COMMON CATARRH

Faculty Lecture Delivered

By

DR ONYEKWERE GB NWAORGU
Department of ORL
26th May 2008.
 Introduction

• “Common catarrh …….”. This phrase was

part of a side comment which I overheard
a sympathizer make on the death of his
friend’s relation on the FDM ward in 1998.
 Introduction continued

• Patient died of an advanced

nasopharyngeal cancer!

• This sympathizer was misinformed! You

may argue that the sympathizer may be a
lay public and not educated; far from it as
later experiences revealed!
 Introduction continued

• I have thus chosen this topic so that all –

professionals academics and the lay public

alike may benefit from our experience.

 THE WORD “COMMON”-
Definition
• Belonging equally to or shared equally by
two or more; joint: common interests.

• Of or relating to the community as a

whole; public: for the common good.

• Widespread; occurring frequently or

habitually; usual; prevalent: common cold
• Having no special designation, status, or
rank; not distinguished or exceptional;
inconspicuous; ordinary; plebeian; -- often
in a depreciatory sense: a common
cleaner, sailor etc.
 THE WORD “CATARRH”
• Catarrh is inflammation of a mucous membrane,
especially of the respiratory tract, accompanied
by excessive secretions.

• Disease of the mucous membrane of the nasal

passages and those cavities of the head
(paranasal sinuses) communicating with them.

• May become instrumental in causing the loss or

impairment of smell, taste and even hearing.
 Symptoms of nasal pathologies include:
• Nasal discharge – clear/watery, mucoid,
purulent, bloody
• Sneezing
• Nasal obstruction
• Disorders of smell
• Nasal voice/speech: hypo- and hyper-
nasality, or a mixture of the two.
• Various pathologies which range from
inflammatory to neoplastic do afflict the
nose and sinuses.

• This lecture will dwell on those lesions

which appear to be relatively common:
rhinosinusitis, adenoid enlargement and its
sequelae, nasal polyposis, sinonasal and
nasopharyngeal malignancies.
 Table I: Relative prevalence of sinonasal
& nasopharyngeal lesions
1996 1997 1998 1999 2000 2001 Total

Acute 12 16 10 10 11 4 63
sinusitis
Chronic 96 138 131 123 111 38 637
sinusitis
Adenoid 9 30 40 29 33 15 156
vegetation
Sinonasal 16 21 16 15 8 1 77
cancer
Nasoph. 6 16 15 3 12 6 58
cancer
Nasal 2 9 7 12 6 3 39
polyps
Total 141 230 219 192 181 67 1030
 Rhinosinusitis

• Inflammation of the nasal and sinus mucosae,

• A very common disease.
• No globally accepted definition for the acute or
chronic state.
• Acute rhinosinusitis, symptoms ≤ 4 weeks
• while it is assumed chronic if the symptoms and
signs have lasted for 12 weeks or more.
Rhinosinusitis: Predisposing Factors
• Common cold
• Dental infection
• allergic diseases,
• nasal polyposis,
• Anatomical abnormalities within the nasal cavity
• Mucosal oedema resulting from hormonal
changes (pregnancy),
• immunological defects etc
 Pathogenesis of rhinosinusitis
• Phase 1

• Phase 11

• Phase 111
 Chronic rhinosinusitis

• Always follow from an acute rhinosinusitis of

either long standing/ inadequately treated

• It is important to investigate the patient

adequately with a view to identifying the
underlying predisposing factor/s
 Fluid levels in the maxillary sinus

• Most useful
investigation that is
easily available is
plain radiograph of
paranasal sinuses
even though CT
scan of paranasal
sinuses is the sine qua
non.
 Sinus mycosis

• Invasive forms of sinus

mycosis is on the
increase; may mimic
malignancy and should
be differentiated from
allergic fungal sinusitis
which is associated with
positive tissue
eosinophilia and skin
sensitivity
• Significant reduction in serum levels of IgG,
IgA, 4th complement factor, complement factor
B and circulating immune complexes noted in
Nigerians with chronic sinusitis; suggesting
immunodeficiency as a its predisposing factor

• IgG and IgA serum levels showed significant

correlation with the duration of chronic sinusitis

• Nigerian males with sinusitis appeared to be

more immunocompetent than their female
counterparts
• Global reduction in the rate of rhinosinusitis
complications with a corresponding significant
decrease in mortality since the introduction of
antibiotics

• Most worrying complications of sinusitis involve

the orbit and intracranial cavity
Frontal mucocele: complication of
frontal rhinosinusitis
 Table II: Types of sinusitis
complications and prevalence
Complications Prevalence
ORBIT (23, 41%)
Orbital cellulitis 17 (74%)
Lid deformity 3 (13%)
Blindness 2 (9%)

