ENT Gerard Kelly MD MEd FRCS ORLHNS FRCS

ENT Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed) ENT surgeon, Moor Allerton Golf Club 15 th May 2014 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 o making the correct diagnosis o practical treatment polyps o why should we worry about unilateral polyps nose bleed anything else you thinks important and practical

aims improve our understanding of nose conditions discuss some example cases formulate management plans for nasal disease

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 list the presentation of a nasal malignancy recognise nasal sepal deviation list aetiologies in septal perforation recognise and manage nasal polyps

first though. . . history and examination in ENT

history ears noses throats otorrhoea otalgia itch hearing tinnitus balance nasal obstruction rhinorrhoea facial pain smell epistaxis post nasal drip dysphagia dysphonia odynophagia pain neck lumps weight loss

history ears noses throats otorrhoea otalgia itch hearing tinnitus balance nasal obstruction rhinorrhoea facial pain smell epistaxis post nasal drip dysphagia dysphonia odynophagia pain neck lumps weight loss

examination of the nose

examination

examination with auriscope

rhinosinusitis

sinusitis

rhinosinus itis rhin

theories of rhinosinusitis

classification of rhinosinusitis

Non-allergic Rhinitis Allergic Rhinitis UK/FF/0108/11 April 2011

Allergic Rhinitis UK/FF/0108/11 April 2011

Allergic Rhinitis Epidemiology Allergic rhinitis is the most common form of noninfectious 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 References 1. 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 2. Wallace DC et. J Allergy Clin Immunol 2008; 122: S 1 -84

Prevalence of clinically confirmed allergic rhinitis in Europe Reference: April 2011 Bauchau V et al. Eur Respir. UK/FF/0108/11 J 2004; 24: 758 -764

Clinical Diagnosis Rhinitis definition 1 n Nasal discharge n Blockage n Sneeze / itch } 2 or more symptoms for > 1 hour on most days n History n Examination n Investigations Allergic Non-Allergic Rhinitis (Infection/structural abnormality/ vasomotor/primary disease) Reference: 1. Bousquet J et al. Allergy 2008; 63 Suppl 86: 8 -160 UK/FF/0108/11 April 2011

Clinical symptoms of allergic rhinitis primary clinical manifestations congestion rhinorrhoea itching sneezing secondary clinical effects lethargy malaise UK/FF/0108/11 April 2011

Social and economic impact of allergic rhinitis IMPAIRED WELL BEING DAILY ACTIVITIES IMPAIRED DISRUPTED SLEEP LEARNING & COGNITIVE FUNCTIONS DISTURBED LETHARGY REDUCED WORK & SCHOOL PRODUCTIVITY Canonica GW et al. Allergy 2007: 62 (Suppl. 85): 17 -25 UK/FF/0108/11 April 2011

Investigations Skin prick testing (SPT) Panel of common aeroallergens + allergen identified as relevant in history Serum allergic specific-Ig. E In cases where SPT is negative or SPT cannot be performed Rhinoscopy Indication Atypical features (i. e. one sided obstruction) present or multiple pathology suspected Classic findings Pale oedematous mucosa Congestion Mucus secretion UK/FF/0108/11 April 2011

Investigations Skin prick testing (SPT) Panel of common aeroallergens + allergen identified as relevant in history Serum allergic specific-Ig. E In cases where SPT is negative or SPT cannot be performed Rhinoscopy Indication Atypical features (i. e. one sided obstruction) present or multiple pathology suspected Classic findings Pale oedematous mucosa Congestion Mucus secretion UK/FF/0108/11 April 2011

Investigations Skin prick testing (SPT) Panel of common aeroallergens + allergen identified as relevant in history Serum allergic specific-Ig. E In cases where SPT is negative or SPT cannot be performed Rhinoscopy Indication Atypical features (i. e. one sided obstruction) present or multiple pathology suspected Classic findings Pale oedematous mucosa Congestion Mucus secretion UK/FF/0108/11 April 2011

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) British society for allergy and clinical immunology Perennial (UK) House dust mite (Dermatophagoides pteronyssinus) + Animal Dander Occupational Flour, grain, latex, wood dust, detergents UK/FF/0108/11 April 2011

Rhinitis Management 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

Diagnosis of allergic rhinitis Asthma? consider Intermittent symptoms Mild Moderate oral antihistamine or intranasal antihistamine +/- decongestant or leukotriene antagonist oral antihistamine or intranasal antihistamine +/- decongestant or topical nasal steroid or leukotriene antagonist or cromogycate

