428 Med J Malaysia Vol 59 No 3 August 2004

Case report

A middle – aged gentleman was diagnosed with adultonset bronchial asthma and was treated with inhaledsteroids and beta – 2 – agonists. Two years later hedeveloped nasal symptoms i.e. nasal congestion,rhinorrhoea and sneezing.

He was referred to an otorhinolaryngologist and wasdiagnosed to have allergic rhinitis. Diagnosticendoscopy revealed boggy and hyperplastic turbinateswith no evidence of polyposis or mucopurulentdischarge. He was prescribed intranasal steroids andantihistamines and after 3 months of medicaltreatment did not show any improvement. A CTscan performed showed features of pansinusitis withmucosal edema obstructing the osteo - meatalcomplex bilateral.

He underwent endoscopic sinus surgery for bilateramucosal disease following which he was well forabout a year. His symptoms then recurred and onsubsequent endoscopy revealed edematous mucosa

obstructing the osteo – meatal complex. CT scanrevealed sinusitis with mucosal disease obstructing theright osteo – meatal – complex. After optimal medicaltherapy for 2 to 4 weeks with antibiotics, oral andintranasal steroids, there was no significantimprovement and patient opted for revisionendoscopic sinus surgery. After surgery hissymptoms persisted and was referred to our center.

Our initial endoscopic findings showed the right nasalcavity to have edematous mucosa obstructing themaxillary ostia and frontal recess. The sphenoidostia was patent. The left nasal cavity showed similarfindings but with an adequate middle meatalantrostomy. Both nasal cavities were filled with thickmucoid discharge and cytology confirmed it as allergicmucin.

Skin Prick Test was positive with moderate reactivity tomixed mites, cat fur and aspergillus correlating withthe specific IgE test. CT scan showed bilateral mucosaldisease involving both maxillary sinuses and

Hashimoto’s Thyroiditis: A Rare Cause forRhinosinusitis

CASE REPORT

This article was accepted: 10 April 2004Corresponding Author: Jeevanan Jahendran, Department of Otorhinolaryngology and Head and Neck Surgery, Hospital UniversitiKebangsaan, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur

J Jeevanan, MBBS, B S Gendeh, MS ORL HNS, S Satpal, MBBS

Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Universiti Kebangsaan, Jalan Yaacob Latif, Bandar TunRazak, 56000, Cheras, Kuala Lumpur

Summary

Rhinosinusitis is a common disorder with various etiological factors. In our clinical practice allergy seems to bea predominant cause followed by other less common causes like infection, drugs and aspirin hypersensitivity.We present a case of chronic rhinosinusitis secondary to hypothyroidism. Although hormonal causes likehypothyroidism have been proven to cause nasal congestion and rhinosinusitis, this is the first reported caseof chronic rhinosinusitis in Hashimoto’s thyroiditis in our center. This is a diagnosis of exclusion for chronicrhinosinusitis not responding to optimal medical therapy.

Key Words: Hashimoto’s thyroiditis, Rhinosinusitis, Hypothyroidism

22/HASHIMOTO'S 29/09/2004 9:49pm Page 428

Hashimoto’s Thyroiditis: A Rare Cause for Rhinosinusitis

Med J Malaysia Vol 59 No 3 August 2004 429

obstructing the osteo – meatal – complex bilaterally.(Fig 1) He was given a trial of medical therapy andoption for a third revision surgery if he did notrespond to treatment.

During this time, the patient had done a screeningblood test on his own including blood counts, renal,liver, cholesterol and thyroid panels. He wasincidentally found to have normal free thyroxine levelswith an elevated thyroid stimulating hormone level.He was referred to an endocrinologist and wasinvestigated further. Interestingly, he had low serumcortisol levels and tests for thyroid microsomalantibodies and thyroglobulin antibodies werepositive. He was diagnosed with Hashimoto ’sthyroiditis and was put on hydrocortisone andthyroxine. On his subsequent follow - up 2 monthslater, diagnostic endoscopy showed normal mucosa inboth nasal cavities with patent ostia bilaterally andabsence of thick mucoid discharge.

Symptomatically he was feeling better and was onmaintenance therapy with intranasal steroids. Arepeat scan done recently showed marked diseaseresolution with minimal residual disease in the

maxillary sinus. (Fig. 2) At present he is only onthyroxine tablets and intranasal steroids and isdoing well on follow - up.

