Acute and chronic nasal rhinitis fatimah alomran , khulud alqahtani , mashael alrubaian

contents • Definition • Classification • Clinical features • Signs • Investigation • Complication • treatment

Definition of Rhinitis rhinitis, the inflammation of nasal mucous membrane is caused by viruses, bacteria, irritants or allergens.

Acute rhinitis viral bacterial Irritative type

A ) VIRAL RHINITIS 1 ) Common cold (Coryza) Transmition : airborne droplets that transmit the virus. Organisms : Several viruses (adeno virus, picorna virus and its sub-groups sucha s rhinovirus, coxsackie) The Incubation period : The Incubation period usually is 1–4 days and illness lasts for 2–3 weeks. Clinical features : begin with burning sensation at the back of nose soon followed by nasal stuffiness , rhinorrhea and sneezing . General symptoms ; chills , low grade fever , Headache IMPORTANT : nasal discharge is watery and profuse but may become mucopurulent due to secondary bacterial invasion.

PROGNOSIS The disease is usually self-limiting and resolves spontaneously after 2–3 weeks with Bed rest and give more fluids BUT we can give some medications to control symptoms like: -antihistaminic and nasal decongestants. Analgesics to relieve headache, fever and myalgia Non aspirin containing analgesics are preferable as aspirin causes increased shedding of virus Antibiotic are required when secondary infecion.supervenes notice: occasionally, complications such as sinusitis, pharyngitis, tonsillitis, bronchitis, pneumonia and otitis media may result

2) Influenzal rhinitis : Aetiology : Influenza viruses A, B or C 2) Influenzal rhinitis : Aetiology : Influenza viruses A, B or C. Clinical features : are similar to common cold. Treatment : Antihistaminics , Nasal decongestants Complications : common due to bacterial invasion . 3) Rhinitis associated with exanthemas: Measles, rubella and chickenpox are often associated with rhinitis which precedes exanthemas by 2–3 days. Secondary infection and complications are more frequent and severe.

B ) BACTERIAL RHINITIS 1 ) Diphtheritic rhinitis : rare Organism : corynebacterium . It may be : Primary Secondary to faucial diphtheria May occur in acute or chronic form Notable Symptom A Greyish membrane is seen covering the inferior turbinate and the floor of nose ; membrane is tenacious and its removal causes bleeding . Excoriation of anterior nares and upper lip may be seen . Treatment : Isolation of the patient, systemic penicillin and diphtheria antitoxin.

2) Nonspecific infections : it may be ; primary : - affect children - it is caused by streptococcus , staphylococcus , pneumococcus. - Notable Symptom a greyish white tenacious membrane may form in the nose which with attempted removal causes bleeding secondary: result of bacterial infection supervening acute viral rhinitis

C ) irritative rhinitis Caused by exposure to : Dust , smoke , irritating gases ( ammonia formaline ..) , trauma inflicated on the nasal mucosa during intranasal manipulation ( e.g. removal of a foreign body . There is an immediate catarrhal reaction with sneezing, rhinorrhea and nasal congestion. The symptoms may pass off rapidly with removal of the offending agent or may persist for some days if nasal epithelium has been damaged. Recovery will depend on the amount of epithelial damage and the infection that supervenes.

CHRONIC RHINITIS Chronic simple Rhinitis Hypertrophic Rhinitis Atrophic Rhinitis Rhinitis Sicca Rhinitis Caseosa

1) CHRONIC SIMPLE RHINITIS Aetiology : Recurrent attacks of acute rhinitis in presence of Predisposing factors leads to chronicity. Predisposing factors : - Persistence of nasal infection due to sinusitis, tonsillitis, and adenoids. - Chronic irritation from dust, smoke , snuff. - Nasal obstruction. - Vasomotor rhinitis - Endocrinal or metabolic factors, e.g. hypothyroidism.

Pathology : Simple chronic rhinitis is an early stage of hypertrophic rhinitis. there is hyperemia and edema of mucous membrane with hypertrophy of seromucinous glands and increase in goblet cells. blood sinusoid turbinates are distended.

Clinical features : - Nasal obstruction - Nasal discharge Clinical features : - Nasal obstruction - Nasal discharge. It may be mucoid or mucopurulent. Postnasal drip. - Headache - Swollen turbinates – They pit on pressure, shrink with application of vasoconstrictor drops (this differentiates the condition from hypertrophic rhinitis). - Post-nasal discharge. Mucoid or mucopurulent discharge.

Treatment : 1- Treat the cause with particular attention to sinuses, tonsils, adenoids, habits (smoking or alcohol indulgence)environment or work situation(smoky or dusy surroundings). 2- Nasal irrigations with alkaline solution. 3- Nasal decongestants help to relieve nasal obstruction. 4- Antibiotics help to clear nasal infection.

