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The Medical and Surgical Treatment of Chronic Rhinitis
R. Moulton-Barrett, MD
Defination of Chronic Rhinitis
symptoms of : nasal congestion rhinorrhoea anosmia sneezing or itchy nose lasting > 3 months in one year
• 40 million people in USA • 50% seek medical advise• 50% allergic in origin • 6 million dollars spent on decongestants / yr.
Physiology of Nasal Congestion
3 portions: vestibule respiratory ( 92 % by area:120 sq cm's) and olfactory
Flow: Inspiratory - laminar, above inferior turbinate Expiratory - circum-laminar to paranasal
sinuses
Vestibule: 1/3 nasal resistance ( by acoustic rhinometry and MRI )
Nasal Valve: 2/3's total nasal resistance ( 0.72 cm2 )
the most narrow portion of the nasal cavity
Anatomy of the Inferior Turbinate
Nerve: Post-ganglionic pterygopalatine ganglion fibres Inf Post Lat branch of Greater Palatine Nerve
Artery: Single branch of sphenopalatine artery enters 1-1.5 cm's from posterior superior bone travels anteriorly along superior periosteum
Swelling: 40% of blood: through spongy submucosal venous tissue
containing small vessels with leaky basement membranes
60% of the blood passes through a/v shunts: Sympathetic dependent - reduces can overdrive by parasympathetics + engorges not histamine sensitive
Acoustic Rhinometry• assesses cross-sectional area andgeometry• (experimental) Hilberg 1989
Posterior Rhinometry • Resistance = Pressure/Flow: disputed in terms of
value Myrind N, 1980. Measurement of nasal airway resistance -is it only for article writers. Clinical Otolaryngol 5:161-163.
Measurement of Nasal Resistance
Dynamic variation in nasal resistance
Site: anterior-superior leading edge Hydrostatic presssure: positionalNervous innervation : nasal cycle ( sympathetic tone ) Inflammatory process: chronic rhinitis Drug manipulation: vasoconstriction: 35% <
resistanceInflam. mediators: histamine independent
peptide and prostaglandin dependent
Physiology of Rhinorrhoea
Serous & Mucoserous Glands parasympathetic and histamine dependent induce with methacholine 'challenge' test 50-100 cilia/cell beats mucus posteriorly at 0.3-1 cm/minute a drop of saccarin: taste in 20 minutes, if delayed: perform microscopy rule out immotile
cilia
Sneezing and Itching
Histamine related: released by mastcells eosinophils & most importantly basophil
cells
Success of therapy: antihistamine/cromoglycate:
proportional to histamine in nasal smears > mast, eosinophil, basophil cells, in vitro histamine release in response to allergens
Nasal Cytometry
Purpose: 1. determine likelihood medical treatment success 2. make diagnosisCollection: plastic bag and swab to slideStains: Hansel's or Wright'sAnalysis: > 5 neutrophils/high power field: 84% sensitive for sinusitis
>25% eosinophil/100 cells: 70% diagnostic allergic rhinitis (AR)
The other 30%: eosinophilic non- allergic rhinitis ( NARE)
Check H & P& Labs: h/o asthma FH AR (24%)
IgE>50U/ml ( usually >700u/ml=AR), skin or nasal allergen challenge testing • If NARE: 93% respond to intra-nasal steroid therapy vs.
