+ Conflict of interest. + Sinus and Nasal Anatomy. + What is your diagnosis? 1) Allergic Rhinitis. 2) Non-Allergic rhinitis. 3) Chronic Rhinosinusitis

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Rhinitis & Sinusitis Conflict of interest I have no conflict of interest to declare for this lecture Al Chiodo, MD FRCSC Assistant Professor Director of Undergraduate

Sinuses per side (8 total): Frontal, Maxillary, Ethmoid & Sphenoid Nasal cavity points toward the ear To develop an approach to nasal obstruction To review the causes

I have a runny nose most of the year and I have a lot of post-nasal drip. I get a couple of colds each year.

1 Rhinitis & Sinusitis Conflict of interest I have no conflict of interest to declare for this lecture Al Chiodo, MD FRCSC Assistant Professor Director of Undergraduate Medical Education Department of Otolaryngology-Head & Neck Surgery University of Toronto Objectives Sinus and Nasal Anatomy To briefly review nasal and sinus anatomy 4 Sinuses per side (8 total): Frontal, Maxillary, Ethmoid & Sphenoid Nasal cavity points toward the ear To develop an approach to nasal obstruction To review the causes of rhinitis To describe an approach to the management of acute and chronic rhinosinusitis Approach to Nasal Obstruction What is your diagnosis? ID: 23 y.ro. M I feel congested. I have a runny nose most of the year and I have a lot of post-nasal drip. I get a couple of colds each year. I ve tried over the counter nasal sprays but they don t help. Can you help me? What is your diagnosis? 1) Allergic Rhinitis 2) Non-Allergic rhinitis 3) Chronic Rhinosinusitis 4) Acute Rhinosinusitis 5) Septal Deviation

Interactive Question Is the obstruction unilateral, bilateral, or alternating? Unilateral Structural/foreign body/tumour Bilateral Rhinitis/Sinusitis Alternating Nasal cycle Duration of symptoms?

2 Interactive Question Is the obstruction unilateral, bilateral, or alternating? Unilateral Structural/foreign body/tumour Bilateral Rhinitis/Sinusitis Alternating Nasal cycle Duration of symptoms? Days URTI? Weeks Rhinitis/Acute Rhinosinusitis? Months Rhinitis/Chronic Rhinosinusitis? Is there seasonal or diurnal fluctuation? Seasonal Allergic Rhinitis? Diurnal fluctuation Non-Allergic rhinitis? Associated nasal symptoms? Nasal discharge, facial pressure, reduced sense of smell, epistaxis, facial pain/paresthesias, visual symptoms RED FLAG symptoms: Unilateral Nasal Obstruction Severe Epistaxis Adolescent Male Juvenile Nasopharyngeal Angifibroma Asian Patient Nasopharyngeal Carcinoma What other symptom is a warning sign of nasopharyngeal carcinoma? 1. Neck stiffness 2. Unilateral serous otitis media 3. Sneezing 4. Green/yellow nasal discharge 5. Weight loss Physical exam-describe your findings Key Questions on History: Previous nasal surgery/trauma Systemic Diseases Wegener s Granulomatosis, Cystic Fibrosis, Asthma Medications Decongestants ASA/NSAIDS ACE inhibitors Can cause inflammation of nasal lining (rhinitis) Beta Blockers Oral contraceptive Recreational Drug Use/Alcohol Pregnancy Rhinitis Case History Inflammation of nasal mucosa Classification of Rhinitis ARIA (Allergic Rhinitis and its Impact on Asthma) Guidelines Infectious (bacterial/viral/other) 2.Allergic (intermittent/persistent) 3.Occupational (intermittent/persistent) 4.Drug Induced (rhinitis medicamentosa) 5.Hormonal (pregnancy) 6.Other (NARES, irritants, emotional, food, atrophic) 7.Idiopathic Jean is a 32 year old woman who presents with nasal congestion, clear rhinorrhea with post nasal drip along with itchy ears and palate. Her symptoms are worse in April and May but recur in September. What would you expect on examination? What is your diagnosis? How would you treat her?

Allergic Rhinitis Definition: IgE mediated inflammation of the nose after allergen exposure Classification: Seasonal or Perennial Seasonal: occurs at certain times of the year Spring Trees Summer

Nasal congestion Rhinorrhea (usually clear) Nasal pruritis (itchiness) Itchy eyes Exam Findings: Boggy/swollen inferior turbinates Allergic shiners Swollen eyes/eyelids Diagnosis: Detailed history &

