The document describes various types of rhinitis including infective causes like the common cold from viruses like rhinovirus and influenza. It also discusses chronic rhinitis, which can be simple or hypertrophic. Non-infective causes like allergic rhinitis are mentioned. Specific conditions involving the nasal mucosa are outlined such as atrophic rhinitis, ozaena, rhinoscleroma, and nasal cholesteatoma. Causes, symptoms, examinations, and treatments are provided for each condition in the summary.

2.  Inflammation of nasal mucosa
 INFECTIVE
 Acute – common cold (non specific), diptheria
(specific)
 Chronic (non specific) – simple chronic rhinitis,
hypertrophic rhinitis, rhinitis sicca, rhinitis
caseosa, granuloma, sarcoidosis, atrophic rhinitis
 Chronic (specific) – rhinosporodiosis,
rhinoscleroma, TB, leprosy, syphilis, lupus,
fungal
 NON INFECTIVE
 Allergic rhinitis, VMR

3.  Common cold/ Coryza
 Non specific rhinitis
 Any sex any age
 Etiology – rhinovirus (mc), influenza (Severe
form), parainfluenza, adenovirus, ECHO viruses
 Secondary infection – bacterial – streptococci,
pneumococci, H. influenzae, staphylococci
 Predisposing factors – change of climate, cold
and wet climate, low immunity, vitamin and
nutritional deficiency, diabetes, TB, thyroid
disorders
 Transmission – airborne – sneezing , coughing,
talking, contact - kissing

4.  C/F – lasts for 2 – 3 weeks
 Burning sensation of back of nose, nasopharynx,
throat dryness – initial symptom
 Sore throat, fever low grade, bodyache, nasal
stuffiness, rhinorrhoea, sneezing, post nasal
discharge, dry cough
 Influenza – malaise, joint pain, acute respiratory
obstruction – children
 Secondary bacterial infection – mucopurulent
discharge
 Self limiting disease, influenza – high morbidity,
mortality

5.  Complications – pharyngitis, tonsillitis,
lymphadenitis, sinusitis, otitis media, LRTI, GI
infection, laryngitis
 D/D – Allergic rhinitis, VMR, Chronic rhinitis
 Treatment – Bed rest/ Isolation
 Plenty of fluids/ nutritious diet
 Steam inhalation with inhalant capsules
 Decongestants, nasal drops, analgesics, antipyretics,
Vitamin C, antibiotics (if mucopurulent discharge ),
NSAID
 NO ASPIRIN – INCREASED SHEDDING OF VIRUS
 Avoid smoking, alcohol, dirty and crowded places
 Influenza vaccine

6.  Acute specific rhinitis
 Etiology – Corynebacterium diptheriae
 Age – children (carriers)
 C/F – fever, malaise, joint pain, nasal
obstruction, blood stained discharge from nose
 Signs – purulent nasal discharge, foul smelling
 Excoriation of nasal skin
 Greyish white pseudomembrane over nasal floor,
inferior turbinate and septum , loosely attached,
rarely bleeds on removal
 Less toxic, loose membrane – due to mucous
blanket covering the mucosa

7.  D/D – chronic rhinitis, atrophic rhinitis,
influenza, F/B (but U/L)
 Investigations – X Ray PNS, Nasal swab c/s
 Treatment – Isolation
 Anti diptheria serum/ antitoxin
 Pencillin/ Erythromycin
 PRIMARY BACTERIAL RHINITIS - Pneumococci,
streptococci, staphylococci – more common in
children
 RHINITIS WITH EXANTHEMAS – Measles, Rubella,
Chicken pox

8.  Predisposing factors – recurrent attacks of
acute rhinitis, infections in sinuses, pharynx,
chronic irritation due to dust, smoke,
smoking, alcohol, pollution, DNS, Allergic
rhinitis, VMR, hypothyroidism, lack of
exercise, nasal drops overuse
 Types
 Initial stage – chronic simple rhinitis -
reversible
 Advanced stage – chronic hypertrophic
rhinitis - irreversible

9.  CHRONIC SIMPLE RHINITIS
 C/F – Nasal obstruction – worst on lying at
night
 Nasal discharge – mucoid/ mucopurulent
 Post nasal discharge
 Headache – enlarged turbinates touch septum
 Loss of smell
 Signs – secretions present, enlarged
turbinates which pit on pressure and shrink
on applying vasoconstrictor

