2. Discolosures
• Grant/Research Support: no
disclosure
• Consultant: no disclosure
• Major Shareholder: Locumdoctor4u
Ltd. (Locum and Concierge Medical
Services)
• I will not be discussing “off-label”
uses of medications or investigations
3. ENT Referrals
i.
Most ENT referrals are linked to Audiological and
Otological problems.
ii.
Out of 271 consecutive referrals to the RHP ENT
Department triaged in 2011, 58% could be potentially
managed in Primary Care.
CLPCT NHS Survey 2011 – E Cervoni
GP Trainees 27/11/13,
Education Centre RPH
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4. ENT Referrals
i.
Snoring and sleep apnoea were relatively common reasons of
referrals.
ii. In a rather significant proportion of cases, relevant information,
with specific reference to the physical examination, were missing.
iii. Among the referrals redirected to the GPwSI in ENT, deafness with
wax, epistaxis and blocked nose were the most common
complaints.
GP Trainees 27/11/13,
Education Centre RPH
CLPCT NHS Survey 2011 – E Cervoni
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7. Rhinosinusitis
Inflammation of the nose and
Inflammation of the nose and
paranasal sinuses characeterized
paranasal sinuses characeterized
by the presence of 2 or more
by the presence of 2 or more
symptoms of which one MUST be
symptoms of which one MUST be
nasal obsteruction or rhinorrhoea
nasal obsteruction or rhinorrhoea
with:
with:
±facial pain/pressure
±facial pain/pressure
±hypo/anosmia
±hypo/anosmia
Associated with
and/or CT abnormal changes:
Endoscopic signs:
- polyps and/or
- polyps and/or
- purulent secretion from the middle
- purulent secretion from the middle
meatus and/or
meatus and/or
- oedema/mucosal
oedema/mucosal obstruction
obstruction
prevalent in the middle meatus
prevalent in the middle meatus
GP Trainees 27/11/13,
Education Centre RPH
- mucosal changes at the level
- mucosal changes at the level
of the osteo-meatal complex or
of the osteo-meatal complex or
of the paranasal sinuses
of the paranasal sinuses
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8. CLASSIFICATION
on severity of the symptoms
Rhinosinusitis may be classified into mild, moderate or
severe on the basis of VAS score.
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10
To assess the severity of the symptoms the patient is asked
to answer the following question:
How painful are the symptoms of your sinusitis?
How painful are the symptoms of your sinusitis?
No pain
10 cm
GP Trainees 27/11/13,
Education Centre RPH
Worst possible
pain
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9. CLASSIFICATION
on duration
12 weeks
ACUTE/RECURRENT
(complete resolution of the symptoms)
(complete resolution of the symptoms)
CHRONIC
(incomplete resolution of the symptoms)
(incomplete resolution of the symptoms)
GP Trainees 27/11/13,
Education Centre RPH
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10. Acute Rhinosinusitis:
clinical features
Sudden onset of its symptoms of which one must be nasal
obstruction or rhinorrhoea
±facial pain/pressure
±facial pain/pressure
±hypo/anosmia
±hypo/anosmia
And duration <12 weeks
Presence of endoscopic signs of:
Presence of endoscopic signs of:
••Purulent secretion from the middle meatus
Purulent secretion from the middle meatus
••Oedema and/or obstruction of the middle meatus
Oedema and/or obstruction of the middle meatus
Presence of abnormal changes to CT imaging
Presence of abnormal changes to CT imaging
GP Trainees 27/11/13,
Education Centre RPH
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11.
