CT Scan of the Sinuses showing chronic sinusitis

Causes

They commonly occur in more general diseases such as asthma and cystic fibrosis.
Late onset asthma rather than childhood asthma is associated with nasal polyps. Of the patients with polyps 20% to 40% will have coexisting asthma. Although nasal allergy is present in some cases, more than two thirds of the patients show no evidence of systemic allergic disease. However, 90% of nasal polyps have eosinophilia- Absolute Eosinphil count will be high. These polyps tend to recur more than in other conditions. Nasal polyps are rare in children between the ages of two and 10 years. If found in children cystic fibrosis should be excluded.

Symptoms

Nasal polyps are common in both sexes.One-sided nasal polyps are rare and associated with a range of conditions and need further investigations both in adults and children eg.Antrochoanal polyp, Ringerts pappilloma
Polyps look like small grapes and can appear singly or in clusters in the nasal cavity. The can cause:
• Blocked nose
• Runny nose and/or sneezing are seen in about half of patients
• A poor sense of smell (Anosmia or Hyposmia) and taste which may not always return after treating the polyps
• Chronic Catarrh

Treatment

D N Endoscopy, where a small illuminated endoscope is used to see up the nose will exclude any infection or any unusual feature.

Medical treatment

Nasal polyps are known to shrink when nasal sprays or drops containing nasal steroids are used. Stronger steroids in drop form can be used but should only be used with care and limited to short courses because some is absorbed into the body.
Polyps respond and shrink using drops or sprays in up to 80% of people. New nasal steroid sprays can be taken to control symptoms for many years as very little is absorbed into the body and they can work well, but many take up to six weeks of treatment before their full effect can be felt.
Steroids in tablet form(Methyl Prednisolone, Defla cort) can provide good relief of symptoms but the effects are short-lived and they are used sparingly because of concerns about side effects. If medicines don’t work then surgery is needed.
Injection of Methyl Prednisolone 80 mg IM once in a month for 3 months can be tried.

Surgical treatment

Nasal Polypectomy. Nasal polyps blocking the nose can be removed surgically and this often helps the patient to breathe better. In three out of four patients the polyps come back after an average period of four years.
FESS.Functional endoscopic sinus surgery is the standard procedure to get the ethmoids opened and better removal of polyps.

Nasal blockage is the sensation of reduced air flow either through one nostril (unilateral) or both nostrils (bilateral). IT can be due to the following
• Mucosal swelling
• Septal deviation
• Collapse of the nasal valves
• Nasopharyngeal obstruction
• Nasal polyps

Allergic rhinitis
The mucosa is the thin moist lining that covers the bone and cartilage inside the nose.This occur in all types of rhinitis and sinusistis.
Vasomotor rhinitis
Clear mucus production is the primary problem with less nasal obstruction. This is due to overactivity of the glands in the nose.
Rhinitis medicamentosa
Overuse of some decongestant nasal sprays (Otrivine, Nasivion). These can help decongest the nose for a few hours if you have a cold but should not be taken for more than a few days as they damage the lining of the nose.
Chronic rhinitis and sinusitis
It is associated with a greenish mucus throughout the day.
Atrophic rhinitis -Ozena
Where neither allergy nor infection can be found yet the lining of the nose is swollen.
A range of rare conditions can affect the lining of the nose. These often cause a lot of crusting, spotting of blood and nasal obstruction. If there is a lot of crusting or whistling then your doctor may refer you to an ear nose and throat surgeon for further tests.

Septal deviation
The septum is a thin piece of bone and cartilage seperating the left and the right side of the nasal cavity. In some people the septum is bent or deviated over to one side and this blocks the air passage of the nose.
Septal deviation may be associated with a visibly deformed nose and a history of nasal trauma although it is not necessary as the cartilage may bend and deform as your nose grows.
Nasal obstruction is the predominant symptom, usually on one side. However, if other symptoms are present other disease processes must be excluded.
Management depends on the severity of nasal obstruction. Surgery to correct the deformity can be undertaken if the nose is blocked or unsightly.

