rhinitis, nasal septum · rhinitis (bsaci guideline 2017, scadding et al.) inflammation of the...
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Rhinitis,
Nasal Septum
HELGA KRAXNER MD, PHD
MAGDA KRASZNAI MD, PHD
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Rhinitis (BSACI guideline 2017, Scadding et al.)
Inflammation of the nasal mucosa and
submucosa characterized by the
undermentioned symptomps :
– nasal secretion
– sneezing
– nasal blockage or congestion
– itching in the nose
Involvement of conjunctivae →
rhinoconjunctivitis
Involvement of sinus linings → rhinosinusitis
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Classification
Allergic rhinitis
Infectious rhinitis
Other (Non-allergic rhinitis - NAR)
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Allergic rhinitis
➢ ARIA (2008):
– intermittent, persistent
– moderate, severe
➢ Seasonal, perennial, mixed
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Infectious rhinitis
➢ acute
➢ chronic
➢ specific
➢ non specific
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Other etiology
➢ Hormone dependent
➢ Occupational
➢ Environmental
➢ Food
➢ Drug
➢ Emotional
➢ Atrophic
➢ Idiopathic
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Triggers for non-allergic
rhinitis (NAR) I.
Eosinophilic or NARES (50% develop aspirin sensitivity with asthma and nasal polyposis)
Autonomic (formerly known vasomotor) – physical/chemical agents
Drugs (α-adrenerg blockers, β-blockers, ACE-inhibitors, chlorpromazine, cocaine, nasal decongestants – prolonged use, aspirin/NSAID)
Hormonal (pregnancy, puberty, HRT, contraceptive pill, hypothyroidism, acromegaly)
Food (alcohol, spices, pepper, sulphites)
Atrophic (primary: Kleb. Oz., sec.: trauma, surgery, radiation)
Primary mucus defect (cystic fibrosis)
Primary cellular dyskinesia (Karteneger and Young syndrom)
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Triggers for non-allergic
rhinitis (NAR) II. Systemic inflammatory diseases (Sjögren’s syndrome, SLE, RA,
Churg-Strauss syndrome)
Immune deficiency (antibody deficiency)
Malignancy (lymphoma, melanoma, squamous cell carcinoma)
Granulomatous diseases (sarcoidosis, granulomatosis with polyangiitis)
Structural abnormalities (septal deviation)
Local allergic rhinitis – allergens as for AR, skin test negative
Occupational (allergic, non allergic, can induce asthma, HMW protein agents – latex, flour, animals, LMW agents –irritants - chlorine, ammonia, immune sensitization – di-isocyanates, glutaraldehyd)
Idiopathic (unknown cause – diagnosis of exclusion)
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Diagnosis/differential
diagnosis
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Rhinitis (BSACI guideline 2017, Scadding et al.)
Inflammation of the nasal mucosa and
submucosa characterized by the
undermentioned symptomps :
– nasal secretion
– sneezing
– nasal blockage or congestion
– itching in the nose
Involvement of conjunctivae →
rhinoconjunctivitis
Involvement of sinus linings → rhinosinusitis
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History
➢ Family
➢ Social (environment, occupation, pets, schooling, home)
➢ Symptoms: period, frequency, severity, intensity, duration
➢ Allergic disease in the past, i.e. in childhood
➢ Drugs
➢ alpha- and beta-blockers,
➢ anti-hypertensives,
➢ aspirin and other NSAID
➢ oral contraceptives
➢ Topical sympathomimetics
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Allergic rhinitis - History
Family
Social (pets, occupation, schooling)
Drugs
alpha- and beta-blockers,
anti-hypertensives,
aspirin and other NSAID
oral contraceptives
Topical sympathomimetics
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History
What kind of nasal/ respiratory symptoms has the patient?
Has he any symptom characteristic for allergic
rhinitis (RA)?
