Lecture (4)

21/12/2021 ‫عماد ناظم الكواز‬.‫د‬

The Nose
Inflammatory Diseases Of The Nose and Paranasal Sinuses

Vestibulitis / Furnucle

➢ Definition : Diffuse inflammation & excoriation of the nasal

vestibule( vestibulitis) , If the disease is confined to the hair follicles,
it is termed furnculosis (boil).

➢ Risk factors :
▪ Persistent rhinorrhea e.g. common cold, F.B.
▪ Trauma( nose prick).
▪ Diabetes.

➢ Causative micro-organism
▪ The most common bacteria causing vestibulitis are the staphylococci.

➢ Clinical features:
▪ Painful swelling of nasal vestibule.
▪ In vestibulitis ,the skin is diffusely red tender & excoriated.
▪ In furnculosis, localized red ,tender nodule in the nasal vestibule & if
pus collection developed the pain will increase & become throbbing ,
rupture of abscess cause purulent nasal discharge.
 ➢ Treatment:
o Medical :
1. General : Antistaphylococcal antibiotics; Cloxacillin and
Flucloxacillin + analgesia.
2. local Lubrication of the infected area with an ointment like fucidic
acid cream.
o Surgical :
▪ Incision & drainage if abscess formed.
▪ Squeezing must be avoided to prevent spread of infection through the
valveless facial and ophthalmic veins to the cavernous sinus.

➢ Complications:
▪ Septal abscess.
▪ Cavernous sinus thrombosis.

Rhinitis
➢ Definition: Inflammation of the nasal cavity.
➢ Classification:
o Acute rhinitis: Common cold
o Chronic rhinitis:
A- Atrophic rhinitis.
B- Hypertrophic rhinitis ( Rhinitis medicamentosa).

➢ Common cold (coryza)

o Definition : Acute viral infection of the upper airways.
o Causative organism: Caused by Rhinovirus (most common),
Parainfluenza virus,Adenovirus, Enterovirus, Respiratory Syncytial
Virus (RSV).
o Mode of transmission: Airborne droplets .
o Incubation period: 1-3 days.

o Clinical features-symptoms
✓ Prodromal stage: there is vasoconstriction causing mucosal
ischemia, the patient compliant from nasal dryness and sneezing
with general body ache , It lasts for few hours.
✓ Acute stage: there is vasodilatation causing mucosal hyperemia and
congestion , the patient compliant from bilateral nasal obstruction &
 discharge first watery and then mucopurulant due to bacterial
superinfection, there is fever, headache & malaise.
✓ Recovery stage: after few days symptoms diminishes and nose starts
to open again unless bacterial infection superadded , the condition
may last for 2 weeks.

o Signs :
Congested nasal mucosa with watery or mucopurulent discharge.

o Complications:
• Sinusitis ,otitis media, pharyngitis, laryngitis , bronchitis &
bronchopneumonia.
• Anosmia which may be permanent(viral neuritis).

o Management
✓ The disease is self-limiting and needs. supportive measures:
✓ Bed rest & steam inhalation.
✓ Plenty of warm fluid.
✓ Vitamin C.
✓ Analgesic& antipyretic: paracetamol.
✓ Decongestant for short term: ephedrine or xylometazolin drops
locally.
✓ Antibiotics only if complications occur: otitis media, tonsillitis,
sinusitis, bronchitis.

Rhinitis Medicamentosa ( Chronic Hypertrophic Rhinitis)

❖ Definition: Chronic rhinitis with hypertrophy of nasal mucosa
especially the inferior turbinate.

❖ Causes : Prolong use of topical nasal decongestant drop.

✓ Rebound congestion occurs several hours after using such drop due to
increasing tolerance to the drug over time requiring more frequent and
larger doses to achieve the same effect.
 ❖ Clinical pictures
o Symptoms:
• Bilateral nasal obstruction.
• Bilateral mucoid nasal discharge & postnasal drip.
o Signs
• Hypertrophied inferior turbinate.

❖ Treatment
o Immediate cessation of decongestant drugs.
o Medical: Replacement by topical and topical & systemic steroid.
o Surgical : Reduction of the inferior turbinate (Inferior turbinectomy)
either partial turbinectomy or submucosal diathermy.

