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Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and Royal Brompton Hospitals.

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Presentation on theme: "Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and Royal Brompton Hospitals."— Presentation transcript:

1 Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and Royal Brompton Hospitals

2 The Nose Clinic RBH Stephen Durham Hesham Saleh

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4 Rhinitis – Inflammation of the Nasal Mucosa Nasal discharge Nasal discharge Blockage Blockage Sneeze/itch Sneeze/itch } Rhinitis definition 2 or more symptoms for > 1 hour on for > 1 hour on most days most days

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6 Rhinosinusitis – Inflammation of the Nasal and Sinus Mucosa Nasal discharge Nasal discharge Blockage Blockage Sneeze/itch Sneeze/itch } Rhinitis definition 2 or more symptoms for > 1 hour on for > 1 hour on most days most days

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8 Chronic Rhinosinusitis – EPOS 2007 Obstruction/CongestionObstruction/Congestion Discharge/PurulenceDischarge/Purulence +/- Pain/Pressure +/-Hyposmia/Anosmia Endoscopic signs of: PolypsPolypsand/or Mucopurulent dischargeMucopurulent dischargeand/or Oedema/mucosal obstructionOedema/mucosal obstructionand/or CT Changes Symptoms > 12 weeks

9 Rhinosinusitis Allergic (seasonal or perennial) Infective (acute or chronic) Structural (polyps, septum, turbinates, etc) Other (idiopathic, NARES, hormonal, etc) Differential Diagnosis

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12 Moderate-severe one or more items. abnormal sleep. impairment of daily activities, sport, leisure. abnormal work and school. troublesome symptoms Persistent. > 4 days per week. > 4 days per week. and > 4 weeks. and > 4 weeks Mild normal sleep normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms Intermittent. Š 4 days per week. or Š 4 weeks ARIA Classification in untreated patients

13 Diagnosis of Allergic Rhinitis HISTORY NASAL EXAMINATION SKIN PRICK TEST or RAST

14 Diagnosis of Allergic Rhinitis History is often very suggestiveHistory is often very suggestive

15 Allergic Salute

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18 Nasendoscopy

19 Anterior Rhinoscopy

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24 Allergy skin prick testing

25 Allergic Rhinitis and Infective Rhinosinusitis may coexist no published prospective reports on the incidence of infective rhinosinusitis in populations with and without clearly defined allergic rhinosinusitis no published prospective reports on the incidence of infective rhinosinusitis in populations with and without clearly defined allergic rhinosinusitis EPOS 2007 EPOS 2007

26 Rhinosinusitis Allergic (seasonal or perennial) Infective (acute or chronic) Structural (polyps, septum, turbinates, etc) Other (idiopathic, NARES, hormonal, etc) Differential Diagnosis

27 Infective AcuteAcute ChronicChronic –Specific BacterialBacterial FungalFungal –Non-specific Immune deficiencyImmune deficiency –Systemic –Local

28 Acute Rhinosinusitis – EPOS 2007 Obstruction/CongestionObstruction/CongestionOR Discharge/PurulenceDischarge/Purulence +/- Pain/Pressure +/-Hyposmia/Anosmia Symptoms < 12 weeks Sudden onset

29 Acute Sinusitis

30 Chronic Rhinosinusitis – EPOS 2007 Obstruction/CongestionObstruction/Congestion Discharge/PurulenceDischarge/Purulence +/- Pain/Pressure +/-Hyposmia/Anosmia Endoscopic signs of: PolypsPolypsand/or Mucopurulent dischargeMucopurulent dischargeand/or Oedema/mucosal obstructionOedema/mucosal obstructionand/or CT Changes Symptoms > 12 weeks

