RHINITIS IIIRD BHMS 2018-2019 BATCH - 8/02/2021 BY DR SHREYA N. PADIYAR ASSISTANT PROFESSOR DEPARTMENT OF SURGERY - Yengage
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RHINITIS
IIIRD BHMS
2018-2019 BATCH
8/02/2021
BY
DR SHREYA N. PADIYAR
ASSISTANT PROFESSOR
DEPARTMENT OF SURGERY
OBJECTIVES At the end of the class students should be able to understand: • Rhinosporidiosis. • Allergic rhinitis. • Vasomotor rhinitis.
RHINOSPORIDIOSIS • It is the infestation of the nose by a spore bearing fungus, which affects mainly the nose.
ETIOLOGY 1) Age: young adults upto the age of 50 years. 2) Sex: Males (common). 3) Causative fungus: Rhinosporidium Seeberi or Rhinosporidium Kinealyi affects the nose.
4) Geographical distribution: seen in coastal areas of tropical countries like India, Sri lanka, Bangladesh, Africa and South America. 5) Occupation: common in farmers. 6) Trauma may be a predisposing cause.
PATHOLOGY • Polypoid mass is found in nose which is vascular. • Sporangia scattered in the polypoid mass. They are chitinous cysts containing spores. • Spread: airborne/ dust mixed with the dung of the cattle/ contact with contaminated water while bathing.
SYMPTOMS • The disease mostly affects nose and nasopharynx; other sites such as lip, palate, conjunctiva, epiglottis, larynx, trachea, bronchi, skin, vulva and vagina may also be affected. • Epistaxis. • Nose block.
• Rhinorrhea. • Protrusion of the masses.
SIGNS 1) The polypoid masses appear vascular mulberry like appearance attached to the septum or the turbinates. 2) The masses may bleed on touch and are friable. 3) Sporangia can be seen as minute greyish spots on the inferior surface of the masses.
INVESTIGATION • Biopsy: shows several sporangia, oval or round in shape and filled with spores which may be seen bursting through its chitinous wall.
TREATMENT • Complete excision of the mass with diathermy knife and cauterization of its base. • Recurrence may occur after surgical excision.
ALLERGIC RHINITIS • It is characterized by spasmodic attacks of severe sneezing and rhinorrhea. • It is a reaction to certain allergens.
ETIOLOGY 1) Age: from 15 years of age onwards. May affect children also. 2) Predisposing factors: a) Heredity. b) Hormonal : begins at puberty and increases during pregnancy. c) Change in weather. d) Emotional.
3) Precipitating factors (allergens):- a) Exogenous (external allergens):- i) Inhalants: dusts, pollen, animal dander. ii) Ingestants: eggs, fish, milk, citrus fruits. iii) Contactants like cosmetics and powders. iv) Irritants like fumes, smoke.
v) Drugs. vi) Infection: Bacteria, Fungi…
b) Endogenous (within the body): • Intestinal helminths, tissue proteins in transudates and exudates.
PATHOGENESIS
Inhaled allergens produce specific IgE antibody
This antibody gets fixed to the blood basophils or mast cells
On subsequent exposure antigen + IgE antibodyDegranulation of mast cells which releases certain chemical mediators.
Symptomatology of allergic disease
Depending on the tissues, there will be vasodilation, mucosal oedema,
infiltration with eosinophils, excessive secretion from nasal glands.• Clinically, allergic response occurs in two phases: 1) Acute or early phase: • It occurs immediately within 5–30 min, after exposure to the specific allergen and consists of sneezing, rhinorrhoea nasal blockage and bronchospasm. • It is due to release of vasoactive amines like histamine.
2) Late or delayed phase: • It occurs 2–8 h after exposure to allergen without additional exposure. • It is due to infiltration of inflammatory cells—eosinophils, neutrophils, basophil, monocytes and CD4 + T cells at the site of antigen deposition causing swelling, congestion and thick secretion. • In the event of repeated or continuous exposure to allergen, acute phase symptomatology overlaps the late phase.
• Clinically Allergic rhinitis is divided into 2 types: a) Seasonal: • Hay fever due to pollen grains at the time of pollination.
b) Perennial: Symptoms present throughout the ear.
SYMPTOMS • Irritation of nose. • Paroxysmal sneezing of recurrent type. • Rhinorrhea is watery and copious. • Nasal obstruction. • Anosmia (intermittent or continuous). • Headache.
Other symptoms: • Itching and watering of eyes. • Eustachian tube blockage may lead to middle ear problems. • Allergic pharyngitis. • Asthma.
SIGNS • Acute stage: Mucosa is pale with watery secretions. • Chronic stage: Mucosa is bluish or purplish due to venous stasis. • Infection may be superimposed.