Collapse of the nasal valves
Normally on breathing in through the nostrils there is a small amount of collapse of the nostrils.
Occasionally the problem is primarily due to a ‘floppy’ valve or side wall of the nose collapsing. Treatment using external nasal splints can sometimes be help at night. Surgery in this area is not straightforward.
Adenoids
The back of the nose just before it enters the back of the throat is called the nasopharynx. The adenoids are the most common cause of nasal obstruction in children reaching maximum size between the age of three and five and then reduce in size often by the age of seven or eight and can hardly be seen by the late teens.
Snoring alone is not an indication for adenoid removal but if the child also stops breathing while asleep (apnoea - stops breathing for more than 10 seconds regularly without a cold) then adenoidectomy and tonsillectomy may be helpful.
In children with a blocked nose on one side and a one sided nasal discharge, a foreign body may be in the nose

Treatment

Aim at the cause. Dont try to misuse OTC nasal drops without medical supervision. Please see an ENT surgeon and get examined to see the cause of nasal blockage and get the correct treatment.

Atrophic rhinitis (Ozena) is a rare chronic inflammatory disease that affects the lining of the nasal cavity. This condition is characterized by a wasting away or an atrophy of the bony ridges and the mucus membranes inside of the nasal cavity. It is characterized by progressive nasal mucosal atrophy, nasal crusting, fetor, and enlargement of the nasal space with paradoxical nasal congestion.
The nasal cavities are roomy with lot of crusts which is foul smelling.
Exact cause unknown, but Endocrine, nutritional deficieancy, autoimmune causes, infective etiology are blamed.

Pathology

The ciliary epithelium is replaced by stratified squamous epithelium, atrophy of mucous glands.The turbinates also atrophy.

Symptoms

The symptoms include nasal crusting, discharge, and a bad odor

Examination of the nasal passage shows greenish discharge. Septal perforation may co exist.

Treatment

Nasal irrigation with alkaline solution(1 litre boiled and cold water add 1 tsp salt, sugar and soda bicarb) or normal saline.
25%glucose in glycerin nasal drops
Local antibiotic ointment, drops
Systemic antibiotics with anerobic cover.

Surgery

The aim of surgery is either to narrow the nasal cavity or in special cases to close the nostril. Closure of the nostril (Young’s operation), is achieved by raising a circular skin flaps. Raising the skin flap is difficult, the suture line may break down and an excessive scar tissue may form resulting in vestibular stenosis.

Modified Young’s operation aim at partial closure of nostrils one at a time.

Prognosis

There is a tendency to recover spontaneosly.

Having a cold or Flu?

The cold and flu are both respiratory illnesses, but they are caused by different types of viruses.

Flu symptoms usually come on quickly (within 3-6 hours) and consist of a fever, body aches, dry cough, and extreme tiredness. Cold symptoms are less severe and people experience a stuffy nose, productive cough, slight tiredness, and limited body aches.

Flu Virus
Influenza A and B viruses are responsible for seasonal flu epidemics each year …

Symptoms

Avoid Getting a Cold and Flu

Wash your hands often. You can pick up cold germs easily, even when shaking   someone’s hand or touching doorknobs or handrails.

Avoid people with colds when possible.

Sneeze or cough into a tissue and then throw the tissue away.

Clean surfaces you touch with a germ-killing disinfectant.

Don’t touch your nose, eyes, or mouth. Germs can enter your body easily by these paths.

A flu shot can greatly lower your chance of getting the flu.

What to do then?

Drink plenty of fluids.

Get plenty of rest.

Use a humidifier — an electric device that puts water into the air.

