Nose, sinus, nasopharynxDr K Outhoff

Contents

• Allergic Rhinitis• Nasal furunculosis• Epistaxis• Local anaesthetic drugs• Rhinosinusitis– Viral– Bacterial– Fungal

• Iatrogenic conditions

A. Nasal Obstruction

• Viral URTI • Adults :– Deflected nasal septum– Polyps– Granulomatous disease -TB, Syph, Lep– Rhinitis– Chronic sinusitis– Iatrogenic – topical vasoconstrictors, reserpine,

TCA’s

A. Nasal obstruction

• Children: – large adenoids– choanal atresia– post nasal space tumours (angiofibromata)– foreign body– rhinitis

Allergic rhinitis

Allergic rhinitis

• Sneezing, pruritus, rhinorrhoea, swollen turbinates, nasal polyps

• Treatment options1. Topical nasal corticosteroids2. Topical antihistamines3. Systemic antihistamines

4. Topical sympathomimetics (pseudoephedrine)5. Prophylactic nasal sprays – Sodium cromoglycate6. Desensitizing injections ( anaphylaxis)

Topical corticosteroid nasal spraysmainstay of treatment

• Effective, fewer side effects than oral or parenteral routes, minimal absorption from nasal mucosa

• Reduce swelling and stuffiness• Take a few days to work at full potential

– Beclomethasone– Budesonide– Triamcinolone– Mometasone– Fluticasone

(may dry nasal mucosa; crusting, bleeding)

Histamine • Found largely in mast cell and basophil granules in skin, lungs,

GIT• and histaminergic neurones in brain• Mediator of hypersensitivity response• Acts on H-1 receptors:– Contracts smooth muscle (ileum, bronchioles, uterus)– Dilates blood vessels– Increased vascular permeability– Itching from sensory neuronal stimulation

Topical antihistamines (H-1) for allergic rhinitis

• Azelastine:– Also inhibits release of inflammatory cytokines

• Levocabastine:– Long acting– For short term symptomatic treatment

Systemic Antihistamines (H-1)• ↓rhinorrhoea• sneezing, • eye symptoms• Not as effective as steroids for nasal congestion

Newer antihistamines: relatively free of sedation, alcohol, benzo potentiation as do not cross BBB

• Chlorpheneramine (Allergex – old generation)• Cetirizine (Zyrtec)• Levocetirizine• Loratidine• Desloratidine• Fexofenadine

Systemic antihistamines

• Well absorbed• Metabolised in liver• Excreted in urine• Older antihistamines:

Peripheral anti-muscarinic effects : dryness of mouth, blurred vision, constipation, urinary retention, and sedation

• Newer antihistamines: Less sedating, prolongation QT interval

Topical sympathomimetic decongestants

• Oxymetazoline (Iliadin N/Spray)• Xylometazoline• Ephedrine –containing preparations

– Vasoconstrictors, ↓oedema– Useful if severe congestion preventing topical

steroids, cromoglycate from working

– Limit use to 2-3 days – Beware rhinitis medicamentosa

Sodium Cromoglycate nasal spray / drops

• May be used for allergic conjunctivitis and rhinitis• Prevents release of mediators from mast cells• Mucous membranes less sensitive to allergens• Use long term, preventative• Well tolerated• Short lived sneezing, nasal irritation

• NO LONGER AVAILABLE IN RSA as nose drops. (eye drops still available)

Systemic corticosteroids

• Intractable, severe allergic rhinitis• Short course oral prednisolone• Anti-inflammatory• Prolonged use can suppress adrenal production of

corticosteroids• Abrupt discontinuation →nausea, vomiting, shock• Mask signs of infection• Impair natural immune response to infection• For specialist use only

• SAMF 2008: ‘systemic steroids have no role in the routine management of allergic rhinitis’

Systemic corticosteroids cont...

• Impair calcium absorption, new bone formation

• Short course prednisolone well tolerated• Prolonged use: fluid retention, weight gain,

potassium loss, headache, muscle weakness, peptic ulceration, easy bruising, convulsions, psychiatric symptoms, etc!

Nasal furunculosis

• Infection of hair follicles usually by Staphylococcus

Rx: • Analgesia

For cellulitis, systemic upset: • Amoxicillin• Flucloxacillin

Drug treatment of Epistaxis

• First aid, ice, transfusion• 2.5-10% Cocaine solution

nasal spray: anaesthetises and constricts vessels

• Anterior ribbon gauze pack with paraffin, iodoform paste

• Posterior pack

Local Anaesthetic Drugs I: Cocaine

surface local anaestheticreuptake inhibitor of sympathomimetic amines:• intense vasoconstriction• mydriasis of pupil• anxiety• tremor• euphoria

Local Anaesthetic Drugs II: Lignocaine: • IV regional anaesthesia• Infiltration anaesthesia (with or without vasoconstrictor, adrenaline)• Epidural anaesthesia• Topical anaesthesia

– Spray– Gel

Rapid diffusion through tissues (2-3min)Duration of action: 1-3 hours

• Side effects: dose related: – Dizziness, agitation– Drowsiness, respiratory depression, convulsions– Heart block: direct effect– Nausea, vomiting, transient tinnitus

• amide-type local anaesthetic

Paranasal sinuses

• Ciliated cells sweep mucous into nose• Viral infections depress cilia activity• Cause oedema around sinus ostia to nose• Collection of stagnating mucous• May become secondarily infected by bacteria

• Polyps, deflected septum, nasal mucosal swelling, tooth roots, also predispose.

