Clinical Examination and Differential Diagnosis in Rhinology
Summary
The diagnosis of a sinonasal disease begins with the patient′s clinical history, preferably taken in the form of a standard questionaire. The second step is nasal examination, including nasal endoscopy. In the third step, complementary diagnostic tools are used such as assessment of nasal flow and resistance (peak nasal inspiratory flow [PNIF], anterior rhinomanometry, and acoustic rhinometry), allergy tests (skin prick test and serum-specific immunoglobulin E [IgE]), olfactory function testing (olfactometry), inflammation testing (cytology and nasal nitric oxide [NO]), microbiology testing (meatal swab), quality of life questionnaires, and the patient′s reported outcomes. The last step is imaging; computed tomography (CT) is the gold standard for assessing the extent of disease (acute/chronic rhinosinusitis and fungal diseases), while leaving magnetic resonance imaging (MRI) for ocular/intracranial complications and biopsy to assess tissue pathology (neoplasia, vasculitis, and granuloma). In addition, lower airway diseases (asthma, chronic obstructive pulmonary disease [COPD], and bronchiectasis) should always be investigated.
Introduction
The common cold (100%), (allergic) rhinitis (15–30%), and chronic rhinosinusitis (CRS, 10–15%), including nasal polyposis (2–4%), are the most prevalent diseases affecting the nose and paranasal sinus mucosa (percentages indicate prevalence in the general population). Other sinonasal disorders important in the differential diagnosis are nonallergic rhinitis, acute and chronic infections, structural abnormalities, vasculitides, and granulomatous diseases, as well as benign and malignant tumors ( Table 8.1 ). Sinonasal disease is frequently associated with lower airway disease, such as asthma, COPD, and bronchiectasis. In this chapter, we summarize the main diagnostic tools that are used in the differential diagnosis of nasal and sinonasal disease, including clinical nasal symptoms (their definition and classification, etiology, and severity), nasal signs and clinical nasal examination, imaging, quality of life, and assessment of nasal patency and the loss of smell. In addition, we propose algorithms for multidisciplinary consultation and referral.
Clinical Diagnosis
History Taking
Technique and Systematization
Before asking questions about specific rhinologic symptoms, the examiner should always let the patient express what he or she feels and discuss the importance of his or her complaints. After hearing the patient′s reason for consultation, the examiner can then ask general questions to determine a preliminary presumptive diagnosis. Each symptom must then be described in detail. If the history suggests an allergic etiology, an additional specific questionnaire should be completed to determine if there is a family or personal history of allergic diseases, such as asthma, atopic dermatitis, allergic rhinitis, or food allergies. Possible environmental/food allergens also should be investigated.
Note
The patient′s history is absolutely essential for understanding and diagnosing nasal and sinus diseases, and, in some cases, it may lead to the diagnosis, despite normal ENT examination (see case study).
A structured history should include the presenting complaint (the main reason why the patient is seeking medical help; should ideally refer to one major symptom or complaint), history of the presenting complaint (the duration, intensity, variability, and exacerbating and mitigating factors of the symptom, as well as any accompanying symptoms), past medical history (all concurrent diseases and operations; of particular interest for the rhinologist are airway and allergic diseases, such as asthma, COPD, and eczema), family history (e.g., asthma or eczema in the family), social history (smoking and alcohol consumption or drug exposure, such as cocaine [see Video 5, Cocaine-induced Rhinitis, Early Stage ], but also household conditions, such as pets; smoke exposure; use of fans, carpets, or feather pillows; possible exposure to occupational allergens in the workplace), and allergies and drug history, including possible abuse of over the counter decongestants (see Video 4, Rhinitis Medicamentosa ). Following a standard routine and systematizing the above, as seen in the following case study, can help to avoid omissions.
