Chronic hypertrophic rhinitis

Chronic hypertrophic rhinitis is understood to mean chronic inflammation of the nasal mucosa, the main pathological feature of which is hypertrophy of it, as well as of the interstitial tissue and glandular apparatus, caused by degenerative tissue processes, which are based on the violation of the IUD. Chronic hypertrophic diffuse rhinitis is characterized by diffuse hypertrophy of the intranasal tissues with a predominant localization in the nasal concha.

[1], [2], [3], [4],

Causes of the chronic hypertrophic rhinitis

Chronic hypertrophic diffuse rhinitis is more common in men of mature age and is due to the same reasons as chronic catarrhal rhinitis. Significant role in the occurrence of chronic hypertrophic diffuse rhinitis is played by foci of infection in neighboring ENT organs, unfavorable climatic and working conditions, harmful household habits, and allergies.

[5], [6], [7]

Pathogenesis

In chronic hypertrophic diffuse rhinitis, hypertrophic (hyperplastic) processes develop slowly and touch first the lower and then the middle turbinate and the rest of the nasal mucosa. This process is most pronounced in the anterior and posterior ends of the inferior turbinate.

In the pathogenesis of chronic hypertrophic diffuse rhinitis, an important role is played by such factors as chronic inflammation, impaired microcirculation, oxygen starvation of tissues, distortion of their metabolism, decreased local immunity and activation of saprophytic microorganisms.

[8], [9], [10], [11], [12]

Symptoms of the chronic hypertrophic rhinitis

Subjective symptoms do not fundamentally differ from those in chronic catarrhal rhinitis, however, obstruction of the nasal passages by hypertrophied structures of the nasal cavity causes constancy of difficulty or even absence of nasal breathing. Patients complain of the ineffectiveness of nasal decohecticants, dry mouth, snoring during sleep, persistent mucous or mucopurulent nasal discharge, foreign body sensation in the nasopharynx, poor sleep, increased fatigue, decreased or no smell, etc. Due to compression lymphatic and venous vessels of the hypertrophied interstitial tissue are impaired and the blood circulation of the lymph flow in the entire nasal cavity and in the forebrain, which leads to headaches, loss of memory and mental performance. In the first phase of chronic hypertrophic diffuse rhinitis, patients often complain of intermittent deterioration of nasal breathing, typical of vasomotor rhinitis, and the difficulty or absence of nasal breathing becomes permanent.

Objective symptoms

The patient is constantly with his mouth open and closes it only when he draws attention to this “defect”. During walking, running and other physical activity, the body can be provided with oxygen only during oral breathing. At rest, with the mouth closed, a patient with a pronounced obstruction of the nasal passages can realize forced breathing through the nose for only a few seconds longer than with a trial holding the breath. The voice of the patients is different nasalism; with this lesion, unlike that with paralysis of the soft palate, called closed nasal (rhynalalia clausa), with paralysis of the soft palate - open nasal (rhynolalia operta).

The clinical course of chronic hypertrophic diffuse rhinitis is long, slowly progressing, which without appropriate treatment can continue to a great age.

[13], [14], [15],

Stages

There are the following phases of the hypertrophic process:

• 1st phase - the so-called mild hypertrophy of the nasal mucosa, characterized by hyperemia and edema of the mucous membrane, moderate lesion of the ciliary epithelium; in this phase, the muscle fibers of the venous plexuses of the inferior nasal concha are not affected by the degenerative-sclerotic process and their vasomotor function is preserved; at this stage of the process, the effectiveness of nasal decorogestants is maintained; the lower turbinates retain elasticity and flexibility during palpation;
• Phase 2 is characterized by metaplasia of the ciliary epithelium, hypertrophy of the glandular apparatus, the initial phenomena of vascular muscle fiber degeneration, lymphocytic-histiocytic infiltration and thickening of the subepithelial layer; these phenomena lead to compression of the lymphatic and blood vessels, edema of the interstitial tissue, due to which the mucous membrane becomes pale or acquires a whitish-bluish color; at this stage, the effectiveness of vasoconstrictor agents is gradually reduced;
• Phase 3 in the foreign literature is referred to as “edematous”, “myxomatous” or “polypoid hypertrophy”, it is characterized by the phenomena of intervascular hypercollagenosis, diffuse infiltration of all elements of the mucous membrane, walls of the blood and lymph vessels and the glandular apparatus; These pathological changes are characterized by varying degrees of severity, with the result that the surface of the nasal concha may take on a different appearance — smooth, uneven, polypodiform, or a combination of these types of hypertrophy.

