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Accurate investigations in rhinology..?

• Problems: AR, Polyps, Rhinosinusitis
– Impairment of Quality of life
Diagnostic tools in Rhinology:
– Significant morbidity and even mortality
AR, Nasal polyps and rhinosinusitis
– Serious consequences like Wegeners’ granulomatosis

– Exacerbate lower respiratory symptoms

Dr. E V Raman – May extend to involve lower respiratory tract

Manipal Hospital, Bengaluru

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Uses of investigations Diagnostic tools

• Early diagnosis
• History • Assessing sense of smell and
– Correct diagnosis, Extent of disease and severity • Nasal examination taste
• Management. • Investigations: Scopy • Nasal nitric oxide
– Anterior rhinoscopy • Nasal sampling: lavages,
– Plan: line of management, duration and followup cytology, biopsies
– Posterior rhinoscopy
• Insight into – Nasal endoscopy (rigid • Nasal patency evaluation
and flexible) • Microbiology
– Pathogenesis. • Blood and additional tests
– Diaphanoscopy
– Changes during therapy (Pharmacotherapy, immunotherapy) • Allergy tests • Imaging
• Future tools
– Different forms of inflammatory and non inflammatory disease

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History: Recommendations Nasal Examination

• History: Adequate time and attention • Inspection:
– Complete and accurate history
• Nose & face, both during inspiration & expiration
– Both rhinitis symptoms and possible co- morbidities.
– Major anomalies can be visualized directly
– The history should suggest further diagnostic tests
• The shape:
• ENT referral is needed for:
– unilateral nasal problems – AR: Horizontal nasal crease across the dorsum of the nose

– nasal perforations, ulceration or collapse – Nasal polyps: widened dorsum of the nose
– sero-sanguineous discharge • Covering skin of the nose: color changes, edema, scars
– severe crusting within the nasal cavity • The surrounding structures: forehead, eyes, cheeks & upper lip
– recurrent infection
• Palpation:
– periorbital cellulitis (refer urgently)
• Nasal obstruction
– severe sleep problems
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Anterior rhinoscopy Posterior Rhinoscopy

• Possible clinical findings
– Rhinorrhoe with transparent • Possible conditions
/ discoloured secretions – Congenital choanal atresia,
– Asymmetries (nasal septum) – Acute adenoiditis
– Mucosal aberrations or – Irritation of the
edema rhinopharynx,
– Nasal polyps – Postnasal discharge
– Neoplasms, corpora aliena, – Antro-choanal polyps and
etc. – Thornwald cysts.
– One can assess the
Mirror test
accessibility of the nose and
the shape of the conchae. • Often replaced by nasal endoscopy

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Nasal endoscopy Nasal endoscopy

Nasal endoscopy
• Technique:
– Flexible or rigid scope attached to a strong light source by glass fibre.

• Diagnostic examination: Scope with optic angle 25-30°, calibre2.5-4 mm

• Other optics: mostly used in surgery

– Preceded by local anaesthetic preferably in combination with decongestivum

• Advantage of global evaluation of endonasal cavity • Moderately sensitive and highly specific in predicting CT scan results.

• Good evaluation of the septum, the whole nasal cavity & the
nasopharynx .
• Area of the middle meatus: clinical importance in rhinosinusitis.
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• Nasal polyps: presence and severity can be scored by validated systems with a
good reproducibility.
• Correlation between size of polyps and the subjective symptom ..!
Allergic and inflamed mucosa, secretions or swelling in the middle meatus,
15 and possible presence of nasal polyps are evaluated 16

Diaphanoscopy
• Inspection, palpation and anterior rhinoscopy
• Transillumination of human tissue or a cavity with a light
– easy and rapid ways
source to evaluate the opacity of the hollow sinus.
– corner stone of every physical examination.
• Maxillary sinus:
– Light source in the mouth of the patient, watched in a darkened room. • Persistent nasal symptom: complete and thorough
– Sinus is accessible (vacant): light shines through sinus and pupil. examination using nasal endoscopy.
• The frontal sinus:
• Rigid endoscopy : more patient friendly and better
– light source is placed at the bottom of the frontal sinus.
image
• Useful only in case of a unilateral acute maxillary or frontal
sinusitis of an adult patient, who did not yet undergo sinus
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Allergy tests Nasal provocation tests

• Presence of specific IgE
– in vivo (skin tests, SPT)

– In vitro (RAST, CAP-RAST & equivalent assays}

• SPT:
– Unanimously considered the gold standard

– First-line approach for allergic sensitization • Non-specific nasal challenges:

