Furunculosis of the nasal vestibule: causes, diagnosis, complications, treatment

Definition: Acute inflammation of the mucosal lining of the paranasal sinuses lasting no longer than 4 weeks.

Acute rhinitis is a common association so it's better called (Acute rhinosinusitis, ARS).
Viral rhinosinusitis (VRS): ARS of less than 10 days duration.
Acute bacterial rhinosinusitis (ABRS): ARS of more than 10 days duration.

Etiology:

Predisposing factors:

• Viral infections.
• Obstructive anatomy; Deviated nasal septum, nasal polyps, allergic rhinitis or osteomas.
• Disturbed muco-ciliary clearance; Kartagner syndrome, or cystic fibrosis -Immune deficiency (IgA deficiency).
• Air pollution and overcrowdings.
  

Routes of spread:

Nasal:

• Extension of upper respiratory tract infection.
• Missed foreign body or nasal pack.
• Nasogastric tube

Dental:

Dental caries or oro-antral fistula causes maxillary sinusitis.

External trauma:

Facial fractures and penetrating injuries.

Causative organisms:

• Viral: Rhinovirus, corona virus, influenza and respiratory syncytial virus.
• Bacterial "acute bacterial rhinosinusitis ABRS":
• Streptococcus Pneumoniae, Hemophilus influenza, Staph aureus and Maroxilla catarrhalis (children).

Pathogenesis:

ARS usually starts by catarrhal followed by suppurative rhinosinusitis.

Clinical picture: 

Acute rhinosinusitis is mainly a clinical diagnosis. It is most appropriately made on the basis of the medical history, symptoms, and clinical examination.

Symptoms:

• History of URTI is usually present.
• Constitutional symptoms: Fever, headache, malaise.
• Nasal obstruction (unilateral or bilateral).
• Rhinorrhea (unilateral or bilateral).
• Facial pain and headache.
• Hyposmia or anosmia.

Over the affected sinus.

• Acute maxillary sinusitis: facial pain is felt over the cheek and referred to upper teeth and ear.
• Acute frontal sinusitis: Facial pain is felt over the forehead. It starts in the morning as the sinus fills up during sleeping and secretions are under tension. Headache gets worse by the mid-day as the air doesn’t adequately replace the coming down pus (Vacuum headache). At the end of the day headache disappears as the sinus becomes well drained and aerated.

• Acute ethmoiditis: Facial pain is felt over the inner canthus and retro-orbital. It may be referred to the parietal region.
• Acute sphenoidal sinusitis: Facial pain is felt retro-orbital and referred to the occiput. Increasing by leaning forward. More severe in the morning.

NB: When to suspect ABRS clinically?

• ARS symptoms last for 10 days or get worse.
• High grade Fever.
• Purulent discharge.

Signs:

• Affected sinus is tender.
• Congestion and edema of nasal mucosa.
• Mucopurulent or purulent nasal discharge. Its location varies according to the affected sinus;
• Pus in the middle meatus (anterior group of sinuses).
• Pus in the superior meatus (posterior ethmoid).
• Pus in the spheno-ethmoidal recess (sphenoid sinus).
• Oral examination shows post-nasal discharge.

Investigations:

Usually not needed in uncomplicated cases as it’s a clinical diagnosis.

1- Radiology: X ray sinus view: opacity or fluid level.

2- CT paranasal sinuses: investigation of choice

3- Culture & sensitivity.

Treatment of Acute Sinusitis:

Medical: 

• Symptomatic treatment: analgesics, decongestants, antihistamines, saline nasal irrigation, mucolytic, and intranasal corticosteroids.
• Antibiotics may be considered in patients with symptoms or signs of acute rhinosinusitis that do not improve within seven days or that worsen at any time 
• Most guidelines recommend amoxicillin as first-line therapy. For patients allergic to penicillin, trimethoprim/sulfamethoxazole or macrolides may be used as an alternative to amoxicillin.

Surgical:

• Indicated in resistant or complicated sinusitis.
• The aim of surgery is to drain the sinus and to restore aeration. - Functional endoscopic sinus surgery (FESS) has largely replaced open surgical approaches and become the standard technique for treatment.

Open approaches:

• Maxillary sinus: Antral puncture and lavage.
• Frontal sinus: Trephine surgery through the sinus floor.
• Ethmoids: External ethmoidectomy.
• Sphenoid sinus: External spheno-ethmoidectomy.

Key points

ARS is an inflammation of the mucosal lining of nose and paranasal sinuses.

ARS is a clinical diagnosis.