Nasal and Para nasal inflammatory disease PPT

Inflammatory diseases of Nose and Paranasal sinuses
MATHEW VARGHESE V
MSN(RAK),FHNP (CMC Vellore),CPEPC
Nursing officer
AIIMS Delhi
1mathewvmaths@yahoo.co.in

Related Anatomy and Physiology

Skeletal Framework of Nasal cavities
Unpaired Bones :
• Ethmoid
• Sphenoid
• Frontal bone
• Vomer
Paired Bones :
• Nasal
• Maxillary
• Palatine and lacrimal bones
• Inferior conchae

Regions of Nasal Cavities

Functions of Nasal Cavities
Main: Sense of smell (olfaction)
Accessory
• Temperature and humidity of respired air
regulation
• Trap and remove particulate from air
• Capturing foreign material in abundant
mucus.
• Mucus normally is moved posteriorly by
cilia on epithelial cells in the nasal cavities
and is swallowed

Paranasal Sinus
• These are the invaginations from the nasal
cavity that drain into spaces associated with
the lateral nasal wall
There are four paranasal air sinuses
1. Ethmoidal sinuses
2. Sphenoidal sinuses
3. Maxillary sinuses
4. Frontal sinuses
• Functions: skull lighter and add resonance to
the voice

Paranasal Sinus

Inflammatory diseases of Nose
• Rhinitis
Rhinitis is inflammation and swelling of the mucous
membrane of the nose, characterized by a runny
nose and stuffiness and usually caused by
the common cold or a seasonal allergy

Classification
• Acute V/s Chronic
• Acute rhinitis commonly results from viral
infections but may also be a result of allergies,
bacteria, or other causes.
• Chronic rhinitis usually occurs with chronic
sinusitis (chronic rhino sinusitis).
• Allergic V/s Non allergic

Allergic Rhinitis
• Allergic rhinitis is caused by a reaction of the
body’s immune system to an environmental
trigger.
• The most common environmental triggers
include
Dust
Molds
Pollens
Grasses
Trees
Animals

Symptoms of Allergic rhinitis
• Itching
• Sneezing
• Runny nose
• Stuffiness
• Itchy and watery eyes
• Headaches and swollen eyelids
• Cough and wheeze.

Treatment of Allergic Rhinitis
• Avoiding the substance that triggers the
allergy
• Nasal corticosteroid sprays decrease nasal
inflammation
• Antihistamines help prevent the allergic
reaction
• Nasal irrigation
• Antibiotics do not relieve the symptoms of
allergic rhinitis.

Non allergic Rhinitis
1. Acute viral rhinitis
• Acute viral rhinitis can be caused by a
variety of viruses, usually the common
cold
• Symptoms consist of runny nose,
sneezing, congestion, postnasal drip,
cough, and a low-grade fever.

Treatment
• Stuffiness can be relieved by taking
decongestants
• Antihistamines help control a runny
nose
• Antibiotics are not effective for acute
viral rhinitis.

2. Chronic rhinitis
• Chronic rhinitis is usually an extension of rhinitis caused
by inflammation or a viral infection.
• It also may rarely occur with some other diseases.
a. Syphilis
b. Tuberculosis
c. Rhinoscleroma (a skin disease characterized by
very hard, flattened tissues that first appear on the
nose)
d. Rhinosporidiosis (an infection in the nose
characterized by bleeding polyps)
e. Leishmaniasis
f. Histoplasmosis,
g. Leprosy

Clinical features
Chronic rhinitis causes nasal obstruction
and, in severe cases, crusting, frequent
bleeding, and thick, foul-smelling, pus-
filled discharge from the nose.
• Treatment:
• Decongestants may relieve symptoms
• Treatment of underlying cause

3. Atrophic rhinitis
• Atrophic rhinitis is a form of chronic
rhinitis in which the mucous membrane
thins (atrophies) and hardens, causing
the nasal passages to widen (dilate)
and dry out.
• This atrophy often occurs in older
people.

C/F & Mnt.
• Crusts form inside the nose, and an
offensive odor develops.
• People may have recurring severe
nosebleeds and can lose their sense of
smell (anosmia).
• Treatment is aimed at reducing the
crusting, eliminating the odor, and
reducing infections.

