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Chronic rhinitis

To date, there is no single classification of chronic rhinitis. Numerous attempts to create an acceptable classification of chronic rhinitis, taking into account the features of etiology, pathogenesis, morphological and typical variants, have not yet been fully completed and continue to this day.

Meanwhile, the classification of LB.Dainyak (1987), which takes into account a number of positions of other classifications verified by practice, has many supporters among domestic authors. With small reductions proposed by I. B. Soldatov (1990), it is most convenient for considering individual forms of chronic rhinitis. Based on this classification, chronic rhinitis has the following forms.

1. Catarrhal rhinitis.

2. Hypertrophic rhinitis:

a) limited;

b) diffuse.

3. Atrophic rhinitis:

a) simple - limited, diffuse;

b) fetid runny nose or ozena.

4. Vasomotor rhinitis:

a) an allergic form;

b) neurovegetative form.

Chronic catarrhal rhinitis. This form of chronic rhinitis most often develops as a result of repeated acute rhinitis, which is facilitated by the constant exposure to adverse environmental factors - a gassed, dusty atmosphere, frequent temperature changes, dampness and drafts. The development of chronic rhinitis is predisposed by prolonged congestive hyperemia of the nasal mucosa caused by alcoholism, a chronic disease of the cardiovascular system, kidneys, etc. In the etiology of the disease, hereditary conditions, malformations, disturbances in normal anatomical relationships that cause difficulty in nasal breathing can be important. Chronic runny nose also develops as a secondary disease in the pathology of the nasopharynx and paranasal sinuses.

Morphological changes in chronic catarrhal rhinitis are less pronounced compared with other forms of rhinitis and are localized in the surface layers of the mucous membrane. Atrial fibrillation to one degree or another loses cilia, which can be restored with a favorable development of the process. In some places, the epithelial cover is disturbed and replaced by squamous epithelium. The surface of the mucous membrane is covered with exudate, consisting of secretions, mucous and goblet cells, as well as white blood cells. In the subepithelial layer, round-cell infiltration is detected, mainly by lymphocytes and neutrophils. The vessels of the mucous membrane of the nasal concha are dilated, their walls can be thinned. With a prolonged course of chronic rhinitis, sclerosis develops in the submucosal layer.

Clinic and symptoms. Symptoms of chronic catarrhal rhinitis are generally consistent with symptoms of acute rhinitis, but are much less intense. The patient complains of discharge from the nose of a mucous or mucopurulent character. Difficulty in nasal breathing is not constant. It intensifies (like nasal discharge) in the cold. Often there is alternating congestion of one of the halves of the nose. Usually it manifests itself when lying on your back or on your side. In these cases, there is a rush of blood to the underlying parts of the nose. The vessels of the cavernous tissue of the nasal concha, due to the loss of tone in a relaxed state, overflow with blood, which causes nasal congestion. With a change in body position, congestion passes to the other side.

With rhinoscopy, diffuse hyperemia of the mucous membrane is determined, often with a cyanotic hue. The lower nasal concha, moderately swollen, narrow the lumen of the common nasal passage, but do not completely cover it.

Chronic catarrhal rhinitis can be accompanied by a violation of the sense of smell in the form of its weakening (hyposmia). Complete loss of smell (anosmia) is rare. A transition of catarrhal inflammation from the nasal cavity to the mucous membrane of the auditory tube with the subsequent development of tubootitis is possible.

The diagnosis of the disease is established on the basis of complaints, medical history, anterior and posterior rhinoscopy.

In order to distinguish catarrhal chronic rhinitis from hypertrophic, the mucous membrane is anemicized with vasoconstrictors (3 - 10% cocaine solution, 3% ephedrine solution, or 0.1% adrenaline solution, using it only as an additive of 3-4 drops per 1 ml of any anesthetic, e.g. 2% dicaine solution).

A marked reduction in the mucous membrane of the turbinates indicates the absence of true hypertrophy inherent in hypertrophic rhinitis. Differential diagnostics between false and true hypertrophy can also be carried out using a button probe. In case of false hypertrophy, the probe more easily bends the mucous membrane to the bone wall. With true hypertrophy, a densified tissue is determined that is not amenable to pressure exerted on it.

Treatment. The success of treatment depends on the possibility of eliminating the adverse factors causing the development of chronic rhinitis. Useful stay in a dry warm climate, hydrotherapy and spa therapy. It is necessary to treat common diseases associated with chronic rhinitis, as well as the elimination of intranasal pathology (deformity, sinusitis, adenoid vegetation).

Local treatment consists in the use of antibacterial and astringent drugs in the form of a 3 - 5% solution of protargol (collargol), 0.25-0.5% solution of zinc sulfate, 2% salicylic ointment, etc. Assign to the nose of the UHF, endonasally UFO (tube -quartz). The prognosis is usually favorable.

Chronic hypertrophic rhinitis. The causes of hypertrophic rhinitis are the same as catarrhal. The development of this or that form of chronic rhinitis, apparently, is associated not only with the influence of external adverse factors, but also with the individual reactivity of the patient himself.

