Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and...
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Transcript of Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and...
![Page 1: Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and Royal Brompton Hospitals.](https://reader034.fdocuments.in/reader034/viewer/2022051315/56649b44550346318e8b7728/html5/thumbnails/1.jpg)
Differential Diagnosis of Differential Diagnosis of RhinosinusitisRhinosinusitis
Hesham Saleh, FRCSHesham Saleh, FRCSConsultant RhinologistConsultant Rhinologist
Charing Cross and Royal Brompton HospitalsCharing Cross and Royal Brompton Hospitals
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The Nose ClinicThe Nose ClinicRBHRBH
Stephen DurhamStephen Durham Hesham SalehHesham Saleh
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Rhinitis – Inflammation of the Rhinitis – Inflammation of the Nasal MucosaNasal Mucosa
Nasal dischargeNasal discharge BlockageBlockage Sneeze/itchSneeze/itch }}
Rhinitis definitionRhinitis definition2 or more symptoms2 or more symptoms
for > 1 hour onfor > 1 hour on most daysmost days
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Rhinosinusitis – Inflammation of Rhinosinusitis – Inflammation of the Nasal and the Nasal and SinusSinus Mucosa Mucosa
Nasal dischargeNasal discharge BlockageBlockage Sneeze/itchSneeze/itch }}
Rhinitis definitionRhinitis definition2 or more symptoms2 or more symptoms
for > 1 hour onfor > 1 hour on most daysmost days
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Chronic Rhinosinusitis – EPOS 2007Chronic Rhinosinusitis – EPOS 2007
• Obstruction/CongestionObstruction/Congestion• Discharge/PurulenceDischarge/Purulence
+/- Pain/Pressure+/- Pain/Pressure
+/-Hyposmia/Anosmia+/-Hyposmia/Anosmia
Endoscopic signs of:Endoscopic signs of:• PolypsPolyps
and/orand/or• Mucopurulent dischargeMucopurulent discharge
and/orand/or• Oedema/mucosal Oedema/mucosal
obstructionobstruction
and/orand/or
CT ChangesCT ChangesSymptoms > 12 weeksSymptoms > 12 weeks
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RhinosinusitisRhinosinusitis
AllergicAllergic(seasonal or perennial)(seasonal or perennial)
InfectiveInfective(acute or(acute orchronic)chronic)
StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)
OtherOther(idiopathic, NARES, (idiopathic, NARES,
hormonal, etc)hormonal, etc)
Differential DiagnosisDifferential Diagnosis
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Moderate-severeModerate-severeone or more itemsone or more items
. abnormal sleep. abnormal sleep
. impairment of daily . impairment of daily activities, sport, leisureactivities, sport, leisure
. abnormal work and . abnormal work and schoolschool
. troublesome symptoms. troublesome symptoms
PersistentPersistent . > 4 days per week. > 4 days per week
. . andand > 4 weeks > 4 weeks
MildMild normal sleepnormal sleep& no impairment of daily & no impairment of daily
activities, sport, leisureactivities, sport, leisure& normal work and & normal work and
schoolschool& no troublesome & no troublesome
symptomssymptoms
IntermittentIntermittent
. Š 4 days per week. Š 4 days per week
. . oror Š 4 weeks Š 4 weeks
ARIA ClassificationARIA Classification
in untreated patientsin untreated patients
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Diagnosis of Allergic RhinitisDiagnosis of Allergic Rhinitis
HISTORYHISTORY
NASAL EXAMINATIONNASAL EXAMINATION
SKIN PRICK TEST or RASTSKIN PRICK TEST or RAST
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Diagnosis of Allergic RhinitisDiagnosis of Allergic Rhinitis
• History is often very suggestive History is often very suggestive
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Allergic SaluteAllergic Salute
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NasendoscopyNasendoscopy
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Anterior RhinoscopyAnterior Rhinoscopy
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Allergy skin prick testingAllergy skin prick testing
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Allergic Rhinitis and Infective Allergic Rhinitis and Infective Rhinosinusitis may coexistRhinosinusitis may coexist
“ “no published prospective reports on the no published prospective reports on the incidence of infective rhinosinusitis in incidence of infective rhinosinusitis in populations with and without clearly populations with and without clearly defined allergic rhinosinusitis”defined allergic rhinosinusitis”
EPOS 2007EPOS 2007
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RhinosinusitisRhinosinusitis
AllergicAllergic(seasonal or perennial)(seasonal or perennial)
InfectiveInfective(acute or(acute orchronic)chronic)
StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)
