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  1. 1. بسم الله الرحمن الرحيم NASAL INFLAMMATIONS Presented by :- Ass.professor Mohammad shaddad ENT consultant
  2. 2. Furunclosis of the vestibule (boil) <ul><li>Acute infection of the hair follicles by staphylococcus, </li></ul><ul><li>Etiology: </li></ul><ul><li>Nose picking (mechanical trauma). </li></ul><ul><li>Lowered immunity (esp. Diabetics). </li></ul><ul><li>Clinical picture: </li></ul><ul><li>Pain & swelling of the nasal tip. </li></ul><ul><li>The boil is seen inside the vestibule as tender, red nodule which may be fluctuant later & may open & drain. </li></ul><ul><li>Complications: </li></ul><ul><li>Cavernous sinus thrombosis (the boil lies in the dangerous area of the face) mostly after squeezing of the boil. </li></ul><ul><li>Treatment: </li></ul><ul><li>Systemic antibiotic. </li></ul><ul><li>Local antibiotic cream. </li></ul><ul><li>Analgesics. </li></ul><ul><li>Incision with pus accumulation. </li></ul><ul><li>(N.B) in recurrent cases, a blood sugar should be tested. </li></ul>
  3. 3. Acute Non Specific rhinitis Acute coryza (common cold) <ul><li>It is viral infection caused by rhinoviruses of more than 100 type 2ry bacterial infection may occurs. </li></ul><ul><li>Route of infection: </li></ul><ul><ul><li>Droplet infection </li></ul></ul><ul><ul><li>Incubation period 1-3 days . </li></ul></ul><ul><li>Predisposing Fs: </li></ul><ul><li>General: low body resistance. </li></ul><ul><li>Local: </li></ul><ul><ul><li>Nasal disease causing n. obstruction. </li></ul></ul><ul><ul><li>Nasal irritation by smoking & dusty occupation. </li></ul></ul>
  4. 4. <ul><li>Clinical picture: Passes into the following stages: </li></ul><ul><li>ischemic stage: (vasoconstriction) </li></ul><ul><li>Burning sensation & dryness in the nose with sneezing. </li></ul><ul><li>Generalized body aches. </li></ul><ul><li>Hyperaemic stage: (vasodilatation & secretion) </li></ul><ul><li>Nasal obstruction, watery discharge. </li></ul><ul><li>Fever & malaise. </li></ul><ul><li>stage of 2ry infection: (suppurative rhinitis) </li></ul><ul><li>Nasal obstruction & Nasal discharge & Mucoid mucopurulent, purulent. </li></ul><ul><li>Constitutional symptoms with high </li></ul><ul><li>Stage of resolution: (recovery) </li></ul>
  5. 5. Complications: <ul><li>Sinusitis. </li></ul><ul><li>Otitis media. </li></ul><ul><li>Descending infection: laryngitis, bronchitis pneumonia. </li></ul><ul><li>Permanent anosmia. </li></ul><ul><li>Treatment: </li></ul><ul><li>Rest, plenty of warm fluids. </li></ul><ul><li>Analgesics, antipyretics & Vit.C. </li></ul><ul><li>Antibiotics to avoid 2ry bacterial. Infection. </li></ul><ul><li>Oral decongestants, antihistaminic. </li></ul><ul><li>Local nasal drops. </li></ul><ul><li>Steam inhalation. </li></ul><ul><li>Prophylaxis - Avoid predisposing factors. </li></ul><ul><li>- Avoid exposure to persons with common old. </li></ul>
  6. 6. <ul><li>Influenzal rhinitis </li></ul><ul><li>Similar to common cold, but more sever. </li></ul><ul><li>Caused by influenza viruses, types A,B,&C. </li></ul><ul><li>Clinical picture: Similar to common cold with the following differences: </li></ul><ul><li>- Sever headach, fever & malaise. </li></ul><ul><li>- Mild rhinorrhoea & sneezing. </li></ul><ul><li>- 2ry bacterial infection more common. </li></ul><ul><li>- Complication may occur & more sever. </li></ul><ul><li>Treatment: : - As common cold. </li></ul><ul><li>- Vaccination of high risk groups. </li></ul>
