Rhinitis And Nasal Obstruction

Question 1

What is rhinitis?

Answer 1

Rhinitis is a term implying inflammation of the nasal mucosa.

There is generalised swelling of the mucosa, increased volume and viscosity of nasal secretions and impairment of normal ciliary function.

Question 2

What are the symptoms of rhinitis?

Answer 2

Clinically, rhinitis is defined by the onset of two or more of the following symptoms - nasal discharge, sneezing, nasal itching and congestion

Question 3

What is the most common cause of nasal obstruction?

Answer 3

Rhinitis

Question 4

What are the causes of nasal obstruction?

Answer 4

Rhinitis 
Foreign bodies 
Nasal septum abnormalities 
Occlusion of the nasal valve 
Turbinate hypertrophy 
Adenoid hypertrophy 
Nasal polyps 
Rhinosinusitis
Neoplasm 
Choanal atresia

Question 5

What are types of rhinitis?

Answer 5

Infective rhinitis- viral (RSV, influenza virus), bacterial (s.pneumoniae, h. influenzae), fungal rhinitis.
Allergic rhinitis
Non-allergic rhinitis

Question 6

What are causes of nasal septum abnormalities?

Answer 6

Nasal septum abnormalities such as nasal septal deviation (congenital or acquired), haematoma or perforation (trauma, nose picking and cocaine abuse).

Question 7

What are causes of occlusion of the nasal valve?

Answer 7

The valve is at the narrowest part of the nose and is the apex where the septum and the upper lateral cartilage meet.

Causes of occlusion include septal deviation, ageing and nasal valve scarring after nasal surgery.

Question 8

What are causes of turbinate hypertrophy?

Answer 8

This may be idiopathic or caused by long-standing allergic rhinitis (seasonal and perennial), inflammation (eg, rhinitis caused by the common cold) and long-term use of over-the-counter (OTC) vasoconstrictive nasal sprays.

Question 9

What is the presentation of turbinate hypertrophy?

Answer 9

The enlarged turbinates lose their ability to expand and shrink and therefore result in nasal obstruction.

Patients with this condition often present with complaints of continuous nasal obstruction unrelieved by nose drops, antihistamines, or allergic desensitisation.

Examination with a nasal speculum reveals enlargement of the inferior turbinate.

Question 10

What is the management of turbinate hypertrophy?

Answer 10

Treatment consists of alleviating symptoms with a steroid nasal spray and antihistamines for allergies, discontinuing habitual use of OTC vasoconstrictive nasal sprays, and surgical procedures to shrink the turbinates.

Question 11

What is adenoid hypertrophy?

Answer 11

This is more common in children than it is in adults.

It occurs when excessive adenoid tissue blocks the nasopharynx and results in snoring, nasal obstruction, postnasal drainage and infections.

In children, the condition can be expected to regress over time.

Adenoidectomy may be required for significant functional impairment (hearing and speech).

Question 12

What are nasal polyps?

Answer 12

Nasal polyps are lesions arising from the nasal mucosa, occurring at any site in the nasal cavity or paranasal sinuses but most frequently seen in the clefts of the middle meatus.

Question 13

Which condition should you test for if a child presents with nasal polyps?

Answer 13

If they occur in children, cystic fibrosis testing is merited.

Question 14

When are nasal polyps worrying?

Answer 14

They must be distinguished from more serious pathology such as nasal tumours, particularly if they are unilateral.

Question 15

Which conditions are associated with nasal polyps?

Answer 15

Asthma 
Aspirin sensitivity 
Cystic fibrosis 
Allergic fungal sinusitis 
Churg-Strauss syndrome

Question 16

What is the presentation of nasal polyps?

Answer 16

Patients may have a history of recurring acute or chronic sinusitis.

Symptoms depend on the size of the polyp (small polyps may be asymptomatic) and include:
Nasal airway obstruction.
Nasal discharge:
-Watery anterior rhinorrhoea, sneezing, postnasal drainage.
-Green secretions suggest infection (due to a polyp blocking the sinus ostia).
-Unilateral, blood-tinged secretion suggests a tumour, foreign body, nose picking, or misapplication of nasal spray.
Dull headaches.
Snoring and obstructive sleep symptoms.
Hyposmia or anosmia (decreased smell) and reduced taste.

Question 17

What are the differentials of nasal polyps?

Answer 17

Nasal polyps tend to be bilateral. With unilateral lesions, suspect a tumour.

Foreign body- particularly if there is unilateral, blood-tinged discharge in young children.

Chronic rhinosinusitis without polyps.

Sinusitis

Allergic fungal rhinosinusitis

Tumours, benign and malignant

Question 18

What are the investigations for nasal polyps?

Answer 18

Rigid or flexible endoscopy (rhinoscopy) carried out by specialists- this allows localisation and determination of the extent of the polyps.

Plain X-ray films are of limited value.

CT scans are helpful

Investigation of underlying chronic rhinosinusitis may be appropriate.

Question 19

What is the management of nasal polyps?