OtherOther(idiopathic, NARES, (idiopathic, NARES,
hormonal, etc)hormonal, etc)
Differential DiagnosisDifferential Diagnosis
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InfectiveInfective
• AcuteAcute
• ChronicChronic– SpecificSpecific
• BacterialBacterial
• FungalFungal
– Non-specificNon-specific• Immune deficiencyImmune deficiency
– SystemicSystemic
– LocalLocal
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Acute Rhinosinusitis – EPOS 2007Acute Rhinosinusitis – EPOS 2007
• Obstruction/CongestionObstruction/Congestion
OROR• Discharge/PurulenceDischarge/Purulence
+/- Pain/Pressure+/- Pain/Pressure
+/-Hyposmia/Anosmia+/-Hyposmia/Anosmia
Symptoms < 12 weeksSymptoms < 12 weeks
Sudden onsetSudden onset
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Acute SinusitisAcute Sinusitis
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Chronic Rhinosinusitis – EPOS 2007Chronic Rhinosinusitis – EPOS 2007
• Obstruction/CongestionObstruction/Congestion• Discharge/PurulenceDischarge/Purulence
+/- Pain/Pressure+/- Pain/Pressure
+/-Hyposmia/Anosmia+/-Hyposmia/Anosmia
Endoscopic signs of:Endoscopic signs of:• PolypsPolyps
and/orand/or• Mucopurulent dischargeMucopurulent discharge
and/orand/or• Oedema/mucosal Oedema/mucosal
obstructionobstruction
and/orand/or
CT ChangesCT ChangesSymptoms > 12 weeksSymptoms > 12 weeks
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Chronic Rhinosinusitis - EndoscopyChronic Rhinosinusitis - Endoscopy
• Pus in MMPus in MM
• Oedema in MMOedema in MM
• PolypsPolyps
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Chronic Rhinosinusitis - CTChronic Rhinosinusitis - CT
• Confirms diagnosisConfirms diagnosis
• Map for surgeryMap for surgery
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PLAIN X-RAY
• 54% Sensitivity and 46% Specificity in 54% Sensitivity and 46% Specificity in sinusitis (Kuhn, 1986)sinusitis (Kuhn, 1986)
• 75% of Plain X-Rays do not correlate with 75% of Plain X-Rays do not correlate with CT (McAlister and Lusk, 1989)CT (McAlister and Lusk, 1989)
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Fungal InfectionsFungal Infections
AspergillosisAspergillosis BlastomycosisBlastomycosis
RhinosporoidosisRhinosporoidosis CryptococcosisCryptococcosis
PhycomycosisPhycomycosis ActinomycosisActinomycosis
CandidiasisCandidiasis HisptoplasmosisHisptoplasmosis
Sporotrichosis MucormycosisSporotrichosis Mucormycosis
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• Non-invasiveNon-invasive– Fungal ball (mycetoma)Fungal ball (mycetoma)
– Allergic fungal sinusitis (AFS)Allergic fungal sinusitis (AFS)
• InvasiveInvasive– Chronic invasive (indolent) fungal rhinosinusitisChronic invasive (indolent) fungal rhinosinusitis
– Acute invasive (fulminant) fungal rhinosinusitisAcute invasive (fulminant) fungal rhinosinusitis
Current Classification Current Classification (deShazo, 1997)(deShazo, 1997)
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• Non-invasiveNon-invasive– Fungal ball (mycetoma)Fungal ball (mycetoma)
– Allergic fungal sinusitis (AFS)Allergic fungal sinusitis (AFS)
• InvasiveInvasive– Chronic invasive (indolent) fungal rhinosinusitisChronic invasive (indolent) fungal rhinosinusitis
– Acute invasive (fulminant) fungal rhinosinusitisAcute invasive (fulminant) fungal rhinosinusitis
Current Classification Current Classification (deShazo, 1997)(deShazo, 1997)
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Fungus Ball (Mycetoma)Fungus Ball (Mycetoma)
• Opacification
• Double density (dense hyphae)
• Bony sclerosis
• No erosion
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Fungus Ball (Mycetoma)Fungus Ball (Mycetoma)
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Allergic Fungal SinusitisAllergic Fungal Sinusitis
• Type I HypersensitivityType I Hypersensitivity
• 80% of Patients Have 80% of Patients Have Diffuse PolypsDiffuse Polyps
• Elevated IgE to Fungus Elevated IgE to Fungus and Positive Skin Testand Positive Skin Test
• Thick Greenish Secretions Thick Greenish Secretions with Fungal Hyphaewith Fungal Hyphae
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Allergic Fungal SinusitisAllergic Fungal Sinusitis
• Sinus opacificationSinus opacification
• ExpansionExpansion
• Bony erosionBony erosion
• No tissue invasionNo tissue invasion
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InfectiveInfective
• AcuteAcute
• ChronicChronic– SpecificSpecific
• BacterialBacterial
• FungalFungal
– Non-specificNon-specific• Immune deficiencyImmune deficiency
– SystemicSystemic
– LocalLocal
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Immunodeficiency in Chronic Immunodeficiency in Chronic RhinosinusitisRhinosinusitis
TotalTotal
IgA + IgGIgA + IgG22
Selective IgGSelective IgG22
