Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed) ENT surgeon, Leeds 6 th March 2014, Leeds Masonic Hall ENT The Leeds Teaching Hospitals NHS Trust and general practice my nose is blocked – an update on rhinosinusitis & snoring

aims give an overview of common (E)N(T) conditions shows some example cases refine our thinking of ENT problems

objectives list the main symptoms in nose conditions relate each symptom to one condition list the ways to examine the nose identify an nasal polyp classify rhinosinusitis list 6 treatments for chronic rhinosinusitis (CRS) define association with CRS & respiratory disease list 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 References 1.Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86: Wallace DC et. J Allergy Clin Immunol 2008; 122: S1-84

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) 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 symptoms Mild oral antihistamine or intranasal antihistamine +/- decongestant or leukotriene antagonist Asthma? Moderate oral antihistamine or intranasal antihistamine +/- decongestant or topical nasal steroid or leukotriene antagonist or cromogycate consider

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

Diagnosis of allergic rhinitis Persistent symptoms Asthma? Moderate severe topical nasal steroid oral antihistamine or leukotriene 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 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) consider

Diagnosis of allergic rhinitis Persistent symptoms Asthma? 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 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 References 1.Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86: Wallace DC et. J Allergy Clin Immunol 2008; 122: S1-84

Common co-morbidities: Rhinoconjunctivitis Incidence 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 UK/FF/0108/11 April 2011 Reference 1. Wallace DC et al. J Allergy Clin Immunol 2008; 122: S1-84

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 UK/FF/0108/11 April 2011 Reference: 1.Scadding GK et al. Clin Exp Allergy 2008; 38:19-42

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

Nasal Decongestants (oral/topical) Background Relieve nasal congestion Cause nasal vasoconstriction and decreased oedema Topical - risk of rhinitis medicamentosa Side effects Oral - Hypertension Caution with caffeine &other stimulants Topical - Local stinging/burning Nasal dryness Sneezing UK/FF/0108/11 April 2011 References 1. 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 2 nd generation formulations which cause less sedation UK/FF/0108/11 April 2011 References 1. Scadding GK et al. Clin Exp Allergy 2008; 38: Dykewicz MS. J Allergy Clin Immunol 2003; 111: S 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: Rosenwasser LJ. Am J Med 2002; 113 (9A) 17S-24S 3. Scadding GK et al. Clin Exp Allergy 2008; 38: 19-42

Intra-nasal steroids Local Side-effects Nasal irritation (propylene glycol/ benzalkonium chloride) Nasal bleeding/crusting Septal perforation (rare – advise to use device away from septum) Warn patients Avoidance with correct delivery technique May be related to device induced trauma No evidence of nasal tissue atrophy UK/FF/0108/11 April 2011

Intra-nasal steroids - systemic side effects Minimal absorption from nasal mucosa Up to 80% of intranasal dose swallowed Extensive hepatic first-pass metabolism by cytochrome P450 system Minimal systemic levels No significant HPA suppression or effects on growth Second generation INS References 1. 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 BMI evening alcohol male

snoring treatments weight reduction position stopping evening alcohol CPAP MAD surgery

snoring treatments surgery tonsillectomy, nasal polypectomy LAUP U3P sclerosant injection coblation, radiofrequency somnoplasty pillar implants

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