Rhinology (Allergy & Sinus) : Rhinology Conditions

Rhinology Conditions


Sinusitis and headache are each extremely common diseases, and although sometimes they can be related, often they are separate issues. With millions of Americans suffering from each of these problems, there is bound to be some overlap and confusion on the part of the patient as to what their diagnosis truly is. “Sinus headache” is a common complaint that patients present with, but evidence suggests that this phrase may not be a real clinical diagnosis.


Sinusitis can be divided into many different categories, but the simplest distinction is the difference between Acute Sinusitis and Chronic Sinusitis. Acute sinusitis is defined as sinusitis lasting four weeks or less. Chronic sinusitis is defined as sinusitis lasting longer than 12 weeks. An acute exacerbation of chronic sinusitis is defined as a sudden worsening of symptoms in a patient who has chronic sinusitis with a return of symptoms to baseline after treatment.
The diagnostic criteria put forth by the International Headache Society for “headache attributed to sinusitis” require a frontal headache (meaning in the region of your forehead), evidence of rhinosinusitis (on a CT, MRI, nasal endoscopy or by lab data), and resolution of the headache with appropriate sinusitis treatment (Table 1). The clinical evidence may include drainage in the nasal cavity, nasal obstruction, decreased or absent sense of smell, and/or fever. Chronic rhinosinusitis is not validated as a cause of headache or facial pain except in cases of acute relapse. These headaches are caused by the pressure of mucus against the lining of the sinus cavities when that mucus becomes trapped and unable to drain into the nasal cavity due to inflammation and swelling of the openings.



Do you experience runny nose, sneezing and nasal congestion in the same season year after year? Do you seem to get “colds” often? If so, you may be suffering from a common condition known as hay fever, or allergic rhinitis. An understanding of the causes, symptoms and treatments can help make your symptoms more bearable.


Allergic rhinitis is a condition in which the body reacts to the environment in a hyperactive way. Even normal substances in the environment can become symptom-producing allergens in certain individuals. Although hay and weeds are common culprits, pollens from grasses and trees, mold, dust mite, and animal dander can also cause symptoms. The various pollens produce seasonal symptoms, whereas mold, dust mite and animal dander may result in perennial, or year-round, symptoms. Since pollen and mold counts can vary widely, a variety of resources are available to determine which allergens are found in your region, and when they tend to be highest in quantity (www.aaoaf.org, www.pollen.com). Regardless of the allergen, the result of exposure is the same. Histamine and other inflammatory chemicals are released in the body, and the symptoms of allergies ensue.


Nasal symptoms such as runny nose, sneezing, and congestion are the most common but other areas of the body can also be affected by allergies. Itching of the eyes with redness and watering, headache, intermittent ear plugging, chronic cough, wheezing, intermittent hoarseness, sore throat, and fatigue can also be experienced. Chronic sinus and ear infections, and even asthma may accompany allergic rhinitis.


Your doctor may recommend further evaluation to determine if you have sensitivity to particular environmental allergens. Two types of tests are commonly performed: skin testing or a blood test also known as a (radioallergosorbent) RAST test or an in vitro test. During skin testing a small amount of allergen is pricked or injected into the skin and then checked for a reaction after waiting several minutes. You may develop a bump at the site of testing if you are allergic. In in vitro testing a sample of your blood is drawn and sent to the lab. In this test levels of an antibody to specific allergens are measured and may be elevated in allergic rhinitis.


Upper respiratory infections (URIs) are among the most common reasons people seek medical attention and are the leading reason why people miss school or work. URIs are most commonly caused by viruses and can occur year-round, although most frequently in the cold or rainy months.
The respiratory tract refers to the pathway that carries air to the lungs, and can be divided into upper and lower parts. The lower respiratory tract consists of the lungs and windpipe, while the upper respiratory tract includes the nose, sinuses, throat (pharynx) and voice box (larynx). Although sinusitis, laryngitis and strep throat are all infections of the upper respiratory tract, the term URI usually refers to acute viral rhinitis. Another name for this condition is the “common cold.”
The symptoms of a viral URI typically include nasal congestion, sneezing, and a runny nose with clear mucus. A sore or scratchy throat, hoarse voice, ear fullness, headache and low-grade fever may also be present. Similar symptoms may be caused by influenza virus infection (also called “the flu”), but this usually causes more severe symptoms such as high fever, malaise, and aching muscles.


