Clinical Village – Station 13

Methodology • Rhinoscopy should be done using headlight to free up both hands. Rhinoscopy should be used to open vestibule. • The vision of the anterior third of nasal cavities in rhinoscopy can be magnified using otoscopy or headlight with binocular microscope (Figure 1). • Flexible or rigid endoscope is needed to examine the entire nasal cavities with excellent magnification. • Two crossings should be done in nasal endoscopy, looking over the inferior and middle meatuses, up to the

nasopharynx, examining mucosa and mucus appearance and colouring, abnormal anatomy or blood or masses presence. Middle meatus is the landmark to explore.

Findings • In health. Normal anatomy and mucosa colouring. No masses or polyps, no rhinorrhea and free meatus. Absence of hemorrhage. Good permeability (2-3mm). • In diseases. Reduction of permeability, abnormal anatomy and mucosa coloring. Presence of tumors, polyps, inflammation, rhinorrhea, and/or hemorrhage.

Introduction • Background. Nasal diseases are among the most prevalent in primary care and specialist consultation. Since diagnostic tools and complementary tests raise the direct costs and extend the time to indicate the best therapy, to select the most efficient is a must. • Definition & objective. Direct examination of the nasal cavities using rhinoscopy and/or nasal endoscopy has been shown to be the most efficient technique for the differential diagnosis of infectious / inflammatory / neoplastic diseases of the nose.1-4 • Indications & Contraindications. Any disease of the nose should be investigated by using rhinoscopy / nasal endoscopy. There is no formal contraindication although hemorrhagic diseases should be carefully managed.

Figure 2. Healthy and diseased rhinoscopy and nasal endoscopy.

• Rhinoscopy and nasal endoscopy are the most efficient techniques to facilitate the differential diagnosis of sinonasal diseases.

• Instruments needed are accessible, not expensive. and gathered up for the use in office.

• Middle meatus is the landmark to explore, where signs of sinonasal disease can be found (rhinorrhea, tumors, nasal polyps, inflammation).

References 1.  Isaac A, et al. JAMA Otolaryngol Head Neck Surg 2015 [Epub ahead] 2. Wuister AM, et al. Otolaryngol Head Neck Surg 2014; 150(3):359-64 3. Eren E, et al. Clin Otolaryngol 2013;38(6):481-6. 4. Aziz T, et al. J Otolaryngol Head Neck Surg 2014;43:11.

1.  Rhinoscopes 2.  Otoscope 3.  Videofiberoscope

4. Nasoendoscope 5. Headlight 6. Headlight with binocular microscope

Figure 1. Needed material:

1. Differences in rhinoscopy or endoscopic view. 2. Left nostril healthy rhinoscopy/endoscopic view. 3. Right inferior turbinate hypertrophy (i.e. allergy rhinitis)

4. Left purulent rhinorrhea from middle meatus (acute or chronic rhinosinusitis) 5. Left chronic rhinosinusitis with nasal polyps.

Rhinoscopy view

Endoscopic view

1 2 3 4 5

Nasal  septum  

Inferior  turbinate  

Purulent  rhinorrhea  

RHINOLOGY Rhinoscopy / Nasal endoscopy

 A del Cuvillo, C Langdon, S Centellas, A Garcia-Piñero, J Sánchez, J Mullol

Cádiz, Barcelona, and València, Spain

Take Home

Clinical Village – Station 13

Methodology

•  Subjective Olfactory Test. Barcelona Smell Test-24 (BAST-24, see Figure 1). •  Smell Outcomes. Smell detection (DT), smell recognition/memory (CO) and forced choice success (AC) among 4 possible answers. Secondary outcomes: smell definition (DF) and spontaneous identification (ID) . •  Indication. To test the olfactory function in healthy and smell impaired individuals. Figures 3, 4 and 5 show examples of explorations. •  Environment. The room should be quiet and noise-isolated, well-ventilated, with controlled humidity and temperature (21-23ºC). •  Examination time. Examiner and patients should not wear perfumes and/or creams. Patients should avoid spicy foods, beverages, and smoking.

