Download Dr.Hussein L.3+4 Inflammations of the Nose Results from: 1

Dr.Hussein
L.3+4 Inflammations of the Nose
Results from:
1. Infection, both viral and bacterial.
2. Allergy and vasomotor rhinitis.
3. Physical and chemical trauma i.e. rhinitis medicamentosa.
Inflammations of the External Nose
(Infection of the skin over the nose)
1. Furunculosis:
Acute staphylococcal infection of the pilocebaceous hair follicle in the
vestibule of the nose. Its hard tender with discharge, the infection may spread
through the valveless facial veins & superior ophthalmic veins to the
cavernous sinus. Squeezing is highly contraindicated.
Clinical features:
a. pain with red tender nose.
b. Headache.
c. Pus discharge from the swelling.
Treatment:
Systemic antibiotics: flucloxacillin, erythromycin, cephalexin.
Complications:
a. Cavernous sinus thrombosis.
b. Cellulitis of the lip and the face.
2. Non-specific infective nasal vestibulitis:
Which is dermatitis in t h e nasal vestibule secondary to nasal discharge,
which may lead to painful fissures.
Treatment:
Local antibiotic like chlorhexidine cream & local steroid ointment.
3. Erysipelas:
Acute spreading streptococcal dermatitis. It begins as small break in the skin
which then swollen & indurated.
4. Impetigo:
Acute contagious staphylococcal infection which start as bullae & rupture
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forming crusts.
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Inflammation of the Nasal Cavities
(Acute Rhinitis)
1. The common cold (coryza):
Rhinovirus is the most frequent cause, others like adenovirus, picorna virus
and RSV.
Etiology:
Virus infection which is conveyed by contact or air born droplets.
Pathogenesis:
Transient ischemia of the mucosa results in swelling, hyperemia and
profuse secretion of clear seromucinous fluid which become
mucopurulent later by secondary infection.
Clinical features: Four stages:
1. Ischemic stage: after an incubation period of 1-3 days, burning sensation
in the nasopharynx and nasal mucosa, sneezing with feeling of
shivering.
2. Hyperemic stage: profuse rhinorrhea, nasal obstruction, and pyrexia.
3. Stage of secondary infection: the discharge becomes yellow or green
and thick.
4. S t a g e of resolution: resolution occur in 5--1 0 d a y s .
Differential diagnosis: Allergic rhinitis; and vasomotor rhinitis.
Complications: Secondary infection of the respiratory tract and ear.
Treatment:
- Prophylactic: avoid contact with a known case.
- Therapeutic: rest and warmth.
 Analgesic: aspirin & paracetamol.
 Pseudoephidrine by mouth relieves congestion.
 Antihistamine and vitamin C.
 Antibiotic for treatment of secondary infection.
 Inhalation of steam with menthol.
 Local vasoconstrictors in the form of drops or sprays give quick relief from
nasal obstruction but should not used more than 1 week because it may
lead to hypertrophic rhinitis (rhinitis medicamentosa).
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2. Acute rhinitis associated with influenza and the exanthemata.
3. special forms of acute infective rhinitis
rarely seen, due to diphtheria, erysipelas, glanders, anthrax.....
Chronic rhinitis
1. Chronic non-specific rhinitis:
Which could be:
a. Simple chronic rhinitis.
b. Hypertrophic rhinitis:
This is seen in those using topical vasoconstrictors for a long time and in
large quantities (rhinitis medicamentosa).
c. atrophic rhinitis:
It’s a chronic inflammation of the nasal mucosa, in which atrophy
occur due to periarterial fibrosis and endarteritis.
Etiology:
Not fully known, but infection, endocrine disorders, and vitamin
deficiency claimed.
Types:
1. Primary atrophic rhinitis (ozaena):
Degeneration of the ciliated epithelium and formation of thick
adherent crusts in the nose, atrophy of the turbinate and become
secondarily infected with saprophytic organisms, the airway is widened,
but sensation of nasal obstruction is experienced, more common in
females about puberty, foul stench is not noticed by the patient, who is
anosmic, epistaxis sometimes occurs due to separation of the crusts.
Treatment:
1) Removal of the crusts is best achieved by syringing with
warm isotonic solution.
2) Glucose 25% in glycerin drops prevent adherence of crusts
and inhibit saprophytic infection.
3) Local or systemic antibiotic.
4) Other measures may be used like KI therapy, or stilbosterol
Locally or systemically to increase the blood supply of the
atrophic mucosa.
5) Surgical measures: reduce the caliber of the airway, by
submucosal insertion of graft, Teflon paste submucosal
injection, closure of the nostrils for a period of several
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months give striking improvement in the mucous
membrane.