4. Vasomotor rhinitis
• Vasomotor rhinitis is a form of chronic
rhinitis. Nasal stuffiness, sneezing, and a
runny nose—common allergic
symptoms—occur when allergies do not
seem to be present.
• Treatment of vasomotor rhinitis is by trial
and error and is not always satisfactory. If
inflammation of the sinus is not severe,
treatment is aimed at relieving symptoms.

Nursing Management of rhinitis
• Patient education
• Instruct client to avoid exposure to allergens
• Instruct about use of medications and nasal spray
• Teach about steam inhalation
• Teach about use of nasal instillation of drugs
• In case of infective rhinitis teach about infection
control measures including hand hygiene
• Provide information about influenza vaccines
• Give special attention to vulnerable population
including Immuno compromised patients

Bacterial Nasal Infections
1. Nasal vestibulitis
• Minor infections at the opening of the nose, called
nasal vestibulitis, may result in pimples at the
base of nasal hairs (folliculitis) and sometimes
crusts around the nostrils.
• The cause is usually the bacteria Staphylococcus.
• The infection may result from nose picking or
excessive nose blowing and causes annoying
crusts and bleeding when the crusts slough off.
• Bacitracin ointment or mupirocin ointment usually
cures nasal vestibulitis.

2. Nasal furuncles
• More serious infections result in boils
(furuncles) in the nasal vestibule.
• Nasal furuncles may develop into a
spreading infection under the skin
(cellulitis) at the tip of the nose
• Treatment - Antibiotics

Nasal polyps
• Polyps are common teardrop-shaped
growths that form around the openings
to the sinus cavities.
• A mature polyp resembles a peeled,
seedless grape.

Nasal polyps

Symptoms
• Sneezing
• Nasal congestion
• Obstruction
• Drainage of fluid down the throat (postnasal drip)
• Facial pain
• Excessive discharge from the nose
• Loss of smell (anosmia)
• Reduced ability to smell (hyposmia)
• Itching around the eyes
• Chronic sinus infections

Nasal polyps
• Treatment
– Corticosteroids
– Sometimes surgery
• .Most surgical procedures are done
with an endoscope.

Sinusitis
• Sinusitis is inflammation of the
sinuses, most commonly caused by a
viral or bacterial infection or by an
allergy.
• It may be acute (short-lived) or chronic
(long-standing).

Acute sinusitis
• Sinusitis is defined as acute if it is
totally resolved in less than 30 days.
• In people who have a normally
functioning immune system, acute
sinusitis is usually caused by a viral
infection.
• Sometimes acute sinusitis is caused by
bacteria.

Chronic sinusitis
• Sinusitis is defined as chronic if it has
been ongoing for more than 90 days.
• Causative Factors include chronic
allergies, nasal polyps, and exposure to
environmental irritants (such as
airborne pollution and tobacco smoke).
• Positive family history

Sub acute $ Recurrent
• Sinusitis may also be sub acute (lasting
from 30 to 90 days) or recurrent (4 or
more episodes of acute sinusitis per
year).

Symptoms
Acute and chronic sinusitis have similar symptoms
Yellow or green pus discharged from the nose
Pressure and pain in the face
Congestion and blockage in the nose
Tenderness (pain when touched) and swelling
over the affected sinus
Reduced ability to smell (hyposmia)
Bad breath (halitosis)
A productive cough (especially at night)

Site specific symptoms
• Maxillary sinusitis causes pain over the cheeks
just below the eyes, toothache, and headache.
• Frontal sinusitis causes headache over the
forehead.
• Ethmoid sinusitis causes pain behind and
between the eyes, tearing, and headache (often
described as splitting) over the forehead.
• Sphenoid sinusitis causes pain that does not occur
in well-defined areas and may be felt in the front
or back of the head.

Complications of sinusitis
• Spread of a bacterial infection to
adjacent tissue
• Changes in vision or swelling around
the eye, Eye pain
• Meningitis and cause severe headache
and confusion.

Diagnosis
• History
• P/E
• PNS – X ray
• CT
• Sinus fluid culture by nasal endoscope

Treatment
• Treatment of sinusitis is aimed at
improving sinus drainage and curing the
infection
• Steam inhalation
• Hot, wet towels over the affected sinuses
and hot beverages may help relieve the
swollen membranes and promote
drainage.
• Nasal irrigation or using a Saline nasal
spray also can help symptoms.

