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Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed) ENT surgeon, Leeds

ENT. my nose is blocked – an update on rhinosinusitis & snoring. and general practice. Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed) ENT surgeon, Leeds 6 th March 2014, Leeds Masonic Hall. The Leeds Teaching Hospitals NHS Trust. aims. g ive an overview of common (E)N(T) conditions

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Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed) ENT surgeon, Leeds

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  1. ENT my nose is blocked – an update on rhinosinusitis & snoring and general practice Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed) ENT surgeon, Leeds 6th March 2014, Leeds Masonic Hall The Leeds Teaching Hospitals NHS Trust

  2. aims • give an overview of common (E)N(T) conditions • shows some example cases • refine our thinking of ENT problems

  3. objectives • list the main symptoms in nose conditions • relate each symptom to one condition • list the ways to examine the nose • identify an nasal polyp • classify rhinosinusitis • list 6 treatments for chronic rhinosinusitis (CRS) • define association with CRS & respiratory disease • list treatments for nasal polyps • formulate a management plan for snoring

  4. first though... • history and examination in ENT

  5. Allergic Rhinitis Epidemiology • Allergic rhinitis is the most common form of non-infectious rhinitis • At least 500 million individuals world-wide have allergic rhinitis and it is one of the most common reasons for attendance with a primary care practitioner • Almost 30% of adults and 40% of children are affected • World-wide the prevalence of allergic rhinitis continues to increase • References • Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160 • Wallace DC et. J Allergy ClinImmunol 2008; 122: S1-84 UK/FF/0108/11 April 2011

  6. 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 Dander • Occupational • Flour, grain, latex, wood dust, detergents British society for allergy and clinical immunology UK/FF/0108/11 April 2011

  7. Asthma? Diagnosis of allergic rhinitis consider Intermittent symptoms Moderate oral antihistamine or intranasal antihistamine +/- decongestant or topical nasal steroid or leukotriene antagonist or cromogycate Mild oral antihistamine or intranasal antihistamine +/- decongestant or leukotriene antagonist

  8. Asthma? Diagnosis of allergic rhinitis consider Persistent symptoms Mild oral antihistamine or intranasal antihistamine +/- decongestant or topical nasal steroid or leukotriene antagonist or cromogycate

  9. Asthma? Diagnosis of allergic rhinitis consider Persistent symptoms Moderate severe topical nasal steroid oral antihistamine or leukotriene antagonist Review after 2 -4 weeks If better, step down and continue for > 1 month

  10. Asthma? Diagnosis of allergic rhinitis consider Persistent symptoms Moderate severe topical nasal steroid oral antihistamine or leukotriene antagonist Review after 2 -4 weeks If not better, review diagnosis review compliance query infective / other cause increase nasal steroid ipratropium (rhinorrhoea) decongestant or oral steroid (blockage)

  11. Asthma? Diagnosis of allergic rhinitis consider Persistent symptoms Moderate severe topical nasal steroid oral antihistamine or leukotriene antagonist Review after 2 -4 weeks If not better, review diagnosis review compliance query infective / other cause increase nasal steroid ipratropium (rhinorrhoea) decongestant or oral steroid (blockage) If not better, refer

  12. Common co-morbidities: Asthma • Approximately 80% of asthmatics have rhinitis • Allergic rhinitis may precede asthma • Rhinitis impairs asthma control • Treatment of allergic rhinitis may improve asthma control • Allergic Rhinitis and its Impact in Asthma (ARIA) promotes assessing everyone with allergic rhinitis for asthma • References • Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160 • Wallace DC et. J Allergy ClinImmunol 2008; 122: S1-84 UK/FF/0108/11 April 2011

  13. Common co-morbidities: Rhinoconjunctivitis Incidence • Ocular symptoms are common • Rhinoconjunctivitis symptoms have been reported in more than 75% of patients with seasonal allergic rhinitis • Clinical significance • Severely impairs QOL • Often a forgotten aspect of care Reference 1. Wallace DC et al. J Allergy ClinImmunol 2008; 122: S1-84 UK/FF/0108/11 April 2011

