ALLERGIC RHINITIS

Definition: IgE mediated hypersensitivity of the mucous

membrane of the nose upon exposure to antigenic
substance.
Incidence: common, 10-20% of population.
Types: 1. seasonal 2. perennial 3.perennial with seasonal
exacerbation.
Etiology:
Predisposing factors:
1. Genetic predisposition: 50% of cases occur in atopic
patient (atopy: tendency to develop an exaggerated Ig E
antibody response).
2. Temperature changes.
3. psychgenic.
Exciting factors:
1. inhalant: commonest factors e.ghouse dust,
tree & grass pollens.
2. Injestant: foods (milk, fish) & drugs ( aspirin,
antihypertensive).
3. Injectant: e.g penicillin.
4. Infactant: fungal parasitic & bacterial antigen.
5. Contactant: e.g face powder.
Pathogenesis:
1. 1st exposure: formation of IgE antibodies
which bind to specific sites on surface of
mast cells.
2. 2nd exposure: +Ag-Ab reaction on
surfaces of must cells with degranulation
of cells & release of chemical mediators:
e.g histamine, bradykinine, serotonine
resolution in local inflammatory reaction:
 Vasodilation: plasma exudate.
 Increase glandular secretions.
 Cellular infiltrate (oesinophilis).
 Smooth muscle contraction.
Symptoms: +ve family history in 50%.
1. Itching sensation.
2. Paroxysmal sneezing.
3. Bilateral profuse watery discharge.
4. Bilateral alternating nasal obstruction.
5. Associated allergic symptoms e.g eye, skin or chest.

Signs:
1. Pale bluish edematous mucosa.
2. Swollen edematous turbinates.
3. Excessive mucoid secretions.
4. Nasal polyps may be present.
Investigations:
1. Skin- prick test: skin of forearm is pricked with a needle
passed in extract of different allergens. +ve test is
detected by centeral wheel surrounded by erythema.

2. Nasal challenge test: allergen applied inform of spray.

3. Radioallergosrbency test (RAST): incubation of patient

serum with specific concentrations of antigens & level
of IgE is by radioimmune.

4. High level of IgE by radioimmun.

5. Nasal smear; full of oesinophilis.

Treatment:
1. Avoidance of exposure.
2. Immunotherapy: injection of gradually increasing dose
of specific antigen over long period of time formation of
blocking antibodies.
3. Mast cell stabilizer e.g. sodium chromoglicate.
4. Antihistaminic: systemic & local (spray).
5. Steroids: systemic (short course) &local spray.
6. Surgery:
- Reduction of size of turbinate.
- Nasal polypectomy
 Vasomotor rhinitis
It is also called intrinsic rhinitis or non allergic perennial rhinitis. It may be
related to drugs ( e.g. antihypertensive and contraceptive) or hormonal
imbalance at menopause.

Clinical picture:
1. Nasal obstruction and watery nasal discharge, which is often precipitated
by temperature changes, and dusty atmosphere.
2. Examination; shows swollen, edematous turbinates, with excessive
mucoid ecretios.

Treatment :
It is often unsatisfactory.
1. Topical steroids may be beneficial.
2. If the turbinates are markedly swollen we may do submucous dithermy or
submucosal injection of long acting steroids (vidion N1).
 Nasal polyps
Definition:
Projections of edematous. Pedunculated mucosa of the nose and/or
Paranasal sinuses.
Types:

2- Antrochoanal
Etiology:
Inflammatory or retention cyst:
Arise from mucosa of maxillary
antrum → directed posteriorly.
After passage through sinus ostium →
directed towards the choana →
nasopharynx.
- Uncommon.
- Age: young adult.
- Sex: equal
1- Ethmoidal
Etiology:
1. Allergy:
* Most accepted cause.
* 90% of polyps → oesinophilia.
* Allergic rhinitis, Usually present.
* 20-40% → bronchial asthma.
2. Inflammatory, chronic sinusitis.
Incidence:
- Common.
- Age: adult.
If occurs in a child 2-10yrs → cystic fibrosis, should be
suspected. There are extensive nasal plyps leading to
broadening of the nasal bridge due to distention before
fusion of the nasal bones. There is very thick and
tenacious nasal discharge (Mucoviscidosis). Sweat test
(sodium level) is diagnostic. It has a very high rate of
recurrence.
- Sex: equal.
- Accumulated nasal
discharge in the obstructed
side.
Anterior rhinoscopy:
-Swollen inferior turbinate.
-Accumulated secretions.
-Sometimes → polyp seen.
Posterior rhinoscopy:
Single polyp appears in the
nasopharynx.
Symptoms:
Allergic:
-Bilateral gradual nasal obstruction.
-Manifestation of allergic rhinitis.
Inflammatory:
-PND: thick and purulent.
-Unilateral or bilateral nasal obstruction and
discharge.
-Sinus headache.
Signs:
Allergic:
-Bilateral, multiple, pale, glistening pedunculated
masses (grap-like growth) that fill the nasal bridge
in long standing cases (Hypertolirism).
-Manifestations of allergic rhinitis.
Inflammatory:
-Polyps: usually few pink, soft and arising mainly
from the middle meatus.
-Purulent discharge: mainly from the middle
meatus.
 Investigations:
-Sinus view: unilateral maxillary 1. Culture and sensitivity.
opacity. 2. Allergic skin test.
-CT scan. 3. CT scan nose & paranasal sinuses.
4. Biopsy from the ploys (macrophages or
eosinophilia).
Treatment:
Endoscopic removal of nasal, Allergic:
nasopharyngeal, and sinus parts 1. Medical → small early polyps.
through a wide middle meatal
antrostomy. * Systemic steroids.
N.B: in recurrent cases → radical * Topical steroids.
antrum operation was done. * Antibiotics ê 2ry infection.
* Anti allergic treatment.
2. Surgery:
N.B: * Simple polypectomy.
Differential diagnosis of unilateral * Intranasal ethmoidectomy (endoscopic or
nasal mass: microscopic).
1. Benign neoplasm especially - Preoperative & postoperative steroids should be given.
inverted, firm papillary polyps. - There is high rate recurrence 40% after surgery
2. Malignant neoplasm: unilateral, (9months → 2years).
bad odor, soft, bleeding on touch Inflammatory:
mass.
3. Meningocele and 1. Medical:
encephalocoele: soft, pulsating, * Antibiotics.
reddish, polyp with superior * Decongestant.
attachment to skull base. * Mucolytics.
2. Surgical: Transnasal endoscopic sinus surgery (FESS).
 Paranasal sinuses
Anatomy paranasal sinuses

Air filled spaces, 4 pairs on each side, within skull bones & open in the
Latebral wall of nose.
Lining: pseudostratified columnar ciliated epithelium which is continuous
with that of the nose through their ostia.
Arranged in 2 groups:
* Anterior group: Maxillary, Forntal & Anterior sinuses.
* Posterior group: Posterior ethmoid & Sphenoid sinuses.
Maxillary sinus:
• It is contained within the body of maxilla.
• Development begins in the 3rd fetal month.
• Pneumatization starts at bieth, growth continues to 18 years of age.
Boundaries:
•

• Anteriorly: cheek.
• Posteriorly: pterygopalaine fossa.
• Roof: floor or orbit.
• Floor: palatine and alveolar process of maxilla.
• Medially: lateral nasal wall.
Level of floor of sinus varies with that of nasal floor, before age of 9 years
sinus floor is at higher level, after the age of 9 years sinus floor is at lower
level.

Maxillary sinus ostium:

It is made by confluence of maxillary sinus mucosa and nasal mucosa. On
looking to the maxillary ostium from inside the sinus it will appear like an ellipse
just below the junction of roof and medial wall half way between anterior and
posterior walls.
Frontal sinus:
• It is present between outer and inner tables of frontal bone.
• it begins development after birth.

• The two frontal sinuses may be of unequal size.

• The frontal sinus ostium lies in the most dependent area of the sinus.

• Frontal recess, is the space where frontal sinus opens.

• The frontal sinus ostium and recess look an hour glass.