[16], [17], [18], [19], [20],

Forms

The difference between chronic hypertrophic limited rhinitis from the above-described HGDR lies only in the fact that the zone of the hypertrophic process covers a limited area of the concha, while the rest of their parts remain almost normal. According to localization, several types of this pathological condition are distinguished: hypertrophy of the posterior ends of the inferior nasal concha, hypertrophy of the anterior ends of the inferior nasal concha, hypertrophy of the medial nasal concha — pituitary or in the form of concha bullosa, which is an enlarged cell of the ethmoid bone.

Hypertrophy of the posterior ends of the inferior nasal concha is the most common type of chronic hypertrophic limited rhinitis. The reasons for the development of this pathological condition are the same as in chronic hypertrophic diffuse rhinitis, but most often it is a chronic inflammatory process in the lymphoid apparatus of the nasopharynx, in the ethmoid labyrinth, the sphenoid sinus and allergy. Patients complain about the difficulty of nasal breathing, especially in the expiratory phase, when the hypertrophied part of the shell plays the role of a kind of valve that blocks the choanas. Speech becomes nasal by the type of closed nasal. Patients feel the presence in the nasopharynx of a foreign body or mucus clot, so they constantly "snort" nose, trying to push this "lump" in the throat.

With anterior rhinoscopy, the picture may seem normal, but with posterior rhinoscopy, fleshy, sometimes polypous-modified formations are defined, which partially or completely obstruct the choanal lumen. Their color varies from bluish to pink, but more often it is grayish-whitish, translucent. Their surface can be smooth or resemble mulberry berry or papilloma. As a rule, the process is bilateral, but is developed asymmetrically. Similar phenomena can be observed in the region of the posterior ends of the middle turbinate.

Hypertrophy of the anterior ends of the concha is less common than hypertrophy of the posterior ends of them, and is more often observed in the area of the anterior ends of the middle concha. The causes of hypertrophy of the middle turbinate are the same as the hypertrophy of the inferior nasal concha. In a unilateral process, its cause most often is unilateral concha bullosa or latently the current inflammation of a paranasal sinus. Often, this type of hypertrophy is combined with hypertrophy of the anterior end of the inferior nasal concha.

Hypertrophy of the mucous membrane of the posterior edge of the nasal septum. This type of chronic hypertrophic limited rhinitis is in most cases combined with hypertrophy of the posterior ends of the inferior nasal concha. In the case of posterior rhinoscopy, the edge of the nasal septum is framed on one side, more often on both sides, by peculiar formations, the joan hanging into the lumen, floating in the rhythm of respiratory movements, which is why they are called “wings” or “tails” of the nasal septum.

Hypertrophy of the mucous membrane of the nasal septum is the most rare phenomenon and is a thickening of the mucous membrane in the form of pillow-shaped formations, more or less extended. As a rule, the process is two-way.

[21], [22], [23]

Complications and consequences

Acute and chronic Eustachitis and tubo-otitis caused by obstruction of the nasopharyngeal mouths of the auditory tube of the edematous and hypertrophied mucous membrane of the nasopharynx and the posterior ends of the inferior nasal conchae, sinusitis, adenoiditis, tonsillitis, tracheobronchitis, dacryocystitis, conjunctivitis, etc., and often frequently used by patients and patients, often with chyne cystitis, conjunctivitis and others. Respiratory tract, dysfunction of the digestive organs, cardiovascular system, various hepatic and renal syndromes.

[24], [25], [26], [27], [28], [29]

Diagnostics of the chronic hypertrophic rhinitis

Diagnosis in typical cases of difficulties does not cause. It is based on the patient's history, patient complaints, and data from the functional and endoscopic examination of the rhinosinus region. When making a diagnosis, it should be borne in mind that chronic hypertrophic diffuse rhinitis is often accompanied by latently current sinusitis, the thickening of the whole polypous-purulent process in the anterior sinuses.

