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Differential Diagnosis of Rhinosinusitis

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Title: Differential Diagnosis of Rhinosinusitis


1
Differential Diagnosis of Rhinosinusitis
  • Hesham Saleh, FRCS
  • Consultant Rhinologist
  • Charing Cross and Royal Brompton Hospitals

2
The Nose Clinic RBH
Hesham Saleh
Stephen Durham
3
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4
Rhinitis Inflammation of the Nasal Mucosa
Rhinitis definition
  • Nasal discharge
  • Blockage
  • Sneeze/itch

2 or more symptoms for gt 1 hour on most days
5
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6
Rhinosinusitis Inflammation of the Nasal and
Sinus Mucosa
Rhinitis definition
  • Nasal discharge
  • Blockage
  • Sneeze/itch

2 or more symptoms for gt 1 hour on most days
7
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8
Chronic Rhinosinusitis EPOS 2007
  • Endoscopic signs of
  • Polyps
  • and/or
  • Mucopurulent discharge
  • and/or
  • Oedema/mucosal obstruction
  • and/or
  • CT Changes
  • Obstruction/Congestion
  • Discharge/Purulence
  • /- Pain/Pressure
  • /-Hyposmia/Anosmia

Symptoms gt 12 weeks
9
Rhinosinusitis
Differential Diagnosis
10
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12
ARIA Classification
Persistent . gt 4 days per week . and gt 4 weeks
Intermittent . Š 4 days per week . or Š 4 weeks
  • Moderate-severe
  • one or more items
  • . abnormal sleep
  • . impairment of daily activities, sport, leisure
  • . abnormal work and school
  • . troublesome symptoms

Mild normal sleep no impairment of daily
activities, sport, leisure normal work and
school no troublesome symptoms
in untreated patients
13
Diagnosis of Allergic Rhinitis
HISTORY
NASAL EXAMINATION
SKIN PRICK TEST or RAST
14
Diagnosis of Allergic Rhinitis
  • History is often very suggestive

15
Allergic Salute
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18
Nasendoscopy
19
Anterior Rhinoscopy
20
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21
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24
Allergy skin prick testing
25
Allergic Rhinitis and Infective Rhinosinusitis
may coexist
  • no published prospective reports on the
    incidence of infective rhinosinusitis in
    populations with and without clearly defined
    allergic rhinosinusitis
  • EPOS 2007

26
Rhinosinusitis
Differential Diagnosis
27
Infective
  • Acute
  • Chronic
  • Specific
  • Bacterial
  • Fungal
  • Non-specific
  • Immune deficiency
  • Systemic
  • Local

28
Acute Rhinosinusitis EPOS 2007
  • Obstruction/Congestion
  • OR
  • Discharge/Purulence
  • /- Pain/Pressure
  • /-Hyposmia/Anosmia

Sudden onset
Symptoms lt 12 weeks
29
Acute Sinusitis
30
Chronic Rhinosinusitis EPOS 2007
  • Endoscopic signs of
  • Polyps
  • and/or
  • Mucopurulent discharge
  • and/or
  • Oedema/mucosal obstruction
  • and/or
  • CT Changes
  • Obstruction/Congestion
  • Discharge/Purulence
  • /- Pain/Pressure
  • /-Hyposmia/Anosmia

Symptoms gt 12 weeks
31
Chronic Rhinosinusitis - Endoscopy
  • Pus in MM
  • Oedema in MM
  • Polyps

32
Chronic Rhinosinusitis - CT
  • Confirms diagnosis
  • Map for surgery

33
PLAIN X-RAY
  • 54 Sensitivity and 46 Specificity in sinusitis
    (Kuhn, 1986)
  • 75 of Plain X-Rays do not correlate with CT
    (McAlister and Lusk, 1989)

34
Fungal Infections
  • Aspergillosis Blastomycosis
  • Rhinosporoidosis Cryptococcosis
  • Phycomycosis Actinomycosis
  • Candidiasis Hisptoplasmosis
  • Sporotrichosis Mucormycosis

35
Current Classification (deShazo, 1997)
  • Non-invasive
  • Fungal ball (mycetoma)
  • Allergic fungal sinusitis (AFS)
  • Invasive
  • Chronic invasive (indolent) fungal rhinosinusitis
  • Acute invasive (fulminant) fungal rhinosinusitis

36
Current Classification (deShazo, 1997)
  • Non-invasive
  • Fungal ball (mycetoma)
  • Allergic fungal sinusitis (AFS)
  • Invasive
  • Chronic invasive (indolent) fungal rhinosinusitis
  • Acute invasive (fulminant) fungal rhinosinusitis

37
Fungus Ball (Mycetoma)
  • Opacification
  • Double density (dense hyphae)
  • Bony sclerosis
  • No erosion

38
Fungus Ball (Mycetoma)
39
Allergic Fungal Sinusitis
  • Type I Hypersensitivity
  • 80 of Patients Have Diffuse Polyps
  • Elevated IgE to Fungus and Positive Skin Test
  • Thick Greenish Secretions with Fungal Hyphae

