Chronic Sinusitis

1 Ground Rules

• Be on time

• Put your mobile phones on silent

• Participate actively

• Have a little fun on the way

2 3 4 5 6 7 8 9 10

Learning outcomes By the end of the session the participants will be able to

 Describe Chronic Sinusitis and its types

 Describe clinical presentations of Chronic sinusitis

 Describe the investigations required to be done for Chronic sinusitis

 Describe the treatment options for different types of Chronic sinusitis

12 Rhinosinusitis May be Better Term Because

 Allergic or nonallergic rhinitis nearly always precedes sinusitis

 Sinusitis without rhinitis is rare

 Nasal discharge and congestion are prominent symptoms of sinusitis

 Nasal mucosa and sinus mucosa are similar and are contiguous Differentiating Sinusitis from Rhinitis

Rhinitis Sinusitis Nasal congestion Nasal congestion Rhinorrhea clear Purulent rhinorrhea Itching, red eyes Postnasal drip Seasonal symptoms Headache Nasal crease Facial pain Cough, fever Anosmia 15 16 Normal Sinus

 Sinus health depends on:

 Mucous secretion of normal viscosity, volume, and composition.

 Normal muco-ciliary flow to prevent mucous stasis and subsequent infection.

 Open sinus ostia to allow adequate drainage and aeration. Definition

Inflammation of the mucosal lining of the paranasal sinuses. Acute, subacute, and chronic. One of the most common diseases. Definition

 Acute-up to 3 weeks  Subacute-3 weeks to 3 months  Chronic-more than 3 months Epidemiology

 Affects 30-35 million persons/year.

 25 million office visits/year.

 Direct annual cost $2.4 billion and increasing.

 Added surgical costs: $1 billion.

 Third most common diagnosis for which antibiotics are prescribed. The Sinusitis-Asthma Connection

 Failure to control upper airway inflammation leads to suboptimal asthma control.

 Mechanism is not understood

 Evidence Implications

 Correcting the rhinosinusitis results in better asthma control.

21 Ostiomeatal Complex

 Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain.

 Posterior ethmoids drain into the upper meatus. Normal Sinus CT Scan through the OMU

Eyeball Ethmoid sinus

Maxillary sinus Nasal cavity Blow-up View of the Ostiomeatal Unit Area

Ethmoid sinus

Maxillary infundibulum

Uncinate process

Middle turbinate

Maxillary sinus Obstruction of the OMU with Associated Acute Sinusitis

Sinusitis in the ethmoid sinus.

Sinusitis in the maxillary sinus. Resolution of Acute Sinusitis after Treatment with Antibiotics Definition of Chronic Sinusitis

 Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children

 Eosinophilic inflammation or chronic infection

 Associated with positive CT scans

 Poor (if any) response to antibiotics Etiology

 Allergic and nonallergic rhinitis

 Uncorrected anatomic conditions

 Ciliary dyskinesia

 Cystic fibrosis

 Tumors

 Immunodeficiency disorders

 IgA, IgM

 Granulomatous diseases Pathogenesis

 Impaired local mechanisms . Drainage . Mucociliary . Primary . Ciliary-kartegener . Mucous-young’s . Secondary . Viral . Bacterial . OMC . Ventilation  Immunodeficiency . Systemic immune deficiency . Chronic infections Classification

 Duration . Acute . Subacute . Chronic

 Aetiological . Infections . Allergic . Structural . Others Classification(cont’d)

Duration Etiology Diseases

Acute Non specific Common cold

Acute Non Specific Influenza

Acute Specific Diptheria (Bacterial)

Acute Specific Syphilis (Bacterial) Duration Pathological Etiology Diseases

Chronic CLASSIFICATION(cont’d)Granulomatous Specific Rhinoscleroma (Bacterial) Tuberculosis Spirocheatal Leprosy Chronic Granulomatous Specific Rhinosporiadiasis (Fungal) Asperigillosis Mucor Mycosis Chronic Granulomatous Non specific Wegener’s Mid line lethal Sarcoidosis Chronic Membranous Specific (Bacterial)

