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OHNS Website: http://ohns.ucsf.edu
Rhinitis, Sinusitis and beyond: what the primary care provider should know
Marika Russell, MD, FACS
Assistant Professor of Clinical Otolaryngology
San Francisco General Hospital
OHNS Website: http://ohns.ucsf.edu
Outline
● Normal anatomy ● Examination techniques● Nasal obstruction● Rhinitis vs. Sinusitis
− Diagnosis− Management strategies− When to refer
● Q&A
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What’s in a nose?
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Nasal Anatomy
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Nasal Anatomy
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Sinonasal Anatomy
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Anterior nasal examination
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Anterior nasal examination
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Endoscopic examination
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Endoscopic examination
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Nasal obstruction
● Medical (dynamic) vs. structural (anatomic/fixed) ● History
− Timing (onset, day vs. night, seasonal vs. year-round)− Triggers (environment, pets)− Laterality− Associated symptoms (sneezing, nasal discharge, nasal itching,
itchy eyes, epiphora) − Comorbid conditions (ie. Asthma)
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Nasal obstruction
● Exam− Inferior turbinate hypertrophy/bogginess− Nasal discharge− Polyps
● Response to medical treatment− Topical treatment− Oral medications
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Nasal obstruction
● Medical− Insidious onset,
absence of trauma− Some day-to-day
variability− (Bilateral)− Environmental triggers− Some responsiveness
to medications
● Structural− Life-long or history of
trauma− Minimal day-to-day
variability− (Unilateral)− Not environmental− Unresponsive to
medications
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Nasal obstruction
● ENT Examination− Underlying structural problems
Dynamic lateral nasal wall collapse Septal deflection Septal spurs Internal valve narrowing Saddle deformity
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Allergic Rhinitis
● Background− AR is IgE mediated inflammatory response of nasal mucosa− Characterized by nasal congestion, rhinorrhea, sneezing and/or
nasal itching− Classified by temporal pattern
Seasonal (ie. pollen) Perennial/year round (ie. dust mites, mold) Episodic (ie. pet exposure)
− Classified by frequency Intermittent (<4 days/wk or <4wks/yr) Persistent (>4 days/wk or >4wks/yr)
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Allergic Rhinitis
● Background cont’d− Classified by severity
Mild (symptoms present but not interfering with QOL) Severe (exacerbation of coexisting asthma, sleep disturbance,
impairment of daily activities)
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Allergic Rhinitis
● AAO-HNS Clinical guidelines− 14 key action statements
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Allergic Rhinitis
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Allergic Rhinitis
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Allergic Rhinitis
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Non-Allergic Rhinitis
● Causes− NAR with eosinophilia (NARES)− Hormone related
Hypothyroidism, acromegaly, puberty, pregnancy, post-menopausal
− Medication associated Rhinitis medicamentosa, anti-hypertensives, NSAIDS, OCPs
− Irritant Temperature, humidity, barometric changes, gustatory exposure
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Non-Allergic Rhinitis
● Causes cont’d− Atrophic
Cocaine, surgery, aging, XRT, infectious
− Idiopathic/Vasomotor
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Non-Allergic Rhinitis
● History− Timing− Exacerbating and alleviating factors− Environmental triggers− Patients with onset >age 35 without family history of allergies, no
obvious pet/outdoor triggers, no association with perfumes/fragrances very likely to have NAR
● Exam− Boggy, edematous nasal mucosa− Clear mucoid drainiage
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● Diagnostic testing− Skin/RAST testing negative− Imaging not useful unless suspected sinus disease
● Treatment − Varies with etiology
Recognition and avoidance of underlying trigger
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Rhinosinusitis
● Definition− Symptomatic inflammation of paranasal sinuses and nasal cavity
● Acute (ARS)− < 4weeks duration
● Chronic (CRS)− >12 weeks duration− +/- acute exacerbations