Antibiotics
• For acute sinusitis that is severe (3 or
more days of symptoms such as fever of
102.2º F (39º C) or higher and severe pain)
or persistent (for 10 or more days),
antibiotics such
as amoxicillin/clavulanate or doxycycline a
re given.
• People who have chronic sinusitis take the
same antibiotics but for a longer period of
time, typically 4 to 6 weeks.

Surgery
• When antibiotics are not effective,
surgery may be performed either to
wash out the sinus and obtain material
for culture or to improve sinus
drainage, which allows the
inflammation to resolve.
• Nasal obstruction that interferes with
drainage may also require surgery.

What is sinus surgery?
• Sinus surgery is a procedure that aims
to open the pathways of the sinuses
and clear blockages.
• This is an option for people with
ongoing and recurrent sinus infections,
for people with abnormal sinus
structure, or abnormal growths in the
sinus

Functional endoscopic sinus surgery
(FESS)
• FESS is carried out with a tool called an
endoscope. This is an illuminated, thin fiber-optic
tube.
• The endoscope is inserted into the nose to reach
the openings of the sinuses.
• Micro-telescopes and surgical instruments can
then be passed down the endoscope and used to
carry out the procedure.
• The surgeon will use these tools to remove
obstructive tissues and other blockages to clear
the sinuses.

FESS
• The entire procedure is carried out
through the nostrils and leaves little to no
scarring. Some swelling may occur, but it
will disappear quite quickly.
• A person who has this surgery will usually
only feel mild discomfort for a short
period of time.
• FESS can be performed frequently. It can
also be carried out on an outpatient basis.

Image-guided surgery
• Image-guided endoscopic surgery is a newer
procedure that may be recommended for
severe forms of sinus blockages or after
previous sinus surgeries.
• In addition to using an endoscope, this type of
surgery uses a near-three-dimensional
mapping system to show the surgeon the
position of the surgical instruments.
• This is done using CT scans and infrared
signals

Caldwell-Luc operation
• This procedure is less common and more
invasive. It tends to be carried out when
there is a growth present inside the sinus
cavity.
• The Caldwell-Luc operation aims to
remove growths and improve sinus
drainage. It creates a pathway between
the nose and the cavity beneath the eye
called the maxillary sinus.
• This window then aids drainage.

Nursing Management of sinusitis
• For the post op patient: assess for profuse nasal bleeding,
respiratory distress, ecchymosis, and orbital and facial edema
for the first 24 hours.
• Apply ice compresses to the nose and cheek to minimize
edema and control bleeding
• Semi-High flowler’s position for 24-48 hours
• Remove nasal packing the am after surgery.
• Mild analgesics as necessary
• Teach clients to increase fluid intake to thin secretions, avoid
blowing the nose for 7-10 days (snif or spit), sneeze with
mouth open, limit strenuous activity for ~ 2 weeks.
• Nasal sprays may be started 3-5 days after surgery to
moisten the nasal mucosa.

Fungal Sinus Infections
• Fungus balls are overgrowths
of Aspergillus fungi in healthy people.
• Symptoms include sinus pain,
pressure, nasal congestion, and
drainage of fluids.
• Surgery is needed to open the affected
sinus and remove the fungal debris.

Invasive fungal sinusitis
• is a very serious disorder that develops
most often in people whose immune
system is impaired by chemotherapy or by
diseases such as poorly controlled
diabetes, leukemia, lymphoma, multiple
myeloma, or AIDS.
• It may spread rapidly.
• Symptoms include pain, fever, and
discharge of pus from the nose.
• Treatment is surgery and antifungal drugs

Allergic fungal sinusitis
• is a chronic sinusitis in which fungi cause
an allergic reaction characterized by
marked nasal congestion and the
formation of nasal and sinus polyps
• Surgery is typically required to open up
the sinuses and to remove the fungal
debris.
• Long-term treatment is also required with
corticosteroids and antifungal drugs