Chronic Others (irritative rhinitis) Simple Hypertrophic Atrophic Sicca Caseosa Sx of Chronic Sinusitis

 Nasal discharge

 Nasal congestion

 Headache

 Facial pain or pressure

 Olfactory disturbance

 Fever and halitosis

 Cough (worse when lying down) Quality-of-Life Issues

 Fatigue  Missing school/work

 Concentration  Halitosis

 Nuisance  Decreased production

 Sleep disturbance  Impaired studying

 Emotional well being  Sniffing/snorting

 Social interactions  Blowing nose Diagnosis

 Primarily based on HPI & PE.  Imaging based on demographics and exam findings. Differential diagnosis  Granulomatous • Granulomatous (Bacterial) (Non specific)  Rhinoscleroma • Wegener’s  Tuberculosis • Mid line lethal • Sarcoidosis  Spirocheatal • Irritative  Leprosy • Simple  Granulomatous • Hypertrophic (Fungal) • Atrophic  Rhinosporiadiasis • Sicca  Asperigillosis • Caseosa  Mucor Mycosis Investigations for Chronic Sinusitis

 CT or MRI scanning

 Anatomic defects, tumors, fungi

 Allergy testing

 Inhalants, fungi, foods

 Sinus aspiration for cultures

 Bacterial

 Fungal

 Immunoglobulins Radiographic Imaging?

 CT Scans:

 Patients presenting with complications of sinusitis

. Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema

 Patients with sinus symptoms accompanied by severe, boring, mid- head pain

. Rule out sphenoid sinusitis. X-Ray Image of Sinuses with Maxillary Sinusitis Sinus CT Normal Water’s and Towne’ s Views of the Sinuses Lateral View Showing Normal Sphenoid Sinus Medical Treatment of Chronic Sinusitis

 Nasal steroid spray

 Guafenesin

 Decongestants

 Steam inhalation

 Nasal irrigation

 Antibiotics with exacerbations Surgical Treatment of Chronic Sinusitis

 Maxillary sinus  Conservative  Antral lavage  Intranasal antrostomy  Radical  Caldwell-lac operation Surgical Treatment of Chronic Sinusitis(cont’d)

 Frontoethmosphenoid sinus  Conservative  Trephination of frontal sinus  Sphenoid sinus washout  Intranasal ethmoidectomy  Transantral ethmoidectomy  Functional endoscopic sinus surgery(FESS)  Radical  External frontoethmosphenoidectomy  Osteoplastic flap Complications of sinusitis Classification

 Orbital  Osteomyelitis of Maxilla and Frontal bone  Mucocele  Intracranial complications  Meningitis, intracranial abscess, cavernous sinus thrombosis  Locoregional complications  Pharyngitis, laryngitis, otitis media GRANULOMATOUS DISEASES OF NOSE

1.Definition  Chronic inflammatory response of the body characterized by granuloma formation in the involved part of the body 2.What is a granuloma?  Whenever the infecting agent is overwhelming for the body responses of acute inflammation to handle, body tries to cordon off the offending agent by forming a granuloma.  The granuloma consists of macrophages, lymphocytes and plasma cells GRANULOMATOUS

 Specific  Bacterial . Rhinoscleroma . Tuberculosis . Spirochaetal . Leprosy  Fungal • Rhinospordiosis • Asperigellosis • Mucormycosis  Nonspecific . Wegeners . Midline lethal . Sarcoidosis RHINOSCLEROMA 1.Aetiology  Klebsiella rhinoscleromatis or Frisch bacillus 2.Pathology  Starts in nose  Extends to  Nasopharynx  Esophagus  Larynx  Trachea  Bronchi RHINOSCLEROMA 3.Incidence . Age- any . Sex-equal 4.Clinical features . Stages a. Atrophic . Resembles –atrophic rhinitis . Characterized by foul smelling purulent discharge, crusting b. Granulomatous . Granulomatous nodules in mucosa . Painless and non-ulcerating . Subdermal infiltration of external lower nose and lip-woody feel c. Cicatricial . Stenosis of nose . Distortion of upper lip . Adhesions of nose,nasopharynx and esophagus . Subglottic Stenosis -stridor RHINOSCLEROMA

