OTORHINOLARYNGOLOGY

ZHANG TAO PhD，MD

E.N.T DEPARMENT,1ST HOSPITAL. JNU
E-mail: 985775392@QQ.com
 The speciality of ear, nose and throat, now better known as
"Otolaryngology-head and neck surgery, stands at cross-road with
several specialities and subspecialties such as :
Ø Otology, otoneurology
Ø Paediatric otolaryngology
Ø Rhinology, allergy
Ø Laryngology, phonosurgery
Ø Head and neck oncology
Ø Skull base surgery
Ø Endoscopic and minimal access surgery
Ø TCM Otorhinolaryngology
 SECTION Ⅰ：Rhinololgy
Anatomy, physiology and diseases of nose and paranasal sinuses.
Ø Nasal septum and its diseases
Ø Acute and Chronic Rhinitis
Ø Allergy and Allergic Rhinitis
Ø Nasal polypi
Ø Epistaxis
Ø Acute and Chronic Sinusitis
Ø Neoplasms of nasal cavity and sinuses
Ⅰ. Anatomy of Nose

It is pyramidal in shape with its root up and the base

directed downwards. Description Terms: nasal root, nasal
bridge, nasal dorsum,nasal apex, alae narsi, nasal columella,
alae groove, nasolabial fold.
 1. External Nose

