RHINOSINUSITIS Prof.Dr. Jehad K. Albaba. Definition: RRRRhinosinusitis is defined as inflammation of the lining of the nose & sinusis

RHINOSINUSITISRHINOSINUSITIS

Prof .Dr. Jehad K. AlbabaProf .Dr. Jehad K. Albaba

DefinitionDefinition::

Rhinosinusitis is defined as inflammation of Rhinosinusitis is defined as inflammation of the lining of the nose & sinusis.the lining of the nose & sinusis.

Prof .Dr. Jehad K. Prof .Dr. Jehad K. AlbabaAlbaba

ClassificationClassification

ALLERGICALLERGIC::

SEASONAL.SEASONAL. PERENNIAL.PERENNIAL.

INFECTIOUSINFECTIOUS::

ACUTE.ACUTE. CHRONIC.CHRONIC.

Specific.Specific. Non-specificNon-specific


Classification (Cont..)Classification (Cont..)

OTHEROTHER

IDIOPATHIC.IDIOPATHIC.

OCCUPATIONAL.OCCUPATIONAL.

HORMONAL.HORMONAL.

DRUG-INDUCED.DRUG-INDUCED.


IRRITANTSIRRITANTS

EMOTIONALEMOTIONAL..

ATROPHIC.ATROPHIC.

Prevalence Of RhinttisPrevalence Of Rhinttis

% %GENERAL GENERAL POPULATIONPOPULATION

Rhinitis symptomsRhinitis symptoms9-159-15% %

Allergic rhinitisAllergic rhinitis 5-20%5-20%((22))


AnatomyAnatomy


Anatomy (Conti..)Anatomy (Conti..)

Artries of nose

Nerves of nose

Function of the noseFunction of the nose

AirwayAirway Heating and humidificationHeating and humidification FiltrationFiltration SmellSmell Nose and voice Nose and voice Nasal reflexesNasal reflexes


Clinical aspects of rhinosinusitisClinical aspects of rhinosinusitis

Increase nasal secretionIncrease nasal secretion Nasal obstructionNasal obstruction Bleeding or hemorrhagic secretion Bleeding or hemorrhagic secretion Fetor Fetor Altered or absent sense of smellAltered or absent sense of smell Paine in the head or in the face.Paine in the head or in the face. Disease of neighboring organs such as teeth, Disease of neighboring organs such as teeth,

lacrimal apparatus, eyes, mouth, throat, and lungs.lacrimal apparatus, eyes, mouth, throat, and lungs.


Allergic rhinitisAllergic rhinitis

Allergy Allergy

is an exaggerated harmful response of living tissue is an exaggerated harmful response of living tissue when exposed to an allergen. Allergic rhinitis is very when exposed to an allergen. Allergic rhinitis is very common disease; it affects 15% of Americans and common disease; it affects 15% of Americans and 10% of Europeans. The prevalence of disease is 10% of Europeans. The prevalence of disease is increasing due to pollution; about 13% of patient has increasing due to pollution; about 13% of patient has hereditary factor. hereditary factor.

Allergic rhinitis is antigen antibody reaction, IgE is the Allergic rhinitis is antigen antibody reaction, IgE is the main antibody.main antibody.


Predisposing factorsPredisposing factorsNon- immunological factorsNon- immunological factors

The autonomic nervous systemEnvironmental factors continued

Autonomic imbalanceHumidity - Temperature

Unspecific hyper-reactivityAir pollution

Adrenergic blockadAspirin intolerance – a receptor disease


Allergens Allergens andand allergen extracts allergen extractsInhaled allergensIngested allergens

PollenFood allergy

Moulds Medications

Animal danderStructure and occurrence

House dust -houseDust mite

Allergen extracts

FeathersExtraction

Other inhalant allergensPotencyStability

Occupational allergyStandardization


POTENTIAL INVOLVEMENT OF MULTIPLE POTENTIAL INVOLVEMENT OF MULTIPLE ORGANS WITH ALLERGIC RHNITISORGANS WITH ALLERGIC RHNITIS

Clinical AssociationClinical Association 47.1% are having pulmonary allergy47.1% are having pulmonary allergy 12.8% are having eczema skin allergy12.8% are having eczema skin allergy 2.1% are having both pulmonary & eczema2.1% are having both pulmonary & eczema..

