Rhinitis &

Sinusitis

Near East University Faculty of Medicine

Rhinitis
It is an inflammation of the nasal cavity mucosa.

Symptoms:

◼ Sneezing
◼ Itchy nose
◼ Runny nose
◼ Disordered smell
◼ Nasal congestion
Rhinitis Classification

[Link] Rhinitis
[Link] Rhinitis
[Link]-Infectious Non-Allergic Rhinitis

The most common chronic disease.

[Link] Infectious Rhinitis

◼ Rhinitis is the disease that occurs when viral,

bacterial or fungal microorganisms settle in
the nasal mucosa.
[Link] Infectious Rhinitis

◼ Flu
◼ Exenthematous diseases (measles, rubella, chickenpox, etc.)
◼ Diphtheritic rhinitis
◼ Nasal vestibulitis
◼ Frunculosis
◼ Toxic shock syndrome due to nasal packing
[Link] Infectious Rhinitis

◼ Atrophic Rhinitis
◼ Rhinitis Sicca
◼ Nasal Tuberculosis
◼ Chronic Diphtheritic Rhinitis
◼ Lupus Vulgaris
◼ sarcoidosis
◼ rhinoscleroma
◼ leprosy
◼ Fungal Infections of the Nose
◼ Nasal Syphilis
[Link] Infectious Rhinitis -
Atrophic Rhinitis
◼ Atrophic Rhinitis:

Atrophic rhinitis is the progressive atrophy of the nasal mucosa and

turbinates. It is a chronic rhinitis characterized by the presence of
viscous secretions that rapidly crust and have a foul odor. The nasal
passages are abnormally wide.
[Link] Infectious Rhinitis -
Atrophic Rhinitis
◼ Nasal dryness, nasal
obstruction, and epistaxis
are among the symptoms
that bother the patient.

◼ Since syphilis is the disease

most often confused with
atrophic rhinitis, necessary
serological tests should be
performed.
[Link] Rhinitis

◼ Allergic rhinitis is a disease that develops

due to type I hypersensitivity reaction of
nasal mucous membranes.
 [Link] Rhinitis

Genetically affected individuals.

Reaction against a specific

external protein (aeroallergen).

Allergic sensitization.

Secretion of specific IgE against

the relevant protein.
 [Link] Rhinitis

Specific IgE coats the mast cells

in the nasal mucosa.

During respiration, the specific

protein that reaches the nose
binds to the IgE sensitive to this
protein.

Early and late mediators are

released into the environment.
 [Link] Rhinitis

Early-release mediators (2-5 minutes)

• It causes vasodilation, hypersecretion, and

increased capillary permeability in the nasal
mucosa.

Late-synthesized mediators

• Leukotrienes, prostaglandin D2 (within hours)

[Link] Rhinitis -
Symptoms
◼ Sneezing
◼ Itching (nose, eyes, palate, ears)
◼ Rhinorrhea
◼ Post-nasal drip
◼ Nasal congestion
◼ Anosmia
◼ Headache, earache
◼ Tearing, red eyes, periocular edema
◼ Fatigue, weakness, and exhaustion
[Link] Rhinitis - Findings

There are no characteristic physical

examination findings for allergic rhinitis.

◼ Allergic salivation
◼ Dennie-Morgan lines on the lower eyelid
◼ Sinusitis
◼ Nasal polyps
◼ Nasal mucosa over the turbinates is pale,
bluish, and edematous.
◼ Serous discharge
◼ Open-mouth breathing due to nasal
congestion
◼ Swelling under the eyes, dark lines,
conjunctivitis, and periorbital edema
[Link] Rhinitis
◼ The average age of onset is 8-11, but it can begin at any age.

◼ 80% of cases occur before the age of 20.

◼ The prevalence is as high as 40% in childhood and decreases

with age.

◼ Allergic rhinitis is much less common in older people.

