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Lecture notes, cheat sheets
ENT diseases. Diseases of the nasal cavity. Chronic rhinitis. Atrophic rhinitis. Vasomotor rhinitis (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) Lecture No. 13. Diseases of the nasal cavity. Chronic rhinitis. atrophic rhinitis. Vasomotor rhinitis 1. Chronic catarrhal rhinitis Chronic catarrhal rhinitis develops as a result of recurrent acute rhinitis. Prolonged congestive hyperemia of the nasal mucosa caused by alcoholism, a chronic disease of the cardiovascular system, kidneys predisposes to the development of chronic rhinitis. In the etiology of the disease, hereditary prerequisites, malformations, violations of normal anatomical relationships that cause difficulty in nasal breathing may be important. Chronic runny nose also develops as a secondary disease in the pathology of the nasopharynx and paranasal sinuses. Clinic The symptoms of chronic catarrhal rhinitis basically correspond to those of acute rhinitis, but are much less intense. The patient complains of discharge from the nose of a mucous or mucopurulent nature. Difficulty in nasal breathing is aggravated (as is discharge from the nose) in the cold. Often there is an alternating congestion of one of the halves of the nose. With rhinoscopy, diffuse hyperemia of the mucous membrane is determined, often with a cyanotic tint. The inferior turbinates are moderately swollen, narrowing the lumen of the common nasal passage. Chronic catarrhal rhinitis may be accompanied by hyposmia. The transition of catarrhal inflammation from the nasal cavity to the mucous membrane of the auditory tube is possible, followed by the development of tubo-otitis. Diagnosis The diagnosis of the disease is established on the basis of complaints, anamnesis, anterior and posterior rhinoscopy. Differential diagnostics To distinguish catarrhal chronic rhinitis from hypertrophic, anemization of the mucous membrane is performed with vasoconstrictor agents. A noticeable reduction in the mucous membrane of the turbinates indicates the absence of true hypertrophy, characteristic of hypertrophic rhinitis. Differential diagnosis between false and true hypertrophy can also be made using a bellied probe. In the case of false hypertrophy, the probe bends the mucous membrane to the bone wall more easily. With true hypertrophy, a compacted tissue is determined, which is hardly amenable to the pressure exerted on it. Treatment It is necessary to eliminate the adverse factors that cause the development of chronic rhinitis. It is useful to stay in a dry warm climate, hydro- and balneotherapy is indicated. Local treatment consists in the use of antibacterial and astringent preparations in the form of a 3-5% solution of protargol (collargol), 0,25 - 0,5% solution of zinc sulfate, 2% salicylic ointment, etc. UHF is prescribed for the area nose, endonasal UVI (quartz tube). The prognosis is usually favorable. 2. Chronic hypertrophic rhinitis The causes of hypertrophic rhinitis are the same as catarrhal. Clinic Hypertrophic rhinitis is characterized by persistent nasal congestion. Complicates nasal breathing and abundant mucous and mucopurulent discharge. Obstruction of the olfactory fissure leads to hyposmia and further anosmia. In the future, as a result of atrophy of the olfactory cells, essential (irreversible) anosmia may occur. The timbre of the voice in patients becomes nasal. As a result of compression of the lymphatic slits by the fibrous tissue, the lymphatic drainage from the cranial cavity is disturbed, which causes a feeling of heaviness in the head, disability and sleep disturbance. Treatment Treatment of hypertrophic rhinitis is predominantly surgical. If there is bone hypertrophy of the turbinates, one of the options for submucosal intervention is performed. With limited hypertrophy of the anterior and posterior ends of the inferior turbinates or their lower edge, these sections are excised (conchotomy). These surgical interventions are usually performed under local anesthesia (such as lubrication of the mucous membrane with 3-10% cocaine solution or 2% dicaine solution with the addition of 2-3 drops of 0,1% adrenaline solution per 1 ml of anesthetic and intracarcinal administration 5 ml of 1-2% solution of novocaine or 0,5% solution of trimecaine). The operation ends with a loop tamponade. The tampons are removed after 2 days. However, given the possibility of significant bleeding after the removal of tampons, especially after cutting off the posterior ends of the inferior turbinates (posterior conchotomy), complete removal of tampons can be performed at a later date. Irrigation of tampons with antibiotic solutions is recommended to prevent infection. 