CHRONIC SINUSITIS It is long- standing infection of the Para nasal sinuses. Recently defined as persistent symptoms and signs for 8 weeks, or 4 episodes per year of acute sinusitis each lasting 10 days There is hypertrophic changes in the mucosa, evidenced by CT scan. It may follow an acute attack if not properly treated or may be insidious in origin.

Predisposing factors 1-Anatomical abnormalities causing sinus ostium obstruction like Deviated septum, nasal polyps, adenoid hypertrophy and allergic rhinitis. 2-Recurrent acute infections. 3- Ciliary dysfunction. 4- Mucus overproduction or increased viscosity. 5-Dental causes which accounts for about 20% cases of chronic maxillary sinusitis.

Clinical presentation SYMTOMS Nasal obstruction Nasal discharge which may be greenish-yellow. Post nasal drip which may lead to chronic sore throat due to chronic pharyngitis and laryngitis. Facial pain or Headache. Smell disorders like anosmia, hyposmia and cacosmia (unpleasant smell). Epistaxis

SIGNS There is usually swelling and congestion of the nasal mucus membrane with mucupurulent discharge in the nose; there also may be features of the causative or predisposing factors. Endoscopic examination of the nose is important to evaluate the nose and Para nasal sinuses, especially the area of the middle meatus which is the site of the drainage of the sinuses.

Investigations X-ray of the paranasal sinuses which may show haziness or opacity of the affected sinuses. CT scan is an excellent tool to investigate sinus diseases; it shows the anatomical details of the sinuses and the extension of the disease process. It shows the anatomy of the area of the middle meatus and the region called the Osteomeatal Unit which is the area of the drainage of the maxillary, frontal and ethmoid sinuses, and is essential investigation for endoscopic sinus surgery.

Treatment 1-If acute infection is present; a course of broad spectrum antibiotic is needed for 2 to 3 weeks; together with short course nasal decongestants and mucolytics. 2-Treatment of the underlying cause. 3- Surgical intervention: NO response to treatment or recurrent acute attacks of acute sinusitis.

Surgery of the sinuses is now mostly done with endoscopes, directed to area of the drainage of the sinuses (osteomeatal unit) to drain the sinuses and improves the ventilation((FESS)) Other procedures Antral washout, which is puncturing the maxillary sinus with trocar and canula through the inferior meatus ( diagnostic and therapeutic) Intranasal antrostomy. Caldwell-Luc operation. External Frontoethmoidectomy.

Allergic Rhinitis It is defined as hypersensitivity reaction of the nasal mucus membrane to a variety of stimuli. It is a common medical problem affecting about percent of the general population (in western studies). It can be classified as seasonal allergic rhinitis and perennial allergic rhinitis.

In the seasonal type the symptoms are present mainly in certain season of the year. In the perennial type the symptoms are present in most of the days of the year with possible occasional exacerbations in some periods. Etiology Allergic Rhinitis is caused by allergens (antigens) -- Inhalants : pollens, moulds, house dust mites and animal epithelium. -- Ingestants : Certain foods and drugs Familial predisposition.

Pathology &Pathogenesis Type I hypersensitivity reaction which involves IgE, Mast cells and other cells. When the antigen comes into contact with the mast cell in nasal mucosa, it cross links 2 molecules of IgE on the surface of mast cell leading to its degranulation and release of vasoactive mediators, which are mainly histamine and prostaglandins. These mediators are responsible for the pathological changes in the nasal mucosa, which are swelling, excessive discharge and increased vascular congestion and vascular permeability.

Clinical Picture Symptoms : Nasal obstruction because of the swelling and congestion of the nasal mucus membrane. Nasal discharge which is called Rhinorrhoea. Sneezing. Eye symptoms. Signs Edematous mucus membrane: pale, sometimes bluish discoloration. Thin mucus discharge. Longstanding cases hypertrophy of the mucus membrane and even polyp formation may occur.

Investigations Skin prick test which is a sensitive test to diagnose allergy and to identify the allergen. Nasal smear examination which may show eosinophilia. Certain blood tests which measure the level of IgE in the blood which is elevated in cases of allergy.

Management 1-Avoidance of the allergen if possible. 2-Medical therapy A-Antihistamines B-Steroids: usually topical steroids in the form of drops or sprays. Rarely short course of systemic steroids may be needed. C-Sodium chromoglycate, in the form of topical drops or sprays. D- Topical anticholinergics. 3- Immunotherapy.

Non Allergic Rhinitis It is a form of chronic rhinitis similar to allergic rhinitis in its clinical presentation but negative history of allergy and negative allergic test. It is also called Vasomotor Rhinitis or Intrinsic Rhinitis. Thought to be caused by imbalance of the autonomic nervous supply to the nose and hyper reactivity of the nasal mucosa to external environmental factors. Clinically: either rhinorrheoa or nasal block. Treatment is either nasal steroids and antihistamines or topical anticholinergic drugs like ipratropium bromide. Surgery, in septal deviation or turbinate hypertrophy.

Deviated Nasal Septum Some mild form of septal deviation is common in the general population and this needs no treatment, only those cases of gross deviation of the nasal septum and causing symptoms and complications need treatment. Etiology 1-One theory suggests that the nose may be compressed during birth. 2-Trauma

Clinical presentations Nasal obstruction, it can be unilateral or bilateral. Epistaxis. Symptoms of associated complications, like nasal discharge and pain (facial pain or headache), when there is sinusitis. The deviation may in the form of sharp angulation called (spur) or smooth curve.

Investigations X-ray of the sinuses or CT scan if available may be needed when there is suspicion of sinusitis. Treatment Surgery is needed to correct the deviated septum. The operation is called Septoplasty.

Septal Perforation It is defined as a direct communication between the right and left nasal cavities via a hole in the septum. Causes: Iatrogenic, like post septal surgery, is the commonest cause. Traumatic, like chronic nose picking. Chronic inflammatory conditions like syphilis, TB and atrophic rhinitis. Chronic exposure to irritants, like in cocaine addicts. Malignant diseases in the nose.

Clinical Picture: The perforation may be asymptomatic and the condition is diagnosed accidentally. The symptoms may be irritating crusts in the nose, bleeding when the crust separates and whistling sound in the nose when the perforation is small.

Management Asymptomatic, no treatment. Nasal douching when bleeding and crusting is a problem and application of a lubricant ointment like vasaline. Non surgical closure using a silastic prosthesis ( biflanged buttons). Surgical closure may be done for symptomatic perforations and these have poor outcome.