“Doctor, I’m bunged up!” A GP’s guide to managing blocked noses and sinusitis.

www.entleeds.co.ukwww.entleeds.co.uk
Mr Sanjay VermaMr Sanjay Verma
PhD FRCS(ORL-HNS) MAPhD FRCS(ORL-HNS) MA
Consultant ENT and skull baseConsultant ENT and skull base
surgeonsurgeon
““Doctor, I’m bunged up!” A GP’s guide toDoctor, I’m bunged up!” A GP’s guide to
managing blocked noses and sinuses.managing blocked noses and sinuses.

An IntroductionAn Introduction
• Trained in the Eastern regionTrained in the Eastern region
• TWJ Fellowship to Toronto General Hospital andTWJ Fellowship to Toronto General Hospital and
the Hospital for Sick Children, Torontothe Hospital for Sick Children, Toronto
• Appointed to Leeds General Infirmary; ClinicalAppointed to Leeds General Infirmary; Clinical
Governance Lead for ENT and College SurgicalGovernance Lead for ENT and College Surgical
Tutor for LGITutor for LGI
• Specialise in complex ear and nasal surgery,Specialise in complex ear and nasal surgery,
endoscopic sinus surgery (including balloonendoscopic sinus surgery (including balloon
sinuplasty), children's ENT problems, andsinuplasty), children's ENT problems, and
managing tumours of the skull basemanaging tumours of the skull base

Causes of Nasal BlockageCauses of Nasal Blockage

Allergic rhinitisAllergic rhinitis

Related Anatomic Structures
Compromised by Allergic Rhinitis

Allergens
Seasonal
 Pollens
 Fungi
 Grass
Perennial
 House dust mite
 Dog/cat dander
 Feathers

Allergic Rhinitis: Symptoms
 Rhinorrhoea
 Nasal blockage
 Sneezing
 Itchy/red eyes
 Hyposmia

Allergic Rhinitis: Diagnosis
History
Skin prick test
IgE
RAST

Allergic Rhinitis: Treatment
Avoid contact with allergen
Hyposensitisation (Grazax etc)
Drug therapy

Drug options for Allergic Rhinitis
Drug type Itch /
sneezing
Discharge Blockage Impaired
smell
Nasal
preparations
Antihistamines +++ ++ + _ Azelastine
Anticholinergics _ +++ _ _ Ipratropium
Decongestants _ + +++ _ Xylometazoline
Oxymetazoline
Mast Cell
Stabilizers
+ + + _ Sodium
cromoglycate
Topical
Corticosteroids +++ +++ ++ +
Fluticasone
Mometasone
Beconase
2 sprays/nostril
OD

Mechanical BlockageMechanical Blockage
 Deviated septum
 Enlarged inferior
turbinates
 Enlarged middle
turbinates

Septal Haematoma
 Trauma / Surgery
 Obstruction
 Widening of dorsum of nose
 Ballooning of septum / fluctuant
 Can become abscess
 Can destroy nasal cartilage-collapse
 Needs draining and packing

Septal Perforation
 Traumatic- digital/ laceration/ facial trauma
 Iatrogenic- surgery
 Inflammatory-TB/ Syphilis/ Wegeners
 Malignant
 Cocaine use-vasoconstriction/ irritant
 Obstruction
 Snoring
 Septal button

The Internal Nasal Valve

Boundaries include:
• Septum
• Upper lateral
cartilages
• Anterior end of Inf.
Turbinate

1.3cm from nares

Accounts for 50% of
airway resistance

Inferior turbinate can
affect this area greatly

Turbinate Disorders
 Allergic rhinitis

Probably the most frequent cause of
turbinate-related nasal obstruction.
 Acute rhinosinusitis
 Chronic Rhinosinusitis

Leads to longstanding changes in
mucosa.

Fibrosis, polyposis.
 Vasomotor Rhinitis

Nasal congestion, rhinorrhoea only
 Drug Induced Rhinitis

Turbinate Disorders
 Nasal Polyposis

Etiology unclear - ?
denervated mucosa

Samter’s Triad
 Atrophic Rhinitis

Progressive slow atrophy
of nasal mucosa

Association with
aggressive turbinate
resection

Medical Management
 Allergic Rhinitis – Nasal steroids with oral
and/or topical antihistamines
 Drug induced rhinitis – cessation of topical
medicine and switch to steroids.
 Nasal Polyposis – systemic steroids,
topical steroids.