Answer 19

Medical management with topical and possibly systemic corticosteroids is usually considered the initial treatment of choice, with endoscopic sinus surgery reserved for those patients who fail to improve.

Topical corticosteroids are the mainstay of treatment. Nasal drops are preferred to sprays.

Unilateral polyps may be a sign of malignancy and should always be referred to ENT.

Children with nasal polyps should be referred to be tested for cystic fibrosis.

Review for associated/underlying disease- eg, covert asthma and aspirin sensitivity.

As there is no single causative factor, treatment targets the underlying inflammatory process.

Medical management is first-line, unless the nature of the polyp is uncertain (eg, suspected malignancy).

Patients should be educated regarding the recurring nature of this problem.

Question 20

What are the complications of nasal polyps?

Answer 20

Acute bacterial sinusitis
Sleep disruption
May contribute to symptoms of asthma
Massive polyps can lead to craniofacial structural abnormalities with resulting proptosis, hypertelorism and diplopia.

Question 21

What is aspirin-sensitive nasal polyp?

Answer 21

Aspirin sensitivity associated with nasal polyposis, rhinosinusitis and asthma is called asthma-exacerbated respiratory disease (AERD).

Hypersensitivity to aspirin or other non-steroidal anti-inflammatory drug (NSAID) is associated with a more severe and protracted course of nasal polyps and a distinct pattern of cellular, biochemical and molecular markers of inflammation.

Question 22

What is the presentation of aspirin-sensitive polyps?

Answer 22

Typically occurring in the third and fourth decades of life; more common in females and in non-atopic.

Ingestion of aspirin or an NSAID induces a reproducible reaction within 20-120 minutes:

• In any individual the form of the reaction is consistent.
• Any combination of symptoms may occur, including systemic upset with facial flushing, perspiration and intense lethargy, rhinorrhoea, nasal congestion, conjunctivitis, respiratory symptoms (cough and bronchospasm) and gastrointestinal symptoms.
• A severe reaction can include shock and respiratory arrest.

Aspirin sensitivity should be suspected in patients with severe or recurrent nasal polyps and intrinsic asthma.

Question 23

What is the management of aspirin-sensitive nasal polyps?

Answer 23

Patients should be warned to avoid all drugs with cyclo-oxygenase-1 (COX-1) inhibitory activity. Selective COX-2 inhibitors appear to be safe but it is suggested that the first dose should be administered in hospital under direct observation with monitoring for two hours and resuscitation facilities available.

Paracetamol is usually (not always) tolerated; single doses of ≤500 mg are safe in 94% of patients.

A diet avoiding preservatives, additives and high salicylate foods may be helpful (for some patients in open studies).

Aspirin desensitisation can be carried out in a hospital setting.

Surgery is less successful (compared with aspirin-tolerant patients).

Question 24

What are the causes of nasal discharge ?

Answer 24

The most important causes are:
Coryza, i.e. the common cold.
Hay fever: this is usually seasonal and predictable each year.
Perennial rhinitis: this is rhinitis which occurs all year round and is usually due to allergy.
Rebound congestion can occur when topical decongestant drugs are stopped. These are usually drugs like ephedrine or xylometazoline drops but can include abuse of cocaine.
Nasal polyps are usually the result of chronic allergy or inflammation but they also result in persistent nasal discharge.
Cerebrospinal fluid (CSF) rhinorrhoea is a rare but important cause which can follow a head injury. The meninges are torn and cerebrospinal fluid leaks down the nose. Ascending infection may cause meningitis.

Question 25

What is the management of coryza?

Answer 25

Self-limiting

Benefit from antivirals has not been demonstrated.

Question 26

What is coryza?

Answer 26

Coryza is an extremely common condition caused by a rhinovirus, although a number of other viruses may cause similar symptoms. The incubation period is 12-48 hours.

Secondary infection of mucus can lead to sinusitis and even bronchitis, especially when immunity is impaired by diseases such as cystic fibrosis or by smoking. Being exposed to cold, especially if core temperature drops, does predispose to the illness and the virus grows best in tissue cultures just below 37°C.

Question 27

What is allergic rhinitis?

Answer 27

Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens.

Question 28

What is the classification of allergic rhinitis?

Answer 28

It may be classified as follows, although the clinical usefulness of such classifications remains doubtful:

• seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
• perennial: symptoms occur throughout the year
• occupational: symptoms follow exposure to particular allergens within the work place

Question 29

What is the presentation of allergic rhinitis?

Answer 29

sneezing
bilateral nasal obstruction
clear nasal discharge
post-nasal drip
nasal pruritus

Question 30

What is the management of allergic rhinitis?

Answer 30

Allergen avoidance
If the person has mild-to-moderate intermittent, or mild persistent symptoms:
-Oral or intranasal antihistamines
If the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective
-Intranasal corticosteroids
A short course of oral corticosteroids are occasionally needed to cover important life events
there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline).

Question 31

Why shouldn’t decongestants be used for a long period of time?

Answer 31

They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal.