Gerard KellyMD MEd FRCS (ORL-HNS) FRCS (Ed)ENT surgeon, Leeds6thMarch 2014, Leeds Masonic Hall
ENT
The Leeds TeachingHospitals NHS Trust
and general practice
my nose is blocked – an update on rhinosinusitis & snoring
aims
give an overview of common (E)N(T) conditionsshows some example casesrefine our thinking of ENT problems
objectives
list the main symptoms in nose conditionsrelate each symptom to one conditionlist the ways to examine the noseidentify an nasal polypclassify rhinosinusitislist 6 treatments for chronic rhinosinusitis (CRS)define association with CRS & respiratory diseaselist treatments for nasal polypsformulate a management plan for snoring
first though...
history and examination in ENT
Allergic Rhinitis Epidemiology
Allergic rhinitis is the most common form of non-infectious rhinitisAt least 500 million individuals world-wide have allergic rhinitis and it is one of the most common reasons for attendance with a primary care practitionerAlmost 30% of adults and 40% of children are affectedWorld-wide the prevalence of allergic rhinitis continues to increase
UK/FF/0108/11 April 2011
ReferencesBousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63Suppl86:8-160Wallace DC et. J AllergyClinImmunol2008; 122: S1-84
Allergic Rhinitis Classification
BSACI Guidelines
Seasonal (UK)Tree pollen (birch, plane, ash + hazel)Grass pollen (timothy, rye + cocksfoot)Weed pollen (mugwort+ nettle)Fungal spores (Cladosporiumspp,Alternariaspp+Aspergilusspp)Perennial (UK)House dust mite (Dermatophagoidespteronyssinus)+ Animal DanderOccupationalFlour, grain, latex, wood dust, detergents
UK/FF/0108/11 April 2011
British society for allergy and clinical immunology
Diagnosis of allergic rhinitis
Intermittent symptoms
Mildoral antihistamineorintranasal antihistamine+/- decongestantorleukotriene antagonist
Asthma?
Moderateoral antihistamineorintranasal antihistamine+/- decongestantortopical nasal steroidorleukotriene antagonistorcromogycate
consider
Diagnosis of allergic rhinitis
Persistent symptoms
Asthma?
Mildoral antihistamineorintranasal antihistamine+/- decongestantortopical nasal steroidorleukotriene antagonistorcromogycate
consider
Diagnosis of allergic rhinitis
Persistent symptoms
Asthma?
Moderate severetopical nasal steroidoral antihistamineorleukotriene antagonistReview after 2 -4 weeks
If better, step down and continue for > 1 month
consider
Diagnosis of allergic rhinitis
Persistent symptoms
Asthma?
Moderate severetopical nasal steroidoral antihistamineorleukotriene antagonistReview after 2 -4 weeks
If not better,review diagnosisreview compliancequery infective / other causeincrease nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)
consider
Diagnosis of allergic rhinitis
Persistent symptoms
Asthma?
