Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and...

Differential Diagnosis of Differential Diagnosis of RhinosinusitisRhinosinusitis

Hesham Saleh, FRCSHesham Saleh, FRCSConsultant RhinologistConsultant Rhinologist

Charing Cross and Royal Brompton HospitalsCharing Cross and Royal Brompton Hospitals

The Nose ClinicThe Nose ClinicRBHRBH

Stephen DurhamStephen Durham Hesham SalehHesham Saleh

Rhinitis – Inflammation of the Rhinitis – Inflammation of the Nasal MucosaNasal Mucosa

Nasal dischargeNasal discharge BlockageBlockage Sneeze/itchSneeze/itch }}

Rhinitis definitionRhinitis definition2 or more symptoms2 or more symptoms

for > 1 hour onfor > 1 hour on most daysmost days

Rhinosinusitis – Inflammation of Rhinosinusitis – Inflammation of the Nasal and the Nasal and SinusSinus Mucosa Mucosa

Nasal dischargeNasal discharge BlockageBlockage Sneeze/itchSneeze/itch }}

Rhinitis definitionRhinitis definition2 or more symptoms2 or more symptoms

for > 1 hour onfor > 1 hour on most daysmost days

Chronic Rhinosinusitis – EPOS 2007Chronic Rhinosinusitis – EPOS 2007

• Obstruction/CongestionObstruction/Congestion• Discharge/PurulenceDischarge/Purulence

+/- Pain/Pressure+/- Pain/Pressure

+/-Hyposmia/Anosmia+/-Hyposmia/Anosmia

Endoscopic signs of:Endoscopic signs of:• PolypsPolyps

and/orand/or• Mucopurulent dischargeMucopurulent discharge

and/orand/or• Oedema/mucosal Oedema/mucosal

obstructionobstruction

and/orand/or

CT ChangesCT ChangesSymptoms > 12 weeksSymptoms > 12 weeks

RhinosinusitisRhinosinusitis

AllergicAllergic(seasonal or perennial)(seasonal or perennial)

InfectiveInfective(acute or(acute orchronic)chronic)

StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)

OtherOther(idiopathic, NARES, (idiopathic, NARES,

hormonal, etc)hormonal, etc)

Differential DiagnosisDifferential Diagnosis

Moderate-severeModerate-severeone or more itemsone or more items

. abnormal sleep. abnormal sleep

. impairment of daily . impairment of daily activities, sport, leisureactivities, sport, leisure

. abnormal work and . abnormal work and schoolschool

. troublesome symptoms. troublesome symptoms

PersistentPersistent . > 4 days per week. > 4 days per week

. . andand > 4 weeks > 4 weeks

MildMild normal sleepnormal sleep& no impairment of daily & no impairment of daily

activities, sport, leisureactivities, sport, leisure& normal work and & normal work and

schoolschool& no troublesome & no troublesome

symptomssymptoms

IntermittentIntermittent

. Š 4 days per week. Š 4 days per week

. . oror Š 4 weeks Š 4 weeks

ARIA ClassificationARIA Classification

in untreated patientsin untreated patients

Diagnosis of Allergic RhinitisDiagnosis of Allergic Rhinitis

HISTORYHISTORY

NASAL EXAMINATIONNASAL EXAMINATION

SKIN PRICK TEST or RASTSKIN PRICK TEST or RAST

Diagnosis of Allergic RhinitisDiagnosis of Allergic Rhinitis

• History is often very suggestive History is often very suggestive

Allergic SaluteAllergic Salute

NasendoscopyNasendoscopy

Anterior RhinoscopyAnterior Rhinoscopy

Allergy skin prick testingAllergy skin prick testing

Allergic Rhinitis and Infective Allergic Rhinitis and Infective Rhinosinusitis may coexistRhinosinusitis may coexist

“ “no published prospective reports on the no published prospective reports on the incidence of infective rhinosinusitis in incidence of infective rhinosinusitis in populations with and without clearly populations with and without clearly defined allergic rhinosinusitis”defined allergic rhinosinusitis”

EPOS 2007EPOS 2007

RhinosinusitisRhinosinusitis

AllergicAllergic(seasonal or perennial)(seasonal or perennial)

InfectiveInfective(acute or(acute orchronic)chronic)

StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)

OtherOther(idiopathic, NARES, (idiopathic, NARES,

hormonal, etc)hormonal, etc)

