Certain people produce an abnormal response to various foreign substances. These
can be proteins, or else haptens such as pollens, which combine with amino-acids
in the body to form proteins. Whereas in non-sensitive subjects the
reticulo-endothelial system reacts to foreign proteins by producing a specific
antibody, susceptible people produce additional reaginic antibodies, associated
with the IgE immunoglobulins, and these allergic subjects show a high IgE level
in the blood. The sensitization process is eventually due to the combination of
the IgE reaginic antibody with cells such as tissue mast cells. On exposure to
the foreign protein the allergen combines with cell-bound reaginic antibodies to
release histamine and similar amines. This leads to local vasodilatation, but
more importantly to an increase in capillary permeability resulting in local
oedema. There is a cellular infiltration of eosinophils and, in long-standing
cases, also of plasma cells. The seromucinous glands of the nasal mucosa are
stimulated to increased activity resulting in the outpouring of thin mucus.
AETIOLOGY. The condition of nasal allergy is hereditary in about half of the
cases - the probability of a child of two atopic parents developing nasal
allergy is about 75%, and with one atopic parent it is 50%. When allergy
manifests itself in the very young patient, it is often associated with asthma
and flexural eczema. Allergic rhinitis is common in young adults, but it is
possible for nasal allergy to appear for the first time in patients in their
sixth decade.
There are many allergens, which can be either inhalants or ingestants. Inhalants
are much the commoner, and include pollens, the house-dust mite, animal danders,
feathers, wool and moulds. Ingestants include fish, especially shellfish,
tomatoes, citrus fruit, milk and drugs such as aspirin.
SYMPTOMS. The complaints are of nasal stuffiness, sneezing and profuse watery
rhinorrhoea. There is associated conjunctival irritation giving rise to
epiphora. These symptoms erupt suddenly when the patient is in contact with the
allergen, and may be preceded by an itchy feeling of the soft palate or nose.
Those patients suffering from pollen allergy, which is the commonest, have
seasonal symptoms which are more marked in hot windy weather. The symptoms of
hay fever will therefore vary from year to year, and indeed from place to place,
sufferers having more marked symptoms in low-lying areas with profuse
vegetation, and fewer symptoms in hilly districts. Patients suffering from
perennial allergies, and allergies to the house-dust mite or animal danders,
have less marked symptoms, with acute exacerbations from time to time.
CLINICAL FEATURES. It is important to take a detailed personal and family
history in an attempt to pin-point the allergen. In those whose symptoms are of
short duration, it may be possible to establish certain altered circumstances of
life which will lead to an understanding of the cause.
Anterior rhinoscopy will show pallor and swelling of the turbinates with an
increase of thin watery secretions, if seen in the acute phase. The conjunctivae
are congested. During remission the nasal mucous membrane should appear normal,
although it is not uncommon to see a small oedematous raised mound on the floor
of the nose, at the level of the anterior end of the inferior turbinate. In
long-standing allergy, nasal polypi may be present.
TREATMENT. The following forms of treatment are available. Avoidance of
allergen. Use of a decongestant antihistamine spray. Antihistamine tablets.
Hyposensitization. Sodium cromoglycate. Steroids. It is essential before
embarking on treatment to assess the degree of the patient's disability. For
example, there is an enormous spectrum of hay fever from, at one end of the
scale, the patient who is really miserable with sneezing, blocked nose and
profuse rhinorrhoea for 5 months of the year, to one who gets mild discomfort on
only one or two warm windy days in the summer. The treatment should be tailored
to the patient's needs.