Rhinosinusitis

• Viral– Acute: no antibiotics

• Bacterial– Acute: see next– Chronic: culture for anaerobes (Bacteroides) and

Staphylococcus• Fungal– Invasive– Non-invasive

Sinuses

Acute bacterial sinusitis (ABS)• Fever, pain, tenderness, discoloured nasal discharge• Aetiology:

– S. pneumoniae – H. Influenzae – Moraxella catarrhalis (consider if no rapid clinical response)

Rx: • Analgesia• Antibiotics:

– Amoxicillin 10 days (first choice) or – Co-amoxiclav 10 days if failed therapy

– Penicillin allergy: erythromycin / clarithromycin/ moxifloxacin

• (decongestant nasal drops – eg pseudoephedrine)

Acute bacterial sinusitis and otitis media**SP Oliver. Antimicrobial agents for common outpatient conditions. Mims Disease Review 2009/2010

Updated guidelines for the management of URTI in SA 2008 SA Fam Prac 2009

Bugs First line Second line -No rapid response

Pen. allergy

AcuteS. pneumoniaeH. influenzaeM. catarrhalis

Amoxicillin Co-Amoxiclav Moxifloxacin

(Cefpodoxime)(Cefuroxime)

(Moxifloxacin) Macrolide:ErythromycinAzithromycinClarithromycin

ChronicMultiple bacteria +anaerobes

Co-Amoxiclav+ metronidazole

Clindamycin?

Moxifloxacin orMacrolide

Add Metronidazole

Amoxicillin

• Beta-lactam penicillin• Inhibits bacterial cell wall synthesis• Stomach upset• Allergic reactions

Amoxicillin mechanism of action

Fungal sinusitis

• Recently been blamed for causing most cases of chronic rhinosinusitis

• Most are benign except when occur in immuno-compromised patients where they become invasive (acute and chronic)

• Prognosis is different for each• Pathogens:

– Aspergillus and– Mucor species

Rx: Surgical debridement for all.Adjuvant medical

Ramadan HH. Fungal sinusitis 2009. emedicine. medscape.com

Fungal sinusitis:adjuvant drug therapy

Allergic fungal sinusitis and sinus mycetoma:• Surgical treatment only

Acute and Chronic invasive fungal sinusitis:• Initiate systemic antifungals

– Amphotericin B ivi– Replace with oral ketaconazole or itraconazole once disease

under control

Chronic granulomatous fungal sinusitis:• Surgical debridement followed by systemic antifungal

medication

Iatrogenic / drug induced conditions I• Blocked nose: (↑NA): TCA’s, reserpine,

vasoconstrictors

• Rhinorrhoea: ↑Ach with physostigmine (acetylcholine esterase inhibitor, glaucoma Rx)

• Epistaxis: beclomethasone, ipratroprium bromide (antimuscarinic), ASPIRIN, warfarin

• Immunosuppression: prolonged systemic corticosteroids, chemotherapy

Iatrogenic / drug induced conditions II

• Septum perforation: steroids post Ø, cocaine

• Drying of nasal mucosa: ipratropium bromide, beclomethasone inhaler

• Nasal polyps: chronic drug allergy, aspirin

• Rhinitis medicamentosa: sympathomimetic vasoconstricting decongestants

Rhinitis medicamentosa

• Iatrogenic obstruction• Decongestant vasoconstrictive sprays or drops• Damage mucosa (anoxia)• Rebound engorgement• Mucosal oedema• Further drug use• Vicious cycle

Treatment nose, sinus, etcCondition Aetiology Treatment options

topicalTreatment options oral

Allergic rhinitis allergens SteroidsAntihistamine

(Cromoglycate)

Antihistamine

Steroid: prednisolone

Infective sinusitis S. PneumoniaeH. InfluenzaeMoraxella catarrhalis

AmoxicillinAmoxicillin-ClavulanateMacolides / Moxifloxacin

Nasal furunculosis Staphylococcus Analgesia AmoxicillinFlucloxacillin

Epistaxis BeclomethasoneAspirinWarfarinAntimuscarinics

Cocaine

Rhinitis medicamentosa

Sympathomimetic vasoconstricting decongestants

Stop drugs