rhinitis, nasal septum · rhinitis (bsaci guideline 2017, scadding et al.) inflammation of the...

Rhinitis,

Nasal Septum

HELGA KRAXNER MD, PHD

MAGDA KRASZNAI MD, PHD

Rhinitis (BSACI guideline 2017, Scadding et al.)

Inflammation of the nasal mucosa and

submucosa characterized by the

undermentioned symptomps :

– nasal secretion

– sneezing

– nasal blockage or congestion

– itching in the nose

Involvement of conjunctivae →

rhinoconjunctivitis

Involvement of sinus linings → rhinosinusitis

Classification

Allergic rhinitis

Infectious rhinitis

Other (Non-allergic rhinitis - NAR)

Allergic rhinitis

➢ ARIA (2008):

– intermittent, persistent

– moderate, severe

➢ Seasonal, perennial, mixed

Infectious rhinitis

➢ acute

➢ chronic

➢ specific

➢ non specific

Other etiology

➢ Hormone dependent

➢ Occupational

➢ Environmental

➢ Food

➢ Drug

➢ Emotional

➢ Atrophic

➢ Idiopathic

Triggers for non-allergic

rhinitis (NAR) I.

Eosinophilic or NARES (50% develop aspirin sensitivity with asthma and nasal polyposis)

Autonomic (formerly known vasomotor) – physical/chemical agents

Drugs (α-adrenerg blockers, β-blockers, ACE-inhibitors, chlorpromazine, cocaine, nasal decongestants – prolonged use, aspirin/NSAID)

Hormonal (pregnancy, puberty, HRT, contraceptive pill, hypothyroidism, acromegaly)

Food (alcohol, spices, pepper, sulphites)

Atrophic (primary: Kleb. Oz., sec.: trauma, surgery, radiation)

Primary mucus defect (cystic fibrosis)

Primary cellular dyskinesia (Karteneger and Young syndrom)

Triggers for non-allergic

rhinitis (NAR) II. Systemic inflammatory diseases (Sjögren’s syndrome, SLE, RA,

Churg-Strauss syndrome)

Immune deficiency (antibody deficiency)

Malignancy (lymphoma, melanoma, squamous cell carcinoma)

Granulomatous diseases (sarcoidosis, granulomatosis with polyangiitis)

Structural abnormalities (septal deviation)

Local allergic rhinitis – allergens as for AR, skin test negative

Occupational (allergic, non allergic, can induce asthma, HMW protein agents – latex, flour, animals, LMW agents –irritants - chlorine, ammonia, immune sensitization – di-isocyanates, glutaraldehyd)

Idiopathic (unknown cause – diagnosis of exclusion)

Diagnosis/differential

diagnosis

Rhinitis (BSACI guideline 2017, Scadding et al.)

Inflammation of the nasal mucosa and

submucosa characterized by the

undermentioned symptomps :

– nasal secretion

– sneezing

– nasal blockage or congestion

– itching in the nose

Involvement of conjunctivae →

rhinoconjunctivitis

Involvement of sinus linings → rhinosinusitis

History

➢ Family

➢ Social (environment, occupation, pets, schooling, home)

➢ Symptoms: period, frequency, severity, intensity, duration

➢ Allergic disease in the past, i.e. in childhood

➢ Drugs

➢ alpha- and beta-blockers,

➢ anti-hypertensives,

➢ aspirin and other NSAID

➢ oral contraceptives

➢ Topical sympathomimetics

Allergic rhinitis - History

Family

Social (pets, occupation, schooling)

Drugs

alpha- and beta-blockers,

anti-hypertensives,

aspirin and other NSAID

oral contraceptives

Topical sympathomimetics

History

What kind of nasal/ respiratory symptoms has the patient?

Has he any symptom characteristic for allergic

rhinitis (RA)?