Vasomotor rhinitis
AETIOLOGY. There are several aetiological factors which are recognized as
causing vasomotor rhinitis. They can be present singly, or several may coexist
in the same patient. The commonest is psychological stress and occurs in
adolescence, in females in their forties and in men in their sixties. The
sufferers tend to be introspective, and to react to conflict with resentment and
feelings of frustration and depression. Change of climate is also important, and
vasomotor rhinitis is frequently encountered in immigrants from warmer
countries. The symptoms are apparent within 3 months of arrival. Endocrine
conditions affect the nose. The most physiological is pregnancy, particularly
during the third trimester. The contraceptive pill, particularly the older
high-oestrogen variety, causes similar symptoms. Myxoedema can also be
implicated. As vasomotor rhinitis is due to relative parasympathetic
over-activity, any sympatholytic drug will cause it. The principal drugs are
b-blockers used in the treatment of hypertension and angina pectoris.
Psychotropic drugs, especially the phenothiazines, are another potent cause.
SYMPTOMS. The complaints are of nasal blockage, watery rhinorrhoea and sneezing.
The symptoms are intermittent and last for several hours at a time. They are
stimulated by change of posture and of temperature, and often trouble the
patient on lying down in bed at night. They are again obvious first thing in the
morning on rising, especially if the ambient temperature is low, when there is
profuse watery rhinorrhoea with sneezing, and constant blowing of the nose does
not relieve the obstruction. The sinus ostia become blocked by the general
mucosal hyperaemia causing pressure changes within the sinuses, and thus dull
vascular-type face-aches arise.
CLINICAL FEATURES. Anterior rhinoscopy reveals enlarged turgid turbinates,
especially the anterior ends of the inferior turbinates, with an increased mucus
production. The septum is of normal colour, which differentiates the clinical
picture from that of an infective condition. Purulent crusts and sticky
secretions are absent. Examination of the pharynx often shows a granular
pharyngitis with irritated or enlarged lateral pharyngeal bands due to the
postnasal catarrh. Vasomotor rhinitis does not lead to polyp formation.
TREATMENT. It is worth repeating that vasomotor rhinitis is a variation of
normal rather than a disease entity. Many of the sufferers who seek medical help
are tense and unhappy, and are seeking reassurance and psychological support. It
is a common problem, and rather than blindly instigating medical or surgical
treatment, it is advisable, as a first step, to emphasize the normality of the
nasal reflexes and their causes, so that the patient can learn to avoid
stimulating them.
Decongestants are the lynchpin of medical treatment. They can be administered
either locally as drops or orally as tablets. Local decongestants must never be
used for more than one month at a time, or they will lead to rhinitis
medicamentosa. If they are not effective in this length of time, continuation is
not warranted. The best decongestants are Naphthizine and Xylometazoline
(Halasoline), which cause the least rebound reactive hyperaemia when their
effect ceases. Systemic decongestants such as suprastine can be used over a
longer period of time. In the rather disturbed patient, amitryptiline is a
useful drug, because, apart from improving the patient's depression, it also has
a fairly strong anticholinergic effect.
Failure of medical treatment requires surgical intervention. In patients whose
principal symptom is obstruction, reduction of the size of the turbinates is
indicated. If the inferior turbinate is only moderately enlarged, this is best
achieved by ultrasound desintegration or submucosal vasotomy. If the enlargement
is gross, a partial inferior turbinectomy is effective.
Chronic hypertrophic rhinitis
Chronic hypertrophic rhinitis is a rather misleading term which suggests that
there is an increase in the size and number of the cells of the nasal mucosa.
However, as it is a generally accepted term, it will be retained. The essential
pathological feature is of fibrosis within the turbinates leading to reduced
venous outflow, and it is caused by repeated nasal infections, chronic sinusitis
and irritation due to air pollutants.
SYMPTOMS. The principal symptom is of nasal obstruction with some impairment of
the sense of smell.
CLINICAL FEATURES. The nasal mucosa is congested. The anterior and posterior
ends of the inferior turbinates, and the anterior end of the middle turbinate,
are particularly affected, and posterior rhinoscopy shows the enlarged posterior
ends as mulberry-like swellings.
TREATMENT. In the established case, medical treatment with decongestant drops or
tablets is of little avail. Reduction of the size of the turbinates by partial
turbinectomy should be carried out. If only a limited portion of the turbinate
is affected, it can be removed locally. Only a very limited portion of the
middle turbinate should ever be removed, lest atrophic rhinitis be produced, the
symptoms of which are more unpleasant than those of the original condition.
