using a questionnaire rather than invasive testing to document
disease was to mirror common clinical practice.
Research personnel were trained in drug administration, and
these personnel instructed all participants in use of the study drug.
Sinus symptoms improved significantly in adults, suggesting
efficacy of the dose of medication used in this population. Our
findings are entirely consistent with those of other multicenter
studies of nasal steroids in the treatment of asthma.4,5
Our overall goal was to study the treatment of sinonasal disease
in a diverse patient population with poorly controlled asthma to
maximize the generalizability of the results to clinical practice
rather than to test the unified airway disease hypothesis in a highly
select group of patients.
Anne E. Dixon, MA, BM, BCha
Mario Castro, MD, MPHb
Rubin I. Cohen, MDc
Lynn B. Gerald, PhD, MPHd
Janet T. Holbrook, PhDe
Charles G. Irvin, PhDa
Shyam Mohapatra, PhDf
Stephen P. Peters, MDg
Sobharani Rayapudi, MDh
Elizabeth A. Sugar, PhDi
Robert A. Wise, MDh
for the American Lung AssociationAsthma Clinical Research Centers
From athe Department of Medicine, University of Vermont, Burlington, Vt; bthe
Department of Medicine, Washington University School of Medicine, St Louis,
Mo; cThe Thalheim Asthma Center Hofstra, North Shore-Long Island Jewish School
of Medicine, New Hyde Park, NY; dthe Arizona Respiratory Center, Mel and Enid
Zuckerman College of Public Health, University of Arizona, Tucson, Ariz; the Departments of eEpidemiology, hMedicine, and iBiostatistics, Johns Hopkins University,
Baltimore, Md; fthe Department of Medicine, University of South Florida, Tampa,
Fla; and gthe Section on Pulmonary, Critical Care, Allergy & Immunologic Diseases,
Wake Forest University, Winston-Salem, NC. E-mail: Anne.Dixon@uvm.edu.
Supported by grants from the National Heart Blood and Lung Institute (UO1HL089464,
U01 HL089510, and UL1 TR000448) and the American Lung Association. Study
drug and placebo were provided by Merck (Whitehouse Station, NJ).
Disclosure of potential conflict of interest: A. E. Dixons institution has received funding
from the National Institutes of Health and Merck; she has received consultancy fees
from Roche and has received grants or has grants pending from Pfizer and receives
royalties from Springer. M. Castros institution has received funding from the
National Institutes of Health (NIH) and has received grants or has grants pending
from Boston Scientific, Amgen, Ception, Cephalon, Teva, Genentech, Medimmune,
Merck, Novartis, GlaxoSmithKline, Sanofi Aventis, Vectura, Next Bio, and
KalosBios; he has received consultancy fees from Asthmatx/Boston Scientific,
Genentech, IPS/Holaira, and Neostem; has received payment for delivering lectures
from GlaxoSmithKline, Genentech, Boston Scientific, Boehringer Ingelheim,
and Teva; receives royalties from Elsevier; and has stock/stock options from