Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed)

ENT surgeon, Moor Allerton Golf Club

15th May2014

ENT

Th

e L

eed

s Te

ach

ing

H

osp

itals

NH

S T

rust

managing common nasal conditions

Back to Medical School group of GP'smanaging common nasal conditions

to include rhinitis

o making the correct diagnosis o practical treatment

polyps o why should we worry about unilateral polyps

nose bleed anything else you thinks important and practical

aims

improve our understanding of nose conditions

discuss some example cases

formulate management plans for nasal disease

objectives

list symptoms to be elicited in nasal conditionslist ways on nasal examinationdiscuss the evidence base in treating sinusitisdescribe a nasal cautery techniquecouncil a patient on sinus surgerylist differential in nasal lesionslist the presentation of a nasal malignancyrecognise nasal sepal deviationlist aetiologies in septal perforation recognise and manage nasal polyps

first though...

history and examination in ENT

history

ears

otorrhoeaotalgiaitchhearingtinnitus balance

noses

nasal obstructionrhinorrhoeafacial painsmellepistaxispost nasal drip

throats

dysphagiadysphoniaodynophagiapainneck lumpsweight loss

history

ears

otorrhoeaotalgiaitchhearingtinnitus balance

noses

nasal obstructionrhinorrhoeafacial painsmellepistaxispost nasal drip

throats

dysphagiadysphoniaodynophagiapainneck lumpsweight loss

examination of the nose

examination

examination with auriscope

rhinosinusitis

sinusitis

rhinosinusitis

theories of rhinosinusitis

classification of rhinosinusitis

A cu te rh in os in u s it is

P o llen s

S eas on a l

H ou se d u s t / m ite A n im a l

P eren ia l

A lle rg ic

A n a tom ic a lD ru g in d u ced

V asom oto rM ed ic am en tos a

N on a lle rg ic

C h ron ic rh in os in u s it is

Non-allergic RhinitisAllergic Rhinitis

UK/FF/0108/11 April 2011

Allergic Rhinitis

UK/FF/0108/11 April 2011

Allergic Rhinitis Epidemiology

Allergic rhinitis is the most common form of non-infectious rhinitis

At least 500 million individuals world-wide have allergic rhinitis and it is one of the most common reasons for attendance with a primary care practitioner

Almost 30% of adults and 40% of children are affected

World-wide the prevalence of allergic rhinitis continues to increase UK/FF/0108/11 April 2011

References1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-1602. Wallace DC et. J Allergy Clin Immunol 2008; 122: S1-84

Prevalence of clinically confirmed allergic rhinitis in Europe

Reference:Bauchau V et al. Eur Respir J 2004; 24: 758-764UK/FF/0108/11 April 2011

Clinical Diagnosis

Nasal discharge Blockage Sneeze / itch }

Rhinitis definition1

2 or more symptoms for > 1 hour on

most days

Allergic

Rhinitis

Non-Allergic

Rhinitis

(Infection/structural abnormality/vasomotor/primary disease)

History Examination Investigations

UK/FF/0108/11 April 2011

Reference:1. Bousquet J et al. Allergy 2008;63 Suppl 86:8-160

Clinical symptoms of allergic rhinitis

primary clinical manifestations congestionrhinorrhoea itching sneezing

secondary clinical effectslethargymalaise

UK/FF/0108/11 April 2011

IMPAIRED WELL BEING

DISRUPTED SLEEP

LETHARGY

DAILY ACTIVITIESIMPAIRED

LEARNING & COGNITIVEFUNCTIONS DISTURBED

REDUCED WORK & SCHOOL PRODUCTIVITY

Canonica GW et al. Allergy 2007: 62 (Suppl. 85): 17-25 UK/FF/0108/11 April 2011

Social and economic impact of allergic rhinitis

Investigations

Skin prick testing (SPT)Panel of common aeroallergens + allergen identified as relevant in history

Serum allergic specific-IgEIn cases where SPT is negative or SPT cannot be performed

RhinoscopyIndicationAtypical features (i.e.one sided obstruction) present or multiple pathology suspected

Classic findingsPale oedematous mucosaCongestionMucus secretion

UK/FF/0108/11 April 2011

Investigations

Skin prick testing (SPT)Panel of common aeroallergens + allergen identified as relevant in history