Atrophic rhinitis
Atrophic rhinitis is becoming much less common in advanced communities. In its
primary form it is probably therefore a disease associated with malnutrition,
poor living conditions and infection, and can occur in several members of a
family group. It can also, in its secondary form, be the end-result of treated
nasal disease, for example, sarcoidosis, tuberculosis, midline granuloma or
rhinitis caseosa, and can rarely be the aftermath of excessive nasal surgery
such as turbinectomy or an unsuccessful submucous resection.
PATHOLOGY. The atrophic changes in the mucosa are secondary to an endarteritis
and periarteritis which cause a diminished blood supply with atrophy of the
ciliated columnar epithelium and its metaplasia to a cuboidal or stratified
squamous epithelium. A thick viscid secretion is exuded, which dries rapidly to
form crusts. Both nasal cavities are usually affected.
SYMPTOMS. The earliest complaint is a feeling of dryness in the nose. Nasal
crusting causes blockage. Epistaxis is frequent, if small in amount, when the
crusts separate. Headache is common.
CLINICAL FEATURES. Mucosa of the nasal cavity is atrophic and dry. The nasal
cavities contain crusts.
TREATMENT. The variety of medical and surgical treatments advocated for atrophic
rhinitis is an indication of their unproven worth in most instances.
Infection, particularly of the sinuses, should be sought and treated. Twenty
five per cent glucose in glycerin nasal drops or cream on the polymer basis help
to lessen crust formation, and give some symptomatic relief in less severe
cases. When nasal obstruction due to crusting is a prominent feature, nasal
douching is the most satisfactory method of removal and normal saline is the
solution of choice. Surgical treatment aims at narrowing the nasal cavities. The
mucosa of the floor of the nose, the lower lateral wall up to the attachment of
the inferior turbinate and the lower half of the septum can be raised through a
sublabial incision, and Teflon is packed into the space leading to a narrower
nostril of reduced depth, and this is probably the most satisfactory procedure.
Alternatively, the nostrils can be surgically closed anteriorly and after a
period of years when they are re-opened it is found that healthy respiratory
epithelium has regenerated.
Ozaena
These disease is specific type of chronic atrophic rhinitis and is due to
Klebsiella ozaenae.
SYMPTOMS. The most characteristic symptom of ozaena is foetor which may be
noticed at some distance from the patient. Fortunately the sufferer is unaware
of it as complete anosmia is present. Nasal crusting causes blockage.
CLINICAL FEATURES. When the nose is examined the nasal passages are seen to be
wide. The inferior turbinates are flattened and may be difficult to distinguish
upon the lateral walls of the nose. The mucous membrane is usually dark in
color; it may be dry, and may even be shiny in appearance. Crusting is common,
as the atrophy of the mucous membrane makes it impossible for the nasal
secretions to be expelled from the nose in the normal way. The crusts are yellow
as a rule but may be dark and of a greenish colour, and may fill in the nasal
cavities. The bone of the inferior turbinate may share in the atrophic process.
When the crusts are removed the nasal cavities are unduly wide, so that the
posterior wall of the nasopharynx can be seen.
Examination of the nasopharynx may show crusting, and there is usually glazing
of the posterior wall, due to an extension of the atrophic condition. In some
cases this change may be traced down to the laryngeal cavity.
TREATMENT. Treatment is same as in the case of atrophic rhinitis and antibiotics
should be given.
INFLAMMATION OF THE SINUSES
Sinusitis is a very common disease: it is estimated that 5% of the population of
Europe suffer from chronic sinusitis. The maxillary antrum is the most commonly
affected in adults, followed in decreasing order of frequency by the ethmoids,
frontal, and shpenoid sinuses. In children the ethmoid sinuses are most
frequently affected. Infection of several sinuses is described as polysinusitis,
and of all the sinuses pansinusitis, unilateral or bilateral.
