Differential Diagnosis of Rhinosinusitis

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Differential Diagnosis of Rhinosinusitis

• Hesham Saleh, FRCS
• Consultant Rhinologist
• Charing Cross and Royal Brompton Hospitals

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The Nose Clinic RBH
Hesham Saleh
Stephen Durham
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Rhinitis Inflammation of the Nasal Mucosa
Rhinitis definition

• Nasal discharge
• Blockage
• Sneeze/itch

2 or more symptoms for gt 1 hour on most days
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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
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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
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Rhinosinusitis
Differential Diagnosis
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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
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Diagnosis of Allergic Rhinitis
HISTORY
NASAL EXAMINATION
SKIN PRICK TEST or RAST
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Diagnosis of Allergic Rhinitis

• History is often very suggestive

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Allergic Salute
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Nasendoscopy
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Anterior Rhinoscopy
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Allergy skin prick testing
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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

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Rhinosinusitis
Differential Diagnosis
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Infective

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

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Acute Rhinosinusitis EPOS 2007

• Obstruction/Congestion
• OR
• Discharge/Purulence
• /- Pain/Pressure
• /-Hyposmia/Anosmia

Sudden onset
Symptoms lt 12 weeks
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Acute Sinusitis
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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
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Chronic Rhinosinusitis - Endoscopy

• Pus in MM
• Oedema in MM
• Polyps

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Chronic Rhinosinusitis - CT

• Confirms diagnosis
• Map for surgery

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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)

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Fungal Infections

• Aspergillosis Blastomycosis
• Rhinosporoidosis Cryptococcosis
• Phycomycosis Actinomycosis
• Candidiasis Hisptoplasmosis
• Sporotrichosis Mucormycosis

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Current Classification (deShazo, 1997)

• Non-invasive
• Fungal ball (mycetoma)
• Allergic fungal sinusitis (AFS)
• Invasive
• Chronic invasive (indolent) fungal rhinosinusitis
• Acute invasive (fulminant) fungal rhinosinusitis

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Current Classification (deShazo, 1997)

• Non-invasive
• Fungal ball (mycetoma)
• Allergic fungal sinusitis (AFS)
• Invasive
• Chronic invasive (indolent) fungal rhinosinusitis
• Acute invasive (fulminant) fungal rhinosinusitis

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Fungus Ball (Mycetoma)

• Opacification
• Double density (dense hyphae)
• Bony sclerosis
• No erosion

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Fungus Ball (Mycetoma)
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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

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Allergic Fungal Sinusitis

• Sinus opacification
• Expansion
• Bony erosion
• No tissue invasion

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Infective

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

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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)
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Primary Ciliary Dyskinesia

• Dextrocardia
• Rhinosinusitis
• Bronchiectasis
• Infertility

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Saccharin Test
lt 35 minutes
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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.
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Electron Microscopy
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Cystic Fibrosis

• Infective Rhinosinusitis (Pseudomonas)
• 37 of Patients Have Polyps
• Viscid Secretions
• Polyps in Children

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Rhinosinusitis
Differential Diagnosis
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Structural
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Structural (Mechanical)

• Deviation of nasal septum
• Nasal polyps
• Hypertrophy of inferior turbinates
• Enlarged adenoids
• Foreign bodies
• Choanal atresia

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Deviated Nasal Septum
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Nasal Polyps
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Symptoms

• Nasal obstruction
• Anosmia
• Postnasal drip

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Diagnosis
Anterior rhinoscopy and endoscopy

• Gray-pink glistening structures
• Insensitive

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View nasal endoscopy of normal patient
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Samters Triad

• 36 of Patients Have Diffuse Polyps
• Bone Expansion
• High Recurrence Rate

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Inferior Turbinates Hypertrophy
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Adenoids
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Foreign Body
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Choanal Atresia
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Rhinosinusitis
Differential Diagnosis
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Other

• Idiopathic
• NARES
• Occupational
• Hormonal
• Drugs
• Food
• Irritants
• Emotional

• Granulomas
• Tumours
• CSF leak

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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
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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.

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NARES (Non-Allergic Rhinitis with Eosinophilia
Syndrome)

• Non-atopic
• Females gt males
• Eosinophilia
• Steroid responsive

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Occupational Rhinitis

• Symptoms improve in weekends and holidays
• Allergic
• Non-allergic

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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

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Hormonal

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

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Drug Induced

• Local
• Rhinitis medicamentosa
• Systemic
• Antihypertensives
• Aspirin
• Contraceptive pill

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Preservatives

• Benzoates, salicylates
• Tetrazine
• Colourings

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Irritants

• Pollution
• Gustatory

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Emotional
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Sarcoidosis
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Wegeners Granulomatosis
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Atrophic Rhinitis
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Neoplasms
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CSF Leak
View video here
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Rhinosinusitis
Differential Diagnosis
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Thank You