Diseases of Rhinology (Part 1)

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Diseases of Rhinology (Part 1)

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III. NASAL FRACTUREA frontal blow usually
fractures both nasal bones and possibly the bony
and cartilaginous septum, causing flattening of
the nose and nasal obstruction. A blow from the
side usually fractures both nasal bones, causing
deviation of the nose to the opposite
side.
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In treating nasal fractures there is a tendency
to disregard the intranasal appearances and
concentrate on obtaining a good-looking external
nose. This neglect may lead to subsequent
impairment of the airway.
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Many nasal fractures are simple lateral
displacement rather than depressed fractures.
Firm pressure with one or both thumbs on the
covex side of the nose pushes it back into
position. If fracture cannot be reduced by this
technique, it should be managed under local
anesthesia, using an elevator under nasal bone,
the bony fragment are elevated back to normal
position.
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IV. FURUNCULOSIS OF THE NASAL VESTIBULE
acute staphylococcal infection of a hair
follicle in the vestibule. Clinical features
Pain, Headache , Evacuation of
pus.TreamentSystemic antibiotics, hot wet
packs, relief of pain.
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ComplicationsCavernous sinus thrombosis,
Cellulitis of upper lip.Caution Dont attemp to
squeeze the furuncle or to incise it especially
before pus has localized.
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V. CHRONIC RHINITIS1. AetiologyAttacks of
acute rhinitis in rapid succession and the
maintenance of the acute inflammatory condition
may predispose to chronic rhinitis.
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These including1) Neighbouring infections as
sinusitis, chronic tonsillitis, and adenoids.2)
Nasal obstruction, e.g. deviation of the septum,
foreign body in nasal cavity.3) Chronic
irritation as from dust, smoke, sudden and
extreme changes of room temperature and abuse of
therapeutic vasoconstrictors--Rhinitis
medicamentosa.
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2. Pathology two clinical types.Simple chronic
rhinitis. In the early stages there is
distension of the venous or cavernous tissue
of the turbinates. There is a hypertrophy
of the mucous glands.Hyperplastic rhinitis. It
is characterized by thickened and edematous
changes in the mucous membrane and periosteum.
The epithelium loses cilia and shows a
tendency to squamous metaplasia.
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3. Clinical feature
Symptom Simple Hyperplastic
nasal obstruction Variable and alternate Continuous
Nasal secretion postnasal drip Viscid or mucopurulent Same
A blocked or heavy feeling in the nose Mild Apparent
Anosmia Transient Usual
Inferior turbinates Red, swollen and oedematous Mulberry-link hyperplastic
Pits with a probe Soft Firm
Shrinks with 1 ephedrine Marked Less marked
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4. TreatmentCorrection of any predisposing
factors, treatment of any sinusitis or other
adjacent infection must be undertaken.Local
antibiotic and mild vasoconstrictors used as nose
drops, usually of 1 ephedrine and furacilin or
3 streptomycin. Topical steroids.
Electrocauterization. Partial turbinectomy or
submucosa resection of the turbinate.
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VI. ATROPHIC RHINITIS1. AetiologyThe exact
aetiology is not fully known. Besides infection,
other factors such as undue patency of the nasal
airway and possibly endocrine or vitamin
disturbances may play a part.Destruction of the
nasal mucosa may cause secondary atrophic
rhinitis. An excessive operative procedures
especially on the inferior turbinates is
an example.
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2. PathologyDegeneration of the ciliated
epithelium and seromucinous glands cause the
formation of thick adherent crusts in the nose.
The body structures of the turbinates are
partially absorbed and the airway widened.
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3. Clinical featuresThe nose is dry and often
filled with crusts. The patient complains of
nasal stuffiness and a foul odor known as ozena.
This may be the most disturbing symptom, though
it is not noticed by the patient itself who is
anosmic. Epistaxis may often follow separation of
the crusts.
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Examination reveals yellow or green crusts
associated with some surface purulent exudates.
After removal of the crusts, the nasal cavity
becomes wide open and the nasopharynx becomes
clearly seen. The turbinates are thin and
atrophic. These changes are usually present on
both sides. The nasopharynx and oropharynx
frequently appear dry smooth and shiny rather
than normally pink and moist.