5.Diagnosis . Biopsy-shows infiltration of submucosa by plasma cells, lymphocytes,eosinophils,Mikulicz cells and Russell bodies(diagnostic) . Makuliczs cells-large foam cells with central nucleus and vacuolated cytoplasm . Russell bodies-homogenous eosinophilic inclusion bodies found in plasma cells. They occur due to accumulation of immunoglobulin's secreted by plasma cells RHINOSCLEROMA

6.Treatment a. Medical . Streptomycin(1 gm/day) . RIFAMPACIN(2 GM/day)-together for 4-6 weeks . Steriods-to reduce fibrosis b. Surgical . Establish airway . Correct nasal defomity SYPHILIS 1.Types A. Congenital-manifests in two forms . Early . First 03 months . Manifests –snuffles . Purulent nasal discharge . Nasal vestibule and upper lip-fissuring and excoriation . Late . Around puberty . Clinical picture-tertiary syphilis . Gummatous lesions destroy nasal structures . Other stigmata-corneal opacities, deafness and Hutchinson’s teeth SYPHILIS b. Acquired . Primary-chancre of vestibule of nose . Secondary . Rarely recognized . Manifests –rhinitis, crusting and fissuring of vestibule . Diagnosis . Mucous patches in pharynx . Skin rash . Fever . lymphadenitis SYPHILIS

. Tertiary syphilis . Commonly nose involved . Manifests as gumma on nasal septum,nasal septum is destroyed leading to perforation . Nasal discharge is offensive with crusts SYPHILIS

2.Diagnosis . Serological tests . VDRL . TPHA . Biopsy 3.Treatment . Benzathaine pencillin-2.4 million units I/M every week for 03 weeks . Crusts-irrigation with alkaline solution . Bony and cartilaginous sequestra removed SYPHILIS

4.Complications . Vestibular stenosis . Perforation of septum and hard palate . Secondary atrophic rhinitis . Saddle nose deformity TUBERCULOSIS

1.Types . Primary-rare . Secondary-lung infection 2.Sites . Anterior part of septum . Anterior end of inferior turbinate 3.Clinical picture . Nodular infiltration . Ulceration . Perforation of septum TUBERCULOSIS

4.Diagnosis . Biopsy-acid fast bacillus 5.Treatment . Antituberculosis therapy 6.Lupus vulgaris . Low grade TB infection . Affecting-nasal vestibule and skin of nose and face . Skin lesions-brown gelatinous nodules(apple jelly nodules) . Vestibulitis . Septum-perforation LEPROSY

1.Geograhical prevalence-trophics 2.Etiology-myco.leprae 3.Clinical picture . Nose –part of systemic disease . Sites-anterior part of septum,ant part of inf turbinate . Initially-nasal discharge-excessive,rede and swollen mucosa . Later-crusting,bledding and nodular lesions-ulceration and perforation LEPROSY

4.Diagnosis(acid fast leprae bacillus in foaming histiocytes called lepra cells) . Biopsy . Scrapping of nasal mucosa 5.Treatment a.MEDICAL . Dapsone . Rifampacin . Isoniazid b.SURGICAL . Reconstuctive procedures FUNGAL INFECTIONS OF THE NOSE Rhinosporidiosis Definition

 Infection by Rhinosporidium seeberi,

 Affecting mucous membranes of nose & nasopharynx;

 characterized by formation of friable, bleeding or polypoidal lesions

 Other sites: lips, palate, antrum, conjunctiva, lacrimal sac, larynx,

trachea, bronchus, ear, scalp, skin, penis, vulva, vagina, hand &

feet. Epidemiology

 88 – 95% cases are found in India & Sri Lanka

 Common in Kerala, Karnataka & Tamil Nadu

 Age : 20 – 40 yrs.