➢ Watery nasal discharge

➢ Sneezing attacks

➢ Itching (eyes, nose, throat, ears)

➢ Watery eyes

➢ Blocked nose

➢ Caughing

Allergic rhinitis questionnaire to

recognize AR

Symtoms on only one side of your nose Yes No

Thick green or yellow discharge from your nose Yes No

Postnasal drip with thick mucus and/or runny nose Yes No

Facial pain Yes No

Recurrent nose bleeds Yes No

Loss of smell Yes No

Do you have any of the following symptoms?

Allergic rhinitis questionnaire to

recognize AR

Watery runny nose Yes No

Sneezing, escpecially violent and in bouts Yes No

Nasal obstruction Yes No

Nasal itching Yes No

Conjunctivitis (red, itchy eyes) Yes No

Do you have any of the following symptoms for at least

one hour on most days (or on most days during the

season if your symptoms are seasonal)?

➢ Nasal symptoms only on one side

➢ Nasal or postnasal purulent discharge

➢ Facial pain, headache

➢ Loss of smell

➢ Nasal bleeding

➢ Facial- and periorbital swelling

➢ Fever, bad general condition

Alarm symptomps

Examination by a specialist is

required

https://www.merckmanuals.com/en-ca/professional/eye-

disorders/conjunctival-and-scleral-disorders/allergic-conjunctivitis

https://webeye.ophth.uiowa.edu/eyeforum/cases/103-Pediatric-

Orbital-Cellulitis.htm

Nasal crusting

Severe crusting especially high inside the nose –

unusual, requires further investigation

Consider: chronic rhinosinusitis, nose picking,

granulomatous polyangiitis, sarcoidosis or other

vasculitis, cocain abuse, ozaena, non-invasive ventilation. Topical steroids rarely cause crusting

Lower respiratory tract

infection

Coughing, wheezing, shortness of breath – can

occur with rhinitis since bronchial hyperreactivity

(can be induced by upper airway inflammation)

Disorder of the upper and lower respiratory tract

often coexist – 80% of people with asthma have

rhinitis – COMMON AIRWAY HYPOTHESIS

Assess possibility of asthma

➢ Have you had any attack or recurrent attacks of

wheezing?

➢ Do you have a troublesome cough, especially at

night?

➢ Do you cough or wheeze after excercise?

➢ Does your chest feel tight?

Examination

Visual assessment (allergic salute, chronic mouth

breathing, allergic shiners, assessment of nasal

airflow, depressed nasal bridge – post surgical?

Cocain abuse? Granulomatous polyangiitis?,

widened bridge – polyps?, purple nasal tip due to

sarcoidosis

Anterior rhinoscopy (structure, mucosa, secretion)

Nasal endoscopy (posterior rhinoscopy)

Allergen specific IgE (SPTs, serum immunoassay)

Lab tests

Allergic salute

Allergic mug

Dennie-Morgan’s infraorbital lines

Symptoms

„Adenoid face” https://radiopaedia.org/articles/adenoid-facies-2

underdeveloped thin nostrils

short upper lip

prominent upper teeth

crowded teeth

narrow upper alveolus

high-arched palate

hypoplastic maxilla

Recurrent upper respiratory tract allergies:

•Dennie's lines: horizontal creases under

the lower eyelids

•a nasal pleat: the horizontal crease just

above the tip of the nose produced by

the recurrent upward wiping of nasal

secretions

•allergic shiners: bilateral shadows under

the eyes produced by chronic venous

congestion

Georges Biard, CC BY-SA 3.0,

https://commons.wikimedia.org/w/index.php?curid=

31432974

Laboratory investigations

Full blood count, differential white blood cell count, CRP, immunoglobulin profile,

microbiological examination of sputum and sinus

swabs in chronic infection

Thyroid function tests

Nasal secretion – Beta-2 transferrin for CFS

identification

Urine toxicology (cocain abuse susp.)

