Allergic rhinitis is an IgE-mediated type 1 hypersensitivity reaction in the mucous membranes of the nasal airways.
The disease is very common, affecting approximately 30% of the population.
It can be seasonal or perennial .
Inhalants : They may be seasonal(Pollens from grasses, flowers and trees ) or perennial (house dust ; Epithelial debris from domestic cats and dogs )
Food and drugs: include various types of foods, but especially wheat and dairy products and drugs, such as aspirin, iodine and antibiotics,
profuse watery nasal discharge
itching and watering of the eyes
In the acute stage: pale edematous mucosa with excessive thin watery mucoid secretion is typical.
In the chronic stage: the mucosa is swollen, but its colour is deeper red or even slightly blue, depending on the degree of venous congestion.
a precise history ;
oedema and vasodilatation of the mucosa.
eosinophils in the nasal secretion
blood tests : allergen-specific IgE in the serum.
A voidance of the allergen
use of drugs
A voidance of the allergen
The use of drugs
1.antihistamines are the best treatment for symptomatic relief, but the classic antihistamines are often soporific .
2. Steroids :injection;or oral medication; the local inhalers and sprays
3.sympathomimetic and vasoconstrictor drugs (in the form of drops and sprays)
4. mast cell stabilizer(in the form of inhalers and sprays): Sodium cromoglycate (Rynacrom), for example, prevents the type I hypersensitivity reaction being initiated by the arrival of the antigen in the nasal mucosa
Through skin testing, we can identify the exact of the allergen. Weekly injections of increasing dosage of the allergen are given for several months before the expected exposure; this implies starting early in the year in the case of hay pollinosis. Yearly boosting injections are also needed. But its safety in still in question.
It has little part to play in the management of nasal allergy,
Nasal polyps are greyish masses of pedunculated tissue resembling a bunch of grapes. They are generally multiple, nearly always bilateral and produce nasal blockage by their presence. It has a very high recurrence rate.
The cause is essentially unknown. Vasomotor imbalance, saccharide abnormalities , allergy , infections, aspirin hypersensitivity and the change of micro-environment in the middle meatus may all have a role. The cause of nasal polyps is a result of many factors action.
Histologically polyps have a ciliated columnar epithelium, a loose vascular grossly edematous stroma, and are infiltrated with plasma cells and many eosinophils. The epithelium may become squamous if the polyp presents at the nostril.
Symtom: nasal obstruction usually bilateral; mucoid or purulent discharge, pus indicates associated sinus suppuration; olfactory dysfunction; headache;
physical examination : polyps looks soft, bleeds uneasily and are painless. In less advanced cases, smaller polyps may closely resemble blobs of mucus but are not cleared by blowing the nose. In advanced cases , the multiple grey polypoidal masses may totally fill the nose bilaterally, the external nose may become broadened ,the condition is known as “frog face”.
medical treatment : prednisolone, followed by the use of aqueous bec1omethasone, or a similar preparation.
surgical treatment : avulse the polyps ;control the predisposing factors such as sinusitis, deviation of nasal septum.
After surgical treatment, decongestant drops and the use of steroid(in the form of drops and sprays) are very helpful and should be provided long term .
Anatomy of PNS
Nasal sinuses are a group of air containing spaces that surround the nasal cavity.
Characteristic of maxillary sinus
Early in development
Large capacity (13ml-30ml)
Low floor and high ostia
Ostia is situated in postero-lateral wall:lowest
Anterior wall: zygomatic process of maxillary, canine fossa, infraorbital foramen
Posterior wall: pterygopalatine and infratemporal fossa
Medial or nasal wall: maxilla, perpendicular plate of palatine bone, uncinate process of ethmoid bone, lacrimal bone.
maxillary sinus ostia
Roof: floor of orbit
Floor( alveolar process ): below the nasal floor
Anterior ethmoidal sinus (smaller,much)
opens in middle meatus
Posterior ethmoidal sinus (larger,few)
opens in superior meatus
Roof :cribriform plate, orbital plate of frontal bone
Floor :orbital plate of maxilla, palatines bones
Lateral or orbital wall : lamina papyracea, lacrimal bone
Medial or nasal wall: middle and superior turbinate bones
Posterior wall : related to sphenoid sinus
A bony septum between two frontal sinuses.
Opens into anterior part of middle meatus through frontonasal duct.