[Link] Rhinitis
Symptoms may be present year-round (perennial rhinitis)

Symptoms may be present in certain seasons (seasonal rhinitis)

Mixed type
[Link] Rhinitis

If there are only one-sided symptoms in the nose, a structural

obstruction, polyp, foreign body or deviation, etc. should be
considered.
[Link] Rhinitis - Triggers

◼ Inhaler Triggers
◼ Chemical Triggers
◼ Foods
 [Link] Rhinitis -
Classification
Intermittent: Persistence:

Less than 4 days per week 4 days or longer per week

OR
Less than 4 weeks per year 4 weeks or longer per year

Moderate – Severe:
Mild:
One or more of these:
Sleep periods are normal Sleep disturbances are present
AND Daily activities are limited
No restrictions on daily activities,
School or work life is affected
sports, etc.
No impact on school or work Problematic symptoms are present
No problematic symptoms
[Link] Rhinitis - Tests
Nasal Smear
Total IgE
Skin Tests

Diagnosis: History + examination + laboratory tests

[Link] Rhinitis

Antihistamines
Topical corticosteroids
Immunotherapy (vaccine therapy)

If the allergen can be identified, avoid the allergen.

[Link] Rhinitis
Complications:

◼ Otorhinolaryngitis
◼ Eustachian tube dysfunction
◼ Sinusitis

Comorbid conditions:

◼ Asthma
◼ Atopic dermatitis
◼ Nasal polyps
3. Non-allergic Non-infectious
rhinitis
◼ It describes mucosal inflammation not caused by structural
abnormalities, infectious, or allergic causes of the nose.

◼ It causes rhinitis by causing pathology in the vascular structure

of the nasal mucosa.
3. Non-allergic Non-
infectious rhinitis -
Pathophysiology
◼ Nasal mucosal vessels and glands are under the influence of the
autonomic nervous system.
◼ The sympathetic system causes vasoconstriction, while
stimulation of the parasympathetic system causes vasodilation
and hypersecretion of the mucosal glands.
◼ In the normal nasal cycle, congestion occurs on one side of the
nose and decongestion on the other side, occurring
approximately every 2.5 hours.
◼ This is achieved through a balance between the sympathetic
and parasympathetic systems.
◼ In vasomotor rhinitis, this balance is disrupted, and
parasympathetic influence becomes dominant. As a result,
symptoms such as nasal congestion, runny nose, and sneezing
occur.
3. Non-allergic Non-infectious rhinitis -
Drug Induced Rhinitis (Rhinitis
Medicamentosa)

◼ Sympathomimetics used as decongestants can cause rebound

vasodilation if used frequently and for prolonged periods.

◼ Infants are more susceptible to this condition.

◼ If the patient uses decongestants again to relieve nasal

congestion, the condition will enter a chronic cycle.
3. Non-allergic Non-infectious rhinitis -
Drug Induced Rhinitis (Rhinitis
Medicamentosa)

◼ In the treatment of rebound rhinitis, the decongestant used

should first be discontinued, and then the underlying cause of
nasal congestion should be eliminated.

◼ This factor causing the patient's dependence on decongestants

may be infectious, allergic, or structural (such as a deviated
septum, nasal polyp, etc.).
3. Non-allergic Non-infectious
rhinitis– Hormonal Factors
◼ Estrogen causes vasodilation and swelling in the nasal mucosa.

◼ Nasal congestion may occur due to increased estrogen levels,

especially during the second and third trimesters of pregnancy,
during the premenstrual period, or with oral contraceptive use.

◼ For this type of rhinitis that occurs during pregnancy, topical

steroids, systemic decongestants, and antihistamines can be
used safely after consultation with a gynecologist.

◼ Sneezing, itching, or discharge are generally not common in

estrogen-induced rhinitis.
3. Non-allergic Non-infectious
rhinitis– Hormonal Factors
◼ Chronic rhinitis can develop in hypothyroidism due to congestion
and hypertrophy of the mucosal glands. Treatment is directed at
the hypothyroidism itself.

◼ Diabetes mellitus has been reported to rarely cause rhinitis.

3. Non-allergic Non-infectious rhinitis - Eosinophilic
Non-allergic Rhinitis
–

◼ It is a specific entity characterized by symptoms resembling

allergic rhinitis, with a predominance of eosinophils on nasal
cytology, normal IgE levels, and negative skin tests.