 Male: Female ratio = 4 : 1

 People with blood group “O” more susceptible Classification Benign a. Nasal ------78% b. Nasopharyngeal ------16% c. Mixed (naso-nasopharyngeal, nasolacrimal) -- 05% d. Bizarre (Conjunctival / Tarsal / Cutaneous) --- rare

Malignant ------rare

Generalized, deep seated & difficult to eradicate Clinical Presentation Epistaxis + viscid nasal discharge + nose block

Nasal mass: papillomatous or polypoid, granular, friable, bleeds on touch, pedunculated or sessile, pink surface studded with white dots [Strawberry apperance], involves septum & turbinates

Nasal mucosa: edematous, hyperemic, covered with copious viscid secretions containing spores

Lymph nodes: not affected Nasal mass Bleeding nasal mass Nasal + Nasopharynx Nasal + Nasopharynx Oropharyngeal mass Mass in uvula Cutaneous granulomas Mode of transmission 1. Bathing (head dipping) in infected water: infective

spores enter via breached nasal mucosa

2. Droplet infection by cattle dung dust

3. Contact transmission: contaminated fingernails

are responsible for cutaneous lesions

4. Haematogenous: to other sites in infected pt Differential diagnosis

1. Infected antrochoanal polyp

2. Inverted papilloma

3. Other granulomas:  Rhinoscleroma  Tuberculosis  Leprosy  Fungal (aspergillosis, mucormycosis)

4. Malignancy of nose / paranasal sinus Investigations

1. Biopsy & Histo-pathological examination

2. Microscopic examination of nasal discharge for

spores Haematoxylin & Eosin stain Periodic Acid Schiff stain Gomori Methenamine Silver stain Medical Treatment

 Dapsone: arrests maturation of spores (inhibits folic

acid synthesis) & increases granulomatous response

with fibrosis

 Dose: 100 mg OD orally (with meals) for one year

 Give Iron & Vitamin supplements

 Side effects: Methemoglobinemia & anemia Surgical management

 At least 2 pints blood to be kept ready

 General anesthesia with Oro-tracheal intubation

 2% Xylocaine (with 1:2 lakh adrenaline) infiltrated till surrounding mucosa appears blanched

 Mass avulsed using Luc’s forceps & suction

 After removal of mass, its base cauterized

 Avoid traumatic implantation during surgery

 Laser excision: minimal bleeding, no implantation Fungal granulomas Fungal Sinusitis A. Invasive (hyphae present in submucosa)

1. Acute invasive or fulminant (< 4 weeks)

2. Chronic invasive or indolent (> 4 weeks)

 Granulomatous  Non - granulomatous

B. Non-invasive

1. Allergic 2. Fungal ball 3. Saprophytic

Aspergillosis & Mucormycosis are common Predisposing factors for invasive fungal infection

 Uncontrolled diabetes mellitus

 Profound dehydration

 Severe malnutrition

 Severe burns

 Leukemia, lymphoma

 Chronic renal disease, septicemia

 Long term tx with (steroids, anti-metabolites, broad spectrum antibiotics) Clinical Features  Acute invasive fungal sinusitis by Mucormycosis

 Unilateral nasal discharge + black crusts due to

ischaemic necrosis, proptosis, ophthalmoplegia

 Cerebral & vascular invasion may be present

 Significant inflammation with fibrosis & granuloma

formation seen in chronic invasive fungal sinusitis

 Locally destructive with minimal bone erosion Black crusting Treatment

 Remove precipitating factors

 Surgical debridement of necrotic debris

 Amphotericin B infusion: 1 mg / kg / day IV daily / on

alternate days (total dose of 3 g). Liposomal

Amphotericin B less toxic & more effective

 Itraconazole: 100 mg BD for 6-12 months

 Hyperbaric oxygen: fungistatic +  tissue survival Surgical debridement Allergic fungal sinusitis  Associated with ethmoid polyps & asthma

 Unilateral thick yellow nasal discharge with mucin,

eosinophils & Charcot Leyden crystals

 C.T. scan: radio-opaque mass with central area

of hyper density (due to hyphae)

 Tx: Surgical debridement + anti-histamines +

steroids (oral & topical) Allergic fungal sinusitis Allergic fungal sinusitis C.T. scan coronal cuts C.T. scan axial cuts Fungal ball (Mycetoma)

Refractory sinusitis with foul smelling cheesy material in maxillary sinus

Tx: Surgical removal. No anti-fungal drugs.

