RHINITIDIS

CHRISTIEN MARIE T. NUFABLE, MD , FPSOHNS

WVSU-COM
It takes little talent to see what lies under one's nose, a good deal to
know in what direction to point that organ.
When your nose runs and your feet smell,

then you are born upside down!!!!!!

 OBJECTIVES

• To review the anatomy of the nose and paranasal

sinuses.
• To discuss the different functions of the nose and the
paranasal sinuses.
• To review the methods of physical assessment of the
nose and paranasal sinuses.
• Describe the common abnormalities found in the
physical assessment.
• To discuss the pathophysiology of common inflammatory
condtions in the nose and paranasal sinus disease.
 ANATOMY OF THE NOSE

• External Nose
• Internal Nose
 External nose

Bony vault

Bony vault

Cartilaginous vault

Nasal lobule
Nasal lobule
 Bony vault
• Nasal bones
• Ascending process of
the maxilla
• Nasal process of the
frontal bone
• Perpendicular plate of
the ethmoid bone
– Nasion
– rhinion
 Cartilaginous vault
• Upper lateral cartilages
• Quadrangular cartilage
 Nasal lobule
• Lower lateral cartilages
• Alae
• Vestibular regions
• columella
 Muscles
• elevator muscle group:
procerus, levator labii
superioris alaeque nasi.
• depressor muscle group: alar
nasalis, depressor septi nasi.
• compressor muscle group:
transverse nasalis.
• dilator muscle group: dilator
naris anterior and posterior.
• Nasal flaring: in respiratory
distress to aid in respiration.
 Blood supply
• External carotid artery
(facial artery)
– Lateral nasal a
– Angular a
– Alar a
– Septal a
– External nasal a
 Blood supply
• Internal Carotid a
(ophthalmic a)
– Dorsal nasal a
 Lymphatic drainage
• Submandibular nodes
• Submental nodes
 Sensory innervation
• Trigeminal n
– Ophthalmic division
• Nasociliary
• External nasal n
• infratrochlear
– Maxillary division
• Infraorbital n
 Motor innervation
• Facial nerve
 Internal nose
• Nasal vestibule

• Internal nasal valve/limen nasi/ os internum/

nasal valve of Mink
• Posterior choana
 Internal nose
• Medial wall
– septum
– Septal cartilage/
quadrangular cartilage
– Perpendicular plate of
ethmoid
– Vomer
– Crests of the maxilla and
palatine bones
 Internal nose
• Lateral wall
– Ethmoid bone
– Maxilla
– Posteriorly: palatine bone and pterygoid bone

• The main features of the lateral wall (2):

• Turbinates (Conchae): three bony elevations
covered by mucus membranes;
– superior, middle, and inferior turbinates.
– They divide the nasal cavity into 4 groove-like air
passages.
• Meatus: named after the turbinates, each lies
below and lateral to the corresponding turbinate.
• a. Spheno-ethmoidal recess Lies above the superior
turbinate and receives the ostium of sphenoidal
sinus.
• b. Superior Meatus
• c. Middle meatus
• d. Inferior meatus
 Blood supply
• Internal carotid a • External carotid a
(ophthalmic a) (internal maxillary a)
– Anterior ethmoidal a – Sphenopalatine a
– Posterior ethmoidal a – Descending palatine a
– Pharyngeal a
• Facial a
– Superior labial a
Blood supply
KEISSELBACH’S PLEXUS
Little’s area​
Great palatine artery 
Sphenopalatine artery​
Anterior ethmoidal artery
 Superior labial artery​
 Venous drainage
• Sphenopalatine and
anterior facial v
• Ophthalmic v
• Superior sagittal sinus
 Nerve supply
• Trigeminal n
– Anterior ethmoid
• Sphenopalatine
ganglion
• Olfactory n
 Lymphatic drainage
• Submandibular nodes
• Upper deep cervical
nodes
 MUCOSA