Serum allergic specific-IgEIn cases where SPT is negative or SPT cannot be performed

RhinoscopyIndicationAtypical features (i.e.one sided obstruction) present or multiple pathology suspected

Classic findingsPale oedematous mucosaCongestionMucus secretion

UK/FF/0108/11 April 2011

Investigations

Skin prick testing (SPT)Panel of common aeroallergens + allergen identified as relevant in history

Serum allergic specific-IgEIn cases where SPT is negative or SPT cannot be performed

RhinoscopyIndicationAtypical features (i.e.one sided obstruction) present or multiple pathology suspected

Classic findingsPale oedematous mucosaCongestionMucus secretion

UK/FF/0108/11 April 2011

Allergic Rhinitis Classification

BSACI Guidelines

Seasonal (UK)Tree pollen (birch, plane, ash + hazel)Grass pollen (timothy, rye + cocksfoot)Weed pollen ( mugwort + nettle)Fungal spores ( Cladosporium spp,Alternaria spp + Aspergilus spp)

Perennial (UK)House dust mite (Dermatophagoides pteronyssinus) + Animal Dander

Occupational Flour, grain, latex, wood dust, detergents

UK/FF/0108/11 April 2011

British society for allergy and clinical

immunology

Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160UK/FF/0108/11 April 2011

Rhinitis Management

Diagnosis of allergic rhinitis

Intermittent symptoms

Mild

oral antihistamineorintranasal antihistamine+/- decongestantor leukotriene antagonist

Asthma?

Moderate

oral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Mild

oral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severe

topical nasal steroid

oral antihistamineorleukotriene antagonist

Review after 2 -4 weeks

If better, step down and continue for > 1 month

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severe

topical nasal steroid

oral antihistamineorleukotriene antagonist

Review after 2 -4 weeks

If not better, review diagnosisreview compliancequery infective / other cause

increase nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severe

topical nasal steroid

oral antihistamineorleukotriene antagonist

Review after 2 -4 weeks

If not better, review diagnosisreview compliancequery infective / other cause

increase nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)

If not better, refer

consider

Common co-morbidities: Asthma

Approximately 80% of asthmatics have rhinitis

Allergic rhinitis may precede asthma

Rhinitis impairs asthma control

Treatment of allergic rhinitis may improve asthma control

Allergic Rhinitis and its Impact in Asthma (ARIA) promotes assessing everyone with allergic rhinitis for asthma

UK/FF/0108/11 April 2011

References1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-1602. Wallace DC et. J Allergy Clin Immunol 2008; 122: S1-84

Common co-morbidities: Rhinoconjunctivitis

IncidenceOcular symptoms are commonRhinoconjunctivitis symptoms have

been reported in more than 75% of patients with seasonal allergic rhinitis

Clinical significanceSeverely impairs QOLOften a forgotten aspect of care

UK/FF/0108/11 April 2011

Reference1. Wallace DC et al. J Allergy Clin Immunol 2008; 122: S1-84

rhinosinusitis

Allergen Avoidance

Background

Success of intervention measured by clinical improvement

Strategy success influenced by individual host sensitivity to allergen

Sensitivity differs betweens allergens Effectiveness

Studies do not show consistent reduction in symptoms or medication requirements

UK/FF/0108/11 April 2011

Reference:1.Scadding GK et al. Clin Exp Allergy 2008; 38:19-42

rye grass

house dust mite

allergen avoidance

mattress, pillow, duvet coverssynthetic duvets, pillowsavoid woollen blanketsvacuum frequentlyavoid carpets, curtainskeep clothing in cupboardskeep animals out of bedroomslow relative humidityboil wash sheet, duvet covers

allergen avoidance

allergen avoidance

allergen avoidance

Fel d1

treatments

UK/FF/0108/11 April 2011

Intranasal Steroids

risks?