Differential DiagnosisDifferential Diagnosis

InfectiveInfective

• AcuteAcute

• ChronicChronic– SpecificSpecific

• BacterialBacterial

• FungalFungal

– Non-specificNon-specific• Immune deficiencyImmune deficiency

– SystemicSystemic

– LocalLocal

Acute Rhinosinusitis – EPOS 2007Acute Rhinosinusitis – EPOS 2007

• Obstruction/CongestionObstruction/Congestion

OROR• Discharge/PurulenceDischarge/Purulence

+/- Pain/Pressure+/- Pain/Pressure

+/-Hyposmia/Anosmia+/-Hyposmia/Anosmia

Symptoms < 12 weeksSymptoms < 12 weeks

Sudden onsetSudden onset

Acute SinusitisAcute Sinusitis

Chronic Rhinosinusitis – EPOS 2007Chronic Rhinosinusitis – EPOS 2007

• Obstruction/CongestionObstruction/Congestion• Discharge/PurulenceDischarge/Purulence

+/- Pain/Pressure+/- Pain/Pressure

+/-Hyposmia/Anosmia+/-Hyposmia/Anosmia

Endoscopic signs of:Endoscopic signs of:• PolypsPolyps

and/orand/or• Mucopurulent dischargeMucopurulent discharge

and/orand/or• Oedema/mucosal Oedema/mucosal

obstructionobstruction

and/orand/or

CT ChangesCT ChangesSymptoms > 12 weeksSymptoms > 12 weeks

Chronic Rhinosinusitis - EndoscopyChronic Rhinosinusitis - Endoscopy

• Pus in MMPus in MM

• Oedema in MMOedema in MM

• PolypsPolyps

Chronic Rhinosinusitis - CTChronic Rhinosinusitis - CT

• Confirms diagnosisConfirms diagnosis

• Map for surgeryMap for surgery

PLAIN X-RAY

• 54% Sensitivity and 46% Specificity in 54% Sensitivity and 46% Specificity in sinusitis (Kuhn, 1986)sinusitis (Kuhn, 1986)

• 75% of Plain X-Rays do not correlate with 75% of Plain X-Rays do not correlate with CT (McAlister and Lusk, 1989)CT (McAlister and Lusk, 1989)

Fungal InfectionsFungal Infections

AspergillosisAspergillosis BlastomycosisBlastomycosis

RhinosporoidosisRhinosporoidosis CryptococcosisCryptococcosis

PhycomycosisPhycomycosis ActinomycosisActinomycosis

CandidiasisCandidiasis HisptoplasmosisHisptoplasmosis

Sporotrichosis MucormycosisSporotrichosis Mucormycosis

• Non-invasiveNon-invasive– Fungal ball (mycetoma)Fungal ball (mycetoma)

– Allergic fungal sinusitis (AFS)Allergic fungal sinusitis (AFS)

• InvasiveInvasive– Chronic invasive (indolent) fungal rhinosinusitisChronic invasive (indolent) fungal rhinosinusitis

– Acute invasive (fulminant) fungal rhinosinusitisAcute invasive (fulminant) fungal rhinosinusitis

Current Classification Current Classification (deShazo, 1997)(deShazo, 1997)

• Non-invasiveNon-invasive– Fungal ball (mycetoma)Fungal ball (mycetoma)

– Allergic fungal sinusitis (AFS)Allergic fungal sinusitis (AFS)

• InvasiveInvasive– Chronic invasive (indolent) fungal rhinosinusitisChronic invasive (indolent) fungal rhinosinusitis

– Acute invasive (fulminant) fungal rhinosinusitisAcute invasive (fulminant) fungal rhinosinusitis

Current Classification Current Classification (deShazo, 1997)(deShazo, 1997)

Fungus Ball (Mycetoma)Fungus Ball (Mycetoma)

• Opacification

• Double density (dense hyphae)

• Bony sclerosis

• No erosion

Fungus Ball (Mycetoma)Fungus Ball (Mycetoma)

Allergic Fungal SinusitisAllergic Fungal Sinusitis

• Type I HypersensitivityType I Hypersensitivity

• 80% of Patients Have 80% of Patients Have Diffuse PolypsDiffuse Polyps

• Elevated IgE to Fungus Elevated IgE to Fungus and Positive Skin Testand Positive Skin Test

• Thick Greenish Secretions Thick Greenish Secretions with Fungal Hyphaewith Fungal Hyphae