Introduction

•  The sense of smell is of crucial significance since provides us critical information about nourishment, sensual attraction, emotions, and even warnings of potential hazards such as fire or spoiled food.1

•  Common cold, sinonasal inflammation (allergic rhinitis, acute and chronic rhinosinusitis/nasal polyps), and trauma brain injury are among the most common causes of olfactory dysfunction.1-2 •  The OLFACAT (Olfaction in Catalonia) survey reported an overall prevalence of olfactory dysfunction in the general population as high as 19.4%, including a total loss of smell of 0.3%. However, only 6.9% of participants subjectively considered their smell as being poor or very poor. This survey estimates over 82 million EU citizens suffering from some olfactory dysfunction.3

•  About one-third of the patients with olfactory disorders have severe problems with ingestion, harm avoidance, and social communication and express a noticeable reduction in quality of life.4

•  Olfactometries: UPSIT, Sniffin’ Sticks, Smell Diskettes, BAST-24.

Ø  Olfactory tests are helpful tools to diagnose and follow-up the loss of smell and its severity due to a variety of causes. Ø  Due to the nature of odor identification, closely related to familiar aromas and odors, olfactory tests are usually limited to specific countries and regions: Pennsylvania Smell Identification Test (UPSIT) and the Connecticut Chemosensory Clinical Research Center identification test (CCCRC) in the USA, Sniffin’ Sticks test and Smell Diskettes Test in the EU. Ø  BAST-24 is a valid, reliable, and reproducible olfactory test validated for Catalan, Spanish, and Mediterranean populations.

Take Home References

1.  Enriquez K, et al. Curr Opin Otolaryngol

Head Neck Surg 2014;22:34–41. 2.  Guilemany JM, et al. Int Arch Allergy

Immunol 2012;158:184-90. 3.  Mullol J, et al. BMJ Open 2012;2:e001256. 4.  Croy I, et al. Chem Senses 2014;39:185-94. 5.  Cardesín A, et al. Rhinology 2006;44:83-9.

Figure 1. BAST-24 consists of 20 odors to assess the 1st cranial nerve and 4 odors for the 5th cranial nerve. It is validated for Catalan, Span ish, and Med i ter ranean populations.5

0

2

4

6

8

10

12

14

16

18

20

DT DF CO ID AC

I PAR CRANEAL 1st  CRANIAL  NERVE   I PAR CRANEAL

02468101214161820

DT DF CO ID AC

1st  CRANIAL  NERVE  

0 2 4 6 8

10 12 14 16 18 20

DT DF CO ID AC

I PAR CRANEAL 1st  CRANIAL  NERVE  

Figure 5. Persistent allergic rhinitis 1st CN: 90% DT, 80% CO, 40% AC

Figure 3. Healthy individual 1st CN: 100% DT, 95% CO, 75% AC  

Figure 4. Nasal polyposis 1st CN: 40% DT, 35% CO, 30% AC

RHINOLOGY Olfactory test / BAST-24

 A Garcia-Piñero, C Langdon, S Centellas, A del Cuvillo, J Sánchez, J Mullol

València, Barcelona, and Cádiz, Spain

Figure 2. Smell jars are presented at 1cm of the nose.

RHINOLOGY

Clinical Village – Station 13

Nasal provocation test

Introduction Specific nasal provocation test (NPT) consists of eliciting an allergic response from the nasal mucosa by controlled exposure to allergens. This response is characterized by itching, sneezing, runny nose and edema of the nasal mucosa with increased resistance to airflow. • Indications: Confirmation of allergic rhinitis, evaluation of patient’s sensitivity (response threshold), research on pathophysiological mechanisms of nasal response to allergens, assessment of efficacy and safety profile of drugs used to treat rhinitis, monitoring of clinical response after specific immunotherapy, etiologic study of occupational respiratory diseases, assessment of NSAID exacerbated respiratory disease (L-ASA NPT). • Allergen application techniques: Allergen volume should be 0.1ml aprox. Different devices are available: syringe, dropper, micropippete, nasal spray, impregnated cotton, impregnated disk.

Take Home • Nasal provocation test is useful in the assessment of allergic response to allergens. • Although it is a long test for daily clinical practice, nasal provocation is very useful in clinical research and to rule out NSAID hypersensitivity. • The use of objective tests to assess NPT should be mandatory.

J Sánchez, A del Cuvillo, S Centellas, A Garcia-Piñero, C Langdon, J Mullol. Barcelona, Cádiz, and Valencia, Spain.