2) HYPERTROPHIC RHINITIS Characterized by thickening of mucosa, submucosa, seromucinous glands, periosteum and bone. Changes are more marked on the turbinates.

Aetiology : - Recurrent nasal infections. - Chronic sinusitis. - chronic irritation of nasal mucosa due to smoking, industrial irritants, prolonged use of nasal drops. - Vaso-motor rhinitis. - Allergic rhinitis.

SYMPTOMS Nasal obstruction. Nasal discharge is thick and sticky. Headache Transient anosmia SIGNS Hypertrophy of turbinates. Turbinal mucosa is thick and does not pit on pressure. It shows little shrinkage with vasoconstrictor drugs. Maximum changes are seen in the inferior turbinate “Mulberry Appearance”

TREAREMENT surgery Linear cauterization. Submucosal diathermy. Nasal obstruction can be relieved by reduction in size of turbinates. The various methods are: Medical like chronic simple rhinitis surgery Linear cauterization. Submucosal diathermy. Cryosurgery of turbinates. Partial or total turbinectomy. Submucous resection of turbinate bone. Reduction of turbinates size by laser.

3) ATROPHIC RHINITIS (OZAENA) Chronic inflammation of nose characterized by atrophy of nasal mucosa and turbinate bones. (two type primary,secondary) Nasal cavities are roomy and full of foul-smelling crusts. Primary atrophic rhinitis : Aetiology : ( H E R N I A) Exact cause is not known, Various theories regarding its causation are: 1- Hereditary factors 2- Endocrinal disturbances : Starts puberty, involves females more than males, tends to cease after menopause.

Pathology : 3- Racial factors – White. 4- Nutritional deficiency : Deficiency of vitamin A, D or iron. 5- Infective 6- Autoimmune process Pathology : Stratified squamous epithelium. Atrophy of seromucinous glands, venous blood sinusoids and nerve elements. Obliterative endarteritis of arteries in the mucosa, periosteum and bone. Resorption of turbinate bones  widening of nasal chambers.

Commonly seen in females and starts around puberty. Clinical features : Commonly seen in females and starts around puberty. Foul smell from the nose. Marked anosmia Nasal obstruction Epistaxis when the crusts are removed. Nasal cavity full of greenish or greyish black dry crusts. Nasal cavities appear roomy. Nasal mucosa appear pale. Septal perforation and dermatitis of nasal vestibule. Nose shows saddle deformity. May extend to pharynx or larynx. Hearing impairment because of obstruction to Eustachian tube.

Treatment : 1- Medical : 1- Nasal irrigation and removal of crusts Treatment : 1- Medical : 1- Nasal irrigation and removal of crusts. 2- 25% glucose in glycerine. – Inhibits the growth of proteolytic organisms which are responsible for foul smell. 3- Local antibiotics – KemicetineTM antiozaena solution and vitamin D2. 4- Oestradiol spray – increase vascularity of nasal mucosa and regeneration of seromucinous glands. 5- Placental extract injected submucosally. 6- Potassium iodide by mouth promotes and liquefies nasal secretion.

2- Surgical : A) Young’s operation – Both the nostrils are closed completely just within the nasal vestibule by raising flaps. They are opened after 6 months or later. Modified young’s operation - Aims to partially close the nostrils. B) Narrowing the nasal cavities. Among the techniques followed, some are : Submucosal injection to teflon paste. Insertion of fat, cartilage, bone or teflon strips under the mucoperiosteum of the floor and lateral wall of nose Section and medial displacement of lateral wall of nose.

SECONDARY ATROPHIC RHINITIS : Specific infections like syphilis, lupus, leprosy and rhinoscleroma. Longstanding purulent sinusitis, radiotherapy or nose or excessive surgical removal of turbinates. UNILATERAL ATROPHIC RHINITIS : Extreme deviation of nasal septum. Atrophic rhinitis on the wider side. TREATMENT: MEDICAL THERAPY : *ALKALINE NASAL DOUCHE *Nasal drops *Kemicetine(local antibiotic) 2. Surgical : Young’s operation, Modified young’s operation

Severe deviated nasal septum

4 ) RHINITIS SICCA So the mucous membrane of the nose is abnormally dry with little or no nasal secretion. Seromucinous gland which help to moist this part of nasal cavity Crust removal cause ulceration and epistaxis and may lead to septal perforation

5 ) RHINITIS CASEOSA

Reference Diseases of Ear, Nose and Throat & Head and Neck Surgery, 6/e PL Dhingra, Shruti Dhingra and Deeksha Dhingra.