Depending of the organism, its virulence, pathophysiologic factors, and
immunologic resistance, sinusitis may take a catarrhal, purulent, hypertrophic
or atrophic form, with mixed forms being common. The pathology within the sinus
also depends on the duration of the disease process. Acute and chronic sinusitis
may be distinguished.
Acute sinusitis
Acute inflammation of the paranasal sinuses is usually due to an extension of an
infection from the nasal cavity. The sinuses may be involved singly or two or
more may become infected. The commonest cause is an acute rhinitis, but it may
also follow dental infection such as apicitis or apical abscess, dental
extraction if an oro-antral fistula develops, injuries to the facial bones, and
operations on the nose. Obstruction to the normal aeration of, or drainage from,
a sinus because of a deviated nasal septum, enlarged adenoids, the presence of a
foreign body in the nose or allergic rhinitis can all predispose to sinus
infection. Acute sinusitis may take a catarrhal or purulent form.
BACTERIOLOGY. While the acute rhinitis which precedes the acute sinusitis is
viral in origin, the sinusitis itself is a bacterial infection which excites the
production of pus. The responsible organisms are pneumococci, streptococci,
staphylococci, Haemophilus influenzae and Escherichia coli. In infection of
dental origin, Bacillus dentalis and B. necrodentalis may also be present.
Anaerobic organisms, such as bacteroides, are sometimes found in the pus from
infected sinuses.
PATHOLOGY. All the paranasal sinuses are essentially bony boxes lined by
respiratory epithelium, which is continuous with the epithelium of the nose
through the ostium of each sinus. The essential change in sinusitis is blockage
of the ostium, and hence stasis of the secretion within the sinus. The latter
becomes infected by bacteria causing an acute inflammatory response within the
mucosa which becomes thickened, and hence the ostium remains closed. There is
leucocytic infiltration of the mucosa, and in virulent infection there can be
ulceration of the lining epithelium. The maxillary sinus is most commonly
affected, because the ostium is high on the medial wall and drainage is not
aided by gravity.
SYMPTOMS. The symptoms vary in severity, and their extent depends upon the
degree to which the ostium is blocked, upon the causal organism and upon the
patient's general health.
There is a feeling of fullness and tension over the sinus or sinuses affected.
In more severe cases there is a vascular-type face-ache which throbs and becomes
more severe when the head is dependent or when venous pressure is raised by
straining. The pain may be excruciating, and associated with lacrimation and
epiphora, and the muscles on that side of the face may go into spasm, indicating
the degree of discomfort.
The site of the pain can indicate which sinus is involved. Maxillary sinusitis
causes pain in the infraorbital region, or in the teeth and gums. Ethmoidal
sinusitis gives pain over the bridge of the nose and between the eyes, and
frontal sinusitis gives pain in the supra-orbital area. This pain of frontal
sinusitis often has a characteristic periodicity, starting in the forenoon,
increasing around midday and decreasing in the afternoon. Sphenoidal sinusitis,
which is rare, can cause occipital, vertical or retro-orbital pain.
The nose is obstructed on one or both sides, and the watery rhinorrhoea
associated with the prodromal coryza or influenza changes to a thicker
mucopurulent secretion, which in severe cases can be almost entirely purulent in
character. The sense of smell is reduced, or there may be an unpleasant smell,
cacosmia. In children there can be excoriation of the vestibule of the nose and
the upper lip. Much of the purulent secretion runs into the nasopharynx and
pharynx, due partly to the action of the cilia, but also because the ostium of
the maxillary sinus, which is most commonly affected, lies posteriorly in the
middle meatus of the nose. There is an associated systemic upset, with malaise,
headache and fever, and the circulating white-cell count is raised.
