Please note that the following is a general guideline only.
GENERAL DISCUSSION
Rhinitis definition
Characterized by; Non-purulent nasal drip/ post nasal drip/ nasal obstruction
No evidence of pus in the sinus drainage pathway, no polyps (on endoscopy)
No CT evidence of sinusitis
Important subtypes of rhinitis are
1 allergic rhinitis
2 Local allergic rhinitis -local upper and lower airway allergy, but not demonstrated systemically ie -ve skin testing, -ve RAST testing)
3 Vasomotor rhinitis
4 rhinitis medicamentosa
5 hormonal
6 chemical
Sinusitis definition
Characterized by >2/5 major sinus symptoms-
Nasal obstruction,
nasal drip (usually purulent),
post nasal drip,
anosmia,
pain
and at least one of CT evidence of sinusitis / Pus in the sinus drainage pathway (on endoscopy) or polyps
Important subtypes are
1 Acute sinusitis -If symptoms are acute ie 4-8 weeks (usually post viral)
2 Chronic Rhino Sinusitis (CRS) with nasal polyposis (>3 months)
3 CRS without polyposis
4 Other rare types
Fungal sinusitis: fungal ball, chronic invasive, acute invasive in the immunocompromised
Granulomatous; Wegners/ TB
Secondary to mucociliary dysfunction i.e. Cystic fibrosis etc
Specific cause- ie dental infection, apparent anatomic problem blocking the sinus drainage
RHINITIS SUBTYPES-Discussion in more detail
1 Allergic Rhinitis
Classification
Intermittent: <4 days per week or <4 weeks
Persistent: >4 days per week or >4 weeks
Aetiology
allergens: seasonal and perennial groups
seasonal allergens → primarily pollens (grasses-spring, weeds-winter, trees)
perennial allergens → moulds, house dust, and animal danders
Pathophysiology
Type I hypersensitivity reaction (i.e. mast cell degranulation, TH2 driven)
Clinical
sneezing, rhinorrhea, congestion and itching
+ve Family Hx of atopy
injected conjunctiva
increased lacrimation
dark discolouration below the lower eyelids
transverse nasal crease-nasal salute
turbinate hypertrophy/ rhinorrhea (clear and profuse to stringy and mucoid)
Investigations
Should only be done if significant systemic illness ie poorly controlled asthma
Skin prick test
Blood test -RAST or ELIZA, nasal provocation test
FBC
elevated eosinophil count: nonspecific
Treatment
1 Medical therapy
Nasal symptoms - Rx with topical steroids ie Nasal irrigation followed by Nasonex (II BD) trial 3 months
Extra-nasal symptoms may respond to second-generation antihistamine ie Loratidine 10 mg od in an adult
Asthma medication as needed
2 Failed medical therapy with nasal symptoms (with or without asthma) - turbinate reduction followed by ongoing medical therapy (there is evidence that asthma control is better post surgery)
3 Ongoing asthma and very positive allergy test to a few agents; immunotherapy
No evidence for allergy avoidance
Early exposure to pathogens reduces this condition by induction of TH1 rather than TH2 (low allergy in farming communities, families with may siblings)
2 Local Allergic Rhinitis
Definition
Clinically similar to allergic rhinitis BUT no systemic evidence of allergy (i.e. -ve skin allergy, RAST, ELIZA)
Epidemiology
onset in early adulthood
Aetiology
nasal and respiratory mucosa eosinophilia with no evidence of systemic allergy
may still be a local allergy of the airways
Treatment (as per allergic rhinitis)
Topical therapy
If fails surgery-turbinoplasty
Ongoing symptoms- nasal provocation test- if positive consider immunotherapy (note -ve skin and RAST)
3 Vasomotor rhinitis
Epidemiology
onset in middle age / elderly
Pathophysiology
due to autonomic imbalance-hypoactive adrenergic system relative to parasympathetic
Clinical
present with profuse rhinorrhoea often with clear triggers eg cold, spicy foods
Treatment
medical - ipratropium (atrovent) spray and nasonex II BD longter
surgical- vidian neurectomy (stop the parasympathetic supply to the nose)
4 Drug-induced
ACE inhibitors, estrogens, B-blockers, many others
5 Rhinitis medicamentosa
loss of sympathetic tone due to down-regulation of alpha receptors caused by overuse of sympathomimetic decongestants
treat by the withdrawal of decongestant – consider 1 nostril at a time, use topical nasal steroids during withdrawal
6 Hormonal
estrogen - increases parasympathetic drive and decreases sympathetic activity
pregnancy – onset in the second month, resolves after delivery
menstruation, puberty, exogenous estrogen - OCP
hypothyroidism – myxoedema of turbinates
7 Occupational –
rhinitis induced by irritant at work. Avoidance / topical nasal steroids
SINUSITIS Types and discussion
1 Acute Bacterial
Definition
Bacterial sinusitis following a viral illness lasting up to up to 4-week duration
Diagnosis
Double worsening-(virus--- then better---- then bacterial sinusitis)
Short hx of
-purulent rhinorrhea
-face pain/pressure
-nasal obstruction.
-other; ansomia/ fever/aural fullness/cough and headache
Need to differentiate between viral (<10 days –self-limiting) and bacterial (up to 4 weeks more severe)
Aetiology
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
Treatment
Decongestants-otrivin IV QID for 4 days, Nasal irrigation
Good response to antibiotics: -Amoxycillin, Triprim, macrolide
If no improvement culture guided antibiotics-best
2 CRS without nasal polyposis
Definition
Sy of CRS without polyps
Epidemiology
60% of CRS
Pathophysiology
mostly due to neutrophils
Diagnostics
2 Major sy + clinical/ CT evidence
No polyps on examination
pus in the sinus drainage pathway is noted
Treatment
Topical rinse followed by topic steroids spray (Nasonex II BD)
Culture guided antibiotics help
if no pus no antibiotics
Steroids 3 weeks
No improvement sinus surgery is the gold standard followed by rinsing/ topical steroids spray for 3 months.
Natural course
Earlier onset
Better prognosis
very good response to sinus surgery
3 CRS with Nasal Polyposis
Definition
Fulfils the criteria for CRS with notable polyps
Epidemiology
30 % of CRS
Pathophysiology
Eosinophillic type
Though to be the mucosal dysregulated immune response
Various associations; supra antigens, allergy to fungi, biofilms. Cause, however, is likely to be a dysregulated immune response and destruction of the mucosa.
Diagnosis
criteria for CRS and noted nasal polyps
Treatment
Combination of surgery followed by topical therapy
Pre op : can trial 4-6 weeks of Macrolide (mainly for its anti-inflammatory aspect) / oral steroids/ rinsing followed by Nasonex II BD
The response will most likely be temporary
Surgery involves full sinus clearance making a good passage for delivery of the above mentioned topical Rx
post op 2 weeks of steroids and macrolide along with long term rinsing and topical steroid spray
Adjutants
if Samster’s (Asthma, aspirin hypersensitivity, and polyps) may benefit from post-op aspirin desensitization
if intra op evidence of allergic fungal mucin; immunotherapy for fungi
if an association with asthma and positive skin allergy test; post-op desensitization (note this takes up to 3 years to accomplish)
Evidence that post-surgical improvement of nasal airway improve asthma control
4 Fungal Sinus Disease is discussed separately