10.  CHRONIC HYPERTROPHIC RHINITIS
 Advanced stage
 Irreversible mucosal thickening, no pitting on
pressure or no shrinkage of turbinates due to
fibrosis – permanent hypertrophied turbinates
 Persistent severe nasal obstruction at night
 Mouth breathing, hawking, thick voice
 Diffuse hypertrophy mainly of inferior turbinate –
papillary hypertrophy anterior end, mulberry
hypertrophy posterior end (pinkish)

11.  Diagnosis – DNE, X Ray PNS
 Treatment
 Treat the cause
 Antibiotics for acute exacerbations
 Alkaline nasal douching
 For early stage – topical steroids, nasal
decongestants
 For advanced stage – turbinoplasty –
turbinectomy, SMR, diathermy, electrocautery,
LASER
 COMPENSATORY HYPERTROPHY RHINITIS – due to
marked DNS on opposite side

12.  Due to prolonged use of local nasal decongestant
drops – oxymetazoline, xylometazoline – more
than 1 week
 Rebound congestion
 C/F
 Nasal obstruction worst at night, headache due
to blockage ostia
 Bloody red nasal mucosa with granulations,
turbinate hypertrophy
 Treatment – stop nasal drops, oral/systemic
steroids, intranasal steroids, turbinate reduction

13.  Cocaine
 Antihypertensives – ACE inhibitors, beta blockers
 Aspirin, NSAID
 OCP, estrogens
 Gabapentin, methyldopa
 HORMONAL RHINITIS – puberty, menstruation,
pregnancy , sex (honeymoon rhinitis)
 EMOTION INDUCED RHINITIS – stress, anxiety,
tension, grief, emotions
 FOOD INDUCED RHINITIS – hot spicy food,
alcohol
 IRRITATIONAL RHINTIS – dust, smoke, ammonia,
acid fumes, formalin, FB

14.  Atrophic changes affecting the anterior nasal
cavity due to dry and dusty enviroment
 Etiology – farmers, miners, bakers, iron and
goldsmith, alcoholics, nutritional deficiency, post
nasal surgery
 Pathology – respiratory epithelium changes to
squamous, atrophy of seromucinous glands
 C/F – dirty black crusts in anterior 1/3rd of nasal
cavity which on removal can cause ulceration,
nasal bleed, perforation, dry mucosa
 Non foul smelling nasal discharge
 Nasal obstruction, Epistaxis

15.  Treatment
 Change of place of work, lifestyle
 Avoid nose picking, removal of crusts
 Use masks and filters at work
 Lubrication with antibiotic steroid ointment
 25% glucose in glycerine nasal drops – 3
drops TDS for 2-3 months
 Alkaline nasal douching

16.  NASAL CHOLESTEATOMA
 Chronic inflammation of nose due to formation
of granulations and foul smelling offensive
cheesy material in nasal cavity
 Affects nose and PNS (mainly maxillary sinus)
 Etiology – nasal stenosis, adhesions, synechiae,
sinusitis, FB Nose, rhinolith, fungal infections
 Pathology – stagnation of secretions,
accumulated discharge, caseous material
formation, destruction of bony walls, on
microscopy – cholesterol crystals
 Males (mc), any age (3rd and 4th decade mc)

17.  C/F – foul smelling nasal discharge, nasal
obstruction, loss of smell, headache, halitosis,
defective taste
 Signs – cheesy material (white debris) in nasal
cavity, ulceration of nasal mucosa, perforation
and destruction of walls, external deformity
 Investigations
 DNE, CT PNS, X Rays
 Biposy
 Fungal culture
 D/D – Malignancy, Fungal sinusitis

18.  Complications – Intracranial spread, orbital
complications (rare)
 Prognosis - good
 Treatment
 Oral Pencillin thrice a day for 7 days
 Endoscopic removal of cause
 Removal of debris and granulation tissue
 FESS – for restoration of sinus drainage