Chronic Inflammatory Disease of Nasal
Cavity and Paranasal Sinuses
• Rhino sinusitis
• Inflammation of the paranasal sinuses and nasal cavity
• Rhinosinusitis may present in the acute or chronic
form, and chronic rhinosinusitis (CRS) may present with
or without nasal polyps.
• The most common symptoms of CRS are nasal
obstruction, nasal congestion, discharge, fatigue,
headache, facial pressure, and dysosmia, which may
also show worsening in certain seasons, such as winter
• CRS frequently occurs in conjunction with nasal polyps
and asthma, presenting as a complex allergic entity

CRS
• The mainstay in the treatment of CRS is
nasal corticosteroids, both in the
presence and absence of nasal polyps .
• Other predominant treatment options
in the absence of nasal polyps are nasal
wash, nasal decongestants, and
systemic corticosteroids.

Sinonasal Inflammatory Polyp
• Inflammatory nasal polyps are
inflammatory, polypoidalsinonasal mucous
tissues that arise in response to
inflammatory stimuli, such as allergy and
infections, or as a component of a
systemic process such as aspirin
intolerance or cystic fibrosis .
• The mainstay in the medical treatment of
sinonasal polyps is nasal corticosteroids.

Paranasal Nasal Sinus Mucocele
• Mucoceles are defined as benign cystic
lesions limited by the mucosa of the
paranasal sinus itself and occurring
most frequently in the paranasal sinus
• Surgical excision is the standard
treatment for these lesions, with the
endoscopic approach being the gold
standard

Bacterial Infections
• Rhinoscleroma
• is a chronic granulomatous disease of
the nasal cavity, nasopharynx, and
paranasal sinuses caused by
Klebsiellarhinoscleromatis

Leprosy
• Leprosy is caused by Mycobacterium
leprae and is characterized by
involvement of the skin and peripheral
nerves.
• Depression of the nasal bridge is a
characteristic feature of leprosy. The
nasal mucosa is the main point of entry
and exit of the bacteria .

Protozoal
• Mucocutaneousleishmaniasis
• Mucocutaneousleishmaniasis is caused by
Leishmaniabrasiliensis.
• Almost 40% of patients develop mucocutaneous
involvement, with the typical early symptoms
being nasal obstruction associated with a nodule
or polyp at the inferior turbinate.
• The disease eventually progresses to destroy the
nasal septum and destroy the nose and mouth if
not controlled.

Viral Infection
• Herpes
• Herpes simplex is caused by herpes
simplex virus (HSV) type I or II and
manifests as painful blisters or ulcers
around the nose and mouth .
• Oral lesions are generally caused by HSV
type I. Tingling, itching, or burning may be
experienced before the appearance of the
blisters .

Nursing Process related to Nasal and
paranasal diseases
• Assessment
• Take proper health history
• Take in detailed symptom analysis on OLDCARTS format
 Onset
 Location
 Duration
 Characteristics
 Aggravating factors
 Relieving factors
 Time
 Setting

Assessment
• Take history of allergy and allergens
• Proper physical examination using all 4
techniques
 Inspection
 Percussion
 Palpation
 Auscultation

Nursing diagnoses
• Ineffective airway clearance related excessive
mucus production secondary to inflammation
• Acute pain related to nasal mucosal irritation
• Impaired verbal communication related to
nasal cavity obstruction secondary to polyps
• Altered body temperature ,hyperthermia
related to inflammation
• Knowledge deficit related to management and
home care of nasal and paranasal
inflammatory disease r/t lack of exposure

Nursing Interventions
Maintaining a patent airway
• The breath sounds must be assessed every 2
hourly.
• Asess RR, Rhythm,pattern
• ABG results must be interpreted to determine the
degree of oxygenation provided by the ventilators
or oxygen.
• Assess for cough and swallow reflexes
• Use an oral artificial airway to maintain patency
• Nasal and oral care is provided to keep the upper
airway free of accumulated secretions debris

Maintaining a patent airway
• Position on alternate sides 2-4 hrs to prevent
secretions accumulating in the airways on one
side.
• Maintain the neck in a neutral position
• Oronasopharyngeal suction may be necessary
to aspirate secretions..
• Chest percussion and postural drainage may
be prescribed to assist in the removal of
tenacious sections
• Dentures are removed

Acute pain related to nasal mucosal
irritation
• Perform a comprehensive assessment. Assess
location, characteristics, onset, duration,
frequency, quality and severity of pain.
• Observe for nonverbal indicators of pain:
moaning, guarding, crying, facial grimace
• Accept patient’s description of pain
• Obtain vital signs.
• Assess the client’s current use of medications.