Avoid alcohol and tobacco

Antibiotics rarely help

Medicines

What are the causes Bad Breath

Anything that decreases the flow of saliva or stimulates the growth of anaerobic bacteria.Saliva irrigates the mouth, stimulates swallowing thereby flushing away debris. As saliva contains oxygen, the dryer your mouth and the thicker your saliva, the less the washing action and the lower the oxygen level creating a more anaerobic environment for bacteria to produce sulfur compounds. This oral stagnation is more pronounced in mouth breathers and those who snore. Certain medications for high blood pressure, antihistamines and depression can decrease saliva flow. Dehydration and stress also reduces the flow of saliva. Morning breath occurs due to decreased salivary flow during sleep.

These anaerobic bacteria breakdown proteins as the start to digestion, and produce these sulfur compounds as a by-product. These proteins come from oral cellular debris dead bacteria, saliva, food debris, mucous, post nasal drip and phlegm.

An important factor in bacterial growth is the pH of the mouth. Bacteria reproduce faster in a more acid environment. Coffee and acidic foods increase acidity. Hormonal changes have even been implicated with bad breath. During menstruation, estrogen causes sloughing of body lining tissue including that of the mouth. This gives additional nutrition for anaerobic bacteria.

Other causes of bad breath include:

• tonsil or throat infection -Chronic pharyngitis, Tonsillolith
• dry mouth
• smoking
• alcohol and certain foods e.g. Garlic
• inflammation of the oesophagus, (Oesophagitis), reflux GERD
• inflammation of the sinuses - Chronic Sinusitis and Postnasal drip
• build up of bacteria on the tongue-Stomatitis
• crash dieting - when energy producing food such as Carbohydrates are with held from the body, stored body fat is broken down instead. The waste product from this type of energy break down are ‘Ketones’, which give a sweet and sickly smell

Sinusitis and bad breath

Chronic sinus infections are among the most common form of upper respiratory infection in children and adults.

The most common symptoms of chronic sinus infection include:
1. Purulent postnasal discharge.
2. “Fullness” or congestion around the sinus areas
3. Chronic coughing, frequently at night.
4. Chronic sore throat.
5. Bad Breath.
Recognize the symptoms of chronic sinus infection and to prevent the causes of sinus infection, including removing the irritants from the environment or treating the allergies.

Postnasal Drip

Post nasal drip refers to the sensation of thick phlegm in the throat, which can become infected.This is part of the mucous - nasal cilia system that defends us from disease. When the amount of liquid secreted by the nose and sinus is reduced, and the cilia of the nose and sinus slow down, the fluid thickens and you become aware of its presence. This also gives bad taste and smel in mouth.

Gingivitis

Bacteria play an important role in many dental problems such as bad breath (halitosis), gum disease, plaque and possibly sensitive teeth. Plaque also starts out with a sticky film of live bacteria. If it is not removed at this stage, it starts growing on the sugar and minerals and hardens to become calculus which may lead to gum irritation, gingivitis and eventually to periodontal disease causing halitosis

Chronic Tonsillitis

Chronic tonsillitis and chronic pharyngitis is a common cause of Halitosis.
Tonsil Stones (tonsilloliths) are caused by an accumulation of sulfur-producing bacteria and debris that become lodged in the tonsils. This debris (which can include mucous from post nasal drip) putrefies in the back of your throat, and collects in the tonsil crypts (small divots or pockets which appear on the surface of the tonsils).
When this debris combines with the Volatile Sulfur Compounds produced by the anaerobic bacteria beneath the surface of your tongue, along with the tonsil stones it can also create chronic Halitosis.

How is Bad Breath treated?

• Improving oral hygiene - correct brushing technique and regular flossing of teeth
• avoiding smoking, drinking alcohol and eating spicy foods
• using an antiseptic mouth wash -Betadine gargle
• chewing sugar free gum to increase the flow in saliva
• using a tongue cleaner to brush and clean the tongue

Medications

If all the above self help remedies fail, go to a dentist and ENT surgeon, he may be able to help you. A course of Ciprofloxacin with metronidazole or Tinidazole may help to curb the anaerobic infections.