19.  Chronic inflammatory condition of nose associated with
progressive atrophy of nasal mucosa and turbinate bones
charaacterised by greenish yellow crusts (posterior part),
foul smell (OZAENA)
 Types
 Primary
 Idiopathic
 Endocrinal imbalance – more common in females during
menstrual age (puberty to menopause), aggravated during
menstruation and pregnancy
 Nutritional deficiency – Vitamin A, D, Iron – more in poor
socio economic group, malnourished
 Racial – more in whites and yellow races
 Hereditary – AD
 Climate - Common in tropical countries like India

20.  Secondary infection – Klebsiella ozaenae (perez
bacilli), Diptheroids, Proteus, E coli
 Autoimmune disorder
 Broad nose
 Secondary –
 DNS (U/L)
 TB, syphilis, leprosy, lupus, rhinoscleroma
 Trauma
 Excessive turbinatectomy
 RT
 Chronic rhinosinusitis

21.  Pathology
 Respiratory -> squmaous epithelium – stagnated mucous
– crusts – secondary infection
 Gland atrophy – dryness
 Nerves atrophy – nasal blockage, anosmia (I)
 Periarteritis and endarteritis – diminished blood supply to
mucosa
 Symptoms
 Foul offensive smell – perceived by others
 Anosmia/ hyposmia (merciful)
 B/L Nasal Obstruction – crusts, nerve atrophy
 Greenish yellow crusts – posterior part
 Epistaxis – dislodgement of crusts
 Headache

22.  Signs
 Depression of bridge of nose, broadened nose
 Nasal vestibulitis
 Fetor
 Roomy nasal cavities, turbinate atrophy
 Pale dry mucosa
 Nasopharynx visible on ant rhinoscopy
 Septal perforation
 Complications – atrophic pharyngitis (dry throat,
irritation, atrophic laryngitis (cough, hoarseness),
 Sinusitis with small PNS, middle ear infection
(Eustachian tube obstruction), Maggots in nose
(foul smell, nerve atrophy)

23.  Investigations
 CBC – Hb
 Serum Iron and proteins
 VDRL
 C/S of Nasal swab
 X Ray PNS, CT PNS – hypoplasia, opacity,
thickened walls of maxillary sinus, erosion of
lateral wall
 Chest X Ray – TB
 Nasal smear/biopsy
 D/D – Rhinitis sicca, Syphilis, leprosy,
rhinoscleroma, rhinoloith, FB, Sinusitis (no crusts)
 Prognosis – life long , regress after middle age

24.  Treatment
 Purpose – restore hydration, minimize crusting
 Medical
 Alkaline nasal douching – 56.8 g (2 parts) Sodium
chloride/ salt, 28.4 g (1 part) of Sodium
bicarbonate/baking soda (loosen crusts), 28.4 g (1 part) of
Sodium biborate/washing soda (anti septic) in 280 ml (2
glasses) of warm water irrigation using 20 ml syringe , 2-3
times a day for life long
 25% glucose in glycerine nasal drops/ paint after crust
removal – inhibit proteolytic organisms/ foul smell
 Gauze pack soaked in liquid paraffin – lubricate nose,
loosen crusts
 Kemicetene anti ozaenae solution
 Potassium iodide orally – loosens secretions

25.  Placental extract injections submucosally
 Estrogen/ Estradiol nasal spray – increase vascularity
of nasal mucosa
 Vitamin A, D, E, Iron
 Chloramphenicol nasal drops
 Streptomycin/ Rifampicin
 Surgical
 Young’s operation- both nasal apertures completely
closed for upto 2 years anteriorly
 Modified young’s operation – a 3 mm opening left for
breathing
 Submucosal injection of teflon paste, fat, cartilage
 Section and medial displacement of lateral wall
 Transfer of stenson’s duct to maxillary sinus

26.  Mikulicz disease
 Chronic granulomatous disease characterised by
sclerosis and stenosis of nasal passages can also
effect pharynx, larynx, trachea
 Etiology
 Klebsiella rhinoscleromatis
 Young age – 2nd or 3rd decade
 Females
 Rural areas
 Poor socio economic status, poor nutrition and
hygiene
 North India, East Europe, Middle East, South
America, Africa