In anterior rhinoscopy, in the first pathomorphological phase, the almost normal condition of the inferior nasal concha can be observed, despite the fact that the patient complains of difficulty in nasal breathing. This is due to the adrenergic situational reaction “to the doctor” that preserves its function of the vasoconstrictors of the venous plexuses. The same reaction in this phase is detected by lubricating the lower turbinates with a solution of adrenaline. In the future, the phenomenon of reflex and medical deconhestion decreases and disappears completely. The nasal passages are occluded by enlarged, dense lower and middle nasal concha, while the middle concha acquires a bullous or edematous appearance, descending to the level of the lower concha. In the nasal passages mucous or mucopurulent discharge is determined. In the phase of connective tissue hypertrophy, the surface of the inferior nasal concha becomes hilly, sometimes polypous-modified. The color of the mucous membrane of the nasal concha evolves depending on the pathological phase, from pinkish-bluish to pronounced hyperemia with subsequent acquisition of a grayish-bluish color.

In the posterior rhinoscopy, the bluish color of the nasal mucosa and hypertrophied, edematous, bluish, mucous secretions, the posterior ends of the inferior nasal conchas, often hanging into the nasopharyngeal cavity, attract attention. The same changes may also affect the middle turbinates. The same changes can be observed in the posterior margin of the nasal septum. The edema and hypertrophy of the mucous membrane arising here is located on both sides in the form of nolipo-like formations that have been called PeN “wings” abroad.

With diaphanoscopy and radiography of the paranasal sinuses, a decrease in the transparency of these or other sinuses is often found due to thickening of the mucous membrane or levels of transudate resulting from the absence of a drainage function of the sinuses.

In the study of the known methods of the state of nasal breathing and smell, as a rule, there is a significant deterioration, up to a complete absence.

Diagnosis of chronic hypertrophic limited rhinitis in typical cases of difficulties does not cause, however, in case of atypical forms of hypertrophy, for example, with condyloma granulomatosis with erosion, the disease must be differentiated primarily from tumors and some forms of tuberculosis and syphilis of the nasal cavity.

[30]

Differential diagnosis

Differential diagnostics is performed with deformations of the nasal septum, essential hypertrophy of the nasopharyngeal tonsils, angiofibroma of the nasopharynx, atresia of the nasal passages and Joan, polypous rhinitis, specific infections of the nose (tuberculosis, tertiary syphilis), malignant nasal lashes, and sections).

[31], [32], [33], [34], [35], [36]

Treatment of the chronic hypertrophic rhinitis

Treatment of chronic hypertrophic diffuse rhinitis is divided into general and local; local - for symptomatic, medical and surgical. General treatment does not differ from that in chronic catarrhal rhinitis. Symptomatic is the use of decohegants, a drop from rhinitis, drug corresponds to the local treatment of chronic catarrhal rhinitis described above. However, it should be noted that with true hypertrophy of the endonasal anatomical structures, in particular the lower and middle turbinate, local non-surgical treatment can bring only a temporary improvement in nasal breathing. The main treatment for chronic hypertrophic diffuse rhinitis is surgical, which, however, does not always lead to a final recovery, especially with the constitutional predisposition of body tissues to hypertrophic processes.

The principle of surgical treatment in chronic hypertrophic diffuse rhinitis is the thermal, mechanical or surgical effect on the hypertrophied nasal concha to restore nasal breathing, smell and achieve subsequent scarring of the wound surface, which prevents the recurrent hypertrophic process. The use of one or another type of influence is dictated by the phase of the hypertrophic process.

In the phase of “mild hypertrophy”, it is advisable to use galvanic caustic, cryosurgical effects, laser or ultrasonic destruction, intra-carcinoma mechanical disintegration. These methods are aimed at provoking the inflammatory process and the subsequent hardening of the submucosal structures (mainly vascular plexuses) of the nasal concha to reduce their volume.

Electroplating (galvanothermy, electrocautery) is a method of cauterization of tissues with the help of special metal (iridium-platinum or steel) tips heated by electric current, fixed in special handles equipped with a current switch connected to a step-down transformer. The operation is performed after application anesthesia (2-3-fold lubrication of CO 5-10% solution of cocaine + 2-3 drops of 0.1% solution of adrenaline). Instead of cocaine, you can use a 5% solution dikanna. For deeper anesthesia, intratravel anesthesia can be applied with solutions of trimecain, ultracain or novocaine at an appropriate concentration. The procedure is as follows. Under the protection of the nasal mirror, the end of the galvanic kauter is brought to the far part of the lower turbinates, put into working condition, pressed to the mucosal surface, immersed in the shell tissues and in such a position is removed outside the entire surface of the shell, resulting in a deep linear coagulated tissue burn. Usually spend two such parallel burn lines, placing them one above the other. At the end of the exposure, the galvanocauter is removed from the tissue in a hot state, otherwise, having cooled rapidly in the tissues, it sticks to them and tears off part of the coagulated surface and underlying vessels, which leads to bleeding.