UK/FF/0108/11 April 2011

Bioavailability of nasal steroids

References1. Nasonex Summary of Product Characteristics. Date accessed April 20112. Kariyawasam H, Scadding G.Journal of Asthma and Allergy 2010: 3 19–283. Rhinocort Summary of Product Characteristics. Date accessed April 20114. Beconase Summary of Product Characteristics. Date accessed April 2011UK/FF/0108/11 April 2011

0

5

10

15

20

25

30

35

40

45

50

0.1 0.5 0.5

11

44

% B

ioavailab

ilty

Betametasone

BudesonideMometasoneFluticasone

epistaxis and cautery

Case

Epistaxis

Naspetin ointment

Vs

Cautery and Naseptin ointment

theories of rhinosinusiti

s

theories of rhinosinusitis

investigation - sinus x ray

Exposure toradiation

poor sensitivitypoor specificity

investigation - CT scan

nasal polyps

nasal polyps - treatment

medicalsteroids

surgicalpolypectomy

unilateral nasal

discharge

unilateral nasal discharge

child

foreign body or neoplasm

unilateral nasal polyp

unilateral nasal polyp

neoplasm

benign or malignant

unilateral nasal polyp

is it really unilateral?

unilateral nasal polyp

neoplasm

benign or malignantwoodworking,

metal, textile and leather industries

unilateral nasal polyp

neoplasm

benign or malignantwatch for pain, eye

involvement, tears, movement,

facial sensation

unilateral nasal polyp

neoplasm

benign or malignantNasal obstruction

(36%), epistaxis (30%) & nasal discharge (21%) were the most common presentation

unilateral nasal polyp

neoplasm

benign or malignantinverted papilloma

nasal pain crusting

Case

Septal perforation - investigations

FBC normalESR 16 mm/h CRP

<5.0 mg/lU&E normal glucose 5.0

mmol/lsyphilis negative ACE

negativeANCA negative

Nasal septal perforation

surgerytraumacocaine useinfection

post trauma, syphilisWegener’s granulomatosissarcoidosisidiopathic

objectives

list symptoms to be elicited in nasal conditionslist ways on nasal examinationdiscuss the evidence base in treating sinusitisdescribe a nasal cautery techniquecouncil a patient on sinus surgerylist differential in nasal lesionslist the presentation of a nasal malignancyrecognise nasal sepal deviationlist aetiologies in septal perforation recognise and manage nasal polyps

Head Neck. 2013 Aug 30. doi: 10.1002/hed.23485. [Epub ahead of print]Sinonasal adenocarcinoma: A 16-year experience at a single institution.Bhayani MK1, Yilmaz T, Sweeney A, Calzada G, Roberts DB, Levine NB, Demonte F, Hanna EY, Kupferman ME.Author informationAbstractBACKGROUND:Adenocarcinoma is a rare tumor of the sinonasal tract. The purpose of this study was to characterize a single

institution's experience with this malignancy.METHODS:Retrospective review was performed of patients with adenocarcinoma of the sinonasal tract from 1993 to 2009.

Demographic data, disease presentation, treatment, and survival rates were collected and evaluated.RESULTS:We identified 66 patients with sinonasal adenocarcinoma; 48 were men and 18 women. Average age at time of

diagnosis was 57.1 years (range, 20-88 years), and median follow-up was 55.3 months (range, 1-238 months). The ethmoid sinus (38%) and nasal cavity (36%) were the most common sites of origin. Nasal obstruction (36%), epistaxis (30%), and nasal discharge (21%) were the most common presenting symptoms. Fifty-one percent of patients presented with T1 or T2 tumors. Surgery was the primary form of treatment in 81% of patients. Twenty-six percent of surgical patients underwent an endoscopic tumor resection. Adjuvant radiation was utilized in 50% of patients and chemotherapy in 10%. Recurrence was seen in 24 patients (37%): 29% recurred locally and 7.6% recurred distantly. The overall 5-year survival was 65.9%. Survival was decreased significantly in patients with T4 tumors (p < .05), high-grade histology (p < .05), and sphenoid sinus involvement (p < .05). Survival was not affected by surgical approach between endoscopic and open approaches (p = .76).

CONCLUSION:Sinonasal adenocarcinomas are commonly identified in the sinonasal cavity and are associated with a relatively

favorable prognosis, despite a substantial local failure rate of 30%. Advanced-stage tumors, sphenoid sinus and skull base invasion, and high-grade histology portend poor prognosis. In our experience, endoscopic resection was not associated with adverse outcomes and suggests that this minimally invasive approach can provide acceptable oncologic outcomes in selected patients. © 2013 Wiley Periodicals, Inc. Head Neck, 2014.

Copyright © 2013 Wiley Periodicals, Inc.KEYWORDS:adenocarcinoma, endoscopy, sinonasal, skull base, surgery