27.  Pathogenesis
 Air borne – droplet/ contamination material
 Pathology
 Begins in vestibule of nose, then spread to nose, pharynx,
larynx, trachea, bronchi
 Histopathology
 Mikulicz cells – large foam cells containing bacilli
 Russell bodies- homogenous eosinophilic inclusion bodies
 C/F
 Prodromal/catarrhal stage – nasal mucosa congested, foul
smelling purulent yellowish nasal discharge, sneezing
 Atrophic stage – atrophy but pink mucosa, nasal
obstruction, crusting, headache, epistaxis
 Granulomatous stage – multiple painless rubbery nodule,
non ulcerative, enlarge to form hard pale granulomas

28.  Broadening, thickening and woody feel of
nose (Hebra nose)
 Dyspnoea and stridor (if larynx affected)
 Cicatrization stage
 Fibrosis of external nose (Tapir nose)
 Stenosis of vestibule, nasopharynx, larynx
with adhesions leading to respiratory distress
 Diagnosis – biopsy
 D/D – Atrophic rhinitis (pale mucosa), tertiary
syphilis

29.  Treatment
 Prolonged antibiotics for 4-6 weeks
 Streptomycin – DOC
 Tetracycline
 Amoxycillin, ciprofloxacin, rifampicin,
ampicillin, doxycycline
 Steroids – to reduce fibrosis
 Nasal reconstruction – to establish airway
 RT – not effective

30.  Chronic granulomatous disease affecting the mucous
membrane of nose, nasopharynx manifesting as vascular
polyps
 Can also affect larynx, bronchi, conjuctiva, skin, genitals,
lip and palate and spread to liver and spleen through
blood
 Endemic in coastal areas- india, srilanka, africa, south
america
 Young age – 15 to 40 years M:F 4:1
 Etiology – Rhinosporidium seeberi (aquatic protozoa)/
Kinealyi
 water borne – contaminated water of ponds with animal
dung – cattle, horses, mules
 Air borne – dust mixed with animal dung
 Trauma is a predisposing factor

31.  Pathology
 Sporangia – chitinous cyst containing spores
 Symptoms
 Nasal obstruction U/L
 Epistaxis
 Blood tinged nasal discharge
 Post nasal discharge, hyposmia
 Signs
 U/L leafy pink to purple granular polypoidal mass with
black spots bleeds on touch, pedunculated and friable
attached to nasal septum or lateral wall or nasopharynx
 Avoid probe test
 Biopsy – avoided as bleed, sporangia, can do DNE
 D/D – Nasal growth

32.  Treatment
 Complete excision of mass by diathermy
knife or LASER and cauterization of base
 Endoscopic examination – to identify pedicle
 For larger mass – lateral rhinotomy approach
 Dapsone
 Amphotericin B

33.  Mycobacterium tuberculosis
 Secondary to pulmonary TB
 Affects anterior part of nasal cavity (cartilaginous
septum), ant end of inferior turbinate
 Stages
 Catarrhal – inflammation and congestion
 Nodular – tuberculoma formation
 Ulcerative – septal perforation
 Cicatrization – fibrosis, stenosis, adhesions
 Pathology – acid fast bacilli, epitheloid cells,
langheran giant cells

34.  C/F
 Serosanginous nasal discharge, later stage –
blood stained
 Nasal obstruction
 Pain – due to exposed nerve endings
 Signs – bright nodular thickening of septum
with perforation, adhesions, stenosis
 Investigations – chest x ray, swab c/s, biopsy
, sputum for AFB, biopsy, x ray pns
 Treatment – ATT, surgical reconstruction

35.  Indolent and chronic form of TB
 F:M 2:1
 Early adult age
 Nasal vestibule (mc), skin of nose and face
 Pathology – granuloma formation, fibrosis,
stenosis
 C/F
 Foul smelling nasal discharge, crusting, nasal
obstruction, epistaxis
 Butterfly appearance of nasal skin
 Reddish brown APPLE JELLY NODULES – become
prominent on pressing by a glass slide
 Chronic vestibulitis, septal perforation

36.  Diagnosis – biopsy, c/s, mantoux test, chest
x ray
 Complications – atrophic rhinitis, chronic
dacrocystitis
 Treatment
 ATT
 Reconstructive surgery