➢ Watery nasal discharge
➢ Sneezing attacks
➢ Itching (eyes, nose, throat, ears)
➢ Watery eyes
➢ Blocked nose
➢ Caughing
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Allergic rhinitis questionnaire to
recognize AR
Symtoms on only one side of your nose Yes No
Thick green or yellow discharge from your nose Yes No
Postnasal drip with thick mucus and/or runny nose Yes No
Facial pain Yes No
Recurrent nose bleeds Yes No
Loss of smell Yes No
Do you have any of the following symptoms?
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Allergic rhinitis questionnaire to
recognize AR
Watery runny nose Yes No
Sneezing, escpecially violent and in bouts Yes No
Nasal obstruction Yes No
Nasal itching Yes No
Conjunctivitis (red, itchy eyes) Yes No
Do you have any of the following symptoms for at least
one hour on most days (or on most days during the
season if your symptoms are seasonal)?
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➢ Nasal symptoms only on one side
➢ Nasal or postnasal purulent discharge
➢ Facial pain, headache
➢ Loss of smell
➢ Nasal bleeding
➢ Facial- and periorbital swelling
➢ Fever, bad general condition
Alarm symptomps
Examination by a specialist is
required
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https://www.merckmanuals.com/en-ca/professional/eye-
disorders/conjunctival-and-scleral-disorders/allergic-conjunctivitis
https://webeye.ophth.uiowa.edu/eyeforum/cases/103-Pediatric-
Orbital-Cellulitis.htm
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Nasal crusting
Severe crusting especially high inside the nose –
unusual, requires further investigation
Consider: chronic rhinosinusitis, nose picking,
granulomatous polyangiitis, sarcoidosis or other
vasculitis, cocain abuse, ozaena, non-invasive ventilation. Topical steroids rarely cause crusting
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Lower respiratory tract
infection
Coughing, wheezing, shortness of breath – can
occur with rhinitis since bronchial hyperreactivity
(can be induced by upper airway inflammation)
Disorder of the upper and lower respiratory tract
often coexist – 80% of people with asthma have
rhinitis – COMMON AIRWAY HYPOTHESIS
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Assess possibility of asthma
➢ Have you had any attack or recurrent attacks of
wheezing?
➢ Do you have a troublesome cough, especially at
night?
➢ Do you cough or wheeze after excercise?
➢ Does your chest feel tight?
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Examination
Visual assessment (allergic salute, chronic mouth
breathing, allergic shiners, assessment of nasal
airflow, depressed nasal bridge – post surgical?
Cocain abuse? Granulomatous polyangiitis?,
widened bridge – polyps?, purple nasal tip due to
sarcoidosis
Anterior rhinoscopy (structure, mucosa, secretion)
Nasal endoscopy (posterior rhinoscopy)
Allergen specific IgE (SPTs, serum immunoassay)
Lab tests
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Allergic salute
Allergic mug
Dennie-Morgan’s infraorbital lines
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Symptoms
„Adenoid face” https://radiopaedia.org/articles/adenoid-facies-2
underdeveloped thin nostrils
short upper lip
prominent upper teeth
crowded teeth
narrow upper alveolus
high-arched palate
hypoplastic maxilla
Recurrent upper respiratory tract allergies:
•Dennie's lines: horizontal creases under
the lower eyelids
•a nasal pleat: the horizontal crease just
above the tip of the nose produced by
the recurrent upward wiping of nasal
secretions
•allergic shiners: bilateral shadows under
the eyes produced by chronic venous
congestion
Georges Biard, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=
31432974
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Laboratory investigations
Full blood count, differential white blood cell count, CRP, immunoglobulin profile,
microbiological examination of sputum and sinus
swabs in chronic infection
Thyroid function tests
Nasal secretion – Beta-2 transferrin for CFS
identification
Urine toxicology (cocain abuse susp.)
