1. Rhinology in General Practice
Dr Robert Sands
GPST2
Forest Practice, Loughton

2. Allergic Rhinitis

3. Definition:
‘an inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitized to allergens’

4. Affects 30% of the world's population, and 20% of the UK population, and is increasing in incidence.
Children of school age and adolescents - seasonal allergic rhinitis.
Adults - perennial allergic rhinitis.

5. Pathophysiology:
Sensitization to an allergen results in the production of IgE which is specific to that allergen. This IgE binds to the surface of mast cells in the nasal mucosa.
Re-exposure to the allergen results in the allergen binding to IgE on the surface of mast cells. This triggers the release of histamine and other inflammatory mediators.

6. Associated with:
Allergic conjunctivitis
Eczema
Asthma

7. Classification:
Seasonal —symptoms occur at the same time each year. (grass and tree pollen allergens - 'hay fever‘).
Perennial —symptoms occur throughout the year, (house dust mites and pets).
Occupational —symptoms are due to exposure to allergens at work (flour allergen in a baker).

8. More recent classification:
Mild intermittent.
Moderate severe intermittent.
Mild persistent.
Moderate severe persistent.
(Generally more useful in clinical practice)

9. Common allergens: House dust mites Grass, tree, and weed pollens
Allergens carried on animal hair
Allergens encountered at work

10. Complications:
Underestimated as a cause of impaired quality of life - adversely affect work, home, and social life.
In children, poorly controlled symptoms may contribute to learning problems and sleep disturbance.
Associated with poor Asthma control.
Predisposes to sinusitis.

11. Diagnosis: Typical symptoms:
Sneezing
Itching
Nasal discharge (rhinorrhoea)
Blockage
Eye symptoms - bilateral itching, redness, and swelling
Diagnosed by identifying its characteristic features and excluding infectious and irritant causes of rhinitis.
Try to identify common allergen and ask about atopy.
Infective cause:
Acute onset.
URTI, such as cough, fever, or lymphadenopathy.
Nasal discharge is green or yellow (yellow nasal discharge may also be indicative of allergic rhinitis). If discharge is clear, infection is unlikely.
Irritant cause:
Physical irritant rhinitis may follow changes in temperature or humidity, or occur with exercise.
Chemical irritant rhinitis may follow exposure to volatile chemicals.
Allergic rhinitis and irritant rhinitis may coexist. Irritant rhinitis - more severe.

12. Allergy testing:
When the type of rhinitis (infective, irritant, or allergic) is unclear from the history.
Symptoms are persistent or poorly controlled.
Burdensome allergen avoidance strategies, such as house dust mite avoidance measures, are being considered.
If allergy testing is negative, consider non-allergic causes for the rhinitis, including drugs, hormonal causes, and non-allergic rhinitis with eosinophilia syndrome.

13. Assessment: History: Frequency, severity, and persistence of symptoms.
Quality of life - effect on sleep, recreation, and work.
Associated allergic conjunctivitis.
Previous treatments for allergic rhinitis and their effectiveness.
Personal preference for oral or intranasal treatments.

14. Chronic nasal congestion: mouth breathing, cough, and halitosis.
Examination:
Chronic nasal congestion: mouth breathing, cough, and halitosis.
Examine the nose for:
Nasal polyps.
Deviated or perforated nasal septum.
Mucosal swelling.
Horizontal nasal crease across nose dorsum (in severe rhinitis).

15. Management: Nasal Douching
‘As-required' treatment for occasional symptoms
allergic conjunctivitis, children aged 2–5 years of age, and people who prefer oral treatment, prescribe an oral antihistamine (such as cetirizine, fexofenadine or loratadine).
all other people, prescribe intranasal azelastine first line -  (applied two to four times daily) is the only intranasal antihistamine that is licensed in the UK for the treatment of allergic rhinitis. Rapid onset of action.

16. ‘preventive’ treatment to control more frequent or persistent symptoms:
Advise the person to avoid the causative allergen, if possible.
If allergen avoidance is inadequate or not possible, prescribe drug treatment.
Nasal blockage, or nasal polyps are present - intranasal corticosteroid.
Sneezing or nasal discharge, prescribe an oral antihistamine (if oral treatment is preferred or allergic conjunctivitis is present) or an intranasal corticosteroid (if a more effective treatment is required).
Combination of both.

