To through a light on:: Objectives 1-inflammation of the nose 2- acute inflammation of paranasal sinuses(acute sinusitis)

Inflammation of the Nose 1- Inflammation of the nasal vestibule (e.g. furunculosis) Furunculosis: it is acute bacterial infection of a hair follicle in the vestibule caused by Staphylococcus aureus. Clinical features: there is red tender nodule, which is very painful; later on Evacuation of pus usually occurs spontaneously after 4−5 days.

Complications: 1- Infection may spread through the valveless facial and superior ophthalmic veins to cavernous sinus causing cavernous sinus thrombsis which is characterized by: Fever. Vomiting. Convulsion. Edema of the eyelids. Ophthalmoplegia. Immobile pupil. Retinal hemorrhage and papilloedma. Blindness. 2- Cellulitis of upper lip. 3- Septal abscess.

Treatment: Systemic antibiotic (cloxacillin, flucloxacillin, erythromycin). Local moist heat application and analgesia like paracetamol. Advice the patient not to squeeze the boil to avoid the risk of blood-stream spread.

2-Rhinitis: It is defined as inflammation of the mucosa of the nasal cavity and divided into acute rhinitis and chronic rhinitis. Chronic rhinitis is subdivided into chronic specific and chronic non-specific rhinitis.

1- Acute rhinitis A- Common cold (coryza): it is a viral infection of the nasal mucosa caused by many viruses e.g. rhinovirus, adenovirus, Influenza, Parainfluenza, respiratory syncytial viruses...etc.

Predisposing factors: Environmental (↓ temperature, ↓ humidity). Immune deficiency (↓ IgA). Vitamin deficiency (vitamin C deficiency). Fatigue. Nasal obstruction → interfere with normal mucous transport → infection. Foci of chronic infection (chronic adenoiditis, chronic tonsillitis). ↓ Acidity of nasal secretion. General diseases (renal failure, diabetes mellitus).

Mode of transmission: is by: Droplet as in coughing and sneezing. Direct contact as kissing. Pathology: Ischaemic stage due to vasoconstriction. Hyperaemic stage in which there is edematous mucosa and profuse clear fluid. Stage of secondary infection, the discharge becomes mucopurulent. Stage of resolution; there is reversal of previous stages.

Clinical Features: 4 stages: Ischaemic stage: after incubation period of 1−3 days there is burning sensation and sneezing. Hyperaemic stage: after few hours there will be profuse watery rhinorrhoea, nasal obstruction & fever. Stage of secondary bacterial infection: the rhinorrhoea become muco-purulent, thick and greenish in color, ↑ fever and nasal obstruction. Stage of resolution: occurs in 5−10 days by reversal of previous stages.

Differential diagnosis: Allergic rhinitis (no fever). Influenzal rhinitis (there are more severe constitutional symptoms). Vasomotor rhinitis.

Complications: Acute sinusitis. Acute otitis media. Acute tonsillitis Acute pharyngitis. Lymphadenitis. Lower respiratory complications (laryngitis, tracheitis, bronchitis, pneumonia). Gastroentritis (rare). Nephritis. Rheumatism.

Treatment: Rest. Analgesia e.g. aspirin. Decongestant e.g. pseudoephedrine (systemic) or phenylephrine (topical). Decongestant help to ↓ nasal obstruction. Antihistamines. Antibiotics (reserved for treatment of complications e.g. acute otitis media).

B- H1N1 Influenza virus disease: This is a virus originated from animal influenza viruses & it is unrelated to human seasonal H1N1 viruses. This new virus may cause death & severe illness not normally seen in seasonal H1N1 viruses, it may cause death in healthy young people. Pregnant women, younger children and those with chronic lung diseases and other medical conditions are at greater risk to develop severe illness & death. Mechanism of transmission: Similar to seasonal influenza, from person to person by infected droplets expelled by coughing or sneezing or by direct contact with contaminated hands or kissing.

Clinical Features: (similar to human seasonal influenza) Fever, cough, headache, muscle & joint pain, sore throat, runny nose and sometimes vomiting & diarrhea. Treatment: (similar to human seasonal influenza) Rest. Drinking plenty of fluids. Analgesia. In severe cases use antiviral agent like: Tamiflu. The majority of people experience mild illness & recover fully without treatment.

2- Chronic Rhinitis: A- Chronic non-specific rhinitis. B- Chronic spesific rhinitis,it is due to spesific causes e.g.TB,syphilis,leprosy…etc

A- Chronic non-specific rhinitis. Atrophic rhinitis. Aetiology: Infection e.g. syphilis, chronic sinusitis. Surgery e.g. inferior turbinectomy. Poor nutrition e.g. vitamins and iron deficiency. Genetic. Hormonal. Autoimmune

Pathology: two types Type 1 (most common): Characterized by endarteritis of terminal arterioles. Type 2 (less common): Characterized by vasodilatation of the capillaries. Other pathological changes in both types (1 & 2) are metaplasia of columnar epithelium to squamous epithelium and decrease in the number and size of alveolar glands.

Clinical picture: Atrophic rhinitis is more common in females and presented at puberty and it is bilateral. It is characterized by: Nasal obstruction due to crust. Epistaxis due to separation of the crust Anosmia. On examination there is characteristic greenish foul smell crust and abnormally patents nasal passages.

Investigations: Radiology of paranasal sinuses to exclude chronic sinusitis. Serological test for syphilis (VDRL, TPI, FTA test) to exclude syphilis. Complete blood picture, serum protein and iron to exclude nutritional deficiencies.