Discussion

Chronic rhinosinusitis is a common problemencountered in otolaryngology clinics worldwide andmost people including physicians tend to lumpthese group of patients into the allergy category.Recent data seems to suggest otherwise asepidemiological studies indicate only 15% to 20% ofindividuals are truly atopic. Among patients withrhinitis 50% are not allergic and this is supported bynegative skin prick tests in 28% to 60% ofindividuals with rhinosinusitis. Non - allergic rhinitis iswidely recognized today as a condition encompassinga rather broad variety of disorders giving rise torhinitis.

In this case, the initial diagnosis of allergic rhinitis wasmade based on the presenting symptoms withoutconfirmatory allergy testing. Both allergic and non -allergic rhinitis have similar symptoms and signs.To provide an accurate diagnosis in a patient with

Fig 1: Coronal section of paranasal sinusesdone a month after the second surgeryrevealing almost complete obstructionof both osteo - meatal units withmucosal thickening within bothmaxillary sinuses and part of theethmoid sinus cavity. Both inferiorturbinates are enlarged bilaterally.

Fig 2: CT scan done after 3 months oftreatment with thyroxine showingalmost complete resolution of themucosal disease except for minimalresidual disease on the floor of theleft maxillary sinus.

22/HASHIMOTO'S 29/09/2004 9:49pm Page 429

References

1. Settipani G A. Systemic diseases associated with nasalsymptoms. Am J Rhinol 1987; 1: 33.

2. Chavanne L. Secretions nasal et Gland Thyroid. OtolRhinol Laryngol Int 1936; 20: 653-64.

3. Proetz AW. Further observations on the effects of thyroidinsufficiency on the nasal mucosa. Laryngoscope 1950;60: 627-33.

4. Tolczynski B, Crossley H. Significance of thyroiddeficiency in allergic rhinitis. Eye, Ear, Nose, Throat Mon1962; 41: 39-45.

5. Gupta OP, Bhatia MS, Agarwal MS, Mehrotra MD, MishrSK. Nasal, pharyngeal and laryngeal manifestations ofhypothyroidism. Ear, Nose ,Throat J 1977; 56: 10-22.

It is postulated that the generally hypoactivesympathetic status in hypothyroidism leads topredominance of parasympathetic activity in thenose, with resultant vasodilation and congestion.Limited animal studies have attempted to reproducethese changes, however have only produced furtheruncertainties. The largest study reviewing the effectsof hypothyroidism on the upper airway was byGupta et al in 1977 where 64% of sixty – sixpatients were found to have nasal congestion5. Hefound 41% of these patients on examining the nose hadpale, edematous nasal mucosa. Nasal biopsies frompatients with hypothyroidism showed an increase inground substance with an acid mucopolysaccharideand proliferation of mucus glands.

Gupta et al and Weisskopf though finding thesehistopathlogical changes concluded that nasal biopsieswere nonspecific, mainly showing chronicinflammatory changes5.

We can conclude that in patients with rhinosinusitisnot responding to conventional therapy, anunderlying cause must be looked for. In our casethough we had evidence to suggest that we weredealing with allergic rhinitis, poor response totreatment should have been an indicator to investigatefurther. To infer that hypothyroidism was the solecause of rhinosinusitis would be conjectural anddifficult to prove. However, his good response tothyroxine seems to concur with the findings ofChavanne that the only treatment necessary for rhinitisassociated with hypothyroidism is the correction ofthyroid deficiency2.

CASE REPORT

430 Med J Malaysia Vol 59 No 3 August 2004

rhinosinusitis, the clues begin in the history takingwhere one must be aware not only of nasal disordersbut also systemic conditions with nasalmanifestations. Examination of the nasal passagesand the nasopharynx including the nature of thedischarge may give an idea about the etiology.However, more often then not, boggy andedematous mucosa of the turbinates and lateralnasal wall may be the only non – specific finding.

With both medical and surgical treatment failing afterone year, it should have raised suspicion about theetiology more so after the failed second surgery.Though allergy testing was done at a later date witha positive result, the poor response to therapyshould lead one to consider the possibility of lesslikely causes of rhinosinusitis like allergic fungalsinusitis or non – allergic rhinitis with eosinophiliasyndrome among others. The incidental finding ofhypothyroidism in this patient was not consideredinitially as a cause for rhinosinusitis as only 3% ofpatients with non – allergic rhinitis is due tohypothyroidism1. Chavanne in 1936 reported therelationship between hypothyroidism and rhinitiswhere after surgical thyroidectomy, he foundengorgement of the turbinates with pale mucosawhich could be reversed with thyroxine injections2.This was confirmed by Proetz, Tolczynski andWithers in their studies which showed increasenasal secretions in hypothyroid patients3, 4. However,the frequency of which nasal symptoms occurringin hypothyroid patients remain uncertain.

22/HASHIMOTO'S 29/09/2004 9:49pm Page 430