➢ Atrophic Rhinitis
o Definition: Chronic inflammation of the nasal mucosa characterized
by progressive atrophy of the mucosa and underlying bone of the
turbinate.

o Causes:
o Excess nasal surgery
o Endocrinal hormonal disturbance:
Starts at puberty.
Females more than males.
Cease after menopause.
o Nutritional deficiency:
 Deficiency of vitamin A, D or iron.
o Chronic bacterial infections as Klebsiella ozaenae.
o Irritant exposure (occupational).

o Clinical features
✓ Symptoms:
• Patient is usually adolescent or young adult female.
• Nasal obstruction in spite of wide nasal passages due to lack of
sensation of air flow.
• Nasal discharge : green-black , crusty & offensive.
• Anosmia ( atrophy of olfactory mucosa).
• Epistaxis .

✓ On examination:
• Bad odor (fetor )not appreciated by the patient who is anosmic.
• Wide nasal cavity (roomy nose).
• Dry atrophic mucosa.
• Crustation due to ciliary destruction so the nasal secretions are no
longer expelled from the nose., its green to black crusts; their
separation reveals bleeding ulcerated mucosa

o Treatment
✓ Treatment of the cause.
✓ Medical
• Alkaline nasal douche(dissolve crust).
• Menthol paraffin oil nasal drop (decrease offensive odor).
• Nasal drops composed of 25% glucose in glycerin ( inhibit proteolytic
organism growth).
• Estrogen locally , vitamin replacement.
• Rifampicin capsule 600 mg once daily for 3months.
✓ Surgical
• Alternating closure of nostrils for one year to help recovery of mucosa
(Young's operation).

Non infective rhinitis

❖ Allergic rhinitis
➢ Definition: Is an abnormal hypersensitivity reaction of the sino-nasal
mucosa to certain external substances "allergens" or "antigens".
➢ Types:
1. Seasonal : if the allergen & symptoms occur in spring and autumn.
2. Perennial (Non-seasonal): if the allergen is present most days of the
year like house dust mite or domestic animals.

➢ Mechanism of allergy:
o Allergic rhinitis is classified as type I reaction.
o 1st time exposure to the antigen formation of IgE antibodies which
become fixed to mast cells of nasal mucosa.
o Re-exposure to the same antigen the allergen will interacts with
IgE antibodies on the mast cell surface mast cell degranulation&
release of chemical mediators as histamine & leukotrienes.
o The action of chemical mediators:
• Vasodilatation &increase capillary permeability.
• Increase sero-mucinous gland secretion.
• Cellular infiltration with eosinophils.
➢ Clinical pictures:
o Symptoms:
• There is a prodromal nasal itching which is soon followed by violent
sneezing.
• Bilateral nasal obstruction& profuse watery nasal discharge.
• Anosmia.
• Other allergic manifestation as allergic conjunctivitis.
o Signs:
• The nasal mucosa become pale bluish and edematous, thin watery
discharge with hypertrophy of inferior turbinate.
• Nasal polyps may be seen.

➢ Investigations :
• Blood tests :Eosinophilia and serum IgE elevated.
• Nasal smear/cytology shows increase eosinophil count.
• Skin prick test.
• Nasal challenge test .
• RAST (radio allegro sorbent test) applications of antigen to the
patient’s serum (contain antibodies) lead to antigen –antibodies
reaction(in vitro).
➢ Treatment:
1. Avoid exposure to the causative allergen (Allergen avoidance ).
2. Medical :
• Antihistamines : Systemic as loratadine or topical as azelastine.
• Steroids: Topical as nasal sprays like, or. short course of systemic
steroids as oral prednisolone are effective in severe symptoms.
• Mast cell stabilizer as ketotifen, Sodium cromoglycate .
• Topical anticholinergic drugs: ipratropium bromide nasal spray is
only effective against watery rhinorrhea.
3. Immunotherapy (Hypo sensitization): Injection of gradually
increasing doses of the causative antigen to induces a blocking
antibodies IgG which bind the antigen before it is able to react with
IgE.
4. Surgical:
• Inferior turbinectomy , polyps removal(FESS).