Ethmoid sinuses:
• The ethmoid bone is divided into:
• Two ethmoid labyrinth which form ethmoid sinuses on both sides.
• Cribiform plate of ethmoid which separates the nose from anterior
cranical fossa.
• Perpendicular plate of ethmoid which forms part of nasal septum.
• The ethmoid sinus consists of 7-17 small air cells.
• It is divided into anterior group and posterior group by basal lamella
(oblique part of middle turbinate).
Sphenoid sinus:
• It is lies within the sphenoid bone.
• Pneumatization of sinus begins in the 3rd year.
• The ostium lies high in the anterior wall and opens in the Spheno
ethmoidal recess.
Relations:
• Roof: sella turcica.
• Pos teriorly: optic nerve. Posterolalerally: ICA.
 Physiology of the paranasal
sinuses
 Functions of the paranasal sinuses:
1. Helps in resonating the voice.
2. Lightens the weight of the skull.
3. Shock absoirption in trauma to the face or skull.
4. Assists in humidification and moistening the nasal cavity.
 Osteomeatal complex:
Describe the area in which the frontal, maxillary & ethmoidal sinuses
drain. It is bounded by middle turbinate medially, lamina papyracea
laterally and basal lamella posteriorly and superiorly. Any mucosal
thckcning or anatomical abnormality will affect these sinuses.
 Mucociliary clearness:
• The secretions of goblet cells & seromucinous glands form a mucous
layer “mucous blanket” above the epithelium.
• Cilia carry this blanket towards the ostium of the sinus → nose →
nasopharynx.
 Sinusitis
Chronic sinusitis Acute sinusitis
Definition:
Chronic inflammation of the mucous Acute inflammation of the mucous
membrane lining of the paranasal membrane lining the paranasal sinuses.
sinuses with irreversible pathological One or more may be involved.
changes. Usually rhniosinustis.
Etiology:
1) Repeated acute attacks with
Exciting causes:
incomplete resolution: A) Nasal
A. Persistent of predisposing factors   Acute rhinitis; commonest cause.
persistent obstruction of the  Viral exanthemata.
 Neglected F.B.
osteomeatal complex.  Nasal packing.
B. Inadequate treatment with residual B) Dental
infection.  Dental infection.

 Extraction of 2nd premolar or 1st molar.

2) High virulence of organism.
C) External
3) Low body resistance.  Compound facial fracture.

 Penetrating F.B. e.g. gunshot.

Predisposing factors:
A) Local: any nasal disease obstructing the
sinus ostium e.g. D.S, nasal polyps.
B) General: low general resistance.
Organism: Streptococcus pneumonia,
haemophilus influenza & Anaerobes (dental
origin).
1. Mucosa: congested, edematous with Pathology:
fibrosis. Congestion & oedema of sinus mucosa
2. Cilia: degeneration with loss of ciliary  occlusion of sinus ostium 
function. impairment of sinus drainage &
3. Late cases: the mucosa is either atrophic mucociliary clearance  accumulation
or hypertrophic “irreversible pathology”. of secretions inside the sinus  stasis &
infection with  pus formation.
A) General: manifestations of septic focus, Symptoms:
history of repeated acute attacks. A) General: fever, history of acute
B) Local: rhinitis.
1- B) Local:
2- 1- Nasal obstruction: unilateral or
3- bilateral.
2- Nasal discharge:
-Unilateral or bilateral.
4- Facial pain & headache:
-Same. -Mucopurulent or purulent.

-Dull aching, periodic & recurrent. -Postnasal drip  irritative cough.

5- Symptoms of descending infections: 3- Hyposmia: cacosmia (bad smell) 

-Otitis media.
dental origin.
-Recurrent pharyngitis.
4- Facial pain & headache.
Laryngitis & bronchitis.
-

6- Symptoms of complications.
 - On the affect sinus.
-Sever, throbbing.

Coughing, bending forwards.

-Vacuum headache  frontal sinus ostium
obstruction with absorption of air 
periodic pain & headache.
5- Facial edema & swelling.
6- Symptoms of complications.
Signs:
A) General: fever: higher in children.
Local: B) Local:
1. 1- Tenderness over the affected sinus on
2. deep pressure.
3. 2- Anterior rhinoscopy:
•Mucosa: edematous & congested.

