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

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

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

ENT surgeon Moor Allerton Golf Club 15 th May2014 ENT The Leeds Teaching Hospitals NHS Trust m anaging common nasal c onditions Back to Medical School group of GPs managing ID: 776615

nasal rhinitis allergic april nasal rhinitis allergic april 2011 0108 asthma symptoms common 2008 allergy patients unilateral spt diagnosis

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Slide1

Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed)ENT surgeon, Moor Allerton Golf Club15th May2014

ENT

The Leeds Teaching Hospitals NHS Trust

managing common nasal conditions

Slide2

Back to Medical School group of

GP's

managing

common nasal

conditions

to

include

rhinitis

making the correct diagnosis

practical treatment

polyps

why should we worry about unilateral polyps

nose bleed

anything else you thinks important and practical

Slide3

aims

i

mprove our understanding of nose conditions

d

iscuss some example cases

formulate management plans for nasal disease

Slide4

objectives

list symptoms to be elicited in nasal conditions

list ways on nasal examination

discuss the evidence base in treating sinusitis

describe

a nasal cautery technique

council a patient on sinus surgery

list differential in nasal lesions

l

ist the presentation of a nasal malignancy

recognise nasal

sepal deviation

list aetiologies in septal perforation

recognise

and manage nasal polyps

Slide5

first though...

history and examination in ENT

Slide6

history

earsotorrhoeaotalgiaitchhearingtinnitus balance

nosesnasal obstructionrhinorrhoeafacial painsmellepistaxispost nasal drip

throats

dysphagia

dysphonia

odynophagia

pain

neck lumps

weight loss

Slide7

history

earsotorrhoeaotalgiaitchhearingtinnitus balance

nosesnasal obstructionrhinorrhoeafacial painsmellepistaxispost nasal drip

throats

dysphagia

dysphonia

odynophagia

pain

neck lumps

weight loss

Slide8

examination of the nose

Slide9

examination

Slide10

examination with auriscope

Slide11

rhinosinusitis

Slide12

sinusitis

Slide13

rhin

osinus

itis

Slide14

theories of rhinosinusitis

Slide15

classification of rhinosinusitis

Slide16

Non-allergic RhinitisAllergic Rhinitis

UK/FF/0108/11 April 2011

Slide17

Allergic Rhinitis

UK/FF/0108/11 April 2011

Slide18

Allergic Rhinitis Epidemiology

Allergic rhinitis is the most common form of non-infectious rhinitisAt least 500 million individuals world-wide have allergic rhinitis and it is one of the most common reasons for attendance with a primary care practitionerAlmost 30% of adults and 40% of children are affectedWorld-wide the prevalence of allergic rhinitis continues to increase

UK/FF/0108/11 April 2011

References

Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63

Suppl

86:8-160

Wallace DC et. J Allergy

Clin

Immunol

2008; 122: S1-84

Slide19

Prevalence of clinically confirmed allergic rhinitis in Europe

Reference:

Bauchau V et al. Eur Respir J 2004; 24: 758-764

UK/FF/0108/11 April 2011

Slide20

Clinical Diagnosis

Nasal discharge

BlockageSneeze / 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

Slide21

Clinical symptoms of allergic rhinitis

primary clinical manifestations congestionrhinorrhoea itching sneezingsecondary clinical effectslethargymalaise

UK/FF/0108/11 April 2011

Slide22

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

Slide23

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 suspectedClassic findingsPale oedematous mucosaCongestionMucus secretion

UK/FF/0108/11 April 2011

Slide24

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 suspectedClassic findingsPale oedematous mucosaCongestionMucus secretion

UK/FF/0108/11 April 2011

Slide25

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 suspectedClassic findingsPale oedematous mucosaCongestionMucus secretion

UK/FF/0108/11 April 2011

Slide26

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 DanderOccupational Flour, grain, latex, wood dust, detergents

UK/FF/0108/11 April 2011

British society for allergy and clinical immunology

Slide27

Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160

UK/FF/0108/11 April 2011

Rhinitis Management

Slide28

Diagnosis of allergic rhinitis

Intermittent symptoms

Mildoral antihistamineorintranasal antihistamine+/- decongestantor leukotriene antagonist

Asthma?

