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3/18/2016
1
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
ROBIE GRAY PA‐CUNIVERSITY OF COLORADO SINUS CENTERRHINOLOGYENT FOR THE PA‐C CONFERENCE MARCH 2016
Allergic vs Non‐Allergic Rhinitis
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Allergic vs Non‐Allergic Rhinitis
Objectives:
• Identify history of allergic vs non‐allergic rhinitis
• Recognize clinical and laboratory findings that facilitate differentiation
• Current guidelines for treatment
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Allergic vs Non‐Allergic Rhinitis
• No Disclosures
3/18/2016
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Allergic vs Non‐Allergic Rhinitis
• Clinical Practice Guidelines: Allergic Rhinitis
American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43
• The Diagnosis and Management of Rhinitis: An Updated Practice Parameter
Joint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐84
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
What is Rhinitis?
One or more of the following:
• Congestion
• Rhinorrhea anterior or posterior
• Sneezing and Pruritus
Typically associated with inflammation though some forms of
rhinitis are not
Associated Conditions
• Allergy
• Asthma
• Sino‐pulmonary issues
• Aspirin sensitivity
• Less common
– Cystic Fibrosis
– Immunodeficiencies
– Autoimmune conditions
3/18/2016
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Rhinitis Morbidity
• Quality of life: fatigue, headaches, sleep disturbances, and cognitive impairment
• Complicating respiratory conditions
• Reduced work/school
• Direct and indirect costs in the U.S. of 11 billion dollars according to the Joint Task Force on Practice Parameters
Allergic Rhinitis
IgE mediated reactions to environmental triggers following sensitization• Perennial• Seasonal• Episodic
Characterized by frequency and severity• Intermittent • Persistent• Mild• More severe
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Allergic Rhinitis: cardinal symptoms
Rhinorrhea
SneezingPruritus
Congestion
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Allergic RhinitisPhysical Exam Findings
Nasal Crease Allergic Shiner
Atopic Dermatitis Wheezing
Allergic Rhinitis: nasal exam
Allergic Rhinitis Diagnostics
Allergy Testing Recommendations
• Should perform and interpret or refer to a clinician who can: specific IgE skin or blood testing for those not responding to empiric treatment; or diagnosis is uncertain; or targeted therapy is desired.
American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43
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Allergic Rhinitis Diagnostics
• Skin Testing: preferred method to confirm an IgE‐mediated response taking advantage of type I hypersensitivity reactions
• Skin prick, Intradermal, and Intradermal dilution (known in the past as serial dilution or skin endpoint titration)
• RAST: radioallergosorbent
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Skin Prick Testing
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Intradermal Testing
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RASTRadioallergosorbent Test
• Measurement of total serum IgE and IgE levels against allergy antigens
• Benefits: no risk for allergic reaction; results not effected by medications or skin conditions; no need for extensive testing materials or rescue medications
• Caution: inappropriate use of this screening test in unselected populations may produce positive results in asymptomatic patients as IgE antibody responses are more frequent than symptomatic disease
Allergic Rhinitis Co‐Morbidities
• Asthma
• Atopic dermatitis
• Sleep disordered breathing
• Rhinosinusitis
• OtitisAmerican Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43
Allergic Rhinitis Treatments
Strong Recommendations
• Intranasal steroids
• PO second generation/less sedating antihistamines
Recommendations Against
• Routine sinonasal imaging
• PO leukotriene receptor antagonist as primary therapy
American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43
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Allergic Rhinitis Treatments
Recommendations
• Immunotherapy SCIT or SLIT
• Duration of Allergy Immunotherapy 3‐5 years if there is a beneficial response
• Allergy Immunotherapy is not always a cure but does relieve symptoms in up to 80% of patients
• Newer FDA approved sublingual tablets for seasonal use: grass and ragweed
Allergic Rhinitis Treatments
Options
• Environmental controls
• Intranasal antihistamines
• Combo therapy
• Surgical referral
• Acupuncture
American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43
LaForce CF, Corren J, Wheeler WJ, et al. Efficacy of Azelastine nasal spray in SAR patients who remain symptomatic after treatment with Fexofenadine. Ann Allergy Asthma Immunol. 2004;93:154‐159
Allergic Rhinitis Treatments
Recommendations• Intranasal Cromolyn effective in some patients with minimal side
effects
• Nasal Saline is beneficial
• Oral Decongestants can reduce nasal congestion but have significant side effects
• Omalizumab demonstrates effectiveness but only indicated for allergic asthma and chronic urticaria
The Diagnosis and Management of Rhinitis: An Updated Practice Parameter
Joint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐84
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Allergic Rhinitis Treatments
• Oral Corticosteroids: short courses for severe nasal symptoms OK
• Parenteral single dose is discouraged and recurrent administrations are contraindicated
Joint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐84
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Special Considerations in AR Treatments
Pregnancy
• Second and First Generation Antihistamines
• Cromolyn
• Montelukast
• Intranasal Corticosteroids
• AI Continuation
Non‐Allergic Rhinitis
