Spectrum of nasal disease in an asthma clinic: when is an ENT opinion indicated?

To characterise the spectrum of nasal symptomatology and nasendoscopic abnormalities seen in patients attending an asthma clinic, and to relate these symptoms to the likelihood of finding nasendoscopic abnormalities which merit treatment.

Forty-three patients attending a problem asthma clinic were enrolled in an observational study. Cardinal nasal symptoms--obstruction, congestion, hyposmia, rhinorrhoea, sneezing, epistaxis or other symptoms--were graded as none (zero), mild (one), moderate (two) or severe (three), giving a maximum nasal symptom score of 21. Asthma symptoms and lung function were measured. Nasendoscopy was then performed.

Obstruction was the most common cardinal nasal symptom (seen in 15 patients), the median nasal symptom score was 5.3 (range zero to 14) and only three patients had no nasal symptoms. There was no correlation between nasal symptom score and severity of asthma symptoms or forced expiratory volume in one second. Twenty-two patients had a normal appearance on ENT examination (median nasal symptom score four). The nasendoscopic abnormalities seen comprised polyps (n = 8; median nasal symptom score five), deviated nasal septum (n = 7; median nasal symptom score four), oedematous mucosa (n = 4; median nasal symptom score seven) and other abnormalities (n = 2). Individual nasal symptoms were poor predictors of individual nasal pathologies, with hyposmia the best individual predictor of any abnormality (positive predictive value 80 per cent). The presence of a combination of symptoms increased the likelihood of any nasendoscopic abnormality, with obstruction, rhinorrhoea and hyposmia together having a positive predictive value of 100 per cent.

Nasal symptoms are much more frequent than structural abnormalities in patients attending a problem asthma clinic. The threshold for ENT referral should be lower when the patient complains of a symptom complex including hyposmia. Furthermore, concurrent hyposmia, obstruction and rhinorrhoea should be seen as an indication for ENT referral.