SINUS WALL & CAVITY (18, 32%)

Fronto-ethmoidal mucocele 6 (33%)
Fronto-cutaneus fistula 5 (27%)

OROPHARYNX (10, 18%)/LARYNX (1, 2%)

Chronic pharyngitis 7 (70%)

INTRACRANIAL (3, 5%)

Subdural abscess 2 (66.6%)
• Early presentation, diagnosis and institution of
appropriate treatment in rhinosinusitis ensure
restoration of normal sinus function

• Such treatment involves increasing ostial

ventilation and intercepting the inflammation in
the early acute phase

• If however the sinusitis persists and the

pathology becomes more pronounced, sinus
drainage or any of the appropriate surgical
options should be undertaken.
Tree planting
 Nasal polyps
• Common finding in patients with chronic
rhinosinusitis

• About 25 - 30% of chronic rhinosinusitis

patients have nasal polyps

• Incidence in the general population is 1 – 4%

with a slightly higher male preponderance and
more in the elderly.
Left nasal polyp & X-ray features
• Factors contributing to the pathogenesis of nasal
polyps include:
- Allergy,
- Fungus,
- Staphylococci and staphylococci superantigens,
- Role of eosinophils,
- Genetic factors,
- Cytokines,
- Protein mediators as well as environmental
factors
• Nasal polyps no doubt do have significant
impact on the quality of life and symptom scores
of the afflicted patient.

• Initial medical treatment with steroids (oral,

intranasal) is advised but the need for surgery is
likely.

• The patient has to be informed early of the

possibility of recurrences
 Sinonasal malignancies
• Sinonasal malignancies -are rare in human
subjects

• constitute less than 1 percent of all malignancies

and 3 percent of those in the upper
aerodigestive region.

• These tumours are predominantly squamous cell

carcinoma & most often arise from the maxillary
sinus
Sinonasal malignancies
Sinonasal malignancies
• Predisposing factors to the development of
Sinonasal malignancies include exposure in
industries such as nickel refining, leather
tanning, hardwood dust, furniture making and
tobacco smoke amongst others.

• A significant risk for sinonasal squamous cell

carcinoma for bakers, grain millers, construction
workers, carpenters and farm workers
• Nigeria has no documented epidemiological
study on the predisposing factors to the
development of sinonasal cancers.

• Available data from this environment are

derived from retrospective studies of hospital
data

• None is conclusive as to the specific

predisposing factors to the development of
sinonasal malignancies
• Nasal cavity target site for air pollutants and
thus chemically induced toxicity and
carcinogenicity.

• Pollutants include lead, alkane hydrocarbons,

carbon monoxide, formaldehyde, acetaldehyde

• Sources of pollutants: indiscriminate burning of

refuse, exhaust fumes (heavy leaded petroleum
products), generators.
Atmospheric pollution
• Pollutants inflict significant damage to the nasal
mucosa
• 3-fold increase in 8-hydroxydeoxyguanosine
from damaged DNA
• Nuclear accumulation of p53 protein in
dysplastic lesions
• Possibility that p53 is no longer functional,
• Epithelial cells with a selective advantage for
clonal expansion provided
Sinonasal & Nasopharyngeal lymphoma
• Rising trend in frequency in recent years in
Ibadan
• Variable manifestations & late presentation
• High-grade diffuse large cell types were the
commonest histologically
• Association with HIV infection in this
environment is yet to be determined.
Sinonasal lymphoma
• Epstein-Barr virus is highly associated with nasal
T/NK cell lymphoma.
• EBV ability to establish latent infections in
lymphoid cells and cellular proliferation well
proven
• EBV infection is viewed as a mix of latent,
reactivated, transforming or replicative types of
infection.
• Chronic exposures to complex mixtures of air
pollutants may induce EBV reactivation &
replication
• Sinonasal cancer is especially challenging in a
patient who has been diagnosed with chronic
rhinosinusitis with temporary improvement and
recurrent symptoms

• Patients who present with unilateral nasal

symptoms, prolonged symptoms resistant to
routine treatments, and radiological evidence of
bony erosion require a high index of suspicion
for sinonasal cancer
Let’s do your paint works!!
 Adenoid enlargement
• Aggregation of lymphoid
tissue, pyramidal shaped
with its base on the
posterior nasopharyngeal
wall
• X-ray of the postnasal
space (nasopharynx) is a
reliable way of assessing
adenoidal size
 Endoscopic view of enlarged
• Are part of the adenoid
secondary immune
system

• Together with the

tonsils are involved in
the production of
mostly secretory IgA
• Development of middle-ear disease in children
may result from functional and mechanical
obstruction of the eustachian tube by the
adenoids.