Pain Management
• Anticipate the need for pain management
• Provide a quiet environment
• Use nonpharmacological pain relief methods
(relaxation exercises, breathing exercises,
music therapy).
• Provide optimal pain relief by administering
prescribed pain relief medication.
• Review patient’s medication records and flow
sheet.

Patient Education
• Prevention of upper airway infections
• Emphasize frequent handwashing
• When to contact health care provider
• Need to complete antibiotic treatment
regimen
• Annual influenza vaccine for those at
risk

Anxiety and Depression
• Allow asking of questions and provide
information.
• Permit verbalization of feelings.
• Interventions to reduce anxiety and
promote comfort
• Reassuring manner.
• Stay with the patient during episodes of
anxiety.
• Relaxation techniques

Conclusion
• These are the common acute and
chronic inflammatory diseases of nasal
and paranasal sinuses. Understanding
and proper knowledge regarding this
disease will enable nurses to manage
their client in proper way without
complication.

References
• 1. Riechelmann H; Europäischen Akademie für Allergie und Klinische
Immunologie (EAACI) under European Rhinologic Society (ERS). [Chronic
Rhinosinusitis - EPOS 2012 Part I]. Laryngorhinootologie. 2013; 92: 193-201.
• 2. Gorbach SL, Falagas M. The 5-Minute Infectious Diseases Consult. Boston:
Wolters Kluwer. 2001.
• 3. Passali D, Cingi C, Cambi J, Passali F, Muluk NB. A survey on chronic
rhinosinusitis: opinions from experts of 50 countries. Eur Arch
Otorhinolaryngol. 2016;.
• 4. Robinson, Robert. Nose, Paranasal Sinuses, and Nasopharynx. In: Head and
Neck Pathology: Atlas for Histologic and Cytologic Diagnosis. Philadelphia:
Lippincott Williams & Wilkins. 2012; 142.
• 5. Stamm AC, Draf W, editors. Micro-endoscopic sinus surgery in children. In:
Micro-endoscopic Surgery of the Paranasal Sinuses and the Skull Base. Berlin:
Springer. 2012; 363.
• 6. Hssaine K, Belhoucha B, Rochdi Y, Nouri H, Aderdour L, et al. Paranasal sinus
mucoceles: About 32 cases. Rev Stomatol Chir Maxillofac Chir Orale. 2015;
00188-00183. 65mathewvmaths@yahoo.co.in

References
• . Scangas GA, Gudis DA, Kennedy DW. The natural history and clinical characteristics
of paranasal 24 www.avidscience.com 25 Chronic Inflammatory Diseases Chronic
Inflammatory Diseases www.avidscience.com sinus mucoceles: a clinical review. Int
Forum Allergy Rhinol. 2013; 3: 712-717.
• 8. Lee TJ, Li SP, Fu CH, Huang CC, Chang PH. Extensive paranasal sinus mucoceles: a
15-year review of 82 cases. Am J Otolaryngol. 2009; 30: 234- 238.
• 9. Grammer, Leslie, Paul Greenberger. Radiologic Evaluation of Allergic and Related
Diseases. In: Patterson’s Allergic Diseases. 7th edn. Baltimore: Wolters Kluwer
Health/Lippincott Williams & Wilkins. 2009; 165.
• 10. Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF. Rhinosinusitis:
developing guidance for clinical trials. J Allergy Clin Immunol. 2006; 118: S17-61.
• 11. http://www.avidscience.com/wp-content/uploads/2016/04/CID-16-01
• 12.https://www.msdmanuals.com/home/ear,-nose,-and-throat-disorders/nose-and-
sinus-disorders/introduction-to-nose-and-sinus-disorders
• 13. http://www.scielo.br/pdf/rboto/v74n2s0/en_a02.pdf
• 14.http://www.mariobussi.com/en/diseases-of-major-interest/diseases-of-nose-and-
paranasal-sinuses.html
• 15. https://www.slideshare.net/kapradh/diseases-of-the-paranasal-sinuses

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