DISEASES OF THE NOSE ALLERGIC RHINITIS Chronic or recurrent Ig-E mediated inflammation of the nasal mucosa With symptoms

ms of rhinorrhea, sneezing, nasal itching, nasal congestion, PND and occly, an impaired sense of smell and taste TYPE I IMMEDIATE HYPERSENSITIVITY REACTION (Gell and Coombs classification) Can be classified as intermittent or persistent (formerly: seasonal and perennial) and mild, moderate, severe Intermittent AR Symptoms occurring less than 4 days/week or less than 4 weeks MILD AR MODERATE AR SEVERE AR Abnormal sleep, impairment of daily activities, problems caused at work or school Persistent AR Occurring more than 4 days/week for more than 4 weeks Normal sleep, normal daily activities

Physical examination: - allergic salute - facial grimacing - allergic facies: allergic crease & allergic shiners Anterior rhinoscopy include: - pale - blue/grey - dull red boggy turbinates - watery or mucoid minimal to profuse nasal discharge - mucus threads Ant. Rhinos excludes other conditions like: - nasal polyposis - infection - anatomic abnormalities (septal deviation) TREATMENT: - avoidance - pharmacotherapy - immunotherapy Pharmacologic treatment: - oral and topical antihistamines (Levo) & decongestants - anticholinergics (Ipratropium Bromide) - oral and topical steroids - antileukotrienes - mast cell stabilizers (Cromolyn Sodium) - nasal saline douche - antibiotics - poor control with simple drugs - symptoms spanning more than one season - severe symptoms that interfere with the patients work and lifestyle - allergens not readily available

Prevalence: - children and young adults - 10-30% of adults and 40% of children suffer this condition Rhinitis may appear simple disorder but it can lead to more serious problems if overlooked and left untreated. Sequelae of rhinitis: - sinusitis - otitis media - tonsillopharyngitis - laryngitis - asthma UNIFIED AIRWAYS OR ONE AIRWAY, ONE DISEASE Rhinitis and asthma frequently co exist; whole airway may suffer different manifestations of the same disease DIAGNOSIS: Should be strongly considered in the presence of the ff medical history: - nasal itchiness - sneezing - rhinorrhea - nasal congestion/obstruction - associated itching and watering or reddening of eyes - triggered by exposure to particulate antigens GOLD STANDARD: ALLERGY SKIN TEST

Controllers: Adjunctive Medication

For immunotherapy:

Principles if immunotherapy: - administration of increasing doses of antigen by injection - result is the eventual lowering of allergen specific IgE

 NON-ALLERGIC RHINITIS Symptoms similar to AR, except that there is no triggering allergen - Allergy skin tests are not positive - Not immunoglobulin E mediated - There are a number of various etiologies: Certain medications: nasal decongestant sprays antihypertensives cocaine birth control pills Other examples of various causes: Hormones Hypothyroidism Emotions Temperature changes Inhaled irritants such as gases, fumes, chemicals and aerosols Gustatory stimuli such as hot or spicy foods/drinks

chronic rhinosinusitis widening of the nasal dorsum area

MANAGEMENT - Nasal steroids first line therapy to most patients with NP for 4-6 wks - Combi of topica and short term systemic steroid therapy can help, avoiding surgery - Antibiotic, mucolytic, decongestants m/b given adjunctively - Endoscopic sinus surgery INFECTIONS ACUTE BATERIAL RHINOSINUSITIS Rhinosinusitis: group of disorders generally characterized by inflammation of the mucosa of the nose and PNS Sinusitis is preceded by rhinitis and rarely occurs without it, Rhinosinusitis An inflammatory condition involving the lining of the nasal cavity and PNS which lasts up to 4 weeks or 28 days Diagnosis: - symptoms of URTI that have not improved after 10 days or worsen after 5 to 7 days Most common Bacterial pathogens involved: - Streptococcus pneumonia - Haemophilus infleunzae - Moraxella catarrhalis Others: - anaerobes - Staph aureus Predisposing factors: - Viral URTI - Allergic rhinitis - Non-allergic rhinitis - Nasal polyps - Vasomotor rhinitis - Trauma - Dental infections - Immunocompromised state Physical examination: Inspection Certain facial features may reveal signs of underlying AR or sinusitis Tenderness Congested turbinates, purulent discharge, PND Predisposing nasal polyps, PND

TREATMENT: - Sleeping with head elevated - Regular exercise - Avoidance of inhaled irritants - Oral decongestants - Steroid nasal sprays - Anticholinergic sprays - Surgical management of anatomic causes NASAL POLYPOSIS Benign inflammatory disorder of the nasal and sinus mucosa Most common mass lesion of the nasal cavity Outpouching of the mucosa covering the ethmoid or maxillary sinuses Commonly associated with allergy Round, soft, moist, grape-like, gelatinous or fleshy, pedicled masses Amber-colored or have a peeled-grape appearance but may become reddened or hemorrhagic from local irritation or secondary infection Sizes range filling the nasal cavity, sinuses, and extending into the oropharynx through the choanae

Risk factors: - chronic infection - alelrgies - trauma - metabolic disease - aspirin intolerance SSX unilateral or bilateral nasal obstruction mouth breathing halitosis anosmia

Palpation of maxillary and frontal/ethmoid sinuses Anterior and posterior rhinoscopy Nasal endoscopy

Complications: - periorbital edema - orbital cellulitis Treatment: - Antibiotics - Intranasal steroids - Oral and topical decongestants - Adjunctive treatment with nasal saline spray - Supportive treatment with mucolytics CHRONIC BACTERIAL RHINOSINUSITIS M/C predisposing factor is an untreated or a poorly treated acute sinusitis usually of more than 3 months duration Other: trauma, structural abnormalities of the nose, allergy and presence of nasal polyps or other nasal masses Present with: - chronic nasal obstruction - chronic purulent foul smelling nasal and postnasal discharge - symptoms less severe than acute sinusitis BUT may be presenting symptoms of a more serious underlying disorder like a neoplasm.

Most common - Coagulase negative Staph sp (51%) - Staph aureus (20%) - Strep pneumonia (4%) - Anaerobes (3%) MANGEMENT: - medical therapy of antibiotics: 3-4 weeks - decongestant or mucolytics - saline nasal douche - no response to adequate medical therapy - endoscopic sinus surgery if indicated EPISTAXIS