Surgical Management
 Total inferior Turbinectomy

Disadvantages –
• Postoperative haemorrhage rate of 5-8%
• Nasal crusting
• Synechiae 6-12% of the time
• Atrophic rhinitis?

Surgical Management
 Partial Turbinectomy

Anterior portion, at
nasal valve, is
resected.

Advantages
• Addresses nasal valve
• Courtis showed 92%
satisfaction at >2 years

Disadvantages
• Similar to total, but less
severe

Surgical Management
 Submucous Diathermy

Advantages
• Decreased risk of
haemorrhage
• Preserves mucociliary
clearance and air
conditioning

Disadvantages
• Technical difficulty
• Tendency to recurrence
– 25% in a 1988 study by
Mabry et al

Surgical Management
 Coblation

Radiofrequency plasma
tissue disrupter

Minimal thermal damage
to surrounding healthy
tissue

Can potentially be
performed in an
outpatient setting

Middle turbinate surgeryMiddle turbinate surgery

Sinusitis OverviewSinusitis Overview
 Inflammation of the sinus liningInflammation of the sinus lining
caused bycaused by

Bacterial, viral and/or microbialBacterial, viral and/or microbial
infectionsinfections

Structural issuesStructural issues
• Ostial blockageOstial blockage
• Nasal polypsNasal polyps
 Defining symptomsDefining symptoms

EitherEither Nasal blockageNasal blockage oror NasalNasal
dischargedischarge (anterior or posterior)(anterior or posterior)

+/-+/- Facial pain or pressureFacial pain or pressure

+/-+/- Reduction or loss of sense of smellReduction or loss of sense of smell
 Acute sinusitisAcute sinusitis

Symptoms < 12 weeksSymptoms < 12 weeks
 Chronic sinusitisChronic sinusitis

Symptoms > 12 weeksSymptoms > 12 weeks

Acute Sinusitis: Clinical Presentation
 Symptoms progress over 2 to 3 days
 Nasal congestion & discharge (usually thick &
coloured, not clear)
 Localized pain +/- referred pain
 Tenderness or pressure sensation over sinuses
 Headache
 Cough due to postnasal drip
 Halitosis
 Malaise

Acute sinusitis: Examination findings
Erythematous oedematous nasal mucosa
Purulent secretions in middle meatal area
- May be absent if ostia completely blocked
Percussion tenderness
- Over the involved sinuses
- Over the maxillary molar +/- premolar teeth
Halitosis
+/- fever

Acute sinusitis: referred pain patterns

Complications of acute sinusitisComplications of acute sinusitis
 OrbitalOrbital
 Osteomyelitis of Maxilla and FrontalOsteomyelitis of Maxilla and Frontal
bonebone
 MucoceleMucocele
 Intracranial complicationsIntracranial complications

Meningitis, intracranial abscess,Meningitis, intracranial abscess,
cavernous sinus thrombosiscavernous sinus thrombosis

Orbital ComplicationsOrbital Complications
 Orbital cellulitisOrbital cellulitis
 Orbital abscessOrbital abscess

Mode of SpreadMode of Spread
• DirectDirect
• Thrombophlebitis of vesselsThrombophlebitis of vessels

PresentationPresentation
• Aching around the orbitAching around the orbit
• Oedema of conjunctivaOedema of conjunctiva
• DiplopiaDiplopia
• Proptosis- laterProptosis- later
• Blindness (red colour vision first)Blindness (red colour vision first)
 TreatmentTreatment
- IV Abs and Nasal decongestants- IV Abs and Nasal decongestants
- CT scan- CT scan
- Urgent Drainage- Urgent Drainage

OsteomyelitisOsteomyelitis
 Occurs where there is diploic boneOccurs where there is diploic bone
 Maxilla in children and Frontal in adultsMaxilla in children and Frontal in adults
 MaxillaMaxilla

Painful swelling of the cheek and lower eye lidPainful swelling of the cheek and lower eye lid

CTCT

TreatmentTreatment

IV ABs and debridementIV ABs and debridement

Osteomyelitis….Osteomyelitis….
 Frontal BoneFrontal Bone

Dangerous and more extensive.Dangerous and more extensive.

Dull local pain and swelling of the upper eye lid.Dull local pain and swelling of the upper eye lid.