37.  Hansen’s disease
 Lepromatous leprosy – nose involved in all cases
 Tropical/subtropical warm/wet climate
 Anterior end of inferior turbinate (mc), septum
 Mycobacterium leprae
 Mode of transmission – prolonged contact, droplet
infection
 C/F
 Catarrhal stage – coryza with bacterial infiltration following
nose picking
 Nodular stage – thickening of affected part, secondary
atrophic rhinitis
 Ulcerative stage – septal perforation, nasal destruction
 Cicatrization stage – fibrosis, stenosis of vestibule
 Saddle nose deformity, columellar retraction, AR

38.  Diagnosis – biopsy
 Treatment
 Dapsone – DOC for 2 months
 Rifampicin, clofazimine, isoniazid
 Surgical reconstruction – after disease free

39.  Treponema Pallidium – spirochete
 ACQUIRED SYPHILIS
 Primary
 CHANCRE – hard, non painful, ulcerated papule most
commonly involves nasal vestibule with enlarged rubbery
LN – rare
 Secondary
 Simple catarrhal rhinitis- skin rash, rhinitis, fever, crusting
 Tertiary – MC
 Gumma – affects bony part of septum (mc), cartilage part
(rare) – swelling seen, ulcerates, scarring
 Septal perforation, palatal perforation, collapse of nasal
bridge, pain, headache worst at night, crusts, bleeding,
offensive nasal discharge , vestibular stenosis

40.  Congenital
 Birth – 1st three months of life
 Snuffles – excoriation of nasal vestibule or skin
of upper lip, features of simple catarrhal rhinitis
 Delayed – puberty – Gumma formation
 Diagnosis – biopsy, VDRL test
 Treatment
 Pencillin – DOC
 Doxycycline, amoxycillin
 Alkaline nasal douching
 Surgical reconstruction when disease cured/free

41.  Granulomatous disease associated with
abnormality of cell mediated and humoral
immunity
 Resembles TB but Non caseating
 Females , 3rd to 5th decade
 Involves almost all organs – nose, lungs, eyes,
salivary glands, tonsils, larynx, skin, ears
 Nasal features – submucosal bluish red nodules
on septum and inferior turbinate, vestibule
 Crusts with nasal obstruction, pain, epistaxis
 Also cause – lymphadenopathy, facial nerve
palsy, sudden deafness

42.  Diagnosis
 Biopsy – non caseating granuloma without myc.
Tuberculosis
 Chest X Ray – diffuse pulmonary infiltrates with
hilar adenopathy
 Bronchopulmonary lavage
 Gallium 67 scan
 Kveim test – positive
 Increased serum and urinary calcium, ESR,
Alkaline phosphatase
 Treatment – topical steroid nasal spray, oral
steroids
 Methotrexate – for refractory cases

43.  Autoimmune condition associated with necrotizing
granulomas and vasculitis of upper and lower
respiratory tract
 1st site affected – nasal cavity
 Also involves kidneys and skin
 M=F, 40-50 years of age
 Very rapid destruction but less severe
 Type 1 – limited to nose
 C/F – ulceration of nose with very large crusts, blood
stained nasal discharge, pain over dorsum of nose,
doesn’t respond to medical treatment
 Can lead to septal perforation, saddle nose
 Associated with weakness, fatigue, night sweats,
arthralgia

44.  Type 2 – with pulmonary symptoms like cough,
hemoptysis, pleuritic pain and cavity in lung
 Type 3 – multi organ involvement
 Eyes – NLD obstruction, proptosis
 Ear – serous otitis media, profound SNHL
 Oropharynx – ulcers, gingival lesions
 Subglottis and trachea - stenosis
 Kidneys – renal failure – cause of death
 Skin
 Prognosis – high chances of recurrence


45.  Diagnosis
 CBC – anaemia, raised ESR, eosinophilia
 Raised RFT
 Urine – red cells, casts and albumin
 X Ray chest – cavity
 Biopsy (from turbinates) – vasculitis, granuloma
 Anti Neutrophilic Cytoplasmic Antibody (ANCA)
 C ANCA (cytoplasmic) – more specific than p
ANCA (perinuclear)
 More sensitive for type 3 disease
 D/D – Sinonasal lymphoma