Allergic Fungal SinusitisAllergic Fungal Sinusitis

• Sinus opacificationSinus opacification

• ExpansionExpansion

• Bony erosionBony erosion

• No tissue invasionNo tissue invasion

InfectiveInfective

• AcuteAcute

• ChronicChronic– SpecificSpecific

• BacterialBacterial

• FungalFungal

– Non-specificNon-specific• Immune deficiencyImmune deficiency

– SystemicSystemic

– LocalLocal

Immunodeficiency in Chronic Immunodeficiency in Chronic RhinosinusitisRhinosinusitis

TotalTotal

IgA + IgGIgA + IgG22

Selective IgGSelective IgG22

Selective IgASelective IgA

HypogammaglobHypogammaglob

25 (6.5%)25 (6.5%)

6 (1.6%)6 (1.6%)

3 (0.8%)3 (0.8%)

5 (1.3%)5 (1.3%)

11 (2.9%)11 (2.9%)

385385Immunoglobulins in M-P Immunoglobulins in M-P rhinorrhearhinorrhea

Primary Ciliary DyskinesiaPrimary Ciliary Dyskinesia

• DextrocardiaDextrocardia

• RhinosinusitisRhinosinusitis

• BronchiectasisBronchiectasis

• InfertilityInfertility

Saccharin TestSaccharin Test

< 35 minutes< 35 minutes

Nasal Muco-Ciliary ClearanceNasal Muco-Ciliary Clearance

Greenstone M., Stanley P., MacWilliam L., Greenstone M., Stanley P., MacWilliam L., Dewar A., Cox T., Mackay I.S., Cole P.J. Dewar A., Cox T., Mackay I.S., Cole P.J.

Mucociliary function and ciliary ultrastructure Mucociliary function and ciliary ultrastructure in patients presenting with rhinitis to in patients presenting with rhinitis to

Brompton Hospital Nose Clinic. Eur.J. Respir. Brompton Hospital Nose Clinic. Eur.J. Respir. Dis. Suppl. 128, p 457-9. 1983.Dis. Suppl. 128, p 457-9. 1983.

Electron MicroscopyElectron Microscopy

Cystic FibrosisCystic Fibrosis

• Infective Rhinosinusitis Infective Rhinosinusitis (Pseudomonas)(Pseudomonas)

• 37% of Patients Have 37% of Patients Have PolypsPolyps

• Viscid SecretionsViscid Secretions

• Polyps in ChildrenPolyps in Children

RhinosinusitisRhinosinusitis

AllergicAllergic(seasonal or perennial)(seasonal or perennial)

InfectiveInfective(acute or(acute orchronic)chronic)

StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)

OtherOther(idiopathic, NARES, (idiopathic, NARES,

hormonal, etc)hormonal, etc)

Differential DiagnosisDifferential Diagnosis

StructuralStructural

Structural (Mechanical)Structural (Mechanical)

• Deviation of nasal septumDeviation of nasal septum

• Nasal polypsNasal polyps

• Hypertrophy of inferior turbinatesHypertrophy of inferior turbinates

• Enlarged adenoidsEnlarged adenoids

• Foreign bodiesForeign bodies

• Choanal atresiaChoanal atresia

Deviated Nasal SeptumDeviated Nasal Septum

Nasal PolypsNasal Polyps

SymptomsSymptoms

• Nasal obstructionNasal obstruction

• AnosmiaAnosmia

• Postnasal dripPostnasal drip

DiagnosisDiagnosis

• Gray-pink glistening Gray-pink glistening structuresstructures

• InsensitiveInsensitive

Anterior rhinoscopy and endoscopyAnterior rhinoscopy and endoscopy

View nasal endoscopy of of normal patientnormal patient

Samter’s TriadSamter’s Triad

• 36% of Patients Have 36% of Patients Have Diffuse PolypsDiffuse Polyps

• Bone ExpansionBone Expansion

• High Recurrence RateHigh Recurrence Rate

Inferior Turbinates HypertrophyInferior Turbinates Hypertrophy

AdenoidsAdenoids

Foreign BodyForeign Body

Choanal AtresiaChoanal Atresia

RhinosinusitisRhinosinusitis

AllergicAllergic(seasonal or perennial)(seasonal or perennial)

InfectiveInfective(acute or(acute orchronic)chronic)

StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)

OtherOther(idiopathic, NARES, (idiopathic, NARES,

hormonal, etc)hormonal, etc)