Pyramidal in shape with its root up and the base directed

downwards, consists of osteocartilaginous framework,
covered by muscles and skin.
 1) Framework of External Nose
Bony Part
Upper one-third of the
external nose is bony while lower
two-thirds are cartilaginous. The
bony part consists of two nasal
bones which meet in the midline
and rest on the upper part of the
nasal process of the frontal bone,
held between the frontal
processes of the maxillae.
 Cartilaginous Part
(a) Upper lateral cartilages
They extend from the undersurface of
the nasal bones above, to the alar
cartilages below. They fuse with each
other and with the upper border of the
nasal septal cartilage in the midline
anteriorly. The lower free edge of
upper lateral cartilage is seen
intranasally as limen vestibuli (nasal
valve) on each side.
(b) Septal cartilage. Its anterosuperior border runs from
under the nasal bones to the nasal tip. It supports the dorsum
of cartilaginous part of the nose. They fuse with the upper
border of the Lateral cartilages in the midline anteriorly.
(c) Alar cartilages (Lower lateral cartilages) is U-shaped
(horseshoe), it has a lateral crus which forms the ala and a medial
crus which runs in the columella. Lateral crus overlaps lower edge of
upper lateral cartilage on each side.
2) Nasal Musculature
Osteocartlaginous framework of
nose is covered by muscles which
bring about movements of the
nasal tip, ala and the overlying skin.
They are the procerus, nasalis
( transverse and alar parts), levator
labii superiors alaque nasi, anterior
and posterior dilator nares and
depressor septi. They are part of
facial muscles.
3) Nasal Skin The skin over the
nasal bones and upper lateral
cartilages is thin and freely mobile
while that covering the alar
cartilages is thick and adherent, and
contains many sebaceous glands.
It is the hypertrophy of these
sebaceous glands which gives rise to
a lobulated tumour called
rhinophyma. Most dermopathy
occur in alae groove and nasal apex.
 2. Internal Nose
It is divided into right and left
nasal cavities by nasal septum.
Each nasal cavity communicates
with the exterior through
naris(nostril) and with the
nasopharynx through posterior
nasal aperture(choana).
Consists of a skin-lined portion
the vestibule, and a mucosa-
lined portion, the nasal cavity
proper.
1) Vestibule of nose
üAnterior and inferior part of nasal cavity
is called the vestibule. It is lined by skin
and contains sebaceous glands, hair
follicles and the hair called vibrissae.
üUpper limit on the lateral wall is marked
by limen nasi(nasal valve).
üMedial wall is formed by the columella
and lower part of the nasal septum up
to its mucous and skin (mucocutaneous)
junction.
2) Nasal Cavity Proper Each nasal cavity has a lateral wall, a
medial wall, a roof and a floor. Two openings: naris and choana.
Lateral wall It is marked by three scroll-like bony projections
called turbinates or conchae: inferior, middle and superior.
Below and lateral to each turbinate is the corresponding meatus.
 A. Lateral Wall
(a) Inferior meatus. It runs along the whole length of the
lateral wall, nasolacrimal duct opens in its anterior part.
(b) Middle meatus. It runs in posterior half of the lateral wall. In
the middle meatus there is a rounded bulge called bulla
