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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 1 forming crusts. ================================================================= 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). 2 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 3 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. 4 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: 5 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. 6 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. 7 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: 8 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 9 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. 10 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. 11 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. 12