Other investigations

Olfactory tests

Cytology

Exhaled nitric oxid (high in eosinophilic lower

respiratory truct inflammation, asthma)

Nasal nitric oxid (low in cystic fibrosis, primer ciliar

dyskinesia and sinus obstruction)

Radiology (CT scan)

Nasal challenge

Objective measures of nasal airways (allergen,

aspirin challenges, before septal surgery and

turbinate reduction)

(Tests for asthma)

Seasonal Allergic Rhinitis

Three main symptomps (triad)

– Clear, watery nasal discharge

– Sneezing attacks

– Nasal obstruction

Tiredness, headache, inability to work

Conjunctivitis, itching in the throat

Bronchial asthma

Causes

– Trees (hazelnut, alder, birch tree, ash tree – from the beginning of February till the end of March)

– Herbs meadow-grass, ray-grass, rye, corn, grains –from the end of April till July

– Weeds - ragweed, wormwood, mugwort, nettle –from August till October

– Fungi - Alternaria, Cladosporium – from July till October

Hazelnut

Alder

Birch tree

Ragweed

Mugwort

Perennial Allergic Rhinitis

Independent from the season, persistent symptomps

Nasal obstruction is dominant

Eye symptomps very rarely

It can associate with pollinosis

Causes– House dust mites (Dermatophagoides pteronyssinus,

Dermatophagoides farinae

– Animal hair, epithelial scales, humours (dog, cat, rabbit)

– Fungal spores (Aspergillus, Mucor, Penicillium)

Pollen catch

Pollen calendar

March April May June July August September

Hazelnut

Cottonwood

Willow

White birch

Hornbeam

Birch tree

Oak

Linden

Grasses

Rye

Lanceloar rip grass

Pigweed

Nettle

Mugwort

Ragweed

Epidemiology of Allergic

Rhinitis I.

The incidence and prevalence of AR

is increasing continously all over the

world

20% of the population is affected

In Hungary some 2 million people

suffer from AR

Epidemiology of Allergic

Rhinitis II.

Disease of schoolchildren and young adults

Genetic disposition, atopic disease in the

family

Date of birth

Social conditions

More frequent in townspeople

Environmental factors, air pollution

Changing in the flora

The specific IgE is detected in the

skin

Patch tests

Prick tests

Intracutan tests

PRICK test

Prick teszt

The Prick-test must not be

performed during the following

conditions: During heavy symptomps

Skin diseases (eczema, psoriasis)

Infectious diseases with fever

In acute diseases, heavy asthmatic state

Under the effect of certain drugs (antihistamins,

steroids – local or systematic, antidepressive or

tranquillazer drugs)

Determination of Serum

Specific IgE

radioisotope

fluorescent

enzyme

RAST: radio-allergo-sorbent test

ELISA: enzyme-linked immunosorbent assay

Advantages of RAST and

ELISA:

safe

precise

does not depend on

- skin reaction

- drugs

Therapy of AR

Allergen avoidance (causal treatment)

Pharmacotherapy (symptomatic treatment)

Immunotherapy (specific desensitization -

causal)

Allergen avoidance

Change of climate

Change of occupation

Elimination of mould

Removal of pets, domestic animals

Pharmacotherapy

(symptomatic)

Antihistamines

Corticosteroids (local, systemic)

Leukotrien receptor antagonists

Chromoglycates (local or systemic) – inhibit the

liberation of H substances from mast cells (histamin,

serotonin)

Decongestants – temporarily!

Anticholinergs

Antihistamins I.2. generation, peroral

Loratadine Desloratadin

Cetirizin Levocetirizin

(Terfenadine) Fexofenadin

Rupatadine

Bilastin

Ebastine, Mizolastine

Local

➢ Azelastin (nasal spray, also in combination, eye drops)

➢ Emedastin difuramate (eye drops)

➢ Olopatadine (eye drops, nasal spray)

➢ Antazolin (eye drops)

➢ Levocabastinum (eye drops)

Antihistamins II.

➢ Non sedative

➢ Strong and selective periferial H1R antagonism

➢ Quick beginning of action

➢ Long halflife in the serum (long action, 24 hours)

➢ Wide therapeutic range

➢ Antiallergic and antiinflammatory effect

➢ No cardial side effect

➢ For mild or moderate symptoms of children and adults

Desloratadine Placebo

Note: Illustration represents result for a single patient.Courtesy of F. Horak, 2002.