31 Chronic Rhinosinusitis - Endoscopy Pus in MM Pus in MM Oedema in MM Oedema in MM Polyps Polyps

32 Chronic Rhinosinusitis - CT Confirms diagnosis Confirms diagnosis Map for surgery Map for surgery

33 PLAIN X-RAY 54% Sensitivity and 46% Specificity in sinusitis (Kuhn, 1986)54% Sensitivity and 46% Specificity in sinusitis (Kuhn, 1986) 75% of Plain X-Rays do not correlate with CT (McAlister and Lusk, 1989)75% of Plain X-Rays do not correlate with CT (McAlister and Lusk, 1989)

34 Fungal Infections AspergillosisBlastomycosis RhinosporoidosisCryptococcosis PhycomycosisActinomycosis CandidiasisHisptoplasmosis Sporotrichosis Mucormycosis

35 Non-invasiveNon-invasive –Fungal ball (mycetoma) –Allergic fungal sinusitis (AFS) InvasiveInvasive –Chronic invasive (indolent) fungal rhinosinusitis –Acute invasive (fulminant) fungal rhinosinusitis Current Classification (deShazo, 1997)

36 Non-invasiveNon-invasive –Fungal ball (mycetoma) –Allergic fungal sinusitis (AFS) InvasiveInvasive –Chronic invasive (indolent) fungal rhinosinusitis –Acute invasive (fulminant) fungal rhinosinusitis Current Classification (deShazo, 1997)

37 Fungus Ball (Mycetoma) Opacification Double density (dense hyphae) Bony sclerosis No erosion

38 Fungus Ball (Mycetoma)

39 Allergic Fungal Sinusitis Type I HypersensitivityType I Hypersensitivity 80% of Patients Have Diffuse Polyps80% of Patients Have Diffuse Polyps Elevated IgE to Fungus and Positive Skin TestElevated IgE to Fungus and Positive Skin Test Thick Greenish Secretions with Fungal HyphaeThick Greenish Secretions with Fungal Hyphae

40 Allergic Fungal Sinusitis Sinus opacificationSinus opacification ExpansionExpansion Bony erosionBony erosion No tissue invasionNo tissue invasion

41 Infective AcuteAcute ChronicChronic –Specific BacterialBacterial FungalFungal –Non-specific Immune deficiencyImmune deficiency –Systemic –Local

42 Immunodeficiency in Chronic Rhinosinusitis Total IgA + IgG 2 Selective IgG 2 Selective IgA Hypogammaglob 25 (6.5%) 6 (1.6%) 3 (0.8%) 5 (1.3%) 11 (2.9%) 385 Immunoglobulins in M-P rhinorrhea

43 Primary Ciliary Dyskinesia DextrocardiaDextrocardia RhinosinusitisRhinosinusitis BronchiectasisBronchiectasis InfertilityInfertility

44 Saccharin Test < 35 minutes

45 Nasal Muco-Ciliary Clearance Greenstone M., Stanley P., MacWilliam L., Dewar A., Cox T., Mackay I.S., Cole P.J. Mucociliary function and ciliary ultrastructure in patients presenting with rhinitis to Brompton Hospital Nose Clinic. Eur.J. Respir. Dis. Suppl. 128, p 457-9. 1983.

46 Electron Microscopy

47 Cystic Fibrosis Infective Rhinosinusitis (Pseudomonas)Infective Rhinosinusitis (Pseudomonas) 37% of Patients Have Polyps37% of Patients Have Polyps Viscid SecretionsViscid Secretions Polyps in ChildrenPolyps in Children

48 Rhinosinusitis Allergic (seasonal or perennial) Infective (acute or chronic) Structural (polyps, septum, turbinates, etc) Other (idiopathic, NARES, hormonal, etc) Differential Diagnosis

49 Structural

50 Structural (Mechanical) Deviation of nasal septumDeviation of nasal septum Nasal polypsNasal polyps Hypertrophy of inferior turbinatesHypertrophy of inferior turbinates Enlarged adenoidsEnlarged adenoids Foreign bodiesForeign bodies Choanal atresiaChoanal atresia