Potts puffy tumorPotts puffy tumor

High risk of intracranial complicationsHigh risk of intracranial complications

IV ABs and debridementIV ABs and debridement

MucoceleMucocele
 Frontal, Ethmoid, Maxillary, SphenoidFrontal, Ethmoid, Maxillary, Sphenoid
 Due to permanent blockage of the drainageDue to permanent blockage of the drainage

collection of sterile mucous, gradually expands and causes erosion ofcollection of sterile mucous, gradually expands and causes erosion of
sinus walls from pressuresinus walls from pressure
 PresentationPresentation

Headache and swellingHeadache and swelling

Displacement of the eye ballDisplacement of the eye ball

Endoscopic vs open techniques for drainageEndoscopic vs open techniques for drainage

Open techniquesOpen techniques
• FrontoethmoidectomyFrontoethmoidectomy
• Osteoplastic flap operationOsteoplastic flap operation

Intracranial complicationsIntracranial complications
 Meningitis- commonestMeningitis- commonest
 Intracranial abscessIntracranial abscess

ExtraduralExtradural

SubduralSubdural

CerebralCerebral
 EncephalitisEncephalitis
 Cavernous sinus thrombophlebitisCavernous sinus thrombophlebitis

Chronic sinusitisChronic sinusitis
 Inflammation involving nasal mucosa and
paranasal sinuses lasting longer than 12
weeks
 Criteria

Anterior and/or posterior mucopurulent drainage

Nasal obstruction

Facial pain, pressure and/or fullness

Decreased sense of smell
 Subtypes

With nasal polyposis

Without nasal polyposis

Allergic fungal rhinosinusitis

When to refer: nasoendoscopyWhen to refer: nasoendoscopy
• Anterior rhinoscopy mayAnterior rhinoscopy may
demonstrate rhinitis and largedemonstrate rhinitis and large
polyps, but may miss smallerpolyps, but may miss smaller
polyps and mucopuspolyps and mucopus
• Endoscopic investigation of theEndoscopic investigation of the
nose after topical decongestionnose after topical decongestion
is necessary especially tois necessary especially to
exclude differential diagnosesexclude differential diagnoses
• BewareBeware unilateralunilateral polypspolyps

Inverted PapillomaInverted Papilloma
 4% of sinonasal tumors4% of sinonasal tumors
 Site of Origin: lateralSite of Origin: lateral
nasal wallnasal wall
 UnilateralUnilateral
 Malignant degenerationMalignant degeneration
in 2-13% (avg 10%)in 2-13% (avg 10%)

Malignant lesionsMalignant lesions
 Squamous cell carcinomaSquamous cell carcinoma
 Adenoid cystic carcinomaAdenoid cystic carcinoma
 Mucoepidermoid carcinomaMucoepidermoid carcinoma
 AdenocarcinomaAdenocarcinoma
 HemangiopericytomaHemangiopericytoma
 MelanomaMelanoma
 Olfactory neuroblastomaOlfactory neuroblastoma
 Osteogenic sarcoma, fibrosarcoma, chondrosarcoma,Osteogenic sarcoma, fibrosarcoma, chondrosarcoma,
rhabdomyosarcomarhabdomyosarcoma
 LymphomaLymphoma
 Metastatic tumorsMetastatic tumors
 Sinonasal undifferentiated carcinomaSinonasal undifferentiated carcinoma

Radiological imagingRadiological imaging
• Coronal CT is scan of choiceCoronal CT is scan of choice
• CT scanning is mandatory before sinus surgeryCT scanning is mandatory before sinus surgery
• MRI may be helpful for:MRI may be helpful for:
 diagnosis of fungal disease and tumourdiagnosis of fungal disease and tumour
 if intracranial extension of disease is suspectedif intracranial extension of disease is suspected

Aims of managementAims of management
• To alleviate symptoms of chronicTo alleviate symptoms of chronic
sinusitissinusitis
• To remove polyps, improve nasalTo remove polyps, improve nasal
obstruction and olfactionobstruction and olfaction
• To prevent recurrence of nasal polypsTo prevent recurrence of nasal polyps

Medical TreatmentMedical Treatment
• Management ofManagement of
allergiesallergies
• AntihistaminesAntihistamines
• Leukotriene ReceptorLeukotriene Receptor
AntagonistsAntagonists
• Saline irrigationSaline irrigation
• CorticosteroidsCorticosteroids
• DecongestantsDecongestants