3. Atrophic rhinitis Simple atrophic rhinitis. This form of chronic rhinitis can be primary or secondary. Secondary atrophic rhinitis is a consequence of exposure to various adverse environmental factors. In the development of atrophic rhinitis, various injuries play a role, causing tissue damage and blood supply to the nasal cavity. The process of atrophy can be local and diffuse. Subjective sensations of dryness can be very painful. With anterior rhinoscopy, the posterior wall of the nasopharynx is freely visible. The mucous membrane acquires a dry lacquer sheen and is covered with crusts of dried mucus. When the process captures the olfactory zone, hypo- and anosmia develops. In some cases, patients note an unpleasant odor that is not captured by others. Treatment It is necessary to eliminate or reduce the impact of harmful environmental factors. A course of treatment with ointments and iodine-glycerin is prescribed locally. In the morning and evening, the patient should inject Voyachek's diachilic ointment into the nose on a cotton swab for 10 minutes. 2 times a week, the doctor or the patient himself lubricates the nasal mucosa with a solution of iodine-glycerin. Such treatment is carried out for 2 months and is repeated 3 times a year. It is also recommended to insert cotton swabs into the nose with rosehip or sea buckthorn oil in olive or peach oil in a ratio of 1:3-1:4 or with the addition of an oil solution of vitamin A (no more than 50 IU). Oral intake of vitamin A and a complex of multivitamins with microelements (for example, Vitrum) is also appropriate. Ozen. Ozena is characterized by chronic atrophic fetid rhinitis, characterized by deep atrophy of the entire mucous membrane, as well as the bony walls of the nasal cavity and nasal concha. Ozena is characterized by the release of a thick secret, which dries into fetid crusts. The etiology and pathogenesis of the disease continue to be insufficiently elucidated to date. The infectious nature of ozena is confirmed by the patterns of vegetation of Klebsiella in the human body. This is its constant presence in patients with ozena and its absence in healthy people, as well as in patients with other diseases. In the pathogenesis of ozena, an essential role is played by hereditary-constitutional features that are inherited as a recessive trait, environmental conditions, as well as alimentary and vegetative insufficiency. Clinic Ozena most often develops in people with chameprosopia, i.e., in people with broad faces. The bridge of their nose is usually wide and seems as if pressed down and flattened, and the nasal openings appear to be facing anteriorly and upward. This shape of the nose often resembles the appearance that is observed in some forms of congenital syphilis. The disease usually begins at a young age, women are more often ill. After the onset of menopause, many clinical manifestations of ozena decrease. For patients with ozena, the presence of severe atrophy of the mucous membrane of the nasal cavity, a decrease in the size of the nasal conchas, especially the lower ones, are characteristic. As a result of atrophy of the mucous membrane and turbinates, the nasal cavity becomes wide. With anterior rhinoscopy, not only the posterior wall of the nasopharynx, but also the pharyngeal mouths of the auditory tubes are freely visible. Sometimes the openings of the sphenoid sinus located in the direction of the posterior and upward are visible. Often, during lakes, the entire nasal cavity is filled with crusts to such an extent that neither the mucous membrane nor even the shells themselves can be seen behind them. An extremely unpleasant, fetid odor emanates from the crusts. Actually, of all the objective signs of ozena, the stench should be put in the first place as a constant and most significant objective symptom. Treatment Crusts from the nose are removed by washing the nasal cavity with 2% sodium bicarbonate solution, 1% hydrogen peroxide solution, 0,1% potassium permanganate solution, or saline. For washing, use an Esmarch mug or a special nasal watering can. In order to prevent the washing liquid from getting into the auditory tube and the tympanic cavity, the patient should slightly tilt his head forward and to the side opposite to the washed half of the nose. The mouth opens slightly, and then the washing liquid, pouring in through one half of the nose, pours out through the other. Crusts can also be removed with Gottstein tamponade. Tamponade of both halves of the nose is performed with several gauze turundas or cotton swabs introduced into the nasal cavity with a special narrow spatula. It is better to administer tampons with some ointment (diachylic, alkaline) or with iodine-glycerin for 2-3 hours. When the tampons are removed, fetid crusts go away, and mechanical and medicinal irritation of the nasal mucosa causes an abundant release of liquid mucus. After removing the crusts, the nasal cavity is lubricated with diakhil ointment or iodine-glycerin. In the treatment, antibiotics are used that are active against Klebsiella ozena: streptomycin, monomycin, neomycin, kanamycin, chloramphenicol. In most cases, due to the ineffectiveness of the conservative, they resort to the surgical method of treating ozena. 