Effect of desloratadine on

nasal obstruction

Summary of „side effects” of

desloratadine

Non sedative

No elongation in QT interval

Can be taken idependently of meal

Available in tablet and syrup forms as well

Does not amplify the effect of alcohol

No interaction with other drugs

Can be given from 1 year of age

Local cortikosteroids I.

➢ Mometason furoat

➢ Budesonid

➢ Fluticason furoat

➢ Fluticason proprionat

➢ Ciclenosid

➢ They differ in receptor affinity and in

pharmacokinetic features

➢ They are very similar in effectivity and safety

Local cortikosteroids II.

➢ They are the most effective drugs in AR

➢ They decrease all nasal symptoms

➢ They are effective in hours

➢ High concentration on receptors

➢ Very little side effects (mucosal dryness, crusting)

➢ No systemic side effects even in maximaldoses (max. 400ug/nap) (i.e. bonemetabolism, glaucoma, cataracta)

➢ In moderate or severe symptoms of adultsand children (from determined years of age)

Mometazon furoat nasal spray

Characteristics

➢ Significant receptor

affinity

➢ High effectivity

➢ Rapid beginning of its

action

➢ Well tolerated

®

Mometason furoat rapidly and effectively

reduces the nasal symptomps of AR

A nazális tünetek csökkenése Nasonex hatására

SAR-ben (n=196 *p<0,001)

0

0,5

1

1,5

2

2,5

3

Orrfolyás Orrdugulás Viszketés Tüsszentés

Tüneti

ponts

zám

1. nap 3. nap 7. nap 14. nap

Magyar és mtsai. A glükokortikoid mometazon furoát orrspray formában való adásának hatása szezonális

allergiás rhinitisben. Orvosi Hetilap 2000,141 (25), 1407-1411.

*

**

** *

**

*

**

*

Nasonex rapidly and effectively reduces

the non-nasal symptomps of AR

A nem nazális tünetek csökkenése Nasonex hatására

SAR-ben (n=196 *p<0,001)

0

0,5

1

1,5

2

2,5

Könnyezés

Szemviszketés/égés

SzájpadviszketésFülviszketés

Tü

ne

ti p

on

tszá

m

1. nap 3. nap 7. nap 14. nap

Magyar és mtsai. A glükokortikoid mometazon furoát orrspray formában való adásának hatása szezonális

allergiás rhinitisben. Orvosi Hetilap 2000,141 (25), 1407-1411.

*

*

**

*

** *

* **

* *

Nasonex does not cause atrophic

changes in the nasal mucosa

(moreover regenerates it)

A B

Before MFNS treatment After 12 months MFNS treatment

Minshall E, et al. Otolaryngol Head Neck Surg. 1998;118(5):648

Systemic corticosteroids

Short time (7-21 days), per oral administartion, max. 1mg/kg/day

Depot steroid or intranasal steroid injection MUST BE avoided any time (uncertain absorption, severe side effects)

Specific contraindication: childhood, pregnancy

Intranasal chromons

Dinatrium-chromoglicate

Nedocromil-sodium

Local antiinflammatory-antiallergic products without systemic side effects

They are safe to use for children and during pregnancy, in mild nasal or eye symptoms

Decongestant products

Local

Local nasal vasocontrictor products with

different mechanisms of action

Alpha-1 agonists: ephedrin, pseudoephedrin,

phenilephrin

Alpha-2 agonists: imidazol derivates: oxi- and

xylometazolin

In moderate or severe symptoms temporary

additional therapy, for 7-10 days max.

ADDICTIVE! – rhinitis medicamentosa

Combinations of

antihistamin and oral

decongesstant

➢ They improve nasal breathing

➢ Systemic sympathomymetic effect – must be

taken into consideration (HT?)