51 Deviated Nasal Septum

52 Nasal Polyps

53 Symptoms Nasal obstructionNasal obstruction AnosmiaAnosmia Postnasal dripPostnasal drip

54 Diagnosis Gray-pink glistening structuresGray-pink glistening structures InsensitiveInsensitive Anterior rhinoscopy and endoscopy

55 View nasal endoscopy View nasal endoscopy of normal patient View nasal endoscopy

56 Samters Triad 36% of Patients Have Diffuse Polyps36% of Patients Have Diffuse Polyps Bone ExpansionBone Expansion High Recurrence RateHigh Recurrence Rate

57 Inferior Turbinates Hypertrophy

58 Adenoids

59 Foreign Body

60 Choanal Atresia

61 Rhinosinusitis Allergic (seasonal or perennial) Infective (acute or chronic) Structural (polyps, septum, turbinates, etc) Other (idiopathic, NARES, hormonal, etc) Differential Diagnosis

62 Other IdiopathicIdiopathic NARESNARES OccupationalOccupational HormonalHormonal DrugsDrugs FoodFood IrritantsIrritants EmotionalEmotional GranulomasGranulomas TumoursTumours CSF leakCSF leak

63 Non-allergic Idiopathic Vasomotor Rhinitis Nasal Hyperactivity toNasal Hyperactivity to –Cold air –Temperature changes –Tobacco, pollutants –Perfumes, bleach Nasal Hyper-reactivity is also present in 40 - 50% of patients with allergic rhinitis

64 Neuronal markers in allergic rhinitis: expression and correlation with sensory testing. S OHanlon, P Facer, K Simpson, G Sandhu, HA Saleh, P Anand. Laryngoscope 2007 Sep;117(9):1519-27. Increased Nerve Fiber Expression of Sensory Sodium Channels Nav1.7, Nav1.8, and Nav1.9 in Rhinitis. SM Keh, P Facer, K Simpson, G Sandhu, HA Saleh, P Anand. Laryngoscope. 2008; Laryngoscope. 2008; 118(4):573-9. The role of neuronal mechanisms in allergic rhinitis. S OHanlon, SM Keh, HA Saleh Otorinolaringologia. 2008; Otorinolaringologia. 2008;58: 17-30. Neurogenic Rhinitis ?Neurogenic Rhinitis ?

65 NARES (Non-Allergic Rhinitis with Eosinophilia Syndrome) Non-atopicNon-atopic Females > malesFemales > males EosinophiliaEosinophilia Steroid responsiveSteroid responsive

66 Occupational Rhinitis Symptoms improve in weekends and holidays AllergicAllergic Non-allergicNon-allergic

67 Occupational Rhinitis storage mitesstorage mites graingrain latexlatex glues and guar gumglues and guar gum rats, mice, guinea pigsrats, mice, guinea pigs basilis subtilis enzymesbasilis subtilis enzymes wood dust e.g. mahogany, western red cedarwood dust e.g. mahogany, western red cedar isotonic acid hydrazine/trimellitic anhydrideisotonic acid hydrazine/trimellitic anhydride

68 Hormonal PregnancyPregnancy PubertyPuberty PremenstrualPremenstrual HypothyroidismHypothyroidism AcromegalyAcromegaly Old mans dripOld mans drip

69 Drug Induced LocalLocal –Rhinitis medicamentosa SystemicSystemic –Antihypertensives –Aspirin –Contraceptive pill

70 Preservatives Benzoates, salicylatesBenzoates, salicylates TetrazineTetrazine ColouringsColourings

71 Irritants PollutionPollution GustatoryGustatory

72 Emotional

73 Sarcoidosis

74 Wegeners Granulomatosis

75 Atrophic Rhinitis

76 Neoplasms

77 CSF Leak View video here here

78 Rhinosinusitis Allergic (seasonal or perennial) Infective (acute or chronic) Structural (polyps, septum, turbinates, etc) Other (idiopathic, NARES, hormonal, etc) Differential Diagnosis

79 Thank You


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