Moderate severetopical nasal steroidoral antihistamineorleukotriene antagonistReview after 2 -4 weeks
If not better,review diagnosisreview compliancequery infective / other causeincrease nasal steroidipratropium (rhinorrhoea)decongestant or oral steroid (blockage)If not better, refer
consider
Common co-morbidities:Asthma
Approximately 80% of asthmatics have rhinitisAllergic rhinitis may precede asthmaRhinitis impairs asthma controlTreatment of allergic rhinitis may improve asthma controlAllergic Rhinitis and its Impact in Asthma (ARIA) promotes assessing everyone with allergic rhinitis for asthma
UK/FF/0108/11 April 2011
ReferencesBousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160Wallace DC et. J AllergyClinImmunol2008; 122: S1-84
Common co-morbidities:Rhinoconjunctivitis
IncidenceOcular symptoms are commonRhinoconjunctivitis symptoms have been reported in more than 75% of patients with seasonal allergic rhinitisClinical significanceSeverely impairs QOLOften a forgotten aspect of care
UK/FF/0108/11 April 2011
Reference1. Wallace DC et al. J AllergyClinImmunol2008; 122: S1-84
Allergen Avoidance
BackgroundSuccess of intervention measured by clinical improvementStrategy success influenced by individual host sensitivity to allergenSensitivity differsbetweensallergens
EffectivenessStudies do not show consistent reduction in symptoms or medication requirements
UK/FF/0108/11 April 2011
Reference:1.Scadding GK et al.ClinExp Allergy 2008; 38:19-42
allergenavoidance
mattress, pillow, duvet coverssynthetic duvets, pillowsavoid woollen blanketsvacuum frequentlyavoid carpets, curtainskeep clothing in cupboardskeep animals out of bedroomslow relative humidityboil wash sheet, duvet covers
Nasal Decongestants (oral/topical)
BackgroundRelieve nasal congestionCause nasal vasoconstriction and decreased oedemaTopical - risk of rhinitismedicamentosa
Side effectsOral-HypertensionCaution with caffeine &other stimulantsTopical-Local stinging/burningNasal drynessSneezing
UK/FF/0108/11 April 2011
References1. Wallace DC et. J AllergyClinImmunol2008; 122: S1-84
OralAntihistamines
Seasonal and perennial allergic rhinitisBSACI guidelines state that regular therapy is more effective than ‘as needed use’ in persistent rhinitisReduce sneezing, rhinorrhoea and nasal and ocularpruritisbut have less effect on nasal congestionARIA recommend 2ndgeneration formulations which cause less sedation
UK/FF/0108/11 April 2011
References1. Scadding GK et al.ClinExp Allergy 2008; 38: 19-422.DykewiczMS. J AllergyClinImmunol2003; 111: S520-93. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63Suppl86:8-160
Intranasal Steroids
ARIA guidelines state that intranasal steroids are the most effective drugs for the treatment of allergic rhinitisEffective in relieving nasal congestion, rhinorrhoea, sneezing and nasal itchingGrade A level of recommendation forseasonal and perennial allergic rhinitisRecommended to be administered regularly for optimal benefit
UK/FF/0108/11 April 2011
References:1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63Suppl86:8-1602.RosenwasserLJ. Am J Med 2002; 113 (9A) 17S-24S3. Scadding GK et al.ClinExp Allergy 2008; 38: 19-42
Intra-nasal steroids
Local Side-effectsNasal irritation (propylene glycol/benzalkoniumchloride)Nasal bleeding/crustingSeptalperforation (rare – advise to use device away from septum)Warn patientsAvoidance with correct delivery techniqueMay be related to device induced traumaNo evidence of nasal tissue atrophy
UK/FF/0108/11 April 2011
Intra-nasal steroids -systemic side effects
Minimal absorption from nasal mucosaUp to 80% of intranasal dose swallowedExtensive hepatic first-pass metabolism by cytochrome P450 systemMinimal systemic levelsNo significant HPA suppression or effects on growth
Second generation INS
References1.LaForce. J AllergyClinImmunol1999; 103: S388-96
Summary
Allergic rhinitis is a common disease with a significant clinical and socioeconomic impactAccurate diagnosis and focussed therapeutic intervention is essentialImportant to diagnose and treat any associated co-morbiditiesAddress factors that improve patient tolerability and compliance with therapy
UK/FF/0108/11 April 2011
snoring
common
snoring
directly related to collar size
snoring
BMIevening alcoholmale
snoring treatments
weight reductionpositionstopping evening alcoholCPAPMADsurgery
snoring treatments
surgerytonsillectomy, nasal polypectomyLAUPU3Psclerosantinjectioncoblation, radiofrequencysomnoplastypillar implants
Nasal septal perforation
surgerytraumacocaine useinfectionpost trauma, syphilisWegener’s granulomatosissarcoidosisidiopathic
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