Sixth Annual ENT for the PA-C | March 30 – April 3, 2016 ... ENT for... · • Occupational • Hormonal • Drug‐induced • Atrophic. ... Non‐Allergic Rhinitis with Eosinophilia

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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



Objectives:

• Identify history of allergic vs non‐allergic rhinitis

• Recognize clinical and laboratory findings that facilitate differentiation

• Current guidelines for treatment



• No Disclosures

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• 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


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

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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


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.


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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


Skin Prick Testing


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


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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


Options

• Environmental controls

• Intranasal antihistamines

• Combo therapy

• Surgical referral

• Acupuncture


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


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


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• Oral Corticosteroids: short courses for severe nasal symptoms OK

• Parenteral single dose is discouraged and recurrent administrations are contraindicated



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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Vasomotor Rhinitis“idiopathic rhinitis”

• Rhinorrhea: think cholinergic secretory activity

• Gustatory: think vagally mediated

• Nasal congestion: think heightened nociceptive neuron sensitivity


Infectious: Rhinosinusitis


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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NARESNon‐Allergic Rhinitis with Eosinophilia Syndrome

Wrights Stain Distilled Water

5‐20% Eosinophils on smear


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


Drug induced

• ACEI

• Phosphodiesterase 5 selective inhibitors

• Phentolamine

• Alpha receptor antagonists

• ASA/NSAID

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Drug InducedRhinitis Medicamentosa

Intranasal alpha‐adrenergic decongestants

Cocaine


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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Non‐Allergic Rhinitis Treatments

• Intranasal corticosteroids

• Intranasal antihistamines

• Intranasal anticholinergic

• Intranasal capsaicin: nociceptors


Non‐Allergic Rhinitis Treatments

• Stop or change causative medication

• Oral or topical decongestants short term

• Nasal Hygiene

• PO ABRS or topical antibiotics (think Atrophic)


Rhinitis: When to Look Deeper

• Failure or non‐response to empiric treatment

• Anosmia

• Nasal obstruction

• Epistaxis

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Endoscopes

• Pictures courtesy Todd Kingdom, MD CU Sinus Center


Normal Chronic Sinusitis


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


Nasal Polyps/AERD


Nasal Polyps/AERD

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CRS‐Chronic Rhinosinusitis


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.


Case:Ms. S

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How Do We Know If Someone Has A CSF Leak?


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


ANATOMY AND SURGICAL OPTIONS

Rhinitis

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Nasal Obstruction

Picture courtesy Todd Kingdom CU Sinus Center


Surgical OptionsNasal obstruction


Turbinates

Picture Courtesy Todd Kingdom MD, CU Sinus Center

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Nasal Obstruction Surgery:Inferior Turbinate Hypertrophy



Nasal Obstruction Surgery:Inferior Turbinate Reduction



Septoplasty

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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


Thank You!

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016 ... ENT for... · • Occupational • Hormonal • Drug‐induced • Atrophic. ... Non‐Allergic Rhinitis with Eosinophilia

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