Common syndromes of nasal diseases

In diseases of the nose and paranasal sinuses, which vary in etiology and pathogenesis, there are a number of common clinical syndromes that reflect dysfunction of this system and determine the main complaints of patients.

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

Causes and pathogenesis of primary inflammation of the rhinosinus system organs

After birth, the child breathes mainly through the nose. Only in case of congenital defects in the development of endonasal structures (nostril stenosis, chondral atresia, etc.) nasal breathing is impaired. However, in a considerable number of newborns, nasal breathing is still impaired, which causes a number of general and local deficiencies in the child's development, arising as a result of chronic hypoxia due to impaired nasal breathing and constant sagging of the lower jaw. In these cases, after primary rhinitis in the first years of life, children develop excessive secretion and, as a consequence, hypertrophy of the nasal mucosa and interstitial tissue located among the venous system of the nasal conchae. At the same time, vasomotor disorders also occur, which are initially periodic in nature and then become permanent. Under these conditions, local immunity of endonasal structures decreases, barrier functions are disrupted, as a result of which the saprophytic microbiota becomes pathogenic, which leads to the emergence and generalization of the inflammatory process, which often spreads to the entire lymphoid system of the upper respiratory tract. Nasal secretion containing pathogenic microorganisms penetrates the paranasal sinuses, trachea and bronchi, which often leads to allergization of the body and the development of asthmatic syndrome.

The causes of primary inflammatory diseases of the rhinosinus system in early childhood are artificial feeding, childhood infections, improper hygienic maintenance of the child, for example, isolating him from the cold factor or careless attitude towards the child. It is known that cold is an effective means of hardening the body with its general effect, but inhalation of cold and humid air disrupts the immune function of the upper respiratory tract and promotes the transformation of saprophytic microbiota into pathogenic. Other causes of impaired nasal breathing in children include curvature of the nasal septum, hereditary syphilis with nasal localization, gonococcal rhinitis, foreign bodies, hypertrophy of adenoid tissue, angiofibroma of the nasopharynx, banal inflammatory diseases, etc.

[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Nasal obstruction syndrome

This syndrome includes an open mouth, noisy nasal breathing, poor sleep, the presence of defects in the development of the maxillofacial region, developmental delays in the child, etc. Thus, with a long-term violation of the respiratory function of the nose in children, not only violations in the development of the maxillofacial skeleton are observed, but also violations in the development of the spine (scoliosis), the shoulder-scapular region, and deformations of the chest. Changes in the timbre of speech (closed nasal), difficulties in singing, physical education, and disorders of the olfactory and gustatory functions are also characteristic.

Impaired nasal breathing can also cause a number of reflexogenic symptoms, such as vasomotor dysfunctions, changes in metabolism (COS), hematopoiesis, etc.

Vascular dysfunction syndrome

The vascular plexuses of the nose and the autonomic fibers that innervate them are sensitive to changes in the general vascular tone of the body and especially the vessels of the brain. The superficial location of the vessels in the nasal cavity and the weakness of their walls often cause nosebleeds in conditions such as hypertensive crisis, coagulation disorders and other blood diseases. In addition, disruption of the regulation of vascular tone by the trigeminal-autonomic innervation often causes the occurrence of conditions such as increased vasoconstriction or dilation of the vascular endonasal plexuses, which often correlates with similar conditions of the cardiovascular system. As a rule, disruption of vasomotor reactions in the structures of the nose can be caused by both mechanical and physical factors (irritating spine of the nasal septum, cold air, etc.), and the effect of internal adrenergic factors caused by activation of the emotional sphere or diseases of the adrenal glands. The initial stages of these conditions are characterized by alternating narrowing and widening of the vessels, after which comes the stage of paresis of the vascular wall, an increase in its permeability, the occurrence of edema of the interstitial tissue with its organization into sclerotic tissue. This condition is called hypertrophic rhinitis.

The syndrome of impaired vascular tone of endonasal structures is characterized by periodic and then permanent impairment of nasal breathing and all other consequences of this condition described above.

Syndromes of impaired secretory function of the nasal mucosa

These syndromes can manifest themselves as increased or decreased secretion of mucus by the glandular apparatus of the nasal mucosa, which is under the dual influence of the parasympathetic and sympathetic nervous systems. The predominance of the influence of the first causes increased activity of the glands, manifested by the so-called rhinorrhea, the predominance of the second - dryness and subatrophy of the nasal mucosa.