2. Secondary atrophic rhinitis:
In deviated septum, syphilis, lupus, radical turbinectomy.
d. Rhinitis sicca:
affect those working in dusty environments, result in viscid and
stagnant mucous blanket which forms crusts, these are not foetid.
Treatment:
Lubrication by sprays or ointments.
e. Rhinitis caseosa:
rare condition when cheesy debris is extruded into the nose from infected
sinus.
2. Chronic specific Infective Rhinitis:
Syphilis, yaws, lupus vulgaris, sarcoidosis, diphtheria...
Inflammation Of The Paranasal Sinuses
May involve one sinus or several sinus (multisinusitis), or in all of one side or
both sides (pansinusitis, unilateral or bilateral).
Acute non-specific infective sinusitis:
Etiology:
1. Acute infective rhinitis due to cold or influenza and it is the
commonest cause of acute sinusitis.
2. Swimming and diving.
3. Dental extraction and infection enter the maxillary antrum from the
dental root.
4. Fracture involving the sinus.
5. Barotraumatic sinusitis.
6. Local causes: nasal obstruction due to septal deviation, nasal polyps,
allergic rhinitis.
7. General causes: debilitation, immunodeficiency.
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Bacteriology:
Pneumococcus, streptococcus, staphylococcus, H. influenza, and klebsiella
pneumonia, while E. coli and anaerobic strept. are associated with infection
of dental origin.
Pathogenesis:
Hyperaemia
oedema
cellular infiltration
increase mucous
production exudation purulent secretion.
Acute maxillary sinusitis:
The origin of the infection may be either nasal 90% or dental 10% after
dental apical abscess or extraction of the premolar or molar teeth. Pain in the
cheek which may be referred to frontal or temporal region, tenderness over the
cheek, oedema, discharge in the middle meatus with postnasal drip.
Investigation:
Radiograph examination which show an opacity, or fluid level.
Constitutional symptoms:
Pyrexia, malaise, mental depression.
Acute frontal sinusitis:
Usually associated with an infection of the homolateral anterior ethmoidal
cells and often the maxillary sinus.
Clinical features:
1. Frontal headache start after waking and subsides in the afternoon.
2. Extreme tenderness to pressure on the orbital roof, percussion of the anterior
sinus wall is painful.
3. Edema of the upper lid.
4. Discharge in the high anterior portion of the middle meatus.
Acute ethmoiditis and acute sphenoiditis:
Commonly involved with other sinuses and seldom produces a separate
clinical entity in the adults, and treatment of acute infection in larger sinuses
produces resolution in the ethmoids and sphenoid sinuses.
Differential diagnosis:
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1. Pain of dental origin.
2. Migraine.
3. Trigeminal neuralgia.
4. Neoplasms of the sinuses.
5. Erysipelas.
6. Temporal arteritis.
7. Herpes Zoster.
Treatment:
1. Treatment of infection: amoxicillin and flucloxacillin will cover most organisms,
a sample of pus must be sent for culture and sensitivity, in infection of dental
origin metronidazole must be added.
2. Treatment of pain: paracetamol or codeine tablets can be given.
3. Local heat: by radiant heat, hot water bottle and steam.
4. Establishment of drainage by:
a. decongestants: such as 0.5 or 1% ephedrine in normal saline either
in the form of drops or spray, sometimes cocaine 5% w i t h
adrenaline I in 10000 is a powerful vasoconstrictor but should not
be used repeatedly.
b. Irrigation of acutely infected sinus: antral lavage can be done
under local anesthesia or general anesthesia, after a course of
antibiotics(2-3 days) then irrigation done through the inferior meatus.
Simple chronic suppurative sinusitis
Etiology
Follows single or repeated attacks of acute sinusitis.
Pathology
Every stage from hypertrophic change even including
formation to one of an atrophic character may he found.
polypus
Bacteriology
The organisms are usually mixed .streptococci often including some
anaerobics being the commonest, pneumocoeci may be found, B.proteus,
ps.pyocyanea, E.coli.
Clinical features
1. The same clinical features of acute sinusitis but of lesser degree and
acute exacerbation may occur at intervals.
2. May be merely nasal or postnasal discharge.
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3. Nasal obstruction and headache as heavy feeling in the head or dull
ache over the sinus.
4. Anosmia or Cacosmia with some constitutional symptoms.
Treatments
1. Medical treatment: systemic antibiotics and oral decongestants may be of
value.
2. Surgical treatments: of chronic sinusitis
a) Local irrigation of the maxillary sinuses by puncturing the inferior
meatus may be of benefit
b) Intranasal antrostomy is effective if repeated antral lavage failed.
c) Sub-labial antrostomy (Caldwell-Luc operation) is indicated in long standing
cases.
d) Functional endoscopic sinus surgery regarded the most effective method
which is now used in the advanced centers to eradicate disease from
sinuses.
e) External frontoethmoidectomy for eradication of diseases from the frontal
and ethmoid sinuses.
