Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed)ENT surgeon, Leeds

6th March 2014, Leeds Masonic Hall

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and general practice

my nose is blocked – an update on rhinosinusitis & snoring

aimsgive an overview of common (E)N(T)

conditionsshows some example casesrefine our thinking of ENT problems

objectiveslist the main symptoms in nose conditionsrelate each symptom to one conditionlist the ways to examine the noseidentify an nasal polypclassify rhinosinusitislist 6 treatments for chronic rhinosinusitis

(CRS)define association with CRS & respiratory

diseaselist treatments for nasal polyps formulate a management plan for snoring

first though...history and examination in ENT

Allergic Rhinitis Epidemiology

Allergic rhinitis is the most common form of non-infectious rhinitis

At least 500 million individuals world-wide have allergic rhinitis and it is one of the most common reasons for attendance with a primary care practitioner

Almost 30% of adults and 40% of children are affected

World-wide the prevalence of allergic rhinitis continues to increase UK/FF/0108/11 April 2011

References1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-1602. Wallace DC et. J Allergy Clin Immunol 2008; 122: S1-84

Allergic Rhinitis Classification

BSACI GuidelinesSeasonal (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 Dander

Occupational Flour, grain, latex, wood dust, detergents

UK/FF/0108/11 April 2011

British society for allergy and clinical

immunology

Diagnosis of allergic rhinitis

Intermittent symptomsMild

oral antihistamineorintranasal antihistamine+/- decongestantor leukotriene antagonist

Asthma?

Moderate

oral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Mild

oral antihistamineorintranasal antihistamine+/- decongestantor topical nasal steroidorleukotriene antagonistorcromogycate

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severe

topical nasal steroid

oral antihistamineorleukotriene antagonist

Review after 2 -4 weeks

If better, step down and continue for > 1 month

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severe

topical nasal steroid

oral antihistamineorleukotriene antagonist

Review after 2 -4 weeks

If not better, review diagnosisreview compliancequery infective / other cause

increase nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)

consider

Diagnosis of allergic rhinitis

Persistent symptoms

Asthma?

Moderate severe

topical nasal steroid

oral antihistamineorleukotriene antagonist

Review after 2 -4 weeks

If not better, review diagnosisreview compliancequery infective / other cause

increase nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)

If not better, refer

consider

Common co-morbidities: Asthma Approximately 80% of asthmatics have rhinitis

Allergic rhinitis may precede asthma

Rhinitis impairs asthma control

Treatment of allergic rhinitis may improve asthma control

Allergic Rhinitis and its Impact in Asthma (ARIA) promotes assessing everyone with allergic rhinitis for asthma

UK/FF/0108/11 April 2011

References1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-1602. Wallace DC et. J Allergy Clin Immunol 2008; 122: S1-84

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

Reference1. Wallace DC et al. J Allergy Clin Immunol 2008; 122: S1-84

Allergen AvoidanceBackgroundSuccess 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

allergen avoidancemattress, pillow, duvet coverssynthetic duvets, pillowsavoid woollen blanketsvacuum frequentlyavoid carpets, curtainskeep clothing in cupboardskeep animals out of bedroomslow relative humidityboil wash sheet, duvet covers

Nasal Decongestants (oral/topical)

BackgroundRelieve nasal congestionCause nasal vasoconstriction and decreased

oedemaTopical - risk of rhinitis medicamentosa Side effectsOral - Hypertension

Caution with caffeine &other stimulants

Topical - Local stinging/burningNasal drynessSneezing

UK/FF/0108/11 April 2011

References1. Wallace DC et. J Allergy Clin Immunol 2008; 122: S1-84

Oral Antihistamines

Seasonal and perennial allergic rhinitis

BSACI guidelines state that regular therapy is more effective than ‘as needed use’ in persistent rhinitis

Reduce sneezing, rhinorrhoea and nasal and ocular pruritis but have less effect on nasal congestion

ARIA recommend 2nd generation formulations which cause less sedation

UK/FF/0108/11 April 2011

References1. Scadding GK et al. Clin Exp Allergy 2008; 38: 19-422. Dykewicz MS. J Allergy Clin Immunol 2003; 111: S520-93. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160

Intranasal Steroids

ARIA guidelines state that intranasal steroids are the most effective drugs for the treatment of allergic rhinitis

Effective in relieving nasal congestion, rhinorrhoea, sneezing and nasal itching

Grade A level of recommendation for seasonal and perennial allergic rhinitis

Recommended to be administered regularly for optimal benefit

UK/FF/0108/11 April 2011

References:1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-1602. Rosenwasser LJ. Am J Med 2002; 113 (9A) 17S-24S3. Scadding GK et al. Clin Exp Allergy 2008; 38: 19-42 

Intra-nasal steroids

Local Side-effectsNasal irritation (propylene glycol/ benzalkonium

chloride)Nasal bleeding/crustingSeptal perforation (rare – advise to use device away

from septum)

Warn patientsAvoidance with correct delivery techniqueMay be related to device induced traumaNo evidence of nasal tissue atrophy

UK/FF/0108/11 April 2011

Intra-nasal steroids - systemic side effects

Minimal absorption from nasal mucosaUp to 80% of intranasal dose swallowed

Extensive hepatic first-pass metabolism by cytochrome P450 system

Minimal systemic levelsNo significant HPA suppression or effects on growth

Second generation INS

References1. LaForce. J Allergy Clin Immunol 1999; 103: S388-96

Summary

Allergic rhinitis is a common disease with a significant clinical and socioeconomic impact

Accurate diagnosis and focussed therapeutic intervention is essential

Important to diagnose and treat any associated co-morbidities

Address factors that improve patient tolerability and compliance with therapy

UK/FF/0108/11 April 2011

snoring

common

snoring

directly related to collar size

snoring

BMIevening alcoholmale

snoring treatments

weight reductionpositionstopping evening alcoholCPAPMADsurgery

snoring treatments

surgery

tonsillectomy, nasal polypectomyLAUPU3Psclerosant injectioncoblation, radiofrequency somnoplastypillar implants

Nasal septal perforationsurgerytraumacocaine useinfection

post trauma, syphilisWegener’s granulomatosissarcoidosisidiopathic