Pathomorphological changes in hypertrophic rhinitis differ from those in catarrhal predominance of proliferative processes.
The development of fibrous tissue is observed mainly in places of accumulation of cavernous formations. Hypertrophy of the mucous membrane of the nasal concha often reaches considerable size. There are three types of shell hypertrophy: smooth, tuberous and polypous. It can be diffuse and limited. The most typical site of hypertrophy is the anterior and posterior ends of the lower and anterior end of the middle turbinate. Hypertrophy can also occur in other areas of the nose - in the anterior part of the nasal septum and at its posterior edge, on the vomer.

Possible swelling of the mucous membrane in the region of the nasal concha, especially the middle, resembling nasal polyps. This puffiness and polyp-like thickening, unlike polyps, has a wide base. Subsequently, polypous hypertrophy can gradually transform into polyps. This is facilitated by allergization of the body (auto- and exogenous in nature). The occurring bone hypertrophy of individual nasal concha is a variation of the abnormality of the nose.

Clinic and symptoms. Hypertrophic rhinitis is characterized by a constant nasal congestion, depending on the excessive increase in the nasal concha, practically not contracting under the action of vasoconstrictors. It makes nasal breathing and profuse mucous and mucopurulent discharge difficult. Due to obstruction of the olfactory fissure, hyposmia and then anosmia occur. In the future, as a result of atrophy of olfactory marks, essential (irreversible) anosmia may occur.

The voice timbre in patients becomes nasal (rhynolalia clausa).

As a result of compression of the lymphatic fissures by the fibrous tissue, lymph outflow from the cranial cavity is disturbed, which causes a feeling of heaviness in the head, disability and sleep disturbance.

Turning off nasal breathing leads to impaired ventilation of the paranasal sinuses, as well as a disease of the underlying respiratory tract. Hypertrophy of the posterior ends of the lower nasal concha violates the function of the auditory tube and leads to tubo-otitis. Thickening of the anterior lower nasal concha can compress the outlet of the lacrimal nasal canal with the subsequent development of dacryocystitis and conjunctivitis.

Endoscopic examination allows you to determine the nature of hypertrophy. A uniform increase in the turbinates is observed with diffuse hypertrophy, an increase in individual elements (front and rear ends of the turbinates, sections of the nasal septum) indicates limited hypertrophy.

Treatment. Treatment of hypertrophic rhinitis is mainly surgical. Methods of treating diffuse hypertrophy pursue the development in the postoperative period of the sclerosing scar process in the submucosal layer, which reduces the size of the nasal concha. For this purpose, various methods for intra-cauterization of tissue are used (by electricity - electrocautery, ultra-low temperatures - cryodestruction), as well as by such effects as ultrasonic or mechanical disintegration. A laser beam is also used for this purpose. Cauterization of the surface of the turbinates in the form of 2 to 3 strips extending from the posterior end of the inferior turbinate to the anterior, leading to significant damage to the ciliated epithelium, has been less popular in recent years.

In cases where there is bone hypertrophy of the nasal concha, one of the options for submucosal intervention is performed. After a vertical incision of the mucous membrane at the anterior end of the lower or middle nasal concha, a bone skeleton is allocated with a raspator and then either a partial excision of the bony structures of the concha is performed or flattened. This intervention is usually complemented by a displacement of the shell laterally, i.e. lateroposition, or laterofixation is performed. The operation ends with a loop swab.

With limited hypertrophy of the anterior and posterior ends of the lower nasal concha or their lower edge, these sections are excised (conchotomy). Conhotomy is not a complicated surgical procedure. However, the insidiousness of this operation lies in the fact that excessive conchotomy, performed with the capture of bone structures, will soon lead to a significant reduction in the shells after scarring and the development of atrophic rhinitis, painfully tolerated by the patient.

When removing limited hypertrophic areas (the anterior and posterior ends of the inferior nasal concha, as well as the anterior end of the middle nasal concha), use a loop or nasal scissors, which have two options - for the lower and middle concha. The loop is inserted into the nose under the control of vision and superimposed as close as possible to the base of the hypertrophied area. Subsequent tightening of the loop cuts it off. If hypertrophy captures the lower edge of the nasal concha, then this section is cut off with scissors or a conchotome. In fig. 2.7.4 presents options for some of the considered intranasal operations.

The considered surgical interventions are usually performed under local anesthesia (lubrication of the mucous membrane with 3 - 10% cocaine solution or 2% dicaine solution with the addition of 2 - 3 drops of 0.1% adrenaline solution per 1 ml of anesthetic and intraoral administration of 5 ml of 1 - 2% novocaine solution or 0.5% trimecaine solution). The operation ends with a loop swab. Tampons are removed after 2 days. However, given the possibility of significant bleeding after removal of tampons, especially after removal of the posterior ends of the lower nasal concha (posterior conchotomy), complete removal of tampons can be done at a later date. To prevent infection, irrigation of tampons with antibiotic solutions is recommended. It is unnecessary to add that before the conchotomy the patient should be examined, including and in terms of the state of the blood coagulation system.
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Chronic rhinitis

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