3 Allergic Rhinitis Definition: IgE mediated inflammation of the nose after allergen exposure Classification: Seasonal or Perennial Seasonal: occurs at certain times of the year Spring Trees Summer Grass Fall Weeds Perennial: occurs throughout the year Dust mites Pet dander Severity Classification: Mild Moderate/Severe Impacts Sleep, Work, School Allergic Rhinitis: Signs & Symptoms Symptoms: Nasal congestion Rhinorrhea (usually clear) Nasal pruritis (itchiness) Itchy eyes Exam Findings: Boggy/swollen inferior turbinates Allergic shiners Swollen eyes/eyelids Diagnosis: Detailed history & physical exam Ask about triggers Rule out other causes of rhinitis (i.e. medications) Refer for allergy testing if unclear diagnosis/severe symptoms Allergic Rhinitis: Management Eliminate underlying cause (avoidance if possible) Saline sprays/irrigation Intranasal Corticosteroids Oral H-1 Blocker (antihistamine) Decongestants (systemic, topical)** Leukotriene receptor antagonist (LTRA) Consideration for Immunotherapy Rhinitis Medicamentosa Overuse of topical decongestant (>5-7 days) Oxymetazoline Altered vasomotor tone (ie rebound) Temporary relief followed by worsening nasal congestion Pts require more and more decongestant Treatment: Wean off decongestant, use in one nostril till other nostril Consider prednisone Start intranasal corticosteroid spray *Be careful of overuse Case History Bill is a 35 year old male who presents to you with a 10 day history of a URTI. He is getting increasing nasal purulence with rhinorrhea and post nasal drip. He has been up nights coughing and has severe nasal congestion/obstruction. He has facial pain and pressure with decreased sense of smell and fullness in his ears. He is miserable! You look with your otoscope in his nose and see: Case History What is your diagnosis? What symptoms on history help confirm your diagnosis? How would you manage him?

4 Rhinosinusitis Inflammation of mucosal lining of sinuses Acute vs. Chronic Acute: Less than 4 weeks Chronic: Longer than 8-12 weeks Recurrent Acute > 4 episodes of acute bacterial sinusitis/year Usually well in-between episodes Acute Sinusitis: Etiology Ostial obstruction Septal Deviation Polyps URTI Allergy Non-ostial obstruction Decreased mucosal flow Immotile Cilia Syndrome Cystic Fibrosis Immune system related Autoimmune/Immunosuppression Direct extension Spread from dental infection Acute Rhinosinusitis: Diagnosis Acute Bacterial Rhinosinusitis (ABRS) P O D S Major Symptom Facial Pain/Pressure/fullness Nasal Obstruction Nasal purulence/discoloured postnasal Discharge Hyposmia/anosmia (Smell) Requires at Least 2 Symptoms (PODS) - 1 must be O or D Clinical diagnosis X-rays are not indicated unless complications of ARS are being considered Consider if viral URTI persists beyond 10 days or worsens after 5-7 days Bacterial etiology suspected if sinus symptoms persist > 7 days Acute Rhinosinusitis Acute Rhinosinusitis: Management 2/3 of acute bacterial RS (ABRS) clear spontaneously without antibiotics Importance of determining severity of ARS and not determining if a patient is presenting with an URTI or ABRS If symptoms present <7 days: treat as viral illness If symptoms present >7 days: treat as ABRS ABRS treatment determined by symptom severity; severe (antibiotic treatment) vs. not severe (no antibiotic treatment) Microbiology includes viruses and typical respiratory pathogens S. pneumonia, H. flu, M. catarrhalis Antibiotics (7-10 day course): 1 st line: Amoxicillin 2 nd line: Amoxicillin-Clavulinic Acid, Macrolide, Fluroquinolone Nasal Corticosteroid /-Short term topical/systemic decongestant /-Nasal saline irrigation, Humification

Acute Bacterial Rhinosinusitis Case History Treatment Our patient Bill returns to your clinic after having a course of amoxicillin for seven days along with nasal steroids with saline rinses.

He is now two and a half months since his initial URTI and still has purulent secretions, facial pain, nasal congestion and obstruction with hyposmia.

Chronic Rhinosinusitis: Etiology Burden of Chronic Rhinosinusitis Inflammatory Disease involving the nasal mucosa and paranasal sinuses Many similarities to asthma Similar population of inflammatory

5 Acute Bacterial Rhinosinusitis Case History Treatment Our patient Bill returns to your clinic after having a course of amoxicillin for seven days along with nasal steroids with saline rinses. His symptoms did not resolve after 2 weeks. He was then treated with Zithromax for 5 days with a refill on the antibiotics used after one month. He is now two and a half months since his initial URTI and still has purulent secretions, facial pain, nasal congestion and obstruction with hyposmia. Exam on nasal otoscopy confirms purulence in the middle meatus? How would you manage him now? Chronic Rhinosinusitis: Etiology Burden of Chronic Rhinosinusitis Inflammatory Disease involving the nasal mucosa and paranasal sinuses Many similarities to asthma Similar population of inflammatory cells, cytokine profile, and tissue remodelling Variable Phenotypic Expression CRS without polyps CRS with polyps 5% Canadian population million annual office visits (U.S.) 545,000 ER visits Estimated cost: $6 Billion/year (2004) Quality of life comparable or worse than COPD, congestive heart failure, back pain, angina Chronic Rhinosinusitis Chronic Rhinosinusitis Predisposing/Modifying Factors? Bacterial infection Altered microbiome Fungus Genetics Allergy Anatomic abnormality Cilia Motility Disorder Immunocompromised state Still Unclear Etiology BUT, it is a disease of INFLAMMATION Microbiology: S. aureus P. aeriginosa Anaerobes Symptoms greater than 8-12 weeks Diagnosis requires both symptoms & objective findings*

