Friday, March 30, 2012

WHAT NASODREN IS AND WHAT IT IS USED FOR

NASODREN nasal spray is a natural extract of fresh tubers of the plant Cyclamen europaeum L.

NASODREN is used for localised relief of the symptoms of nasal congestion (blocked up feeling in your nose), nasal secretions, loss of smell and facial pain by clearing and draining the mucous secretions retained in sinuses (passages leading to the nose), nasal cavities and upper respiratory tract, providing fast symptom relief from the very first dose.

When you use NASODREN, you will experience an intense discharge of dammed up secretions from the nose and paranasal cavities, which can last up to two hours. As a result, the headache or facial pain, which often accompanies nasal congestion, rapidly ceases.

In cases of otitis media, the dammed up secretions are rapidly eliminated, resulting in a decrease of earache and recovery of hearing loss.

NASODREN is recommended for the treatment and symptomatic relief of diseases of nasal and paranasal cavities, and of the middle ear:

• Acute or chronic recurrent inflammation of the paranasal sinuses (rhinosinusitis): catarrhal or purulent maxillary rhinosinusitis, frontitis, ethmoiditis, sphenoiditis, or combined rhinosinusitis.

• Acute exudative or purulent otitis media, chronic exudative, acute secretory otitis media or purulent otitis media.

• In postoperative care, after nasal or nasosinusal surgery.





This medical device is available without prescription. However, you still need to use NASODREN carefully to get the best results from it.

- Keep this instructions. You may need to read it again.

- Ask your pharmacist if you need more information or advice.

- You must contact a doctor if your symptoms worsen after 5 days or do not improve after 10 days.

- If any of the side effects gets serious, or if you notice any side effect not listed in this leaflet, please tell your doctor or pharmacist.

Content:

1. What NASODREN is and what it is used for

2. Before you use NASODREN

3. How to use NASODREN

4. Possible side effects

5. How to store NASODREN

6. Further information


2. BEFORE USING NASODREN

Do not use NASODREN

• If you are allergic (hypersensitive) to Cyclamen, Primula and other Primulaceae, which could lead to swelling of the nasal mucosa, eyelids and/or face.

Take special care with NASODREN

• Apply only one spray per day into each nostril.

• Avoid inhaling during application.

• Avoid eye contact. Contact with the eyes may result in irritation and symptoms of acute conjunctivitis.

• Take note of the section “If you are taking medicines”.

• A brief sensation of mild and transient itchiness or burning, sneezing and shedding of tears or an increase in nasal secretions can occur a few minutes after administration. This is entirely normal and occurs when NASODREN begins to take effect and indicates an optimum reaction to this product’s effectiveness. Treatment should therefore not be interrupted. There may be a pinkish colored discharge from the nose; this should also be no cause to worry.

If you are taking medicines

Please tell your doctor or pharmacist if you are taking or have recently taken any other medicines, including medicines obtained without a prescription. Specially, if you are receiving treatment with anticoagulants (such as coumarin derivatives, acetylsalicylic acid) or anticholinergics (such as atropine).

Other nasal products can be used 1.5-2 hours after using NASODREN.

Using NASODREN with food and drink

NASODREN is not affected by food and drink.

If you are pregnant or breast-feeding

Ask your doctor or pharmacist for advice before using NASODREN.

There is no experience regarding the administration of NASODREN during pregnancy and breast-feeding. Therefore, NASODREN should not be used if you are pregnant or breast-feeding unless prescribed by your doctor.

Using NASODREN in children

NASODREN can be used in children aged 5 years and above.

Driving or using machines

Driving or using machines is not recommended for 2 hours after using the spray, because NASODREN is clearing and draining the mucus.


3. HOW TO USE NASODREN

NASODREN is for use in your nose only.

Follow instructions and pictures below.


How to prepare the solution

1. Open the vial containing the powder by turning the cap counter-clockwise and removing the stopper.

2. Open the plastic ampoule with the liquid by breaking off the upper part.

3. Pour the entire liquid into the vial with the powder.

4. Screw the spray nozzle onto the vial and shake gently until fully dissolved. Wait until no foam is visible.

5. Remove the protective cap from the spray nozzle.

6. Prior to the first administration, press the spray nozzle 2-3 times, aiming it away from the body into the air, avoiding the eyes!



How to use NASODREN

7. Hold your head vertically, do not lean forwards or backwards. Insert the spray nozzle into the right nostril. Stop breathing for a short time (3-5 seconds) and spray the solution into the right nostril by pressing the spray nozzle once only. Breathe out deeply through the mouth once and then breathe normally. Do not inhale during administering the spray!

8. Then repeat into the left nostril; as described under 7 above.

9. Clean the spray nozzle with a clean paper tissue. Replace the protective cap on the spray nozzle.

How much NASODREN to use

The solution should be sprayed daily only once into each nostril, preferably at the same time of day, approximately 2 hours before bedtime. Increasing the daily dose does not result in an increased effect.

How long should you use NASODREN for

The treatment normally lasts 7-10 days but may be extended to 12-14 days if necessary.

