w hat the primary care provider should know Marika Russell MD FACS Assistant Professor of Clinical Otolaryngology San Francisco General Hospital Outline Normal anatomy Examination techniques ID: 418271
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Slide1
Rhinitis, Sinusitis and beyond: what the primary care provider should know
Marika Russell, MD, FACS
Assistant Professor of Clinical Otolaryngology
San Francisco General HospitalSlide2
Outline
Normal anatomy
Examination techniques
Nasal obstruction
Rhinitis vs. Sinusitis
Diagnosis
Management strategies
When to refer
Q&ASlide3
What’s in a nose?Slide4
Nasal AnatomySlide5
Nasal AnatomySlide6
Sinonasal AnatomySlide7
Anterior nasal examinationSlide8
Anterior nasal examinationSlide9
Endoscopic examinationSlide10
Endoscopic examinationSlide11
Nasal obstruction
M
edical (dynamic) vs. structural
(anatomic/fixed
)
History
Timing (onset, day vs. night, seasonal vs. year-round)
Triggers (environment, pets)
Laterality
Associated symptoms (sneezing, nasal discharge, nasal itching, itchy eyes,
epiphora
)
C
omorbid conditions (
ie
. Asthma)Slide12
Nasal obstruction
Exam
Inferior turbinate hypertrophy/
bogginess
N
asal discharge
P
olyps
Response to medical treatment
Topical treatment
Oral medicationsSlide13
Nasal obstruction
Medical
I
nsidious onset, absence of trauma
Some
day-to-day variability
(Bilateral)
Environmental triggers
Some responsiveness to medications
Structural
Life-long or history of trauma
Minimal day-to-day variability
(Unilateral)
Not environmental
Unresponsive to medicationsSlide14
Nasal obstruction
ENT Examination
Underlying structural problems
Dynamic lateral nasal wall collapse
Septal
deflection
Septal
spurs
Internal valve narrowing
Saddle deformitySlide15
Allergic Rhinitis
Background
AR is
IgE
mediated inflammatory response of nasal mucosa
Characterized by nasal congestion, rhinorrhea, sneezing and/or nasal itching
Classified by temporal pattern
Seasonal (
ie
. pollen)
Perennial/year round (
ie
. dust mites, mold)
Episodic (
ie
. pet exposure
)
Classified by frequency
Intermittent (<4 days/
wk
or <4wks/
yr
)
Persistent (>4 days/
wk
or >4wks/
yr
)Slide16
Allergic Rhinitis
Background cont’d
Classified by severity
Mild (symptoms present but not interfering with QOL)
Severe (exacerbation of coexisting asthma, sleep disturbance, impairment of daily activities)Slide17
Allergic Rhinitis
AAO-HNS Clinical guidelines
14 key action statementsSlide18
Allergic RhinitisSlide19
Allergic RhinitisSlide20
Allergic RhinitisSlide21
Non-Allergic Rhinitis
Causes
NAR with eosinophilia (NARES)
Hormone related
Hypothyroidism, acromegaly, puberty, pregnancy, post-menopausal
Medication associated
Rhinitis
medicamentosa
, anti-
hypertensives
, NSAIDS, OCPs
Irritant
Temperature, humidity, barometric changes, gustatory exposureSlide22
Non-Allergic Rhinitis
Causes cont’d
Atrophic
Cocaine, surgery, aging, XRT, infectious
Idiopathic/VasomotorSlide23
Non-Allergic Rhinitis
History
Timing
E
xacerbating and alleviating factors
Environmental triggers
Patients with onset >age 35 without family history of allergies, no obvious pet/outdoor triggers, no association with perfumes/fragrances very likely to have NAR
Exam
Boggy, edematous nasal mucosa
Clear
mucoid
drainiageSlide24
Diagnostic testing
Skin/RAST testing negative
Imaging not useful unless suspected sinus disease
Treatment
Varies with etiology
Recognition and avoidance of underlying triggerSlide25
Rhinosinusitis
Definition
Symptomatic inflammation of
paranasal
sinuses and nasal cavity
Acute (ARS)
< 4weeks duration
Chronic (CRS)
>12 weeks duration
+/- acute exacerbations
Recurrent ARS
>4 episodes per year without persistent
sxs
in between episodesSlide26