Moderateoral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate

consider

Slide29

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Mildoral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate

consider

Slide30

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severetopical nasal steroidoral antihistamineorleukotriene antagonistReview after 2 -4 weeks

If better, step down and continue for > 1 month

consider

Slide31

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severetopical nasal steroidoral antihistamineorleukotriene antagonistReview after 2 -4 weeks

If not better, review diagnosisreview compliancequery infective / other causeincrease nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)

consider

Slide32

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severetopical nasal steroidoral antihistamineorleukotriene antagonistReview after 2 -4 weeks

If not better, review diagnosisreview compliancequery infective / other causeincrease nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)If not better, refer

consider

Slide33

Common co-morbidities: Asthma

Approximately 80% of asthmatics have rhinitisAllergic rhinitis may precede asthmaRhinitis impairs asthma controlTreatment of allergic rhinitis may improve asthma controlAllergic Rhinitis and its Impact in Asthma (ARIA) promotes assessing everyone with allergic rhinitis for asthma

UK/FF/0108/11 April 2011

References

Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160

Wallace DC et. J Allergy

Clin

Immunol

2008; 122: S1-84

Slide34

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

Reference

1. Wallace DC et al. J Allergy

Clin

Immunol

2008; 122: S1-84

Slide35

rhinosinusitis

Slide36

Allergen Avoidance

BackgroundSuccess of intervention measured by clinical improvementStrategy success influenced by individual host sensitivity to allergenSensitivity differs betweens allergens

EffectivenessStudies 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

Slide37

rye grass

Slide38

house dust mite

Slide39

allergen avoidance

mattress, pillow, duvet covers

synthetic duvets, pillows

avoid woollen blankets

vacuum frequently

avoid carpets, curtains

keep clothing in cupboards

keep animals out of bedrooms

low relative humidity

boil wash sheet, duvet covers

Slide40

allergen avoidance

Slide41

allergen avoidance

Slide42

allergen avoidance

Fel d1

Slide43

treatments

UK/FF/0108/11 April 2011

Slide44

Intranasal Steroids

risks?

UK/FF/0108/11 April 2011

Slide45

Bioavailability of nasal steroids

ReferencesNasonex Summary of Product Characteristics. Date accessed April 2011Kariyawasam H, Scadding G.Journal of Asthma and Allergy 2010: 3 19–28Rhinocort Summary of Product Characteristics. Date accessed April 2011Beconase Summary of Product Characteristics. Date accessed April 2011

UK/FF/0108/11 April 2011

Mometasone

Fluticasone

Slide46

epistaxis and cautery

Slide47

Case

Slide48

Epistaxis

Naspetin ointment

Vs

Cautery and Naseptin ointment

Slide49

theories of rhinosinusitis

Slide50

theories of rhinosinusitis

Slide51

investigation - sinus x ray

Exposure toradiationpoor sensitivitypoor specificity

Slide52

investigation - CT scan

Slide53

nasal polyps

Slide54

nasal polyps - treatment

medical

steroids

surgical

polypectomy

Slide55

u

nilateral nasal discharge

Slide56

unilateral nasal discharge

c

hild

f

oreign body or neoplasm

Slide57

u

nilateral nasal polyp

Slide58

unilateral nasal polyp

neoplasm

b

enign or malignant

Slide59

unilateral nasal polyp

is it really unilateral?

Slide60

unilateral nasal polyp

neoplasm

b

enign or malignant

woodworking,

metal

,

textile

and

leather

industries

Slide61

unilateral nasal polyp

neoplasm

b

enign or malignant

watch for pain, eye involvement, tears, movement, facial sensation

Slide62

unilateral nasal polyp

neoplasm

b

enign or malignant

Nasal obstruction

(

36%), epistaxis

(

30

%) &

 nasal discharge

(

21%) were the

most common presentation

Slide63

unilateral nasal polyp

neoplasm

b

enign or malignant

i

nverted

papilloma

Slide64

nasal pain crusting

Slide65

Case

Slide66

Septal perforation - investigations

FBC normal

ESR 16 mm/h CRP <5.0 mg/l

U&E normal glucose 5.0 mmol/l

syphilis negative ACE negative

ANCA negative

Slide67

Nasal septal perforation

surgery

trauma

cocaine use

infection

post trauma, syphilis

Wegener’s granulomatosis

sarcoidosis

idiopathic

Slide68

objectives

list symptoms to be elicited in nasal conditions

list ways on nasal examination

discuss the evidence base in treating sinusitis

describe

a nasal cautery technique

council a patient on sinus surgery

list differential in nasal lesions

l

ist the presentation of a nasal malignancy

recognise nasal

sepal deviation

list aetiologies in septal perforation

recognise

and manage nasal polyps

Slide69

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

MK

1

Yilmaz T

Sweeney A

Calzada

G

Roberts DB

Levine NB

Demonte F

Hanna EY

Kupferman

ME

.

Author information

Abstract

BACKGROUND:

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