40
Allergic Fungal Sinusitis
  • Sinus opacification
  • Expansion
  • Bony erosion
  • No tissue invasion

41
Infective
  • Acute
  • Chronic
  • Specific
  • Bacterial
  • Fungal
  • Non-specific
  • Immune deficiency
  • Systemic
  • Local

42
Immunodeficiency in Chronic Rhinosinusitis
Immunoglobulins in M-P rhinorrhea
385
Hypogammaglob
11 (2.9)
Selective IgA
5 (1.3)
Selective IgG2
3 (0.8)
IgA IgG2
6 (1.6)
Total
25 (6.5)
43
Primary Ciliary Dyskinesia
  • Dextrocardia
  • Rhinosinusitis
  • Bronchiectasis
  • Infertility

44
Saccharin Test
lt 35 minutes
45
Nasal Muco-Ciliary Clearance
Greenstone M., Stanley P., MacWilliam L., Dewar
A., Cox T., Mackay I.S., Cole P.J. Mucociliary
function and ciliary ultrastructure in patients
presenting with rhinitis to Brompton Hospital
Nose Clinic. Eur.J. Respir. Dis. Suppl. 128, p
457-9. 1983.
46
Electron Microscopy
47
Cystic Fibrosis
  • Infective Rhinosinusitis (Pseudomonas)
  • 37 of Patients Have Polyps
  • Viscid Secretions
  • Polyps in Children

48
Rhinosinusitis
Differential Diagnosis
49
Structural
50
Structural (Mechanical)
  • Deviation of nasal septum
  • Nasal polyps
  • Hypertrophy of inferior turbinates
  • Enlarged adenoids
  • Foreign bodies
  • Choanal atresia

51
Deviated Nasal Septum
52
Nasal Polyps
53
Symptoms
  • Nasal obstruction
  • Anosmia
  • Postnasal drip

54
Diagnosis
Anterior rhinoscopy and endoscopy
  • Gray-pink glistening structures
  • Insensitive

55
View nasal endoscopy of normal patient
56
Samters Triad
  • 36 of Patients Have Diffuse Polyps
  • Bone Expansion
  • High Recurrence Rate

57
Inferior Turbinates Hypertrophy
58
Adenoids
59
Foreign Body
60
Choanal Atresia
61
Rhinosinusitis
Differential Diagnosis
62
Other
  • Idiopathic
  • NARES
  • Occupational
  • Hormonal
  • Drugs
  • Food
  • Irritants
  • Emotional
  • Granulomas
  • Tumours
  • CSF leak

63
Non-allergic IdiopathicVasomotor Rhinitis
  • Nasal Hyperactivity to
  • Cold air
  • Temperature changes
  • Tobacco, pollutants
  • Perfumes, bleach

Nasal Hyper-reactivity is also present in 40 -
50 of patients with allergic rhinitis
64
Neurogenic Rhinitis ?
  • Neuronal markers in allergic rhinitis expression
    and correlation with sensory testing.
  • S OHanlon, P Facer, K Simpson, G Sandhu, HA
    Saleh, P Anand.
  • Laryngoscope 2007 Sep117(9)1519-27.
  • Increased Nerve Fiber Expression of Sensory
    Sodium Channels Nav1.7, Nav1.8, and Nav1.9 in
    Rhinitis.
  • SM Keh , P Facer, K Simpson, G Sandhu, HA Saleh,
    P Anand.
  • Laryngoscope. 2008 118(4)573-9.
  • The role of neuronal mechanisms in allergic
    rhinitis.
  • S OHanlon, SM Keh, HA Saleh
  • Otorinolaringologia. 200858 17-30.

65
NARES (Non-Allergic Rhinitis with Eosinophilia
Syndrome)
  • Non-atopic
  • Females gt males
  • Eosinophilia
  • Steroid responsive

66
Occupational Rhinitis
  • Symptoms improve in weekends and holidays
  • Allergic
  • Non-allergic

67
Occupational Rhinitis
  • storage mites
  • grain
  • latex
  • glues and guar gum
  • rats, mice, guinea pigs
  • basilis subtilis enzymes
  • wood dust e.g. mahogany, western red cedar
  • isotonic acid hydrazine/trimellitic anhydride

68
Hormonal
  • Pregnancy
  • Puberty
  • Premenstrual
  • Hypothyroidism
  • Acromegaly
  • Old mans drip

69
Drug Induced
  • Local
  • Rhinitis medicamentosa
  • Systemic
  • Antihypertensives
  • Aspirin
  • Contraceptive pill

70
Preservatives
  • Benzoates, salicylates
  • Tetrazine
  • Colourings

71
Irritants
  • Pollution
  • Gustatory

72
Emotional
73
Sarcoidosis
74
Wegeners Granulomatosis
75
Atrophic Rhinitis
76
Neoplasms
77
CSF Leak
View video here
78
Rhinosinusitis
Differential Diagnosis
79
Thank You
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