Medication use and chronic rhinosinusitis-related fatigue.

Dear Editor:

In their recent article (Bhattacharyya N, Kepnes LJ. Associations between fatigue and medication use in chronic rhinosinusitis. Ear Nose Throat J 2006;85:510-15), Bhattacharyya and Kepnes describe an association between fatigue and nonsedating antihistamine and antibiotic use in patients with chronic rhinosinusitis (CRS). Medication has now been added to a list of proven or postulated causes of CRS-related fatigue: systemic response to local inflammation, sleep disturbance, upper airway resistance syndrome, psychological distress, and reflex response to nasal irritation. (1) Although the etiology is uncertain, the response of fatigue to endoscopic sinus surgery is consistent: Virtually all studies demonstrate improvement. As suggested by this study, part of this response might be related to a decreased need for medication.

The conclusion that nonsedating antihistamines and antibiotics contribute to CRS-related fatigue rests, as noted in the article, on the variable chosen as a control for the confounder of disease symptomatic severity. Without a satisfactory control, the conclusion that patients with more fatigue were also more likely to take more medications would be expected and unremarkable.

As a control, scores for the following symptoms were chosen: nasal obstruction, rhinorrhea, and dysosmia. These symptoms are more likely to correlate with CT evidence of CRS than headache or facial pain or pressure. (2,3) CT evidence of CRS, however, correlates poorly with CRS symptom severity. (4)

Indirect evidence suggests that fatigue may be more closely associated with heavy-headedness and frontal headache than with local nasal symptoms. In a study of 65 general medical patients presenting with unexplained chronic fatigue, the association of fatigue with heavy-headedness (odds ratio [OR], 21.9; 95% confidence interval [CI], 10.9 to 44.0) and facial pressure (OR, 9.7; 95% CI, 5.2 to 18.2) appeared more significant than the association of fatigue with nasal obstruction (OR, 4.3; 95% CI, 2.3 to 7.9) and postnasal drip (OR, 2.8; 95% CI, 1.6 to 5.0). (5) I wonder, therefore, whether using a combined symptom score of heavy-headedness and frontal headache as a control for disease severity in a future study would also demonstrate the same associations.

The importance of determining all causes of CRS-related fatigue is underscored by the high prevalence and substantial reduction in quality of life noted in this and other studies. (6,7) The authors have opened a new and interesting area of inquiry that deserves significant attention.

References

(1.) Chester AC. Hypothesis: The nasal fatigue reflex. Integr Physiol Behav Sci 1993;28:76-83.

(2.) Kenny TJ, Duncavage J, Bracikowski, et al. Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan. Otolaryngol Head Neck Surg 2001;125:40-3.

(3.) Bhattacharyya N. A comparison of symptom scores and radiographic staging systems in chronic rhinosinusitis. Am J Rhinol 2005;19:175-9.

(4.) Wabnitz DA, Nair S, Wormald PJ. Correlation between preoperative symptom scores, quality-of-life questionnaires, and staging with computed tomography in patients with chronic rhinosinusitis. Am J Rhinol 2005;19:91-6.

(5.) Chester AC. Symptoms of rhinosinusitis in patients with unexplained chronic fatigue or bodily pain: A pilot study. Arch Intern Med 2003;163:1832-6.

(6.) Bhattacharyya N. The economic burden and symptom manifestations of chronic rhinosinusitis. Am J Rhinol 2003;17:27-32.

(7.) Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995;113:104-9

Alexander C. Chester, MD

Clinical Professor of Medicine

Georgetown University Medical Center

Washington, D.C.

Response

We appreciate Dr. Chester's comments regarding our article. In fact, our interest in the fatigue component of chronic rhinosinusitis has been prompted by Dr. Chester's work in the same area.

In choosing a control for the potential confounder of increasing symptoms on medication use, we chose three symptoms that are directly related (locally) to the nose: nasal obstruction, rhinorrhea, and dysosmia. As Dr. Chester notes, we chose these because they correlate with objective evidence of CRS better than other variables.

We agree that, in general, CT evidence of CRS correlates poorly with symptom scores, and we have elaborated on this in some detail in a large recent study (Bhattacharyya N. Clinical and symptom criteria for the accurate diagnosis of chronic rhinosinusitis. Laryngoscope 2006; 116(Suppl 110):1-22). In establishing the control, we chose what we thought would be more specific (rather than sensitive) symptoms of CRS. There may be, as suggested by Dr. Chester, a better correlation between medication use and heavy-headedness and facial pressure. However, we do not typically inquire about or catalog the former symptom in our daily clinical practice. We also agree that looking for associations between medication use and heavy-headedness and frontal headache would be worthwhile and plan to do this in the future. We also look forward to Dr. Chester's continuing work in this somewhat neglected area of research.

Neil Bhattacharyya, MD, FACS

Division of Otolaryngology

Brigham and Women's Hospital and

Associate Professor of Otology & Laryngology 

Harvard Medical School

Boston, Mass.