• Presence of nasal polyps. • Allergic salute: - Itching in the nose and rhinorrhea may lead the patient to lift the tip of his nose upwards with his palm which appears like a salute.
• Darrier’s line: Repeated allergic salute results in a horizontal crease
on the dorsum of the nose little superior to the tip of the nose.
DARRIER’S
LINECOMPLICATIONS 1) Recurrent sinusitis because of obstruction to the sinus ostia. 2) Formation of nasal polypi. 3) Serous otitis media. 4) Orthodontic problems and other ill-effects of prolonged mouth- breathing especially in children. 5)Bronchial asthma.
DIAGNOSIS Based on clinical features and the paroxysmal attacks.
INVESTIGATIONS 1) Total and differential count: Peripheral eosinophilia. 2) Nasal smear: Consists of eosinophils. 3) Haemogram may show eosinophilia. 4) Skin tests: Skin prick tests. 5) Nasal provocation tests: Inhalation of allergens.
6) Elimination tests for food. 7) RAST (Radio allegro sorbent test): in vitro test for the assay of IgE antibodies specific for particular antigens. This test is expensive.
TREATMENT 1) Avoidance of the allergen. 2) Desensitization: • Specific: by specific vaccines or inhalants. • Non- specific stock vaccines. 3) Symptomatic.
4) Vitamin C and Calcium. 5) Surgical : • In case of nasal obstruction due to nasal polypi, hypertrophic turbinates etc… • Septic foci: Removal of sources of infections like tonsilitis, sinusitis, adenoids.
VASOMOTOR RHINITIS • It is nonallergic rhinitis but clinically simulating nasal allergy with symptoms of nasal obstruction, rhinorrhoea and sneezing. • The condition usually persists throughout the year and all the tests of nasal allergy are negative.
ETIOLOGY • Allergens are not responsible. • Imbalance of the autonomic nervous system is considered to be the cause. • Emotions play a role as autonomic nervous system is controlled by hypothalamus.
PATHOLOGY • Sympathetic stimulation causes vasoconstriction and shrinkage of mucosa, while parasympathetic stimulation causes vasodilation and engorgement. • Overactivity of parasympathetic system also causes excessive secretion from the nasal glands.
• Nasal mucosa is also hyper-reactive and responds to several nonspecific stimuli, e.g. change in temperature, humidity, blasts of air, small amounts of dust or smoke. • Eosinophils are not observed frequently.
CLINICAL FEATURES 1) Paroxysmal sneezing. Bouts of sneezing start just after getting out of the bed in the morning.
2) Excessive rhinorrhea. This accompanies sneezing or this may be the only predominant symptom. It is profuse and watery and may even wet several handkerchiefs. The nose may drip when the patient leans forward
3) Nasal obstruction. This alternates from side to side. Usually more marked at night. It is the dependent side of nose which is often blocked when lying on one side.
• 4) Postnasal drip. • Sneezing is less, but nasal obstruction and rhinorrhea is predominant.
COMPLICATIONS Long standing cases will lead to: • Nasal polypi. • Hypertrophic rhinitis. • Sinusitis.
TREATMENT • Medical: 1) Avoidance of physical factors which provoke symptoms, e.g. sudden change in temperature, humidity, etc.. 2) Oral nasal decongestants. 3) Steroids.
OTHER TYPES OF NON-ALLERGIC RHINITIS 1) Rhinitis medicamentosa. 2) Drug induced: Hypotensive medicines, contraceptives etc… 3) Pregnancy: Hormonal nasal blockage. 4) Honeymoon rhinitis: follows sexual excitement causing nasal blockage. 5) Emotional.
6) Hypothyroidism. 7) Gustatory with spicy and pungent food. (causes more of rhinorrhea compared to nasal blockage).
SUMMARY • Rhinosporidiosis. • Allergic rhinitis. • Vasomotor rhinitis.
QUESTION BANK • Define allergic rhinitis and discuss its pathology, etiology, its types, clinical features and management. (1+2+2+1+2+2). • Define Rhinosporidiosis and explain its etilogy and clinical features. (1+2+2). • What is vasomotor rhinitis? Explain its pathology and Clinical features? (1+2+2).
ASSIGNMENT • Define allergic rhinitis and discuss its pathology, etiology, its types, clinical features and management. • Define Rhinosporidiosis and explain its etiology, pathology, clinical features, investigations, and treatment. • What is vasomotor rhinitis? Explain its etiology, pathology, clinical features, complications, treatment and other types of non allergic rhinitis.
REFERENCE 1) A short book of E.N.T. diseases by KB Bhargava, 11th edition, Usha Publications. 2) Diseases of Ear, Nose, and Throat & head and neck surgery by PL Dhingra, 7th edition, Elsevier publications. 3) Textbook on ear, nose, and throat diseases by Mohammed Maqbool, 11th edition, Jaypee publications.
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