Saline IrrigationSaline Irrigation
• Increase mucociliaryIncrease mucociliary
flow ratesflow rates
• Brief vasoconstrictiveBrief vasoconstrictive
effecteffect
• Mechanically rinseMechanically rinse
• Adding baking sodaAdding baking soda
 Alkaline medium leadsAlkaline medium leads
to thinning of mucusto thinning of mucus

CorticosteroidsCorticosteroids
• Oral and nasal steroidsOral and nasal steroids
 Short course, high doseShort course, high dose
Prednisolone or BetnesolPrednisolone or Betnesol
nasal steroid drops willnasal steroid drops will
often improve symptomsoften improve symptoms
 Lower bioavailability inLower bioavailability in
nasal steroid spraysnasal steroid sprays
 Poor response in certainPoor response in certain
groupsgroups

Surgical TreatmentSurgical Treatment
• Functional endoscopic sinusFunctional endoscopic sinus
surgery (FESS)surgery (FESS)
• Balloon sinuplastyBalloon sinuplasty
• Relieva StratusRelieva Stratus

FESS

Surgical Treatment: what is theSurgical Treatment: what is the
evidence for it?evidence for it?

• 80 NHS Trusts, 87 NHS hospitals, 298 ENT80 NHS Trusts, 87 NHS hospitals, 298 ENT
consultants, 538 ENT surgeon for 6 months in 2000consultants, 538 ENT surgeon for 6 months in 2000
• Patients prospectively enrolled and followed up at 3Patients prospectively enrolled and followed up at 3
and 12 months post-operatively with the patientand 12 months post-operatively with the patient
centred SNOT-22 questionnairecentred SNOT-22 questionnaire
• 3128 patients, of which two-thirds had polyps present3128 patients, of which two-thirds had polyps present

• Sinus surgery is generally safeSinus surgery is generally safe
• CSF leak 0.064%, periorbital haematoma 0.2%CSF leak 0.064%, periorbital haematoma 0.2%
• Overall high level of patient satisfactionOverall high level of patient satisfaction
• Most effective in patients with polyp diseaseMost effective in patients with polyp disease

Balloon SinuplastyBalloon Sinuplasty

Balloon Sinuplasty: Outcomes DataBalloon Sinuplasty: Outcomes Data
Levine, HL, et al, Multicenter Registry of Balloon Catheter Sinusotomy Outcomes for 1,036 Patients. Annals of Otology, Rhinology & Laryngology. April
2008; Vol. 117(4): 263-270.
40 weeks
PatiENT Registry
27 sites n=1036 pts,
3276 sinuses
No serious adverse
events
2.4% patient
revision rate
95.2% symptom
improvement
CLEAR Study
SNOT-20 Score
-1.30 @ 2 yr (1)
(1) Scores statistically significant and clinically
improved at every time point over baseline
2 years
Patient
Satisfaction
Safety
6 months
No serious adverse events
Efficacy
1 year
91.6% functional
patency @ 1 yr

Relieva StratusRelieva Stratus

SummarySummary• Patient with blocked noses and sinuses may havePatient with blocked noses and sinuses may have
multiple issues that require addressingmultiple issues that require addressing
• Medical management in primary care can be successfulMedical management in primary care can be successful
in improving symptoms in many patientsin improving symptoms in many patients
• Referral to specialist ENT if diagnosis unclear or failureReferral to specialist ENT if diagnosis unclear or failure
of medical treatmentof medical treatment
• Septal surgery, turbinate reduction and FESS are ofSeptal surgery, turbinate reduction and FESS are of
proven valueproven value
• Coblation turbinate redcuction, Balloon sinuplasty andCoblation turbinate redcuction, Balloon sinuplasty and
Relieva Stratus offer safe and effective adjuncts toRelieva Stratus offer safe and effective adjuncts to
conventional sinus surgeryconventional sinus surgery

Thank youThank you
andand
……..any..any
QuestionsQuestions

Contact details for Mr VermaContact details for Mr Verma
• E-mail:E-mail: drsanjverma@gmail.comdrsanjverma@gmail.com
• Personal website:Personal website: www.entleeds.co.ukwww.entleeds.co.uk

Up to date information on ENT problems forUp to date information on ENT problems for
patients and GPspatients and GPs
• Secretary (Spire and Nuffield)Secretary (Spire and Nuffield)

Jayne Thompson: 0113 388 2129Jayne Thompson: 0113 388 2129

“Doctor, I’m bunged up!” A GP’s guide to managing blocked noses and sinusitis.

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