CLINICAL FEATURES. Anterior rhinoscopy shows signs of an acute inflammatory
response. The inferior and middle turbinates are red and swollen, and the colour
of the mucosa overlying the septum is similar. The degree of swelling of the
turbinates may preclude an adequate view of the middle meatus, but this swelling
can be reduced by the local application of 0,1% adrenaline solution on a pledget
of cotton wool. If the ostia are patent, pus will be seen in the middle meatus,
high up and anteriorly in frontal sinusitis, and lower and more posteriorly if
the anterior ethmoidal cells or the maxillary sinus is affected. If mucopus is
seen running medial to the middle turbinate, this indicates infection in the
posterior ethmoidal or sphenoid sinuses.
Posterior rhinoscopy will show mucopus on the superior surface of the soft
palate, or dried yellow crusts on the roof of the nasopharynx. There is often an
associated granular pharyngitis. There may be flushing and some swelling of the
affected cheek in maxillary sinusitis, while oedema of the eyelids or forehead
suggests infection of the frontal or ethmoidal sinuses. Tenderness over the
inflamed sinus is elicited on pressure.
Radiography of the sinuses is indicated in acute sinusitis. Should there be a
diagnostic problem the standard occipitomental and occipitofrontal views are
usually sufficient, although oblique views of the ethmoids or submentovertical
views for the sphenoid sinus may be required. The acutely inflamed sinus will
appear homogeneously opaque or a fluid level may be present. Bacteriological
analysis of the discharge should be done. CT-scan of the sinuses is indicated.
Chronic sinusitis
Chronic sinusitis usually follows an episode of acute sinusitis. The latter may,
however, be far in the past and forgotten by the patient. The essential
abnormality is intermittent or constant blockage of a sinus ostium resulting in
poor aeration and stasis of secretions leading to infection. One or more of the
paranasal sinuses may be involved. The condition may be unilateral or bilateral.
The maxillary sinuses are the most commonly affected.
PREDISPOSING CAUSES. These can be divided into nasal and dental. Any
pathological process resulting in a decreased airway over a long period of time
will predispose to chronic sinusitis. In children the commonest cause is adenoid
enlargement. In adults a unilateral pansinusitis may be associated with a
deviate nasal septum. This is not necessarily on the convex side of the
deviation, but may be on the contralateral side as compensatory hypertrophy of
the middle turbinate causes poor aeration of the middle meatus, into which most
sinuses drain through their ostia.
Allergic rhinitis, particularly of the perennial type, causes oedema with
narrowing of the ostia. When allergy and chronic sinusitis, particularly of the
ethmoidal labyrinth, coexist, nasal polypi are found. Chronic rhinitis, which
often has a social or occupational aetiology such as excessive smoking or the
inhalation of dust or fumes, is a further predisposing factor.
Chronic maxillary sinusitis may have a dental origin. An apical dental
granulation or abscess, chronic periodontal disease or the presence of an
oro-antral fistula are possible causes. The roots of all the upper teeth, with
the exception of the incisors, can lie in intimate relationship to the floor of
the maxillary sinus. Once chronic infection of dental origin is established in
the maxillary sinus, the infection can spread to neighbouring sinuses leading to
a unilateral pansinusitis.
PATHOLOGY. Chronic sinusitis may take a catarrhal, purulent, hypertrophic,
atrophic and mixed form. In hypertrophic change the depth of the mucosa is
greatly increased, and it can become heaped up into polypoidal folds. The number
of seromucinous glands and goblet cells is increased; there is infiltration of
the perivascular spaces by chronic inflammatory cells, there is fibrosis in the
lamina propria; and the venous channels become tortuous and thick-walled.
In atrophic type the pathological changes are related to the arterioles,
endarteritis obliterans occurs, and there is loss of the pseudostratified
ciliated columnar epithelium over part of the mucosa, with a dense chronic
inflammatory cell infiltrate in the deeper layers.
SYMPTOMS. The symptoms of chronic sinusitis may be divided into nasal symptoms
and those arising elsewhere in the upper respiratory tract.