• efficiency, safety and relatively low costs.
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– Stimuli may directly act on a single receptor
• histamine, adenosine monophosphate, and methacholine,
– Activate complex mechanism
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• Mannitol, capsaicin, hyperosmolar solutions and cold air. 20

AR: Diagnosis Assessing sense of smell

• Rhinitis and/or rhinosinusitis:
• Complain of smell and taste dysfunction
– Smell tests
• University of Pennsylvania Smell Identification Test
(UPSIT)
• Connecticut Chemosensory Clinical Research Center
Test (CCCRC)
• Smell diskettes test
• Odourant confusion matrix
• Alcohol sniff test
• Random test etc..
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Assessing sense of taste Nasal NO

• Five basic taste sensations: salt, bitter, sour, umami & • Role of NO:

sweet – Complex: possibly include antibacterial effects, pro-inflammatory

effects, & regulation of blood flow & ciliary beat frequency.
– Sour taste: Citric acid or hydrochloric acid
– Exhaled NO levels: Raised in eosinophilic asthma
– Bitter taste: caffeine or quinine hydrochloride
• Provide a rapid, low cost, objective measure inflammation.
– Salty taste: sodium chloride
• greater levels of NO are produced in the upper than in the
– Sweet taste: saccharose
lower respiratory tract
– Umami taste: monosodium glutamate
• Measurement: Chemilluminescence- non-invasive techniques
• Electrogustometry: widely used to examine sensitivity
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Nasal Sampling: lavages, cytology, biopsies Comparison of different techniques

• Nasal blow secretions
• Nasal lavage
• Sinus packs / filter paper
• Endoscopy guided swab
• Microsuction technique
• Nasal brush
• Nasal scraping
• Nasal biopsy: Polyps, Papilloma

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Evaluation of Nasal Patency Microbiology

• Peak nasal inspiratory flow
• Colonization versus infection

• Culture sensitivity:
– Swab from Nose or Sinus…?

• Rhinomanometry – poor correlation: Misinterpretation of the results.

• Acoustic rhinometry
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Evaluation of Mucociliary Clearance Blood and Additional Tests

• Allergic Rhinitis:
• Mucociliary clearance time – Allergen-specific IgE.
• Nasal NO (very low ) in contrast to CRS, NP and other nasal • Severe non-infectious, non-allergic rhinitis:
inflammatory conditions. – Full blood count (AEC),
• Electron microscopy evaluation of the epithelial cilia – thyroid function, thyroid auto- antibodies

• Ciliary beat frequency measurement – Anti- nuclear antibodies, extractable nuclear antibodies (anti-Ro
& anti La: Sjogren’s syndrome- QLIPS)
• The definite proof epithelial cell cultures & Ciliogenesis in
– pregnancy test or tests for drugs of addiction on urine.
vitro
– Beta-2 transferrin, Glucostix test strips

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Blood and Additional Tests Blood and Additional Tests

• Rhino Sinusitis without polyps • Rhino Sinusitis with polyps
– Churg Strauss syndrome(CSS):
– Full blood count: TC, DC, ESR and/or C Reactive Protein
• ANCAs (pANCA pattern with specificity for MPO)
– Renal, liver and thyroid function – Aspirin sensitivity:
– Humoral immunity markers: IgG subclasses, specific antibody • Aspirin provocation test
levels (tetanus, haemophilus, pneumococcus) and response to • Cellular antigen stimulation test (CAST)
– Fungal sinusitis:
immunization if low
• Deficits in the innate and acquired immunity
– cellular immunity markers: T and B cell numbers and ratios
– Primary ciliary dyskinesia:
– HIV status. • Mucociliary clearance time, Nasal NO, Electron microscopic
– Serum ACE level evaluation, ciliogenesis in vitro
– Cystic fibrosis:
– c-ANCA
• Blood analysis for CFTR gene mutations (homozygote & heterozygote
gene mutations)
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Imaging in Rhinology
Radiological Evaluation
• X-ray
•A CT scan
• USG –mandatory before sinus
• CT: MDCT, MSCT surgery
– Caution in Children..! –during surgery
•MRI
– Timing..
–helpful for the diagnosis of
• MRI fungal disease and tumor or if
• CT + MRI: intracranial extension of
disease is suspected.
– Complimentary..!

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Summary

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References
• Scadding et al. Diagnostic tools in Rhinology EAACI
position paper. Clinical and Translational Allergy
2011, 1:2.
• Google images for Pictures

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