ethmoidalis3 which is due to the middle ethmoidal air cell
which opens on or above it.
• Clinically, bulla ethmoidalis is
belongs to anterior group of
ethmoidal cells as it lies anterior to
the ground lamella of middle
turbinate. Below and in front of the
bulla is a gap called hiatus
semilunaris4, which leads into a
funnel-shaped space called
ethmoidal infundibulum2. Floor and
medial wall of the infundibulum are
formed by the uncinate process5 of
the ethmoid .
Ostiomeatal complex, OMC
• bulla ethmoidalis
• hiatus semilunaris
• ethmoidal infundibulum
• uncinate process
• middle turbinate
• sinus ostiea of maxillary,
frontal sinus and anterior
ethmoid sinus
The chronic paranasal sinusitis
was caused by the obstruction of
ostiomeatal complex.
• Frontal sinus opens into the infundibulum or just of posterior
wall of agger nasi cell2. Anterior ethmoidal sinuses also open
into the infundibulum.
The agger nasi is a small
ridge on the lateral side of
the nasal cavity. It is located
midway at the anterior
edge of the middle nasal
concha, directly above the
atrium of the middle
meatus. It is formed by a
mucous membrane that is
covering the ethmoidal
crest of the maxilla.
Maxillary sinus opens in posterior part of the infundibulum,
and into the middle meatus5. Sometimes, it may also have
an accessory opening.
(c) Superior meatus is limited only to posterior third of lateral
wall. Posterior ethmoidal sinuses open into it1.
(d) Sphenoethmoidal recess lies above the superior turbinate
and receives the opening of the sphenoid sinus1.
Drainage of Sinuses
B. Medial wall Nasal septum forms the medial wall.
 Nasal Septum consists of
osteocartilaginous framework,
covered with nasal mucous
membrane. Its principal constituents
are:
(i) The perpendicular plate of
ethmoid
(ii) The vomer
(iii) The large septal (quadrilateral)
cartilage wedged between the
above two bones anteriorly.
 Other bones which make
minor contributions at the
periphery are:
ü crest of nasal bones
ü nasal spine of frontal
bone,
ü rostrum of sphenoid
ü crest of palatine bones
ü crest of maxilla
ü the anterior nasal spine
of maxilla.
C. Roof
Anterior part formed
by frontal & nasal bones;
posterior part formed by
the body of sphenoid
bone; and the middle
horizontal part is formed
by the cribriform plate of
ethmoid through which
olfactory nerves enter the
nasal cavity.
D. Floor
It is formed by
palatine process of
the maxilla in its
anterior three-
fourths and
horizontal part of
the palatine bone
in its posterior
one-fourth.
3) Lining Membrane of Internal Nose

Vestibule. Anterior and inferior part of nasal cavity. It is lined

by skin containing hair, hair follicles and sebaceous glands.
Olfactory region
Upper one-third of
lateral wall (up to
superior concha),
corresponding part of
the nasal septum and
the roof of nasal cavity
form the olfactory
region. Here, mucous
membrane is paler in
colour.
• Respiratory region. Lower two-thirds of the nasal cavity form
the respiratory region. It is highly vascular and also contains
erectile tissue. Its surface is lined by pseudostratified ciliated
columnar epithelium which contains plenty of goblet cells.
pseudostratified ciliated columnar epithelium
The Function of Cilia
4) Nerve Supply of Nasal Cavity