Nasal discharge is the cardinal symptom of chronic purulent sinusitis. This
discharge is intermittently mucopurulent and most obvious in the nasopharynx as
postnasal catarrh. This is due to the fact that the cilia move the thickened
mucous blanket posteriorly, and also that the maxillary sinus is the most
commonly affected and its ostium lies most posteriorly in the middle meatus of
the nose.
Nasal obstruction is due both to the inflammatory response causing thickening of
the nasal, lining, and to the thick tenacious secretions. The nose still
undergoes vasomotor reflexes, and the stuffiness will be more marked in the
recumbent position and in warm atmospheres.
While pain and fever are well-known symptoms of acute sinusitis, it is rarely a
presenting symptoms of the chronic disease, except in the presence of an acute
exacerbation, of the chronic infection. The pain will, therefore, only last for
a limited period of time, and it is rare to find chronic sinusitis as the cause
of a prolonged face-ache.
There are two alterations to the sense of smell associated with chronic sinus
infection. In patients with marked nasal obstruction there will be short periods
of anosmia due to the poor airflow into the superior meatus of the nose. The
second olfactory symptom is cacosmia, where the patient is aware of the
unpleasant smell of the purulent secretions. This is more common in those whose
chronic sinusitis is secondary to dental disease.
In children excoriation of the nasal vestibule is found, due to the constant
moistness of the nose.
It is important to remember that many patients with chronic sinusitis present
with symptoms from other areas of the respiratory tract. It is a not uncommon
finding in those suffering from chronic granular pharyngitis, chronic
suppurative otitis media and chronic laryngitis. These conditions are maintained
by the long-term, continuing flow of unhealthy purulent secretions passing
backwards and downwards from the sinuses.
CLINICAL FEATURES. On anterior rhinoscopy the nasal mucosa is found to be
inflamed. The mucosa of the nasal septum is also involved. The secretions in the
nose are thick and stringy, and purulent crusts may be present. On occasion,
mucopus can be seen in the middle meatus. Particularly if the ethmoidal sinuses
are involved, there can be a polypoidal change in the anterior end of the middle
turbinate, or nasal polypi may be present.
On posterior rhinoscopy, catarrh, which may be purulent, can be seen. This can
either be fluid and lying on the superior surface of the soft palate, or can be
seen as purulent dry crusts on the roof of the nasopharynx.
On examination of the pharynx, the lymphoid follicles which lie on the posterior
pharyngeal wall, and are barely perceptible in the healthy individual, will be
obvious as discrete nodules, a condition known as granular pharyngitis, or as
continuous bands, known as the lateral pharyngeal bands, and situated behind the
posterior pillars of the fauces.
RADIOGRAPHY. As none of these clinical features are specific, and as they may
not be very obvious on examination, it will be realized that radiography
provides an important aid to diagnosis.
Opacity of a sinus will undoubtedly suggest infection, especially if there is a
difference in one side from the other. A fluid level will also suggest
infection, but is unlikely to be found unless the X-ray is carried out during an
acute exacerbation of the chronic infection. Mucosal thickening, is the
commonest abnormality, on radiography of a patient suspected of having chronic
sinus infection, and it is unfortunately also the least diagnostic. Any
condition causing swelling of the nasal mucosa can also cause swelling of the
sinus mucosa, and it is therefore important to correlate the radiographic
appearances with the clinical appearances of the nose. If the mucosal thickening
on the X-ray is more marked than examination of the nose would lead one to
suspect, or if there is a difference in degree in one side compared with the
other, it is more likely that chronic infection is present.
A swab should be taken to determine the organisms and their sensitivity to
antibiotics. CT-scan of the sinuses is indicated.
TREATMENT OF SINUSITIS
Maxillary sinus
Acute maxillitis
1. Lavage of the sinus.
Two different methods are in routine use: access via the inferior meatus (sharp
puncture) and access via the middle meatus (blunt puncture).
Principle of lavage through the inferior meatus
Local anesthesia of the inferior meatus is induced. A needle of Culycovsky is
placed against the lateral nasal wall beneath the origin of the inferior
turbinate. After pushing the needle through this usually thin part of the
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