Chronic hypertrophic rhinitis

Chronic hypertrophic rhinitis is understood as chronic inflammation of the nasal mucosa, the main pathomorphological sign of which is its hypertrophy, as well as interstitial tissue and glandular apparatus, caused by degenerative tissue processes, which are based on the violation of adaptive-trophic dysfunctions of the nasal mucosa. Chronic hypertrophic diffuse rhinitis is characterized by diffuse hypertrophy of intranasal tissues with predominant localization in the area of the nasal turbinates.

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

Causes chronic hypertrophic rhinitis

Chronic hypertrophic diffuse rhinitis is more common in mature men and is caused by the same reasons as chronic catarrhal rhinitis. A significant role in the development of chronic hypertrophic diffuse rhinitis is played by foci of infection in adjacent ENT organs, unfavorable climatic and industrial conditions, bad household habits, and allergies.

[ 5 ], [ 6 ], [ 7 ]

Pathogenesis

In chronic hypertrophic diffuse rhinitis, hypertrophic (hyperplastic) processes develop slowly and affect first the lower and then the middle nasal conchae and the remaining areas of the nasal mucosa. This process is most pronounced in the area of the anterior and posterior ends of the lower nasal conchae.

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

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

Symptoms chronic hypertrophic rhinitis

Subjective symptoms are not fundamentally different from those of chronic catarrhal rhinitis, but obstruction of the nasal passages by hypertrophied structures of the nasal cavity causes constant difficulty or even absence of nasal breathing. Patients complain of ineffective nasal decongestants, dry mouth, snoring during sleep, constant mucous or mucopurulent discharge from the nose, a sensation of a foreign body in the nasopharynx, poor sleep, increased fatigue, decreased or absent sense of smell, etc. Due to compression of the lymphatic and venous vessels of the hypertrophied interstitial tissue, blood circulation and lymphatic drainage in the entire nasal cavity and in the forebrain are also disrupted, which leads to headaches, decreased 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; later, difficulty or virtual absence of nasal breathing becomes permanent.

Objective symptoms

The patient constantly remains with an open mouth and closes it only when he pays attention to this "defect". During walking, running and other physical activity, oxygen supply to the body is possible only with mouth breathing. At rest, with a closed mouth, a patient with severe obstruction of the nasal passages can perform forced breathing through the nose for only a few seconds longer than during a trial breath-hold. The voice of patients is characterized by a nasal quality; with this lesion, in contrast to that with paralysis of the soft palate, called closed nasal quality (rhynalalia clausa), with paralysis of the soft palate - open nasal quality (rhynolalia operta).

The clinical course of chronic hypertrophic diffuse rhinitis is long-term, slowly progressing, and without appropriate treatment can continue until old age.

[ 13 ], [ 14 ], [ 15 ]

Stages

The following phases of the hypertrophic process are distinguished:

• 1st phase - the so-called soft hypertrophy of the nasal mucosa, characterized by hyperemia and edema of the mucous membrane, moderate damage to the ciliated epithelium; in this phase, the muscle fibers of the venous plexuses of the inferior turbinates are not yet affected by the degenerative-sclerotic process and their vasomotor function is preserved; at this stage of the process, the effectiveness of nasal decongestants is preserved; the inferior turbinates retain elasticity and pliability during palpation;
• The 2nd phase is characterized by metaplasia of the ciliated epithelium, hypertrophy of the glandular apparatus, initial signs of degeneration of the vascular muscle fibers, 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 vasoconstrictors gradually decreases;
• The 3rd phase in foreign literature is called "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 blood and lymphatic vessels and glandular apparatus; these pathomorphological changes differ in varying degrees of severity, as a result of which the surface of the nasal turbinates can acquire a different appearance - smooth, bumpy, polyp-like or a combination of these types of hypertrophy.

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

Forms

The difference between chronic hypertrophic limited rhinitis and the above-described CGDR is only that the zone of the hypertrophic process covers a limited area of the nasal concha, while the rest of their parts remain practically normal. According to localization, there are several varieties of this pathological condition: hypertrophy of the posterior ends of the inferior nasal concha, hypertrophy of the anterior ends of the inferior nasal concha, hypertrophy of the middle 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 turbinate is the most common type of chronic hypertrophic limited rhinitis. The causes of this pathological condition are the same as those of chronic hypertrophic diffuse rhinitis, but most often it is a chronic inflammatory process in the lymphoid apparatus of the nasopharynx, in the ethmoid labyrinth, sphenoid sinus, and allergy. Patients complain of difficulty in nasal breathing, especially during the exhalation phase, when the hypertrophied part of the turbinate acts as a kind of valve blocking the choanae. Speech becomes nasal, like closed nasality. Patients feel the presence of a foreign body or a clot of mucus in the nasopharynx, so they constantly "snort" with their nose, trying to push this "lump" into the throat.