Treatment: A-Conservative: Removal of crusts by forceps, suction or by syringing with warm isotonic solution or alkaline solution. Glucose 25% in glycerin drops to prevent infection. Systemic antibiotic e.g. rifampicin 600 mg/ 1 day for 12 weeks. B-Surgery: there are many surgical operations; the most important one is Young's operation in which we close the nostril for several months.

Inflammation of Paranasal Sinuses (Sinusitis): Acute sinusitis: Definition: it is acute infection of the mucosa of paranasal sinuses (for less than 3 weeks duration). Inflammation may be unilateral or bilateral, may affect single sinus or several or all sinuses (pansinusitis). Maxillary sinus the most commonly affected followed by ethmoid, frontal and sphenoidal sinus.

Aetiology: Acute infective rhinitis e.g. common cold (most common cause of acute sinusitis). The infection spread to the sinus from the nose through the ostium. Swimming: the Infection can spread directly through the ostium; also chlorine, which is added to water of swimming pool, is irritant → sinusitis. Dental extraction or infection (uppersecond premolar and molar teeth). The roots of these teeth may penetrate the floor of maxillary sinuses. So that dental infection may spread to maxillary sinuses. External trauma may cause fracture through the sinus wall lead to direct spread of infection through fracture to the sinus.

Predisposing factors: 1- Local: Nasal obstruction e.g. septal deflection, polyp. Obstruction of sinus ostium e.g. allergic rhinitis, tumour. Neighbouring infection e.g. tonsillitis, adenoiditis. Previous infection in the same sinus.

2- General: Debilitation. Mucociliary disorders. There is impairment of mucous transport. (Like Kartagener's syndrome, cystic fibrosis, Young's syndrome). Kartagener's syndrome; sinusitis, bronchiectasis, infertile male with or without situs inversus (autosomal recessive) Young's syndrome; sinusitis, bronchiectasis and obstructive azospermia. Immunodeficiency disorder e.g.: AIDS, DM, renal failure. Irritating atmospheric conditions and cold weather. Cold weather causes vasoconstriction of nasal and sinus mucosa → easy invasion by bacteria.

Causative organisms: Pneumococcus. Haemophilus influenzae. Staphylococcus aureus. Streptococcous pyogenes. Moraxilla catarrhalis.

Pathology: Upper respiratory tract infection → hyperaemia and edema of the mucosa → blockage of ostia & paralysis of the cilia → stasis of secretion in the sinus → secondary bacterial infection → sinusitis. Hyperaemia of the sinus mucosa. Oedema of the sinus mucosa. Cellular infiltration of the sinus mucosa (polymorphonuclear cells). Glandular hyperactivity → ↑ mucous secretion. Exudation: it is serous exudate in early stages then becomes purulent.

Clinical features Fever and malaise. Pain: Maxillary sinusitis → pain in the cheek referred to upper teeth. Frontal sinusitis → pain in the frontal region. Ethmoidal sinusitis → pain between the eyes at the nasal bridge. Sphenoidal sinusitis → retro-orbital headache referred to vertex, temple or occiput. Nasal obstruction. Postnasal drip.

Tenderness. Maxillary sinusitis → tenderness over the cheek. Frontal sinusitis → tenderness over the sinus floor immediately above the inner canthus and tenderness by tapping over anterior sinus wall. Hyperaemia of nasal mucosa. Pus discharge: Maxillary, frontal and anterior ethmoidal sinusitis → pus in middle meatus . Posterior ethmoidal sinusitis → pus in the superior meatus. Sphenoidal sinusitis → sphenoethmoidal recess can be seen by posterior (not anterior) rhinoscopy. Oedema and hyperaemia over the cheek in acute maxillary sinusitis and over frontal bone in acute frontal sinusitis may be seen in children.

Nasal endoscopy → pus in the middle meatus, superior meatus or sphenoethmoidal recess (according to the infected sinuses). Investigation: CBP & ESR → ↑ WBCs & ESR. Swab for culture and sensitivity. Plain X-ray (occiptomental view) may show: Sinus mucosal thickening. Fluid level Total opacification of the sinus. CT scan. Serum immunoglobulins assay (IgG, IgA → to detect immunoglobulin deficiency)(in selected cases).

Treatment: Aims of treatment → To resolve the acute infection. To prevent complication. To correct any precipitating factor e.g.: septoplasty to correct septal deviation.

Medical treatment: (7 days course) Bed rest and analgesia e.g.: paracetamol. Broad spectrum antibiotic e.g.: co-amoxiclav, clarithromycin, cefuroxime. Decongestants → systemic e.g.: pseudoephedrine. → Topical e.g.: ephedrine to improve sinus drainage.

Surgical treatment: (used when there is failure of medical treatment) Functional endoscopic sinus surgery (FESS) is now the treatment of choice in recurrent acute sinusitis. Antral washout, it treat any Infection in the maxillary sinus and also improve drainage from other sinuses. It is done by passing a canula through the inferior meatus into the maxillary sinus and washing the sinus by using syringe and warm saline solution. Inferior meatal antrosomy (when there is history of recurrent infections) we do opening in the inferior meatus for better and longer lasting drainage. Frontal sinus trephination: trephination of the frontal sinus floor via small incision above the medial canthus → washout the sinus. Uncapping of the ethmoidal sinuses to promote drainage from the sinus. Anterior sphenoidotomy: in acute sphenoidal sinusitis.