Nerves of common sensation Olfactory nerves

(a) Olfactory nerves
They carry sense of smell and supply olfactory region of
nose. They are the central filaments of the olfactory cells and
are arranged into 12-20 nerves which pass through the
cribriform plate and end in the olfactory bulb.
(b) Nerves of common sensation
supply
p Anterior and superior part of nasal
cavity is supplied by anterior ethmoidal
nerve.
p Most of posterior two thirds of nasal
cavity is supplied by branches of
sphenopalatine ganglion.
p Vestibule of nose both on its medial
and lateral side is supplied by branches
of infraorbital nerve.
(c) Autonomic Nerves：
Parasympathetic nerve
fibres: they come from
greater superficial
petrosal nerve, travel in
the nerve of pterygoid
canal ( vidian nerve),
supple the nasal glands
control nasal secretion
and supply the blood
vesels of nose cause the
vasodilation.
Sympathetic nerve fibres come from upper two thoracic
segments of spinal cord, travel in deep petrosal nerve and join the
Parasympathetic nerve fibres of greater superficial petrosal nerve
to from the nerve of pterygoid canal ( vidian nerve). They reach
the nasal cavity. Their stimulation causes vasoconstriction.
 5) Blood Supply of nasal cavity
Ø The anterior and posterior
ethmoid arteries, branches of
the ophthalmic artery (crossing
the ethmoid plate).
Ø Sphenopalatine arteries, the
terminal branch of the internal
maxillary artery.
Ø The internal maxillary artery,
usually the penultimate branch
of the external carotid artery.
 6) Lymphatic Drainage
• lymphatics from the external nose and anterior part of nasal cavity
drain into submandibular lymph nodes.
• The rest of nase cavity drain into upper jugular nodes either directly or
through the retropharyngeal nodes.
 Ⅱ. Physiology of Nose
Functions of the nose are
classified as:
Ø Respiration
Ø Air conditioning of inspired air
Ø Protection of lower airway
Ø Vocal resonance
Ø Nasal reflex functions
Ø Olfaction
 1. Respiration
• During quiet respiration, inspiratory air current passes through middle
part of nose between the turbinates and nasal septum.
• During expiration, air current follows the same course as during
inspiration, but the entire air current is not expelled directly through
the nares. Friction offered at limen nasi converts it into eddies under
cover of inferior and middle turbinates and this ventilates the sinuses
through the ostia.
2. Air-conditioning of Inspired Air
Nose is aptly called the "air-conditioner"
for lungs. It filters and purifies the inspired
air and adjusts its temperature and
humidity before it passes it on to the lungs.
(a) Filtration and purification.
Nasal vibrissae at the entrance of nose
act as filters to sift larger particles like fluffs
of cotton. Finer particles like dust, pollen
and bacteria adhere to the mucus which is
spread like a sheet all over the surface of
the mucous membrane.
(b)Temperature control
The inspired air is regulated by
large surface of nasal mucosa, in the
region of middle and inferior
turbinates and adjacent parts of the
septum is highly vascular with
cavernous venous spaces or
sinusoids which control the blood
flow, and this increases or decreases
the size of turbinates. This makes an
efficient "radiator" mechanism to
warm up the cold air.
(c)Humidification
Nasal mucous membrane adjusts
the relative humidity of the inspired
air to 75% or more. Water, to
saturate the inspired air, is provided
by the nasal mucous membrane
which is rich in mucous and serous
secreting glands. About 1000ml of
water is evaporated from the
surface of nasal mucosa in 24 hours.
3. Protection of Lower Airway
a. Mucociliary mechanism.
Nasal mucosa is rich in goblet cells, secretory glands both mucous and serous.
Their secretion forms a continuous sheet called mucous blanket spread over the
normal mucosa. Mucous blanket consists of a superficial mucus layer and a
deeper serous layer, floating on the top of cilia which are constantly beating to
carry it like a "conveyer belt" towards the nasopharynx . The inspired bacteria,
viruses and dust particles are entrapped on the viscous mucous blanket and then
carried to the nasopharynx to be swallowed or spit.
 b. Enzymes & munoglobulins
Nasal secretions also contain an
enzyme called lysozyme which kills
bacteria and viruses. IgA and IgE, and
interferon are also present in nasal
secretions and provide immunity against
upper respiratory tract infections.
The pH of nasal secretion is nearly
constant at 7. The cilia and the lysozyme
act best at this pH. Alteration in nasal pH,
due to infections or nasal drops, seriously
impair the functions of cilia and lysozyme.
c. Sneezing
It is a protective reflex. Foreign particles which irritate nasal
mucosa are expelled by sneezing. Copious flow of nasal
scrections that follows irritations by noxious substance helps
to wash them out.
4. Vocal Resonance
Nose forms a resonating
chamber for certain
consonants in speech. In
phonating nasal consonants
sound passes through the
nasopharyngeal isthmus and
is emitted through the nose.
When nose (or nasopharynx)
is blocked, speech becomes
denasal.
5. Nasal Reflexes Several reflexes are initiated in the nasal mucosa
ü Smell of a palatable food cause reflex secretion of saliva and gastric juice.
ü Irritation of nasal mucosa causes sneezing.
ü Nasal function is closely related to pulmonary functions through nasobronchial
and nasopulmonary reflexes. nasal packing will lead to lowering of PO2.
 6. Olfaction
Smell is perceived in the olfactory region of
nose which is situated high up in the nasal
cavity. This area contains millions of olfactory
receptor cells. Peripheral process of each
olfactory cell reaches the mucosal surface and
is expanded into a ventricle with several cilia
on it. This acts as a sensory receptor to receive
odorous substances. Central processes of the
olfactory cells are grouped into olfactory
nerves which pass through the cribriform plate
of ethmoid and end in the mitral cells of the
olfactory bulb. Axons of mitral cells form
olfactory tract and carry smell to the
prepiriform cortex and the amygdaloid nucleus
where it reaches consciousness.
Electric signals To
Olfactory bulb