Selective IgASelective IgA
HypogammaglobHypogammaglob
25 (6.5%)25 (6.5%)
6 (1.6%)6 (1.6%)
3 (0.8%)3 (0.8%)
5 (1.3%)5 (1.3%)
11 (2.9%)11 (2.9%)
385385Immunoglobulins in M-P Immunoglobulins in M-P rhinorrhearhinorrhea
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Primary Ciliary DyskinesiaPrimary Ciliary Dyskinesia
• DextrocardiaDextrocardia
• RhinosinusitisRhinosinusitis
• BronchiectasisBronchiectasis
• InfertilityInfertility
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Saccharin TestSaccharin Test
< 35 minutes< 35 minutes
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Nasal Muco-Ciliary ClearanceNasal Muco-Ciliary Clearance
Greenstone M., Stanley P., MacWilliam L., Greenstone M., Stanley P., MacWilliam L., Dewar A., Cox T., Mackay I.S., Cole P.J. Dewar A., Cox T., Mackay I.S., Cole P.J.
Mucociliary function and ciliary ultrastructure Mucociliary function and ciliary ultrastructure in patients presenting with rhinitis to in patients presenting with rhinitis to
Brompton Hospital Nose Clinic. Eur.J. Respir. Brompton Hospital Nose Clinic. Eur.J. Respir. Dis. Suppl. 128, p 457-9. 1983.Dis. Suppl. 128, p 457-9. 1983.
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Electron MicroscopyElectron Microscopy
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Cystic FibrosisCystic Fibrosis
• Infective Rhinosinusitis Infective Rhinosinusitis (Pseudomonas)(Pseudomonas)
• 37% of Patients Have 37% of Patients Have PolypsPolyps
• Viscid SecretionsViscid Secretions
• Polyps in ChildrenPolyps in Children
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RhinosinusitisRhinosinusitis
AllergicAllergic(seasonal or perennial)(seasonal or perennial)
InfectiveInfective(acute or(acute orchronic)chronic)
StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)
OtherOther(idiopathic, NARES, (idiopathic, NARES,
hormonal, etc)hormonal, etc)
Differential DiagnosisDifferential Diagnosis
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StructuralStructural
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Structural (Mechanical)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
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Deviated Nasal SeptumDeviated Nasal Septum
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Nasal PolypsNasal Polyps
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SymptomsSymptoms
• Nasal obstructionNasal obstruction
• AnosmiaAnosmia
• Postnasal dripPostnasal drip
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DiagnosisDiagnosis
• Gray-pink glistening Gray-pink glistening structuresstructures
• InsensitiveInsensitive
Anterior rhinoscopy and endoscopyAnterior rhinoscopy and endoscopy
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View nasal endoscopy of of normal patientnormal patient
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Samter’s TriadSamter’s Triad
• 36% of Patients Have 36% of Patients Have Diffuse PolypsDiffuse Polyps
• Bone ExpansionBone Expansion
• High Recurrence RateHigh Recurrence Rate
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Inferior Turbinates HypertrophyInferior Turbinates Hypertrophy
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AdenoidsAdenoids
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Foreign BodyForeign Body
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Choanal AtresiaChoanal Atresia
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RhinosinusitisRhinosinusitis
AllergicAllergic(seasonal or perennial)(seasonal or perennial)
InfectiveInfective(acute or(acute orchronic)chronic)
StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)
OtherOther(idiopathic, NARES, (idiopathic, NARES,
hormonal, etc)hormonal, etc)
Differential DiagnosisDifferential Diagnosis
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OtherOther
• IdiopathicIdiopathic
• NARESNARES
• OccupationalOccupational
• HormonalHormonal
• DrugsDrugs
• FoodFood
• IrritantsIrritants
• EmotionalEmotional
• GranulomasGranulomas
• TumoursTumours
• CSF leakCSF leak
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Non-allergic “Idiopathic”Non-allergic “Idiopathic”“Vasomotor Rhinitis”“Vasomotor Rhinitis”
• Nasal Hyperactivity toNasal Hyperactivity to
– Cold airCold air– Temperature changesTemperature changes– Tobacco, pollutantsTobacco, pollutants– Perfumes, bleachPerfumes, bleach
Nasal Hyper-reactivity is also present inNasal Hyper-reactivity is also present in
40 - 50% of patients with allergic rhinitis40 - 50% of patients with allergic rhinitis
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Neuronal markers in allergic rhinitis: expression and correlation with Neuronal markers in allergic rhinitis: expression and correlation with sensory testing.sensory testing.