17. If rhinorrhoea persists despite combined use of intranasal corticosteroid and antihistamine, add an intranasal antimuscarinic drug (ipratropium bromide).
If nasal blockage is a problem, prescribe an intranasal decongestant for up to 7 days.
Severe symptoms and/or impairing quality of life - 5–10 day course of prednisolone: 20–40 mg a day in adults, 10 mg a day in children.
For people with persistent symptoms despite being on maximal medical therapy, refer for specialist assessment and management.

18. Nasal spray technique:
Gently blow the nose to try and clear it.
Shake the bottle well.
Close off one nostril and put the nozzle in the other, directing it away from the midline. Tilt head forward slightly and keep the bottle upright.
Squeeze a fine mist into the nose while breathing in slowly. Do not sniff hard.
Breathe out through the mouth.
Take a second spray in the same nostril then repeat this procedure for the other nostril.
Nasal drop technique:
Shake the container well.
Tilt the head backwards.
Place the drops in the nostril (squeeze the container gently if necessary).
Keep the head tilted and sniff gently to let the drops penetrate.
Repeat for the other nostril, if required.

19. Sinusitis

20. ‘inflammation of the mucosal lining of the paranasal sinuses’.
The term 'rhinosinusitis' has been adopted by most specialists.
Acute sinusitis refers to sinusitis that completely resolves within 12 weeks.
Chronic sinusitis refers to sinusitis that causes symptoms that last for more than 12 weeks.
Although the sinuses are not fully developed in younger children, computed tomography has shown that symptoms of a runny nose frequently indicate sinus involvement, especially in the autumn months.

21. Acute sinusitis 
usually triggered by a viral upper respiratory tract infection.
0.5–2.0% of people will subsequently develop a bacterial infection, (sinusitis is one of the most common reasons a healthcare professional will prescribe an antibiotic).
Streptococcus pneumoniae and Haemophilus influenzae, although Moraxella catarrhalis may also be a cause.
Chronic sinusitis
although it usually follows an acute episode of sinusitis, chronic sinusitis may have other predisposing factors, including atopy and asthma.
Some people may also develop nasal polyps, but the reason for this is unknown

22. Diagnosis:
Acute sinusitis usually follows a common cold, and is defined as an increase in symptoms after 5 days, or persistence of symptoms beyond 10 days, but less than 12 weeks.
In adults:
Nasal blockage (obstruction/congestion) - usually bilateral and caused by rhinitis.
Discoloured nasal discharge (anterior/posterior nasal drip) 
Facial pain/pressure (or headache) - may be localized over the infected sinus, or it may affect teeth, the upper jaw, or other areas (such as the eye, side of face, forehead). Worse leaning forward.
Reduction (or loss) of the sense of smell.
In children:
Diagnose acute sinusitis by the presence of nasal blockage (obstruction/congestion) or discoloured nasal discharge (anterior/posterior nasal drip) with facial pain/pressure (or headache) and/or cough (daytime and night-time).
Facial pain is less prevalent in children.
There may also be ear discomfort (Eustachian tube blockage).

23. Suspect acute bacterial sinusitis when at least three of the following features are present:
Discoloured or purulent discharge (with unilateral predominance).
Severe local pain (with unilateral predominance).
A fever greater than 38°C.
A marked deterioration after an initial milder form of the illness (so-called 'double-sickening').
Elevated ESR/CRP (although the practicality of this criterion is limited).

24. Assessment:
Inspect and palpate the maxillofacial area to elicit swelling and tenderness.
Perform anterior rhinoscopy:
Nasal inflammation, mucosal oedema, and mucopurulent nasal discharge.
Nasal polyps, or anatomical abnormalities such as septal deviation.
Evidence of other conditions which present with similar signs and symptoms to acute sinusitis, such as a nasal foreign body or a sinonasal tumour.

25. Management:
Paracetamol or ibuprofen.
An intranasal decongestant.
Nasal douching.
Applying warm face packs.
Drinking adequate fluids and rest.
Consider prescribing an intranasal corticosteroid for people with prolonged or severe symptoms.
Advise people to make a follow-up appointment if their symptoms rapidly deteriorate, or they develop a high temperature or marked local pain that is predominately unilateral.
For people with frequent recurrent episodes of sinusitis (more than three episodes requiring antibiotics a year) consider routine referral to an Ear, Nose, and Throat (ENT) specialist.
Not recommended include:
Steam inhalation.
Oral corticosteroids.
Antihistamines (unless there is co-existing allergic rhinitis).
Complementary and alternative medicine.
Mucolytics.