66% if AR. • If non-NARE/AR ( vasomotor ): < 19% respond to intra-
nasal steroid therapy
Mullarkey M, Hill J and Webb R,1980. J Allergy Clin Immunol 65(2),122-126
Causes of Rhinitis
Allergic : 50 %Non-allergic Eosinophilic : 35 %Vasomotor : 12 % Others : infective autoimmune < 3 % atrophic
If only nasal obstruction must r/o masses
AllergicNasal Challenge Test• Primary phase: 5-30 seconds later sneezing occurs histamine dependent secondary to basophil degranulation then delayed intra-nasal eosinophilia
• Secondary phase: 7 hours later also caused by basophil degranulation and parasympathetic overdrive histamine independent
• If the allergen is rechallenged there may be 100x's greater response
Seasonal primary and secondary phases
• when pollen counts are >50/cubic meter April-May: oak May-August: birch April-August: ragweed
• or when in-home dust countsare elevated:
Dermatophygoides pteronyssinus or farinae : fans mattress covers wash carpets open windows dusting humidifiers
Vasomotor Rhinitis
Secondary to: parasympathetic excess or sympathetic reduction• Drugs
– rhinitis medicamentosa - topical cocaine and oxymetolazone - produces prolonged vasoconstriction - followed by reactive hyperemia - via down regulation: alpha1 & 2
blockage
– antihypertensive medications: vasodilators ie. alpha blockers
• Hormonal – estrogenic - BCP & Gravidarum: estrogenic cholinesterase inhibition – acromegaly – hypothyroidism: responds to thyroxine and – old man's drip: responds to testosterone
Medical TherapyIntra-Nasal Steroids• Most useful agent: 60-75% benefit all causes chronic rhinitis placebo 20% benefit
• Inhibits: mast cell migration into nasal mucosa basophil cell, not eosinophil cell degranulation
• least effect on: parasympathetic tone non-histamine related rhinorrhoea of VR
• S/E: freon causes drying crusting and bleeding ( 5% )
aqueous propylene glycol produce burning ( 5% )
very rare side - effects of septal perforation - blindness
• Little benefit for VMR• positioning the patient
Medical therapy
Anti-histamines
• Have little effect on nasal blockage since histamine independent
• Inhibit primary phase reactive symptoms
• As effective as steroids for seasonal AR for sneezing & rhinorrhoea
Cromoglycate
• Inhibition of protein kinase C leads to reduced degranulation • Has no place in the treatment of NARE or vasomotor rhinitis
• Limits phase 1 symptoms and poor for congestion • Use 4-6 times daily
• Though newest drug 'Nedocromil" may reduce nasal obstruction in allergic rhinitis
Ipratropium bromide
• Few side-effects since not absorbed by mucosa
• Inhibits c-GMP synthesis which causes decreased glandular secretion
• 400ug QID may produce cracking and bleeding
• 80ug QID is equally effective in reducing rhinorrhea but not sneezing or obstruction•
Immunotherapy
• Mechanism: cytokine related inhibition of basophil sensitivity via T cells rather than blocking IgG antibodies
• " May be initiated at any time " during medical therapy for AR Gordon, 1992. O-HNS 107;6(2), pg. 861
• Degree of success is multi-factorial and of particular importance is allergen avoidance therapy
• 90% of asthmatics with positive skin and nasal challenge tests benefited by mold immunotherpy ( Goode states: 75%)
• Yet intra-nasal steroids are better tolerated and more effective in the therapy for seasonal AR
Surgical Treatment: General principles
• Rhinorrhoea: neurectomy or steroid injection
• Obstruction: all forms of therapy with good results
• Inferior turbinate: commonest cause of nasal obstruction
• Reduce the inferior turbinate during septoplasty
• Atrophic rhinitis from turbinectomy is extremely rare
Choices: Inferior Turbinate
steroid injection sclerotherpy outfracturesubmucous resection of bone submucosal bipolar electro- cauterymucosa/ soft tissue resection: AgNO3 CO2 laser or needle
cauteryturbinectomy: partial or completeneurectomy: pterygopalatine ganglion or vidian
nerve by: cryo or sclero-therapy cautery or knife endo or non-endoscopically
Outfracture
method: clamp and rotate outwards
advantage: little bleeding easy to perform may combine with posterior
turbinectomy
disadvantage: 25% show no improvement
Thomas, et al, 1985
Submucous Resection of Bone
method: anterior incision over head of the inferior turbinate resection of the anterior 1/3 using curved scissors
advantage: useful - uncontrolled perrenial enlarged inferior turbinate easy
little bleeding or post-operative crusting or drainage preserves mucosa
disadvantage: may require general anaesthesia need packing inferior long-term results to turbinectomy
House P,1951. Submucous Resection of the Inferior Turbinal Bone. Laryngoscope 61(7),637-648.