A significant improvement or total symptomatic relief is achieved after 6-8 applications; however, headaches often associated with the condition may reduce or stop completely after only 3-5 applications of NASODREN. Nevertheless, treatment should be continued for the recommended duration of 7-10 days.

In cases that are complicated by purulent infection, you should contact a doctor.

If a second course of treatment is necessary in severe or chronic cases, this should only be initiated 7-10 days after completion of the previous course.

If you use more NASODREN than you should

NASODREN overdosage can cause an intense burning in the nasopharyngeal space, without serious consequences.

In case of an accidental overdose, irrigation of the nasal cavity through the nostrils with warm water and pharyngeal gargling with warm water can be useful.

If you forget to use NASODREN

If you forget to take a dose, continue with treatment on the next day as recommended.

If you stop using NASODREN

Do not stop treatment sooner than stated in this leaflet because you may not obtain the expected results. Similarly, do not use NASODREN longer than stated here.

If you have any further questions on the use of this product, ask your doctor or pharmacist.


4. POSSIBLE SIDE EFFECTS

Like all products, NASODREN can cause side effects, although not everybody gets them.

Medical attention should be sought if prolonged shedding of tears or saliva lasting more than 2 hours occurs..

If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.


5. HOW TO STORE NASODREN

Keep out of the reach and sight of children

The original package must be protected from light and stored at a temperature lesser than 25°C.

Once solution is prepared, NASODREN must be stored in a refrigerator at a temperature of 2-8°C protected from light.

The expiry date is printed on the carton, the glass vial containing the powder and the purified water. Do not use after the printed expiry date. The expiry date refers to the last day of that month.

Do not use for more than 14 days after preparation of the solution.

It is recommended to insert here as a reminder:

NASODREN was prepared on: ……………


It is stable now for 16 days, until: ……………

This product should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of products that are no longer required. These measures will help to protect the environment.

6. FURTHER INFORMATION



What NASODREN contains

- The active substance is: Lyophilized powder from a natural extract from fresh tubers of Cyclamen europaeum L.

Each dose of nasal spray releases 0.13 ml (2-3 drops) of solution. This quantity corresponds to 1.3 mg powder. The finished solution produces 38 doses to be applied for a maximum of 16 days.

-There are neither artificial ingredients nor preservatives.

A solvent (5 ml of purified water) is provided for reconstitution of the lyophilized powder.

What NASODREN looks like and contents of the pack

NASODREN is a powder used for the preparation of a nasal spray. It contains:

• 1vial containing 50 mg of lyophilized powder.

• 1 ampoule containing 5 ml of solvent (purified water).

• 1 spray nozzle.



More detailed information: www.nasodren.com

Thursday, March 29, 2012

Antroliths and mucositis of paranasal sinuses

Antroliths and mucositis of paranasal sinuses

Antroliths and mucositis form within paranasal sinuses, but there is no apparent symptoms-sinus in both the disorders.



Antroliths are also referred to as antral caluli, antral stones and rhinoliths. Hard-calcified structures found in the maxillary antrum are called antroliths. The calcification of foreign bodies, fragments of bones and roots or mucus lead to antrolith formation. A foreign body acts as a nucleus on which magnesium, calcium phosphate and calcium carbonate mineral salts deposit, initiating the growth of antroliths. The rhinoliths also form around pus and red blood cells, the endogenous nucleus. The antrolith density and shape varies. The antrolith surface is rough and irregular. The rhinoliths color varies from brown to black. These structures without symptoms-sinus are rare. They are observed on the radiographs. The orthopantomographs and waters view display antroliths developing in the antral cavity. However, antroliths may create heaviness in the sinus region.
On rare occasions, antroliths may be related to facial pain, nasal discharge with blood and chronic or acute sinusitis.  Removal of antroliths is must because these structures cause pain and soreness in the sinus membrane, making the patient susceptible to sinusitis.  Caldwell-Luc surgery method is used to remove the antroliths. During this surgical approach, a window is made in the maxillary sinus’ anteriolateral wall to visualize the sinus. The method is also used to remove antrum lining in some chronic maxillary sinusitis cases.
Mucositis is thickened mucous membrane of the maxillary sinus. Thickness of a normal maxillary sinus is approximately one millimeter. However, thickness increases up to fifteen times due to inflammation caused by an allergen or infection. The membrane with over three-millimeter thickness is called mucositis. Inflammatory lesion of the teeth, including periapical or periodontal diseases thickens the membrane. This disorder is usually asymptomatic and is documented on a radiograph. The mucositis appear as a band on the radiograph. The band is more radiopaque than the sinus filled with air. 
Localized swelling or inflammation of the maxillary sinus membrane due to periapical inflammation is referred to as periapical mucositis.  The maxillary posterior teeth having apical periodontitis trigger the inflammation. To resolve the symptoms-sinus, treat the endodontic disorder. Periapical mucositis shall not be confused with mucocele or mucous retention cyst found in the sinus. Mucositis could be recurrent and chronic.
Chemoradiotherapy and / or radiotherapy during maxillofacial surgery may also cause mucositis. This condition can be treated with laser therapy. Mucosal irradiation before starting the therapy can even reduce the mucositis.