46.  Treatment
 Immuno suppressive therapy –
 Oral Cyclophosphamide/Azathioprine – cytotoxic
drugs
 Wysolone
 Cotrimoxazole – for early limited type 1
 IV Ig
 Plasma exchange
 Nasal douching for crusts
 Surgery – reconstruction when disease inactive

47.  Malignant granuloma/ midline lymphoma/
stewart’s granuloma/ peripheral T cell neoplasm
 Slow destruction but very severe
 No pulmonary/renal involvement
 No vasculitis
 Autoimmune disease leading to destruction of
midline of face
 Nasal – ulceration of cartilage and bone,
serosanguinous discharge, swelling of nose
 Can involve upper lip, maxillary sinus, oral cavity
 Can be secondary infected by bacteria
 Destruction of nose and PNS

48.  Diagnosis
 Biopsy
 Immunohistochemical studies
 EBV – RNA
 Treatment
 Curative RT
 Surgical debridement
 No role of steroids or cytotoxic drugs

49.  MC – children, mental retarded adults
 Can enter through anterior and posterior
nares
 Accidental – children – ant nares
 Food particles, vomitus while coughing,
regurgitation – post nares, due to
nasopharyngeal isthmus incompetency
 Iatrogenic – sponge, cotton swabs
 Bullets – penetrating FB
 Infection – atrophic rhinitis - maggots

50.  Types
 Living – maggots, leech
 Non living – organic (seeds, grams), inorganic
(paper, button, pebble, rubber, chalk, beads, cell
battery)
 C/F
 h/o FB
 Sneezing, u/l nasal blockage, u/l bleeding
 u/l foul smelling nasal discharge purulent and
may be blood stained
 Pain
 FB seen – mc site is lower part of nasal cavity
 Oedematous mucosa with granulations

51.  Complications
 Emergency – risk of inhalation into lower
respiratory tract
 Rhinolith – long term FB with deposition of
calcium and magnesium salts
 Nasal infection, sinusitis
 Swallowed in oesophagus
 Diagnosis
 X ray PNS, Lateral view Neck – radio opaque
FB
 DNE

52.  Treatment
 FB removal
 Forceps/hook/ ET catheter – pass behind the
FB to pull it
 Children – under GA
 Leech – removed by putting pinch of salt/
hypertonic saline/ oxalic acid on body

53.  Calculus/concretions Nose
 Stone formation in nasal cavity
 Formed around FB, blood clot, secretions – long
standing, thick mucus
 Due to deposition of carbonates and phosphates
of calcium and magnesium
 C/F
 Large hard irregular but friable mass – greyish
brown or greenish black in colour, stony hard on
probing near floor of nasal cavity
 U/L Nasal obstruction
 u/l foul smelling blood stained nasal discharge
 Head ache, epistaxis

54.  Ulceration of mucosa and granulations
 MC – adults
 Diagnosis – X Ray PNS, DNE
 Complications – Oroantral fistula
 Treatment
 Endoscopic removal under GA
 Break the rhinolith into small pieces
 Large rhinolith – lateral rhinotomy

55.  Maggots in nose
 Larvae of house fly – genus chrysomyia
 Tropics – hot and humid climate
 Months of August to November
 Infest nose, nasopharynx, PNS
 Also ear, tracheostoma and neck flaps
 Etiology
 Poor hygiene
 Foul smelling nasal discharge seen in atrophic
rhintis, syphilis, leprosy, wegner’s
granulomatosis, suppurative sinusitis,
malignancy of maxilla
 Immunocompromised patients - DM

56.  Osteoradionecrosis after RT
 Comatosed patients
 Pathogenesis – foul smell attracts flies which lay
eggs, develop into larva in 24 hours (maggots)
 Larva secrete proteolytic enzymes which cause
extensive destruction
 C/F
 Tickling sensation in nose leading to irritation
 Sneezing
 Lacrimation
 Blood stained nasal discharge, foul smelling
 Nasal obstruction
 Crusting and loss of sensation

57.  Headache, fever, toxemia
 Cellulitis of face and nose, diffuse swelling
 Pain over root of nose
 Congestion, oedema and ulceration of nasal
mucosa
 Complications
 Intracranial complications like meningitis
 Septicaemia/ infection
 Destruction of nose and PNS
 Palatal perforation and fistulae, septal
perforation
 Psychological effect