References 1.  Van Spronsen E, et al. Allergy 2008;63:820-33. 2.  Dordal MT, et al. J Investig Allergol Clin Immunol

2011;21:1-12. 3.  Soliman M, et al. Ann Allergy Asthma Immunol

2014;113:250-6.

Methodology 1. Evaluation: -  NPT starts with the application of an inert substance (usually the diluent used to

prepare the solutions). -  It can be done with a single dose of the allergen or a serial application of increasing

allergen concentrations (at intervals of 15 to 60 min). -  Nasal response should be assessed at 15-30 min after allergen application. The patient

must be kept under observation for 2 hours and should be informed that symptoms may appear later at home.

-  Baseline forced spirometry is recommended at the beginning and end of NPT, even for non-asthmatic patients.

2. Assessment of nasal response: -  Clinical Examination: anterior rhinoscopy, quantification of weight and volume of nasal

secretions. -  Clinical Symptoms Score: VAS (Visual Analogue Scale) score for sneezing, rhinorrhea,

itching, and nasal obstruction. -  Assessment of Nasal Airflow: Nasal Peak Expiratory flow (NPEF) and Nasal Peak

Inspiratory flow (NPIF). -  Assessment of Nasal Airflow Resistance: anterior rhinomanometry. -  Assessment of Changes in Nasal Cavity Geometry: acoustic rhinometry. -  Assessment of Inflammatory Response: nasal irrigation, nasal brushing/biopsy, nasal

nitric oxide (nNO).

F i g u r e 1 . B a s i c equipment for a nasal p r o v o c a t i o n t e s t : micropippete, tips, front light, allergen extract.

Figure 2. NPT using micropippete (A), nasal spray (B), and syringe (C).

A

B

C

RHINOLOGY

Clinical Village – Station 13

Sacharine Test •  It is based on the ciliary transport of the saccharine particle along the

nostril down to the oropharynx. •  A particle of sodium saccharine (1mm) is placed on the surface of the

inferior nasal turbinate, 1cm behind its head (Figure 1). •  Patient should inform any particular taste. The real taste should not be

specified in order to avoid false positives. •  The test is considered normal if detection occurs below 30 minutes. If

the participant does not detect any taste after 60 minutes, a saccharine particle is placed on the tongue to exclude any taste abnormality.

Mucociliary clearance (MCC) is a primary defense mechanism of the upper and lower airways and disruption of this process, whether acquired or inherited, predisposes an individual to chronic upper and lower airway infections.1 The MCC could be hampered for two main reasons: 1) defaults in the movements of the cilia (genetic defects or temporary dysfunction), or 2) dehydration of the mucus leads to increased viscosity and the ciliary clearance becomes thereby ineffective. In the first group we have primary (genetic) and secondary (infection or inflammation) ciliary diskinesia while in the second group we found cystic fibrosis, COPD, or asthma patients. At present, none of the methods studying MCC is the ideal, and there is a variety of investigational methods and techniques for its study.

•  MCC is an important defense mechanism for the airways. •  The study of MCC should be an essential part of the workup of

recurrent respiratory infections, particularly if primary ciliary dyskinesia is suspected.

•  Assessment of ciliary function can be carried out with simple, easy to use and inexpensive equipments.

•  The saccharine test is a useful screening method for detecting diseases with abnormal MCC

•  Nasal NO is a useful method to alert the clinician of a possible defect in mucociliary clearance.

Methodology

Nasal nitric oxide (nNO) •  Nasal NO is measure by a chemiluminescence analyser [parts per

million; ppm] •  The subject is asked to take a deep breath in, close the mouth and do

not exhale (Figure 2). The mean of tree measurements is considered for the assessment.

•  Valid measurement protocols have been reported for adults and infants,2 but reference values do not exist due to high inter-individual variations.

Additional techniques •  Transmission electron microscopy detects changes within the cilia

and/or altered dynein arms (Figure 3).3 Nasal specimens are collected by nasal brushing. Costs and expenditure of time are unfavourable.

•  If a hereditary disorder of cilia function is suspected, cell culture of ciliated cells has been recommended. This time-consuming technique is only available in few specialized centres but it has a nearly ideal sensitivity and specificity.

