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Vasomotor And Atrophic rhinitisBy Lt Col Saeed Ullah, MBBS, MCPS, FCPS Classified ENT, Head and Neck surgeon CMH Quetta

Anatomy of Nose

Anatomy of Nose

Histology

Sensory nerve supply of nose

Sensory nerve supply- septum

Sensory nerve supply-lateral wall

Autonomic nerve supply

Autonomic nerve supply•Sympatheitic stimulation

▫Vasoconstriction▫Smooth muscle around sinusoids constrict▫Decongestion and opening of nose

•Parasympathetic stimulation▫Engorgement of nasal mucosa▫Increase glandular activity▫Nasal congestion and blockage

Definition of rhinitis•Inflammation of nasal lining,

characterized by one or more of the following symptoms▫Nasal congestion▫Rhinorrhoea▫Sneezing▫Itching

Classification of rhinitis

Classification •Non allergic rhinitis

▫Idiopathic rhinitis Vasomotor rhinitis(non allergic, non

infectious prennial rhinitis(NANIPER) Non allergic occupational rhinitis Hormonal rhinitis Drug induced rhinitis Atrophic rhinitis NARES(non allergic rhinitis with eosinophilia

syndrome)

Vasomotor rhinitis(NANIPER)•Non allergic, non infectious perennial

rhinitis•Clinically simulates allergic rhinitis

▫Paroxysmal sneezing▫Watery nasal discharge▫Nasal obstruction

Pathogenesis •Rich blood supply of nasal mucosa•The turbinate’s erectile tissues•Sinusoids surrounded by smooth muscle fibers•Under control of autonomic nerves•Autonomic nerves under control of

hypothalamus•Sympathetic stimulation leads to

vasoconstriction•Parasympathetic stimulation causes

vasodilatation

Pathogenesis •Unstable autonomic nervous system

▫Parasympathetic dominance•Nasal mucosa is hyper reactive

▫Change in temp▫Humidity▫Blasts of air▫Dust and smoke

Symptoms •Paroxysmal sneezing•Excessive rhinorrhea•Nasal obstruction•Post nasal drip

Signs •Congested nasal mucosa•Hypertrophy of nasal mucosa•Mucoid nasal discharge•Nasal polypi •Hypertrophy of turbinates

Investigations •Diagnosis of exclusion

▫Skin prick tests▫Serum IgE level▫Specific antibodies against IgE▫Eosinophils level in nasal smear

Treatment •Medical

▫Avoidance of trigger factores▫Antihistamins▫Nasal decongestants▫Topical steroids

•Surgical ▫Turbinates reduction▫Vidian neurectomy

Atrophic rhinitis

Atrophic rhinitisChronic inflammatory condition in which nasal mucosa, glands & bones are atrophied There is widening of nasal cavities with greenish crusts in nasal cavities

Types of Atrophic rhinitis

1. Primary: exact cause is not known

2. Secondary: to some underlying factors

Primary atrophic rhinitis• Infection

Klebsiella Ozaenae Diphthroid Bacillus Coccobacillus foetidus ozaenae

• Hormonal imbalance At puberty More common in females

• Nutritional Poor socioeconomic status Vit D and iron deficiency

• Heredity• Autoimmune

Organisms (cause,effect)1. Bacillus ozaenae2. Coccobacillus3. Klebsiella ozaenae4. Diphtheroid bacilli

Secondary Atrophic Rhinitis1. Chronic purulent sinusitis2. Enthusiastic surgery on nose3. Syphilis4. Tuberculosis5. Marked DNS with wide nasal cavity on

one side

Pathology • Epithelium

Patches of metaplasia Transition from ciliated columner into stratified

squamous• Lamina propria

Chronic cellular infilterats Granulation tissues, fibrosis

• Mucous glands Decrease in size and number

• Vascular Decreased vascularity

Symptoms Nasal obstruction due to:

CrustsLoss of sense of air passage

Recurrent Epistaxis Offensive smell (stench) Anosmia due to Atrophy of Olfactory

nerve Headache Choking

Signs •External nasal deformity•Very wide nasal cavities•Inf. Turbinates shrunken / rudimentary•Greenish / dirty crusts•Stench (dead body like smell)•Maggots

Wide nasal cavities

Crust formation

Greenish nasal discharge- foul smelling

Investigations

1. X-RAY PNS2. Blood CP, ESR3. X-RAY chest PA4. Swab C/S5. Serology6. Serum iron & Proteins7. Biopsy

TreatmentConservative: Alkaline nasal douches with ¼ lit. of

warm lotion ofSod. Chloride 2 partsSod. Bicarbonate 1 partSod. Diborate 1 part

Removal of crusts 25% Glucose in glycerin nasal drops Oestradiol in Arachis oil

Treatment Surgical Treatment: Narrowing nasal cavities:

Injecting Paraffin or Teflon submucosally Insertion of cartilage graft

Stellate ganglion block Parotid duct transposition Closure of one / both nostrils leaving

3mm holeYoung’s operation

Thank you