  14. Allergen Avoidance • Background • Success of intervention measured by clinical improvement • Strategy success influenced by individual host sensitivity to allergen • Sensitivity differs betweens allergens Effectiveness Studies do not show consistent reduction in symptoms or medication requirements Reference: 1.Scadding GK et al. Clin Exp Allergy 2008; 38:19-42 UK/FF/0108/11 April 2011

  15. allergen avoidance • mattress, pillow, duvet covers • synthetic duvets, pillows • avoid woollen blankets • vacuum frequently • avoid carpets, curtains • keep clothing in cupboards • keep animals out of bedrooms • low relative humidity • boil wash sheet, duvet covers

  16. Nasal Decongestants (oral/topical) Background • Relieve nasal congestion • Cause nasal vasoconstriction and decreased oedema • Topical - risk of rhinitis medicamentosa Side effects Oral -Hypertension Caution with caffeine &other stimulants Topical - Local stinging/burning Nasal dryness Sneezing References 1. Wallace DC et. J Allergy ClinImmunol 2008; 122: S1-84 UK/FF/0108/11 April 2011

  17. Oral Antihistamines • Seasonal and perennial allergic rhinitis • BSACI guidelines state that regular therapy is more effective than ‘as needed use’ in persistent rhinitis • Reduce sneezing, rhinorrhoea and nasal and ocular pruritis but have less effect on nasal congestion • ARIA recommend 2nd generation formulations which cause less sedation References 1. Scadding GK et al. Clin Exp Allergy 2008; 38: 19-42 2. Dykewicz MS. J Allergy ClinImmunol 2003; 111: S520-9 3. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160 UK/FF/0108/11 April 2011

  18. Intranasal Steroids • ARIA guidelines state that intranasal steroids are the most effective drugs for the treatment of allergic rhinitis • Effective in relieving nasal congestion, rhinorrhoea, sneezing and nasal itching • Grade A level of recommendation for seasonal and perennial allergic rhinitis • Recommended to be administered regularly for optimal benefit References: 1. Bousquet J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 2008;63 Suppl 86:8-160 2. Rosenwasser LJ. Am J Med 2002; 113 (9A) 17S-24S 3. Scadding GK et al. Clin Exp Allergy 2008; 38: 19-42 UK/FF/0108/11 April 2011

  19. Intra-nasal steroids Local Side-effects • Nasal irritation (propylene glycol/ benzalkonium chloride) • Nasal bleeding/crusting • Septal perforation (rare – advise to use device away from septum) Warn patients • Avoidance with correct delivery technique • May be related to device induced trauma • No evidence of nasal tissue atrophy UK/FF/0108/11 April 2011

  20. Second generation INS Intra-nasal steroids - systemic side effects • Minimal absorption from nasal mucosa • Up to 80% of intranasal dose swallowed • Extensive hepatic first-pass metabolism by cytochrome P450 system • Minimal systemic levels • No significant HPA suppression or effects on growth References 1. LaForce. J Allergy ClinImmunol 1999; 103: S388-96

  21. Summary • Allergic rhinitis is a common disease with a significant clinical and socioeconomic impact • Accurate diagnosis and focussed therapeutic intervention is essential • Important to diagnose and treat any associated co-morbidities • Address factors that improve patient tolerability and compliance with therapy UK/FF/0108/11 April 2011

  22. snoring • common

  23. snoring • directly related to collar size

  24. snoring • BMI • evening alcohol • male

  25. snoring treatments • weight reduction • position • stopping evening alcohol • CPAP • MAD • surgery

  26. snoring treatments • surgery • tonsillectomy, nasal polypectomy • LAUP • U3P • sclerosant injection • coblation, radiofrequency somnoplasty • pillar implants

  27. Nasal septal perforation • surgery • trauma • cocaine use • infection • post trauma, syphilis • Wegener’s granulomatosis • sarcoidosis • idiopathic

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