Acute and Chronic Nasal Disorders

22 Acute and Chronic Nasal Disorders


For acute and chronic disease also involving sinuses—see related chapters 2426


22.1 Bacterial Infections


22.1.1 Folliculitis and Vestibulitis


• Invasion of pilosebaceous follicle by Staphylococcus aureus


• Risk of cavernous sinus thrombosis—mortality of 10 to 27%


22.1.2 Erysipelas


• Acute β-haemolytic streptococcal infection


• Follows a cut or incision


• Butterfly pattern on face


• Responds well to penicillin/erythromycin


22.1.3 Rhinoscleroma


• Large deforming masses distending the nasal cavity


Klebsiella rhinoscleromatis


• Disease found in developing countries


• Three phases: rhinitic, infiltrative, and nodular


• Finally resulting in adhesions, stenosis, and atresia


• Large red tumour-like masses of the nodular phase are characterized by:


figure Mikulicz cells (large cells with clear cytoplasm containing the bacilli)


figure Russell bodies (which are plasma cells with eosinophilic-staining cytoplasm and prominent nuclei)


• Large doses of streptomycin and tetracycline over 4 to 6 weeks are needed until two consecutive biopsies are negative


• Topical acriflavine solution has also been used


22.1.4 Leprosy


• Fingernail transmission into nose


• Incubation can take 10 years


• Tuberculous or lepromatous forms


• Small anesthetic patches (tuberculoid) or nodular thickening around ant IT (lepromatous)


• Perforation and nasal deformity follow


• Dapsone ± rifampicin/clofazimine to treat


22.1.5 Tuberculosis


• Nasal involvement secondary to chest


• Nodular/ulcerative lesions on ant septum or ITs or choanae


• Caseating epithelioid granulomas with acid-fast bacilli


• Responds to standard Rx with saline douching


• Lupus vulgaris = variant—nodules at vestibule


22.1.6 Syphilis


• Congenital/primary/secondary/tertiary


• Primary chancre on external nose or vestibule at 3–4 weeks after contact; disappears spontaneously after 6 to 10 weeks


• Serology may be negative in early stages, 90% +ve in tertiary stage


• Secondary stage may appear as simple rhinitis


• Tertiary gummas produce tenderness over bridge of nose, posterior septal perforations, and nasal collapse


• Congenital form may present at puberty:


figure Nasal saddling


figure Dental abnormalities


figure SNHL


• Penicillin Rx required


22.2 Allergic Rhinitis


22.2.1 Definition of Rhinitis


• An inflammatory disorder of the nasal mucosa characterized by 2 or more of the following symptoms:


figure Rhinorrhea (anterior and/or posterior)


figure Blockage


figure Itching/sneezing


22.2.2 Facts about Rhinitis


• Commonest immunological disorder in humans: 10 to 25% of individuals globally


• Significant effects on quality of life for sufferers—may account for 30 to 40% of reduced productivity in the workplace


• Most asthmatics also suffer from rhinitis


• Allergic rhinitis and asthma share many common inflammatory processes


22.2.3 Rhinitis and Asthma


• Both allergic and non-allergic rhinitis are risk factors for asthma


• Most exacerbations of asthma are commenced by upper respiratory tract infection (URTI)


• Rhinitis causes bronchial hyperreactivity


• Allergic rhinitis increases the risk of asthma about threefold


22.2.4 Allergic Rhinitis Classification (ARIA)


• Intermittent—<4 days/week or <4 weeks/year


• Persistent—opposite of intermittent


• Mild—normal sleep, daily activities, work/school; no troublesome symptoms


• Moderate/severe—one or more of items not found in mild rhinitis


22.3 Pathophysiology of Rhinitis (Fig. 22.1)


22.3.1 Early Stage


• Allergen contact with IgE on mast cell surface


• Mast cell degranulation releasing mediators and cytokines leads to initial symptoms of:


figure Sneezing


figure Running


figure Itching


figure Blockage after 15 to 20 min


22.3.2 Late Phase


• Leukotrienes, cytokines, and chemokines cause influx of inflammatory cells (eosinophils)


• Cells secrete further mediators and cytokines


• Inflammatory response perpetuated for days/weeks


22.3.3 History


• Distinguish from other types of rhinitis or rhinosinusitis


• Allergen contact—pets, damp home, etc.


• Seasonal vs. perennial


• Concurrent asthma


• Paternal atopy (higher if both parents affected)


• Drug history—e.g., use of nasal sprays, β-blockers


22.3.4 Assessment of the Rhinitic Patient—Examination and Investigations


• Endoscopic examination of nose


• Skin prick allergy tests or radioallergosorbent test (RAST)


• Other rhinological assessment:


figure Spatula misting


figure Peak inspiratory nasal flow rate


figure Acoustic rhinometry


figure Rhinomanometry


figure Mucociliary clearance


22.3.5 Management Options (Fig. 22.2)


• Allergen avoidance


• Topical steroids


• Topical decongestants


• Oral/(topical) antihistamines


• Systemic steroids


• Cromolyn sodium


• Leukotriene receptor antagonists


• Ipratropium bromide


• Immunotherapy


• Surgical turbinate options


22.3.6 Summary


• Rhinitis is a common problem with significant socio-economic effects


• A careful history and examination with skin prick test (SPT) can determine the appropriate level of medical management


• Remember to manage the combined airway


22.4 Non-allergic, Non-infectious Rhinitis


22.4.1 Non-allergic, Non-eosinophilic Rhinitis (NENAR)


Also known as idiopathic or vasomotor rhinitis


• Diagnosis of exclusion


• Non-specific triggers: temperature, humidity, irritants (e.g., cigarette smoke)


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Jul 4, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Acute and Chronic Nasal Disorders

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