Functional Endoscopic Sinus Surgery

FESS is a treatment procedures carried out with the help of rigid nasal endoscopes. Most patients having FESS will only need diagnostic procedures, not a surgical operation. I began FESS operation from 1987 when I started working at the Bahrain Defence Force hospital. One way FESS differs from traditional sinus surgery is that a thin rigid optical telescope, called an endoscope, is used in the nose to view the nasal cavity and sinuses. The endoscope allows for better visualization and magnification of diseased or problem areas. This endoscopic exam, along with CT scans, may reveal a problem that was not evident before.

It has revolutionized the surgical treatment of chronic sinusitis. FESS generally eliminates the need for an external incision.

Preop CT Scan of the sinuses

A CT scan is a must before doing FESS. Plain X-ray has no value in defining sinus pathology.MRI scans are less useful than CT for most sinus problems, but MRI may be needed in some rare cases of sinus tumors.

How is the operation done?

Most FESS operations are done under general anesthetic in the operating theatre. Hypotensive anesthesia is a bonus. There is no external cut; the surgery is done through the nostrils.

A powerful headlight and angled telescopes to see around corners are used. Using specially designed fine bone -cutting instruments, and powered suction debriders when appropriate, the sinus openings will be enlarged and anything blocking the sinuses, such as swollen mucosa or polyps, will be removed.

Other procedures such as Septoplasty and LASER vaporization of inferior turbinates are often done at the same time as FESS. If you need stitches, they will be internal and self-dissolving. At the end of the operation it is usual to have a pack (merocel) in each nostril to soak up any blood. This is kept in for a day.

The goal of FESS is to open the sinuses more widely. Normally the openings to the sinuses are long narrow bony channels covered with mucosa or the lining of the sinuses. If this lining swells from inflammation, the sinuses can become blocked and an infection can develop. FESS removes some of these thin bony partitions and creates larger openings into the sinuses. After FESS, patients can still develop inflammation from allergies or viruses, but hopefully when the sinus lining swells, the sinus will still remain open. This will permit easier treatment of subsequent exacerbations with more rapid resolution and less severe infections.
The ethmoid sinuses are usually opened. This permits direct visualization of the maxillary, frontal, and sphenoid sinuses and diseased or obstructive tissue can be removed if necessary

Indications for FESS

Polyps-allergic nasal polyps, sinusitis-maxillary, ethmoid, frontal risks?
Nasal and sinus operations are very safe procedures in modern medical practice. But no operation is totally risk free. A general anesthetic carries a minimal risk, with consultant anesthetists using modern drugs and monitoring equipment. There is a low risk of bleeding, either during or up to two weeks after the operation.

Other treatment options?
Long term medication with antibiotics, antihistamines, and steroids helps many people with nasal and sinus problems. Operations are normally only considered when these treatments have already been tried and failed.

Other surgical operations for rhino sinusitis now outdated-

• Sinus wash-Antral lavage
• Intranasal antrostomy
• Caldwell-Luc operation (sub labial antrostomy)
• External fronto-ethmoidectomy

Before the operation

Remember to bring any medicines with you to hospital. You will not be allowed anything to eat for about six hours before operation. The six hour rule does not apply to medicines - these should be taken as usual. When you come into hospital, you will be seen by the nurse who will ask various questions about your general health and attach an identity bracelet to your wrist. Similar questions will be asked by the Resident Medical Officer, and possibly by the anesthetist. You will be examined and checks made to ensure you are fit for anesthetic. If you have any worries or questions, this is a good time to ask.