Olfactory Receptor
cells

Odorant receptor

Odorant molecules
 DISEASES OF
NOSE AND NASAL CAVITY
1. Nasal Septal and Its Diseases

DEVIATED NASAL SEPTUM (DNS)

Trauma and errors of development form the two important
factors in the causation of deviated septum. This is an
important cause of nasal obstruction.
1.1 Anatomy
Nasal septum consists of three parts:
A. Columellar septum. It is formed of columella containing the
medial crura of alar cartilages united together by fibrous tissue and
covered on either side by skin.
B. Membranous septum. It consists of
double layer of skin with no bony
or cartilaginous support. It lies
between the columellar and the
caudal border of septal cartilage.
Both columellar and membranous
parts are freely movable from side to side.
 C. Septum proper
It consists of osteocartilaginous
framework, covered with nasal
mucous membrane. Its principal
constituents are:
(i) the perpendicular plate of
ethmoid
(ii) the vomer
(iii) a large septal (quadrilateral)
cartilage wedged between the
above two bones anteriorly.
1.2 Aetiology
A. Trauma. A lateral blow on the nose may cause displacement of
septal cartilage from the vomerine groove and maxillary crest,
while a crushing blow from the front may cause buckling, twisting,
fractures and duplication of nasal septum with telescoping of its
fragments.
B. Racial factors. Caucasians are affected more than Africans.
C. Hereditary factors. Several members of the same family may
have deviated nasal septum.
D. Developmental error.
Nasal septum is formed by the
tectoseptal process which descends to
meet the two halves of the developing
palate in the midline. Unequal growth
between the palate and the base of
skull may cause buckling of the nasal
septum. In mouth breathers, as in
adenoid hypertrophy, the palate is
often hughly arched and the septum is
deviated.
1.3 Types of DNS
 1.4 Clinical Features
DNS can involve any age and sex. Males are affected more than females.
A. Nasal obstruction. Depending on the type of septal deformity, obstruction
may be unilateral or bilateral.
B. Sinusitis. Obstruct sinus ostia resulting in poor ventilation of the sinuses. It
forms an important cause to predispose or perpetuate sinuses infections.
C. Epistaxis. Mucosa over the deviated
part of septum is exposed to the drying
effects of air currents leading to
formation of crusts which when removed,
cause bleeding. Bleeding may also occur
from vessels over a septal spur.
D. Headache. Deviated septum,
especially a spur, may press on the lateral
wall of nose giving rise to pressure
headache.
E. Anosmai. Failure of the inspired air to reach the olfactory region
may result in total or partial loss of sense of smell.
F. External deformity Septal
deformities may be
associated with deviation of
the cartilaginous or both the
bony and cartilaginous
dorsum of nose, deformities
of the nasal tip or collumella.
G. Middle ear infection DNS
also predisposes to middle
ear infection.
1.5 Diagnose
 1.6 Treatment
The patients with no symptoms are
commonly seen and require no treatment.
It is only when deviated septum produces
mechanical nasal obstruction or the
symptoms given obove, Submucous
resection (SMR) operation is indicated.
It is generally done in adults under
general anaesthesia. Septal surgery is
usually done after the age of 17 so as not
to interfere with the growth of nasal
skeleton.
 It consists of elevating the mucoperichondrial and mucoperiosteal
flaps on either side of the septal framework by a single incision
made on one side of the septum, removing the deflected parts of
the bony and cartilaginous septum, and then repositioning the flaps.
2. Disease of Nasal Cavity
（1） The Common Cold and the Flu
Both the flu and the common cold are respiratory
illnesses caused by different viruses. The flu is an infection
of the respiratory system caused by the influenza virus, the
common cold is caused mainly by rhinoviruses. Common
cold/acute viral rhino-sinusitis is defined as duration of
symptoms for less than 10 days. Acute nonviral
rhinosinusitis is defined as an increase of symptoms after 5
days or persistent symptoms after 10 days with less than
12 weeks’ duration.
 common cold Flu
Virus Rhinovirus Influenza
Contagiousness Droplets by inhalation or touch Droplets by inhalation
Onset 1–3 days after virus entrance Sudden
Duration Duration One week One week or more
Children six to eight colds per year, adults Once
Frequency two to four colds per year

Milder Worse
Weakened senses of taste and smell, Fever (39°C or above), body aches,
Symptoms cough, runny or stuffy nose, sneezing, dry cough more common, headache,
scratchy throat sore throat, chills, tiredness

No serious complications May have serious complications,

Complications
pneumonia, bacterial infections
Acetaminophen; Antihistamine and/or Like common cold
decongestant; Adequate fluid intake (eight
Treatment glasses of water or juice); Avoid smoking
and alcohol; No antibiotics
 How to prevent a cold

1. Close contact with people who have a cold should be avoided especially
during the first few days when they are most likely to spread the infection
2. Hands should be washed after touching someone who has a cold
3. Fingers should be kept away from the nose and the eyes to avoid
selfinfecting the cold virus particles

4. A second hand towel should be put in the bathroom for healthy people to use

5. The environment should be humidified

6. The nose and the mouth should be covered with a tissue when coughing or
sneezing
（2） Rhinitis
Rhinitis is a clinical diagnosis and is
defined as inflammation of the nasal
mucosa with one or more symptoms
of sneezing, itching, rhinorrhea, and
nasal blockage lasting for at least 1h
on most days. All diseases causing
rhinorrhea and nasal obstruction
should be considered in the
differential diagnosis of rhinitis.
 Classification of rhinitis