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Other investigations
Olfactory tests
Cytology
Exhaled nitric oxid (high in eosinophilic lower
respiratory truct inflammation, asthma)
Nasal nitric oxid (low in cystic fibrosis, primer ciliar
dyskinesia and sinus obstruction)
Radiology (CT scan)
Nasal challenge
Objective measures of nasal airways (allergen,
aspirin challenges, before septal surgery and
turbinate reduction)
(Tests for asthma)
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Seasonal Allergic Rhinitis
Three main symptomps (triad)
– Clear, watery nasal discharge
– Sneezing attacks
– Nasal obstruction
Tiredness, headache, inability to work
Conjunctivitis, itching in the throat
Bronchial asthma
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Causes
– Trees (hazelnut, alder, birch tree, ash tree – from the beginning of February till the end of March)
– Herbs meadow-grass, ray-grass, rye, corn, grains –from the end of April till July
– Weeds - ragweed, wormwood, mugwort, nettle –from August till October
– Fungi - Alternaria, Cladosporium – from July till October
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Hazelnut
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Alder
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Birch tree
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Ragweed
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Mugwort
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Perennial Allergic Rhinitis
Independent from the season, persistent symptomps
Nasal obstruction is dominant
Eye symptomps very rarely
It can associate with pollinosis
Causes– House dust mites (Dermatophagoides pteronyssinus,
Dermatophagoides farinae
– Animal hair, epithelial scales, humours (dog, cat, rabbit)
– Fungal spores (Aspergillus, Mucor, Penicillium)
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Pollen catch
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Pollen calendar
March April May June July August September
Hazelnut
Cottonwood
Willow
White birch
Hornbeam
Birch tree
Oak
Linden
Grasses
Rye
Lanceloar rip grass
Pigweed
Nettle
Mugwort
Ragweed
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Epidemiology of Allergic
Rhinitis I.
The incidence and prevalence of AR
is increasing continously all over the
world
20% of the population is affected
In Hungary some 2 million people
suffer from AR
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Epidemiology of Allergic
Rhinitis II.
Disease of schoolchildren and young adults
Genetic disposition, atopic disease in the
family
Date of birth
Social conditions
More frequent in townspeople
Environmental factors, air pollution
Changing in the flora
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The specific IgE is detected in the
skin
Patch tests
Prick tests
Intracutan tests
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PRICK test
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Prick teszt
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The Prick-test must not be
performed during the following
conditions: During heavy symptomps
Skin diseases (eczema, psoriasis)
Infectious diseases with fever
In acute diseases, heavy asthmatic state
Under the effect of certain drugs (antihistamins,
steroids – local or systematic, antidepressive or
tranquillazer drugs)
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Determination of Serum
Specific IgE
radioisotope
fluorescent
enzyme
RAST: radio-allergo-sorbent test
ELISA: enzyme-linked immunosorbent assay
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Advantages of RAST and
ELISA:
safe
precise
does not depend on
- skin reaction
- drugs
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Therapy of AR
Allergen avoidance (causal treatment)
Pharmacotherapy (symptomatic treatment)
Immunotherapy (specific desensitization -
causal)
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Allergen avoidance
Change of climate
Change of occupation
Elimination of mould
Removal of pets, domestic animals
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Pharmacotherapy
(symptomatic)
Antihistamines
Corticosteroids (local, systemic)
Leukotrien receptor antagonists
Chromoglycates (local or systemic) – inhibit the
liberation of H substances from mast cells (histamin,
serotonin)
Decongestants – temporarily!
Anticholinergs
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Antihistamins I.2. generation, peroral
Loratadine Desloratadin
Cetirizin Levocetirizin
(Terfenadine) Fexofenadin
Rupatadine
Bilastin
Ebastine, Mizolastine
Local
➢ Azelastin (nasal spray, also in combination, eye drops)
➢ Emedastin difuramate (eye drops)
➢ Olopatadine (eye drops, nasal spray)
➢ Antazolin (eye drops)
➢ Levocabastinum (eye drops)
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Antihistamins II.
➢ Non sedative
➢ Strong and selective periferial H1R antagonism
➢ Quick beginning of action
➢ Long halflife in the serum (long action, 24 hours)
➢ Wide therapeutic range
➢ Antiallergic and antiinflammatory effect
➢ No cardial side effect
➢ For mild or moderate symptoms of children and adults
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Desloratadine Placebo
Note: Illustration represents result for a single patient.Courtesy of F. Horak, 2002.