Surgical treatment of chronic sphenoiditis: are usually part of combined
operation for multisinusitis, the sphenoid sinus may be reached through the
direct nasal rout, or via the maxillary sinus , or via the external
ethmoidectomy. But the FESS (functional endoscopic sinus surgery)
regarded the effective surgery in treating sinuses.
Complex infective chronic sinusitis
It is defined as secondary infection results from chronic obstruction of the
ostium, the bacteriology is the same as in simple one, and in addition
superadded factors may present:
1) Smoking
2) vasomotor and allergic rhinitis 3) nasal polyp.
4) Endocrine disorders as myxoedema 5) abnormal mucociliarydisorders.
Hypertrophic changes may present in the mucosa o f t h e sinuses with excess of
eosinophiles in the discharge when allergy is present, cysts may present in the
sinus.
Clinical features:
The onset is usually insidious, and the condition is usually bilateral and tends to
affect all sinuses, nasal discharge, and anosmia also present.
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Treatments:
1) Treatment of the infection by systemic antibiotics.
2) Treatment of allergy by avoidance of precipitating factors, antihistamines
therapy may be given, topical steroids drops and sprays and correction of any
endocrine problems.
3) Surgical treatment: if medical treatment failed: a) Antral washout may be helpful.
b)
Nasal polypectomy if present.
c) Correction of any obstruction like septal deviation, turbinate
hypertrophy, intranasal antrostomy.
d) Caldwell luc operation for resistant cases and removal o f t h e diseased
mucosa from the antrum.
e) FESS regarded the hope for many cases.
Specific infection o f the paranasal sinuses
Like T.B., syphilis, fungal infection in immunocompromised patient,
treated accordingly and they are rare.
Complication of suppurative sinusitis
Due to the spread infection beyond the bony w a l l s of the sinuses, the mode
of spread either:
1) Direct spread: by osteitis in compact bone, osteomyelitis in diploic bone or by
surgical trauma through fracture lines involving the sinuses.
2) Venous spread
3) lymphatic spread 4) perineural spread.
Complications:
A. Acute:
Local
1) Bony (Osteomyelitis ): as in infection o f t h e frontal sinuses which found
most frequently in young adults, streptococci and staphylococci are the most
common organisms responsible.
Clinical features: a) dull local pain and headache occur over frontal sinuses b)
oedema over the forehead (pott's puffy tumour).
c) Intracranial complication and toxemia may occur.
Diagnosis: by radiography which shows loss of bone patterns, necrosis, and
sequestration can be seen later over the frontal sinuses.
Treatments:
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a) Antibiotics given as prophylaxis during surgery.
b) Treatment of early cases by systemic antibiotics.
c) Antral lavage may be needed and possibly simple trephining o f t h e frontal
sinus floor.
d) Treatment of intracranial complications.
2) Orbital complications:
Spread of infection to the orbit through caries of the lamina papyracea,
and orbital cellulitis with or without the formation of a subperiosteal abscess
.and cavernous sinus thrombosis may occur lately.
Clinical features:
1) Pain referred to the eye.
2) Chemosis which close the eyelids.
3) Proptosis
4) Diplopia.
Treatments:
1) Systemic antibiotics should be given.
2) Antral lavage is imperative.
3) CT scan is indicated to show if pus has formed.
4) Drainage of the abscess and treatment of the sinuses.
3) Intracranial complications:
a) Meningitis, extradural abscess, subdural abscess.
b) Thrombophlebitis of the cavernous sinuses.
c) Brain abscess.
4) Dental complication:
Distant: toxic shock syndrome (due to staphylococcus infection).
B. Chronic: mucocele and pyocele.
C. Associated diseases: Otitis media, adenotonsilitis, and bronchiectasis.
Tumours and cysts of the nose and paranasal sinuses
They are fairly common, may arise from the epithelial, connective tissues
and neural tissues.
A) Epithelial tissue tumours:
1) Papilloma: may arise in the nasal vestibule as w7arty lesion single or
multiple, treated by excision and the base treated by cautery.
2) transitional or inverted papilloma : gross thickening of the epithelial surface
leads to infolding but the basement membrane remains intact .there may be
columnar ,squamous or transitional types of epithelium in the same
tumour, malignant changes may occur in 3 % of cases .more commonly
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occurs in men 5 % .the commonest site is on the lateral w al l of the nasal
cavity and \or antrum and ethmoids ,leads to nasal obstruction treated by
excision through lateral rhinotomy .recurrence suggests malignancy.