Infectious Nonallergic Allergic

rhinitis Rhinitis rhinitis

NARES
acute chronic Eosinophilic others perennial seasonal
rhinitis
A. Acute rhinitis
can be Viral, Bacterial or Irritative type.
• VIRAL RHINITIS (Common cold or
coryza)
Aetiology. It is caused by a virus. The
infection is usually contracted through
airborne droplets. Several viruses
(adeno virus, picorna virus and its
subgroups such as rhinovirus, coxsackie,
and ECHO) are responsible. Incubation
period is 1-4 days and illness lasts for 2-
3 weeks.
(a) Clinical features
To begin with, there is burning
sensation at the back of nose soon
followed by nasal stuffiness,
rhinorrhoea and sneezing. Patient feels
chilly and there is low grade fever.
Initially, nasal discharge is watery and
profuse but may become mucopurulent
due to secondary bacterial invasion.
Secondary invaders include,
Pneumococcus, Staphylococcus, Bacillus
Influenzae.
(b) Treatment Bed rest, plenty of fluids
are encouraged. Symptoms can be easily
controlled with antihistaminics and nasal
decongestants. Analgesics are useful to
relieve headache, fever and myalgia.
Antibiotics are required when secondary
infection supervenes.
(c) Complications The disease is usually
selflimiting and resolves spontaneously
after 2 to 3 weeks, but occasionally,
complications such as sinusitis, pharyngitis,
tonsillitis, bronchitis, pneumonia and otitis
media may result.
B Influenzal rhinitis
Influenza viruses A, B or C are
responsible. Symptoms and signs are
similar to those of common cold.
Complications due to bacterial invasion
are common.
(a) Rhinitis associated with exanthemas.
Measles, rubella, chickenpox are often
associated with rhinitis which precedes
exanthemas by 2-3 days. Secondary
infection and complications are more
frequent and severe.
（B）Bacterial Rhinitis
Nonspecific infections. It may be primary or secondary. Primary
bacterial rhinitis is seen in children and is usually the result of
infection with pneumococcus, streptococcus or staphylococcus. A
greyish white tenacious membrane may form in the nose, which
with attempted removal, causes bleeding.
(C) Irritative Rhinitis
This form of acute rhinitis is caused by exposure to dust,
smoke or irritating gases such as ammonia gas, formaline, acid
fumes, etc. or it may result from trauma. There is an immediate
catarrhal reaction with sneezing, rhinorrhoea and nasal
congestion.
Chronic non-specific inflammations of nose include :
l Chronic simple rhinitis
l Hypertrophic rhinitis
l Atrophic rhinitis
(A) Chronic Simple Rhinitis
(a) Aetiology
The predisposing factors are:
u Persistence of nasal infection due to sinusitis, tonsillitis, and
adenoiditis.
u Chronic irritation from dust, smoke, cigarette smoking, etc.
u Nasal obstruction leading to persistence of discharge in the nose.
u Vasomotor rhinitis.
u Endocrinal or metabolic factors, hypothyroidism, excessive intake
of carbohydrates, lack of exercise.
 Simple chronic rhinitis is an
early stage of hypertrophic
rhinitis. There is hyperaemia and
oedema of mucous membrane
with hypertrophy of
seromucinous glands and
increase in goblet cells. Blood
sinusoids particularly those over
the turbinates are distended.
(c) Clinical Features

ü Nasal obstruction Usually worse on lying

and affects the dependent side of nose.
ü Nasal discharge It may be mucoid or
mucopurulent, thick and viscid and often
trickles into the throat as post-nasal drip.
Patient has a constant desire to blow the
nose or clear the throat.
ü Headache It is due to swollen turbinates
impinging on the nasal septum.
üSwollen turbinates Nasal mucosa
is dull red in colour.
Turbinates are swollen; they pit on
pressure and shrink with application of
vasoconstrictor drops (this
differentiates the condition from
hypertrophic rhinitis). Middle turbinate
may also be swollen and impinge on
the septum.
ü Post-nasal discharge. Mucoid or mucopurulent
discharge is seen on the posterior pharyngeal wall.
(d) Treatment
ØTreat the cause with particular
attention to sinuses, tonsils,
adenoids, allergy, personal habits
(smoking or alcohol indulgence),
environment or work situation
(smoky or dusty surroundings).
ØNasal irrigations with alkaline
solution help to keep the nose free
from viscid secretions and also
remove superficial infection.
ØNasal decongestants help to relieve
nasal obstruction and improve sinus
ventilation. Excessive use of nasal
drops and sprays should be avoided
because it may lead to rhinitis
medicamentosa. A short course of
systemic steroids helps to wean the
patients already addicted to excessive
use of decongestant drops or sprays.
ØAntibiotics help to clear nasal
infection and concomitant sinusitis.
 C. Allergic Rhinitis
It is an IgE mediated immunologic response of nasal
mucosa to airborne allergens and is characterised by
watery nasal discharge, nasal obstruction, sneezing
and itching in the nose. The incidence rate in mainland
China is 4—38 %, with great regional difference.
Seasonal. Symptoms appear in or around a particular
season when the pollens of particular plant, to which
the patient is sensitive, are present in the air.
Perennial. Symptoms are present throughout the year.
 perennial

