Download The Medical and Surgical Treatment of Chronic Rhinitis

The Medical and Surgical
Treatment of Chronic Rhinitis
R. Moulton-Barrett, MD
Defination of Chronic Rhinitis
symptoms of :
•
•
•
•
nasal congestion
rhinorrhoea
anosmia
sneezing or itchy nose
lasting > 3 months in one year
40 million people in USA
50% seek medical advise
50% allergic in origin
6 million dollars spent on decongestants / yr.
Physiology of Nasal Congestion
3 portions:
vestibule
respiratory ( 92 % by area:120 sq cm's)
and olfactory
Flow:
Inspiratory - laminar, above inferior turbinate
Expiratory - circum-laminar to paranasal sinuses
Vestibule:
1/3 nasal resistance ( by acoustic rhinometry and MRI )
Nasal Valve: 2/3's total nasal resistance ( 0.72 cm2 )
the most narrow portion of the nasal cavity
Anatomy of the Inferior Turbinate
Nerve:
Post-ganglionic pterygopalatine ganglion fibres
Inf Post Lat branch of Greater Palatine Nerve
Artery:
Single branch of sphenopalatine artery
enters 1-1.5 cm's from posterior superior bone
travels anteriorly along superior periosteum
Swelling:
40% of blood: through spongy submucosal venous tissue
containing small vessels with leaky basement membranes
60% of the blood passes through a/v shunts:
Sympathetic dependent - reduces
can overdrive by parasympathetics + engorges
not histamine sensitive
Measurement of Nasal Resistance
Acoustic Rhinometry
• assesses cross-sectional area andgeometry
• (experimental)
Hilberg 1989
Posterior Rhinometry
• Resistance = Pressure/Flow: disputed in terms of value
Myrind N, 1980. Measurement of nasal airway
resistance -is it only for article writers.
Clinical Otolaryngol 5:161-163.
Dynamic variation in nasal resistance
Site:
Hydrostatic presssure:
Nervous innervation :
Inflammatory process:
Drug manipulation:
Inflam. mediators:
anterior-superior leading edge
positional
nasal cycle ( sympathetic tone )
chronic rhinitis
vasoconstriction: 35% < resistance
histamine independent
peptide and prostaglandin dependent
Physiology of Rhinorrhoea
Serous & Mucoserous Glands
parasympathetic and histamine dependent
induce with methacholine 'challenge' test
50-100 cilia/cell
beats mucus posteriorly at 0.3-1 cm/minute
a drop of saccarin: taste in 20 minutes,
if delayed: perform microscopy
rule out immotile cilia
Sneezing and Itching
Histamine related:
released by
mastcells
eosinophils
& most importantly basophil cells
Success of therapy: antihistamine/cromoglycate:
proportional to histamine in nasal smears >
mast, eosinophil, basophil cells,
in vitro histamine release in response to allergens
Nasal Cytometry
Purpose:
Collection:
Stains:
Analysis:
1. determine likelihood medical treatment success
2. make diagnosis
plastic bag and swab to slide
Hansel's or Wright's
> 5 neutrophils/high power field: 84% sensitive for sinusitis
>25% eosinophil/100 cells: 70% diagnostic allergic rhinitis (AR)
The other 30%: eosinophilic non- allergic rhinitis ( NARE)
Check H & P& Labs:
h/o asthma
FH AR (24%)
IgE>50U/ml ( usually >700u/ml=AR),
skin or nasal allergen challenge testing
•If NARE: 93% respond to intra-nasal steroid therapy vs. 66% if AR.