The cryosurgical effect is performed using a special cryoapplicator cooled with liquid nitrogen to a temperature of -195.8 ° C. The ultralow temperature causes deep freezing of the tissue and its subsequent aseptic necrosis and rejection. This method has limited use only for diffuse polypous hypertrophy of the lower nasal conchae.

Laser destruction of the lower turbinates is carried out using a surgical laser, the radiation power of which reaches 199 watts. The factor of laser exposure to tissue is a focused laser beam of a specific wavelength in the range of 0.514-10.6 μm. The most common carbon dioxide lasers. Surgical intervention is performed under local application anesthesia and passes bloodlessly.

Ultrasonic destruction is carried out using special resonantly tuned to this frequency ultrasound sharp cone-shaped emitters (surgical instrument), vibrated with a powerful ultrasonic generator that destroys the structure of tissues and superimposed on the above-mentioned surgical instrument. In this case, oscillations with a frequency of 20-75 kHz and an amplitude of oscillation of the working part of 10-50 microns are used. Ultrasonic destruction technique: after application anesthesia, a surgical instrument is vibrated at the frequency of the ultrasound supplied and the surgical instrument is inserted into the thickness of the inferior turbinate to the depth of the supposed intraracine destruction.

Intracranial mechanical disintegration is the simplest and no less effective than the method described above. Its essence lies in making an incision along the anterior end of the inferior nasal concha, followed by inserting a raspator through this incision and damaging the parenchyma of the conch without perforation of its mucous membrane. The operation ends with anterior tamponade of the nose on the corresponding side for 1 day.

In the phase of connective tissue or fibrous hypertrophy, the above methods provide a satisfactory effect while maintaining the contractile function of the muscular system of the vascular walls. In this case, the choice of the method of disintegration is determined by the degree of effectiveness of vasoconstrictor agents. In case of severe hypertrophy of the shells and the absence of the decongestant effect, the method of resection of the concha is used. It should be noted that in addition to scissors, cutting loops are used to remove the lower turbinate, and tearing loops are used to remove nose polyps.

Partial resection of the inferior turbinate is carried out under local application and infiltration anesthesia in two steps. After lubricating the mucous membrane with an anesthetic solution, 1-2 ml of a 2% solution of novocaine in a mixture with 2-3 drops of a 0.1% solution of epinephrine is injected into the nasal shell.

The first tempo is cutting the shell from its front end to the bone base. Then on the hypertrophied area of the shell impose a cutting loop and cut it. The removal of the hypertrophied posterior end of the inferior turbinate is made by a cutting loop.

With an increased osseous base of the inferior nasal concha and hypertrophy of its soft tissues, the latter is removed, then with the help of Luke's forceps, the osseous base of the shell is removed and moved to the lateral wall of the nose, freeing the common nasal passage from it.

Often, resection of the nasal concha is accompanied by significant bleeding, especially when the posterior ends of the inferior nasal concha are removed, so the operation is completed by the anterior nasal loop on Voyachek, and in some cases it becomes necessary to have a posterior nasal tamponade. To prevent infection, swabs with a syringe and needle are impregnated with a solution of antibiotics.

Treatment of chronic hypertrophic limited rhinitis

The treatment is local drug-based and general does not differ from that in chronic hypertrophic diffuse rhinitis. Surgical treatment varies depending on the location and degree of hypertrophy. So, with hypertrophy of the posterior or anterior ends of the inferior nasal concha, diagnosed in the edema phase and satisfactory vasoconstrictor function, disintegration methods can bring good results. With these interventions, one should be afraid of damage to the nasopharyngeal mouth of the auditory tube, since its burn during galvanization and laser exposure can lead to cicatricial obliteration with serious consequences for the middle ear. Electroplating is contraindicated in hypertrophy of the middle turbinate due to the risk of damage and infection of the middle nasal passage.

In case of fibrous or polypous hypertrophy of the anterior or posterior ends of the inferior nasal concha, as well as the middle nasal conch, conchotomy is used using conchotomes, cutting loops or nasal scissors.

Forecast

The prognosis is mostly favorable, but it can be serious if complications arise.

[37], [38], [39], [40], [41], [42],