  7. 7. CHRONIC INFLAMMATION A. Chronic non-specific rhinitis 1.Chronic hypertrophic rhinitis <ul><li>Hypertrophy of the mucous membrane of the nose especially the turbinates. </li></ul>
  8. 8. <ul><li>Etiology: - Repeated acute rhinitis irreversible changes. </li></ul><ul><li> - Allergic rhinitis. </li></ul><ul><li> - Vasomotor rhinitis. </li></ul><ul><li>Symptoms: nasal obstruction & nasal & postnasal discharge. </li></ul><ul><li>Signs : enlarged inferior turbinate which dose not Shrink with the application of vasoconstrictor (irreversible changes). </li></ul>
  9. 9. Treatment: Control of predisposing. Reduction of size of inferior turbinate: * Sub mucous diathermy (Electro coagulation ) * Partial inferior turbinectomy. * Laser turbinectomy
  10. 10. <ul><li>Atrophic rhinitis </li></ul><ul><li>Definition: </li></ul><ul><li>Chronic nonspecific rhinitis with progressive atrophy of the nasal mucosa(with its vessels & glands) & bony turbinates. </li></ul>
  11. 11. <ul><li>Etiology: </li></ul><ul><li>Primary </li></ul><ul><li>(idiopathic or ozaena): unknown cause, </li></ul><ul><li>Endocrinal imbalance, as it more common in females (estrogen lack). </li></ul><ul><li>Infection, purulent sinusitis and rhinitisin young age . Organism may be klebsilla ozaenae. </li></ul><ul><li>Deficiency of iron & vit A. </li></ul><ul><li>Autoimmune disease. </li></ul><ul><li>Autonomic imbalance sympathetic over activity. </li></ul>
  12. 12. <ul><li>B)Secondary: Distraction of nasal mucosa with subsequent atrophic changes: </li></ul><ul><li>Chronic specific rhinitis (granulomas). </li></ul><ul><li>Postoperative: excessive removal of nasal mucosa as after turbinectomy. </li></ul><ul><li>Poste irraditon. </li></ul>
  13. 13. <ul><li>Symptoms: bilateral & female at age of puberty. </li></ul><ul><li>Nasal discharge: greenish crusty with foetor (2ry anaerobic infection & putrefaction under crusts). </li></ul><ul><li>The patient can not smell his bad odour. </li></ul><ul><li>Nasal obstruction : (although the nose is roomy) caused by crusts & dullness of sensation of air over the atrophic mucous membrane. </li></ul><ul><li>Anosmia, due to atrophy of never endings. </li></ul><ul><li>Epistaxis with separation of crusts. </li></ul>
  14. 14. <ul><li>Signs: </li></ul><ul><li>Roomy nose with pale atrophic mucosa & turbinates. </li></ul><ul><li>Greenish or black crusts with marked foetor. </li></ul>
  15. 15. <ul><li>Treatment: </li></ul><ul><li>1.ttt of the cause in 2ry rhinitis </li></ul><ul><li>2. Medical : </li></ul><ul><li>Alkaline nasal wash to dissolves & helps their separation. </li></ul><ul><li>2.5% glucose in glycerin nasal drops </li></ul><ul><li>potassium iodide to stimulate secretion by glands. </li></ul><ul><li>Iron & Vit. A supplementation. </li></ul><ul><li>3. Surgical : </li></ul><ul><ul><li>TO narrow the wide cavity sub mucosal implantation of grafts e.g. fat or bone. </li></ul></ul><ul><ul><li>Temporary occlusion of one nostril, 6months-2years (young’s operation). </li></ul></ul>
  16. 16. <ul><li>B. Chronic specific rhinitis </li></ul><ul><li>1-Rhinoscleroma </li></ul>Definition Chronic specific granuloma of the upper respiratory tract ,affect nose ,larynx &pharynx.
