RHINITIS

COMMON COLD (CORYZA)

Incidence acute, non-allergic, infective, viral / inflammation Definition - MCC of nasal obstruction - in crowded poorly ventilated areas, in children & during winter

CHRONIC HYPERTROPHIC RHINITIS

chronic, non-allergic, non-specific inflammation of nasal mucosa

CHRONIC ATROPHIC RHINITIS

chronic, non-allergic, nonspecific inflammation of nasal mucosa (atrophy of epithelium & glands) dt endarteritis & periarterial fibrosis 0zena = female & puberty

SCLEROMA
Chronic specific inflammation of the URT - sporadically all over the world - endemic in Egypt, Eastern Europe, Russia, Central & South America (scleroma belt). - in adults &low socioeconomic classes bacillus or Klebsiella rhinoscleromatis 1. active granulomatous stage the characteristic cellular infiltration at MucoCutaneous Junction of the vestibule of the noses and the respiratory nasal mucosa. The submucosa appears infiltrated by lymphocytes, plasma cells as well as two characteristic components: i. Mickulicz cells - derived from histiocytes - appear as large vacuolated foam cells containing scleroma bacilli. ii. Russell bodies - eosin-staining degenerated plasma cells iii. Mott cells. - precursors of Russell bodies. 2. fibrotic stage the cellular infiltration is

Etiology

rhinoviruses - mucosal inflammation - musical swelling - mucus production 2ry infection - Strep. pneumonia - Haemophilus influenza - Moraxella catarrhalis - Staph. aureus

characteristic: - mucosal congestion - mucosal edema - hypertrophy of inferior turbinates(IT) early stage late stage reversible irreversible *fibrosis starts in the submucosa = chr. chronic catarrhal/ hypertrophic simple chronic

0zena hormonal, infective( bacillus ozaenae) 2ry = 1. Excessive IT surgical resection 2.Head radiotherapy 3. Marked deviation of the nasal septum (on the roomy side). 4. Granulomata e.g. Scleroma

gradually replaced by fibroblasts and dense fibrous tissue giving the lesions its characteristic hardness. Contraction of the fibrous tissue may lead to narrowing or complete obliteration of the nasal cavity as well as external deformities. 3. Atrophic Stage of the epithelium & sero-mucinous glands. 1. Granulomatous type: firm pale pink granulomatous masses starting near the mucocutaneous junction of the nose and spreading posteriorly may extend to the external nose and upper lip (Hebra nose). 2. Fibrotic type: The nasal cavities arenarrowed or may be obliterated by fibrous stenosis and adhesions 3. Atrophic type: roomy and contains crusts.

Clinical Pictures

Prodromal (ischemic, invasion) few hours - sneezing - burning sensation in NP - nasal obstructn - headache

Hyperemic (secretion) few days

Resolution

-low grade fever - malaise - arthralgia -nasal obstructn - profuse watery rhinorrhea Symptoms lasting beyond 7 days, or worsening instead of improving suggest secondary bacterial infection Complication: 1. Acute sinusitis. 2. Acute otitis media. 3. Chest infection

7-10 days gradual improvement of symptoms

A. Symptoms: 1. Nasal obstruction : usually bilateral or alternating between 2 sides. *on posture changes, dependent side becomes blocked dt gravitational swelling of turbinates 2. Mucoid nasal and post nasal discharge. 3. Hyposmia B. Signs: early stages IT= swollen &congestd mucosa = smooth & slightly congested

1. Anosmia (olfactory nerve fiber atrophy) 2. Nasal obstruction: i. Accumulation of crusts. ii. Misdirection of air currents iii.Inability to sense the airflow. (dt trigeminal nerve endings atrophy) 3. Epistaxis dt crust separation 4. Anterior rhinoscopy shows : i. Roomy nasal cavities ii. Yellowish or greenish crusts iii. Pale atrophic mucosa & IT

late stage IT = hypertrophied mucosa = irreagular (mulberry app) & slightly congested dt underlying fibrosis

Treatmen t

- self-limited !!! supportive =bed rest, analgesics, nasal &occasionally steam inhalations. Antibiotics reserved for secondary bacterial infections

A. Conservative treatment: 1. Avoid precipitating factor e.g. smoke and dust. 2. Saline nasal douches. 3. Topical steroid 4. Vasoconstrictor nasal drops B. Surgical treatment: Surgical size reduction: - Submucous diathermy - Partial inferior turbinectomy - Submucous resection of the bone of IT (turbinoplasty) - Laser turbinoplasty

1. Saline washes 2. Lubricant drops e.g. paraffin drops & 25% glucose in glycerin 3. Surgical treatment - limited value. i. Submucosal implantation of inert materials to narrow the roomy nasal cavities. ii. Temporary closure of the nostrils 2r= 1. removal of cause 2. frequent cleaning with saline wash

1. Long course of antibiotics is the main treatment. the quinolones, the aminoglycosides, and the tetracyclines. Or C/S 2. Surgery may be needed to open the nasal airway and to correct deformities.

