The Nose Knows . . .

Abstract & Commentary

Synopsis: Patients with unexplained chronic fatigue and bodily pain are more likely to have rhinosinusitis symptoms than are people in the general population.

Source: Chester AC. Arch Intern Med. 2003;163:1832-1836.

This paper is a study of consecutive patients younger than 41 who presented for a general physical examination. Chester, an internist, did a history, physical examination, complete blood count, sedimentation rate, thyroxine level, chemistry panel, rapid plasma reagin test, and urinalysis. Patients older than 30 had a chest radiograph.

Unexplained chronic fatigue was defined as chronic fatigue, a continuing troublesome tiredness, or lack of energy for longer than 2 months that was not a normal response to excessive physical or mental demands and not due to a physical or mental illness. Only 6 of the patients with this condition were taking medications other than oral contraceptives. Unexplained chronic bodily pain was defined as widespread musculoskeletal pain for longer than 1 month from no apparent cause. Symptoms needed to be constant or recurrent, present for longer than 1 month, and be problematic (the example given was that "sore throats" had to be frequent and severe enough to be troublesome). Symptoms of chronic rhinosinusitis were adapted from the American Academy of Otolaryngology-Head and Neck Surgery Task Force Report.1

The total sample included 297 patients (45% women) with a mean age of 30.3 years. They were well educated, white, and middle class. There were 65 patients with unexplained chronic fatigue, and Chester diagnosed 15 of these with chronic fatigue syndrome. There were 33 patients with bodily pain and most of them (n = 26) had unexplained chronic fatigue. Thirty eight of the patients had explained chronic fatigue, and 13 had explained acute fatigue.

Chester compared the 65 patients with unexplained chronic fatigue to 232 patients without this symptom (controls). There were no significant differences in age, body mass index (BMI), laboratory findings, marital status, or educational level between the fatigued and the control group. However, both women (60% vs 42%) and smokers (26% vs 13%) were more likely to be in the unexplained chronic fatigue group, as were people with gastrointestinal symptoms, DSM-IV symptoms (58% vs 38%), a lifetime history of psychiatric care (62% vs 42%), and sleep disturbance ( 26% vs 8%).

Patients with unexplained chronic fatigue also had lower recumbent blood pressures (SBP, 120.8 vs 125.3 mm Hg) and more rapid recumbent heart rates (70.2 vs 66.7 beats/min). Those with unexplained chronic fatigue were significantly more likely than were controls to have these rhinosinusitis symptoms: facial pressure, heavy headedness, nasal obstruction, frontal headache, post-nasal drip, sore throat, and cervical node tenderness.

In the subset of those patients with unexplained chronic fatigue whom Chester diagnosed with chronic fatigue syndrome (n = 15), similar increases in rhinosinusitis symptoms were noted, but there were also more symptoms of depression (73% vs 38%), sleep disturbance (47% vs 8%), and a lifetime history of psychiatric care (73% vs 42%) in the chronic fatigue syndrome patients than in the controls.

In the 38 patients who had explained fatigue, the prevalence of gastrointestinal complaints, sleep disturbances, and depression were similar that that of the patients with unexplained chronic fatigue; however, most symptoms of rhinosinusitis were less common in the patients with explained fatigue than in those with unexplained fatigue.

The patients with bodily pain (n = 33) had no important differences in sociodemographic factors, laboratory findings, or physical findings compared with controls, but they, too, were more likely to have the symptoms of rhinosinusitis investigated in this study. They were also more likely to have psychiatric symptoms. None of the patient groups was more likely to have a history of pollen allergy than was the control group.

Comment by Barbara A. Phillips, MD, MSPH

There are lots of things wrong with this paper. Chief among them is the finding that cigarette smoking is more prevalent in those with unexplained chronic fatigue than it is in controls; cigarette smoking is associated with depression,2 snoring and sleep apnea,3 sinusitis,4 and general sleep disturbance.5 Another problem is that there are no objective differences between groups except for heart rate and blood pressure; the data were gathered by Chester in an oral interview and could well be biased.

But smoking was not more common in those with bodily pain than in controls, yet those with bodily pain had more nasal symptoms. And the prevalence of the nonspecific complaints of gastrointestinal problems, sleep disturbances, and depression were similar in the patients who had explained fatigue as in the patients with unexplained chronic fatigue, despite the fact that most symptoms of rhinosinusitis were less common in patients with explained fatigue.

Chester notes that otolaryngologists have observed this relationship between fatigue, pain, and nasal symptoms previously. Patients with rhinosinusitis are likely to have fatigue, and the degree of fatigue correlates with severity of nasal symptoms.6 Further, those with chronic rhinosinusitis score lower in quality of life than an older population with medical problems that would be considered by most of us to be more significant.7

Fatigue and bodily pain are common and troublesome complaints in the internist’s office, and the differential diagnosis and evaluation of these symptoms are complex. This preliminary paper suggests that nasal symptoms are at least as common as are the gastrointestinal, sleep, and psychiatric problems associated with complaints of fatigue and bodily pain. The good news is that several studies suggest that sinus surgery may improve fatigue and bodily pain.8-10

Dr. Phillips, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington, KY, is Associate Editor of Internal Medicine Alert.


1. Lanza DC, Kennedy DW. Otloaryngol Head Neck Surg. 1997;1117(3 part 2):S1-S7.

2. Murphy JM, et al. Am J Psychiatry. 2003;160:1663-1669.

3. Wetter DW, et al. Arch Intern Med. 1994;154:2219-2224.

4. File TM. Semin Respir Infect. 2000;15:184-194.

5. Phillips BA, Danner FJ. Arch Intern Med. 1995;155:734-737.

6. Bhattacharyya N. Am J Rhinol. 2003;17:27-32.

7. Gliklich RE, Metson R. Otolaryngol Head Neck Surg. 1995;113:104-109.

8. Winstead W, Barnett SN. Otolaryngol Head Neck Surg. 1998;119:486-491.

9. Conte LJ, Holtzberg N. Am J Rhinol. 1996;10:135-140.

10. Chambers DW, et al. Laryngoscope. 1997;107:504-510.

Readers are Invited. . .

Readers are invited to submit questions or comments on material seen in or relevant to Internal Medicine Alert. Send your questions to: Robert Kimball, Internal Medicine Alert, c/o American Health Consultants, P.O. Box 740059, Atlanta, GA 30374. For subscription information, you can reach the editors and customer service personnel for Internal Medicine Alert via the internet by sending e-mail to We look forward to hearing from you.