• Modified Skin Keratinized stratified squamous epithelium covering the

vestibule. It contains sebaceous glands, sweat glands, and short,
curved hair called vibrissae.
• Olfactory Specialized olfactory epithelium. Present in the olfactory
cleft, which occupies the area between the superior turbinate,
cribriform plate, and the corresponding area of the septum.
• Respiratory mucosa Ciliated pseudostratified columnar epithelium
with goblet cells. It lines the lower two-thirds of the nasal septum, the
lateral wall of the nose below the superior turbinate, and the floor of
the nasal cavity. It extends into the sinuses through their Ostia and is
thinner there. It is also continuous with the epithelia of the
nasolacrimal duct and Eustachian tube.
 Paranasal sinuses
• Air filled cavities that communicate w/ the nasal
cavities.
• Four types: maxillary, frontal, ethmoids and sphenoid
• Maxillary and ethmoid sinuses are the only sinuses
that are present at birth.
• Lined w/ pseudostratified ciliated columnar
epithelium; thinner and less vascular than nasal
epithelium.
• Mucociliary transport is directed towards the ostium.
 Anatomy

Paranasal sinuses
● Hollows within the several facial bones
● Air-filled cavities that
communicate with the nasal
cavities
● Functions:
○ Act as resonators to the voice
○ Reduce the weight of the skull
 PHYSIOLOGY
• Respiration:
• Purification of inspired air
• Humidification and warming of inspired air (5):
• Olfaction:
• Part of the buttress function of the facial skeleton:
• Cosmoses
• Adding tone to the speech
• Lightening of the facial skeleton over the neck:
• Nasal Cycle
 HISTORY AND PHYSICAL
EXAMINATION
Nose and Paranasal Sinus
History
● Nose
○ Rhinorrhea
○ Nasal congestion
○ Sneezing
○ Changes in olfaction
○ Epistaxis
○ Hearing loss
● Paranasal sinus
○ Facial pain
○ Headache
○ Dental pain
○ Postnasal
drip
 HISTORY AND PHYSICAL
EXAMINATION
1. Inspection and palpation of external nose
● Good light
● Always tilt the head and examine
the nasal vestibule
● Look at skin and scars
● Assess the shape
● Palpate ridge and soft tissue of the
nose
● Note for any tenderness, displacement of
bone/cartilage, or masses

● NORMAL
○ Nose at midline, no deviation, no
gross abnormality
 HISTORY AND PHYSICAL EXAMINATION
2. Inspection and palpation of internal nose
● Inspection
○ Anterior Rhinoscopy: Headlight/Head mirror and light source
with nasal speculum; Otoscope
■ Nasal Speculum: upward, downward direction
■ Can see up to middle turbinate
○ Posterior rhinoscopy: abnormalities on posterior nose
■ Nasal endoscope: higher fiber optic scopes; can view up
to nasopharynx
○ Decongestant

❖ Inspect nasal mucosa (note for color of mucosa)

❖ Note for abnormalities of the nasal septum (septal deviation, septal perforation)
❖ Note for discharges (watery, purulent, bloody, foul smelling)
❖ Note for presence of mass, foreign body
 HISTORY AND PHYSICAL EXAMINATION
2. Inspection and palpation of internal nose
● Palpation
○ Examination with nasal probes: check for tumor
○ Digital examination of postnasal space: using a gloved hand,
accentuate finger behind the soft palate

● NORMAL
○ Pink nasal mucosa, septum at midline or no septal
deviation, no discharges
 HISTORY AND PHYSICAL EXAMINATION

Sinuses
● Palpation
● Transillumination

● NORMAL
○ (–) Tenderness
○ (+)
Transillumination
○
 Physical assessment
• Normal findings
– Located in midline of face
– No swelling, bleeding, lesions, or masses
– Both nostrils patent
– Septum midline
– Nasal mucosa is pink or dull red
– No nasal discharges note
– No sinus tenderness , + transillumination
 Diseases of the Nose
• Congenital Disorders
• Inflammatory Diseases: infections vs
noninfectious
• Epistaxis
• Trauma
• Neoplasms
• Others: foreign bodies, rhinophyma, septal
perforation
RHINITIS
Introduction
● Inflammation of the internal nose or mucous membrane lining in the nasal
passages
● Presents as nasal congestion, sneezing, nasal and palatal itching,
rhinorrhea, and postnasal drainage
● On PE - Inspection of internal nose:
○ Nasal Mucosa
■ Viral rhinitis: red and swollen
■ Allergic rhinitis: pale, bluish, or boggy
 Classification Rhinitis
Non- IgE - IgE-mediated inflammation of the nasal
infectious Mediated mucosa, resulting in eosinophilic and Th2
Rhinitis (allergic) cell infiltration of the nasal lining.
Autonomic Vasomotor
Drug-induced (rhinitis
medicamentosa)
Hypothyroidism
Hormonal
Non-allergic rhinitis with
eosinophilia syndrome
(NARES)