Effect of desloratadine on
nasal obstruction
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Summary of „side effects” of
desloratadine
Non sedative
No elongation in QT interval
Can be taken idependently of meal
Available in tablet and syrup forms as well
Does not amplify the effect of alcohol
No interaction with other drugs
Can be given from 1 year of age
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Local cortikosteroids I.
➢ Mometason furoat
➢ Budesonid
➢ Fluticason furoat
➢ Fluticason proprionat
➢ Ciclenosid
➢ They differ in receptor affinity and in
pharmacokinetic features
➢ They are very similar in effectivity and safety
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Local cortikosteroids II.
➢ They are the most effective drugs in AR
➢ They decrease all nasal symptoms
➢ They are effective in hours
➢ High concentration on receptors
➢ Very little side effects (mucosal dryness, crusting)
➢ No systemic side effects even in maximaldoses (max. 400ug/nap) (i.e. bonemetabolism, glaucoma, cataracta)
➢ In moderate or severe symptoms of adultsand children (from determined years of age)
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Mometazon furoat nasal spray
Characteristics
➢ Significant receptor
affinity
➢ High effectivity
➢ Rapid beginning of its
action
➢ Well tolerated
®
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Mometason furoat rapidly and effectively
reduces the nasal symptomps of AR
A nazális tünetek csökkenése Nasonex hatására
SAR-ben (n=196 *p<0,001)
0
0,5
1
1,5
2
2,5
3
Orrfolyás Orrdugulás Viszketés Tüsszentés
Tüneti
ponts
zám
1. nap 3. nap 7. nap 14. nap
Magyar és mtsai. A glükokortikoid mometazon furoát orrspray formában való adásának hatása szezonális
allergiás rhinitisben. Orvosi Hetilap 2000,141 (25), 1407-1411.
*
**
** *
**
*
**
*
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Nasonex rapidly and effectively reduces
the non-nasal symptomps of AR
A nem nazális tünetek csökkenése Nasonex hatására
SAR-ben (n=196 *p<0,001)
0
0,5
1
1,5
2
2,5
Könnyezés
Szemviszketés/égés
SzájpadviszketésFülviszketés
Tü
ne
ti p
on
tszá
m
1. nap 3. nap 7. nap 14. nap
Magyar és mtsai. A glükokortikoid mometazon furoát orrspray formában való adásának hatása szezonális
allergiás rhinitisben. Orvosi Hetilap 2000,141 (25), 1407-1411.
*
*
**
*
** *
* **
* *
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Nasonex does not cause atrophic
changes in the nasal mucosa
(moreover regenerates it)
A B
Before MFNS treatment After 12 months MFNS treatment
Minshall E, et al. Otolaryngol Head Neck Surg. 1998;118(5):648
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Systemic corticosteroids
Short time (7-21 days), per oral administartion, max. 1mg/kg/day
Depot steroid or intranasal steroid injection MUST BE avoided any time (uncertain absorption, severe side effects)
Specific contraindication: childhood, pregnancy
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Intranasal chromons
Dinatrium-chromoglicate
Nedocromil-sodium
Local antiinflammatory-antiallergic products without systemic side effects
They are safe to use for children and during pregnancy, in mild nasal or eye symptoms
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Decongestant products
Local
Local nasal vasocontrictor products with
different mechanisms of action
Alpha-1 agonists: ephedrin, pseudoephedrin,
phenilephrin
Alpha-2 agonists: imidazol derivates: oxi- and
xylometazolin
In moderate or severe symptoms temporary
additional therapy, for 7-10 days max.
ADDICTIVE! – rhinitis medicamentosa
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Combinations of
antihistamin and oral
decongesstant
➢ They improve nasal breathing
➢ Systemic sympathomymetic effect – must be
taken into consideration (HT?)