◼ Patients experience sneezing attacks, rhinorrhea (runny nose),

and itching.
3. Non-allergic Non-infectious
rhinitis

◼ Emotional rhinitis
◼ Temperature-induced vasomotor rhinitis
◼ Sexual desire
◼ Exercise
3. Non-allergic Non-infectious
rhinitis -Diagnosis
The most important aspect of treating vasomotor rhinitis is excluding other
causes of rhinitis.

Chronic nasal congestion requires a differential diagnosis from allergic

rhinitis.

History is an important part of the diagnosis.

On physical examination, the mucosa of the inferior turbinate, in particular,

appears pale or purplish and swollen.

Negative skin tests are an important diagnostic tool in distinguishing it from

allergic rhinitis.
3. Non-allergic Non-infectious
rhinitis
If etiological factors can be identified, eliminating them is the most
important step in treatment.

Medical Treatment:
Systemic decongestants and topical decongestants, etc.

Surgical Treatment:
Surgical treatment is indicated for patients whose medical
treatment is insufficient and who still have severe symptoms.

Surgery is particularly effective for the inferior turbinates.

 3. Non-allergic Non-infectious
rhinitis

◼ Symptoms appear later in life.

◼ Most common triggers: Changes in weather

conditions, perfumes, odors, smoke, and smoking.

◼ Less allergic conjunctivitis (itching, watering,

hyperemia, and swelling).

◼ Antihistamines are ineffective.

◼ Non-allergic Rhinitis Nasal congestion and rhinorrhea are more
common in non-infectious rhinitis, while sneezing and itching are
more common in allergic rhinitis.
Sinusitis
 Sinuses
Sinuses are named
according to the bone
in which they are
located:
● Maxillary

● Frontal

● Ethmoid

● Sphenoid
Functions of the Sinuses

◼ To warm and humidify the inhaled air

◼ To secrete mucus
◼ To reduce the weight of the head
◼ Resonance (voice resonance)
◼ Insulation: To protect important
organs such as the brain, eyes, and
tooth roots against trauma and
temperature changes
Sinuses

◼ The maxillary, frontal, and anterior

ethmoidal sinuses drain into the middle
meatus.

◼ The posterior ethmoidal and sphenoidal

sinuses drain into the superior meatus.
Sinuses
◼ The small openings through which the
sinuses open into the nose are called ostia.

◼ In infants, there are 3–4 small ethmoidal

sinuses and a small maxillary sinus.

◼ In adults, the maxillary sinuses develop to

about 15 ml in volume, and the ethmoidal
sinuses develop to as many as 18–20.
Sinuses

◼The frontal sinus develops from one

of the anterior ethmoidal cells, which
expands upward (superiorly) and
sideways (laterally) into the frontal
bone around the ages of 6–7.
Sinusitis – Pathophysiology

It develops depending on three factors:

● Obstruction of sinus drainage (ostial
obstruction)

● Impairment of ciliary activity

● Accumulation of secretions within the sinus

Ostial Obstruction

◼An obstruction occurring at the sinus

ostium creates a suitable
environment for bacterial growth by
both impairing the function of the
cilia and causing accumulation of
secretions within the sinus.
◼Obstruction of the ostium also
produces a hypoxic environment
inside the sinus, which further
disrupts ciliary activity.
Symptoms and Findings

MAJOR MINOR

◼ Purulent discharge ◼ Headache

(anterior, ◼ Halitosis (bad
posterior) breath)
◼ Nasal obstruction ◼ Toothache
◼ Facial pain, ◼ Fatigue
pressure ◼ Cough
sensation, fullness ◼ Ear pain, sensation
in the face of pressure in the
◼ Fever ear, fullness
◼ Hyposmia,
SinUSİTİS
ACUTE CHRONIC