Idiopathic Etiology cannot be determined

Structural
Infectious Concha bullosa, nasal
Rhinitis polyps, septalby
Precipitated deviation,
viral (most common), bacterial, or
adenoid enlargement, sinonasal tumors, and
nasal foreign bodies.fungal infection.
Infectious Rhinitis
Infectious Rhinitis

Viral

Bacterial

Fungal
 Infectious Rhinitis
Viral (Common
Cold)
● Inflammation and swelling of the mucous
membranes of the nose
● Most prevalent infectious disease
● Duration of <2 weeks
● Etiology:
○ RNA viruses: rhinovirus, echovirus,
influenza, parainfluenza, mumps, measles,
and respiratory syncytial virus
○ DNA viruses: adenovirus, herpesvirus
 Infectious Rhinitis
Viral (Common Cold)
● First stage:
○ Nasal airway obstruction, excessive nasal discharge, sneezing, some coughing, and
general malaise with or without headache
○ 3-5 days
○ Nasal secretions: watery and profuse → mucoid, more viscid, and scantier

● Secondary bacterial invasion:

○ Purulent rhinorrhea, fever, and often a sore throat
○ PE: red swollen secretion-coated mucosa observed intranasally
○ Sense of taste and smell are diminished
○ Sniffling and repeated nose blowing → reddening of nostrils and upper lip
○ Lasts for 2 weeks
 Infectious Rhinitis
Viral (Common
Cold)
● Signs and Symptoms
○ Throat discomfort
○ Sneezing
○ Runny nose
○ Nasal obstruction
○ Nasal congestion
○ Headache (cause of systemic infection)
○ Fever or tiredness
 Infectious Rhinitis
Viral (Common Cold)
● Treatment
○ Drink water, cool mist humidifier, increased fluid intake, administration of saline
nose drops
○ Rest and isolation of 2 days: treatment of uncomplicated viral cold
○ Symptomatic therapy
○ Decongestant: decrease some of the profuse nasal discharge
○ Nasal spray or drops
○ Analgesic-antipyretic preparations may provide symptomatic relief, with Acetaminophen
being the antipyretic of choice
 Infectious Rhinitis
Viral (Common Cold)
● Prophylaxis and Therapy
○ Antibiotics: value in treating secondary bacterial infections
○ Topical vasoconstrictors (phenylephrine, oxymetazoline): may provide
relief of watery rhinitic discharge, must be used with caution in
infants and young children
○ Antitussive therapy (codeine or dextromethorphan): when
nonproductive cough that seriously disturbs sleep or school
attendance
 Infectious Rhinitis
Viral (Common
Cold)
● Control
○ Spread through droplet infection
○ Controlled by isolation: quarantine measures

● Prevent Complication
○ Room ventilation
○ Don’t go to public place
○ Exercise regularly
 Infectious Rhinitis
Viral
Influenzal Rhinitis
● Respiratory illness accompanied by systemic symptoms of fever, malaise,
and myalgia
● Incubation period: 1-4 days
● Caused by viruses A, B and C of Orthomyxoviruses
● Risk factors
○ Age (young children and the elderly)
○ Immunocompromised
○ Pregnancy
● Transmission
○ Respiratory droplets expelled from the mouth and respiratory system
during coughing, talking, sneezing
○ By touching inanimate objects soiled with the virus and touching
the nose or eye
 Infectious Rhinitis
Viral
Influenzal
Rhinitis
● Diagnostics
○ Rapid
Antig
en
Detec
tion
○ PCR
● Symptomat
ic
Treatment
● Antivirals
○ Oselt
amivi
r
○ Zana
mivir
○ Pera
mivir
○ Aman
 Infectious Rhinitis
Vira
•COVID-19l
● A potentially severe acute respiratory infection caused by the Novel
Coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-
2)
● Clinical Manifestation: respiratory infection with a symptom severity
ranging from a mild common cold illness, to a severe viral pneumonia
leading to acute respiratory distress syndrome that is potentially fatal
● Incubation Period: 1-14 days
● Transmission
○ Direct, indirect, or close contact with infected people through infected secretions such as
saliva and respiratory secretions, or through their respiratory droplets, which are expelled
when an infected person coughs, sneezes, talks, or sings
○ Fomites
○ Airborne transmission can occur in healthcare settings during aerosol generating
procedures
 Infectious Rhinitis
● Signs and Symptoms
Vira ○ Common ○ Other non-specific symptoms

