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
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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
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
Slide3aims
i
mprove our understanding of nose conditions
d
iscuss some example cases
formulate management plans for nasal disease
Slide4objectives
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
Slide5first though...
history and examination in ENT
Slide6history
earsotorrhoeaotalgiaitchhearingtinnitus balance
nosesnasal obstructionrhinorrhoeafacial painsmellepistaxispost nasal drip
throats
dysphagia
dysphonia
odynophagia
pain
neck lumps
weight loss
Slide7history
earsotorrhoeaotalgiaitchhearingtinnitus balance
nosesnasal obstructionrhinorrhoeafacial painsmellepistaxispost nasal drip
throats
dysphagia
dysphonia
odynophagia
pain
neck lumps
weight loss
Slide8examination of the nose
Slide9examination
Slide10examination with auriscope
Slide11rhinosinusitis
Slide12sinusitis
Slide13rhin
osinus
itis
Slide14theories of rhinosinusitis
Slide15classification of rhinosinusitis
Slide16Non-allergic RhinitisAllergic Rhinitis
UK/FF/0108/11 April 2011
Slide17Allergic Rhinitis
UK/FF/0108/11 April 2011
Slide18Allergic 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
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
Slide20Clinical 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
Slide21Clinical symptoms of allergic rhinitis
primary clinical manifestations congestionrhinorrhoea itching sneezingsecondary clinical effectslethargymalaise
UK/FF/0108/11 April 2011
Slide22IMPAIRED 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
Slide23Investigations
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
Slide24Investigations
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
Slide25Investigations
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
Slide26Allergic 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
Slide27Bousquet 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
Slide28Diagnosis of allergic rhinitis
Intermittent symptoms
Mildoral antihistamineorintranasal antihistamine+/- decongestantor leukotriene antagonist
Asthma?
Moderateoral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate
consider
Slide29Diagnosis of allergic rhinitis
Persistent symptoms
Asthma?
Mildoral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate
consider
Slide30Diagnosis 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
Slide31Diagnosis 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
Slide32Diagnosis 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
Slide33Common 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
Slide34Common 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
Slide35rhinosinusitis
Slide36Allergen 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
Slide37rye grass
Slide38house dust mite
Slide39allergen 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
Slide40allergen avoidance
Slide41allergen avoidance
Slide42allergen avoidance
Fel d1
Slide43treatments
UK/FF/0108/11 April 2011
Slide44Intranasal Steroids
risks?
UK/FF/0108/11 April 2011
Slide45Bioavailability 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
Slide46epistaxis and cautery
Slide47Case
Slide48Epistaxis
Naspetin ointment
Vs
Cautery and Naseptin ointment
Slide49theories of rhinosinusitis
Slide50theories of rhinosinusitis
Slide51investigation - sinus x ray
Exposure toradiationpoor sensitivitypoor specificity
Slide52investigation - CT scan
Slide53nasal polyps
Slide54nasal polyps - treatment
medical
steroids
surgical
polypectomy
Slide55u
nilateral nasal discharge
Slide56unilateral nasal discharge
c
hild
f
oreign body or neoplasm
u
nilateral nasal polyp
Slide58unilateral nasal polyp
neoplasm
b
enign or malignant
Slide59unilateral nasal polyp
is it really unilateral?
Slide60unilateral nasal polyp
neoplasm
b
enign or malignant
woodworking,
metal
,
textile
and
leather
industries
Slide61unilateral nasal polyp
neoplasm
b
enign or malignant
watch for pain, eye involvement, tears, movement, facial sensation
Slide62unilateral nasal polyp
neoplasm
b
enign or malignant
Nasal obstruction
(
36%), epistaxis
(
30
%) &
nasal discharge
(
21%) were the
most common presentation
Slide63unilateral nasal polyp
neoplasm
b
enign or malignant
i
nverted
papilloma
Slide64nasal pain crusting
Slide65Case
Slide66Septal 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
Slide67Nasal septal perforation
surgery
trauma
cocaine use
infection
post trauma, syphilis
Wegener’s granulomatosis
sarcoidosis
idiopathic
Slide68objectives
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
Slide69Head 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