ALLERGIC RHINITIS Definitio n Pathophysiolog y clinical hypersensitivity of nasal mucosa to foreign substance (antigens) mediated through IgE antibodies co-morbidity - URTI - nasal polyposis - Otitis Media With Effusion - sinusitis - asthma history of - Associated allergic diseases - Positive family history - Exposure to indoor allergens ( animal) - High socioeconomic status

VASOMOTOR RHINITIS increase reactivity of the nasal mucosa to non-specific stimuli in the absence of usual Ab-Ag reaction Autonomic imbalance (predominant cholinergic effect) precipitating factors: 1. Sudden temperature and humidity changes. 2. Cooling of the skin ( the cause of sneezing on getting out of bed) 3. Emotional instability. 4. Non-specific irritants, such as fumes and smoke. 5. Pregnancy often identical to true allergic rhinitis in its clinical picture However, allergic tests are negative.

RHINITIS MEDICAMENTOSA iatrogenic condition where rhinitis develops as a result of inappropriate use of vasoconstrictor nasal drops

ANTROCHOANAL POLYP solitary polyp that originates from the maxillary antrum then passes through the osteum os the sinus posterior nasal opening (choana) nasopharynx

Clinical features .

1. Sneezing (especially in the morning) 2. BILATERAL nasal discharge 3. Nasal obstruction + hyposmia 4. Itching in throat + irritant cough 5. Itching & watery eyes (more in seasonal AR) 1. Pale, bluish, moist, edematous nasal mucosa 2. Swollen INFERIOR TURBINATE 3. Puffiness & blue circles around the eye + nasal salute 4. Nasal polypi (occasionally) 1. Nasal smears for eosinophilia : eosinophils may present 2. Skin test 3. RAST measure circulating IgE to specific Ag 1. avoid/eliminate allergen 2. topical steroid spray, oral antihistamine 3. hyposensitization therapy

1. Rebound nasal obstruction following the use of vasoconstrictor nasal drops. 2. Fiery red edematous nasal mucosa

1. Long history of AR or vasomotor rhinitis 2. UNILATERAL constant nasal obstruction 3. Polyp seen in endoscopy or posterior rhinoscopy

Diagnosis

1. NEGATIVE allergic test 2. some cases = no eosinophils in nasal smear 1. Drug treatment is similar to that of allergic rhinitis 1. Withdrawal of the offending nasal drops 2. Topical steroid preparations

CT scan of nose & paranasal sinuses

Treatme nt

1. Endoscopic removal (middle meatal antrostomy) 2. Caldwell-Luc approach (sublabial antrostomy)

ALLERGIC RHINITIS
Incidence/ Definition clinical hypersensitivity of nasal mucosa to foreign substance (antigens) mediated through IgE antibodies * 2nd MCC of nasal obstruction in general, *the MCC of chronic or recurrent nasal obstruction 1. initial stage (low dose exposure) production of specific IgE antibodies (1ry humoral response) 2. subsequent exposure 2ry humoral response release of histamine, cytokines & other mediators from stimulated mast cells vasodilatation + fluid transudation ( rhinorrhea & nasal blockage) & neuronal stimulation (sneezing & itching)

NASAL POLYPI
pedunculated portions of edematous mucosa of nose or paranasal sinuses

ACUTE SINUSITIS
acute inflammation of mucous membrane lining paranasal sinuses

CHRONIC SINUSITIS
inflammation of the mucosa of sinuses of at least 12 consecutive weeks

Etiology

- allergy, vasomotor changes, infection, aspirin intolerance * SMATTERS TRIAD 1. aspirin intolerance 2. nasal polyposis 3. bronchial asthma

