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Inflammation of the Nose 1- Inflammation of the nasal vestibule (e.g. furunculosis) Furunculosis: it is acute bacterial infection of a hair follicle in the vestibule caused by Staphylococcus aureus. Clinical features: there is red tender nodule, which is very painful; later on Evacuation of pus usually occurs spontaneously after 4−5 days.
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To through a light on:: Objectives
1-inflammation of the nose 2- acute inflammation of paranasal
sinuses(acute sinusitis) Inflammation of the Nose
1- Inflammation of the nasal vestibule (e.g. furunculosis)
Furunculosis: it is acute bacterial infection of a hair follicle in
the vestibule caused by Staphylococcus aureus. Clinical features:
there is red tender nodule, which is very painful; later on
Evacuation of pus usually occurs spontaneously after 45 days.
Complications: 1-Infection may spread through the valveless facial
and superior ophthalmic veins to cavernous sinus causing cavernous
sinus thrombsis which is characterized by: Fever. Vomiting.
Convulsion. Edema of the eyelids. Ophthalmoplegia. Immobile pupil.
Retinal hemorrhage and papilloedma. Blindness. 2-Cellulitis of
upper lip. 3-Septal abscess. Treatment: Systemic antibiotic
(cloxacillin, flucloxacillin, erythromycin). Local moist heat
application and analgesia like paracetamol. Advice the patient not
to squeeze the boil to avoid the risk of blood-stream spread.
2-Rhinitis: It is defined as inflammation of the mucosa of the
nasal cavity and divided into acute rhinitis and chronic rhinitis.
Chronic rhinitis is subdivided into chronic specific and chronic
non-specific rhinitis. 1- Acute rhinitis A- Common cold (coryza):
it is a viral infection of the nasal mucosa caused by many viruses
e.g. rhinovirus, adenovirus, Influenza, Parainfluenza, respiratory
syncytial viruses...etc. Predisposing factors:
Environmental ( temperature, humidity). Immune deficiency ( IgA).
Vitamin deficiency (vitamin C deficiency). Fatigue. Nasal
obstruction interfere with normal mucous transport infection. Foci
of chronic infection (chronic adenoiditis, chronic tonsillitis).
Acidity of nasal secretion. General diseases (renal failure,
diabetes mellitus). Mode of transmission: is by:
Droplet as in coughing and sneezing. Direct contact as kissing.
Pathology: Ischaemic stage due to vasoconstriction. Hyperaemic
stage in which there is edematous mucosa and profuse clear fluid.
Stage of secondary infection, the discharge becomes mucopurulent.
Stage of resolution; there is reversal of previous stages. Clinical
Features: 4 stages:
Ischaemic stage: after incubation period of 13 days there is
burning sensation and sneezing. Hyperaemic stage: after few hours
there will be profuse watery rhinorrhoea, nasal obstruction &
fever. Stage of secondary bacterial infection: the rhinorrhoea
become muco-purulent, thick and greenish in color, fever and nasal
obstruction. Stage of resolution: occurs in 510 days by reversal of
previous stages. Differential diagnosis:
Allergic rhinitis (no fever). Influenzal rhinitis (there are more
severe constitutional symptoms). Vasomotor rhinitis. Complications:
Acute sinusitis. Acute otitis media. Acute tonsillitis Acute
pharyngitis. Lymphadenitis. Lower respiratory complications
(laryngitis, tracheitis, bronchitis, pneumonia). Gastroentritis
(rare). Nephritis. Rheumatism. Treatment: Rest. Analgesia e.g.
aspirin. Decongestant e.g. pseudoephedrine (systemic) or
phenylephrine (topical). Decongestant help to nasal obstruction.
Antihistamines. Antibiotics (reserved for treatment of
complications e.g. acute otitis media). B- H1N1 Influenza virus
disease:
This is a virus originated from animal influenza viruses & it
is unrelated to human seasonal H1N1 viruses. This new virus may
cause death & severe illness not normally seen in seasonal H1N1
viruses, it may cause death in healthy young people. Pregnant
women, younger children and those with chronic lung diseases and
other medical conditions are at greater risk to develop severe
illness & death. Mechanism of transmission: Similar to seasonal
influenza, from person to person by infected droplets expelled by
coughing or sneezing or by direct contact with contaminated hands
or kissing. Clinical Features: (similar to human seasonal
influenza)
Fever, cough, headache, muscle & joint pain, sore throat, runny
nose and sometimes vomiting & diarrhea. Treatment: (similar to
human seasonal influenza) Rest. Drinking plenty of fluids.
Analgesia. In severe cases use antiviral agent like: Tamiflu. The
majority of people experience mild illness & recover fully
without treatment. 2- Chronic Rhinitis: A- Chronic non-specific
rhinitis.
B- Chronic spesific rhinitis,it is due to spesific causes
e.g.TB,syphilis,leprosyetc A- Chronic non-specific rhinitis.