•Nasal discharge: middle meatus 

Sites of sins pain & tenderness in acute & anterior group.
chronic sinusitis.
Maxillary: pain & tenderness over 3- Posterior rhinoscopy:
•Nasal discharge:
affected sinus.
Ethmoidal: - Superior meatus  posterior group.
Pain  in between eyes. - Spheno ethmoidal recess  sphenoid.
Tenderness  inner canthus.
Frontal:
Pain  supra orbital & across
forehead.
Tenderness  above eyebrow. Floor
of sinus.
Sphenoid: pain  occipital.
Investigations:
1) Laboratory: C. & S. from nasal discharge.
2) Nasal endoscopy: ostium visualization, pus in different areas, anatomical
variations.
3) Radiological:
* X-ray sinus view: mucosal thickening, fluid level.
* C.T scan nose & PNS: investigation of choice.
Treatment:
A) Medical: A) Medical:
1- General: - Same. 1- General: - Bed rest.
- Antibiotics: for 4weeks. - Plenty of fluids.
2- Local: - Same. - Antibiotics: for 10-
- Control of local nasal 14days.
Predisposing factors. - Analgesics.
- Nasal wash: alkaline - Mucolytics.
nasal wash. 2- Local: - Decongestant nasal
drops.
- Steam inhalation.
B) Surgical: B) Surgical:
Indication: Indication: aiming to Surgical
1) Failed medical treatment (up to 4 drainage.
weeks). 1) Failed medical ttt.
2) Presence of mechanical 2) Complications: present or
obstruction in the nose. threatening.
Procedure: Procedure:
Nowadays; → drainage of the affected
According to he affected sinus
sinus by functional endoscopic sinus
surgery (FESS).
Old:
1. Maxillary: puncture & lavage.
2. Frontal: frontal trephine.
3. Ethmoid: fthnoidectomy.
4. Sphenoid: sphenocthmoidectomy.

Old Recent “FESS”

-Repeated puncture & Lavage Endoscopic middle meatal Maxillary

 up to 6 times. antrostomy  widening of the
-Intranasal antrostomy.
normal ostium.
-Radical antrum operation.

External frontal operation  Endoscopic clearance of frontal Frontal

opening sinus floor & recess.
removal of diseased mucosa.
External Intranasal ethnoidectomy Ethmoids
Frontoethroidectomy.
External Sphenoid sinusotomy Sphenoid
Sphenoethroidectomy
 Sinusitis in children
Accidence: - Age: 5-8 yrs.
- Site: maxillary & ethmoid (commonest).
Etiology:
Predisposing factors:
- Ciliary disorders e.g. kartagnar’s syndrome (Bronchitis Dectrocar)
- Mucosal abnormality e.g. cystic fibrosis (Muwvisidrlin).
- Source of infection: common e.g. URT infection & exanthemata.
- Low immunity.
Organism: Strept. Pneumonia, H. influenza & moraxella catarrtalis.
Clinical picture:
Acute: as adult + high fever & complications are more especially
orbital.
Chronic: less facial pain & headache than adult, descending infection
& chronic irritative cough.
Treatment:
(A) Medical: as adult.
(B) Surgical: - No improvement after medical treatment.
- Presence of complication.
 Orbital complications
The commonest complication. 75% of orbital infections are due to
sinusitis.
Aetiology: more common to occurs in ethmoditis especially in
children. Less common t occurs in ethmoditis especially in children.
Less common with maxillary sinus.
Clinical picture: 5 stages.
1- Preseptal cellulitis:
. Mild inflammatory or reactionary edema of the "Preseptal
connective tissue" due to proximity of infection in the ethmoids →
venous obstruction.
. There is: eyelid edem.
2- Subperiosteal abscess “extraperiosteal":
. Pus collection between the orbital periosteum & the lamina
papyracea.
.There is: - Severe pain - Mild Proptosis.
- Good general condition. - Mild limitation of eye movement.
- Chemosis. - Diminution of vision (reversible).
3- Orbital cellulitis:
. Diffuse edema of the orbital contents & bacteria actively invaded
the orbital
contents but pus formation does not occur.
. There is:-Sever pain. - ↑ Proptosis.
-Bad general condition - ↑ limitation of eye movement.
-Chemosis. -Diminution if vision condition
(reversible).

4- Orbital abscess "intraperoisteal“:

. Pus collection within the orbit.
. There is:-Sever throbbing pain. -Marked proptosis.
-Very bad general condition -Total ophthalmoplegia.
-Chemosis -Diminution of vision (irreversible).

5- Cavernous sinus thrombosis:

Due to thrombosis of the superior & inferior ophthalmic veins
“retrograde thrombophilbitis”.
Investigations:
1- Urgent CT scan of the paranasal sinuses & orbit.
2- Fundus examination: Papilloedema (in cavernous sinus
thrombosis).

