RHINITISDEPARTMENT OF SURGERY

By d.Gautam

contents

• Definition • Classification• Clinical features• Signs • Investigation• Complication• treatment

RHINITIS• It is the inflammation of the nasal mucous

membrane

rhinitis

infected

Acute

bacterial viral

chronic

specific Non specific

Atrophic rhinitis

Simple chronic rhinitis

Hypertrophic rhinitis

Rhinitis sicca

Rhinitis caseosa

Granulomatous rhiitis

Non infected

allergic

seasonal perinial

vasomotor

specific

syphilis

leprosy

Tuberculosi

rhinosporidiosis

Rhinoscleroma

Fungal infection

leishmaniosis

Coryza

• It is an acute non specific infective rhinitis.• Also known as “common cold”.

Aetiology • Causative organism: virus and may be either

influenza virus rhinovirus or adenovirus etc.• Spread : is by air borne droplet infection or by

direct contact.• Secondary infection by bacteria may occur

streptococcus staphylococcus pneumococcus etc.

Pathology

• Viral infection of the nasal mucosa

• Acute generalised hyperaemia of the nasal mucosa

• Engorgement of the secretory gland and goblet cells

• Profuse secretion involvement of sinus

• sinusitis

• Involvement of Eustachian tube opening

• ASOM &SOM

CLINICAL FEATURES

• Incubation period:1-3 days• Four stages – Ischaemic stage – Hyperaemic stage– Stage of secondary inflammation – Stage of resolution

ISCHAEMIC STAGE

• Raw sensation & irritation in the pharynx.• Irritation & dryness in the nose.• Sneezing attack.• Malaise with chills.•

HYPEREMIC STAGE

• Profuse watery rhinorrhea• Anosmia • Blocking of nose • Fever and malaise with chills.• Congested nasal mucosa• Headache and otalgia

STAGE OF SECONDARY INFECTION

• Nasal discharge becomes thicker and yellowish and greenish.

• Fever & malaise with chill.• Headache• Otalgia• Congested nasal mucosa

COMPLICATION

• Sinusitis • Acute otitis media.• Pharyngitis.• Pneumonia.• Laryngitis.

STAGE OF RESOLUTION

• Resolution of uncomplicated cases occurs within 6 -10 days.

Treatment

• Antibiotics • Analgesics• Antipyretics• Antihistamine• Vitamin C

• Rest and warm • Give high protein diet • Nasal decongestants locally• Steam inhalation

CHRONIC SIMPLE RHINITIS

• Aetiology • Predisposing factors • Vasomotor rhinitis• DNS• Nasal polypi• Tonsillitis• Sinusitis • Smoking and alcoholism

Clinical feature• Rhinorrhoea-mucopurulent• Headache • Nasal obstruction• Anosmia

SIGNS

• Hyperemic mucosa with oedema.• Post nasal drip .• Thick viscid mucopurulent nasal secreation.• Pharyngitis.

TREATMENT

• Alkaline nasal douching.• Treat the indisposing factors if present.• Stop smoking &alcohol.

Chronic hypertrophic rhinitis

• Etiology • Usually it result from recurrent attack from acute

rhinitis.• Predisposing factors:• sinusitis• Pollution • Dust• Smoke• Tonsilitis

• Nasal polyp• Overuse of nasal drops• Vitamin deficiency

CLINICAL FEATURE

• Nasal obstruction• Rhinorrhoea• Anosmia• Dull headache• Otalgia• Sore throat due to pharyngitis

SIGNS

• Anterior rhinoscopy: Hypertrophy of inferior nasal turbinates.

• Posterior rhinoscopy:Mullbery like appearance

TREATMENT

• Removal or treatment of predisposing factors• Local nasal decongestants drops• Antihistamine• Surgical management for turbinate

hypertrophy• Partial turbinectomy

ATROPHIC RHINITIS • Synonym:ozeana• It is a chronic inflammatory disease of the

nasal mucosa which characterised by progressive atrophy of the mucosa and turbinates', formation of crust and foul smell from the nose known as ozaena.

CLASSIFICATION

• Unilateral or bilateral • Primary or secondary

AETIOLOGY

• Primary:• Exact aetiology not known but predisposing

factor include:• Age : common between 15-40 yrs occurs

usually at puberty.• Sex : more common in female.• Heredity• familial

• Environmental• Nutritional• Hormonal • Vitamin a deficiency• Infection • Secondary :• Chronic specific infection• Extensive surgery• Chronic sinusitis• DNS

PATHOLOGY• It is a condition characterised by atrophic

changes in all the nasal tissues.• Mucosa undergoes atrophy and metaplasia• Cilia and secretory glands also undergo

atrophy with a resultant pale , dry, thin mucosa with thick scanty secretion dry to form crust which may bleed on removal.

• Secondary infection usually results in foul foetid smelling

• Turbinates' undergo atrophy resulting in loss of anatomical landmarks on the nose and a roomy nasal cavity.

• Blood vessels undergo periarteritis & endaritis resulting in ischemia .

• Sensory nerves undergo atrophy and hence the patients may complain of nasal obstruction as he does not feels the air passing through the nose.

