Purulent rhinitis in adults and children

In infectious lesions of the upper respiratory tract develops a number of respiratory and ENT diseases, one of the symptoms of which is purulent rhinitis - containing pus nasal discharge.

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

Epidemiology

According to some experts, about 5% of the population of Central Europe suffers from chronic sinusitis.

And the statistics of the US health services, who studied the epidemiology of chronic rhinosinusitis and related complications, cites data from a national survey, according to which, this problem worries 12.5-15.5% of the total US population.

However, an account of cases diagnosed by doctors using ICD-10 codes as an identifier showed that the prevalence of purulent sinusitis and rhinitis is 2%. Almost eight times more often this diagnosis is made to women. The age category of 20-29 years old accounts for 2.7% of cases; 50-59 years old - 6.6%; over 60 years old - 4.8%.

British Association of Otolaryngologist specialists estimate the overall prevalence of chronic rhinosinusitis among Britons from 15 to 75 years old at 11-13%.

[5], [6], [7], [8]

Causes of the purulent rhinitis

In clinical otolaryngology, rhinitis is called not only inflammation of the mucous membranes of the nose (code J31.0 according to ICD-10), which has a different etiology, but also discharge from it - a runny nose. It can be allergic and vasomotor, infectious and hormonal, professional and medication. Depending on the origin, the nature of nasal discharge varies .

The most common form of common cold catarrh (acute rhinitis or rhinopharyngitis) is caused by rhinoviruses, influenza viruses, or respiratory syncytial virus (HRSV); at the same time, nasal discharge consists of mucin secreted by the goblet cells of the nasal mucosa.

Purulent or purulent (from Lat. Purulen - purulent) discharge, which children call "green snot", appear when a bacterial infection. Acute and chronic purulent rhinitis develop either independently or as a complication of viral rhinitis or  acute nasopharyngitis.

Key causes of purging anaerobius, Porphyromonas asaccharolytica and Prevotella and Fusobacterium bacterioids.

It is estimated that only 0.5-2% of the viral rhinitis is complicated by bacterial ENT diseases, but the exact frequency is unknown: it is difficult to distinguish the virus from the bacterial infection without invasive examination of the sinuses.

Most often purulent rhinitis in adults observed in inflammation of the mucous membranes lining the maxillary (maxillary) sinuses -  Chronic sinusitis  (maxillary sinusitis), paranasal frontal sinuses -  chronic frontal sinusitis, sinus sphenoid and ethmoidal labyrinth -  chronic purulent rinoetmoidite  (which, in turn,, is a complication of the chronic form of sinusitis).

All types of inflammations of ENT doctors can be diagnosed as bacterial purulent sinusitis and rhinitis or infectious rhinosinusitis, since all the paranasal sinuses are called paranasal sinuses. With the alteration of all paranasal sinuses, pansinusitis is diagnosed, which also gives purulent discharge from the nose.

In severe cases of chronic purulent rhinitis, patients have thick purulent snot with odor, indicating maxillary sinusitis, etiologically associated with chronic periodontal inflammation in root granuloma of the teeth (first molars or second premolars).

Adult nasal neoplasia - diagnosis of exclusion; if purulent rhinitis (especially unilateral, with blood) lasts for months, then it may be rhinosporidiosis with bleeding polyps in the maxillary cavity, inverted papilloma, sarcoma or lymphoma. Symptoms of nasal scleroma  (rhinoscleroma) and  Wegener's granulomatosis can also be combined with such a runny nose .

Persistent unilateral purulent rhinitis in a child in 64% of cases is associated with inflammation of the sinuses and impaired drainage. It also occurs at the initial stage of measles and when a foreign body enters the nasal cavity and mechanical obstruction of the nasal passage. In cases of recurrent discharge of purulent snot from both nasal passages, the most frequent diagnosis is  adenoiditis  , a chronic inflammation of the adenoids. In addition, early nasal polyposis based on genetically determined cystic fibrosis, the presence of benign juvenile angiofibroma of the nasopharynx or functional insufficiency of the ciliary epithelium and a violation of nasal mucociliary clearance associated with Congenital Syndrome Cargenera are not excluded .

