Is affected, it can be removed locally. Only a very limited portion of the

middle turbinate should ever be removed, lest atrophic rhinitis be produced, the

symptoms of which are more unpleasant than those of the original condition.

Atrophic rhinitis

Atrophic rhinitis is becoming much less common in advanced communities. In its

primary form it is probably therefore a disease associated with malnutrition,

poor living conditions and infection, and can occur in several members of a

family group. It can also, in its secondary form, be the end-result of treated

nasal disease, for example, sarcoidosis, tuberculosis, midline granuloma or

rhinitis caseosa, and can rarely be the aftermath of excessive nasal surgery

such as turbinectomy or an unsuccessful submucous resection.

PATHOLOGY. The atrophic changes in the mucosa are secondary to an endarteritis

and periarteritis which cause a diminished blood supply with atrophy of the

ciliated columnar epithelium and its metaplasia to a cuboidal or stratified

squamous epithelium. A thick viscid secretion is exuded, which dries rapidly to

form crusts. Both nasal cavities are usually affected.

SYMPTOMS. The earliest complaint is a feeling of dryness in the nose. Nasal

crusting causes blockage. Epistaxis is frequent, if small in amount, when the

crusts separate. Headache is common.

CLINICAL FEATURES. Mucosa of the nasal cavity is atrophic and dry. The nasal

cavities contain crusts.

TREATMENT. The variety of medical and surgical treatments advocated for atrophic

rhinitis is an indication of their unproven worth in most instances.

Infection, particularly of the sinuses, should be sought and treated. Twenty

five per cent glucose in glycerin nasal drops or cream on the polymer basis help

to lessen crust formation, and give some symptomatic relief in less severe

cases. When nasal obstruction due to crusting is a prominent feature, nasal

douching is the most satisfactory method of removal and normal saline is the

solution of choice. Surgical treatment aims at narrowing the nasal cavities. The

mucosa of the floor of the nose, the lower lateral wall up to the attachment of

the inferior turbinate and the lower half of the septum can be raised through a

sublabial incision, and Teflon is packed into the space leading to a narrower

nostril of reduced depth, and this is probably the most satisfactory procedure.

Alternatively, the nostrils can be surgically closed anteriorly and after a

period of years when they are re-opened it is found that healthy respiratory

epithelium has regenerated.

Ozaena

These disease is specific type of chronic atrophic rhinitis and is due to

Klebsiella ozaenae.

SYMPTOMS. The most characteristic symptom of ozaena is foetor which may be

noticed at some distance from the patient. Fortunately the sufferer is unaware

of it as complete anosmia is present. Nasal crusting causes blockage.

CLINICAL FEATURES. When the nose is examined the nasal passages are seen to be

wide. The inferior turbinates are flattened and may be difficult to distinguish

upon the lateral walls of the nose. The mucous membrane is usually dark in

color; it may be dry, and may even be shiny in appearance. Crusting is common,

as the atrophy of the mucous membrane makes it impossible for the nasal

secretions to be expelled from the nose in the normal way. The crusts are yellow

as a rule but may be dark and of a greenish colour, and may fill in the nasal

cavities. The bone of the inferior turbinate may share in the atrophic process.

When the crusts are removed the nasal cavities are unduly wide, so that the

posterior wall of the nasopharynx can be seen.

Examination of the nasopharynx may show crusting, and there is usually glazing

of the posterior wall, due to an extension of the atrophic condition. In some

cases this change may be traced down to the laryngeal cavity.

TREATMENT. Treatment is same as in the case of atrophic rhinitis and antibiotics

should be given.

INFLAMMATION OF THE SINUSES

Sinusitis is a very common disease: it is estimated that 5% of the population of

Europe suffer from chronic sinusitis. The maxillary antrum is the most commonly

affected in adults, followed in decreasing order of frequency by the ethmoids,

frontal, and shpenoid sinuses. In children the ethmoid sinuses are most

frequently affected. Infection of several sinuses is described as polysinusitis,

and of all the sinuses pansinusitis, unilateral or bilateral.

Depending of the organism, its virulence, pathophysiologic factors, and

immunologic resistance, sinusitis may take a catarrhal, purulent, hypertrophic

or atrophic form, with mixed forms being common. The pathology within the sinus

also depends on the duration of the disease process. Acute and chronic sinusitis

may be distinguished.

Acute sinusitis

Acute inflammation of the paranasal sinuses is usually due to an extension of an

infection from the nasal cavity. The sinuses may be involved singly or two or

more may become infected. The commonest cause is an acute rhinitis, but it may

also follow dental infection such as apicitis or apical abscess, dental

extraction if an oro-antral fistula develops, injuries to the facial bones, and

operations on the nose. Obstruction to the normal aeration of, or drainage from,

a sinus because of a deviated nasal septum, enlarged adenoids, the presence of a

foreign body in the nose or allergic rhinitis can all predispose to sinus

infection. Acute sinusitis may take a catarrhal or purulent form.

BACTERIOLOGY. While the acute rhinitis which precedes the acute sinusitis is

viral in origin, the sinusitis itself is a bacterial infection which excites the

production of pus. The responsible organisms are pneumococci, streptococci,

staphylococci, Haemophilus influenzae and Escherichia coli. In infection of

dental origin, Bacillus dentalis and B. necrodentalis may also be present.

Anaerobic organisms, such as bacteroides, are sometimes found in the pus from

infected sinuses.

PATHOLOGY. All the paranasal sinuses are essentially bony boxes lined by

respiratory epithelium, which is continuous with the epithelium of the nose

through the ostium of each sinus. The essential change in sinusitis is blockage

of the ostium, and hence stasis of the secretion within the sinus. The latter

becomes infected by bacteria causing an acute inflammatory response within the

mucosa which becomes thickened, and hence the ostium remains closed. There is

leucocytic infiltration of the mucosa, and in virulent infection there can be

ulceration of the lining epithelium. The maxillary sinus is most commonly

affected, because the ostium is high on the medial wall and drainage is not

aided by gravity.

SYMPTOMS. The symptoms vary in severity, and their extent depends upon the

degree to which the ostium is blocked, upon the causal organism and upon the

patient's general health.

There is a feeling of fullness and tension over the sinus or sinuses affected.