•If non-NARE/AR ( vasomotor ): < 19% respond to intra-nasal steroid therapy
Mullarkey M, Hill J and Webb R,1980. J Allergy Clin Immunol 65(2),122-126
Causes of Rhinitis
Allergic : 50 %
Non-allergic Eosinophilic : 35 %
Vasomotor : 12 %
Others :
infective
autoimmune
atrophic
<3%
If only nasal obstruction must r/o masses
Allergic
Nasal Challenge Test
• Primary phase:
5-30 seconds later sneezing occurs
histamine dependent
secondary to basophil degranulation
then delayed intra-nasal eosinophilia
• Secondary phase: 7 hours later
also caused by basophil degranulation
and parasympathetic overdrive
histamine independent
• If the allergen is rechallenged there may be 100x's greater response
Seasonal primary and secondary phases
• when pollen counts are >50/cubic meter
April-May: oak
May-August: birch
April-August: ragweed
• or when in-home dust countsare elevated:
Dermatophygoides pteronyssinus or farinae : fans
mattress covers
wash carpets
open windows
dusting
humidifiers
Vasomotor Rhinitis
Secondary to:
parasympathetic excess or
sympathetic reduction
• Drugs
– rhinitis medicamentosa -
topical cocaine and oxymetolazone
produces prolonged vasoconstriction
followed by reactive hyperemia
via down regulation: alpha1 & 2 blockage
– antihypertensive medications: vasodilators ie. alpha blockers
• Hormonal
–
–
–
–
estrogenic - BCP & Gravidarum: estrogenic cholinesterase inhibition
acromegaly
hypothyroidism: responds to thyroxine and
old man's drip: responds to testosterone
Medical Therapy
Intra-Nasal Steroids
• Most useful agent:
60-75% benefit all causes chronic rhinitis
placebo 20% benefit
• Inhibits:
mast cell migration into nasal mucosa
basophil cell, not eosinophil cell degranulation
• least effect on:
parasympathetic tone
non-histamine related rhinorrhoea of VR
• S/E:
freon causes drying crusting and bleeding ( 5% )
aqueous propylene glycol produce burning ( 5% )
very rare side - effects of septal perforation
- blindness
• Little benefit for VMR
• positioning the patient
Medical therapy
Anti-histamines
• Have little effect on nasal blockage since histamine independent
• Inhibit primary phase reactive symptoms
• As effective as steroids for seasonal AR for sneezing & rhinorrhoea
Cromoglycate
• Inhibition of protein kinase C leads to reduced degranulation
• Has no place in the treatment of NARE or vasomotor rhinitis
• Limits phase 1 symptoms and poor for congestion
• Use 4-6 times daily
• Though newest drug 'Nedocromil" may reduce nasal obstruction in
allergic rhinitis
Ipratropium bromide
• Few side-effects since not absorbed by mucosa
• Inhibits c-GMP synthesis which causes decreased glandular
secretion
• 400ug QID may produce cracking and bleeding
• 80ug QID is equally effective in reducing rhinorrhea but not
sneezing or obstruction•
Immunotherapy
• Mechanism: cytokine related inhibition of basophil sensitivity
via T cells rather than blocking IgG antibodies
• " May be initiated at any time " during medical therapy for AR
Gordon, 1992. O-HNS 107;6(2), pg. 861
• Degree of success is multi-factorial and of particular importance is
allergen avoidance therapy
• 90% of asthmatics with positive skin and nasal challenge tests
benefited by mold immunotherpy ( Goode states: 75%)
• Yet intra-nasal steroids are better tolerated and more effective in the
therapy for seasonal AR
Surgical Treatment: General principles
• Rhinorrhoea: neurectomy or steroid injection
• Obstruction: all forms of therapy with good results
• Inferior turbinate: commonest cause of nasal obstruction
• Reduce the inferior turbinate during septoplasty
• Atrophic rhinitis from turbinectomy is extremely rare
Choices: Inferior Turbinate
steroid injection
sclerotherpy
outfracture
submucous resection of bone
submucosal bipolar electro- cautery
mucosa/ soft tissue resection: AgNO3
CO2 laser or needle cautery
turbinectomy: partial or complete
neurectomy:
pterygopalatine ganglion or vidian nerve
by: cryo or sclero-therapy
cautery or knife
endo or non-endoscopically
Outfracture
method:
clamp and rotate outwards
advantage:
little bleeding
easy to perform
may combine with posterior turbinectomy
disadvantage:
25% show no improvement
Thomas, et al, 1985
Submucous Resection of Bone
method:
anterior incision over head of the inferior turbinate
resection of the anterior 1/3 using curved scissors
advantage:
useful - uncontrolled perrenial enlarged inferior turbinate
easy
little bleeding or post-operative crusting or drainage
preserves mucosa
disadvantage: may require general anaesthesia
need packing
inferior long-term results to turbinectomy
House P,1951. Submucous Resection of the Inferior
Turbinal Bone. Laryngoscope 61(7),637-648.