Acute rhinosinusitis:
types
Acute viral (common cold)
Duration of the symptoms < 10 days
Duration of the symptoms < 10 days
Acute post-viral
-- Symptoms oncrease after 5 days
Symptoms oncrease after 5 days
-- Persistence of the symptoms after 10 days, but for less than
Persistence of the symptoms after 10 days, but for less than
12 weeks
12 weeks
Bacterial post-viral
Presence of at the least 3 symptoms and/or signs:
Presence of at the least 3 symptoms and/or signs:
-Purulent secretion
-Purulent secretion
-Pain with unilateral preponderance
-Pain with unilateral preponderance
-Fever (>38 C)
-Fever (>38 C)
-Raised ESR and CPR
-Raised ESR and CPR
GP Trainees 27/11/13,
-Worsening of theEducation Centre RPHa phase of remission
-Worsening of the symptoms after a phase of remission
symptoms after
11
12. Acute rhinosinusitis:
differential diagnosis
Viral infection of the upper airways
Allergic rhinitis
Confirmed positivity to a common allergen
Confirmed positivity to a common allergen
It is characterized by rhinorrhoea (which is not
It is characterized by rhinorrhoea (which is not
purulent), senstion of nasal obstruction, itchy nose,
purulent), senstion of nasal obstruction, itchy nose,
sneezing (spontaneus regression of the symptoms
sneezing (spontaneus regression of the symptoms
or following treatment)
or following treatment)
Associated to ophtalmological symptoms/signs
Associated to ophtalmological symptoms/signs
Odontogenic
Absence of nasal signs and symptoms
Absence of nasal signs and symptoms
GP Trainees 27/11/13,
Education Centre RPH
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13. CHRONIC RHINOSINUSITIS
Sudden appearance of two or more symptoms of which ine
should be nasal obstruction or rhinorrhoea
±facial pain/pressure
±facial pain/pressure
±hypo/anosmia
±hypo/anosmia
Duration >12 weeks
Presence of endoscopic signs of:
Presence of endoscopic signs of:
••Nasal polyps
Nasal polyps
••Muco-purulent secretion from the middle meatus
Muco-purulent secretion from the middle meatus
••Oedema and/or obstruction of the middle meatus
Oedema and/or obstruction of the middle meatus
Presence of CT abnormalities
Presence of CT abnormalities
GP Trainees 27/11/13,
Education Centre RPH
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14. Types of chronic rhinosinusitis
With nasal polyps
Without nasal polyps
GP Trainees 27/11/13,
Education Centre RPH
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16. This disequilibrium determines an activation of TH2 immune response.
The response is characterized by the production of cytokines which may
differ depending of the specific nature of the chronic inflammatory
response.
GP Trainees 27/11/13,
Education Centre RPH
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17. Allergic fungal
rhinosinusitis
Usually unilateral, with occasional purulent secretion
Characterized by high levels of IL-4, IL-5 and IL-13.
The high levels of IL-5 observed on those patients affected by allergic fungal
rhinosinusitis highlights who this condition may be considered
independently from oesinophils dysfunction disease.
GP Trainees 27/11/13,
Education Centre RPH
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19. Invasive form
• Acute fulminant
• Chronic: - granulomatous
- invasive
Non-invasive form
• Allergic fungal rhinosinusitis
• Fungal ball
GP Trainees 27/11/13,
Education Centre RPH
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20. NOTE: surgery must be associated to antibiotic therapy and
corticosteroids aiming to reduce the inflammatory component
and/or infective.
There is scientific evidence to support the use of topical steroids,
antibiotics and antifungal drugs.
GP Trainees 27/11/13,
Education Centre RPH
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21. Diagnosis is based on CT, MRI and pathology results
GP Trainees 27/11/13,
Education Centre RPH
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22. Chronic rhinosinusitis:
- Without asthma or allergy
- Whitout asthma, but with allergy
- With asthma and allergy
- With asthma, but without allergy
- With allergy to aspirin
- Allergic fungal
- Cystic fibrosis
GP Trainees 27/11/13,
Education Centre RPH
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23. DIAGNOSIS
- Anamnesis
- Anterior rhinoscopy
- Nasal endoscopy
- Nasal swab
- CT
- MRI
- Biofilm Research
GP Trainees 27/11/13,
Education Centre RPH
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24. Little role of plain x-rays
(Skinner et al., 1991)
F.N.*
F.P.**
A.D.***
3%
20%
77%
Ethimoid
55%
-
36%
Sphenoid
43%
1%
52%
3%
4%
93%
Maxillary sinus
Nasal cavity
* False negatives: Rx normal/pathological
** mucosa
*** False positives: Rx pathological/ normal 27/11/13,
GP Trainees
mucosa Diagnostic accuracy: Education Centre RPH
Rx findings/Intraoperative findings in keeping with Rx
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26. • Extension of the disease
• Presence of bone eroisions
• Presence
of
anatomical
variances
with
possible
operative challenges
ESTENSIONE DELLA PATOLOGIA
PRESENZA DI INTERRUZIONE DELLE LIMITANTI OSSEE
GP Trainees 27/11/13,
PRESENZA DI ANOMALIE ANATOMICHE
Education Centre RPH
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28. Does not offer details of bone structures
Does not offer details of bone structures
Overestimes presence of mucosal abnormalities
Overestimes presence of mucosal abnormalities
GP Trainees 27/11/13,
Education Centre RPH
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29. Excellent visualization of soft tissues.