• Vasomotor
• Foods and ETOH
• Infectious
• NARES
• Occupational
• Hormonal
• Drug‐induced
• Atrophic
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Vasomotor Rhinitis“idiopathic rhinitis”
• Rhinorrhea: think cholinergic secretory activity
• Gustatory: think vagally mediated
• Nasal congestion: think heightened nociceptive neuron sensitivity
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Infectious: Rhinosinusitis
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
NARESNon‐Allergic Rhinitis with Eosinophilia Syndrome
• Paroxysmal sneezing, profuse watery rhinorrhea, nasal pruritus, congestion, and anosmia
• Middle aged
• 5‐20% Eosinophils on smear
• Develop nasal polyposis and AERD
Settipane GA, Klein DE, Non allergice rhinitis: demography of eosinophils in nasal smear, blood total eosinophil counts and IgE levels. N Eng Reg Allergy Proc 1985:6:363‐6
Moneret‐Vautrin DA, Hsieh V, Wayoff M, Guyot JL, Mouton C, Maria Y. Nonallergic rhinitis with eosinophilia syndrome a precursor of the triad: nasal polyposis, inrinsicasthma, and intolerance to ASA. ANN Allergy 1990;64:513‐8
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
NARESNon‐Allergic Rhinitis with Eosinophilia Syndrome
Wrights Stain Distilled Water
5‐20% Eosinophils on smear
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Hormonal
Pregnancy
• Nasal vascular pooling, vascular dilation, and increasing blood volumes
• Starts before 6 weeks and ends 2 weeks post‐delivery
Ovulation
• Associated with the rise in estrogenJoint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐84
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Drug induced
• ACEI
• Phosphodiesterase 5 selective inhibitors
• Phentolamine
• Alpha receptor antagonists
• ASA/NSAID
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Drug InducedRhinitis Medicamentosa
Intranasal alpha‐adrenergic decongestants
Cocaine
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Atrophic Rhinitis
Primary
• Developing countries with warm climates
• Progressive atrophy of the glandular cells
• Crusting, dryness, fetor
• Klebsiella ozaenae, S aureus, Proteus mirabilis and E coli
Zohar Y, Talmi YP, Strauss M, et all. Ozena revisited. J Otolaryngol1990;19:345‐9
Secondary
• Chronic granulomatous disorders
• Chronic sinusitis
• Excessive surgery to turbinates
• Irradiation
Atrophic Rhinitis
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Non‐Allergic Rhinitis Treatments
• Intranasal corticosteroids
• Intranasal antihistamines
• Intranasal anticholinergic
• Intranasal capsaicin: nociceptors
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Non‐Allergic Rhinitis Treatments
• Stop or change causative medication
• Oral or topical decongestants short term
• Nasal Hygiene
• PO ABRS or topical antibiotics (think Atrophic)
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Rhinitis: When to Look Deeper
• Failure or non‐response to empiric treatment
• Anosmia
• Nasal obstruction
• Epistaxis
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Endoscopes
• Pictures courtesy Todd Kingdom, MD CU Sinus Center
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Normal Chronic Sinusitis
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Rhinitis: Special Circumstances
• Nasal polyps
• AERD
• CRS
• CSF rhinorrhea
• Ciliary dysfunctions
• Nasal mass ‐ benign and malignant
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Rhinitis‐Special Circumstances
Inflammatory‐Immunologic Disorders
• Granulomatosis with polyangiitis GPA/Wegener's
• Sarcoidosis
• Midline granuloma
• Churg‐Strauss
• Relapsing polychondritis
• Amyloidosis
• Granulomatous infections
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Nasal Polyps/AERD
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Nasal Polyps/AERD
3/18/2016
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CRS‐Chronic Rhinosinusitis
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Case:Ms. S
• Ms. S intermittent rhinorrhea
• No response to topical or oral medications
• Negative allergy testing
• H/O Cluster headaches
• PMH 3 transsphenoidal pituitary procedures most recent – 5 years ago.
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Case:Ms. S
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How Do We Know If Someone Has A CSF Leak?
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Ciliary Dyskinesia
• Primary associated with bronchiectasis and 50% of the time with situs inversus/Kartagener syndrome
• Secondary causes include CRS, ARS, multiple sinus procedures, or irritant rhinitis (smoking).
PCD‐Primary Ciliary Dyskinesia
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Inverted Papilloma
Malignant
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
ANATOMY AND SURGICAL OPTIONS
Rhinitis
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Nasal Obstruction
Picture courtesy Todd Kingdom CU Sinus Center
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Surgical OptionsNasal obstruction
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Turbinates
Picture Courtesy Todd Kingdom MD, CU Sinus Center
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Nasal Obstruction Surgery:Inferior Turbinate Hypertrophy
Picture Courtesy Todd Kingdom MD, CU Sinus Center
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Nasal Obstruction Surgery:Inferior Turbinate Reduction
Picture Courtesy Todd Kingdom MD, CU Sinus Center
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Septoplasty
3/18/2016
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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Vidian Neurectomy
• Intractable non‐allergic rhinitis
• Favorable anatomy: floor of the sphenoid sinus
• Reported as 50‐90% patients noting improvement
• Side effects dry eye and nasal crusting
Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL
Thank You!