Differential DiagnosisDifferential Diagnosis

OtherOther

• IdiopathicIdiopathic

• NARESNARES

• OccupationalOccupational

• HormonalHormonal

• DrugsDrugs

• FoodFood

• IrritantsIrritants

• EmotionalEmotional

• GranulomasGranulomas

• TumoursTumours

• CSF leakCSF leak

Non-allergic “Idiopathic”Non-allergic “Idiopathic”“Vasomotor Rhinitis”“Vasomotor Rhinitis”

• Nasal Hyperactivity toNasal Hyperactivity to

– Cold airCold air– Temperature changesTemperature changes– Tobacco, pollutantsTobacco, pollutants– Perfumes, bleachPerfumes, bleach

Nasal Hyper-reactivity is also present inNasal Hyper-reactivity is also present in

40 - 50% of patients with allergic rhinitis40 - 50% of patients with allergic rhinitis

Neuronal markers in allergic rhinitis: expression and correlation with Neuronal markers in allergic rhinitis: expression and correlation with sensory testing.sensory testing.

S O’Hanlon, P Facer, K Simpson, G Sandhu, S O’Hanlon, P Facer, K Simpson, G Sandhu, HA SalehHA Saleh, P Anand., P Anand.

LaryngoscopeLaryngoscope 2007 Sep;117(9):1519-27. 2007 Sep;117(9):1519-27.

Increased Nerve Fiber Expression of Sensory Sodium Channels Nav1.7, Increased Nerve Fiber Expression of Sensory Sodium Channels Nav1.7, Nav1.8, and Nav1.9 in Rhinitis.Nav1.8, and Nav1.9 in Rhinitis.

SM Keh , P Facer, K Simpson, G Sandhu, SM Keh , P Facer, K Simpson, G Sandhu, HA SalehHA Saleh, P Anand., P Anand.

LaryngoscopeLaryngoscope. 2008; . 2008; 118(4):573-9.

The role of neuronal mechanisms in allergic rhinitis.The role of neuronal mechanisms in allergic rhinitis.

S O’Hanlon, SM Keh, S O’Hanlon, SM Keh, HA SalehHA Saleh

Otorinolaringologia. Otorinolaringologia. 2008;2008;58: 17-30.

““Neurogenic RhinitisNeurogenic Rhinitis” ?” ?

NARES (Non-Allergic Rhinitis with NARES (Non-Allergic Rhinitis with Eosinophilia Syndrome)Eosinophilia Syndrome)

• Non-atopicNon-atopic

• Females > malesFemales > males

• EosinophiliaEosinophilia

• Steroid responsiveSteroid responsive

Occupational RhinitisOccupational Rhinitis

Symptoms improve in weekends and holidaysSymptoms improve in weekends and holidays

• AllergicAllergic

• Non-allergicNon-allergic

Occupational RhinitisOccupational Rhinitis

• storage mites storage mites • grain grain • latex latex • glues and guar gumglues and guar gum• rats, mice, guinea pigsrats, mice, guinea pigs• basilis subtilisbasilis subtilis enzymes enzymes• wood dust e.g. mahogany, western red cedarwood dust e.g. mahogany, western red cedar• isotonic acid hydrazine/trimellitic anhydrideisotonic acid hydrazine/trimellitic anhydride

HormonalHormonal

• PregnancyPregnancy

• PubertyPuberty

• PremenstrualPremenstrual

• HypothyroidismHypothyroidism

• AcromegalyAcromegaly

• Old man’s dripOld man’s drip

Drug InducedDrug Induced

• LocalLocal– Rhinitis Rhinitis

medicamentosamedicamentosa

• SystemicSystemic– AntihypertensivesAntihypertensives– AspirinAspirin– Contraceptive pillContraceptive pill

PreservativesPreservatives

• Benzoates, salicylatesBenzoates, salicylates• TetrazineTetrazine• ColouringsColourings

IrritantsIrritants

• PollutionPollution

• GustatoryGustatory

EmotionalEmotional

SarcoidosisSarcoidosis

Wegener’s GranulomatosisWegener’s Granulomatosis

Atrophic RhinitisAtrophic Rhinitis

NeoplasmsNeoplasms

CSF LeakCSF Leak

View video View video here

RhinosinusitisRhinosinusitis

AllergicAllergic(seasonal or perennial)(seasonal or perennial)

InfectiveInfective(acute or(acute orchronic)chronic)

StructuralStructural(polyps, septum,(polyps, septum,turbinates, etc)turbinates, etc)

OtherOther(idiopathic, NARES, (idiopathic, NARES,

hormonal, etc)hormonal, etc)

Differential DiagnosisDifferential Diagnosis

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