Wednesday, March 28, 2012

Mucoceles in paranasal sinuses

Mucoceles in paranasal sinuses

The obstructed sinus ostium causes vicious lesions called mucocele. These lesions are also referred to as mucopyoceles and pyoceles. Trauma, bony neoplasams, polyps and intra-antral inflammation contribute to the development of mucoceles. These mucus filled mucoceles feature mucoperiosteum of the sinus affected. The symptoms of sinus include forehead-specific trauma, the frontal sinus fracture, obstruction in the frontonasal duct, prolonged allergic rhinitis and nasal obstruction. The symptoms may persist up to several years.




The lesions are commonly found in the frontal sinuses, followed by ethmoid sinuses and sphenoid and maxillary sinuses.
Mucoceles in frontal sinus
These mucoceles are commonly found within the superomedial part of the orbit. The lesions displace eyeball downward, forward and sideways. Consequent swelling lacks tenderness. The patient may complain about nasal obstruction, nasal voice, proptosis, diplopia and headache.
The affected frontal sinus will appear as a cloud with rounded, ovoid or smooth contours on the radiograph. The slim mucoperiosteal white line will be unclear. In case of mucoceles related to chronic sinusitis, the reactive bone will surround the sinus. Erosion of frontal bone’s vertical plate will be recorded on the image.
Mucoceles in ethmoid sinus
The mucoceles expands the orbit’s medial wall. As a result, the eyeball moves sideways and forward, expanding the middle meatus of nose and causing nasal voice.
Mucoceles in sphenoid sinus
Damage to and expansion of the posterior ethmoid and sphenoid sinuses cause mucoceles. The symptoms of sinusresembles to that of superior orbital fissure syndrome. Vision of the patient decreases. Localized pain in forehead or orbit occurs.
Mucoceles in maxillary sinus
Mucoceles in the maxillary sinus are generally without symptoms of sinus. These lesions are spotted on standard radiographs. Occasionally, the mucoceles put pressure on the superior alveolar nerves, causing pain and swelling and fullness of the cheeks. The lesion expanding in the back may loosen the posterior teeth. Lesion expansion in superior direction leads to proptosis and diplopia. When lesion expands sinus’ medial wall, the nasal cavity’s lateral wall deforms, obstructing the nasal airway.  Infected lesions are called mucopyoceles or pyoceles.
On a radiograph, the maxillary sinus containing mucoceles will appear circular. The sinus will be radiopaque. Erosion of bony walls and septa, and resorption and displacement of teeth will be recorded on the image.
Treatment
Mucoceles shall be excised. However, the treatment of the lesions depends on ability of the surgeon and extent and location of the disease. The surgeon can choose between external and intranasal methods.

Tuesday, March 27, 2012

Anatomy and functions of maxillary sinuses

Anatomy and functions of maxillary sinuses

The largest paranasal sinuses, maxillary sinuses, occupy the maxilla bone. The maxillary sinuses, referred to as the antrum of Highmore, are easily accessible as compared to the other sinuses. The maxillary sinus plays an important role in our body: reduces the weight of the cranium, performs functions of a resonant bone, controls the inhaled air temperature and pneumatizes. The size of right and left maxillary sinuses varies substantially and affects the sinus wall thickness. If the sinus is abnormally big, the walls will be ultra thin. Abnormally small sinus may have thick osseous lamellae. The thick facial walls may also reduce the size of the sinus.




The maxillary sinus cavity resembles to a pyramid. The sinus base contributes to the nose’s lateral wall. The apex of the sinus reaches to the maxilla’s zygomatic process. The maxilla bone’s orbital plate forms the sinus roof that features blood vessels and infraorbital nerve. The flat roof has slight slope in anterior and lateral part. The middle part of the roof forms the maxilloethmoidal sinus wall.
The alveolar process forms the sinus floor, which is situated below the nose floor level. The curved sinus floor may have conical projections representing the teeth root apices. There are occasional incidences of missing bone that lies between the teeth and the sinus. Some times this bone is extremely thin. A bony septum may divide the floor.
The anterior wall of the sinus, associated with the face, features infraorbital nerve’s branches. The opposite wall relates to the infratemporal fossa. The maxillary nerve branches occupy this posterior wall. The wall bulges near the fossa. Both walls contain blood vessels. The convex medial wall consists of maxilla, palatine bone’s vertical plate, the inferior concha and ethmoid’s uncinate process.  The lateral wall is associated with cheek and zygoma.
The maxillary sinus cavity is usually interrupted with septa and bony ridges, dividing the sinus into two areas.  The superior area of the sinus base has an opening that links the sinus and the nose. The opening (s) in the hiatus semilunaris drains into the nose’s middle meatus.
The posterior, middle and anterior superior alveolar nerves and the infraorbital nerve supplies to the mucous membrane. The posterior and anterior superior alveolar branches of the maxillary and infraorbital arteries respectively supply blood to the sinus. The veins draining through the ostium join the nose’s venuous plexuses. The lymphatic vessels move through the ostium and open into the submandibular nodes.
Although paranasal sinuses have many recesses, the recess frequency is quite less in the maxillary sinuses. The sinuses feature alveolar, zygomatic, nasal and infraorbital recesses. Mucoperiosteum lines the maxillary antrum containing air.