Excellent visualization of soft tissues.
Helpful to assess neoplastic pathology
Helpful to assess neoplastic pathology
Helpful to assess the extension of inflammatory processes.
Helpful to assess the extension of inflammatory processes.
GP Trainees 27/11/13,
Education Centre RPH
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32. European guidelines
for the treatment of
rhinosinusitis and nasal
polyps
GP Trainees 27/11/13,
Education Centre RPH
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33. “EVIDENCE BASED MEDICINE”
Categories
Ia
Evidence from meta-analysis of randomised controlled trials
Evidence from meta-analysis of randomised controlled trials
Ib
Evidence from at least one randomised controlled trials
Evidence from at least one randomised controlled trials
IIa
Evidence from at least one controlled study without randomisation
Evidence from at least one controlled study without randomisation
IIb
Evidence from at least one other type of quasi-experimental study
Evidence from at least one other type of quasi-experimental study
III
Evidence from non-experimental descriptive studies, such as
Evidence from non-experimental descriptive studies, such as
comparative studies, correlation studies, and case-control studies
comparative studies, correlation studies, and case-control studies
IV
Evidence from expert committee reports or opinions or clinical
Evidence from expert committee reports or opinions or clinical
experience of respected authorities, or both
experience of respected authorities, or both
GP Trainees 27/11/13,
Education Centre RPH
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Shekelle et al., BMJ 1999
35. Acute rhinosinusitis: therapy
Antibiotic thereapy is indicated
only when strictly required
(confirmed bacterial infection,
fever and severe pain)
GP Trainees 27/11/13,
Education Centre RPH
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36. Acute rhinosinusitis: length of antibiotic therapy
Short treatments appear to have the same effectiveness of longer antibiotic
courses
GP Trainees 27/11/13,
Education Centre RPH
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39. Acute rhinosinusitis: combined therapy
(steroid and oral antibiotic)
Corticosteroids when combined with
oral antibiotics appear to be
particularly effective in producing a
prompt improvement of the
symptoms – evidenca IA
Duration of treatment 3-5 days
GP Trainees 27/11/13,
Education Centre RPH
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40. Acute rhinosinusitis: complications
Between 3,7% and 20%
Can be:
• Orbital (60-75%) ,
• Intracranial (15-20%)
• Bones (5-10%).
Sinusites account for 10% of the intra-cranial complications, and up to 90% of the
orbital complications.
GP Trainees 27/11/13,
Education Centre RPH
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42. Chronic rhinosinusitis without nasal
polyposis
topical steroids
Only 2 recent papers have reported a significant benefit of topical steroids versus
placebo.
Anatomical factors and type of device to affect effectiveness of the treatment.
GP Trainees 27/11/13,
Education Centre RPH
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46. Chronic rhinosinusitis without nasal
polyposis
topical antibiotics
There is no evidence of benefits resulting from topical antibiotic therapy.
GP Trainees 27/11/13,
Education Centre RPH
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47. Chronic rhinosinusitis without nasal
polyposis
oral antibiotics
There is no evidence of benefits from antibiotic therapy < 4 weeks(short term), if
there is no evidence of infection on the basis of microbiology results.
Macrolids are the only class of antibiotics to have shown some benefits (Ib)
GP Trainees 27/11/13,
Education Centre RPH
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52. Rinosinusite cronica con poliposi nasale
terapia antibiotica sistemica
GP Trainees
Non ci sono evidenze sulla 27/11/13, antibiotica topica
terapia
Education Centre RPH
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54. WHY SURGERY?
Remove paranasal obstruction
Improve ventilation and drainage of sinuses
Reduce number of exacerbations
Reduce complications
Improve quality of life
GP Trainees 27/11/13,
Education Centre RPH
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55. PROBABILITY OF SUCCESS OF
ENDOSCOPIC SURGERY
Maximal
Poor paranasal sinuses ventilation
Recurring sinusitis
Sinusitis affwecting only one sinus
“Fungus ball”
Mucocele
Antral polyp
Orbital/intra-cranial complications
GP Trainees 27/11/13,
Education Centre RPH
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57. PROBABILITY OF SUCCESS OF
ENDOSCOPIC SURGERY
Rhinosinusitis with macropolyposis
Intermediate
Minimal
Rhinosinusitis with asthma
ASA-Syndrome
Cystic Fibrosis
Kartagener’s S.
Congenital disorders
GP Trainees 27/11/13,
Education Centre RPH
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