❖ Vasomotor rhinitis(Intrinsic rhinitis)

➢ Definition : Non-allergic , Non infective rhinitis characterized by
nasal obstruction &watery rhinorrhea due to autonomic imbalance
(parasympathetic over activity).
➢ Clinical Picture:
o Symptoms & signs:
• Nasal obstruction which may alternate from side to side.
• Watery rhinorrhea, postnasal discharge and headache can occur.
• hypertrophy of inferior turbinate& nasal polyps may be seen.
➢ Treatment
A. Medical: In mild cases topical nasal steroids, When there is copious
watery discharge, the addition of topical nasal anticholinergics like
ipratropium bromide is usually recommended.
B. Surgical:
✓ Reduction of the size of the inferior turbinate by submucosal
diathermy, or turbinectomy.
✓ Polyps removal (ESS).
✓ Vidian neurectomy: Disruption of parasympathetic fibers to nasal
mucosa , helpful to relieve severe symptoms.

Nasal Polyps
➢ Definition : pedunculated edematous Sino - nasal mucosa which
prolapsed through the meatus to the nasal cavity .
• It’s either ethmoidal polyps or maxillary (Antro-Choanal polyp).
➢ Etiology
▪ Allergy as allergic rhinitis.
▪ Inflammatory as sinusitis.
▪ Mixed Inflammatory and allergy.

❖ Ethmoidal polyps
➢ Ethmoidal polyps originate in the region of the ethmoidal sinuses and
project into the nasal cavity through middle & superior meatus.

➢ Clinical pictures:
o Symptoms :
▪ Bilateral nasal obstruction.
▪ Bilateral nasal discharge which could be mucoid or mucopurulent.
▪ Anosmia.
o Signs:
▪ Anterior rhinoscopy: The polyps are multiple ,bilateral, round
,smooth , pale, glistening (peeled grebes appearance), soft, not tender
and moves backwards when probed, arise from superior and middle
meatus.
▪ These features differentiate the polyp from turbinate hypertrophy.

➢ Investigations:
▪ X-ray of the sinuses and CT scan if endoscopic ethmoidectomy is to
be performed.
➢ Treatment
1. Control of the predisposing factors (allergy).
2. Medical: Its useful in small polyps by topical nasal steroids.
— A patient with more extensive polyps is usually best treated with
systemic steroids( Medical polypectomy).
3. Surgical: Nasal polyps tend to recur and about 50 % of patients
eventually will need surgery:
▪ Simple polypectomy: high recurrence rate.
▪ Endoscopic sinus surgery.
❖ Antro-Choanal polyp
➢ Arises from the maxillary sinus and project from the ostium
posteriorly to the nasopharynx.
➢ It tends to be dumb-bell in shape with a constriction where they pass
the ostium of the sinus. Therefore, it has two compartments;
maxillary(antral) and nasal portions.
➢ Etiology
— It is unknown but may be inflammatory as it has no relation to allergy.

➢ Clinical Pictures
o Symptoms:
• Unilateral nasal obstruction, the obstruction is greater in expiration
than inspiration due to ball-like(valve) effect of the polyp.
• Unilateral nasal discharge and postnasal drip.
o Signs:
• Anterior rhinoscopy : unilateral , single ,pale, soft polyp, sometimes
just the stalk of the polyp can be seen.
• Posterior rhinoscopy to visualize the polyp.
 ➢ Investigations : X-ray and CT scan of the paranasal sinuses.

➢ Treatment
• There is no medical treatment .
• Endoscopic removal (FESS)of the polyp including the maxillary
portion , it has a high incidence of recurrence.
• In recurrence a Cald-Wel-Luc operation can be performed to clear
the maxillary sinus.

The Caldwell-Luc operation was first

described in the late 19th century as a
technique to remove infection and diseased
mucosa from the maxillary sinus via the
canine fossa, while creating intranasal
counterdrainage through the inferior
meatus
Ethmoidal Polyp Antrchoanal Polyp