Case Study
Patient: John Doe, a 24-year-old male teacher
Presenting complaint: watery rhinorrhea
History of the presenting complaint: unilateral, constant; also occurring during sleep. Started 9 months ago following head injury. No seasonal variations. Exacerbating factor: bending. Not helped by medications. No associated nasal obstruction, sneezing, epistaxis, or headaches
Past medical history: briefly hospitalized 6 months ago for concussion. No asthma, no eczema
Social history: nonsmoker; 5 alcohol units per week. Works in school. Has no pets; no adverse occupational exposures
Allergies: none known
Drug history: fluticasone nasal spray twice daily for 3 months
Diagnosis: CSF leak
ENT examination: Unremarkable
Working diagnosis: CSF rhinorrhea
Nasal Symptoms
In rhinitis, major symptoms are nasal (itching, sneezing, watery rhinorrhea, and congestion) associated with nonnasal symptoms, which include eye and bronchial symptoms, sleep apnea, and habitual snoring. There are questionnaires available that can help in the diagnosis of allergic rhinitis.1,2 In rhinosinusitis, major symptoms are nasal congestion/obstruction/blockage, anterior rhinor-rhea or postnasal drip, facial pain or pressure (more predominantly in acute rhinosinusitis [ARS]), and reduction or loss of the sense of smell (predominantly in CRS with nasal polyps).3–5 In addition, international1 guidelines recommend the use of symptoms for the differential diagnosis of rhinitis and rhinosinusitis. In other sinonasal diseases, prominent symptoms may be purulent rhinorrhea and nasal crusting, bleeding, or obstruction (vasculitis and tumors); facial hypoesthesia (tumors); and malocclusion (facial fractures and tumors). Symptoms may be rated using a Likert scale (mild, moderate, or severe) or visual analogue scale (VAS) (0–10 cm). Composites of total nasal, total non-nasal, and global scores also can be obtained.
Rhinorrhea
Nasal discharge is a typical symptom of the common cold, allergic and nonallergic rhinitis, and rhinosinusitis (either acute or chronic). The consistency and color of nasal discharge should be assessed. Also, it is important to determine the localization of the discharge (uni- or bilateral), the time of onset, as well as precipitating and mitigating factors. An acute watery bilateral discharge is usually associated with a common cold or, if chronic, allergic or non-allergic rhinitis ( Fig. 8.1 ). A thick mucopurulent unilateral discharge may be associated with an infection, such as ARS, although mucopurulent discharge can also be seen in noninfectious (e.g., eosinophilic) inflammation; a foreign body (especially in young children and adults with cognitive disorders); or systemic disease, such as Wegener granulomatosis ( Fig. 8.2 ) or sarcoidosis. A unilateral blood-tinged secretion may suggest a tumor. Unilateral watery rhinorrhea, especially when elicited by bending and associated with salty taste, is highly suggestive of cerebrospinal fluid (CSF) rhinorrhea ( Fig. 8.3 ). Typically, nasal hypersecretion associated with nasal hyperreactivity ceases during sleep; watery rhinorrhea on the pillow in the morning is typical of CSF leak ( Fig. 8.4 ) (see Video 6, Encephalocele with CSF Rhinorrhea ).
Note
Epistaxis is a very common symptom; however, recurrent severe epistaxis should always bring into consideration hereditary hemorrhagic telangiectasias (Weber-Rendu-Osler syndrome [ Fig. 8.5 ]). (See Video 7, Rendu-Osler-Weber Syndrome with Septal Button .)
Nasal Obstruction
Also known as nasal congestion, stuffiness, or blockage, nasal obstruction is one of the most common presenting symptoms in clinical practice. It is well known to correlate with a decreased quality of life and may lead to sequelae such as poor sleep, mood fluctuations, and decreased productivity.6 Nasal obstruction can even be a life-threatening condition in newborns, who are mandatory nasal breathers. A choanal atresia in the first days of life can interfere with breastfeeding and cause respiratory distress. In older children (often secondary to adenoid hypertrophy), nasal obstruction may be associated with ear ventilation problems, affecting hearing and speech development, and also could (together with oropharyngeal obstruction) cause sleep apnea syndrome (see Chapter 34). In older children and adults, it may impact very significantly upon their quality of life by causing serious discomfort and by altering sleep patterns, along with the senses of smell and taste.
In history taking, it is important to determine whether nasal obstruction has been present for a long time or if it is of recent onset, for instance, after a nasal trauma, which would strongly suggest a septal deviation after a nose fracture. Long-standing, constant nasal obstruction (uni- or bilateral) with very few other coexisting nasal symptoms can be the result of structural abnormalities, such as septal deviation, but more often is caused by mucosal swelling/hypertrophia of the turbinates caused by rhinitis/rhinosinusitis. Progressive over months or a few years, constant, unilateral nasal obstruction can be associated with nasal tumors, whereas intermittent, reversible nasal obstruction with distinct precipitating factors suggests an inflammatory etiology.
The examiner should also elicit whether the obstruction is alternating between the sides (physiologic nasal cycle), unilateral or bilateral, and constant or intermittent.