1. RHINOGENIC (80%) - follows viral URTI - by sneezing, nose blowing, swimmg or diving - retrograde infection edema narrowing/obstruct around sinus stasis of secretion 2ry bacterial infection ( pneumococci, m.catarrhalis, h.influenzae) 2. DENTAL infection (10%) - upper 2nd premolar, 1s & 2nd molar extraction oro-antral fistula infection (E.coli, anaerobic strep.) - FOUL smelling discharge 3. TRAUMA (10%) - FB, barotraumas, maxilla facial fractures Predisposing factors: 1. Local : Osteomeatal unit obstruction - dt allergy, rhinitis, septal deviation, neighbouring infection, enlarged adenoids, 2. General : - environmental pollution - poor general health - chilling

Pathology

- inter & intracellular edema, V/D - increased vascular permeability - cellular infiltration (plasma cells, eosinophils, basophils, mast cells) types: Seasonal AR (hay fever, rose fever) more in summer & spring pollens of grasses & trees

Perennial AR through out the year dust mites, feathers, animal dander

multiple polyps arise from ethmoid air cells & middle meatus *sometimes, middle turbinate - grape-like - notorious : recur

antrochoanal polyp arise from lining mucosa of maxillary sinus prolapses thru ostium of sinus towards choana solitary

Predisposing factors: 1. Nasal obstruction 2. Allergy 3. Enlarged adenoids (children) 4. Inherited pathology of mucociliary system 5. Environmental pollution, noxious stimuli, tobacco smoke

Clinical Pictures

1. Sneezing (especially in the morning) 2. BILATERAL nasal discharge 3. Nasal obstruction + hyposmia 4. Itching in throat + irritant cough 5. Itching & watery eyes (more in seasonal AR)

1. History of vasomotor or allergic rhinitis 2. Nasal obstruction becomes more complete (not relived by vasoconstrictor) 3. More evident hyposmia frequently become anosmia

1. Pain *see below 2. Mucopurulent nasal & postnasal discharge 3. Nasal obstruction 4. Fever & malaise

1. Nasal obstruction 2. Mucopurulent discoloured nasal & postnasal discharge 3. Facial pain 4. Vacuum headache 5. Hypo/Anosmia 6. Irritant cough + recurrent sore throat + halitosis 1. Inflamed nasal mucosa 2. Mucopurulent discharge around middle meatus 3. Postnasal discharge 1. Endoscopic exam of nose & postnasal spaces 2. CT scan! osteomeatal area 3. Culture & sensitivity 1. eliminate predisposing factors 2. medical : - antibiotics based on culture - antihistamines - topical steroids 3. FESS

1. Pale, bluish, moist, edematous nasal mucosa 2. Swollen INFERIOR TURBINATE 3. Puffiness & blue circles around the eye + nasal salute 4. Nasal polypi (occasionally) Investigati on 1. Nasal smears for eosinophilia : eosinophils may present 2. Skin test 3. RAST measure circulating IgE to specific Ag

1. BILATERAL, MULTIPLE pale glistening soft gelatinous masses with soft surface (grape-like) *appear in miffle meatus nasal cavity nostrils 2. mucosa : pale, edematous 1. CT scan 2. Allergic test exclude AR

1. Swelling over affected sinus * see below 2. Tenderness *see below 3. Redness & edema of nasal mucosa 4. Mucopurulent discharge in middle meatus

1. CT scan 2. Swab for culture & sensitivity 3. CBC

Treatment

1. avoid/eliminate allergen 2. topical steroid spray, oral antihistamine 3. hyposensitization therapy

1. treat underlying vasomotor/allergic rhinitis 2. topical steroid + oral antihistamines 3. FESS surgery (in bilateral complete nasal obstruction)

1. Broad spectrum antibiotics 2. Analgesics 3. Decongestants 4. Local hot application 5. Eradication of odotogenic foci

sinusitis Maxillary

Frontal

Ethmoid

Sphenoid

PAIN - over the cheek - under the eye * increase by bending down & straining - over the forehead - above the eyes * increases on rising up in the morning clears up at afternoon - over the bridge of nosa - between the eyes (inner angle of orbit) * may refer to parietal region/ behind the eyes deep seated pain * may refer to occipital region, behind the eyes & ears

SWELLING - swelling over the cheek - puffiness of eyelids - swelling over forehead - puffiness of eyelids

TENDERNESS over the cheek

upper inner angle of orbit (floor of sinus) just medial to inner canthus