Nose, sinus, nasopharynx Dr K Outhoff

1. Nose, sinus, nasopharynxDr K Outhoff

2. Contents • Allergic Rhinitis • Nasal furunculosis • Epistaxis • Local anaesthetic drugs • Rhinosinusitis • Viral • Bacterial • Fungal • Iatrogenic conditions

3. A. Nasal Obstruction • Viral URTI • Adults : • Deflected nasal septum • Polyps • Granulomatous disease -TB, Syph, Lep • Rhinitis • Chronic sinusitis • Iatrogenic – topical vasoconstrictors, reserpine, TCA’s

4. A. Nasal obstruction • Children: • large adenoids • choanal atresia • post nasal space tumours (angiofibromata) • foreign body • rhinitis

5. Allergic rhinitis

7. Allergic rhinitis • Sneezing, pruritus, rhinorrhoea, swollen turbinates, nasal polyps • Treatment options • Topical nasal corticosteroids • Topical antihistamines • Systemic antihistamines • Topical sympathomimetics (pseudoephedrine) • Prophylactic nasal sprays – Sodium cromoglycate • Desensitizing injections ( anaphylaxis)

8. 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)

9. 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

10. Topical antihistamines (H-1) for allergic rhinitis • Azelastine: • Also inhibits release of inflammatory cytokines • Levocabastine: • Long acting • For short term symptomatic treatment

11. 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

12. 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

13. 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

14. 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)

15. 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’

16. 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!

17. Nasal furunculosis • Infection of hair follicles usually by Staphylococcus Rx: • Analgesia For cellulitis, systemic upset: • Amoxicillin • Flucloxacillin

18. 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

19. Local Anaesthetic Drugs I: Cocaine surface local anaesthetic reuptake inhibitor of sympathomimetic amines: • intense vasoconstriction • mydriasis of pupil • anxiety • tremor • euphoria

20. 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

21. 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.

22. Rhinosinusitis • Viral • Acute: no antibiotics • Bacterial • Acute: see next • Chronic: culture for anaerobes (Bacteroides) and Staphylococcus • Fungal • Invasive • Non-invasive

23. Sinuses

24. 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)

25. Acute bacterial sinusitis and otitis media**SP Oliver. Antimicrobial agents for common outpatient conditions. Mims Disease Review 2009/2010Updated guidelines for the management of URTI in SA 2008 SA Fam Prac 2009

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

27. Amoxicillin mechanism of action

28. 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

29. 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

30. 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

31. 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

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

33. Treatment nose, sinus, etc