l ■
■
Fever
Dry cough
■
■
Sore throat
Nasal congestion
■ Fatigue ■ Headache
COVID-19 ■ Anorexia ■ Diarrhea
● Risk factors ■ Dyspnea ■ Nausea and vomiting
■ Myalgias ■ Anosmia
○ Residence in/travel to ■ Ageusia
location reporting
community transmission
○ Close contact with confirmed
case
○ Older age
○ Male sex
○ Presence of comorbidities
(ex. HPN, CKD, Diabetes)
 Infectious Rhinitis
Vira
•COVID-19
l
● Pathophysiology
○ SARS- Cov-2 binds to ACE2 receptor in humans
○ Spike glycoprotein of SARS-CoV-2 has a high binding affinity to ACE2 on host cells
○ Downregulates ACE2, leading to toxic accumulation of Angiotensin II, which may induce
ARDs and fulminant myocarditis
○ The organs that are more vulnerable because of their ACE2 expression include the
lungs, heart, esophagus, kidneys, bladder, and ileum
■ Explains the extrapulmonary manifestations associated to the infection
 Infectious Rhinitis
Vira
l
COVID-19
● Diagnosed by
○ RT-PCR
■ Recommended test to confirm
■ Detects viral RNA
■ Preferred Specimen: Nasopharyngeal and Nasal swabs
○ Rapid antigen test
■ Recommended only for triage/screening
■ Detects viral proteins
 Infectious Rhinitis
Viral
COVID-19
● Management
○ Supportive care
○ ○ Medications
Supportive therapy and monitoring
■ ■ Antivirals
■ Antipyretics Supplemental oxygen
■ ■ Corticosteroid therapy
■ Oral/IV fluids Appropriate empiric antimicrobials
■ Isolation

○
 Infectious Rhinitis
Viral
Rhinitis of Viral Exanthems
● Rhinitis: prodromal symptom of measles, rubella and chickenpox
● Secondary bacterial infections and complications are more common
 Infectious Rhinitis
Bacteria
l
Suppurative Rhinitis
● Follows viral rhinitis as a secondary bacterial infection in adults, association with
bacterial sinusitis and adenoids in children
● Pneumococcus, Staphylococcus, Streptococcus are frequently involved in these infections
● Treatment: Systemic antibiotics, analgesics, pain relievers and decongestants
 Infectious Rhinitis
Funga
l
Aspergillosis
● Most common fungal infection causing chronic specific rhinitis; caused by Aspergillus species
● Mucopurulent discharge: green-brown
● Treatment
○ Chronic, noninvasive: debridement and topical antifungal drugs
○ Acute, life-threatening: debridement and systemic antifungal drugs (amphotericin B)
Mucormycosis
● Malignant, opportunistic infection; caused by Rhizopus oryzae
● Inhalation of microorganism inoculates in nasal turbinates and/or ethmoid sinuses
● Headache, fever, internal and external ophthalmoplegia, paranasal sinusitis
● Nasal discharge: thick, dark, bloody
● Black or brick-red nasal turbinate
● Microscopically: Nonseptate hyphae
● Treatment
○ Immediate intravenous or intrathecal administration of amphotericin B, debridement of
necrotic tissue and management of underlying condition
 Infectious Rhinitis
Funga
l

Rhinosporidosis
● Very rare disease caused by the spore-forming
fungus Rhinosporidium seeberi.
● Highly vascular, friable granular lesions develop
in the anterior portions of the nose and may
spread to involve the paranasal sinuses and
nasopharynx
RHINITIS
INFECTIO
1 Allergic
US Rhinitis