Saprophytic fungal sinusitis

Seen after sino-nasal surgery due to proliferation of fungal spores on mucous crusts

Tx: Surgical removal. No anti-fungal drugs. Investigations  Biopsy & HPE: Tissue invasion by broad, non-septate, 900 branching hyphae. Fungal penetration of arterial walls with thrombosis & infarction. Staining by Periodic Acid Schiff or Grocott – Gomori Methenamine Silver nitrate stain.

 X-ray PNS: Sinusitis + focal bone destruction

 CT scan: rule out orbital & intracranial extension

 MRI: for vascular invasion & intracranial extension Aspergillosis Mucormycosis Aspergillosis Mucormycosis hyphae hyphae Narrow Broad

Septate Non-septate

Branching at 450 Branching at 900

Dichotomous branching Singular branching Immuno-fluorescent staining NON-SPECIFIC GRANULOMATOUS DISEASES OF NOSE Sarcoidosis Definition & etiology

 Synonym: Boeck’s sarcoid or Besnier – Boeck –

Schaumann syndrome

 Definition: chronic systemic disease of unknown

etiology which may involve any organ with non-

caseating (hard) granulomatous inflammation

 Etiology: 1. Special form of Tuberculosis (?)

2. Unidentified organism Clinical features  Nasal discharge, nasal obstruction, epistaxis

 Mucosal: reveals yellow nodules surrounded by hyperaemic mucosa on anterior septum & turbinates

 Skin (Lupus Pernio or Mortimer’s malady): nasal tip shows symmetrical, bulbous, glistening violaceous lesion (resembling perniosis or cold induced injury) Similar lesions on cheeks, lips & ears [Turkey ears]. Diascopy reveals yellowish – brown appearance. Lupus Pernio Heerfordt’s syndrome Synonym: Waldenström’s uveo-parotid fever

Special form of sarcoidosis with:

1. Transient B/L Facial palsy

2. Parotid enlargement

3. Uveitis

4. Fever Probe test

 Probing of nodular lesion to look for penetration

 Negative in sarcoidosis: probe does not penetrate nodular swelling

because of hard granulomas

 Positive in Lupus vulgaris: probe penetrates up to soft granulation

tissue in centre of nodule Investigations  Biopsy of nodule & HPE: Non-caseating hard granuloma with ill-defined rim of surrounding lymphoid cells (naked tubercle). Giant cells contain asteroid inclusion or Schaumann bodies

 Kveim Siltzbach Test: Intradermal injection of spleen extract from case of sarcoidosis followed 6 wks later by skin biopsy shows development of non-caseating nodules Non-caseating granuloma Non-caseating granuloma Asteroid inclusion bodies Chest X-ray findings

 Stage I = B/L Hilar lymph node enlargement

 Stage II = B/L Hilar lymph node enlargement +

diffuse parenchymal infiltrates

 Stage III = Diffuse parenchymal infiltrates without

Hilar lymph node enlargement

 Stage IV = Diffuse parenchymal infiltrates +

fibrosis with cor pulmonale Hilar lymphadenopathy Treatment 1. Prednisolone: 1 mg/kg/d x 6 wk, taper over 3 mth.

Good response in mucosal disease only.

2. Chloroquine / Methotrexate + Prednisolone:

in pt not responding to steroids

Chloroquine = 250 mg PO on alternate days x 9 mth

Methotrexate = 5mg PO weekly x 3mth

3. Cutaneous lesions: excised & skin grafted Wegener’s granuloma Definition

Autoimmune (?) condition characterized by necrotizing granulomas within nasal cavity & lower respiratory tract, generalised vasculitis & focal glomerulonephritis Clinical Features Nose & paranasal sinus: epistaxis, nasal block, extensive crusts, septal destruction & nasal collapse.

Rule out nasal substance abuse.

