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Differential Diagnosis of Rhinosinusitis

Differential Diagnosis of Rhinosinusitis. Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and Royal Brompton Hospitals. The Nose Clinic RBH. Hesham Saleh. Stephen Durham. Rhinitis – Inflammation of the Nasal Mucosa. Rhinitis definition. }. Nasal discharge Blockage Sneeze/itch.

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Differential Diagnosis of Rhinosinusitis

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  1. Differential Diagnosis of Rhinosinusitis Hesham Saleh, FRCS Consultant Rhinologist Charing Cross and Royal Brompton Hospitals

  2. The Nose Clinic RBH Hesham Saleh Stephen Durham

  3. Rhinitis – Inflammation of the Nasal Mucosa Rhinitis definition } • Nasal discharge • Blockage • Sneeze/itch 2 or more symptoms for > 1 hour on most days

  4. Rhinosinusitis – Inflammation of the Nasal and Sinus Mucosa Rhinitis definition } • Nasal discharge • Blockage • Sneeze/itch 2 or more symptoms for > 1 hour on most days

  5. Obstruction/Congestion Discharge/Purulence +/- Pain/Pressure +/-Hyposmia/Anosmia Endoscopic signs of: Polyps and/or Mucopurulent discharge and/or Oedema/mucosal obstruction and/or CT Changes Chronic Rhinosinusitis – EPOS 2007 Symptoms > 12 weeks

  6. Other (idiopathic, NARES, hormonal, etc) Allergic(seasonal or perennial) Infective (acute orchronic) Structural (polyps, septum,turbinates, etc) Rhinosinusitis Differential Diagnosis

  7. ARIA Classification Intermittent . Š 4 days per week . or Š 4 weeks Persistent . > 4 days per week . and > 4 weeks Moderate-severe one or more items . abnormal sleep . impairment of daily activities, sport, leisure . abnormal work and school . troublesome symptoms Mild normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms in untreated patients

  8. Diagnosis of Allergic Rhinitis HISTORY NASAL EXAMINATION SKIN PRICK TEST or RAST

  9. Diagnosis of Allergic Rhinitis • History is often very suggestive

  10. Allergic Salute

  11. Nasendoscopy

  12. Anterior Rhinoscopy

  13. Allergy skin prick testing

  14. Allergic Rhinitis and Infective Rhinosinusitis may coexist “no published prospective reports on the incidence of infective rhinosinusitis in populations with and without clearly defined allergic rhinosinusitis” EPOS 2007

  15. Other (idiopathic, NARES, hormonal, etc) Allergic(seasonal or perennial) Infective (acute orchronic) Structural (polyps, septum,turbinates, etc) Rhinosinusitis Differential Diagnosis

  16. Infective • Acute • Chronic • Specific • Bacterial • Fungal • Non-specific • Immune deficiency • Systemic • Local

  17. Obstruction/Congestion OR Discharge/Purulence +/- Pain/Pressure +/-Hyposmia/Anosmia Acute Rhinosinusitis – EPOS 2007 Sudden onset Symptoms < 12 weeks

  18. Acute Sinusitis

  19. Obstruction/Congestion Discharge/Purulence +/- Pain/Pressure +/-Hyposmia/Anosmia Endoscopic signs of: Polyps and/or Mucopurulent discharge and/or Oedema/mucosal obstruction and/or CT Changes Chronic Rhinosinusitis – EPOS 2007 Symptoms > 12 weeks

  20. Chronic Rhinosinusitis - Endoscopy • Pus in MM • Oedema in MM • Polyps

  21. Chronic Rhinosinusitis - CT • Confirms diagnosis • Map for surgery

  22. PLAIN X-RAY • 54% Sensitivity and 46% Specificity in sinusitis (Kuhn, 1986) • 75% of Plain X-Rays do not correlate with CT (McAlister and Lusk, 1989)

  23. Fungal Infections Aspergillosis Blastomycosis RhinosporoidosisCryptococcosis PhycomycosisActinomycosis CandidiasisHisptoplasmosis SporotrichosisMucormycosis

  24. Current Classification (deShazo, 1997) • Non-invasive • Fungal ball (mycetoma) • Allergic fungal sinusitis (AFS) • Invasive • Chronic invasive (indolent) fungal rhinosinusitis • Acute invasive (fulminant) fungal rhinosinusitis

  25. Current Classification (deShazo, 1997) • Non-invasive • Fungal ball (mycetoma) • Allergic fungal sinusitis (AFS) • Invasive • Chronic invasive (indolent) fungal rhinosinusitis • Acute invasive (fulminant) fungal rhinosinusitis

  26. Fungus Ball (Mycetoma) • Opacification • Double density (dense hyphae) • Bony sclerosis • No erosion

  27. Fungus Ball (Mycetoma)

  28. Allergic Fungal Sinusitis • Type I Hypersensitivity • 80% of Patients Have Diffuse Polyps • Elevated IgE to Fungus and Positive Skin Test • Thick Greenish Secretions with Fungal Hyphae

  29. Allergic Fungal Sinusitis • Sinus opacification • Expansion • Bony erosion • No tissue invasion

  30. Infective • Acute • Chronic • Specific • Bacterial • Fungal • Non-specific • Immune deficiency • Systemic • Local

  31. Immunodeficiency in Chronic Rhinosinusitis Immunoglobulins in M-P rhinorrhea 385 Hypogammaglob 11 (2.9%) Selective IgA 5 (1.3%) Selective IgG2 3 (0.8%) IgA + IgG2 6 (1.6%) Total 25 (6.5%)

  32. Primary Ciliary Dyskinesia • Dextrocardia • Rhinosinusitis • Bronchiectasis • Infertility

  33. Saccharin Test < 35 minutes

  34. Nasal Muco-Ciliary Clearance Greenstone M., Stanley P., MacWilliam L., Dewar A., Cox T., Mackay I.S., Cole P.J. Mucociliary function and ciliary ultrastructure in patients presenting with rhinitis to Brompton Hospital Nose Clinic. Eur.J. Respir. Dis. Suppl. 128, p 457-9. 1983.

  35. Electron Microscopy

  36. Cystic Fibrosis • Infective Rhinosinusitis (Pseudomonas) • 37% of Patients Have Polyps • Viscid Secretions • Polyps in Children

  37. Other (idiopathic, NARES, hormonal, etc) Allergic(seasonal or perennial) Infective (acute orchronic) Structural (polyps, septum,turbinates, etc) Rhinosinusitis Differential Diagnosis

  38. Structural

  39. Structural (Mechanical) • Deviation of nasal septum • Nasal polyps • Hypertrophy of inferior turbinates • Enlarged adenoids • Foreign bodies • Choanal atresia

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