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• W2075812601 abstract "See article, page 948 The nose, larynx, trachea and lung are closely related organs, anatomically but also in a functional context. This intimate link has culminated in the concept of a ‘united airway’1 predominately based on the shared characteristics of the upper and lower airways disease in rhinitis and asthma. There is indeed a very strong association between these conditions; allergic rhinitis is found in >80% of atopic asthma, and >30% of patients with nasal disease also experience asthma symptoms.2, 3 Surgical treatment of chronic nasal and sinus disease leads to improved asthma outcomes,4 and accumulated evidence has indicated that a coordinated approach to management of a ‘united airway’ has significant benefits. Although the important relationship between the upper and lower airway is increasingly appreciated, disease processes in the larynx and trachea that constitute cardinal components of a united airway have been largely ignored. This may in part be related to traditional medical nomenclature that emphasizes the upper airway (nose, sinuses) and lower airway (lung). We have recently argued that the ‘middle’ airway (larynx and trachea) deserves recognition in its own right.5 For example, laryngeal dysfunction causing middle airway obstruction could masquerade as severe or difficult-to-treat asthma, and there is preliminary evidence that tracheal instability and excessive dynamic collapse can contribute to airway obstruction, particularly in chronic obstructive pulmonary disease.6 However, numerous questions remain that pertain to the pathophysiology of middle airway dysfunction, and its links to asthma and obstructive lung disease. Laryngeal dysfunction may consist of a spectrum of conditions that also include chronic refractory cough, globus pharyngeus and muscle tension dysphonia.7 The initial classic description of laryngeal dysfunction (called vocal cord dysfunction) was published by Christopher and co-workers,8 who regarded the condition as a mimic of asthma. The condition is now also known as paradoxical vocal cord fold movement and has been shown to occur frequently in asthma.9 To date, very little is known about the disease mechanisms implicated in these conditions and their role in a united airway. In the current issue of Respirology, Vertigan and co-workers provide interesting new information about sensory dysfunction as a part of conditions associated with laryngeal dysfunction.10 Studies were conducted in healthy individuals and in an array of clinical syndromes that involve laryngeal dysfunction, with a wide spectrum of questionnaires and quantitative sensory testing techniques being employed. The investigators found high symptom burdens (cough, breathlessness, voice problems) in the case groups, with persuasive overall evidence of substantial laryngeal sensory dysfunction. Stimulation of a particular response often resulted in symptoms in another domain. For example, vocal cord stress tests also resulted in cough and breathlessness, signifying potential central nervous system sensitization and a communal pathway abnormality. Interestingly, up to 40% of some case groups had an asthma diagnosis, although it is unclear whether the condition (especially mild asthma) had been comprehensively excluded in all groups. The research by Vertigan and co-workers10 provides important new information. Sensory dysfunction detected in the middle airway may be in some respects analogous to lower airway hyperresponsiveness found in asthma, although the mechanisms underlying this abnormality of the middle airway are unknown. Sensory dysfunction may also be a shared mechanistic pathway operating in the disease settings under investigation in these studies. It provides a rationale for novel targeted treatments with neuromodulators, such as gabapentin, for conditions such as refractory cough.11 The clinical implications of the findings as reported are less clear and will require detailed investigation of links to other airway diseases, particularly asthma. The complex interactions among the upper, middle and lower airway are poorly understood, and the united airway represents a key challenge for future research aimed at improved management of overall airway disease. For advances to occur, characterization of normal function, pathophysiology and role of the middle airway is vital, and this study places due emphasis on a neglected area of respiratory research." @default.
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• W2075812601 date "2013-07-25" @default.
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• W2075812601 title "Exploring united airways" @default.
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• W2075812601 doi "https://doi.org/10.1111/resp.12135" @default.
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