➢ Less addictive than local products, but less
effective in nasal symptoms (nasal blockage)
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Leukotrien receptor
antagonistsMontelukast, Zafirlukast
➢ LT mediators take part in developing all nasal symptoms
➢ 1 molecule of LT has 5000x higher nasal costipation potential than the histamin has.
➢ LT antagonists decrease the nasal constipation and runny nose.
➢ They are effective in asthma, AR, ASA
Placebo < LTRA < AH < INCS
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Specific immunotherapy
Indications:
Pharmacotherapy is insufficient
Pharmacotherapy has side effects
Seasonal allergic rhinitis – for two seasons at
least
Perennial allergic rhinitis – at least half a year
Condition:
Correlation of positive skin test/serum specific
IgE elevation and patient’s symptoms
Good complience!!!
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Specific immunotherapy
Causal treatment
Decreases the allergic inflammation
Effective in every symptom of atopic disease
The quality of life can be improved
SIT can result in asymptomatic disease for 10-15 years
The dose of symptomatic treatment can be
decreased
Developing asthma can be prevented
Allergen spreading can be prevented
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TH-2
TH-1
IL-4
IFN-γ
IgE
IgG
LPRSITAg
+
-
Effect of Specific ImmuntherapyThe amount of allergen specific blocking IgG antibodies
increases
The Th2 type immunoreaction turns into Th1 type
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Non specific immunotherapy
(biologic therapy)
Monoclonal anti IgE antibodies
Omalizumab
Makes complexes with the free IgE
Decresases the free IgE level
Blocks the IgE interactions
Decreases all the nasal symptoms
It is the 5. step in asthma therapeutic protocol
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Allergen cross-binding
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Effect of non-specific anti-
IgE (omalizumab)
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Differential Diagnosis
Other types of rhinitis
Foreign bodies
Inflammation of the paranasal sinuses
(acute, chronic)
Nasal polyps
Granulomas
Tumors
Liquor fistula
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Symptomps of acute
sinusitis
Allergic rhinitis questionnaire!
Pain, headache (face, forehead,
temporal region, top of the head)
Pain increasing during tilting ahead
Nasal obstruction
Purulent nasal discharge
Hyposmia/anosmia/cacosmia
General symptomps: Fever, weakness
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Complications
Periorbital oedema, orbital cellulitis (eye
movement is painful and inhibited)
Orbital abscess
Zygomaticitis
Periostitis, osteomyelitis (frontal sinusitis)
Subperiosteal abscess
Thrombosis of cavernal sinus
Meningitis (neurological symptomps
appear)
Epidural, subdural abscess, brain abscess
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Liquor-fistula
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Structural and mechanic
disturbances preventing
normal nasal function
➢ Septal deviation
➢ Hypertrophy of nasal turbinates, bullous
conchae
➢ Enlarged adenoids
➢ Anatomical variations of osteomeatal unit
➢ Foreign body
➢ Choanal atresia
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Septal deviation
Most frequent cause of disturbed nasal breathing in adults
Symptoms
Nasal blockage
Frequent and lond-continued rhinitis
Recurrents sinusitis
Disturbed tubal function, recurent otitis
Headache
Hyposmia
Recurrent pharyngeal or laryngeal inflammations because of mouth breathing
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Anatomy of nasal septum
https://anatomy
qa.com/nasal-
cavity-septum-
lateral-wall/
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Blood supply of the nasal septum
http://medipicz.blogspot.
com/2011/01/blood-
supply-of-nasal-
septum.html
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Innervation of the nasal
septum
https://teachmeanatomy.
info/head/organs/the-
nose/nasal-cavity/
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Nasal bleeding
➢ Causes – local, systemic
➢ Location!
➢ Anterior, posterior
➢ Chemical or electrocoagulation
➢ Chemical: TCA or AgNO3
➢ Anterior nasal packing
➢ Posterior nasal packing (Foley-catheter or
Bellocq’s packing)
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https://www.slide
share.net/avipatil
30/epistaxis-
80025991
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https://emedicine.meds
cape.com/article/80545-
overview#a2