If the baby has congenital  syphilis of the nose  or partial atresia of the internal nasal openings (Choan), as well as if the mother has gonorrhea, purulent rhinitis in the newborn is possible. Read also -  Runny nose at the newborn

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Risk factors

In many cases, the appearance of purulent nasal secretions occurs when immunity is weakened. So purulent rhinitis during pregnancy can occur against the background of physiologically determined gestational immunosuppression. In addition, hormonal changes play an important role in the swelling of the nasal mucosa and its congestion during pregnancy.

The following risk factors include:

• contact with the nasal cavity and paranasal sinuses of chlorinated water during bathing;
• a shift in the pH of the mucous membranes of the upper respiratory tract to the strongest acid;
• the presence of foci of persistent infection;
• chronic allergic rhinitis with swelling of the nasal mucosa, creating the prerequisites for blocking the excretory ducts of the paranasal sinuses and attaching a secondary bacterial infection;
• deviation of the nasal septum from the normal anatomical position.

In pediatric practice, attention is paid to common immune dysfunctions: transient hypogammaglobulinemia of infancy and deficiency of class A immunoglobulin (IgA antibodies).

[11], [12], [13], [14]

Pathogenesis

The inflammatory process can be caused by numerous factors, and today the pathogenesis of chronic rhinosinusitis and the accompanying disease of the purulent rhinitis remains controversial.

There is growing evidence that confirms the modern hypothesis of the etiology and pathogenesis of chronic inflammatory diseases of all mucous membranes. Its essence is that the balanced interaction of the cells of the nasal mucosa with the commensal flora - potential pathogens (bacteria, viruses, fungi) is disturbed, as well as the effect of allergens and / or toxic environmental substances, which experts consider to be exogenous stress factors.

The bacteria mentioned above can asymptomatically colonize the nasopharynx, for example, as shown by tests on Staphylococus aureus (nasal swabs on Staphylococcus aureus), asymptomatic carriage is detected in almost one third of adults and no less than half of the children.

Under conditions of immune imbalance, colonizing microorganisms penetrate the mucin barrier and enter the upper layer of the mucous epithelium by adhesion. The mucosal goblet cells begin to function in an enhanced mode. And developing inflammation is a protective reaction to the invasion of bacterial infection of cells of innate immunity: C-reactive proteins of blood plasma, mannose-binding lectin (MBL), epithelial receptor M-cells, various chemical mediators (cytokines), mast cells, macrophages, neutrophils, eosinophils, B - lymphocyte submucosa lymphoid tissue (producing antibodies).

[15], [16], [17],

Symptoms of the purulent rhinitis

The first signs of the transformation of normal nasal secretions (not passing for two weeks or longer) into purulent ones are manifested by the fact that they gradually cease to be colorless, turning into a yellow or greenish thick mucous mass (sometimes with a putrid odor).

The indicative symptoms of sinusitis and chronic rhinosinusitis are: nasal congestion with blockage of nasal breathing and impairment of smell (hyposmia); headache and throbbing pain in the face, while the latter is aggravated by bending (due to increased pressure in the sinuses).

In acute maxillary sinusitis, the pain is much stronger than in chronic (in which the pain may be absent). At frontal pain, the pain is localized in the forehead, in case of rinoetmoiditis - in the orbital region closer to the nose. Of the common symptoms, the most common are fever and weakness.

Pus can get into the pharynx, provoking a cough. In a child, purulent rhinitis can cause eczema in the area of the nostrils, and maxillary sinusitis (sinusitis) is often accompanied by conjunctivitis and earache.

[18], [19]

Complications and consequences

Any inflammatory process with the formation of purulent exudate can have serious consequences and complications.

In chronic form of purulent rhinitis with inflammation of the paranasal sinuses, pus may accumulate in them, which is fraught with the development of an abscess that can lead to the spread of purulent inflammation in the lining of the brain - meningitis.

No less serious danger is the formation of blood clots in the venous reservoirs (cavernous sinuses) of the hard shell of the brain.