Treatment:
1- Hospita1ization.
2- Treatment of orbita1 cellulitis:
-Massive antibiotics with daily: -Examination of visual acuity.
-CT scan.
-Surgical: * Drainage of Subperiosteal abscess.
* Indications: -Progressive ↓ of vision.
-Progressive symptoms over 24 hrs &
no improvement after 48 hours.
-CT; shows subperiosteal collection.
3- Surgical treatment of sinusitis.
 Osteomylitis of skull
Occurs in diploic bones → frontal & maxillary.
Aetiolology: Direct extension of infection to bones or due to thrombophilbitis
of diploic veins.

Maxillary osteomylitis Frontal osteomylitis

Same Pathology: Osteomylitis →
subperiosteal abscess (Pott’s puffy
tumour) → fistula.
Clinical picture:
-General: fever, toxemia. -General: fever, toxemia.

-Pain, Oedema, tenderness over -Pain, Oedema & tenderness over

cheek. forehead.
-Subperiosteal abscess over canine -Frontal fluctuant swelling or fistula.

fossa or oroantral fistula.

Plain X-ray & CT scan. Investigations: Plain X-ray & CT
scan X-ray → moth-eaten appearance
of posterior wall.

Treatment: Hospitalization.
1. Massive antibiotics.
2. Surgical drainage of abscess.
3. Treatment of sinusitis.
 Intracranial complications
1. Meningitis: the most common intracraninal complication.
2. Extradural abscess: occurs with frontal sinusitis &
osteomylitis. Both 1 & 2 are similar to that of chronic ear.
3. Bruin abscess : Similar to that of chronic ear, with
personality changes as a localizing sign.
4. Cavernous sinus thrombosis

Etiology: infection from:

1- Dangerous area of the face (boil & septal abscess). Facial
veins → ophthalmic vs. → CS.
2- * Sinus infection.
* Orbital cellulitis.
3- Latera1 sinus thrombosis.
4- Pharyngeal suppuration e.g. Quinsy. → pterygoid venous
plexus → CS.
Clinical picture:
-1 General: high fever, toxemia, rigors. sever headache. Then, there is
rapid deterioration of general condition.
-2Venous obstruction of eye: Eyelid Oedema, Chemosis & Proptosis.
3- Cr. nerve affection: * Total ophthalmoplegia.
* Pain in distribution of ophthalmic division of
5th nerve.
4- ↑ ICT, then coma & death if untreated.

Investigation: MRI, angiography & MRA.

Treatment: Mortality is 30% if untreatc 25Id of infection (meanings

& brain tissue).
-Hospitalization.
-Antibiotics & anticoagulant.
-Treatment of sinus disease.
 Complications of sinusitis
Classification
A. Orbital complications.

B. Cranial complications:
1. Osteomylitis.
2. Subperiosteal abscess (Pott's puffy tumour).
3. Fistula formation.
C. Intracranial:
1. Extradural abscess.
2. Meningitis.
3. Cavernous sinus thrombosis.
4. Brain abscess (frontal lobe).
N.B. Cranial and intracranial complications often follow acute
frontal sinusitis.
D. Descending infection:
1. Acute otitis media.
2. Laryngitis.
3. Pharyngitis.
4. Bronchitis and asthmatic attacks.
5. Gastro-intestinal troubles as anorexia
and dyspepsia.

E. General:
Symptoms of septic focus as arthritis and
nephritis.

F. Mucocel
 Mucocel
Definition:
an expansion of a sinus by accumulation of mucoid secretion.

Etiology:
1. Chronic fronto-etmoiditis.
2. Osteoma obstructing the ostium.
3. Post traumatic ostial stenosis.
Pathology:
-Sites → frontal → frontoethomidal → sphenoid.
-Mechanism: Ostium obstruction → secretions retention →
cysti expansion & thinning out of walls → wall destroyed with
displacement of surroundings.
Clinical picture:
Swelling: - Site: * Inner canthus (ethmoid).
* Medial ½ of orbital roof (frontal).
- Slowly progressive.
- Painless.
- Hard or egg-shell crackling sensation.
- Proptosis; the direction depends on the affected sinus.
-When infected, forms mucopyocele: * Skin over → inflamed.
* Tenderness.
* Rupture → fistula formation.
Investigations:
1. X-ray sinus view → -Opacification.
-Loss of scalloped appearance of the frontal sinus .
2. CT scan.
Treatment:Surgery; evacuation of mucocel with adequate drainage
to avoid recurrence.