Simple rhinorrhea of an excretory and non-allergic nature may occur in cases where some toxic substances are eliminated with nasal mucus, in patients suffering from renal failure, gout, iodine intoxication, etc. Such a runny nose is not paroxysmal, lasts a long time and is not accompanied by sneezing, impaired nasal breathing and other symptoms characteristic of acute inflammatory, vasomotor or allergic rhinitis. The amount of mucus secreted may vary and in some cases may reach 1 l/day or more. Nasal discharge is transparent, colorless, contains virtually no formed elements, does not thicken and does not form crusts.

Treatment is effective only if the cause of the disease is identified and eliminated. In general, general strengthening physiotherapeutic methods are used, the gastrointestinal tract is improved, smoking and consumption of spicy foods are not recommended, and the consumption of table salt and protein-rich foods is limited. In some cases, belladonna extract, calcium chloride, and antihistamines are prescribed per os.

Syndrome of dry nasal mucosa is usually a consequence of previous ulcerative rhinitis (diphtheria, scarlet fever, etc.) or incorrectly performed surgical operations on the structures of the nasal cavity (repeated cauterization of the nasal turbinates, their radical removal). Endocrine disorders (Graves' disease) have been named as causes of this syndrome. Vivid manifestations of dryness and atrophy of the anatomical structures of the internal nose, including the skeletal system, are observed in ozena.

Treatment is exclusively palliative, determined by the condition of the nasal mucosa and the cause of its dryness and atrophy.

Nasal liquorrhea syndrome

Liquorrhea is a prolonged leakage of cerebrospinal fluid from the natural openings of the skull and spine with mandatory disruption of the integrity of the dura mater. According to the source of origin, subarachnoid and ventricular liquorrhea are distinguished. As a result of gunshot wounds to the skull, this syndrome is observed in 6.2% of cases. Most often, liquorrhea is observed with basal or parabasal wounds, especially if the area of the paranasal sinuses (ethmoid bones, etc.) is affected with disruption of the integrity of their walls bordering the brain and rupture of the meninges. Recognition of liquorrhea is not difficult if there is a halo of transparent yellowish fluid around the blood stain on the bandage. It is more difficult to establish leakage of cerebrospinal fluid through the nose, especially if its release occurs only during sneezing, straining, lifting weights, etc., or if the cerebrospinal fluid enters the nasopharynx and is swallowed. Often, the presence of cerebrospinal fluid is established by detecting air in the fistula area using X-ray of the skull or CT of the brain.

There are two types of nasal liquorrhea: spontaneous and caused by mechanical damage to the dura mater (surgical intervention on the ethmoid sinus, frontal and sphenoid sinuses, injuries with a fracture of the base of the skull and gunshot wounds). Liquorrhea, both spontaneous and caused, is a serious condition that contributes to secondary infection of the meninges and is difficult to cure.

Spontaneous nasal liquorrhea is a rare disease caused by a congenital disruption of the integrity of the cribriform plate and the adjacent dura mater. Spontaneous nasal liquorrhea occurs periodically without apparent cause and may stop for a while. It may occur after physical exertion, with some diseases of the brain, accompanied by venous congestion and increased intracranial pressure.

Nasal liquorrhea can be simulated by liquorrhea that occurs with ear injuries, when cerebrospinal fluid enters the middle ear, penetrates through the auditory tube into the nasopharynx and from there, when the head is tilted, into the nasal cavity.

Treatment

In acute cases of cerebrospinal fluid leakage, broad-spectrum antibiotics are prescribed (intramuscularly and subarachnoidally); dehydration therapy, lumbar punctures with partial replacement of cerebrospinal fluid with air (fistula embolism) are performed. The patient is given an elevated position in bed, which contributes to a smaller leakage of cerebrospinal fluid. Massive loss of cerebrospinal fluid leads to ventricular collapse and severe cerebral hypotension syndrome. In cases of persistent nasal cerebrospinal fluid leakage, surgical treatment is used.

Syndromes of impaired sensitivity of the nasal mucosa

The innervation of the nasal mucosa is represented mainly by the trigeminal nerve and fibers of the autonomic nervous system. The trigeminal nerve provides temperature, tactile and pain sensitivity and plays a vital role in providing a number of protective functions of the nose and the normal state of the nasal mucosa. Trigeminal nerve lesions (syphilis, tumors, injuries, etc.) can cause both disturbances in the sensitivity of the rhinosinus system and trophic changes in the nasal mucosa.