During anterior rhinoscopy, the picture may seem normal, but during posterior rhinoscopy, fleshy, sometimes polypous-altered formations are determined, which partially or completely block the lumen of the choanae. Their color varies from cyanotic to pink, but most often it is grayish-whitish, translucent. Their surface can be smooth or resemble a mulberry or papilloma. As a rule, the process is bilateral, but developed asymmetrically. Similar phenomena can be observed in the area of the posterior ends of the middle nasal conchae.

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

Hypertrophy of the mucous membrane of the posterior margin 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 turbinate. During posterior rhinoscopy, the edge of the nasal septum is framed on one, more often on both sides, by peculiar formations hanging down into the lumen of the choanae, 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 rarest phenomenon and is a thickening of the mucous membrane in the form of cushion-shaped formations, more or less extended. As a rule, the process is bilateral.

[ 21 ], [ 22 ], [ 23 ]

Complications and consequences

Acute and chronic eustachitis and tubootitis caused by obstruction of the nasopharyngeal openings of the auditory tube by edematous and hypertrophied mucous membrane of the nasopharynx and posterior ends of the inferior nasal conchae, sinusitis, adenoiditis, tonsillitis, tracheobronchitis, dacryocystitis, conjunctivitis, etc. Often, chronic hypertrophic diffuse rhinitis leads to inflammatory diseases of the lower respiratory tract, dysfunction of the digestive organs, cardiovascular system, various liver and kidney syndromes.

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

Diagnostics chronic hypertrophic rhinitis

In typical cases, diagnosis is not difficult. It is based on the patient's history, complaints, and functional and endoscopic examination of the rhinosinus area. When making a diagnosis, it should be borne in mind that chronic hypertrophic diffuse rhinitis is often accompanied by latent sinusitis, most often a polypous-purulent process in the anterior nasal sinuses.

During anterior rhinoscopy in the first pathomorphological phase, it is possible to observe a practically normal state of the inferior turbinates, despite the fact that the patient complains of difficulty in nasal breathing. This is due to the adrenergic situational reaction "to the doctor" of the venous plexus vasoconstrictors that retain their function. The same reaction in this phase is detected when lubricating the inferior turbinates with an adrenaline solution. Subsequently, the phenomenon of reflex and drug decongestion decreases and completely disappears. The nasal passages are obstructed by enlarged dense inferior and middle turbinates, while the middle turbinate acquires a bullous or edematous appearance, descends to the level of the inferior turbinates. Mucous or mucopurulent discharge is determined in the nasal passages. In the phase of connective tissue hypertrophy, the surface of the inferior turbinates becomes bumpy, sometimes polypously altered. The color of the mucous membrane of the nasal concha evolves depending on the pathomorphological phase - from pinkish-bluish to pronounced hyperemia with subsequent acquisition of a grayish-bluish color.

During posterior rhinoscopy, attention is drawn to the bluish color of the nasal mucosa and the hypertrophied, edematous, bluish, mucous-covered posterior ends of the inferior turbinates, often hanging down into the nasopharynx. The same changes may also affect the middle turbinates. The same changes may be observed in the area of the posterior edge of the nasal septum. The edema and hypertrophy of the mucosa that arise here are located on both sides in the form of nolipo-like formations, which have received the name "wings" of the PE abroad.

During diaphanoscopy and radiography of the paranasal sinuses, a decrease in the transparency of certain sinuses is often detected due to thickening of the mucous membrane or levels of transudate arising due to the lack of drainage function of the outlet openings of the sinuses.

When examining the state of nasal breathing and olfaction using known methods, as a rule, their significant deterioration is detected, up to and including complete absence.

Diagnosis of chronic hypertrophic limited rhinitis in typical cases does not cause difficulties, however, in atypical forms of hypertrophy, for example, condyloma-like, granulomatous 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 are carried out with deformations of the nasal septum, essential hypertrophy of the nasopharyngeal tonsil, angiofibroma of the nasopharynx, atresia of the nasal passages and choanae, polypous rhinitis, specific infections of the nose (tuberculosis, tertiary syphilis), malignant tumors of the nose, rhinolithiasis, foreign bodies of the nose (these diseases are discussed in the following sections).

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

Treatment chronic hypertrophic rhinitis

Treatment of chronic hypertrophic diffuse rhinitis is divided into general and local; local - symptomatic, medicinal and surgical. General treatment is no different from that for chronic catarrhal rhinitis. Symptomatic consists of the use of decongestants, drops for rhinitis, medicinal corresponds to the local treatment of chronic catarrhal rhinitis described above. However, it should be noted that with true hypertrophy of endonasal anatomical structures, in particular the lower and middle nasal concha, local non-surgical treatment can only bring temporary improvement in nasal breathing. The main treatment for chronic hypertrophic diffuse rhinitis is surgical, which, however, does not always lead to final recovery, especially with a constitutional predisposition of the body's tissues to hypertrophic processes.

The general principle of surgical treatment for chronic hypertrophic diffuse rhinitis is thermal, mechanical or surgical action on the hypertrophied area of the nasal concha to restore nasal breathing, olfaction and achieve subsequent scarring of the wound surface, preventing a repeated hypertrophic process. The use of one or another type of action is dictated by the phase of the hypertrophic process.