Sub clinical Association:Sub clinical Association: 20.3% are having sub clinical pulmonary allergy.20.3% are having sub clinical pulmonary allergy. 75% are having sub clinical skin allergy.75% are having sub clinical skin allergy.


RHINITIS IN ASTHMATIC CHILDRENRHINITIS IN ASTHMATIC CHILDREN

Approximately 80% of children presenting with asthma Approximately 80% of children presenting with asthma

also have rhinitis.also have rhinitis.

Children with a history of allergic rhinitis are more likely Children with a history of allergic rhinitis are more likely

to suffer from exercise induced asthmato suffer from exercise induced asthma..


POSSIBLE REASONS FOR CO-EXISTENCE OF POSSIBLE REASONS FOR CO-EXISTENCE OF RHINITIS AND ASTHMARHINITIS AND ASTHMA

Common ciliated epithelium.Common ciliated epithelium.

Both are associated with allergy.Both are associated with allergy.

Similar allergens are associated with both conditions.Similar allergens are associated with both conditions.

Both have a familiar link with atopy.Both have a familiar link with atopy.

Possible pathophysiological mechanism-sino-bronchial Possible pathophysiological mechanism-sino-bronchial reflex.reflex.


Pathogenesis of allergic rhinitisPathogenesis of allergic rhinitis

First First exposureexposure – sensitization – sensitization


second exposure – allergic symptomssecond exposure – allergic symptoms


Allergic RHINITIS : SYMPTOMSAllergic RHINITIS : SYMPTOMS

““SNEEZERS AND RUNNERS”:SNEEZERS AND RUNNERS”: Itchy nose, sneezing ,watery rhinorrhoea, nasal Itchy nose, sneezing ,watery rhinorrhoea, nasal congestion (variable), diurnal rhythm congestion (variable), diurnal rhythm ( worse during day), often associated conjunctivitis.( worse during day), often associated conjunctivitis. ““BLOCKERS”:BLOCKERS”:Little or no sneezing, thick catarrh (with post nasal Little or no sneezing, thick catarrh (with post nasal

drip), No itch, constant symptoms-possibly worse drip), No itch, constant symptoms-possibly worse at night.at night.


DIAGNOSIS OF RHINITISDIAGNOSIS OF RHINITIS

Detailed medical historyDetailed medical history

E.N.T examinationE.N.T examination EndoscopyEndoscopy Nasal airway assessmentNasal airway assessment

Other tests as appropriate:Other tests as appropriate: Radiology, olfaction, blood tests.Radiology, olfaction, blood tests.

Allergy tests:Allergy tests: nasal smear, nasal swab, RAST, total immunoglobulins.nasal smear, nasal swab, RAST, total immunoglobulins.


TREATMENTTREATMENT: :

Allergic inflammationAllergic inflammation : : Allergen :Allergen :

IgE antibody receptors on mucosal cells ( mast, basophiles, IgE antibody receptors on mucosal cells ( mast, basophiles, eosinophils) .eosinophils) .

Cell activation and accumulation:Cell activation and accumulation: Release of inflammatory mediators… clinical symptoms .Release of inflammatory mediators… clinical symptoms .

So, treatment is to break the process at any stage.So, treatment is to break the process at any stage.


AIMS OF MANAGEMENT OF RHINITISAIMS OF MANAGEMENT OF RHINITIS

Relief of symptomsRelief of symptoms

Isolation and elimination of cause of symptomsIsolation and elimination of cause of symptoms

Awareness of associated problems Awareness of associated problems

E.g. sinusitis, asthmaE.g. sinusitis, asthma


ALLERGIC RHINITIS:ALLERGIC RHINITIS:STEPWISE APPROACH TO TREATMENTSTEPWISE APPROACH TO TREATMENT

1.1. Allergen avoidanceAllergen avoidance6.6. Anti-leukatrinesAnti-leukatrines

2.2. Anti-histamines Anti-histamines7.7. Anti-IgEAnti-IgE

3.3. Topical nasal steroids or Topical nasal steroids or systemicsystemic

8.8. DesensitisationDesensitisation

4.4. DecongestantsDecongestants9.9. SurgerySurgery

5.5. Mast cells stabilizersMast cells stabilizers


Treatment of allergic rhinitis in adultsTreatment of allergic rhinitis in adults* *