58.  Treatment
 Isolate the patient – with mosquito net to avoid
contact with flies, hospitalization
 Nasal hygiene to prevent recurrence
 Inj TT
 Broad spectrum antibiotics for secondary
infection
 Irritate the maggots and plug the nasal cavity by
using cotton pledgets soaked in liquid paraffin,
chloroform, turpentine oil, ether
 Topical oil, liquid paraffin drops
 Nasal douching
 Forceps removal

59.  Acute IgE mediated immunological (type I hypersensitivity)
response of nasal mucosa to a allergen (antigen)
associated with atleast 2 of the following symptoms –
nasal discharge, nasal blockage, itching and watering from
the nose
 Co exists with asthma in 45% patients, allergic dermatitis
 Allergens
 Inhaled – house dust mite, pollens, moulds, animal
dander, insects
 Food – eggs, sea food, pea nut, milk, wheat
 Drugs – aspirin, hypotensive drugs, iodide
 TYPES
 Seasonal – HAY FEVER – more severe, pollens –
tree/grass/weeds
 Perennial – less severe – dust mite, mould, animal dander

60.  Precipitating factors
 Age – younger age – 15-40 years
 Sex – slightly in males
 Flora – geography, climate, season
 Pollutants and smoke – industrialization, urbanization
 Genetics – family history 50% positive
 Infection – effects on tissue
 Endocrine – increased in pregnancy, menstruation,
menopause
 Psychological
 Work place and living conditions – crowded, dirty, dusty,
damp, less sunlight
 Deficiency of Vitamin C,D,Calcium and IgA
 Trauma

61.  Pathophysiology
 Mucosa already sensitized to a allergen (priming)
 Second exposure -> antibody produced against
antigen -> fixes to mast cells ->degranulation of
mast cells -> release of mediators – IMMEDIATE
RESPONSE – within 5-30 minutes of exposure
 Histamine – sneezing, itching, watery discharge
 PG – nasal blockage, Leukotriens – sinusitis, cold,
polyp
 LATE RESPONSE – after 2-8 hours – eosinophils,
neutrophils, basophils, CD4 T cells – swelling,
thick secretions, nasal congestion

62.  C/F
 10-20 bouts of sneezing at a time
 B/L Nasal obstruction
 Watering and itching of nose
 Watering and itching of eyes
 Itching of palate, skin
 Decreased sensation of smell
 Bronchospasm
 Recurrent cold in perennial AR
 Signs – oedematous nasal mucosa pale blue,
oedematous turbinates pale blue, clear/mucoid
secretions, polypoidal mucosa, thickened
septum, high arched palate

63.  Allergic shiners – dark circles around eyes due to
venous stasis
 Allergic salute – rubs nose with the palm
 Dennie Morgan/Darrier’s line – transverse nasal
crease along middle of nasal dorsum
 Complications
 Recurrent Sinusitis, nasal polyp
 Eyes – conjuctivitis and oedema
 Ears – SOM, ET blockage, retracted TM, CHL
 Pharynx – granular pharyngitis, adenoid facies
 Larynx – vc oedema, hoarseness of voice

64.  Intermittent AR – symptoms less than 4
weeks or less than 4 days per week
 Persistant AR – symptoms more than 4 weeks
or more than 4 days per week
 Diagnosis
 Nasal smear – nasal cytology for eosinophilia
(>10%)
 CBC – TLC/DLC, AEC
 DNE
 X Ray PNS/ CT PNS – sinusitis/polyp

65.  IN VIVO TESTS
 Subcuticular test/ skin prick test/ scratch test
 Preferred, reproducible, more accurate, less false
positive
 Wheal more than 3 mm than negative control
 10 min for histamine, 20 min for allergens
 C/I – extensive dermatitis, dermatographism, on
antihistamines
 Intradermal tests
 High risk of anaphylaxis
 Nasal provocation/ challenge test – small amount
of allergen is sniffed by the patient, applied to
mucosa, through nebulizer – anaphylaxis risk

66.  IN VITRO TESTS
 RAST – Radio Allergo Sorbent Test
 FAST – Fluoro Allergo Sorbent Test
 PRIST – Paper Immuno Allergo Sorbent Test
 Specific IgE
 Total IgE
 No risk of systemic reaction
 No affect of dermatitis, dermatographism,
antihistamines
 Less sensitive
 More false negative results