26. Acute sinusitis is caused by a virus in more than 98% of people.
Prescribe an antibiotic for people with acute sinusitis:
Co-morbidity that puts them at high risk for a complication
Acute bacterial sinusitis is suspected.
Amoxicillin for 7 days, or
Phenoxymethylpenicillin for 7 days, or
Doxycycline (not in children less than 12 years of age), erythromycin, or clarithromycin – allergy to penicillin, for 7 days.
Second-line treatments:
Co-amoxiclav for 7 days.
Azithromycin for 3 days (if the person is allergic to penicillin).
Seek specialist advice if a second-line antibiotic is ineffective.

27. Chronic Sinusitis
Natural course of chronic sinusitis - may last several months, but does not usually require referral.
Advise the person to:
Practise good dental hygiene to reduce the risk of dental infection (which can be associated with chronic sinusitis).
Stop smoking.
Avoid underwater diving if there are prominent symptoms.
Consider a course of intranasal corticosteroids for up to 3 months, especially if there is suspicion of an allergic cause (such as concomitant allergic rhinitis).
Seek specialist advice before prescribing long-term antibiotics, as the evidence for this approach is limited.

28. Epistaxis

29. Epistaxis is bleeding from the nose.
80–95% - originates from Little's area on the anterior nasal septum, which contains the Kiesselbach plexus of vessels.
Less commonly - originates from branches of the sphenopalatine artery in the posterior nasal cavity.
Older people
More profuse
Bleeding from both nostrils
Bleeding site cannot be identified on examination

30. Hypertension is common in people that present with epistaxis; however, there is insufficient evidence to establish a causative relationship with epistaxis’
Most episodes of epistaxis are self-limiting and do not require medical treatment.

31. Assessment: ABC History: Examine both nasal passages.
When the bleeding started and from which nostril.
How much blood has been lost.
Whether a temporary pack (such as cotton wool) has been used before seeking medical help. These are not always easily visible, and formal nasal packing can push foreign bodies further into the nose.
Any previous episodes of epistaxis and how they were treated.
Examine both nasal passages.
Look for a bleeding point.
Suspect a posterior bleed if bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on speculum examination.
Determine if there is an underlying cause, particularly in children younger than 2 years of age as epistaxis is unusual in this age group.
Laboratory investigations are not usually needed.

32. Management - Acute: First aid measures:
Sit with their upper body tilted forward and their mouth open. They should avoid lying down, unless they are feeling faint.
Pinch the cartilaginous part of the nose firmly and hold it for 10–15 minutes without releasing the pressure, whilst breathing through their mouth.
Ice packs.

33. Suspected posterior bleed – admit to hospital.
If bleeding stops with first aid measures:
Topical antiseptic preparation - Naseptin®(chlorhexidine and neomycin) cream to be applied to the nostrils four times daily for 10 days.
Check for peanut allergy – if present, consider prescribing mupirocin nasal ointment to be applied to the nostrils two to three times a day for 5–7 days.
If bleeding not stopping - appropriate expertise and facilities are available in primary care, consider:
Nasal cautery.
Nasal packing - Admit the person to hospital if a nasal pack has been inserted in primary care.
Self-care measures.

34. Management - Recurrent:
? Underlying cause.
Consider arranging a full blood count for adults with recurrent epistaxis.
Children younger than 2 years of age .
High risk patients: 
Males aged 12–20 years of age — angiofibroma (benign tumour).
Symptoms suggestive of cancer - nasal obstruction, facial pain, hearing loss, eye symptoms (proptosis or double vision), or persistent lymphadenopathy.
Middle-aged people of Chinese origin — high incidence of nasopharyngeal cancer.
People older than 50 years of age — nasal, sinus, and nasopharyngeal cancers more common.
People with telangiectasia and a family history of hereditary haemorrhagic telangiectasia.
People with occupational exposure to wood dust or chemicals.
Not at high risk:
Topical treatment.
Nasal cautery . This is similarly effective to Naseptin.

35. Thank you!