Atrophic rhinitis. Aetiology: Infection e.g. syphilis, chronic
sinusitis. Surgery e.g. inferior turbinectomy. Poor nutrition e.g.
vitamins and iron deficiency. Genetic. Hormonal. Autoimmune
Pathology: two types Type 1 (most common): Characterized by
endarteritis of terminal arterioles. Type 2 (less common):
Characterized by vasodilatation of the capillaries. Other
pathological changes in both types (1 & 2) are metaplasia of
columnar epithelium to squamous epithelium and decrease in the
number and size of alveolar glands. Clinical picture: Atrophic
rhinitis is more common in females and presented at puberty and it
is bilateral. It is characterized by: Nasal obstruction due to
crust. Epistaxis due to separation of the crust Anosmia. On
examination there is characteristic greenish foul smell crust and
abnormally patents nasal passages. Investigations: Radiology of
paranasal sinuses to exclude chronic sinusitis. Serological test
for syphilis (VDRL, TPI, FTA test) to exclude syphilis. Complete
blood picture, serum protein and iron to exclude nutritional
deficiencies. Treatment: A-Conservative: Removal of crusts by
forceps, suction or by syringing with warm isotonic solution or
alkaline solution. Glucose 25% in glycerin drops to prevent
infection. Systemic antibiotic e.g. rifampicin 600 mg/ 1 day for 12
weeks. B-Surgery: there are many surgical operations; the most
important one is Young's operation in which we close the nostril
for several months. Inflammation of Paranasal Sinuses
(Sinusitis):
Acute sinusitis: Definition: it is acute infection of the mucosa of
paranasal sinuses (for less than 3 weeks duration). Inflammation
may be unilateral or bilateral, may affect single sinus or several
or all sinuses (pansinusitis). Maxillary sinus the most commonly
affected followed by ethmoid, frontal and sphenoidal sinus.
Aetiology: Acute infective rhinitis e.g. common cold (most common
cause of acute sinusitis). The infection spread to the sinus from
the nose through the ostium. Swimming: the Infection can spread
directly through the ostium; also chlorine, which is added to water
of swimming pool, is irritant sinusitis. Dental extraction or
infection (uppersecond premolar and molar teeth). The roots of
these teeth may penetrate the floor of maxillary sinuses. So that
dental infection may spread to maxillary sinuses. External trauma
may cause fracture through the sinus wall lead to direct spread of
infection through fracture to the sinus. Predisposing
factors:
1- Local: Nasal obstruction e.g. septal deflection, polyp.
Obstruction of sinus ostium e.g. allergic rhinitis, tumour.
Neighbouring infection e.g. tonsillitis, adenoiditis. Previous
infection in the same sinus. 2- General: Debilitation. Mucociliary
disorders. There is impairment of mucous transport. (Like
Kartagener's syndrome, cystic fibrosis, Young's syndrome).
Kartagener's syndrome; sinusitis, bronchiectasis, infertile male
with or without situs inversus (autosomal recessive) Young's
syndrome; sinusitis, bronchiectasis and obstructive azospermia.
Immunodeficiency disorder e.g.: AIDS, DM, renal failure. Irritating
atmospheric conditions and cold weather. Cold weather causes
vasoconstriction of nasal and sinus mucosa easy invasion by
bacteria. Causative organisms: Pneumococcus. Haemophilus
influenzae. Staphylococcus aureus. Streptococcous pyogenes.
Moraxilla catarrhalis. Pathology: Upper respiratory tract infection
hyperaemia and edema of the mucosa blockage of ostia &
paralysis of the cilia stasis of secretion in the sinus secondary
bacterial infection sinusitis. Hyperaemia of the sinus mucosa.
Oedema of the sinus mucosa. Cellular infiltration of the
sinusmucosa (polymorphonuclear cells). Glandular hyperactivity
mucous secretion. Exudation: it is serous exudate in early stages
then becomes purulent. Clinical features Fever and malaise. Pain:
Maxillary sinusitis pain in the cheek referred to upper teeth.
Frontal sinusitis pain in the frontal region. Ethmoidal sinusitis
pain between the eyes at the nasal bridge. Sphenoidal sinusitis
retro-orbital headache referred to vertex, temple or occiput. Nasal
obstruction. Postnasal drip. Tenderness. Maxillary sinusitis
tenderness over the cheek. Frontal sinusitis tenderness over the
sinus floor immediately above the inner canthus and tenderness by
tapping over anterior sinus wall. Hyperaemia of nasal mucosa. Pus
discharge: Maxillary, frontal and anterior ethmoidal sinusitis pus
in middle meatus . Posterior ethmoidal sinusitis pus in the
superior meatus. Sphenoidal sinusitis sphenoethmoidal recess can be
seen by posterior (not anterior) rhinoscopy. Oedema and hyperaemia
over the cheek in acute maxillary sinusitis and over frontal bone
in acute frontal sinusitis may be seen in children. Nasal endoscopy
pus in the middle meatus, superior meatus or sphenoethmoidal recess
(according to the infected sinuses). Investigation: CBP & ESR
WBCs & ESR. Swab for culture and sensitivity. Plain X-ray
(occiptomental view) may show: Sinus mucosal thickening. Fluid
level Total opacification of the sinus. CT scan. Serum
immunoglobulins assay (IgG, IgA to detect immunoglobulin
deficiency)(in selected cases). Treatment: Aims of treatment To
resolve the acute infection. To prevent complication. To correct
any precipitating factor e.g.: septoplasty to correct septal
deviation. Medical treatment: (7 days course)
Bed rest and analgesia e.g.: paracetamol. Broad spectrum antibiotic
e.g.: co-amoxiclav, clarithromycin, cefuroxime. Decongestants
systemic e.g.: pseudoephedrine. Topical e.g.: ephedrine to improve
sinus drainage. Surgical treatment: (used when there is failure of
medical treatment)
Functional endoscopic sinus surgery (FESS) is now the treatment of
choice in recurrent acute sinusitis. Antral washout, it treat any
Infection in the maxillary sinus and also improve drainage from
other sinuses. It is done by passing a canula through the inferior
meatus into the maxillary sinus and washing the sinus by using
syringe and warm saline solution. Inferior meatal antrosomy (when
there is history of recurrent infections) we do opening in the
inferior meatus for better and longer lasting drainage. Frontal
sinus trephination: trephination of the frontal sinus floor via
small incision above the medial canthus washout the sinus.
Uncapping of the ethmoidal sinuses to promote drainage from the
sinus. Anterior sphenoidotomy: in acute sphenoidal sinusitis.