67.  TREATMENT
 Avoidance of allergen
 Avoid early morning outdoors for pollen
 Keep pets away for animal dander
 Change bedsheets and pillow covers twice a
week, encass the mattresses, vacuum
cleaner/wet mopping, avoid carpets – dust mite
 Repair leaks, damp walls – indoor moulds
 Change of place, work, enviroment, AC closed
rooms, less articles in room, avoid food and
drugs causing allergy

68.  DRUGS
 Antihistamines
 1st gen – CPM – sedation
 2nd gen – cetrizine, loratidine – less sedation
 3rd gen – levocetrizine, fexofenadine – minimal sedation
 Relieves itching, watering and sneezing
 No effect on nasal obstruction
 Azelastin nasal spray – no long term sedation, safe
 Steroids
 Intranasal steroids – DOC , less side effects, can be used
for longer periods – fluticasone, mometasone, budesonide,
beclomethasone – rarely long term lead to fungal infection
and crusting
 Oral steroids – in severe cases, for shorter periods

69.  Mast cell stabilizers
 Sodium chromoglycate nasal drops/spray
 For prophylaxis
 Decongestants
 For nasal obstruction and mucosal oedema
 Oral – phenylephrine, pseudoephedrine
 Topical – xylometazoline, oxymetazoline, ephidrine –
use less than 7 days – Rhinitis medicamentosa
 Anticholinergic drugs
 Ipratropium bromide – topical
 For watery rhinorrhoea, post nasal discharge
 Not for sneezing, nasal obstruction, pruritus

70.  Antileukotriens
 Monteleukast, zafirleukast, pratileukast
 For nasal obstruction, mucous secretions
 Anti IgE antibody
 Omalizumab
 Above age of 12 years
 For AR associated with moderate to severe asthma
 Saline irrigation
 Surgical – septoplasty, turbinate reduction, FESS
 Immunotherapy – SCIT, SLIT – suppresses IgE, raise
IgG, for severe AR not responding to medical and
avoidance therapy, more effective when single or
fewer allergens
 Desensitization – for specific allergens, drug allergy

71.  PROTOCOL
 MILD – oral antihistaminics
 MODERATE/PERSISTANT – INS
 SEVERE – oral antihistaminics and INS
 VERY SEVERE – Oral steroids and
immunotherapy
 If nasal obstructions – topic nasal
decongestants
 For prophylaxis – intra nasal sodium
chromoglycate

72.  Chronic condition of nasal cavity associated with
nasal blockage and rhinorrhoea due to imbalance in
autonomic nervous system with parasympathetic
overactivity and sympathetic underactivity
 Parasympathetic leads to vasodilation and congestion
 Etiology
 Younger age, females, anxiety and depression,
psychological
 Precipitated by dust, fumes, climate changes,
irritants, alcohol, exercise
 Endocrinal/ hormonal causes
 No cause identified - idiopathic

73.  C/F
 Profuse excessive rhinorrhoea, more early morning –
runners
 B/L alternating nasal obstruction, more at night –
blockers
 Post nasal discharge
 Sneezing, itching - rare
 Less oedematous pale mucosa
 Turbinate hypertrophy
 Mulberry inferior turbinate – posterior end
 Complications
 Polyps, sinusitis
 D/D – Allergic rhinitis, infective rhinitis

74.  Diagnosis
 CBC, Nasal smear, Allergy tests
 CT/MRI
 Treatment
 Antihistamines
 Oral decongestants
 Ipratropium bromide nasal spray – for nasal
secretions
 Topical decongestants – not effective
 Exercise – adjuvant role
 Alprazolam – tranquillizer
 Avoid precipitating factors

75.  Surgery
 Turbinate reduction
 Vidian neurectomy – for refractory cases with
excessive rhinorrhoea – section of the ps fibres
 NARES
 Non Allergic Rhinitis with Eosinophilia
 Perennial
 Negative SPT/ IN VITRO TESTS
 Aggravated by weather changes, chemical
irritants
 Watery discharge, itching, sneezing, epiphora
 Nasal smear - eosinophilia