Itch\Sneezing Discharge Blockage Impaired smell

Sodium Cromoglycate

+ ++-

Oral antihistamines ++++++-

Ipratropium bromide -+++--

Topical decongestants

--+++-

Topical corticosteroids

+++++++++

Oral corticosteroids +++++++++++

MANAGEMENT OF RHINITIS WITH CO-MANAGEMENT OF RHINITIS WITH CO-EXISTENT ASTHMAEXISTENT ASTHMA

INTRANASAL CORTICOSTEROIDS: “(treating INTRANASAL CORTICOSTEROIDS: “(treating upper airway inflammation) indirectly improves upper airway inflammation) indirectly improves asthma symptoms and decreases bronchial hyper-asthma symptoms and decreases bronchial hyper-reactivity…”reactivity…”

ANTIHISTAMINES : improve rhinitis but are ANTIHISTAMINES : improve rhinitis but are not shown to improve asthma.not shown to improve asthma.


INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY

Anatomical abnormalitiesAnatomical abnormalities

Excessive mucosal swellingExcessive mucosal swelling

Presence of irreversibly diseased tissuePresence of irreversibly diseased tissue..


Infective RhinitisInfective Rhinitis

Viral rhinitis (common cold)Viral rhinitis (common cold) Bacterial rhinitis Bacterial rhinitis

Non-specific.Non-specific. Acute .Acute . Chronic.Chronic.

Specific.Specific. Syphilis.Syphilis. TB.TB.

Atrophic Rhinitis.Atrophic Rhinitis.


Vaso motor RhinitisVaso motor Rhinitis

Imbalance in the autonomic nervous system. Imbalance in the autonomic nervous system.


SinusitisSinusitis

Microbiology of sinusitisMicrobiology of sinusitis

VirusesViruses PneumococciPneumococci Hemophilus Influenzae Hemophilus Influenzae Hemolytic streptococciHemolytic streptococci Anaerobes Anaerobes FungusFungus


Source of infectionSource of infection

Spread from noseSpread from nose Spread from sinus to sinusSpread from sinus to sinus Spread from neighboring tissues i.e. from teeth Spread from neighboring tissues i.e. from teeth

to maxilla.to maxilla. Blood borneBlood borne


Predisposing factorsPredisposing factors

Rhinitis wither infective or Allergic Rhinitis wither infective or Allergic Anatomical factors:Anatomical factors:

Deviated septumDeviated septum AtresiaAtresia Cilliary immutilityCilliary immutility

Immuno compromised patient as diabetic or Immuno compromised patient as diabetic or organ transplant.organ transplant.


Symptoms and signs of sinusitisSymptoms and signs of sinusitis

Pain, Headache, and TendernessPain, Headache, and Tenderness. . Discharge Discharge Nasal obstruction Nasal obstruction Anosmia – hyposmia or cacosmiaAnosmia – hyposmia or cacosmia Eczema of the nostrils and conjunctivitisEczema of the nostrils and conjunctivitis General symptoms as cough, generalized weakness and General symptoms as cough, generalized weakness and

depression.depression.


DiagnosisDiagnosis

Clinically from signs and symptomsClinically from signs and symptoms Radiology will give Radiology will give

Mucosal thickening Mucosal thickening Opaque sinusOpaque sinus

Air fluid levelAir fluid level


TreatmentTreatment

Decongestant.Decongestant. Cleaning of discharge. Cleaning of discharge. Antibiotics according to biogram.Antibiotics according to biogram. Topical corticosteroid in presence of allergy.Topical corticosteroid in presence of allergy. Surgery. Surgery.


Complications of sinus infectionComplications of sinus infection

Extension to the external tissue. Extension to the external tissue. Orbital complications. Orbital complications. IIntracranial complications. ntracranial complications. Osteomyelitis of the flat Bones of Skull.Osteomyelitis of the flat Bones of Skull.


Protect your NOSEProtect your NOSE

Documents

RHINOSINUSITIS Prof.Dr. Jehad K. Albaba. Definition: RRRRhinosinusitis is defined as inflammation of the lining of the nose & sinusis