Chronic Rhinosinusitis: Diagnosis Chronic Rhinosinusitis (CRS) C P O D S Major Symptom Facial

postnasal Discharge (may be nonpurulent/discolored) Hyposmia/anosmia (Smell) Nasal Endocopy OR Requires

endoscopy or CT scan) CT Sinuses Chronic Rhinosinusitis: Management Chronic Rhinosinusitis (CRS) May

antibiotic Clavulin Macrolide Fluoroquinolone Oral Steroids (Nasal Polyps) Short course Need

Endoscopy /- CT Scan Maximize Medical Therapy Consider Endoscopic Sinus Surgery?

6 Chronic Rhinosinusitis: Diagnosis Chronic Rhinosinusitis (CRS) C P O D S Major Symptom Facial Congestion/fullness Facial Pain/Pressure/fullness Nasal Obstruction/blockage Nasal purulence/discoloured postnasal Discharge (may be nonpurulent/discolored) Hyposmia/anosmia (Smell) Nasal Endocopy OR Requires at Least 2 Symptoms (CPODS) for > 8-12 weeks Requires objective evidence of sinus inflammation (Nasal endoscopy or CT scan) CT Sinuses Chronic Rhinosinusitis: Management Chronic Rhinosinusitis (CRS) May include: Nasal Saline Irrigations Topical Nasal Steroid Spray Antibiotic 3-4 week duration 2 nd line antibiotic Clavulin Macrolide Fluoroquinolone Oral Steroids (Nasal Polyps) Short course Need confirmation of CRS If no improvement in symptoms or unsure of diagnosis Referral to Otolaryngology Endoscopy /- CT Scan Maximize Medical Therapy Consider Endoscopic Sinus Surgery? Endoscopic Sinus Surgery Endoscopic Sinus Surgery Endoscopes through the nose using image guided surgery technology Remove polyps & infection Enlarge sinus openings

Complications of Sinusitis Complications of Sinusitis Orbital Cellulitis Abscess Intracranial Meningitis Abscess Bony Osteomyelitis RED FLAGS: High Fever and

History of nasal polyps Cystic Fibrosis Primary Ciliary Dyskinesia Take Home Message Interactive Question Rhinitis Many varieties but important to recognize

irrigation, topical nasal corticosteroids Chronic Rhinosinusitis Requires symptoms and objective findings (CT or endoscopy) Treatment: Saline irrigation and

nasopharyngeal carcinoma? 1. Neck stiffness 2. Unilateral serous otitis media 3. Sneezing 4. Green/yellow nasal discharge 5.

7 Complications of Sinusitis Complications of Sinusitis Orbital Cellulitis Abscess Intracranial Meningitis Abscess Bony Osteomyelitis RED FLAGS: High Fever and signs of toxemia Visual Changes (diplopia, proptosis, chemosis) Facial numbness Severe Pain Decreased conciousness RISK FACTORS: Immunocompromised Diabetic History of nasal polyps Cystic Fibrosis Primary Ciliary Dyskinesia Take Home Message Interactive Question Rhinitis Many varieties but important to recognize allergic rhinitis if present Most respond to saline irrigation and topical steroids Acute Rhinosinusitis Clinical diagnosis Treat with antibiotics, saline irrigation, topical nasal corticosteroids Chronic Rhinosinusitis Requires symptoms and objective findings (CT or endoscopy) Treatment: Saline irrigation and topical nasal steroids /- antibiotics /- oral steroids Surgery is only considered after failure of medical treatment What other symptom is a warning sign of nasopharyngeal carcinoma? 1. Neck stiffness 2. Unilateral serous otitis media 3. Sneezing 4. Green/yellow nasal discharge 5. Weight loss Interactive Question What other symptom is a warning sign of nasopharyngeal carcinoma? 1. Neck stiffness 2. Unilateral serous otitis media 3. Sneezing Questions? 4. Green/yellow nasal discharge 5. Weight loss

Rhinosinusitis. John Ramey, MD Joseph Russell, MD

Rhinosinusitis. John Ramey, MD Joseph Russell, MD Rhinosinusitis John Ramey, MD Joseph Russell, MD Disclosure Statement RSFH as a continuing medical education provider, accredited by the South Carolina Medical Association, it is the policy of RSFH to