• Adenoid enlargement may be complicated by:

- conductive hearing loss
- right ventricular failure and pulmonary oedema
- Adenoid facies’ & malocclusion
- psychosocial and or emotional problems
• The above associated conditions
complicating adenoid enlargement can be
avoided or reduced significantly if parents
and indeed the populace are aware of its
features and take appropriate steps for an
early intervention!

• At times the primary physician/family

doctor is to blame as an inappropriate
advice may be given!
• One of the most important debates concerns the
possible effects of A’s & T’s on the patient’s
immunologic integrity.

• Widely cited reports of reduced IgA against

polio after adenoidectomy or an increase in
Hodgkin’s disease after T&A have not been
proven epidemiologically.

• Thus no specific adverse effects are seen after

their removal!
 Current indications for Adenoidectomy
AAO-HNS 2000
• Four or more episodes of recurrent purulent rhinorrhea
in prior 12 months in a child <12. One episode
documented by intranasal examination or diagnostic
imaging.

• Persisting symptoms of adenoiditis after 2 courses of

antibiotic therapy. One course of antibiotics should be
with a beta-lactamase stable antibiotic for at least 2
weeks.

• Sleep disturbance with nasal airway obstruction

persisting for at least 3 months.
• Hyponasal or nasal speech
• Otitis media with effusion >3 months or second
set of tubes
• Dental malocclusion or orofacial growth
disturbance documented by orthodontist.
• Cardiopulmonary complications including cor
pulmonale, pulmonary hypertension, right
ventricular hypertrophy associated with upper
airway obstruction.
• Otitis media with effusion over age 4.
Let’s finish the truck!!
 Nasopharyngeal cancer
• Elmes and Baldwin first reported on
nasopharyngeal carcinoma (NPC) in Nigeria.

• Was considered rare in Nigeria until Martinson’s

report of 56 patients in 1968.

• Various reports from other parts of Nigeria

show that this disease is not uncommon
• The three reports from Ibadan cancer registry: -
- Martinson (1961 -1966),
- Martinson & Aghadiuno (1966 – 1980),
- Nwaorgu & Ogunbiyi (1981 – 2000)
have shown a consistently progressive increase
in the annual average number of patients

• ORL units/departments have increased in

Nigeria; thus the increase in the number of NPC
patients is real!
Cervical presentation of nasopharyngeal cancer
• The etiological/predisposing factors include:
- Genetic,
- Environmental factors,
- Epstein-Bar virus,
- Nitrosamines,
- Polycyclic hydrocarbons,
- Chronic nasal infection and
- Poor ventilation of the nasopharynx
• Early pointers to NPC in the adult include:
- Tinnitus,
- Hearing impairment,
- Sensation of fullness in the ear,
- Progressive nasal obstruction and recurrent
epistaxis.
• Patients may present first to the ophthalmologist
(diplopia, ophthalmoplegia, Horner’s syndrome);
Neurosurgeon (subtemporal lesions);
Neurologist
• Prognosis for NPC is very gloomy in Nigeria.
• Five year survival for stage I, II, III diseases are
90%, 70% and 60% respectively
• Stage IV without distant metastasis is 40%.
• Stage IV disease with distant metastasis has a
zero percent five year survival.
• Only a case of NPC in this environment; a male
who survived for eight years
• The lesions discussed above are some among
those ailments affecting the sinonasal and
nasopharyngeal region which may be taken for
catarrh.

• Unilateral choanal atresia and foreign body in

the nasal cavity may present with unilateral nasal
obstruction and discharge.

• The discharge in the case of impacted nasal

foreign body may be offensive.
• The common denominator in the lesions
presented above is late presentation.
The reasons for this include:
- Poor financial status of the patients
- Ignorance
- Self medication
- Patronage of alternative medicine
- Culture
- Influence of neighbours through their counseling
- Role of some medical personnel
• A basic knowledge of the clinical features and
treatment of Ear, Nose and Throat diseases is
desirable for any graduating medical doctor in
this country.

• I am aware that some have graduated without

exposure to any Otorhinolaryngology (ORL)
posting.

• This trend will hopefully CHANGE.

Gratitude
Dr Sir BCC Okoye (Late)
Faculty lecturer with Prof KT Robbins
Faculty lecturer with Prof. M. G. Stewart and others
Alhaji (Chief) L. Oyelade
Otunba Kunle Kalejaye (SAN)
Emeritus Prof TF Solanke (Late)
Mrs Adenike O Nwaorgu
The junior Nwaorgus’
Thank You