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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
Thank YouThank You