Nasal congestion has a variety of causes, and is usually attributed to either a structural anatomic blockage or swelling of the nasal tissue. Both problems can narrow the nasal cavity and give a sensation of “nasal congestion”. The following is a list of potential causes of nasal congestion:
• Allergies
• Viral infection
• Environmental irritants
• Enlarged turbinates (anatomical structures inside the nasal cavity)
• Deviated nasal septum
• Chronic sinusitis
• Nasal polyps
• Benign and cancerous tumors


A disruption (a hole or tear) in the brain lining (called the dura) and the bone separating the brain and the sinuses will result in the drainage of fluid that normally surrounds the brain into the sinuses. This fluid is known as cerebrospinal fluid or “CSF.” Drainage of CSF into the sinuses can result in a multitude of problems, not to mention the often times annoying constancy of nasal dripping.


Cerebrospinal fluid consists of a mixture of water, electrolytes, glucose, amino acids and various proteins. Cerebrospinal fluid is colorless, clear, and usually does not contain any cells. The primary site of CSF production is the choroid plexus (an area within the brain), which is responsible for 50-80% of its daily production.
All these sites produce CSF at a rate of approximately 20 mL/hr for a total of approximately 500 mL daily. At any given time, there is approximately 90-150 mL of CSF circulating throughout the central nervous system (CNS, which includes the brain and spinal cord). Cerebrospinal fluid circulates around the brain and spinal cord within the subarachnoid space.


Tumors of the nose and paranasal sinuses are rare, accounting for less than 1% of all tumors. These tumors can be either benign or malignant, and they vary greatly in location, size and type. Care for these tumors is individualized to each patient and may involve a multi-disciplinary (team) approach for treatment. Possible treatments include surgery, radiation therapy and chemotherapy depending on the particular tumor and the needs of the patient.


The symptoms associated with nasal and sinus tumors are non-specific. This means they are often difficult to distinguish from other nasal conditions such as allergies or sinus infections. Symptoms may include nasal congestion, facial pain and pressure, runny nose, and post-nasal drip. More worrisome symptoms include recurrent and severe bleeding from the nose, facial swelling, associated eye symptoms and changes in sensation to the face. Any of these symptoms should prompt a visit to the doctor, especially symptoms that are only present on one side or symptoms that represent a significant change from before (especially in an elderly patient).


cosmetic or functional nasal deformity may occur secondary to a crooked septum (the wall in the middle of the nose, that is composed of both cartilage and bone, and divides it between left and right sides), an asymmetric nasal bone, scar tissue, collapse or weakening of nasal structures, or a specific portion of the nose being disproportionate to the remainder of the nose and face. So what causes cosmetic or functional nasal deformity? There are multiple reasons, and often, many of the causes result in both cosmetic and functional problems. The most common causes are listed below. Congenital (present at birth) deformity – a baby born with a cleft lip, cleft palate, nasal mass or other anomaly (problem) may have structural weakness or asymmetry of the nose. Congenital nasal deformities may require multiple staged surgeries to achieve the final desired result.



When unilateral, the right side is affected more often than the left. If the atresia (narrowing or complete blockage) is only on one side, sometimes it is identified at birth but it can go unnoticed for a few years. Most commonly, children will have chronic thick drainage from one side of the nose.


If the atresia is present on both sides, it is much more likely that the newborn infant will have symptoms with significant difficulty breathing and feeding. Patients may have noisy breathing, turn blue while sleeping or feeding, and aspirate milk. When the patient awakens, coughs or cries the mouth will open again, allowing air to move through to the lungs, and symptoms will often temporarily resolve. Feeding slowly can allow the baby to breathe between swallows. However, a feeding tube is often placed from the oral cavity into the stomach to make sure that the patient safely receives adequate feeds.


Epiphora, or excessive tearing, is defined as the overflow of tears from one or both eyes. Epiphora can occur continuously (be present all the time), or it can occur intermittently (be present only sometimes). Epiphora is subdivided into two main categories: overproduction of tears or inadequate drainage of tears. In this article, we will be discussing inadequate drainage as a cause of epiphora.