S O’Hanlon, P Facer, K Simpson, G Sandhu, S O’Hanlon, P Facer, K Simpson, G Sandhu, HA SalehHA Saleh, P Anand., P Anand.
LaryngoscopeLaryngoscope 2007 Sep;117(9):1519-27. 2007 Sep;117(9):1519-27.
Increased Nerve Fiber Expression of Sensory Sodium Channels Nav1.7, Increased Nerve Fiber Expression of Sensory Sodium Channels Nav1.7, Nav1.8, and Nav1.9 in Rhinitis.Nav1.8, and Nav1.9 in Rhinitis.
SM Keh , P Facer, K Simpson, G Sandhu, SM Keh , P Facer, K Simpson, G Sandhu, HA SalehHA Saleh, P Anand., P Anand.
LaryngoscopeLaryngoscope. 2008; . 2008; 118(4):573-9.
The role of neuronal mechanisms in allergic rhinitis.The role of neuronal mechanisms in allergic rhinitis.
S O’Hanlon, SM Keh, S O’Hanlon, SM Keh, HA SalehHA Saleh
Otorinolaringologia. Otorinolaringologia. 2008;2008;58: 17-30.
““Neurogenic RhinitisNeurogenic Rhinitis” ?” ?
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NARES (Non-Allergic Rhinitis with NARES (Non-Allergic Rhinitis with Eosinophilia Syndrome)Eosinophilia Syndrome)
• Non-atopicNon-atopic
• Females > malesFemales > males
• EosinophiliaEosinophilia
• Steroid responsiveSteroid responsive
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Occupational RhinitisOccupational Rhinitis
Symptoms improve in weekends and holidaysSymptoms improve in weekends and holidays
• AllergicAllergic
• Non-allergicNon-allergic
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Occupational RhinitisOccupational Rhinitis
• storage mites storage mites • grain grain • latex latex • glues and guar gumglues and guar gum• rats, mice, guinea pigsrats, mice, guinea pigs• basilis subtilisbasilis subtilis enzymes 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
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HormonalHormonal
• PregnancyPregnancy
• PubertyPuberty
• PremenstrualPremenstrual
• HypothyroidismHypothyroidism
• AcromegalyAcromegaly
• Old man’s dripOld man’s drip
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Drug InducedDrug Induced
• LocalLocal– Rhinitis Rhinitis
medicamentosamedicamentosa
• SystemicSystemic– AntihypertensivesAntihypertensives– AspirinAspirin– Contraceptive pillContraceptive pill
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PreservativesPreservatives
• Benzoates, salicylatesBenzoates, salicylates• TetrazineTetrazine• ColouringsColourings
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IrritantsIrritants
• PollutionPollution
• GustatoryGustatory
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EmotionalEmotional
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SarcoidosisSarcoidosis
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Wegener’s GranulomatosisWegener’s Granulomatosis
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Atrophic RhinitisAtrophic Rhinitis
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NeoplasmsNeoplasms
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CSF LeakCSF Leak
View video View video here
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RhinosinusitisRhinosinusitis
AllergicAllergic(seasonal or perennial)(seasonal or perennial)
InfectiveInfective(acute or(acute orchronic)chronic)
StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)
OtherOther(idiopathic, NARES, (idiopathic, NARES,
hormonal, etc)hormonal, etc)
Differential DiagnosisDifferential Diagnosis
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Thank YouThank You