There is also a risk of persistent loss of smell (anosmia) and the occurrence of vision problems due to inflammation of the tissues of the periorbital region.

Diagnostics of the purulent rhinitis

Bacterial acute and  chronic sinusitis  with edema and inflammation of lining tissue sinuses can be difficult to distinguish from viral rhinitis. Therefore, to find out the specific causative agents of purulent rhinitis, not only general and biochemical blood tests are necessary, but also bacterial screening - an  analysis of nasal mucus. When sinusitis do the analysis of the contents of the paranasal sinuses, which is taken during their puncture.

Instrumental diagnostics uses rhinoscopy, radiography of the nose and paranasal sinuses, ultrasound and CT examination of the paranasal sinuses.

According to the results of analyzes and taking into account the data obtained during the instrumental examination, differential diagnosis is carried out. More information on this issue in the article -  Diseases of the paranasal sinuses

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Treatment of the purulent rhinitis

By prescribing the treatment of purulent rhinitis, ENT doctors aim: to stop the inflammatory process and alleviate the symptoms.

For removal of inflammation for purulent rhinosinusitis, systemic corticosteroids (Prednisolone and Methylprednisolone) can be administered, but only in short courses (to avoid side effects). According to Cochrane review 2013, these drugs quickly give a positive result - especially in acute sinusitis, aggravated by nasal polyps. However, there are still not enough randomized controlled trials to include them in the treatment regimen of purulent nasal discharge.

There are many drugs of this pharmacological group for intranasal use, most commonly used budesonide (solution and powder for inhalation Benacort, spray Tafen nasal) - twice a day.

Antibiotics for purulent rhinitis should be used in cases of proven bacterial etiology of the disease. In pediatric practice, according to experts of the European Academy of Paediatrics, antibiotic therapy should be prescribed only if purulent rhinitis in a child lasts more than two weeks.

In the list of drugs of choice, effective against most strains of bacteria, appear: Amoxiclav or Augmentin (amoxicillin + clavulanate), Azithromycin, Gentamicin, Tobramycin, Ciprofloxacin, Cefuroxime, Clarithromycin, Roxithromycin. For more information about their method of use, side effects and contraindications, see the publication -  Antibiotics for the common cold.

Previously, streptocid was used in case of purulent rhinitis, but at present this sulfonamide group agent is not used because of the resistance developed by bacteria to its action. In addition, pus reduces the bacteriostatic properties of streptocide.

From nasal congestion, systemic antihistamines are used, as well as vasoconstrictor nasal drops with decongestants — naphazoline (Naphthyzinum drops), oxymetazolin (Nazivin drops, Sanorin drops, Noxpray aerosol, etc.) or tramazolin (Lazarin, Rinospray, Adrianol). More in materials:  Drops from a cold  and  Drops from sinusitis, as well as -  How to treat nasal discharge

ENT doctors recommend a very good remedy for purulent snot -  washing the nose with salt, more precisely with isotonic saline or saline. What else can be used to carry out this procedure, in more detail in the article -  Means for washing the nose

How physiotherapy is carried out, you can learn from the publication -  Physiotherapy for rhinitis

An alternative treatment suggests using for instillation into the nose:

• Collegar and Protargol antiseptics “forgotten” by doctors, which contain colloidal silver;
• homemade drops of a tablespoon of aloe juice and a teaspoon of liquid honey;
• Kalanchoe juice in half with boiled water;
• propolis diluted in water (for half a cup - 0.3 g);
• a mixture of stone and eucalyptus oil (4: 1).

Herbal treatment can also be quite effective if you rinse the nasal cavity daily with a decoction of chamomile or calendula diluted with water (3: 1) with juice from sorrel leaves; bury the nose with plantain juice or extract of St. John's wort.

Prevention

To the usual runny nose did not turn into purulent, it is necessary to properly treat it. And, of course, strengthen the body's defenses, taking vitamins, hardening, using only healthy products. In general, the recommendations are the same as for the  prevention of colds.

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Forecast

In this case, the prognosis will be favorable if you do not start the disease and start its treatment on time - at the stage of normal rhinitis.

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