Soft Tissue Cautery
method(s): unipolar single - 3 points or bipolar * cautery
advantage: simple equipment and simple to do
disadvantage: difficult to determine degree of thermal injury, pain may be diffulcult to control by local
anaesthesia mucosal loss with prolonged time for
remucosalization ie. crusting and rhinorrhoea risk of sequestrium formation: persistent swelling fetor rhinorrhoea crusting
* Hurd L,1931. Bipolar electrode fro electrocoagulation of the inferior turbinate. Arch Otol 13,442
Steroid Injection:
method: 0.5cc Kenolog ( 40mg/ml ) on spinal needle
advantage: quick, under local anaesthetic, rapid results
disadvantage: lasts 4 weeks facial flushing ( 5% ) at least 11 reports of blindness ( 1 at UC-
Irvine ) small risk of septal perforation or sequestrium
Mabry R,1983. Corticosteroids in otolaryngology:intraturbinal injection. Otolaryngol Head and Neck Surg 91(6),717-720
CO2 Laser
method: defocused and 10W continuously to the anterior 1/3 of the inferior turbinate
advantage: less bleeding, less pain, faster healing disadvantage: associated with synechiae formation
Selkin S,1985. Laser turbinectomy as an adjunct to rhinoseptoplasty. Arch Otolarygol 111,446-449
KTP Laser
method: 532nm laserscope 1mm wide, 1mm deep 8W continuous X hatched and teflon splints
placed
advantages: 85% improvement at 2-4 year follow-up no packing and no bleeding
disadvantages: specialized equipment 2 weeks of rhinorhoea 8 weeks of crusting
Levine H,1991. The potassium-titanyl phospahte laser fro treatment of turbinate dysfunction. Otolaryngol Head and Neck Surg 104(2),247-251
Cryotherapy
method: closed nitrous oxide cryo 'gun' at -40c for 60-75 seconds to 4 places on the sup & ant head of the inferior turbinate
advantages: local anaesthesia no bleeding little dyscomfort may combine with neurectomy for vasomotor rhinitis 85% improvement at 2 yr. follow-up
disadvantages: until recently required specialized equipment rhinorrhoea if do not combine with neuroectomy, inferior long-term results compared to turbinectomy*
* OzenbergerJ,1973. Cryotherapy for the treatment of dhronic rhinitis. Laryngoscope 83,508-16
Turbinectomy methods: anterior 1/3 or total*
advantage: * despite Goode's criticisms in 1985 do not appear to cause atrophic rhinitis useful for hypertrophic posterior 'mulberry'
turbinates best long term results
disadvantage: most post-operative dyscomfort/pain/crusting usually requires packing 3-5% significant bleeding and when combined with other nasal procedures
under general anaesthesia it led to prolonged
hospitalization.** Elwany S and Harrison R, 1990. Inferior turbinectomy: Comparison of four
techniques. J Laryngol Otol 104,206-209 Ophir, D 1992. Long-term follow-up of the effectiveness and safety of inferior turbinectomy. Plast Reconst Surg 90 (6),985-987
Neurectomy
methods: trans-nasal: Malcolmson, 1959 trans-antral: Golding-Wood, 1962 endoscopic: El Shazly, 1991 advantages: 90% improvement of rhinorrhoea
disadvantages: possible reduction of maxillary sensation conjunctival irritation 'red eye' (25%) may regenerate in time
El Shazly M,1991. Endoscopic Surgery of the Vidian Nerve. Preliminary Report. Ann Otol Rhinol Laryngol 100:536-539.
Cryotherapy: Neurectomy
method: apply probe 1 minute -180C to the vidian nerve 6mm posterior to the sphenopalatine foramen 1cm posterior toposterior border to the middle
turbinate or 1.2cm above & lateral to superior border of the
choana
advantages: quick can use in conjunction with cryo-turbinate reductio well tolerated on out-patient basis 86% improvement
disadvantages: unpredictable extent of result operator experience dependent
Strom M, 1989 . A long-term assessment of cryotherpy for testing vasomotor rhinitis. Ear Nose and Throat 69(12), 839-842