2 Vasomotor
Rhinitis

3 Drug-induced
Rhinitis

4 Non-airflow
Rhinitis

5 Hypertrophic
Rhinitis

6 Atrophic
Rhinitis
Allergic Rhinitis
• AR is a chronic/recurrent IgE-mediated
inflammation of the nasal mucosa.
• Primary symptoms: rhinorrhea, sneezing,
nasal itching, nasal congestion, postnasal
drainage.
• Other accompanying symptoms: frequent
throat clearing, eye itching, tearing, eye
redness, palatal itching, impaired sense of
smell (and taste),fatigue, impaired
concentration, reduced productivity.
• Intermittent or persistent, mild or moderate-
severe
• Perrenial or seasonal

• 500 million people affected worldwide

Allergic Rhinitis
• Philippine prevalence (National Nutrition and
Health Survey/NHES, 2008) 20%
• Urban areas 18%
• Rural areas 22.1%
• Young children 26%
• Adolescents 32%
pathophysiology
PATHOPHYSIOLOGY: Sensitization
Pathophysiology: Sensitization
PATHOPHYSIOLOGY
Pathophysiology: Clinical Phase
Early Response
 Allergic Rhinitis

• Seasonal
• Perrenial
 Seasonal
• Pollen:
– Spring (March-June) = Trees
– Summer (May-August) = Grass
– Fall (August-October) = Weeds
• Mold:
– Spores in outdoors have seasonal variation
(reduced #’s in winter, increased in summer/fall
due to humidity).
 Perrenial
• Fungi/mold:
– Exposure peaks accompany activities such as harvesting,
cutting grass and leaf raking.
• Pet Dander (cats, dogs):
– Can linger up to 4 months after pet removal.
• House dust mites:
– Live in bedding, carpets and upholstery.
– Dietary preference: human epidermal scales.
• Cockroaches:
– Respiratory allergy
– Important allergen in inner-city asthma.
Allergic Rhinitis & its Impact on
Asthma
diagnosis
• The diagnosis of AR is strongly considered in the presence
of the following symptoms: nasal itching,
sneezing,rhinorrhea, and/or nasal congestion or
obstruction, triggered by allergen exposure. Symptoms
may be associated with conjunctival redness, itchy and/or
teary eyes.
• Important elements in history include an evaluation of
• the nature, duration, and time course of symptoms;
• possible triggers for symptoms;
• response to medications;
• comorbid conditions;
• family history of allergic diseases;
• environmental exposures;
• occupational exposures;
• effects on quality of life.
Examination
• Look at the patient to assess any obvious
external features, such as an ” allergic crease
or allergic salute.”
• A full ENT examination should then be
carried out with particular emphasis on the
nose.
• Allergic nasal mucosa is usually bilaterally
swollen pale or bluish in colour, edematous
and covered with watery secretions.
• Detailed allergic work-up, e.g. skin tests,
serum specific IgE tests, or nasal provocation
tests, may be performed for the following:
• Patients with whom a questionable diagnosis
exists
• Patients unresponsive or intolerant to
pharmacotherapy
• Patients with multiple target organ involvement
• Patients for whom immunotherapy is considered
• Patients with suspected Local Allergic Rhinitis
treatment
• Allergen avoidance
• Pharmacotherapy
• Allergen immunotherapy
Allergen Avoidance
• Pets
• Remove pets from bedrooms and, even better, from the entire home
• Vacuum carpets, mattresses and upholstery regularly
• Wash pets regularly (±)
• Molds
• Ensure dry indoor conditions
• Use ammonia to remove mold from bathrooms and other wet spaces
• Cockroaches
• Eradicate cockroaches with appropriate gel-type, non-volatile, insecticides
• Eliminate dampness, cracks in floors, ceilings, cover food; wash surfaces,
fabrics to remove allergen
• Pollen
• Remain indoors with windows closed at peak pollen times
• Wear sunglasses
• Use air-conditioning, where possible
• House dust mite allergen avoidance
• Provide adequate ventilation to decrease humidity
• Wash bedding regularly at 60°C
• Encase pillow, mattress and quilt in allergen
impermeable covers
• Use vacuum cleaner with HEPA filter
• Dispose of feather bedding
• Remove carpets
• Remove curtains, pets and stuffed toys from
bedroom
PHARMACOTHERAPY
• First generation antihistamines
– Chlorpheniramine, Hydroxyzine, diphenhydramine
• 2nd generation antihistamines
– Citirizine, loratidine, terfenadine, astemizole,
azelastine
3rd generation antihistamines
levocetirizine, desloratidine, fexfenadine, rupatidine
• Nasal antihistamines
– azelastine
decongestants

