DISEASE OF THE NOSE AND THE PARANASAL SINUSES Dr.

Hernandez June 29,2010

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Mild- normal sleep, normal daily activities Moderate Severe- abnormal sleep, impairment of daily activities, problems caused at work or school.

A. Rhinitis Allergic Rhinitis Viral Rhinitis Non-allergic Rhinitis Atrophic Rhinitis Rhinitis Medicamentosa B. Rhinosinusitis C. Tumors of the Nose and Paranasal Sinuses Nasal Polyps Inverting Papilloma Carcinoma Rhinitis Inflammation of the lining mucosa of the nose, characterized by one or more of the following symptoms: o Nasal congestion o Rhinorrhea o Sneezing o Itching Rhinitis may appear to be a simple disorder, but it can lead to more serious problems if overlooked and left untreated. Sequelae of Rhinitis: o Sinusitis o Otitis media o Tonsillopharyngitis o Laryngitis o Asthma

New Classification Intermittent symptoms <4 days per week or <4 weeks

Persistent symptoms Mild Normal sleep Normal daily activities, sport, leisure Normal work and school No troublesome symptoms >4 days/week and >4 weeks

Moderate-Severe (one or more items) Abnormal sleep Impairment of daily activities, sport, leisure Problems caused at work or school Troublesome symptoms

Signs and symptoms of Allergic Rhinitis Sneezing - pale boggy turbinates Nasal itchiness -conjunctiva injected Clear, watery rhinorrhea - allegic shiners and nasal salute Nasal congestion -linea nasalis

Classification of Rhinitis 1. 2. 3. Allergic Intermittent or Persistent Infectious Acute or Chronic or Idiopathic Others Idiopathic or Etc. or NARES (non allergic rhinitis with eosinophilia)

Definitions Allergic shiners- infraorbital dark circles probably related to venous plexus engorgement Dennies line- an accentuated line or atopic pleat of the lower eyelid Allergic Rhinitis (accdg to Wang De Yun) Affects about 10-20% of the world population and studies in several countries suggest that it is on the increase.

Al lergic Rhinitis Recurrent Rhinitis due to an IgE mediated reaction of the nasal mucosa to allergens Provoked by exposure to allergens in the environment o Pollens- tree such as alder, hazel, oak, elm and birch grass, weed o House dust mites o Animal danders o Cockroaches and certain mold species

International Study of Asthma and Allergies in Childhood (ISAAC) Study (Phil. 1994) Prevalence of Allergic Rhinitis has increased 6-7 years old- 26.2% 13-14 years old- 19.1% Adult- 38%

Classification of Allergic Rhinitis (ARIA 2007) 1. 2. Intermittent symptoms- <4 days per week or <4 weeks a year Persistent symptoms- >4 days/week and >4 weeks a year

United Airways (Evans R. 1993, Eggleston PA, 1988) Rhinitis and Asthma are common diseases which frequently co-exist Suggesting the concept one airway one disease

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Epidemiologic studies have consistently shown that asthma and rhinitis co-exist in the same patient 65-88% of Adults (Yaacob, 1991; Dahl, 1993) 75%of children with asthma also suffers from Allergic Rhinitis (Mercer MJ, 1991) Approximately 80% of asthmatics have allergic rhinitis Approximately 40% of allergic rhinitis patients have asthma

Rhinitis Medicamentosa A form of idiopathic rhinitis characterized by worsening rebound congestion following prolong use of topical decongestants. Topical decongestants are advised continuous use not longer than 10 days. Rhinoscopy reveals congested and swollen turbinates Treatment: discontinue topical decongestants; shifting to topical nasal steroids and systemic decongestants

Allergic Rhinitis and Its Impact on Asthma Allergic rhinitis is a major chronic airway disease Allergic rhinitis represents a risk factor for asthma A single treatment strategy is needed in patients with allergic rhinitis and asthma Practical Purposes 1. 2. 3. 4. History General ENT examination Endoscopy Radiology

Infectious Rhinitis A. Acute 1. Viral- clear watery discharge, 4-5 days in duration. Commonly caused by a cold virus which is well over a hundred rhinoviruses 2. Bacterial- mucopurulent d/c a. Streptococcus pneumonia b. H. influenza B. ChronicMycobacterium tuberculosis; Mycobacterium leprae; Klebsiella rhinoscleroma; Treponema pallidum; Fungi Other Types of Rhinitis (non-allergic, noninfective) A. B. C. D. E. F. G. H. Idiopathic NARES Occupational rhinitis Hormonal rhinitis Drug induced rhinitis Food Emotional Primary atrophic rhinitis Diagnostic Technique 1. History a. Exposure to specific allergen b. Nasal congestion, rhinorrhea, itching and sneezing c. Family history of allergy

Skin prick test may be performed for the following cases: Patients non-responsive to pharmacotherapy Patients with multiple target organ involvement Patients for hyposensitization Skin test are used to demonstrate an IgE mediated allergic reaction of the skin and represents the primary diagnostic tool in allergy. Radioallergosorbent test (RAST) and enzyme linked immunosorbent assay (ELISA) for some allergens have been shown to be as reliable as skin testing. Skin testing is less expensive, more sensitive, technically easier to perform and results can be interpreted immediately.