Symptoms appear Symptoms appear

Ø < 4 days/a week Ø ≥4 days/a week
Ø or < 4 weeks/a year Ø or≥4 weeks/a year
(a) Aetiology
üInhalant allergens are often the
cause. Pollen from the trees and
grasses, mould spores, mites,
house dust, debris from insects or
house mite are common offenders.
üGenetic predisposition plays an
important part. Chances of children
developing allergy are 20% and
47% respectively, if one or both
parents suffer from allergic
diathesis.
(b) Clinical Features
It may start in infants as young as 6 months or older people.
Usually the onset is at 12-16 years of age.
üSymptoms of seasonal nasal allergy include paroxysmal
sneezing, 10-20 sneezes at a time, nasal obstruction, watery
nasal discharge and itching in the nose. Itching may also
involve eyes, palate or pharynx. Some may get
bronchospasm. The duration and severity of symptoms may
vary with the season.
üSymptoms of perennial allergy are not as severe as that of
the seasonal type. They include frequent colds, persistently
stuffy nose, loss of sense of smell due to mucosal oedema,
postnasal drip, chronic cough and hearing impairment due
to Eustachian tube blockage or fluid in the middle ear.
(c) Pathogenesis
ü Inhaled allergens produce specific IgE antibody in the genetically
predisposed individuals.
ü This antibody becomes fixed to the blood basophils or tissue mast
cells by its Fc end.
üOn subsequent exposure, antigen
combines with IgE antibody at its
Fab end. The mast cells release of
several chemical mediators. Eg.
Histamine.
üThese mediators are responsible
depending on tissues involved,
there may be vasodilation,
mucosal oedema, infiltration with
eosinophils, excessive secretion
from nasal glands or smooth
muscle contraction.
(d) Diagnosis of AR
Endoscopy: serous nasal discharge with
hypertrophic, pale inferior turbinates
prick, scratch and intradermal tests
(d) Complications
Nasal allergy may cause
• Recurrent sinusitis because of
obstruction to the sinus ostia
• Nasal polypi
• Serous otitis media, Eustachian tube
blocked
• Orthodontic problems and other ill-
effects of prolonged mouth breathing
especially in children
• Bronchial asthma. Patients of nasal
allergy have four times more risk of
developing bronchial asthma
(e) Treatment with drugs
u Antihistaminics. They control rhinorrhoea, sneezing
and pruritis.
uSympathomimetic drugs (oral or topical). α-
adrenergic drugs constrict blood vessels and reduce
nasal congestion and oedema. Topical use of
sympathomimetic drugs cause nasal decongestion.
Phenylephrine, oxymetazoline and xylometazoline
are often used to relieve nasal obstruction, but this
may cause vicious cycle leads to rhinitis
medicamentosa.
uCorticosteroids. Oral corticosteroids are very
effective in controlling the symptoms of allergic
rhinitis but their use should be limited. Topical
steroids such as beclomethasone dipropionate,
budesonide, fluticasone and mometasone
inhibit recruitment of inflammatory cells into
the nasal mucosa and suppress latephase
allergic reaction, are used as aerosols and are
very effective in the control of symptoms.
uSodium cromoglycate（色苷酸二钠）. It
stabilises the mast cells and prevents them from
degranulation despite the formation of IgE-
antigen complex.
 Montelukast, a leukotriene-receptor antagonist,
for the treatment of Allergic rhinitis, mild asthma
and exercise-induced bronchoconstriction
(c) Corticosteroids. Oral corticosteroids are very
effective in controlling the symptoms of allergic
rhinitis but their use should be limited. Topical
steroids such as beclomethasone dipropionate,
budesonide, fluticasone and mometasone inhibit
recruitment of inflammatory cells into the nasal
mucosa and suppress latephase allergic reaction,
are used as aerosols and are very effective in the
control of symptoms.
(d) Sodium cromoglycate（色苷酸二钠）. It
stabilises the mast cells and prevents them from
degranulation despite the formation of IgE-antigen
complex.
u Immunotherapy = radical cure ?
Immunotherapy or hyposensitisation is used when drug
treatment fails to control symptoms or produces intolerable
side effects. Allergen is given in gradually increasing doses
till the maintenance dose is reached. Immunotherapy
suppresses the formation of IgE. It also raises the titre of
specific IgG antibody.