Clinical study of mucociliary system C Langdon, A Garcia-Piñero, S Centellas, A del Cuvillo, J Sánchez, J Mullol

Barcelona, València, and Cádiz, Spain

Introduction

1. Guilemany JM, et al. Arch Bronconeumol 2006;42:135-40. 2. Wodehouse T, et al. Eur Respir J 2003;21: 43-7. 3. Papon JF, et al. Eur Respir J 2010;35(5):1057-63.

Figure 1. Under direct vision with a rhinoscope and a Hartman forceps (a) sacharine is placed on the surface of the inferior nasal turbinate (b).

a   b  

Figure 2. Measurements of nasal NO output during breath hold.

Take-home References

a   b  

Figure 3. Transmission electron micros-copy. a) Cilia in healthy nasal mucosa. b) Ultrastructure images of respiratory cilia (ODA, outer dynein arm; IDA, inner dynein arm).

RHINOLOGY

Clinical Village – Station 13

Nasal function assessment

Methodology Active anterior rhinomanometry (AAR). Evaluates nasal permeability indirectly, by measuring nasal flow and nasal resistance at different pressures (Figures 1 & 2). •  Patient should be at rest 30 minutes and avoid the use of local drugs that may

alter nasal resistances during the previous 24-48h. •  Pressure is measured in one nostril and flow on the other. •  Registry is carried out during a regular not forced respiration. •  At least 3-5 respiratory cycles should be measured. •  Baseline exploration can be complemented with a vasoconstriction test.

Acoustic rhinometry. It consists on a sound impulse generated and transmitted through a tube into the nostrils. It determines the cross-sectional areas into the nasal airways while nasal volumes are obtained by extrapolation (Figure 3). •  Patient should be at rest 15-30 minutes. •  When measuring, nostril should be completely occluded with the nose piece and

with the patient in apnea. Avoid deforming the nostrils. •  To reduce variability, at least 3 similar measurements should be obtained. •  Baseline exploration can be complemented with a vasoconstriction test.

Take Home • Objective assessment of nasal function should be mandatory when evaluating nasal obstruction or assessing treatment effectiveness. • Both rhinomanometry (AAR) and acoustic rhinometry (AR) are easy to perform, not invasive, and complementary: - AAR provides dynamic and functional information - AR provides static and geometric information • Limitations: - AAR is not useful when nasal obstruction is so severe that blocks nasal flux - AR is not useful for distal evaluation

References 1. Van Spronsen E, et al. Allergy 2008;63:820-33. 2. Merkle J, et al. Rhinology 2014;52:292-9. 3. Nathan, et al. J Allergy Clin Immunol

2005;115:S442-59. 4. Silkoff PE, et al. Am J Rhinol 1999;13:131-5. 5. Dordal MT, et al. J Investig Allergol Clin Immunol

2011;21:1-12.

Introduction Nasal congestion. Objective restriction of nasal cavity airflow because of mucosal disease and/or increased mucus secretion excluding anatomical variants. Frequent etiology. Septal deviation, turbinate hypertrophy, allergic and non-allergic rhinitis, nasal polyposis, tumors. Assessment: •  Subjective: Detailed clinical history, symptom scoring evaluation,

nasal endoscopy, CQ7 questionnaire (nasal congestion). •  Objective:

•  Direct methods: imaging (CT sacna, MRI), acoustic rhinometry (AR).

•  Indirect methods: rhinomanometry, peak nasal inspiratory flow (PNIF) measurement.

Figure 1. A) Rhinomanometer (Rhinospir Pro) with facial mask. B) Detail of the manometer. C) Patient using the rhinomanometer mask.

Figure 2. Rhinomanometry registries of a control subject (A), a patient with allergic rhinitis in pollen season (B), and a patient with nasal polyposis (C).

A                                                                      B                                                                  C  

J Sánchez, C Langdon, S Centellas, A del Cuvillo, A Garcia-Piñero, J Mullol. Barcelona, Cádiz, and València, Spain.

A   B   C  

Figure 3. Acoustic rhinometer SRE 2000 (Rhinometrics, Lynge, Denmark) (A). Detail of different size nosepieces (B). Scheme of the sound impulse (C). Acoustic rhinometry registries for a patient with nasal polyposis (D) or with allergic rhinitis before and after vasoconstriction (E).

A  

B   C  

D   E