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

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

3. What’s in a nose?

4. Nasal Anatomy

5. Nasal Anatomy

6. Sinonasal Anatomy

7. Anterior nasal examination

8. Anterior nasal examination

9. Endoscopic examination

10. Endoscopic examination

11. 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)

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

13. 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

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

15. 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)

16. 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)

17. Allergic Rhinitis
AAO-HNS Clinical guidelines
14 key action statements

18. Allergic Rhinitis

19. Allergic Rhinitis

20. Allergic Rhinitis

21. 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

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

23. 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

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

25. 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

26. 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)

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

28. 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

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

30. 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

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

32. 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

33. Chronic Rhinosinusitis

34. 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

36. 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

37. Complications of Acute Sinusitis
Pre-septal cellulitis
Subperiosteal abscess

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

39. 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

40. 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

41. 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

42. Questions?