• Oral • Nasal

Pseudoephedrine • Phenylephrine

• Oxymetazoline
phenylpropanolamin • Xylometazoline
e
Mechanism: alpha-adrenergic agonist.
• Effect: vasoconstriction restricts blood flow
to nasal mucosa decreasing nasal obstruction
.
• Side effects:
• Oral: HA, nervousness, irritability, tachycardia,
palpitations, insomnia.
• Topical(nasal): prolonged use (>5-7 days) leads
to rhinitis medicamentosa
• Prolonged use of topical decongestant may induce
rebound congestion upon withdrawal.
• Leads to inflammatory hypertrophy of nasal
mucosa – rhinitis medicamentosa
• Caused by down regulation of alpha-
adrenoreceptors --> less sensitive to endogenously
released NE and exogenously applied
vasoconstrictors.
• Tx: wean over 7-10 days while reducing
inflammation by intranasal steroids.
Antileukotriene Agents

• Montelukast *

• Pranlukast *

• Zafirlukast
Nasal steroids
• Beclomethasone dipropionate
• Budesonide
• Ciclesonide*
• Flunisolide
• Fluticasone propionate
• Mometasone furoate
• Triamcinolone acetonide
• Mechanism:
• reduce inflammation
• suppress neutrophil chemotaxis
• mildly vasoconstrictive
• reduce intracellular edema
• Effect: reduce nasal blockage, pruritis,
sneezing and rhinorrhea.
• most potent single medication for treatment of AR.
• intanasal: acts locally.
• goal: control sx with lowest possible dose.
• >90% achieve symptomatic relief.
• most effective when started several days before exposure
and used on regular basis.
• therapeutic efficacy within 1-3 days, but max efficacy may
take up to 3 weeks.
• compliance is critical.
Side effects: nasal irritation, bleeding (nasal septal
perforation).
Saline Nasal sprays
• i.e.: Salinase, muconase, Sniff, sterimar,
physiomer
• Effects: relief from crusting and can be
soothing.
 Co-morbidities
• Asthma
• Sinusitis
• Otitis Media (with
effusion)
(AR occurs frequently in
pts with asthma and
atopic dermatitis.)
 NONINFECTIOUS ALLERGIC RHINITIS
Idiopathic (Vasomotor) Rhinitis

- Vasomotor rhinitis is a term often used to describe rhinitis symptoms associated with
nonallergic, noninfectious triggers with no clear etiology after the conclusion of an
exhaustive search for a diagnosis.
- Diagnosis is one of exclusion and involves the elimination of allergic and
nonallergic causes.
- May reflect an autonomic dysregulation of nasal function.
- Result from activity of the parasympathetic nerves cause engorgement of the vascular
bed with resultant congestion and increased mucous production
NONINFECTIOUS RHINITIS
Idiopathic (Vasomotor) Rhinitis

Etiology
● Associated with environmental
irritants, changes in atmospheric
conditions and odors or aromas.
 NON INFECTIOUS RHINITIS
Drug-Induced
Rhinitis

- Most important type of drug -induced rhinitis is

rhinitis medicamentosa with the prolonged use of
topical vasoconstrictive nasal sprays (e.g.
oxymetazoline).

- Causes Increased mucous cell secretion and

decreased ciliary action congestion
- Chronic use may lead to Hypertrophic
Rhinitis
NON INFECTIOUS RHINITIS
Drug-Induced Rhinitis
NON INFECTIOUS RHINITIS

Hormonal Rhinitis
● Hormonal influences are associated with rhinitis

● Estrogen causes congestion, that is why in the

pre-menstrual phase and pregnancy nasal congestion is
common
● Deficient Thyroid hormone in hypothyroidism and
myxedema may also cause congestion
● Rhinitis of pregnancy is most common during the later
stages of pregnancy
SUMMARY
QUESTIONS?
Thank you.