After the operation

After the operation, you will wake up in the recovery area, where a nurse will look after you. There will probably be a pack in your nose which means you will have to breathe through your mouth. There may be blood in the mouth or nose. This is quite normal and will stop after a while. When you are sufficiently awake, you will return to the ward. You will stay in bed for several hours. Your throat will feel sore; your nose will be blocked. Spit out any blood or secretions; if swallowed it will make you feel sick. The nurse will attend you frequently to check your pulse and breathing. If you are in any discomfort, please let the nurse know as she can you an injection to help relieve it. You will be allowed to drink as soon as the nurse is happy with your condition. You will be advised not to have too much initially as it might make you sick. Food is started as soon as you are able.

At home
Expect to feel as if you have a bad cold or ‘flu for the first 1 - 2 weeks. This is because the lining of your nose will swell up following the trauma of surgery, like the swelling which occurs in viral infections of the nasal lining following a cold. You may well notice large amounts of dark red, brown or green sticky material coming from the back of your nose into the throat, or when you blow your nose, for up to three months after the operation. This is normal and nothing to worry about.

Things to do

• Take all medicines as prescribed, especially antibiotics or nose drops.
• Attend your follow-up appointments - Important treatment will be given.
• Steam inhalations - at least three times daily for two weeks.
• If Otrivine nose drops have also been prescribed, use them before the inhalations.

Things to avoid (for two weeks)

• Smoking, or any smoky, dirty or dusty atmosphere
• Heavy physical work, including fitness training
• Blowing the nose hard (gentle blowing is acceptable but try a steam inhalation first)
• Close contact with people suffering from cold or flu (avoid large crowds for this reason)

Nosebleeds
A minor degree of bleeding - a few spots on a handkerchief, some bloodstained discharge from the nose - is normal and nothing to worry about. You may get a few large dark red or brown clots coming from the nose, or going back into the throat, in the first 1 - 2 weeks; again this is normal and nothing to worry about. If you get a profuse amount of bright red blood, this is not normal. You should

• Sit down in a chair, pinch the nose and breathe through the mouth.
• If there is someone else around, ask them to put some ice in a plastic bag, and hold it over the bridge of your nose.
• If it doesn’t stop within five minutes you should contact us advice.
• In a more urgent situation, you may call the ENT doctor

Saline Nasal irrigation involves flooding the nasal cavity with warm saline solution (salt water). The goal of nasal irrigation is to clear out excess mucus and particulates and moisturize the nasal cavity. Either a fluid-filled syringe or bulb can be used. The practice has been subjected to clinical testing and has been found to be safe and beneficial, with no apparent side effects
Saline rinses help to prevent the crusting of secretions in the nasal passages, which may otherwise block the sinuses from draining. If the sinus drainage sites become blocked, which could also occur with swelling from allergies or irritants, a sinus infection may develop. Saline rinses also serve to reduce tissue swelling in the nasal passages, and improve the clearance of mucus.

It can be used by patients with chronic sinusitis, allergic rhinitis and after nsasal surgery.
For those who suffer from chronic sinusitis nasal irrigation is a quick and inexpensive way to promote mucociliary function and mucus turnover, decrease edema, and improve drainage through the sinus ostia.

How steam inhalation work in sinus problems?

Increased mucociliary activity has been observed with saline irrigation and steam inhalation which seems to achieve faster recovery. In patients of chronic sinusitis disease, the mucociliary activity is known to be impaired. It is found that steam inhalation improved mucociliary activity significantly in chronic sinus patients.

Nasal inhalation of steam has been proposed as treatment of viral colds on the assumption that increased intranasal temperature will inhibit replication of rhinovirus. The steam inactivates the flu virus. Most people at home use the old fashioned way of head over a bowl of steaming hot water.
Eucalyptus oil or menthol or aromatic herbal leaves (thulasi) in steam inhalation is recommended for relieving nasal congestion and sinus congestion, usually from colds and flu. It can be done two to four times a day to relieve symptoms.

The steam therapy is good after nasal surgery to get rid of the crusts and blood clots.
Safety Precautions- Be careful in children, avoid burns and scalds.