Idiopathic- better term than vasomotor rhinitis, presents with nasal hyperresponsiveness to non specific triggers such as strong smells(perfumes, bleach, solvents) irritants such as tobacco smoke, exhaust fumes and changes in environmental temperature and humidity. Exact mechanism is unknown Atrophic Rhinitis Chronic inflammation of the nose characterized by a progressive atrophy of the nasal mucosa and the turbinates resulting in widened nasal passages, excessive crusting and a foul odor(ozena and anosmia) Idiopathic:organisms implicated are Coccobacillus foctidus ozaena, Klebsiella ozeana Clinical picture: nasal obstruction, atrophied turbinates, excessive crusting and widened nasal cavity Therapy consists of buffered nasal saline irrigation twice daily and Vitamin A

Management of Allergic Rhinitis Allergen avoidance Pharmacotherapy o Topical and systemic anti histamines o Topical, nasal steroids and systemic steroids o Leukotriene receptor antagonist o +/- use of decongestants Immunotherapy

Pharmacotherapy of Allergic Rhinitis Antihistamines Classic Non or less sedating

Decongestant Oral Topical

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Corticosteroids Systemic Topical

Antihistamines Effects relieve pruritus prevent sneezing decrease thin secretions does not improve congestion

Mass cell stabilizers Inhaled Nasal Oral

Nasal Steroids suppress the inflammatory process and are effective in both the prevention and treatment of allergic rhinitis. They can provide effective control of all rhinitis symptoms

Anticholinergics Miscellaneous Mucolytics Montelukast

Anti- inflammatory Effects of Topical Nasal Steroids degree of inhibition of early phase reaction. Primary effect on suppression of late phase reaction Reduction of non-specific activity Inhibition of effect of cytokines

Other drug therapies have only a limited role in most patients. Allergens identification and avoidance can be helpful and other nasal disorders should always be excluded. Surgery may occasionally be needed where rhinitis is associated with a structural disorder of the nose. New Antihistaminic Characteristics Dosage once or twice daily Hepatic metabolism No drug tolerance with prolonged use Antihistamine activity equal to or better than classic antihistamines

The appropriate first choice for most patients with noninfective rhinitis is preventive therapy with a topical nasal steroid. The prevention of inflammation by steroid therapy is the best method of preventing the entire symptom complex of rhinitis. Intranasal corticosteroids are the most effective medications for treating the entire spectrum of allergic rhinitis symptoms. However, their use has been limited in children due to concerns about systemic side effect, including growth retardation.

Antihistamine Side Effect CNS Sedation (Diphenhydramine, Cetridine, Acrivastine, Ebastine at high doses) (non sedating antihistamines- Desloratadine, Fexofenadine, Loratadine) Loss of concentration Dizziness Insomnia Irritability Nervousness Tremors

Oral Bioavailability of Steroids Corticosteroids Mometasone furoate- 0.1% Fluticasone propionate- 1.0% Budesonide- 11% Beclomethasone dipropionate- 20% Flunisolide- 21% Triamcinolone- 23% Dexamethasone- 80% Rhinosinusitis Rhinosinusits is an inflammatory condition involving the paranasal sinuses, as well as the lining of the nasal passages. The most important factor in the pathogenesis of rhinosinusitis appears to be narrowing or obstruction of the sinus ostium.

Anticholinergics Dry mucous membrane Cardiac (palpitation, tachycardia) Blurred vision Constipation Dysuria impotence

(accdg. To Robert Davies) Antihistamines commonly relieve sneezing, itching and rhinorrhea in rhinitis but they have little or no effect on nasal blockade. They are not anti-inflammatory. They are used mainly in patients with mild intermittent rhinitis.