Monday, March 26, 2012

Cysts, a disease of maxillary sinus

Cysts, a disease of maxillary sinus

Cysts, one of the principal maxillary sinus disorders, are divided into extrinsic and intrinsic categories.
Extrinsic cysts
Extrinsic cysts are of dental (odontogenic) and non-dental (non-odontogenic) origin. The dental cysts are generally oval or curved. The dental cysts displace borders of the sinus affected. The sinus wall fuses with the cyst cortex. The cyst expands, whereas the sinus size reduces. A new radiopaque border divides the sinus air space and the cyst lumen, separating the cysts from the sinus. Some times, almost entire sinus is affected and the small remaining part of the sinus stays on the cyst. Expanding cysts may affect the maxillary antrum walls.




The dental cysts, the most common cysts found in the maxillary sinuses, are dentigerous and radicular. When fluid accumulates between the eroded enamel epithelium and crown of a tooth, a dentigerous cyst surrounds the crown. The cyst is usually related to third molar region. These cysts elevate the floor of the maxillary sinus. The tooth displacement is a common symptom. The dentigerous cysts are grouped into kerato and primordial cysts.  The kerato cyst is non-inflammatory cyst. The cyst grows on the dental lamina and may expand into the maxillary sinus. The kerato cyst is generally found in mandibular ramus region.
The radicular cyst develops in the maxilla bone. The cyst may reach to the maxillary sinus. A big cyst may fully cover the sinus and as a result, it is difficult to differentiate between the cyst and other sinus symptoms. The cyst raises the sinus floor, causing a halo. Inflammation of the epithelial cells found in the periodontal ligament causes radicular cysts. These cysts are associated with first molar, canine and lateral incisor teeth.
The non-dental cysts are further divided into anesurysmal bone cyst (ABC), globulomaxillary and traumatic. The globulomaxillary cysts may change or hide the maxillary sinus’ anterior recess and the nasal fossa border.
Intrinsic cysts
Mucus retention cyst, the intrinsic and non-dental cyst, is also referred to as benign mucosal antral cyst, pseudocyst and mesothelial cyst. The lateral wall and antral floor of the maxillary sinus is affected. The maxillary sinus symptoms include numbness and fullness of the cheeks, pain in the face part near the sinus and the teeth, and localized faint pain in the antral area. If cyst obliterates the entire sinus, it may lead to postnasal drip. The other sinus symptoms are headache, fullness and stuffiness. If a retention pseudocyst enlarges and occupies the entire sinus cavity and patient blows the nose or sneezes, the cyst ruptures due to change in pressure.

Friday, March 23, 2012

Cyclamen europaeum extract

Cyclamen europaeum extract


NASODREN, a nasal spray containing Cyclamen europaeum extract, has been developed as an innovative and effective treatment for sinonasal conditions. 

The nose and sinuses play a major role in cleaning and humidifying the air, before it is inhaled into the lungs. This occurs via physiological processes that depend upon local actions.




Drainage of the nasal and paranasal cavities is achieved through an enhanced secretory response, an improved ciliary cleansing activity and mucus secretion.

The mucociliary system is the body’s main defence system. When suffering from Rhinosinusitis, the respiratory mucosa is inflamed. The mucosa becomes increasingly oedematous, gradually blocking mucus outflow.

The sinus becomes blocked with secretions that, in time, could become mucopurulent.

At this point, the patient will suffer from an acute Rhinosinusitis, with symptoms such as nasal obstruction or congestion, anterior or posterior rhinorrhea, with varying degrees of facial pain or headache or even loss of smell, depending on the severity of the Rhinosinusitis. 

On spraying the daily application of Nasodren in each nostril, and a few seconds after the lyophilized cyclamen extract comes into contact with the nasal mucosa, an abundant secretion is observed.

Saponins from Cyclamen extract are well-established, topical surface-active agents, so they are adsorbed on the nasal mucosa without being absorbed into the bloodstream. 

The Cyclamen saponins stimulate the sensitive receptors of the nasal mucosa, inducing a nociceptive response that is transmitted by the trigeminal nerve. Secondarily the sensorial stimulation is also responsible for sneezing, lacrimation and other reflex responses. 

The saponins of Cyclamen europaeum adsorbed by the mucus membrane in the lower part of the nasal cavity produce a local surfactant effect that reduces the surface tension, facilitating watering of the area and mucin secretion, and consequently the drainage of the mucus and a decrease in congestion. 

