Rhinitis, Sinusitis and beyond: what the primary care provider should know Marika Russell, MD, FACS Assistant Professor of Clinical Otolaryngology San Francisco General Hospital

Outline Normal anatomy Examination techniques Nasal obstruction Rhinitis vs. Sinusitis Diagnosis Management strategies When to refer Q&A

What’s in a nose?

Nasal Anatomy

Nasal Anatomy

Sinonasal Anatomy

Anterior nasal examination

Anterior nasal examination

Endoscopic examination

Endoscopic examination

Nasal obstruction Medical (dynamic) vs. structural (anatomic/fixed) History Timing (onset, day vs. night, seasonal vs. year-round) Triggers (environment, pets) Laterality Associated symptoms (sneezing, nasal discharge, nasal itching, itchy eyes, epiphora) Comorbid conditions (ie. Asthma)

Nasal obstruction Exam Response to medical treatment Inferior turbinate hypertrophy/bogginess Nasal discharge Polyps Response to medical treatment Topical treatment Oral medications

Nasal obstruction Medical Structural Insidious onset, absence of trauma Some day-to-day variability (Bilateral) Environmental triggers Some responsiveness to medications Structural Life-long or history of trauma Minimal day-to-day variability (Unilateral) Not environmental Unresponsive to medications

Nasal obstruction ENT Examination Underlying structural problems Dynamic lateral nasal wall collapse Septal deflection Septal spurs Internal valve narrowing Saddle deformity

Allergic Rhinitis Background AR is IgE mediated inflammatory response of nasal mucosa Characterized by nasal congestion, rhinorrhea, sneezing and/or nasal itching Classified by temporal pattern Seasonal (ie. pollen) Perennial/year round (ie. dust mites, mold) Episodic (ie. pet exposure) Classified by frequency Intermittent (<4 days/wk or <4wks/yr) Persistent (>4 days/wk or >4wks/yr)

Allergic Rhinitis Background cont’d Classified by severity Mild (symptoms present but not interfering with QOL) Severe (exacerbation of coexisting asthma, sleep disturbance, impairment of daily activities)

Allergic Rhinitis AAO-HNS Clinical guidelines 14 key action statements

Allergic Rhinitis

Allergic Rhinitis

Allergic Rhinitis

Non-Allergic Rhinitis Causes NAR with eosinophilia (NARES) Hormone related Hypothyroidism, acromegaly, puberty, pregnancy, post-menopausal Medication associated Rhinitis medicamentosa, anti-hypertensives, NSAIDS, OCPs Irritant Temperature, humidity, barometric changes, gustatory exposure

Non-Allergic Rhinitis Causes cont’d Atrophic Cocaine, surgery, aging, XRT, infectious Idiopathic/Vasomotor

Non-Allergic Rhinitis History Timing Exacerbating and alleviating factors Environmental triggers Patients with onset >age 35 without family history of allergies, no obvious pet/outdoor triggers, no association with perfumes/fragrances very likely to have NAR Exam Boggy, edematous nasal mucosa Clear mucoid drainiage

Diagnostic testing Treatment Skin/RAST testing negative Imaging not useful unless suspected sinus disease Treatment Varies with etiology Recognition and avoidance of underlying trigger

Rhinosinusitis Definition Acute (ARS) Chronic (CRS) Recurrent ARS Symptomatic inflammation of paranasal sinuses and nasal cavity Acute (ARS) < 4weeks duration Chronic (CRS) >12 weeks duration +/- acute exacerbations Recurrent ARS >4 episodes per year without persistent sxs in between episodes

Acute Rhinosinusitis: dx Distinguish acute rhinosinusitis (ARS; viral URI) vs. acute bacterial rhinosinusitis (ABRS) ABRS should be diagnosed when symptoms and signs of ARS (purulent nasal drainage with nasal obstruction and facial pain/pressure) persist without evidence of improvement for >10 days beyond onset –OR- improve initially and worsen again (double worsening)

Acute Rhinosinusitis: dx Radiographic imaging should not be obtained for ARS unless a complication or alternative dx is suspected

Acute Rhinosinusitis: tx Viral ARS may be treated symptomatically Analgesics, topical nasal steroids, nasal saline irrigations ABRS may also be treated symptomatically New AAO-HNS clinical guideline recommendation Watchful waiting for up to 7 days after ABRS diagnosis Treatment ABRS includes amoxicillin/Augmentin for 5-10 days Doxyclycline or respiratory flouroquinolone for PCN allergy

Acute Rhinosinusitis: tx Follow-up should be obtained by 7 days after initiation of treatment/watchful waiting Confirm ARS, exclude other illnesses, detect complications

Chronic Rhinosinusitis: dx > 12 weeks of 2 or more of the following: Mucopurulent drainage Nasal obstruction Facial pain/pressure Decreased sense of smell AND inflammation is documented by one or more of the following: Purulent (not clear) mucous or edema in middle meatus Polyps in nasal cavity or middle meatus Radiographic imaging demonstrating paranasal inflammation

Chronic Rhinosinustis: dx Diagnosis of CRS made with objective confirmation of sinonasal inflammation Nasal endoscopy, CT scan

Chronic rhinosinusitis: dx Assess for comorbid conditions that may influence treatment Asthma, CF, immunocompromise, ciliary dyskinesia Consider obtaining allergy and immune function testing Determine presence or absence of polyps (ENTprovider) Steroid responsiveness/appropriateness

Chronic Rhinosinusitis

Chronic Rhinosinusitis: tx Topical nasal steroids, saline irrigations for symptom management High dose predisone taper plus antibiotics x 2 weeks to assess for symptomatic improvement If no improvement or initial improvement but worsening, surgical intervention offered

Complications of Acute Sinusitis Periorbital complications: Chandler classification Preseptal cellulitis Orbital/post-septal cellulitis Subperiosteal abscess Orbital abscess Cavernous sinus thrombosis Intracranial complications Epidural/subdural abscess Cerebral empyema

Complications of Acute Sinusitis Pre-septal cellulitis Subperiosteal abscess

Odontogenic sinusitis Unilateral maxillary sinusitis of dental origin Periodontal disease Periapical lucency Maxillary tooth root in communication with maxillary sinus Treatment is tooth extraction

When to Refer Nasal obstruction/rhinitis Rhinosinusitis Failure of medical treatment Allergy referral Suspected anatomic problem Rhinosinusitis ABRS unresponsive to appropriate medical management or with concern for acute complication CRS unresponsive to conservative medical management Consider trial of high dose steroids/abx Unilateral sinus disease

When to Refer CRS maximal medical management Prednisone 40mg PO daily x 4 days 30mg PO daily x 3 days 20mg PO daily x 3 days 10mg PO daily x 2 days Augmentin 875/125 PO BID x 2 weeks concurrently with steroids If no prior sinus imaging, CT at end of steroid/abx

Final thoughts Rhinitis can be challenging to manage Manage patient expectations prior to specialty visit Consider migraine on differential when suspect CRS Pain/pressure alone not sufficient for dx CRS CT imaging not appropriate in setting of ABRS but when in doubt, obtain for dx CRS

Questions?