● Recurrent ARS− >4 episodes per year without persistent sxs in between episodes
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Acute Rhinosinusitis: dx
● Distinguish acute rhinosinusitis (ARS; viral URI) vs. acute bacterial rhinosinusitis (ABRS)
● ABRS should be diagnosed when symptoms and signs of ARS (purulent nasal drainage with nasal obstruction and facial pain/pressure) persist without evidence of improvement for >10 days beyond onset –OR- improve initially and worsen again (double worsening)
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Acute Rhinosinusitis: dx
● Radiographic imaging should not be obtained for ARS unless a complication or alternative dx is suspected
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Acute Rhinosinusitis: tx
● Viral ARS may be treated symptomatically− Analgesics, topical nasal steroids, nasal saline irrigations
● ABRS may also be treated symptomatically− New AAO-HNS clinical guideline recommendation− Watchful waiting for up to 7 days after ABRS diagnosis
● Treatment ABRS includes amoxicillin/Augmentin for 5-10 days− Doxyclycline or respiratory flouroquinolone for PCN allergy
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Acute Rhinosinusitis: tx
● Follow-up should be obtained by 7 days after initiation of treatment/watchful waiting− Confirm ARS, exclude other illnesses, detect complications
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Chronic Rhinosinusitis: dx
● > 12 weeks of 2 or more of the following:− Mucopurulent drainage− Nasal obstruction− Facial pain/pressure− Decreased sense of smell
● AND inflammation is documented by one or more of the following:− Purulent (not clear) mucous or edema in middle meatus− Polyps in nasal cavity or middle meatus− Radiographic imaging demonstrating paranasal inflammation
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Chronic Rhinosinustis: dx
● Diagnosis of CRS made with objective confirmation of sinonasal inflammation− Nasal endoscopy, CT
scan
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Chronic rhinosinusitis: dx
● Assess for comorbid conditions that may influence treatment− Asthma, CF, immunocompromise, ciliary dyskinesia
● Consider obtaining allergy and immune function testing● Determine presence or absence of polyps (ENTprovider)
− Steroid responsiveness/appropriateness
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Chronic Rhinosinusitis
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Chronic Rhinosinusitis: tx
● Topical nasal steroids, saline irrigations for symptom management
● High dose predisone taper plus antibiotics x 2 weeks to assess for symptomatic improvement
● If no improvement or initial improvement but worsening, surgical intervention offered
OHNS Website: http://ohns.ucsf.edu
OHNS Website: http://ohns.ucsf.edu
Complications of Acute Sinusitis
● Periorbital complications: Chandler classification 1. Preseptal cellulitis
2. Orbital/post-septal cellulitis
3. Subperiosteal abscess
4. Orbital abscess
5. Cavernous sinus thrombosis
● Intracranial complications− Epidural/subdural abscess− Cerebral empyema
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Complications of Acute Sinusitis
Pre-septal cellulitis Subperiosteal abscess
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Odontogenic sinusitis
● Unilateral maxillary sinusitis of dental origin
● Periodontal disease● Periapical lucency ● Maxillary tooth root in
communication with maxillary sinus
● Treatment is tooth extraction
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When to Refer
● Nasal obstruction/rhinitis− Failure of medical treatment
Allergy referral
− Suspected anatomic problem
● Rhinosinusitis− ABRS unresponsive to appropriate medical management or with
concern for acute complication− CRS unresponsive to conservative medical management
Consider trial of high dose steroids/abx
− Unilateral sinus disease
OHNS Website: http://ohns.ucsf.edu
When to Refer
● CRS maximal medical management− Prednisone
40mg PO daily x 4 days 30mg PO daily x 3 days 20mg PO daily x 3 days 10mg PO daily x 2 days
− Augmentin 875/125 PO BID x 2 weeks concurrently with steroids
● If no prior sinus imaging, CT at end of steroid/abx
OHNS Website: http://ohns.ucsf.edu
Final thoughts
● Rhinitis can be challenging to manage− Manage patient expectations prior to specialty visit
● Consider migraine on differential when suspect CRS− Pain/pressure alone not sufficient for dx CRS
● CT imaging not appropriate in setting of ABRS but when in doubt, obtain for dx CRS
OHNS Website: http://ohns.ucsf.edu
Questions?
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