Thanks to the mucociliary movement and the opening of the osteomeatal complex, the secretions, as well as oedema from the paranasal sinus, are drained, cleaning the mucosa of inflammatory mediators, viral particles, and debris that could complicate or perpetuate this situation. The efflux of accumulated mucus and oedema in the nasal and paranasal cavities, induced by Cyclamen europaeum extract, is due to the stimulation of sensitive chemoreceptors from the mucosa close to the nostrils, and the triggering of the cholinergic effect.

Nasodren achieves symptom relief in patients with acute Rhinosinusitis.

Nasodren significantly reduces symptoms such as headache and facial pain on the 2nd day after its administration and removes the mucopurulent secretions on the 4th day, consequently clearing nasal obstruction.

Daily administering of Nasodren for up to ten days has shown to be effective in the first line treatment of Rhinosinusitis, normalizing the inflamed respiratory mucosa in a few days. Thanks to its draining effect, Nasodren provides an effective and innovative treatment in maintaining normal sinonasal physiology.

Thursday, March 22, 2012

Anatomy and functions of maxillary sinuses

Anatomy and functions of maxillary sinuses

The largest paranasal sinuses, maxillary sinuses, occupy the maxilla bone. The maxillary sinuses, referred to as the antrum of Highmore, are easily accessible as compared to the other sinuses. The maxillary sinus plays an important role in our body: reduces the weight of the cranium, performs functions of a resonant bone, controls the inhaled air temperature and pneumatizes. The size of right and left maxillary sinuses varies substantially and affects the sinus wall thickness. If the sinus is abnormally big, the walls will be ultra thin. Abnormally small sinus may have thick osseous lamellae. The thick facial walls may also reduce the size of the sinus.




The maxillary sinus cavity resembles to a pyramid. The sinus base contributes to the nose’s lateral wall. The apex of the sinus reaches to the maxilla’s zygomatic process. The maxilla bone’s orbital plate forms the sinus roof that features blood vessels and infraorbital nerve. The flat roof has slight slope in anterior and lateral part. The middle part of the roof forms the maxilloethmoidal sinus wall.
The alveolar process forms the sinus floor, which is situated below the nose floor level. The curved sinus floor may have conical projections representing the teeth root apices. There are occasional incidences of missing bone that lies between the teeth and the sinus. Some times this bone is extremely thin. A bony septum may divide the floor.
The anterior wall of the sinus, associated with the face, features infraorbital nerve’s branches. The opposite wall relates to the infratemporal fossa. The maxillary nerve branches occupy this posterior wall. The wall bulges near the fossa. Both walls contain blood vessels. The convex medial wall consists of maxilla, palatine bone’s vertical plate, the inferior concha and ethmoid’s uncinate process.  The lateral wall is associated with cheek and zygoma.
The maxillary sinus cavity is usually interrupted with septa and bony ridges, dividing the sinus into two areas.  The superior area of the sinus base has an opening that links the sinus and the nose. The opening (s) in the hiatus semilunaris drains into the nose’s middle meatus.
The posterior, middle and anterior superior alveolar nerves and the infraorbital nerve supplies to the mucous membrane. The posterior and anterior superior alveolar branches of the maxillary and infraorbital arteries respectively supply blood to the sinus. The veins draining through the ostium join the nose’s venuous plexuses. The lymphatic vessels move through the ostium and open into the submandibular nodes.
Although paranasal sinuses have many recesses, the recess frequency is quite less in the maxillary sinuses. The sinuses feature alveolar, zygomatic, nasal and infraorbital recesses. Mucoperiosteum lines the maxillary antrum containing air.

Wednesday, March 21, 2012

Types of nasal polyps

Types of nasal polyps

The Egyptian hieroglyphics records nasal polyps identified forty centuries ago. The polyps’ recurrence is also well documented, but the polyp frequency may vary from disease to disease. To select an appropriate treatment, thorough understanding of different types of the polyps is required. Although there is no standardized classification of the polyps, two common classifications based on amount of eosinophils are discussed here.



The clinical classification suggested by P. Van Cauwenberge divides nasal polyps into the following three types:
I. Unilateral polyps
The unilateral polyps are of two types: I.A. and I.B. The predominant cells in the I.A. polyps are eosinophils, whereas red blood cells (RBCs), neutrophils and lymphocytes are the principal cells in the I.B. polyps.
II. Bilateral polyps
The bilateral polyps are also further categorized considering the predominant cells. The II.A. polyps feature eosinophils while II.B. polyps contain neutrophils and lymphocytes. While treating the II.A. polyps, a doctor shall take into account allergic fungal sinusitis, allergic rhinitis, Churg-Strauss syndrome and aspirin intolerance.  MRI or CT scan of the sinuses, allergy skin tests and other suitable laboratory tests are required. For instance, fungal cultures and surgical debridement may help in case of the polyp associated with allergic fungal sinusitis.
Inflammation may cause the II.B. polyps. The physician shall consider Young’s and cilia dyskinetic syndromes while treating these polyps. A chest x-ray may also require diagnosing Kartagener’s syndrome, which may accompany these polyps.  
III. Miscellaneous – additional information
The third category offers more information about polyps. For example, are polyps associated with immunological abnormalities, bone erosion or anatomical reasons? Are polyps recurrent? This category can be used to analyzing other two types of polyps. For example, The “II.A1 recurrent x 3” implies bilateral polyps mainly with eosinophil cells. These polyps, reappeared thrice after the treatment, are attributed to the aspirin intolerance.
Metin Önerci classified the polyps principally into three categories: inflammatory, choanal / isolated and eosinophilic. The isolated polyps may grow from the uncinate, process, ethmoid bulla or other anatomical structures.  The polyps originating from the sinus mucosa are named after the sinus involved. For example, polyps developing in the maxillary sinus are referred to as antrochoanal. The polyps in sphenoid sinus are known as sphenochoanal.
The classification also reviews additional criteria and related diseases. There are three additional criteria: allergy, asthma / COPD and acetylsalicylic acid intolerance. Granulomatosis, vasculitis, primary ciliary dykinesia, congential / acquired immune insufficiency and cystic fibrosis are associated with polyps.

