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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


Outline

● Normal anatomy ● Examination techniques● Nasal obstruction● Rhinitis vs. Sinusitis

− Diagnosis− Management strategies− When to refer

● Q&A


What’s in a nose?


Nasal Anatomy


Sinonasal Anatomy


Anterior nasal examination


Endoscopic examination


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)


Nasal obstruction

● Exam− Inferior turbinate hypertrophy/bogginess− Nasal discharge− Polyps

● Response to medical treatment− Topical treatment− Oral medications


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


Nasal obstruction

● ENT Examination− Underlying structural problems

Dynamic lateral nasal wall collapse Septal deflection Septal spurs Internal valve narrowing Saddle deformity


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)


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)


Allergic Rhinitis

● AAO-HNS Clinical guidelines− 14 key action statements


Allergic Rhinitis


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



● Causes cont’d− Atrophic

Cocaine, surgery, aging, XRT, infectious

− Idiopathic/Vasomotor



● 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


● Diagnostic testing− Skin/RAST testing negative− Imaging not useful unless suspected sinus disease

● Treatment − Varies with etiology

Recognition and avoidance of underlying trigger


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


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)


Acute Rhinosinusitis: dx

● Radiographic imaging should not be obtained for ARS unless a complication or alternative dx is suspected


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


Acute Rhinosinusitis: tx

● Follow-up should be obtained by 7 days after initiation of treatment/watchful waiting− Confirm ARS, exclude other illnesses, detect complications


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


Chronic Rhinosinustis: dx

● Diagnosis of CRS made with objective confirmation of sinonasal inflammation− Nasal endoscopy, CT

scan


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


Chronic Rhinosinusitis


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


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


Complications of Acute Sinusitis

Pre-septal cellulitis Subperiosteal abscess


Odontogenic sinusitis

● Unilateral maxillary sinusitis of dental origin

● Periodontal disease● Periapical lucency ● Maxillary tooth root in

communication with maxillary sinus

● Treatment is tooth extraction


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


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


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


Questions?

ohns website: rhinitis, sinusitis and beyond: what the primary care provider should know marika...

Documents

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