• Atrophy of the olfactory nerve ending resulting in anosmia

CLINICAL FEATURE

• Nasal obstruction :– Crust in nasal cavity– Atrophy of sensory nerves

• Crusting of nose(ozaena)• Foul smell of nose• Anosmia • Epistaxis • Headache• dryness of nose and throat

SIGNS

• External nasal examination:– Bridge of nose may be depressed ( saddle shaped)

• Anterior rhinoscopy– Nasal cavity is roomy – Causative factors like DNS– Mucosa is pale shiny dry and atrophy – Crust are seen

• Posterior rhinoscopy – Diminished sensation of the mucosa due to the

atrophy of sensory nerve ending

COMPLICATION

• Sinusitis • Middle ear infection • Atrophic pharyngitis • Maggots

INVESTIGATION

• X-ray of nose/sinus• VDRL test• Complete haemogram• Dermatographical examination• XRAY chest• Nasal smear for leprosy and T.B• Biopsy

TREATMENT

• Primary cause should be treated • Nasal drops:– 25% glycerine drops– Chloramphenicol drops– Streptomycin drops

• Placental extract• Antibiotics• Nutritional improvement vitamin A,B,B6• vasodilators

Surgical treatment

• Narrowing of nasal cavity• Submucosal grafting• Partial closure• Cervical sympathectomy

Rhinitis caseosa

• synonym;cholesteatoma. It is a condition characterized by accumulation

of a caseosa (cheesy) material in the nasal cavity

&maxillary sinus .

Aetiology

• The exact etiology is not known.• Associated with inflammation and granulation

of the lining mucosa.• There may be erosion of lateral nasal wall

Clinical feature

• Nasal obstruction• Foul smell • Headache • Thick viscid rhinorrhoea

SIGNS

• Thick cheesy or caseous material • Foetid odor• Involvement of maxillary sinus

TREATMENT

• Caldwell luc operation

RHINITIS SICCA

• It is a disease of nose characterised by drying and crusting affecting only the anterior portion of the nasal cavity.

Aetiology

• Seen in person working dry hot dusty environment like rubber factory worker bottle factory workers.

CLINICAL FEATURE

• Crusting • Drying • Nasal obstruction• Irritation • Epistaxis • Ulceration • Septal perforation

SIGNS

• Anterior rhinoscopy: dry dark red mucosa ulceration

• Posterior rhinoscopy: nasal mucosa normal • No any crust or drying

TREATMENT

• Lubrication of nose-vaseline,oil• Alkaline nasal douching• Change of environment /job

DIPHTHERETIC RHINITIS

• Also known as nasal diptheria.• It is a form of acute infective rhinitis.

Aetiology

• Causative organism: corynebacterium diphtheria.

• Age :common in children.• It is of two types – Primary– Secondary

Primary

• It may affect the nose first without involvement of other tissues.

Secondary • It may affect the nose secondary to faucial

diphtheria.

CLINICAL FEATURES

• Blood stained watery rhinorrhoea.• Skin near the nasal vestibule may show

excoriation due to continuous nasal discharge.• Nasal obstruction• Greyish white membrane is seen on the

turbinate's or nasal septum, it is difficult to remove.

• Constitutional symptoms such as fever malaise etc.

Investigation

• Swab culture may show diphtheria bacilli

Treatment

• Patient is hospitalised and isolated.• Antitoxin serum are given after a skin

sensitivity test.• Penicillin and ampicillin.

ALLERGIC RHINITIS

• Allergic rhinitis is a common disorder which is usually characterized by spasmodic attack of severe sneezing and rhinorrhea.

Aetiology

• Age:all age• Sex: both sex• Predisposing factors:• Hereditary• Harmonasl• Climate• Emotional

• Precipatating factor(allergens)• inhalents • Ingestants• Contactants• Cosmetic powder• Drugs• Irritants• Infection• Intestinal helmenthis

TYPES

• Two types• Seasonal • Perinial

SYMPTOMS

• Irriritants• Paroxysmal sneezing• Rhinorrhoea• Nasal obstruction• Anosmia• Headache

SIGNS

• Mucosa –Acute stage :paleChronic stage :bluish purple– Infection:present– Polyp :present– Allergic salute(tip of nose salute like)– dorrer’s line (crease on dorsum of nose)

INVESTIGATION

• Nasal secretion : eosinophilia• Haemogram• Stool examination• History about allergy• Skin test by intradermal injection• Inhalation of allergens• Elimination test for food• RAST (radio allergosorbant test)

TREATMENT

• Avoidance of allergen• Desensitisation • Symptomatic: • antihistamine • Steroids• General:• Vitamin c• Calcium

LOCAL TREATMENT

• Hydrocortison injection• Zinc ionisation• Cryosurgery• Laser therapy

SURGICAL

• Nasal obstruction• Infection• Vidian neurectomy

CORRELATION WITH MIASM• Rhinitis covers all the three

miasm, psora and syphilis & sycosis.

PSORA

• Psora-functional changes• Rhinitis covers the psora miasm; psora leads

to functional disturbances; i.e. in rhinitis there is inflammation of mucus membrane of nose leading to ischemic conditions and burning, irritation like symptoms.

• Sensation of dryness in the nose troublesome even when the air passes freely.

• Epistaxis more or less profusely more or less frequently.

• Ulcerated nostrils• Nostrils as if it were stuffed up.• Disagreeble sensation of dryness in the nose.

SYPHILIS • It also covers the syphilis miasm because of

the nasal discharge.• Loss of smell.• Snuffle children.• The bones of the nose are destroyed.• Syphilis produce ulceration• The crust of syphilis are dark greenish black or

brown,thick and not always offensive

SYCOTIC

• It also covers the sycotic miasm because t leads to nasal destruction.

• Sense of smell loss.• Sycotic has a red nose with prominent

cappilaries • There is often nasal stoppage due thickening

of the membrane ,there is enlarged turbinated bones.

• New babies of sycotic patient often get snuffles nose dry stuffed up frequently in Childs.

• Screams with anger in its attempt with breathe with its mouth closed