Tuesday, March 20, 2012

Obstructed nasal cavity causes snoring

Obstructed nasal cavity causes snoring

Snoring is the noise produced when the uvula and soft palate vibrate. The uvula, the soft tissue hanging down over the tongue, and soft palate are located in the mouth region. If the two organs move closer to the tongue’s rear, nasal cavity or both, the upper airway gets obstructed. As a result, vibrations occur. To understand snoring better, knowledge of anatomy of the nasal cavity is very useful.



The bony nasal septum, covered with cartilages anteriorly, divides the triangular nasal cavity into left and right halves. Each part features a medial wall, lateral wall, floor and sloping roof. Three scroll- or shelf-like bony structures project from the cavity‘s lateral wall. The projections warm and humidify the air by increasing the nose surface area. The lateral wall separates the nasal cavity from the nasolacrimal canal and lacrimal groove in anterior, the maxillary sinus at the bottom and the orbital cavity located above.
The bony part of the lateral wall consists of medial pterygoid plate (sphenoid), perpendicular plate (palantine), inferior nasal concha, middle and superior conchae of the ethmoid, lacrimal, frontal process (maxilla) and nasal bone. The bony wall has three turbinates: inferior, middle and superior. The region near the turbinate bones represents meatuses. A number of ducts open on the wall at the different meatuses. For instance, the inferior meatus receives the nasolacrimal duct. The middle meatus is the junction for anterior ethmoidal, maxillary and frontal sinuses. The posterior ethmoidal sinuses open on the superior meatus.
The palatine bone’s horizontal plate and maxilla’s palatine process make the nasal cavity floor. The ethmoid bone’s cribriform plate is located in the plain middle part of the nasal cavity roof. The sphenoid bone’s inferior surface forms the back slope of the roof. The nasal cartilages, nasal bone and the frontal bone’s nasal area form the front slope of the roof. The surface of the cavity is irregular.
The sphenoid sinus drains into the spheno-ethmoidal recess, the space located above the superior turbinate. The olfactory cleft, covered with olfactory epithelium, separates the ethmoid’s cribriform plate and superior turbinate from the septum area. Entire nasal cavity barring the vestibule has mucous membrane. The vestibule is part of the nasal cavity located near nostrils. The vestibule features skin lining, sweat and sebaceous glands, and coarse hairs.
Cigarette smoke is a common cause of pain and soreness of the nasalcavity lining. As a result, the lining swells and catarrh condition, an increase in mucus production within the throat and nose, develops. The air passage gets plugged and the patient snores.

Monday, March 19, 2012

Sinus surgeries and consequent medical problems

Sinus surgeries and consequent medical problems

Sinus surgeries are never foolproof. There are chances of a number of complications, such as adhesions, anosmia, bleeding, crusting, epiphora, infection, neuropathic pain, osteitis and / or periorbital emphysema.