  17. 17. <ul><li>Organism: </li></ul><ul><li>-Klebsiella rhinoscleromatis (gram-ve Frish bacillus) </li></ul><ul><li>-Infection requires long &intiamate contact. </li></ul><ul><li>Pathology: </li></ul><ul><li>1. Atrophic stage : as atrophic rhinitis. </li></ul><ul><li>2. Nodular active stage: sub mucosa show rich vascularity &cellular infiltration </li></ul><ul><li>. (Mickulicz cells, Russel bodies .lymphocyte & plasma cell). </li></ul><ul><li>3. Fibrotic stage : there are increase in fibroblasts& collagen fibers with decrease in cellularity & vascularity. </li></ul>
  18. 18. <ul><li>Clinical picture : </li></ul><ul><li>Middle ages (15 -35years) females. Passes in to stages may be more than one stage at a time: </li></ul><ul><li>1 . Atrophic stage similar to atrophic rhinitis </li></ul><ul><li>2 . nodular stage </li></ul><ul><li>a. Bilateral sub mucosal hard </li></ul><ul><li>nodules starting at the mucocutaneous junction. </li></ul><ul><li>b. they coalesce to form a large mass filing </li></ul><ul><li>the nasal & cavity & expanding the nose. </li></ul><ul><li>c. May extend to : -Tip of nose & upper lip </li></ul><ul><li>-Lacrimal passages(dacryoscleroma) </li></ul><ul><li>3- Fibrotic stage stenosis of nasal cavity & deformity. </li></ul>
  19. 19. <ul><li>Investigation: </li></ul><ul><li>Biopsy :Characteristic histopathological picture </li></ul><ul><li>A) Mikulicz cells : </li></ul><ul><li>-Macrophages undergo hydropic degeneration. </li></ul><ul><li>-Large vacuolated foam cells containing the bacilli within in the vaccules </li></ul><ul><li>B) Russel bodies ::bright red degenerated plasma cells </li></ul><ul><li>C) In fibrotic (in active )stage , these cell s are replaced by fibroblasts& dense fibrous tissues The vascularity decrease </li></ul><ul><li>11) Electron microscopy : positive in some case –ve with light microscopy </li></ul><ul><li>111)Culture :short capsulated gram -ve diplo-bacilli. </li></ul>
  20. 20. <ul><li>TREATMENT: </li></ul><ul><li>Medial: </li></ul><ul><li>1.Rifampicin (rimactan):600mq/dialy before meals oraly for 8-10 weeks for 3 month </li></ul><ul><li>Side effects :Hepatotoxic & Reddish coloration of urine . </li></ul><ul><li>2.Striptomycin :1gm/dialyIM for 40 days. </li></ul><ul><li>Side effects: Ototoxic, vestibulotoxic & nephrotoxic. </li></ul><ul><li>3.Others: ampicilin ,cephalosporin. </li></ul><ul><li>4.Local :as atrophic rhinitis </li></ul>
  21. 21. <ul><li>SURGICA L </li></ul><ul><li>1 Removal of localized masses. </li></ul><ul><li>2.Fibrotic narrowing can be removed by Co2 laser. </li></ul><ul><li>Plastic reconstruction e limited success. </li></ul>
  22. 22. <ul><li>Syphilis of the nose </li></ul><ul><li>Organism :Treponema palladum </li></ul><ul><li>(spirochatetes). </li></ul><ul><li>Pathology : </li></ul><ul><li>Either a - Acquired :1ry,2ry or 3ry </li></ul><ul><li>b- Congenital :early &late (Transplacental infection) </li></ul>
  23. 23. <ul><li>Like 2ry acquired. </li></ul><ul><li>Like 3ry acquired +hutchinson teeth, keratitis & SNHL </li></ul><ul><ul><li>Like2ry acquired </li></ul></ul><ul><ul><li>Like3ry acquired </li></ul></ul><ul><li>b)Congenital </li></ul><ul><li>Early(1 st 3ms) </li></ul><ul><li>Late </li></ul><ul><li>Nasal discharge(mucoid b1.stained) </li></ul><ul><li>Headache. </li></ul><ul><li>Septal& perforation . </li></ul><ul><li>Saddle nose deformity </li></ul><ul><li>Red rubbery swelling ucler </li></ul><ul><li>Deep </li></ul><ul><li>Punched out edges </li></ul><ul><li>Indurated margin </li></ul><ul><li>Yellowish necrotic floor </li></ul>Tertiary <ul><li>Persistent cata rrhal rhinitis. </li></ul><ul><li>Nasal Vestibulitis </li></ul><ul><li>Generalized 1ymphadenitis </li></ul><ul><li>(epitrochlear ) </li></ul>White, slightly raised plaques painless ulcer ( snail track ulcer) Secondary Raised inducted pain less swelling or painless Ulcer (sharp edges) <ul><li>Hard red papule ulcer </li></ul><ul><li>Enlarged, discrete, rubbery LNs </li></ul><ul><li>a)Acquired </li></ul><ul><li>Primary </li></ul>Clinical picture Pathology Stage