Bacterial Rhinosinusitis- Pathophysiology Viral URTI is the most common primary inciting cause Predisposing factors: o Allergic rhinitis o Nasal obstruction

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Pathophysiology: inflammation and accompanying edema formation leads to increase secretions which are retained in the sinuses due to impaired mucociliary clearance and obstruction of sinus ostia by edema; this leads to bacterial overgrowth Diagnosis In general, a diagnosis of acute bacterial rhinosinusitis (ABRS) may be made in adults with symptoms of a viral URTI that has not improved after 10 days or worsened after 5 to 7 days lasting up to 4 weeks Microorganisms of Acute Sinusitis

Duration of therapy for Acute Rhinosinusitis 7-14 day course Lack of response to therapy at > 72 hours is an arbitrary time established to define treatment failures If unresponsive tscan could be requested, pato medical management, CT scan may warrant Endoscopic sinus surgery

Chronic Rinusinusitis 1. Most common predisposing factor is an untreated or poorly treated acute rhinosinusitis usually of more than 3 months duration Other predisposing factors include trauma, structural deformities of the nose, allergy and presence of nasal polyps 16% of cultures- mixed infection with gram positive, gram negative and anaerobic organisms; most common organism is coagulase-negative Stapylococcus sp. Patients present with chronic nasal obstruction, chronic purulent foul smelling nasal and post nasal discharge. Symptoms are usually less severe than that of acute sinusitis Medical therapy consists of appropriate antibiotics (2-4) weeks and decongestants,mucolytic if warranted. Saline nasal irrigation and topical nasal steroid could be beneficial. No response warrants radiographic evaluation. E.g CT scan of osteomeatal complex. A referral to an Otorhinolaryngologist is advised. Endoscopic sinus surgery if indicated

Bacteria S. pneumonia- 31 H.influenza- 21% M.catarrhalis- 2% Anaerobes- 6% Staph. Aureus- 4% Staph Pyogenes- 2% Viruses Rhinoviruses Influenza virus Parainfluenza virus

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5. Acute Bacterial Rhinosinusitis 4. Symptoms include mucopurulent nasal aand post nasal discharge, congestion, pain and pressure, heaviness and tenderness over the sinuses, maxillary dental pain; rhiniscopy and endoscopy reveal purulent nasal discharge coating congested nasal mucosa Paranasal sinus series may reveal haziness, air fluid level or total opacification of the sinuses, but this is not routinely requested/ Therapy include appropriate antibiotics decongestants. Mucolytic and nasal saline irrigation when warranted. Antihistamines may be given if there is associated allergy.

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Common Pathogens for Chronic Rhinosinusitis Coagulase negative Staph sp. (51%) S. aureus (20%) Anaerobes (3%) S. pneumonia (4%) On average, multiple organisms are found in 16% of cultures

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Recommended Antibiotic Therapy for ABRS Nasal Polyps No recent antimicrobial use (4-6 weeks) o Amoxicillin o Co-Amoxiclav(90mg/6.4 mg/kg per day) o Cefpodoxime proxetil o Cefuroxime axetil Use if patient is Beta-lactam allergic: o TMP-SMX o Doxycycline(among adults) o Azithromycin, Clarithromycin or erythromycin o Clindamycin o Levofloxacin, Moxifloxacin, Genfloxacin ( if not yet given among adults) Most common mass in the nasal cavity No definite etiology exist, however certain risk factors are associated with the condition: o Chronic infection o Allergies o Trauma o Metabolic disease o Aspirin intolerance Patients present with nasal obstruction, discharge and anosmia Rhinoscopy reveals presence of translucent, grayish white cystic masses

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Management is focused on the relief of symptoms 1. Management of nasal polyps is actually a spectrum between medical and surgical method with the ultimate aim of keeping the patient symptom free. Nasal steroids should now be given as first-line therapy to most patients with nasal polyp for 4-6 weeks A combination of topical and short term systemic steroid therapy can help improve symptoms thereby avoiding surgery. Antibiotics, mucolytics, decongestants may be given when there is evidence of rhinosinusitis Endoscopic sinus surgery, if signs and symptoms of sinusitis does not improve af adequate medical management.

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Inverting Papilloma A unilateral bulky deep red to gray lateral nasal wall lesion which may appear like a polyp with gross translucency. Presents with unilateral nasal obstruction, epistaxis and post nasal drip Malignant transformation is considered to be less than 2% of cases develops squamous cell carcinoma. Histology shows epithelium of the lesion inverting into the underlying stroma. Management is complete excision via endoscopic sinus surgery or lateral rhinotomy with medial maxillectomy

Malignant Tumors of the Nose and Sinuses CA of the nose can present with nasal obstruction and nasal discharge and can be mistaken for rhinosinusitis. CA of the paranasal sinuses presents with one or more of the following; unilateral nasal obstruction, epistaxis, nasal mass, maxillary bulge, loose teeth, a bulging palate, diplopia and blurring of vision Maxillary CA is most common Radiographs will reveal radioopacity of the nose and sinus as well as bone destruction. Most common histopathologic picture is Squamous cell carcinoma Diagnosis: CT scan of the paranasal sinuses Biopsy: incisional via gingivo-buccal approach or biopsy of nasal extension Management: wide excision of the carcinoma or maxillectomy

*********************END OF LECTURE*************** *Disclaimer* The transcriber will not be liable for any errors or inconsistency in this trans. If there are wrong spellings sorry tao lang po me!eheheheh!- aftermaster

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