Adhesions are abnormally joined bands of scar tissues. Damage to the mucosa on surfaces adjacent to the surgery site leads to adhesions. To minimize adhesions, open the olfactory cleft and take extra care while handling mucosa to create space. Douching every day will also help. On completion of the surgical procedure, reexamine the patient after a week. Adhesions, a common complication of the surgery, develop if two different mucosal surfaces come in contact for a reasonable time after the surgery.
Anosmia means inability to smell. Damage to the olfactory mucosa during surgery may cause anosmia. Administer pre-operative oral steroids to avoid anosmia.
Bleeding may occur after the procedure is over. Blood may ooze from the nose or appear in cough. Raise the head of the patient, administer antibiotic and / or use a nasal pack to stop the bleeding.
If mucosa is fully damaged, cilia disappear and the mucus is not cleared. Due to mucus stagnation, crusts form. The surgeon shall avoid full-thickness damage to the mucosa as the cilia may take about a year to function again normally.  The stagnated mucus can cause infection that requires douching. Sniff up topical nasal mupirocin ointment after douching for more relief.
Epiphora refers to excessive production of tears. If the nasolacrimal duct or lacrimal sac is damaged during surgery, ephiphora may appear.  Due to damage, fibrous tissue grows around the duct, causing obstruction.
Stenosis means narrowing a structure. If the mucosa of the frontal recess is denuded, chances of the frontal recess stenosis are high. Therefore, surgeon shall take utmost care to preserve the mucosa. Do not pull out the loose pieces of the mucosa, as it will injure the mucosa further.
Due to exposed bone, localized inflammation of bone (Osteitis) may cause severe pain that may last for more than a week. Surgery or trauma may also cause neuropathic pain.
Periorbital emphysema is a condition in which air gathers in the soft tissues surrounding the eye. If the lamina papyracea is injured during the surgery and the patient sneezes or blows his/her nose within the four days of the surgery, intranasal pressure increases substantially. As a result, air fills into the soft tissues hemming the eye.  The emphysema will heal provided the patient completely avoids blowing the nose. A course of prophylactic antibiotics prevents formation of periorbital cellulites.
If the accessory and natural ostium are left unconnected during any of the sinus surgeries, recirculation of mucus may start. The patient may complain about a postnasal drip.  Injured natural mucus pathways and natural ostium, and trauma may also trigger the recirculation.

Friday, March 16, 2012

5 principles of rhinitis treatment

5 principles of rhinitis treatment

Rhinitis therapy depends on various factors that are divided into five groups: education, surgical procedures, immunotherapy, pharmacotherapy and avoiding allergens.




The first principle of the treatment is educating patients about need for and how to avoid allergens. The education is very important in case of chronic rhinitis. The chronic patients shall have thorough understanding of  type of disease, associated complications, required drugs, drug action, when and how to administer the drug, and side effects of medication. You can distribute up to date brochures featuring addresses of authentic online resources, leaflets and videos among the patients.
For instance, you can visit http://www.whiar.org/ to learn Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines.  The non-governmental organization ARIA focuses on allergic rhinitis. The ARIA has been started to promote allergic rhinitis management considering evidences and asthma symptoms.  The organization aims to plan, manage and finance projects for health improvement across the world.  ARIA, working with World Health Organization, offers diagnostic, preventive and therapeutic help for better basic healthcare facilities. A contact address of the information provider is another plus.

Immunotherapy means restoring or stimulating the immune system of the patient. An appropriate immunotherapy may also prevent from a consequent asthma attack. If pollen-related rhinitis patients do not respond to medication, immunotherapy should be advised. 

For instance, regular allergen-specific vaccination may reduce reaction to allergen exposure and therefore the symptoms of rhinitis. Immunotherapy is the best option in case of single-allergen-associated rhinitis. The best quality of one or two allergen extracts shall be used for the vaccination.

Pharmacotherapy refers to use of drugs for treatment.  Commonly used rhinitis drugs include oral and topical antihistamines and corticosteroids, cromoglicate, antileukotrienes, cholinoceptor antagonists and vasoconstrictors. Oral antihistamines are useful in treating perennial and seasonal allergic rhinitis in both children and adult patients. Initially, topical corticosteroids are administered to treat idiopathic and perennial allergic rhinitis, nasal polyposis and hay fever. The most effective drug for allergic rhinitis is intranasal corticosteroid. Consult your physician before starting any medication.
You cannot completely avoid the exposure to allergens, but you can definitely reduce it.  If you can avoid the allergens, dependence on medication will minimize and chances of getting an asthma attack may fall. For example, use plastic covers for pillows and mattresses, replace carpets with wooden flooring and do not store clothing in your bedroom to avoid dust mites. Do not visit to areas full of pollens. Nasal filters and regular nasal washing also reduces the exposure.
Surgery is the last option when medical therapy fails. The purpose of a surgical procedure recommended for an allergic rhinitis patient is creating efficient nasal airway for medication delivery. In case of non-infectious, non-allergic rhinitis, surgery is suggested to minimize septal deviation or change the inferior turbinate’s size.

Thursday, March 15, 2012

Computed tomography (CT) of a sinus

Computed tomography (CT) of a sinus

The CT is the principal imaging technique that aids sinus disorder diagnosis and helps in planning the surgery. The CT scan furnishes best possible anatomical details. The high-quality scans taken close together are necessary for correct anatomy visualization. Based on the plane along which scanning is done, there are three types of scans: axial, parasagittal and coronal. Usually, first the sinus region is scanned along the coronal plane to reconstruct the anatomy. Then the parasagittal scans are taken and analyzed, and thereafter axial plane scans are reviewed.
The coronal plane scan offers optimal view of the ostiomeatal unit (OMU). The coronal scans should be taken carefully to ensure that a cell on one slice can be followed on the next slice. From these scans, 3-dimensional anatomy of the surgery site can be constructed and visualized. With axial scan, you can identify the frontal sinus’ drainage pathway. This is very helpful if frontal recess is to be touched while surgery. The parasagittal plane scan improves access to the frontal recess and therefore ensures better understanding of the anatomy.