➢ Less addictive than local products, but less

effective in nasal symptoms (nasal blockage)

Leukotrien receptor

antagonistsMontelukast, Zafirlukast

➢ LT mediators take part in developing all nasal symptoms

➢ 1 molecule of LT has 5000x higher nasal costipation potential than the histamin has.

➢ LT antagonists decrease the nasal constipation and runny nose.

➢ They are effective in asthma, AR, ASA

Placebo < LTRA < AH < INCS

Specific immunotherapy

Indications:

Pharmacotherapy is insufficient

Pharmacotherapy has side effects

Seasonal allergic rhinitis – for two seasons at

least

Perennial allergic rhinitis – at least half a year

Condition:

Correlation of positive skin test/serum specific

IgE elevation and patient’s symptoms

Good complience!!!

Specific immunotherapy

Causal treatment

Decreases the allergic inflammation

Effective in every symptom of atopic disease

The quality of life can be improved

SIT can result in asymptomatic disease for 10-15 years

The dose of symptomatic treatment can be

decreased

Developing asthma can be prevented

Allergen spreading can be prevented

TH-2

TH-1

IL-4

IFN-γ

IgE

IgG

LPRSITAg

+

-

Effect of Specific ImmuntherapyThe amount of allergen specific blocking IgG antibodies

increases

The Th2 type immunoreaction turns into Th1 type

Non specific immunotherapy

(biologic therapy)

Monoclonal anti IgE antibodies

Omalizumab

Makes complexes with the free IgE

Decresases the free IgE level

Blocks the IgE interactions

Decreases all the nasal symptoms

It is the 5. step in asthma therapeutic protocol

Allergen cross-binding

Effect of non-specific anti-

IgE (omalizumab)

Differential Diagnosis

Other types of rhinitis

Foreign bodies

Inflammation of the paranasal sinuses

(acute, chronic)

Nasal polyps

Granulomas

Tumors

Liquor fistula

Symptomps of acute

sinusitis

Allergic rhinitis questionnaire!

Pain, headache (face, forehead,

temporal region, top of the head)

Pain increasing during tilting ahead

Nasal obstruction

Purulent nasal discharge

Hyposmia/anosmia/cacosmia

General symptomps: Fever, weakness

Complications

Periorbital oedema, orbital cellulitis (eye

movement is painful and inhibited)

Orbital abscess

Zygomaticitis

Periostitis, osteomyelitis (frontal sinusitis)

Subperiosteal abscess

Thrombosis of cavernal sinus

Meningitis (neurological symptomps

appear)

Epidural, subdural abscess, brain abscess

Liquor-fistula

Structural and mechanic

disturbances preventing

normal nasal function

➢ Septal deviation

➢ Hypertrophy of nasal turbinates, bullous

conchae

➢ Enlarged adenoids

➢ Anatomical variations of osteomeatal unit

➢ Foreign body

➢ Choanal atresia

Septal deviation

Most frequent cause of disturbed nasal breathing in adults

Symptoms

Nasal blockage

Frequent and lond-continued rhinitis

Recurrents sinusitis

Disturbed tubal function, recurent otitis

Headache

Hyposmia

Recurrent pharyngeal or laryngeal inflammations because of mouth breathing

Anatomy of nasal septum

https://anatomy

qa.com/nasal-

cavity-septum-

lateral-wall/

Blood supply of the nasal septum

http://medipicz.blogspot.

com/2011/01/blood-

supply-of-nasal-

septum.html

Innervation of the nasal

septum

https://teachmeanatomy.

info/head/organs/the-

nose/nasal-cavity/

Nasal bleeding

➢ Causes – local, systemic

➢ Location!

➢ Anterior, posterior

➢ Chemical or electrocoagulation

➢ Chemical: TCA or AgNO3

➢ Anterior nasal packing

➢ Posterior nasal packing (Foley-catheter or

Bellocq’s packing)

https://www.slide

share.net/avipatil

30/epistaxis-

80025991

https://accesse

mergencymedici

ne.mhmedical.c

om/

https://emedicine.meds

cape.com/article/80545-

overview#a2