Sympathetic innervation comes mainly from the carotid plexus and from the superior cervical sympathetic ganglion, parasympathetic innervation goes to the mucous membrane of the nose as part of the nerve of the pterygoid canal, bringing parasympathetic fibers from n. petrosus major. Both parts of the ANS take part in the innervation of glands, all internal organs, including the upper respiratory tract, blood and lymphatic vessels, smooth and partly striated muscles. The sympathetic system innervates all organs and tissues of the body and provides a generalized activating effect on them based on adrenergic mechanisms, hence its vasoconstrictor effect on the vessels of the mucous membrane of the nose. The parasympathetic nervous system regulates the activity of internal organs, in particular the secretory function of their glandular apparatus (including the superior respiratory tract), and has a vasodilatory effect.

The syndrome of anesthesia of the nasal mucosa is characterized by the loss of all types of sensitivity and the loss of the sneeze reflex. This syndrome is caused by damage to the trigeminal nerve at various levels, including its sensory terminals located in the nasal mucosa. The latter occurs in ozie, deep forms of banal atrophy of the nasal mucosa, exposure to harmful industrial aerosols and gases. In these forms, anesthesia is not always complete, some types of sensitivity may remain in a reduced form. Total anesthesia occurs only with complete damage to the trunk of the trigeminal nerve or its node by such pathological processes as syphilitic pachymeningitis, purulent meningitis of the posterior cranial fossa, tumors of the MMU and brainstem, injuries and wounds of the corresponding areas of the skull, etc. In these cases, the function of not only the trigeminal nerve is impaired, but also other cranial nerves located in the posterior cranial fossa.

The syndrome of hyperesthesia of the nasal mucosa is usually caused by the presence of a suddenly appearing irritant in the inhaled air, or an acute inflammatory process, an allergic crisis, and sometimes the presence of IT.

Reflex reactions of the nasal mucosa

Due to its high sensitivity, the nasal mucosa can be a source of numerous reflexes at a distance, sometimes simulating various pathological conditions of "unclear etiology". These conditions can concern the bronchopulmonary system (asthmatic syndrome, "causeless" cough, bronchorrhea not caused by any inflammatory process, etc.), gastrointestinal tract (belching, hiccups, pyloric dysfunction manifested by heartburn, etc.), cardiovascular system (arrhythmia, arterial hypertension, angina pectoris, etc.). As an example of the presence of a trigger zone in the nasal mucosa causing vestibular dysfunction, we can cite the observation of Ya.S. Temkin (1965), who associated their occurrence with traumatic curvature of the nasal septum. After eliminating this anatomical defect, vestibular crises ceased. A similar case of riogenic epilepsy was also described. D.I. Zimont (1957) believed that RBN of the ENT owes its occurrence not only to inflammation of the “posterior” paranasal sinuses, but also to reflex spasm of the arteries of the ENT, the source of which is pathological conditions of the rhinosinus system.

Numerous studies have established that the trigger zones of pathological reflexes are various morphological changes in the nasal cavity (deviations of the septum in the upper parts of the nasal cavity, hypertrophy of the middle nasal concha, especially its posterior part, innervated from the pterygopalatine ganglion system). Irritation of these zones leads to spasm of the smooth muscles of the lower respiratory tract and to the phenomena of asthmatic syndrome. Among asthmatics, nasal polyposis is observed in 10% of cases, which is believed to lead to irritation of the trigger zones of the nasal membrane.

Treatment is usually stable only when the cause of the distant syndrome is established and eliminated, in particular, "complete" sanitation of the rhinosinus system. Palliative methods include anesthetic blockades of the nasal mucosa: the nasal septum, the area of the middle nasal concha, ager nasi (the area located slightly above and in front of the middle nasal concha).

Syndromes of remote complications

Diseases of the nasal cavity may lead to remote complications, such as inflammatory diseases of the ear, lymphadenoid system of the pharynx, larynx, trachea and bronchi, lacrimal ducts, and a number of internal organs.

Bronchopulmonary diseases that often arise as complications of pathological processes in the nasal cavity in children simulate pulmonary tuberculosis, but, on the other hand, it has been established that it is the disturbances of nasal breathing that contribute to the more frequent occurrence of this specific lung disease. The syndrome of bronchopulmonary disease in children with obstruction of the upper respiratory tract is characterized by the following signs: pallor, increased fatigue, persistent cough, anemia, subfebrile condition, weakened and harsh breathing, dry wheezing, shortness of breath, regional and mediastinal adenopathy, etc.

In rhinosinus bronchopulmonary diseases, bacteriological examination reveals only numerous saprophytic microorganisms, bronchoscopy reveals the presence of viscous mucus in the lumen of the bronchi, and examination of ENT organs reveals certain manifestations of rhinosinusopathy and obstruction of the upper respiratory tract.