  24. 24. <ul><li>Investigations: </li></ul><ul><li>1-Serologicl tests: </li></ul><ul><ul><li>Waserman reaction (W,R) (VDRL) </li></ul></ul><ul><ul><li>Treponema pallidum immobilization test(TPI) </li></ul></ul><ul><ul><li>unreliable in 1ry syphlis. </li></ul></ul><ul><li>2.Direct smear :motile spirochates </li></ul><ul><li>3.biopsy:endarteritis . </li></ul><ul><li>Complication </li></ul><ul><ul><li>2ry bacterial infection </li></ul></ul><ul><ul><li>2ryatrophic rhinitis </li></ul></ul><ul><ul><li>Perforation bony septum or head palace </li></ul></ul><ul><ul><li>Sadle nose deformity </li></ul></ul><ul><ul><li>Fibrosis& stenosis of nasal cavity </li></ul></ul>
  25. 25. <ul><li>Treatment : </li></ul><ul><li>Penicillin. </li></ul><ul><li>Alkaline nasal wash </li></ul><ul><li>Plastic sugary for septal perforation. </li></ul>
  26. 26. Lupus of the nose(lupus vulgaris) <ul><li>Definition : </li></ul><ul><li>Chronic form of TB . infection that affects skin & mucous membrane . </li></ul><ul><li>Organism: </li></ul><ul><li>Attenuated TB bacilli </li></ul><ul><li>Clinical picture : </li></ul><ul><li>More common in female </li></ul><ul><li>1. Nasal obstruction, discharge,& epistaxis </li></ul><ul><li>2.Apple jelly nodules, buffer fly area of the face, ulcer undermined edges perforation of canfilginous septum. </li></ul>
  27. 27. <ul><li>Investigations; </li></ul><ul><li>1. BIOPSY </li></ul><ul><li>2. Bacteriological ex T.B BACILI. </li></ul><ul><li>Treatment: </li></ul><ul><li>1.ant.TB treatment. </li></ul><ul><li>2.Alkaline nasal wash </li></ul><ul><li>3.Surgical repair of nasal deformity </li></ul>
  28. 28. <ul><li>Leprosy </li></ul><ul><li>Caused by mycobacterium leprae it has three types: </li></ul><ul><li>Tuberculoid leprosy: solitory lesions cause anasthetic cutaneous patches with involvement of one or more related sensory or motor nerves. </li></ul><ul><li>Lepromatous leprosy : diffuse infiltration of the skin , nerves and mucosal surfaces , nasal discharge in these pts contains infectious bacilli root of spread of infection . </li></ul><ul><li>Border line leprosy: skin lesion more numerous. conversion to the above tow types may occur . </li></ul>
  29. 29. <ul><li>Clinical picture ; </li></ul><ul><li>With lepromatous leprosy ; nodular thickening of the nasal mucosa. </li></ul><ul><li>Perforation of the cartilaginous portion of nasal septum perichondritis and periositis which lead to typical nasal deformity </li></ul>
  30. 30. <ul><li>Diagnosis ; </li></ul><ul><li>Of early and intermediate change in the nose , pathognomion of lepromatous leprosy . </li></ul><ul><li>Microscopy of nasal discharge for acid fast bacilli </li></ul><ul><li>Microscopy of scraping of nasal mucosa (anterior end of inferior turbinate)for acid fast bacilli </li></ul><ul><li>Radiology of anterior nasal spine erosion. </li></ul>
  31. 31. <ul><li>Treatment ; </li></ul><ul><ul><li>Dapson </li></ul></ul><ul><ul><li>Rifampicin </li></ul></ul><ul><ul><li>Clofazimine (lamprene) </li></ul></ul><ul><ul><li>local treatment of the nose ; Betnovate in unguentum . </li></ul></ul><ul><li>For years or for life. </li></ul>
  32. 32. Wagener's granulomatosis <ul><li>May affect the upper air way , lung and </li></ul><ul><li>kidney with systemic vasculitis </li></ul><ul><li>Diagnosis ; </li></ul><ul><li>ESR & C- reactive protein </li></ul><ul><li>Anti neutrophil cytoplasmic anti </li></ul><ul><li>Body (ANCA ) </li></ul><ul><li>Histological ; shows vasculitis necrosis </li></ul><ul><li>and granulomatous inflammation </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Cyclophosphomide </li></ul></ul>
  33. 33. Sarcoidosis <ul><li>Chronic systemic disease of un known cause </li></ul><ul><li>Hypothese advanced . </li></ul><ul><li>Clinical picture ; </li></ul><ul><li>Nasal discharge , nasal obstruction ,epistaxis ,facial pain </li></ul>
  34. 34. Sarcoidosis <ul><li>Diagnosis : </li></ul><ul><li>Biopsy </li></ul><ul><li>Kveim skin test </li></ul><ul><li>Radiology of the nasal bone ,chest , </li></ul><ul><li>hand & feet. </li></ul><ul><li>Serum & urinary calcium hypercalcemia . </li></ul><ul><li>Serum level of angiotensin converting </li></ul><ul><li>enzyme </li></ul>
  35. 35. Sarcoidosis <ul><li>Treatment : </li></ul><ul><li>Steroids local or systemic </li></ul><ul><li>Chlorqine Retenal damage . </li></ul><ul><li>Methotrexate. </li></ul><ul><li>Heerfordt,s syndrome transient bilateral facial palsy ,fever ,parotid enlargement and uveal tract disease </li></ul>
  36. 36. Thanks 4 U...

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