Pulmonary: Cough, haemoptysis

Renal: Hematuria & oliguria

Otological: Otalgia, deafness, facial nerve palsy

Oral & pharyngeal: Hyperplastic, granular lesions Clinical Features

Laryngo-tracheal: laryngitis, subglottic stenosis

Ophthalmological: scleritis, conjunctivitis, corneal

ulceration, dacryocystitis, proptosis,optic neuritis, blindness

Others: Skin ulceration, polymyalgia, polyarthritis

If untreated: death within 6 mth due to renal failure Crusting in nasal cavity External nasal deformity Destruction of orbit & nose Differential diagnosis

VASCULITIS GRANULOMAS + VASCULITIS  Polyarteritis nodosa  Allergic granulomatosis  S.L.E.  Loeffler’s syndrome  Rheumatoid arthritis PULMONARY + RENAL  Sjogren’s syndrome  Goodpasture’s syndrome OTHER GRANULOMAS NEOPLASM Specific  Sinonasal lymphoma  T.B.  Metastatic bronchial cancer  Syphilis OTHERS Non-specific  Nasal substance abuse  Sarcoidosis  Systemic myiasis Investigations

 E.S.R.: raised

 Urine microscopic examn: RBC casts & RBCs

 CT PNS: bone destruction in nasal cavity

 Chest X-ray & CT scan: pulmonary nodules

 Serum urea & creatine: ed renal function

 Biopsy of lesion & HPE: Granulomas + Vasculitis

+ Fibrinoid vascular necrosis CT scan PNS: nasal destruction CXR: nodular lesion with cavity C.T. scan lungs

nodular lung infiltrate with cavitation HPE: Granulomatous vasculitis

L = small pulmonary artery lumen surrounded by inflammatory infiltrate including a giant cell (black arrow) Segmental glomerular necrosis

early crescent formation (black arrows) c-A.N.C.A.

 Anti-Neutrophil Cytoplasmic Antibody (ANCA) titre by

immuno-fluorescence.

 c-ANCA = cytoplasmic fluorescence

 Raised c-ANCA titres = 65-96% sensitive in WG

 Becomes -ve when disease is controlled

 p-ANCA = peri-nuclear fluorescence

 p-ANCA titres raised in Polyangitis C – ANCA by indirect immuno-fluorescence Medical Treatment 1. Triple therapy:

Prednisolone: 1 mg/kg/d x 1 mth  Taper over 3 mth

+ Cyclophosphamide: 2mg/kg / day x 6-12 mth

+ Cotrimoxazole: 960 mg OD X indefinitely

2. Plasma exchange & intravenous immunoglobulin

3. Alkaline nasal douche for crusts Sinonasal lymphoma (not a granuloma) Synonyms

 Stewart’s granuloma

 Lethal midline granuloma

 Non-healing midline granuloma

 Idiopathic midline destructive disease (IMDD)

 Sinonasal T-cell lymphoma

 Necrosis with atypical cellular exudate (NACE)

 Midline malignant reticulosis Clinical Features

 Prodromal stage: Blood-stained nasal discharge

 Active stage: Nasal crusting, ulceration, septal

perforation

 Terminal stage: Tumour sloughing, mid-face

mutilation

 D/D: Wegener’s granuloma, Basal cell carcinoma

 Rx: Radiotherapy (5000 cGy) + chemotherapy Mid-face mutilation Wegener’s Sinonasal Granuloma Lymphoma Bilateral involvement Unilateral involvement

Slowly progressive Rapidly progressive

Diffuse ulceration Focal ulceration

Extensive crusting Moderate crusting

Absence of gross Gross destruction of destruction of mid-face mid-face present Pulmonary & renal No pulmonary or renal involvement present involvement Investigation Wegener’s Sinonasal Granuloma Lymphoma Vasculitis present absent

Granulomas present absent

Giant cell present absent Atypical T absent present lymphocytes Angio-invasion absent present

C-ANCA titre raised not raised Churg & Strauss Syndrome

 Synonym: allergic granulomatosis

 C/F: nasal polyps + bronchial asthma

 Chest X-ray: pulmonary lesions

 HPE of nasal polyp: necrotizing granulomas with abundant eosinophils without vasculitis

 Tx: 1. Corticosteroids (topical & systemic) 2. Nasal polypectomy Others(irritative rhinitis)