3) Adenoma: rare.
B) Connective tissue tumours:
1) Fibroma: rare, on the turbinates and septum.
2) Osteoma: there are two types:
a) Compact osteoma occurs most commonly in the frontal sinuses, it is ivory
hard in consistency .arises from periosteal tissue, max be sessile or
pedunculated.
Clinical features:
*) may be asymptomatic until reaches large size, most evident in young
adults.
*) displacement of the eye due to expansion of the affected sinus.
*) empyema or mucocele of the sinus; due to the obstruction of the
frontonasal duct of the sinus.
*) pressure atrophy of the anterior cranial fossa wall, which leads to CSF
leak and infection.
*) dense mass is seen on radiography.
Treatment: removal of the mass.
b) Cancellous osteoma occurs most commonly in the maxillary and ethmoid
sinuses.
3) Fibrous dysplasia: swelling consist of irregular spongy subperiosteal bone with
a thin cortex and i l l defined edge , may be monostotic or polystotic .which may
involves the maxilla and the mandible ,the lesion Presents in the form of
either:
a) Diffuse involving several of the facial and cranial bones.
b) Localized involving the maxillary and the ethmoidal bones, biopsy
indicated to diagnose the condition .
Clinical features: mainly occurs in the adolescents which may leads to
deformity and usually limited to one side .growth is slow. Polystotic fibrous
dysplasia associated with endocrine disorders and cutaneous pigmentation
and called Albright's syndrome.
Treatment: excision best avoided but partial removal of the affected bony
tissue can be undertaken after puberty for cosmetic reasons.
4) Angioma:
Either in the form of capillary or cavernous, the capillary form occurs in the
nasal septum (bleeding polypus of the septum) and leads to epistaxis.
Treatment: excision and cauterization of the bed.
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The cavernous form which may involve the whole tip of the nose.
5) Giant cell granuloma (osteoclastoma): rare
6) Chordoma: most often seen in the nasopharynx, but may arise from other sites
like septum, sphenoid .ethmoid sinuses .arises from notochordal remnants
contains large vacuolated (foam) cells, erodes bone extensively, it is radio
resistant, metastasis are rare.
7) Craniopharyngioma: derived from Rathke's pouch and may extend
intracranially leads to increase in the I.C.P. and endocrine dysfunction.
8) Rhinophyma: it is caused by a fibrosis and hyperplasia of the sebaceous tissue
of the skin of the nose, as a result of acne rosacea , leads to swelling of the
nasal tip and nostrils , treated shaving o IT the excess tissue and skin graft
may be required .
9) Torus palatinus: it is exostosis found in the midline of the hard palate,
ulceration may occur.
Malignant tumours:
a) Epithelial tumours:
*squamous cell carcinoma: is the commonest malignant tumours in the nose
and paranasal sinuses w h ic h lead to destruction of the soft tissues, and
destroys bone and ulcerates into the mouth , pharynx or skin of the face ,
metastasis by lymphatics occur to the upper deep cervical glands .more
common in those working in the nickel industry .
* Lymphoepithelioma.
*Adenocarcinoma: arises from the glands of upper respiratory mucous
membrane especially the maxillary antrum, occurs in those working in hard
wood industry.
*adenoid cystic carcinoma : arises from minor salivary glands on the
alveolus, hard palate, antral floor .spreads through the coarse of cranial
nerves , they are generally radioresislant .
*olfactory neuroblastoma
* Malignant melanoma.
b) Connective tissue tumours:
*sarcoma: which is rare, fibro sarcoma, osteosracoma, lymphosarcoma.
*nasal lymphoma: (Stewart s lethal midline granuloma) it is T-cell
lymphoma leads to destruction of the midface.
*malignant lymphoma (Burkitt lymphoma) there is strong association with
EB virus, occurs in tropical Africa .affecting children.
Sites of malignant tumours:
80 % are squamous cell carcinoma.
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60 % of these tumours arise in the antrum.
30 % in the nasal cavity.
10 % in the ethmoids.
Clinical features:
1) Unilateral nasal obstruction.
2) Bleeding and discharge from the nose.
3) Swelling of the cheek, alveolar margin and nasal bridge or palate.
4) Loosening of the teeth.
5) Unilateral proptosis.
6) Involvement of the facial skin and ulceration of the palate.
7) Pain due to involvement of the maxillary nerve, and facial paraesthesia.
8) Severe headache
9) Epiphora, trismus, and limitation of jaw movements.
10) Metastasis to lymph nodes.
Diagnosis:
1) Radiography, CT scans .MRI
2) Biopsy and histological examination.
Treatment: combination of irradiation and excision gives the best results;
cytotoxic drugs may be helpful in patients with sarcoma and lymphoma.
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