Acute Rhinosinusitis: dx
Distinguish acute
rhinosinusitis
(ARS; viral URI) vs. acute bacterial
rhinosinusitis
(ABRS)
ABRS should be diagnosed when symptoms and signs of ARS (purulent nasal drainage with nasal obstruction and facial pain/pressure)
persist without evidence of improvement for >10 days
beyond onset –OR-
improve initially and worsen again (double worsening)Slide27
Acute Rhinosinusitis: dx
Radiographic imaging
should not
be obtained for ARS unless a complication or alternative dx is suspectedSlide28
Acute Rhinosinusitis: tx
Viral ARS may be treated symptomatically
Analgesics, topical nasal steroids, nasal saline irrigations
ABRS may also be treated symptomatically
New AAO-HNS clinical guideline recommendation
Watchful waiting for up to 7 days after ABRS diagnosis
Treatment ABRS includes amoxicillin/Augmentin for 5-10 days
Doxyclycline
or respiratory
flouroquinolone
for PCN allergySlide29
Acute Rhinosinusitis: tx
Follow-up should be obtained by 7 days after initiation of treatment/watchful waiting
Confirm ARS, exclude other illnesses, detect complicationsSlide30
Chronic Rhinosinusitis: dx
> 12 weeks of 2 or more of the following:
Mucopurulent
drainage
Nasal obstruction
Facial pain/pressure
Decreased sense of smell
AND inflammation is documented by one or more of the following:
Purulent (not clear) mucous or edema in middle meatus
Polyps in nasal cavity or middle meatus
Radiographic imaging demonstrating
paranasal
inflammationSlide31
Chronic Rhinosinustis: dx
Diagnosis of CRS made with objective confirmation of
sinonasal
inflammation
Nasal endoscopy, CT scanSlide32
Chronic rhinosinusitis: dx
Assess for comorbid conditions that may influence treatment
Asthma, CF,
immunocompromise
,
ciliary
dyskinesia
Consider obtaining allergy and immune function testing
Determine presence or absence of polyps (
ENTprovider
)
Steroid responsiveness/appropriatenessSlide33
Chronic RhinosinusitisSlide34
Chronic Rhinosinusitis: tx
Topical nasal steroids, saline irrigations for symptom management
High dose
predisone
taper plus antibiotics x 2 weeks to assess for symptomatic improvement
If no improvement or initial improvement but worsening, surgical intervention offeredSlide35Slide36
Complications of Acute Sinusitis
Periorbital
complications: Chandler classification
Preseptal
cellulitis
Orbital/post-septal cellulitis
Subperiosteal
abscess
Orbital abscess
Cavernous sinus thrombosis
Intracranial complications
Epidural/subdural abscess
Cerebral empyemaSlide37
Complications of Acute Sinusitis
Pre-septal cellulitis
Subperiosteal
abscessSlide38
Odontogenic sinusitis
Unilateral maxillary sinusitis of dental origin
P
eriodontal disease
Periapical
lucency
Maxillary tooth root in communication with maxillary sinus
Treatment is tooth extractionSlide39
When to Refer
Nasal obstruction/rhinitis
Failure of medical treatment
Allergy referral
Suspected anatomic problem
Rhinosinusitis
ABRS unresponsive to appropriate medical management or with concern for acute complication
CRS unresponsive to conservative medical management
Consider trial of high dose steroids/
abx
Unilateral sinus diseaseSlide40
When to Refer
CRS maximal medical management
Prednisone
40mg PO daily x 4 days
30mg PO daily x 3 days
20mg PO daily x 3 days
10mg PO daily x 2 days
Augmentin
875/125 PO BID x 2 weeks concurrently with steroids
If no prior sinus imaging, CT at end of steroid/
abxSlide41
Final thoughts
Rhinitis can be challenging to manage
Manage patient expectations prior to specialty visit
Consider migraine on differential when suspect CRS
Pain/pressure alone not sufficient for dx CRS
CT imaging not appropriate in setting of ABRS but when in doubt, obtain for dx CRSSlide42
Questions?