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4. TreatmentAtrophic rhinitis is resistant to
most forms of treatment. Naristilae menthol co.
has been used in an attempt to increase the
glandular activity and blood supply of the
atrophic mucosa. Local antibiotics such as 3
streptomycin can be used to control the secondary
infections of saprophytic organisms.
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In most instances, gentle, daily irrigation of
the nose with isotonic saline provides as much
symptomatic relief as any known medical
treatment.
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Surgical procedures designed to narrow the airway
have been effective in some patients. Plastics or
bone chips can be implanted in a
submucoperiosteal pocket in the lateral wall of
the nose. This procedure narrows the airway and
may relieve the bad odor and crusting.
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VII. ALLERGIC RHINITIS1. AetiologyAllergic
rhinitis is an anaphylactic reaction of nasal
mucosa to certain substances, such as pollens
from tree, grasses, flower, house dust, wool,
feathers, foods, tobacco, or other contacts
constantly present in our environment.
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Heredity, endocrine and infectionusually play an
important parts. But sometimes, identification of
the offending allergen is difficult. Similar
reactions can be produced by non-allergic factors
as derived from an autonomic imbalance in the
nasal mucosa. This is called vasomotor rhinitis.
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2. PathologyNasal mucosal oedema is caused by
intercellular transudates of the tissue fluid.
Activity of the seromucinous glands increase with
infiltration of eosinophile and plasma cells.
Vascular dilatation occurs particularly in the
inferior turbinates. Polypi usually develop. When
infection supersedes, the mucosa is reddish in
colour and the secretions are more viscid in
nature.
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3. Clinical featuresAllergic rhinitis presents
with the following classic symptoms nasal
obstruction, watery rhinorrhea, itching and
episodic sneezing. Seasonal allergic rhinitis
may last for several weeks in every year.
Perennial allergic rhinitis may be present the
year around.
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Examination discloses a characteristic
appearance. The nasal mucosa is edematous and
pallor, especially the inferior turbinates. The
surface of the mucosa is smooth and glistening,
and the turbinates occupy the large part of nasal
chamber and press against the nasal septum.
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Microscopic examination of the nasal secretion
often provides a useful rule to diagnosis. The
normal nasal secretion contains few or no
eosinophils. While in allergic rhinitis, the
number of eosinophils may be as high as 90.
Besides, the eosinophil count of the blood is
also raised.
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4. TreatmentThe best treatment for allergic
rhinitis is to find the allergen and then to
eliminate it. Of course, this is not always
possible to do so. Another approach is to
desensitize the patient. A very careful clinical
history will give a clue to the allergen (mite,
house dust, pollen, molds, grasses, animal
danders etc.).
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Sometimes, an extensive skin prick test will be
required. Immunotherapy is the administration by
injection of small, increasing dose of an
allergen with the goal of stimulating the bodys
defensive mechanism.
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Antihistamine tablets such as cetirizine have
afforded a big advance in therapy. Topical
steroid and antihistamine nasal spray such as
Rhinocort and Azep are often effective.
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VIII. DEVIATION OF THE NASAL SEPTUM Few adults
have a completely straight septum. Clinically,
only grosser deflections causing mechanical
obstruction or compression need correction. The
cause may be obvious trauma to the nose or errors
of development (septum growth faster than its
surrounding skeletal framework).
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The type of deviation is different
C-shape,S-shape ( a spur or a crest at the
junction of bone and cartilage). 1.
Symptoms1) Obstruction to the nasal airway.2)
Headache When the deviation presses upon the
anterior end of the middle turbinate, a frontal
reflexive headache may present.
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3) Epistaxis. Nosebleeds are produced as a
result of air currents drying the mucosa that
covers a deflected septum.4) The others. A high
deviation of the septum may cause obstruction of
the olfactory fissure, that leading to decrease
the olfactory function. Sinusitis may be
initiated by a deviated septum that occludes a
sinus ostium.DNS also play a role in OSAHS.
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2. TreatmentSubmucous resection of the septum
(SMR) or septoplasty may be performed as
indicated.
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