 Simple rhinitis  Hypertrophic rhinitis  Atrophic rhinitis  Rhinitis Sicca  Rhinitis Caseosa Simple rhinitis

1.Definition  Recurrent attacks in presence of predisposing factors 2.Predisposing factors a. Focus of infection o Tonsils o Adenoids o sinusitis b. Irritants o Smoke o dust c. Nasal obstruction Simple rhinitis(cont’d)

3.Pathology  Hyperemia  Edema of mucous membranes  Hypertrophy of glands 4.Clinical features a. Symptoms  Nasal obstruction  Nasal discharge  headache Simple rhinitis(cont’d)

5.Treatment a. Treatment of cause b. Irrigation c. Decongestants d. Antibiotics Hypertrophic rhinitis

1.Definition Characterized by thickening of . mucosa . sub mucosa . Seromucinous glands . bone Hypertrophic rhinitis(cont’d)

2.Etiology  Recurrent infective foci  Chronic irritation  Decongestants  Vasomotor  allergic Hypertrophic rhinitis(cont’d)

3.Clinical features a. Symptoms . Nasal obstruction . Nasal discharge . Headache . Anosmia b. Signs . Hypertrophy of turbinates . Thickening of mucosa . Vasoconstrictors have no effect Hypertrophic rhinitis(cont’d)

5.Treatment a. Removal of cause b. Turbinates  Cautery  Diathermy  Cryosurgery  Laser  Surgical  Partial inferior turbinectomy  Total inferior turbinectomy Atrophic rhinitis (ozaena)

1. Definition Chronic inflammation characterized by atrophy of  Mucosa  Sub mucosa  Seromucinous glands  bone

Atrophic rhinitis (ozaena)-cont’d

2.Etiology  Hereditary  Endocrinal-females  Racial-white race  Nutritional -vit A,D,Iron  Infections –K.ozenae,diptheria,E.coli  Autoimmune process Atrophic rhinitis (ozaena)-cont’d

3.Pathology  Mucosa –squamous metaplasia  Glands –atrophy  Nerves –degeneration  Arteries –obliterative endarteritis  Bone -resorption Atrophic rhinitis (ozaena)-cont’d

4.Clinical features a. Symptoms  Nasal obstuction  Crusting  Bad smell  Epistaxis b. Signs  Dry crusts  Wide cavities  perforation Atrophic rhinitis (ozaena)-cont’d

5.Treatment a. Medical  Irrigation-normal saline /alkaline douches  25% glucose in glycerine  Local antibiotics  Systemic streptomycin  Rifampacin Atrophic rhinitis (ozaena)-cont’d b. Surgically  Closure  Young’s  Modified young’s

 Medialization of lateral wall  Implants  Cervical sympathethectomy Rhinitis Sicca

1.Definition Chronic inflammation characterized by • Dry crusting 2.Etiology . Hot . Dry . dusty Rhinitis Sicca (cont’d)

3.Pathology  Mucosa –sq metaplasia  Seromucinous glands –atrophy 4.Clinical features 5.Treatment  Cause  Medical  Topical antibiotics  Irrigation Rhinitis caseosa

1.Definition  Chronic inflammation characterized by offensive cheesy material 2.Etiology  Recurrent infection 3.Pathology  Destruction of bony walls 4.Clinical features  Thick cheesy discharge 5.Treatment  Cause  Removal of debris  irrigation Thank You  Q Cause of nasal obstruction in atrophic rhinitis is  A) Polyp  B) Secretions  C) Crusting  D) Deviated nasal septum  E) Hypertrophied turbinates  Q Best surgical treatment for chronic maxillary sinusitis is  A) Repeated antral washout  B) Functional endoscopic sinus surgery  C) Caldwell luc operation  D) Transantral ethmoidectomy  E) Inferior meatal antrostomy  Q A 65 years old diabetic male presented with black, foul smelling discharge from the nose. Examination revealed blackish discoloration of the inferior turbinate. The diagnosis is  A) Mucormycosis  B) Aspergillosis  C) Infarct of inferior turbinate  D) Foreign body  E) Inverted papilloma