Anterior wall: diploeic bone
Posterior wall:thin base separates it from anterior cranial fossa
Medial wall:septum between the two sinuses
Floor:superior orbital wall separating it from orbit
Contained in the body of sphnoid bone and are situated in the posterior part of nasal cavity.
Rudimentary at birth but begin to grow after 3 year.
Capacity varies from 0.5ml to 30ml with an average of 7.5ml
Ostium opens into sphenoethmoidal rescess.
Roof: pituitary gland, optic chiasma,frontal lobe and olfactory tract.
Floor: roof of nasopharynx and vidian nerve.
Posterior wall:thick wall separates it from brainstem and basilar artery.
Sinusitis is the inflammatory condition mucous membrane lining of the sinuses .
The maxillary sinus clinically the most commonly affected, followed by the ethmoid, frontal and sphenoid sinuses in that order .
Maxillary sinusitis may occur alone or with involvement of the other sinuses. Infection in the other groups of sinuses rarely occurs without maxillary sinusitis, and indeed the key to their treatment is generally the control of the maxillary sinusitis itself.
the middle meatus play a pivotal role in most diseases of the sinuses, and that most inflammations of the maxillary, frontal and ethmoid sinuses arise from this point
Aetiology and predisposing factors
Acute sinusitis Clinical features
Chronic sinusitis Clinical features
Aetiology of sinusitis
1. Acute infective rhinitis (common cold or influenza) and other nasal diseases.
2. Dental extraction or infection.
3. Swimming and diving.
4. Fractures involving the sinuses.
Chronic inflammation of the sinuses usually follows recurrent acute sinusitis
The mucous membrane passes through all the usual stages of infection ： outpuring of secretion , purulent, ineffective ciliary action , destructive cilia, membrane thicken, granulation , fibrous tissue formation
1.general symptom: fever; fatigue;loss of appetite
much purulent discharge
headache (its position, time ）
loss of sense of smell
Maxillary sinus pain :an aching over the antrum, often with aching in the upper teeth. There may be tenderness on pressing in the region of the canine fossa .
Frontal sinus pain :is known as a ' vacuum frontal headache '. A distinctive symptom of frontal sinus infection is pain above the eye .coming on at morning ,releasing at afternoon. Tapping over the frontal region may be painful.
Ethmoidal headache is usually deep-seated and felt behind the eyes, with tenderness around the region of the inner canthus .
sphenoidal headache is usually described as being felt deeply in the centre of the head .
1.history and symtom:
2.physical examination: reddened and oedematous, especially those of middle turbinate, middle meatus and uncinate process. A trickle of pus will be seen coming from middle meatus or olfactory sulcus.
3.X-ray examination and CT scanning
4.Diagnostic wash-out (proof puncture). Investigation of the maxillary air sinus can be carried out by puncture through the inferior meatus.Wash-out is a diagnostic procedure to demonstrate the contents of the maxillary sinus.
principles: eradicating the pathogenesis; restoring the patency of the ostia of the sinuses, so promoting drainage; controlling the infection and preventing complication .
1. medical treatment: nasal decongestive drops or sprays (Ephedrine 0.5-1.0% in normal saline) and steroid inhalers and sprays are used to promote sinus drainage; antibiotic according to bacteriology report
4.surgical treatment is occasionally needed in the treatment of acute sinusitis. It is reserved for those patients in whom improvement is not occurring and in whom pain or headache continues to be severe.
CHRONIC SINUSITIS Clinical features Diagnosis Treatment:
1 .general symptom: slighter than acute sinusitis
2.local symptom: Chronic infection of the sinus is characterized in most cases by the formation of polyps
much purulent discharge.
headache: slighter than acute sinusitis.
hyposmia because of nasal obstuction
obstruction of vision :
1.history and symtom:
2.physical examination: reddened, oedematous and hypertrophy especially those of middle turbinate, middle meatus and uncinate process; A trickle of pus coming from middle meatus or olfactory sulcus; the formation of polyps.
3. X-ray examination and CT scanning are the best means of imaging the sinuses
4. Diagnostic wash-out (proof puncture).
medical treatment: nasal decongestive drops or sprays (Ephedrine 0.5-1.0% in normal saline) and steroid inhalers and sprays are used to promote sinus drainage; antibiotic according to bacteriology report
method of maxillary sinus wash-out
operation on the nasal cavity and sinus. Endoscopic sinus surgery is operated broadly.