Diagnosis of allergic rhinitis Persistent symptoms Mild oral antihistamine or intranasal antihistamine +/- decongestant or topical nasal steroid or leukotriene antagonist or cromogycate Asthma? consider

Diagnosis of allergic rhinitis Asthma? consider Persistent symptoms Moderate severe topical nasal steroid oral antihistamine or leukotriene antagonist Review after 2 -4 weeks If better, step down and continue for > 1 month

Diagnosis of allergic rhinitis Asthma? consider Persistent symptoms Moderate severe topical nasal steroid oral antihistamine or leukotriene antagonist Review after 2 -4 weeks If not better, review diagnosis review compliance query infective / other cause increase nasal steroid ipratropium (rhinorrhoea) decongestant or oral steroid (blockage)

Diagnosis of allergic rhinitis Asthma? consider Persistent symptoms Moderate severe topical nasal steroid oral antihistamine or leukotriene antagonist Review after 2 -4 weeks If not better, review diagnosis review compliance query infective / other cause increase nasal steroid ipratropium (rhinorrhoea) decongestant or oral steroid (blockage) If not better, refer

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 References 1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008; 63 Suppl 86: 8 -160 2. Wallace DC et. J Allergy Clin Immunol 2008; 122: S 1 -84 UK/FF/0108/11 April 2011

Incidence Common co-morbidities: Rhinoconjunctivitis Ocular symptoms are common Rhinoconjunctivitis symptoms have been reported in more than 75% of patients with seasonal allergic rhinitis Clinical significance Severely impairs QOL Often a forgotten aspect of care Reference 1. Wallace DC et al. J Allergy Clin Immunol 2008; 122: S 1 -84 UK/FF/0108/11 April 2011

rhinosinusitis

Allergen Avoidance Background Success of intervention measured by clinical improvement Strategy success influenced by individual host sensitivity to allergen Sensitivity differs betweens allergens Effectiveness Studies do not show consistent reduction in symptoms or medication requirements Reference: 1. Scadding GK et al. Clin Exp Allergy 2008; 38: 19 -42 UK/FF/0108/11 April 2011

rye grass

house dust mite

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

allergen avoidance

allergen avoidance

allergen avoidance Fel d 1

treatments UK/FF/0108/11 April 2011

Intranasal Steroids risks? UK/FF/0108/11 April 2011

Bioavailability of nasal steroids 50 44 45 40 % Bioavailabilty 35 30 25 20 15 11 10 5 0 0. 1 Mometasone 0. 5 Fluticasone Betametasone Budesonide References 1. Nasonex Summary of Product Characteristics. Date accessed April 2011 2. Kariyawasam H, Scadding G. Journal of Asthma and Allergy 2010: 3 19– 28 3. Rhinocort Summary of Product Characteristics. Date accessed April 2011 4. Beconase Summary of Product Characteristics. Date accessed April UK/FF/0108/11 April 2011

epistaxis and cautery

Case

Epistaxis Naspetin ointment Vs Cautery and Naseptin ointment

theories of rhinosinusitis

theories of rhinosinusitis

investigation - sinus x ray Exposure to radiation poor sensitivity poor specificity

investigation - CT scan

nasal polyps

nasal polyps - treatment medical steroids surgical polypectomy

unilateral nasal discharge

unilateral nasal discharge child foreign body or neoplasm

unilateral nasal polyp

unilateral nasal polyp neoplasm benign or malignant

unilateral nasal polyp is it really unilateral?

unilateral nasal polyp neoplasm benign or malignant woodworking, metal, textile and leather industries

unilateral nasal polyp neoplasm benign or malignant watch for pain, eye involvement, tears, movement, facial sensation

unilateral nasal polyp neoplasm benign or malignant Nasal obstruction (36%), epistaxis (30%) & nasal discharge (21%) were the most common presentation

unilateral nasal polyp neoplasm benign inverted papilloma or malignant

nasal pain crusting

Case

Septal perforation - investigations FBC ESR U&E syphilis ANCA normal 16 mm/h normal negative CRP glucose ACE <5. 0 mg/l 5. 0 mmol/l negative

Nasal septal perforation surgery trauma cocaine use infection post trauma, syphilis Wegener’s granulomatosis sarcoidosis idiopathic

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 list the presentation of a nasal malignancy recognise nasal sepal deviation list aetiologies in septal perforation recognise and manage nasal polyps

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 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 T 1 or T 2 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 T 4 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