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

2. The Nose Clinic
RBH
Hesham Saleh
Stephen Durham

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

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

8. Chronic Rhinosinusitis – EPOS 2007
Endoscopic signs of:
Polyps
and/or
Mucopurulent discharge
Oedema/mucosal obstruction
CT Changes
Obstruction/Congestion
Discharge/Purulence
+/- Pain/Pressure
+/-Hyposmia/Anosmia
Symptoms > 12 weeks

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

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

15. Allergic Salute

18. Nasendoscopy

19. Anterior Rhinoscopy

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” EPOS 2007

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

27. Infective Acute Chronic Specific Non-specific Bacterial Fungal
Immune deficiency
Systemic
Local

28. Acute Rhinosinusitis – EPOS 2007
Obstruction/Congestion OR
Discharge/Purulence
+/- Pain/Pressure
+/-Hyposmia/Anosmia
Sudden onset
Symptoms < 12 weeks

29. Acute Sinusitis

30. Chronic Rhinosinusitis – EPOS 2007
Endoscopic signs of:
Polyps
and/or
Mucopurulent discharge
Oedema/mucosal obstruction
CT Changes
Obstruction/Congestion
Discharge/Purulence
+/- Pain/Pressure
+/-Hyposmia/Anosmia
Symptoms > 12 weeks

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

32. Chronic Rhinosinusitis - CT
Confirms diagnosis
Map for surgery

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

34. Fungal Infections Aspergillosis Blastomycosis
Rhinosporoidosis Cryptococcosis
Phycomycosis Actinomycosis
Candidiasis Hisptoplasmosis
Sporotrichosis Mucormycosis

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

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

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

38. Fungus Ball (Mycetoma)

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

40. Allergic Fungal Sinusitis
Sinus opacification
Expansion
Bony erosion
No tissue invasion

41. Infective Acute Chronic Specific Non-specific Bacterial Fungal
Immune deficiency
Systemic
Local

42. Immunodeficiency in Chronic Rhinosinusitis
Immunoglobulins in M-P rhinorrhea
385
Hypogammaglob
11 (2.9%)
Selective IgA
5 (1.3%)
Selective IgG2
3 (0.8%)
IgA + IgG2
6 (1.6%)
Total
25 (6.5%)

43. Primary Ciliary Dyskinesia
Dextrocardia
Rhinosinusitis
Bronchiectasis
Infertility

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

46. Electron Microscopy

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

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

49. Structural

50. Structural (Mechanical)
Deviation of nasal septum
Nasal polyps
Hypertrophy of inferior turbinates
Enlarged adenoids
Foreign bodies
Choanal atresia

51. Deviated Nasal Septum

52. Nasal Polyps

53. Symptoms
Nasal obstruction
Anosmia
Postnasal drip

54. Diagnosis Anterior rhinoscopy and endoscopy
Gray-pink glistening structures
Insensitive

55. View nasal endoscopy of normal patient

56. Samter’s Triad 36% of Patients Have Diffuse Polyps Bone Expansion
High Recurrence Rate

57. Inferior Turbinates Hypertrophy

58. Adenoids

59. Foreign Body

60. Choanal Atresia

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

62. Other Idiopathic NARES Occupational Hormonal Drugs Food Irritants
Emotional
Granulomas
Tumours
CSF leak

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

64. “Neurogenic Rhinitis” ?
Neuronal markers in allergic rhinitis: expression and correlation with sensory testing.
S O’Hanlon, P Facer, K Simpson, G Sandhu, HA Saleh, P Anand.
Laryngoscope 2007 Sep;117(9):
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; 118(4):573-9.
The role of neuronal mechanisms in allergic rhinitis.
S O’Hanlon, SM Keh, HA Saleh
Otorinolaringologia. 2008;58:

65. NARES (Non-Allergic Rhinitis with Eosinophilia Syndrome)
Non-atopic
Females > males
Eosinophilia
Steroid responsive

66. Occupational Rhinitis
Symptoms improve in weekends and holidays
Allergic
Non-allergic

67. Occupational Rhinitis
storage mites
grain
latex
glues and guar gum
rats, mice, guinea pigs
basilis subtilis enzymes
wood dust e.g. mahogany, western red cedar
isotonic acid hydrazine/trimellitic anhydride

68. Hormonal Pregnancy Puberty Premenstrual Hypothyroidism Acromegaly
Old man’s drip

69. Drug Induced Local Systemic Rhinitis medicamentosa Antihypertensives
Aspirin
Contraceptive pill

70. Preservatives
Benzoates, salicylates
Tetrazine
Colourings

71. Irritants
Pollution
Gustatory

72. Emotional

73. Sarcoidosis

74. Wegener’s Granulomatosis

75. Atrophic Rhinitis

76. Neoplasms

77. CSF Leak
View video here

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

79. Thank You