Fluctuation usually suggests an inflammatory mucosal condition rather than a mechanical obstruction. Nasal obstruction caused by allergic rhinitis or rhinosinusitis is usual bilateral and alternating, exacerbating the physiologic nasal cycle. Anatomical obstructive causes, such as septal deviation or adhesions ( Fig. 8.6 ), can be unilateral or bilateral, but tend to be associated with constant nasal obstruction, with poor fluctuation, essentially mirroring the nasal cycle.
A unilateral nasal obstruction should always be assessed with a nasal endoscopy. Inverted papilloma ( Fig. 8.7 ), choanal polyp, foreign body reaction, rhinolith, and malignancies usually present themselves unilaterally ( Fig. 8.8 ). If a unilateral mass is found, the etiology must always be clarified with imaging and (unless a vascular tumor is suspected) a biopsy.
A bilateral nasal obstruction presents as a medical emergency in the neonate, whereas a unilateral choanal atresia can present later in life, or even during adulthood. In a young boy or male adolescent, unilateral nasal obstruction accompanied by nosebleeds is often caused by a nasopharyngeal angiofibroma.
Precipitating or relieving factors should be elicited. Worsening in some environments or the resolution of symptoms when the normal patient′s environmental conditions change (e.g., during seasonal variations) is suggestive of an allergic cause.
There are some validated questionnaires available to evaluate the subjective sensation of decreased airflow and its impact on quality of life. The Nasal Obstruction Symptom Evaluation Scale (NOSE)7 and the Congestion Quantifier Seven-Item test (CQ7)8 have been shown to be good assessment tools. Symptom rating using four- or six-point Likert scales or the VAS may be used as well. A variety of techniques, with different levels of evidence ( Table 8.2 ), may be used to assess the presence, severity, etiology, and follow-up of nasal obstruction.
Facial Pain/Pressure/Headache
Facial pain/headaches are often associated with diseases of the paranasal sinuses, including inflammation (pre-dominantly in ARS) and tumors. However, the real cause of headache may be difficult to ascertain, as it is a nonspecific symptom that has many causes (for more information on facial pain, see Chapter 10).
Usually, when there is sinus inflammation, headache is accompanied by nasal symptoms, such as nasal congestion and rhinorrhea. If headache is not accompanied by nasal symptoms, it is very unlikely that it is caused by rhinosinusitis. The headache is typically a facial pressure sensation that can vary in intensity and usually worsens with head movement or by bending over, as in ARS. In chronic disease, increased pain by bending over is not seen more often in rhinosinusitis than in other forms of headache.
ARS do not always affects only one sinus, but when it does, the pain can help the examiner locate the origin of infection. In maxillary sinusitis, the pain is more intense over the maxillary sinuses and the adjacent midface and zygomatic region, but it may also radiate to the forehead. In dentogenic maxillary sinusitis, the dental pain can be more intense and obscure the sinogenic pain. In ethmoidal sinusitis, it is more severe over the nasal root, medial canthus, and retro-orbital/periorbital region. The pain is usually less intense than that associated with maxillary or frontal sinusitis. In sphenoid sinusitis, pressure may be located at the center of the skull, vertex, or occipital region. In frontal sinusitis, it is typically localized over the forehead, with pain radiating toward the medial canthus. Typical features that suggest that a headache is sinogenic include its association with nasal symptoms, its exacerbation with upper respiratory tract infections, and its response to medical or surgical treatment of rhinosinusitis.
Facial pain that follows the distribution of a nerve (e.g., infraorbital) could be related to inflammatory changes affecting the nerve (e.g., secondary to osteitis from maxillary sinusitis); however, it should always raise the possibility of a space-occupying lesion.
Nonsinus headaches frequently are characterized by the same symptoms, thus making it difficult to determine if the headache is really caused by a sinus problem. However, some symptom features can help the examiner make the differential diagnosis. Tension headaches will occur in a band shape that goes from the forehead to the neck and is usually worsened or precipitated by psychological stress. Migraine headache is very intense, often pulsating and (in the case of classic migraine) preceded by aura, located behind and around the eyes, affecting one side of the head, associated with nausea, and usually lasting hours or days. Trigeminal neuralgia is characterized by intense, sudden pain localized in the trigeminal region (ears, forehead, eyes, lips, nose, scalp, jaw, cheeks, and teeth) often triggered by a light touch on the face or by chewing, talking, or brushing one′s teeth. Cluster headache is characterized by very severe unilateral orbital, supraorbital, and/or temporal pain attacks that occur together in bouts. (For a more extensive discussion of facial pain/headache see Chapter 10.)
Tips and Tricks
When a patient presents with headache as the only symptom, it is rarely sinus related.
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