Sublingual dropping hypodermic injection

 Characteristics of Specific Immunotherapy in
WHO views report
1. Perform specific immunotherapy alone or in combination with a
different therapy to treat allergic rhinitis.
2. Effective also for allergic conjunctivitis and allergic asthma.
3. Should be performed by a physician specialized in allergy.
4. Avoid using allergen mixtures for treatment. Use standardized
allergen vaccines.
5. Gradually increase allergen to reach maintenance dose.
6. Optimal maintenance dose contains 5-20 μg of a major allergen for
each injection.
7. Because of the risks of anaphylaxis, respond appropriately in an
emergency.
8. Optimal duration is unknown, generally 3-5 years.
u Surgical treatment
Nasal blockage in allergic rhinitis is often caused by nasal
deformities, such as deviated septum, hypertrophic rhinitis, and
nasal polyps. In this case perform corrective surgery of nasal
cavity to improve nasal ventilation.
Prevention Stuffed animals with artificial fur are major dust
reservoir should not be kept in the room of an allergic child
 D. Vasomotor Rhinitis
It is non-allergic rhinitis but clinically
simulating nasal allergy with symptoms of
watery nasal discharge ( rhinorrhoea), nasal
obstruction, sneezing (usually no itching in
the nose). One or other symptoms may
predominate. The condition usually persists
throughout the year and all the tests of
nasal allergy are negative.
(a) Aetiology
Autonomtic nervous system
is under the control of
hypothalamus and therefore
emotions play a great role in
Vasomotor Rhinitis. Nasal
mucosa is also hyperreactive
and responds to several non-
specific stimuli, e.g. change in
temperture, humidity, blasts of
air, small amounts of dust or
smoke.
(b) Symptoms
ü Excessive rhinorrhoea (watery nasal
discharge). May be the only predominant
symptom.
ü Nasal obstruction, the alternates from side to
side. Usually more marked at night. It is
dependent on side of nose which is often
blocked when lying on one side.
ü Paroxysmal sneezing. Bouts of sneezing start
juse after getting out of the bed in the
morning
ü Postnasal drip.
 (c) Treatment
• Avoidance of physical factors which provoke symptoms,
sudden change in temperature, humidity, blasts of air or dust.
• Antihistaminics and nasal decongestants are helpful in
relieving nasal obstruction, sneezing and rhinorrhoea.
• Topical steroids used as spray or aerosol are useful to control
symptoms.
• Systemic steroids can be given for a short time in very severe
cases.
• Psychological factors should be removed. Tranquillizers may
be needed in some patients.
声明：本课件（116 张PPT中）的部分图片来源于互联网，
本人无意侵犯版权，图片仅用于暨南大学国际学院，耳鼻咽
喉-头颈外科学本科教学使用。
STATMENT: Some of the pictures in this courseware
（total 116 PPTs） are from the Internet. I do not intend
to infringe the copyright. The pictures are only used for
the undergraduate teaching of Otolaryngology-Head and
Neck Surgery in the International College of JINAN
UNIVERSITY. GUANGZHOU.CHINA