◼ < 3 weeks ◼ > 3 months

◼ Usually occurs ◼ Polypoid changes

after acute viral in the mucosa
infections
◼ Associated
symptoms:
Chronic cough,
bronchitis,
fatigue,
Predisposing Factors
Local factors
● Edema of the mucosa around the ostium in upper
respiratory tract infections (URTI).
● Spread of dental infections into the sinus.
● Nasal polyps, foreign bodies, nasal packing, and
tumors.
● Choanal atresia.
Systemic factors
● AIDS, immune system disorders.
● Steroid therapy, uncontrolled diabetes, chemotherapy,
etc.
Acute Bacterial Sinusitis

Streptococcus pneumoniae – the most

common

Haemophilus influenzae

Moraxella catarrhalis
Acute Viral Sinusitis – the
most common
◼ Rhinovirus (most common)
◼ Coronavirus
◼ Influenza A and B, Parainfluenza
◼ Respiratory syncytial virus (RSV)
Adenovirus

In 90% of viral upper respiratory tract infection (URTI)

cases, the sinuses are involved, but only 5–10% develop
bacterial superinfection, which requires antibiotics.
Acute Fungal Sinusitis

Non-invasive: Considered the most common form.

Invasive: Caused by Aspergillus species and fungi
belonging to the Mucorales group.

● Prolonged mucopurulent rhinorrhea

● Immunosuppressive conditions
● Sinusitis unresponsive to antibiotic therapy
● Rapidly progressing swelling around the face/eyes
● Aggressive symptoms spreading around the sinuses
Prognosis

◼ 95% of viral sinusitis cases resolve

spontaneously.

◼ 40% of bacterial sinusitis cases resolve

spontaneously.

◼ Despite successful treatment, recurrence

is seen in about 5% of cases.
Diagnosis

◼ Anterior rhinoscopy

◼ Endoscopic examination of the

nasal cavity
 Diagnosis

X-ray

● Water’s graphy – old school :(

Paranasal sinus CT
Treatment Approach

The primary goals in the treatment of acute

rhinosinusitis are:
● To eradicate the infection
● To reduce the severity and duration of
symptoms
● To prevent complications
Nice guideline
NICE Guideline

Symptoms of acute sinusitis:

◼Symptoms for 10 days or less?
◼Symptoms with no improvement for
more than 10 days?
◼At anytime if the person is:
systemically very unwell, or has
symptoms and signs of a more
serious illness or condition, or has
high risk of complications
 Symptoms for 10 days or less?

◼Do not offer an antibiotic - follow up

for 2-3 weeks.
◼Reassess if symptoms worsen
rapidly or significantly.
Symptoms with no improvement for
more than 10 days?

• Consider no antibiotic or back-up

antibiotic prescription, depending on
likelihood of bacterial cause - use if no
improvement after 7 days.

• Consider prescribing a high-dose

nasal corticosteroid for 14 days for
adults and children aged 12+ (off-label
use)
Refer to hospital if complication
present:

◼Severe systemic infection

◼ Intraorbital or periorbital
complications
◼ Intracranial complications
Sinusitis in Childhood

◼ During childhood, frequent upper respiratory

tract infections, adenoiditis, nasal septum
deviation, choanal atresia, and congenital
diseases such as Kartagener’s syndrome and
cystic fibrosis increase the likelihood of sinusitis.
A
◼ In children, history and physical examination are
more important for diagnosis. Radiographs can
be taken in older children.
Sinusitis in Childhood

◼ The symptoms of sinusitis in children show some

differences compared to adults. Fever is less
prominent than in adults. The main symptom is
persistent mucopurulent discharge, which should
also raise suspicion of chronic adenoiditis.

◼ Evaluation of the nose and paranasal sinuses

must always be performed. Children with
sinusitis present more frequently than adults with
laryngitis, chronic cough (especially at night),
and halitosis.
Functional
Endoscopic
Sinus Surgery
Complications
Local complications:
● Osteomyelitis
● Mucocele
● Pyocele

Orbital complications:
● Chemosis
● Ophthalmoplegia
● Orbital cellulitis
● Subperiosteal abscess
● Orbital abscess
Complications
Intracranial
complications:
● Meningitis
● Encephalitis
● Cavernous or
sagittal sinus
thrombophlebitis
● Extradural abscess
● Subdural abscess