Discussion Asthma control is assessed by daytime symptoms, limitation of activities, nocturnal symptoms/awakening, need for reliever/rescue treatment, and lung function. Several composite control measures, such as ACT10 and the Asthma Control Questionnaire,11 have been developed and are being validated. We have developed a new questionnaire, the G scale, to evaluate the symptoms of rhinosinusitis, as well as the symptoms of asthma, in asthmatic patients. Unexpectedly, asthma symptoms were not well controlled in about one-third of patients, despite taking controller medications. This result suggests that asthma symptoms might be underestimated by doctors in patients treated continuously. Evaluation of asthma control and rhinosinusitis symptoms using the G scale was considered not always superior to a combination of ACT with the SACRA questionnaire, which was designed to reflect asthma control and the condition of allergic rhinitis. However, the G scale might be convenient for screening the concomitant sinusitis, because it contains a question on olfactory dysfunction, which suggests the presence of sinusitis. Certainly, imaging with CT or magnetic resonance imaging (MRI) is much more useful for an accurate and objective diagnosis of sinusitis. It is known that the prevalence of allergic rhinitis as a complication of asthma is 67.3%, and the percentage of patients whose asthma is well controlled is lower in those with allergic rhinitis than those without allergic rhinitis, suggesting that allergic rhinitis may negatively affect asthma control or asthma symptoms.3 The results of the present study, based on patients’ reports of symptom frequencies, support this theory, because the symptoms of rhinitis, such as runny nose, sneezing, and nasal congestion were well correlated with asthma symptoms, such as cough, phlegm, wheeze, and difficulty breathing. The presence of sinusitis, as well as rhinitis, in adult asthmatic patients is a very serious problem, because rhinosinusitis, in many cases of adult asthma, is expected to be eosinophilic chronic rhinosinusitis, which is characterized by bilateral nasal polyps, ethmoidal antrum-dominant lesions, and losing the sense of smell.12 This type of rhinosinusitis, which occurs mainly in adults, is resistant to macrolide therapy, and is sometimes accompanied by sinus and peripheral blood eosinophilia.13,14 According to the retrospective data on FeNO measured in Gunma University Hospital, by the American Thoracic Society/European Respiratory Society-recommended online method, FeNO levels in 12 patients, who complained of olfactory dysfunction and who showed abnormal shadows in bilateral ethmoid sinuses on CT or MRI, were higher than those of asthmatic patients who had not complained of olfactory dysfunction, although both groups had been treated by controller medications for asthma (74.5±35.4 ppb versus 37.3±24.9 ppb; n=12 versus n=58). This observation motivated us to develop the G scale containing the question on olfactory dysfunction. As expected, FeNO was significantly more elevated in asthmatic patients with olfactory dysfunction than in other asthmatic patients, even if their asthma had been treated adequately by standard therapy. Because the diagnosis of rhinosinusitis was not made by CT, MRI imaging, or rhinoscopy in the present study, one can only conclude that olfactory dysfunction, as one of the subjective symptoms, was related to FeNO levels. Although olfactory dysfunction is a representative symptom of eosinophilic sinusitis or nasal polyps, this symptom is not specific for eosinophilic sinusitis or nasal polyps. Among the symptoms of asthma, the frequency of daytime sputum was correlated with FeNO. Interleukin 13, a pleiotropic Th2 cytokine that has been shown to be central to the pathogenesis of asthma, induces goblet cell hyperplasia and increased mucus secretion.15 It also induces nitric oxide synthase in bronchial epithelium,16 resulting in increased breath NO levels. Although increased airway secretion is not a specific phenomenon for Th2-dominant or eosinophilic inflammation, persistent hypersecretion resistant to pharmacotherapy in asthmatic patients may be a key sign that suggests intense eosinophilic inflammation remaining in the lower airways. Epidemiologic evidence suggests that 30%–90% of asthmatic patients have GERD,17,18 and respiratory symptoms associated with asthma are increased among patients with GERD.19 It is suggested that esophageal acid may produce bronchoconstriction and, therefore, exacerbate airflow obstruction in asthmatic patients.20–22 However, the impact of GERD therapy on objective outcome measures of asthma control has been variable.23–26 In patients with no evidence of organic disease, the modified F scale was useful to distinguish functional dyspepsia from nonerosive reflux disease, and to assess dyspeptic symptoms.8 Dyspepsia is defined as one or more of the following symptoms: postprandial fullness, early satiation, and epigastric pain or burning.27 Up to 75% of patients have functional dyspepsia with no underlying cause on diagnostic evaluation.28–30 Upper abdominal symptoms, including both GERD and dyspepsia, were well correlated with the degree of asthma symptoms, without enhancing the intensity of eosinophilic inflammation. On the other hand, the coexistence of upper abdominal symptoms, especially dyspepsia, may suggest decreased eosinophilic inflammation. The presence of GERD contributes more to respiratory symptoms associated with asthma than does dyspepsia, although the coexistence of GERD itself never makes eosinophilic inflammation worse. In this study, the goal was to investigate only whether upper abdominal symptoms or rhinosinusitis symptoms affect eosinophilic inflammation of the lower respiratory tract in asthmatic patients sufficiently treated by standard asthma therapy. The present results do not necessarily suggest that some factors of the G scale, which do not affect FeNO levels, do not reflect airway inflammation of asthma. The possibility that some factors of the G scale or modified F scale may affect airway inflammation, especially noneosinophilic inflammation, under sufficient treatment for asthma, was not ruled out.