4. Vasomotor rhinitis (neurovegetative and allergic forms) In the occurrence of the neurovegetative form of vasomotor rhinitis, the main role is given to functional changes in the central and autonomic nervous system, as well as the endocrine system. The development of vasomotor rhinitis is also facilitated by reflex effects, in particular cooling, a sedentary lifestyle, and medications. The allergic form of vasomotor rhinitis occurs when exposed to various allergens, depending on which seasonal and permanent (year-round) forms are distinguished. Pathogenesis The pathogenesis of allergic rhinitis consists in a specific reaction between the allergen and tissue antibodies, as a result of which mediators of the allergic reaction are released, contributing to the development of the clinical manifestations of the disease. Clinic Clinic of the neurovegetative form of vasomotor rhinitis: difficulty in nasal breathing, profuse serous or mucous discharge, bouts of paroxysmal sneezing, sensation of itching and burning in the nasal cavity. The mucous membrane has a cyanotic color. During rhinoscopy, the turbinates appear swollen, when pressed on them with a bellied probe, the latter easily bends the soft tissues to the bone wall without any resistance. Lubrication of the mucous membrane with vasoconstrictor drugs leads to a rapid contraction of the shells. Outside of an attack, the rhinological picture may have a normal appearance. Clinic of seasonal allergic rhinitis (hay fever). Characterized by a clear seasonality of the onset of exacerbation. During this period, there are paroxysms of sneezing, itching and burning in the nasal cavity, eyes, conjunctival hyperemia. Almost complete nasal congestion and severe rhinorrhea occur, which leads to maceration of the skin in the vestibule of the nose. The mucous membrane in the initial period is sharply hyperemic, there is a significant amount of clear liquid in the nose. In the future, the mucous membrane acquires a cyanotic appearance, and then turns pale. In patients during this period, itching in the eyes, hyperemia of the conjunctiva, a feeling of rawness in the throat, larynx and skin itching are often noted. In some cases, the development of angioedema and larynx is possible. There are various uncomfortable manifestations, headache, fatigue, sleep disturbance, fever. The duration of the disease usually corresponds to the period of flowering of plants and stops on its own after it ends or after the patient changes the allergenic area. Clinic for permanent (year-round) form of allergic rhinitis. The disease is chronic. Severe swelling of the nasal turbinates is detected. The mucous membrane is pale. With posterior rhinoscopy, a pillow-shaped thickening of the mucous membrane of the vomer, expressed on both sides, is often noted. The middle turbinates are also swollen. When examining the nasal concha with a button probe, their doughy density is determined, which does not allow one to feel the bony stroma of the concha. Anemization of the mucous membrane often does not lead to a noticeable reduction in the nasal turbinates. Microscopy of mucus reveals a significant number of eosinophilic leukocytes. The allergic form of vasomotor rhinitis is characterized by the formation of mucous polyps, which can fill the entire nasal cavity, in some cases pushing apart the bone walls and deforming the external nose. Often there is a combination of allergic rhinitis with bronchopulmonary pathology - asthmatic bronchitis and bronchial asthma. Treatment Treatment for the neurovegetative form of vasomotor rhinitis is to eliminate the various causes that cause this disease. Various types of intracarcinal disintegration are also used. An active mobile lifestyle is recommended, hardening procedures - short-term dousing of cold water on the soles of the feet. The systematic use of vasoconstrictors is not recommended. Acupuncture, the impact on the reflex zones of the nasal cavity are also used. Treatment of allergic rhinitis includes three main areas, such as elimination therapy, immunotherapy and drug therapy. The goal of elimination therapy is to eliminate allergens. Of the drug therapy, diphenhydramine, diazolin, suprastin, fenkarol, tavegil, pipolfen are most often used. Quite widely used are two aerosol local antihistamines - histimet (levokabastin) and allergodil (acelastin). Topical corticosteroid preparations are used in the form of dry or wet sprays: baconase (beclomethasone dipropionate), syntaris (flunisolide), flixonase (fluticosone propionate). Authors: Drozdov A.A., Drozdova M.V. << Back: Diseases of the nasal cavity (Curvated nasal septum. Bleeding polyp of the nasal septum. Anterior dry rhinitis. Perforating ulcer of the nasal septum. Inflammatory diseases of the nasal cavity. Acute rhinitis. Acute catarrhal (nonspecific) rhinitis) >> Forward: Inflammatory diseases of the paranasal sinuses (Acute sinusitis. Chronic sinusitis)
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