Soft Tissue Cautery
method(s):
unipolar single - 3 points or bipolar * cautery
advantage:
simple equipment and simple to do
disadvantage: difficult to determine degree of thermal injury,
pain may be diffulcult to control by local anaesthesia
mucosal loss with prolonged time for remucosalization ie.
crusting and rhinorrhoea
risk of sequestrium formation: persistent swelling
fetor
rhinorrhoea
crusting
* Hurd L,1931. Bipolar electrode fro electrocoagulation of the inferior
turbinate. Arch Otol 13,442
Steroid Injection:
method:
0.5cc Kenolog ( 40mg/ml ) on spinal needle
advantage:
quick, under local anaesthetic, rapid results
disadvantage: lasts 4 weeks
facial flushing ( 5% )
at least 11 reports of blindness ( 1 at UC-Irvine )
small risk of septal perforation or sequestrium
Mabry R,1983. Corticosteroids in otolaryngology:intraturbinal
injection. Otolaryngol Head and Neck Surg 91(6),717-720
CO2 Laser
method:
defocused and 10W continuously
to the anterior 1/3 of the inferior turbinate
advantage:
less bleeding, less pain, faster healing
disadvantage: associated with synechiae formation
Selkin S,1985. Laser turbinectomy as an adjunct to rhinoseptoplasty.
Arch Otolarygol 111,446-449
KTP Laser
method:
532nm laserscope 1mm wide, 1mm deep
8W continuous X hatched and teflon splints placed
advantages:
85% improvement at 2-4 year follow-up
no packing and no bleeding
disadvantages: specialized equipment
2 weeks of rhinorhoea
8 weeks of crusting
Levine H,1991. The potassium-titanyl phospahte laser fro treatment of
turbinate dysfunction. Otolaryngol Head and Neck Surg 104(2),247251
Cryotherapy
method:
closed nitrous oxide cryo 'gun' at -40c for 60-75 seconds
to 4 places on the sup & ant head of the inferior turbinate
advantages:
local anaesthesia
no bleeding
little dyscomfort
may combine with neurectomy for vasomotor rhinitis
85% improvement at 2 yr. follow-up
disadvantages: until recently required specialized equipment
rhinorrhoea if do not combine with neuroectomy,
inferior long-term results compared to turbinectomy*
* OzenbergerJ,1973. Cryotherapy for the treatment of dhronic
rhinitis. Laryngoscope 83,508-16
Turbinectomy
methods:
anterior 1/3 or total*
advantage:
* despite Goode's criticisms in 1985
do not appear to cause atrophic rhinitis
useful for hypertrophic posterior 'mulberry' turbinates
best long term results
disadvantage: most post-operative dyscomfort/pain/crusting
usually requires packing
3-5% significant bleeding and
when combined with other nasal procedures under
general anaesthesia it led to prolonged hospitalization.*
* Elwany S and Harrison R, 1990. Inferior turbinectomy: Comparison of four techniques.
J Laryngol Otol 104,206-209
Ophir, D 1992. Long-term follow-up of the effectiveness and safety of inferior
turbinectomy. Plast Reconst Surg 90 (6),985-987
Neurectomy
methods:
trans-nasal: Malcolmson, 1959
trans-antral: Golding-Wood, 1962
endoscopic: El Shazly, 1991
advantages:
90% improvement of rhinorrhoea
disadvantages: possible reduction of maxillary sensation
conjunctival irritation 'red eye' (25%)
may regenerate in time
El Shazly M,1991. Endoscopic Surgery of the Vidian Nerve.
Preliminary Report. Ann Otol Rhinol Laryngol 100:536-539.
Cryotherapy: Neurectomy
method:
apply probe 1 minute -180C to the vidian nerve
6mm posterior to the sphenopalatine foramen
1cm posterior toposterior border to the middle turbinate
or 1.2cm above & lateral to superior border of the choana
advantages:
quick
can use in conjunction with cryo-turbinate reductio
well tolerated on out-patient basis
86% improvement
disadvantages: unpredictable extent of result
operator experience dependent
Strom M, 1989 . A long-term assessment of cryotherpy for testing vasomotor
rhinitis. Ear Nose and Throat 69(12), 839-842