In the phase of "soft hypertrophy" it is advisable to use galvanocautery, cryosurgical action, laser or ultrasound destruction, intraturbinal mechanical disintegration. These methods are aimed at provoking an inflammatory process and subsequent sclerosis of the submucous structures (mainly vascular plexuses) of the nasal conchae to reduce their volume.

Galvanocautery (galvanothermy, electrocautery) is a method of cauterizing tissues using 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 with CO 5-10% cocaine solution + 2-3 drops of 0.1% adrenaline solution). Instead of cocaine, a 5% dicanum solution can be used. For deeper anesthesia, the method of intra-shell anesthesia with solutions of trimecaine, ultracaine or novocaine in the appropriate concentration can be used. The procedure is as follows. Under the protection of the nasal mirror, the end of the galvanocautery is brought to the far part of the inferior nasal conchae, brought into working condition, pressed against the surface of the mucous membrane, immersed in the tissues of the conchae and in this position it is brought out over the entire surface of the conchae, as a result of which a deep linear burn in the form of coagulated tissue remains on it. Usually two such parallel burn lines are drawn, placing them one above the other. At the end of the action, the galvanocautery is removed from the tissue in a red-hot state, otherwise, having quickly cooled in the tissues, it sticks to them and tears off part of the coagulated surface and the underlying vessels, which leads to bleeding.

Cryosurgical action is performed using a special cryoapplicator cooled with liquid nitrogen to a temperature of -195.8°C. The ultra-low temperature causes deep freezing of the tissue and its subsequent aseptic necrosis and rejection. This method has limited application only in diffuse polypous hypertrophy of the inferior nasal turbinates.

Laser destruction of the inferior nasal conchae is performed using a surgical laser, the radiation power of which reaches 199 W. The factor of laser action on the tissue is a focused laser beam of a certain wavelength in the range of 0.514-10.6 μm. Carbon dioxide lasers are the most widely used. The surgical intervention is performed under local application anesthesia and is bloodless.

Ultrasonic destruction is performed using special resonantly tuned to a given ultrasound frequency sharp cone-shaped emitter tips (surgical instrument), set into vibration by means of a powerful ultrasound generator that destroys the tissue structure and is applied to the above surgical instrument. In this case, vibrations with a frequency of 20-75 kHz and an amplitude of oscillation of the working part of 10-50 μm are used. The technique of ultrasound destruction: after application anesthesia, a surgical instrument vibrating with the frequency of the supplied ultrasound is inserted into the thickness of the inferior nasal concha to the depth of the expected intraconcha destruction.

Intraturbinal mechanical disintegration is the simplest and no less effective method than the one described above. Its essence consists of making an incision along the anterior end of the inferior nasal concha with subsequent insertion of a raspatory through this incision and damaging the "parenchyma" of the concha without perforating 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 give a satisfactory effect while maintaining the contractile function of the muscular apparatus of the vascular walls. In this case, the choice of the disintegration method is determined by the degree of effectiveness of vasoconstrictors. In case of pronounced hypertrophy of the turbinates and the absence of a decongestant effect, the method of resection of the nasal turbinates is used. It should be noted that to remove the inferior nasal turbinate, in addition to scissors, cutting loops are used, and to remove nasal polyps, tearing loops are used.

Partial resection of the inferior turbinate is performed under local application and infiltration anesthesia in two stages. After lubricating the mucous membrane with an anesthetic solution, 1-2 ml of a 2% solution of novocaine mixed with 2-3 drops of a 0.1% solution of adrenaline is injected into the turbinate.

The first step is to trim the concha from its anterior end to the bony base. Then a cutting loop is placed on the hypertrophied section of the concha and cut off. The hypertrophied posterior end of the inferior nasal concha is removed with a cutting loop.

In case of enlarged bone base of the inferior nasal concha and hypertrophy of its soft tissues, the latter is removed, then using Luke forceps, the bone base of the concha is broken and moved to the lateral wall of the nose, freeing the common nasal passage from it.

Resection of the nasal conchae is often accompanied by significant bleeding, especially when removing the posterior ends of the inferior nasal concha, so the operation is completed with anterior loop tamponade of the nose according to V.I. Voyachek, and in some cases there is a need for posterior tamponade of the nose. To prevent infection, tampons are soaked in an antibiotic solution using a syringe and needle.

Treatment of chronic hypertrophic limited rhinitis

Local drug and general treatment does not differ from that for chronic hypertrophic diffuse rhinitis. Surgical treatment varies depending on the location and degree of hypertrophy. Thus, with hypertrophy of the posterior or anterior ends of the inferior turbinates, diagnosed in the edema phase and satisfactory function of vasoconstrictors, disintegration methods can bring good results. With these interventions, one should be wary of damaging the nasopharyngeal opening of the auditory tube, since its burn during galvanization and laser exposure can lead to cicatricial obliteration with severe consequences for the middle ear. Galvanocaustics 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 concha, conchotomy is performed using conchotomes, cutting loops or nasal scissors.

Forecast

The prognosis is generally good, but can be serious if complications occur.

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