The CT scans can simulate the sinonasal cavity for endoscopic surgeries.  Since bone anatomy is crucial for an endoscopic surgery, high window level and wide window width are used for bone algorithm technique during the CT scanning of uncomplicated cases of sinusitis. While scanning a complicated sinusitis, iodinated contrast agents are used.  The axial plane scans use soft-tissue algorithm with soft-tissue windows and bone windows.
The tissue density in the CT scan is represented in the Hounsfield unit or number (HU). The tissue density of acute blood (normal hematocrit) is about 80 HU. The unit decreases with fall in hematocrit.
However, CT scans have some limitations. Polyposis may obstruct the OMC views. Claustrophobia may create problems. Inappropriate windows for diagnosing intracranial or intra-orbital disorders are another disadvantage. Differentiating between inflammatory disease and granulation tissue or scarring is difficult. The scan offers poor view of the frontoethmoidal recess. Overcoming these limitations require additional techniques.
For instance, the helical scanning is the best method for the patients having dental restorations and patients unable to stand / bear hyperextension of the neck. The technique acquires axial data that enables multiplanar or three-dimensional reformatting. The helical scanning requires less time. Since helical scanning facilitates multiplanar view in real time, it is always used for intra-operative usage. High-definition multislice helical CT scans of the sinus shall be taken in three planes: axial, parasagittal and coronal.

Tuesday, March 13, 2012

Atopic and environmental factors causing allergies

Atopic and environmental factors causing allergies

Allergies are ubiquitous. Many teenagers are sensitive to atopic diseases, whereas a sizeable chunk of the world population will test positive during a skin-prick test. Although differentiating the allergies from viral upper respiratory system diseases is difficult, younger population is more prone to allergies. And, both environmental and genetic factors play an important role in allergic disorders. 




Atopy, a genetic factor, implies production of immunoglobulin E (IgE) in the presence of environmental protein allergens. The continuous production of IgE causes atopic diseases, including allergic rhinitis, asthma and eczema. Allergic rhinitis is generally divided into three categories: occupational, perennial and seasonal. Occupational allergic rhinitis develops due to allergens found in the work environment, like certain chemicals.  Perennial allergic rhinitis is mainly ascribed to animal dander, cockroaches, molds, dust mites and other indoor allergens. Seasonal allergic rhinitis is associated with an array of outdoor allergens, including molds and pollens.
The atopic population develops one of these diseases or combination of them during early stage of the life. Even if one of the parents is atopic, the chances of developing atopic disorders in children increase substantially. If both father and mother are atopic, their offspring are highly sensitive to the atopic diseases.
Environmental factors like pollen season directly affect the very young individuals. For instance, kids born during pollen season are highly sensitive to allergies because of an immature and weak immune system. Pollen-triggered allergy symptoms also depend on the source and media of plant pollination.
Insects and wind transfer the plant gametes (pollens) from one place to another place.  Insects generally collect pollens from the plants bearing bright color flowers. The pollens of these plants are quite limited in number. These pollens rarely trigger allergies. On the other hand, wind-pollinated vegetation produces a large amount of pollens, causing allergies. Since pollens mainly trap in the nose, rhinitis is the main outcome. If pollens soaked in raindrops and dew, they may affect bronchi, triggering an asthma attack.
Grass pollens are the main cause of allergies. Grass pollinates during summer whereas trees in spring. Grass pollination season is relatively longer than that of trees. Birch pollen allergies are common in North America and Europe, and Asia. The birch pollens react with nut and hazel pollens. Incidences of “birch/apple syndrome” are also recorded in these areas, where soft fruit, vegetables and fresh apples trigger oral allergies. The olive pollens that react with privet cause allergies in the Mediterranean region.

Monday, March 12, 2012

ADVANTAGES OF NASODREN

ADVANTAGES OF NASODREN

1.- It is a new therapy approach to treat Rhinosinusitis

2.- Plant extract based product with high scientific technologic background





3.- Alternative to over-used antibiotics - International trend to restrict antibiotics’ usage and increase awareness of antibiotics’ side effects and resistances

4.- Increased usage of plant extract based products by a certain part of the population

5.-  Unique & Multi-Action Product Profile

6.-  It is the treatment that has proved its efficacy - clinical evidence supported by Clinical Trials

7.-  Time taken to cure is short in Acute Rhinosinusitis (11.6 days) Nasodren versus Placebo (16.6 days)

8.-  Highly effective monotherapy or adjunctive therapy for Rhinosinusitis

9.-  Only one application per day

10.-  Rapid onset of action (2-3 min first signs  - reflex secretion within 15-20 min)

11.- Fast drainage of the sinuses (abundant rhinorrhoea 2-3 hours) Rapid    symptom improvement

12.- Short term treatment. The recommended duration is just 6-8 days

13.- Only one pack of medicine required for a complete course of treatment

14.- Can be used in children over 5 years old

15.- Cost containment in Acute Rhinosinusitis with Nasodren treatment

16.- It is safe, with mild, transient and local concomitant events (nasal burning and sneezing) and aligned with mechanism of action.

17.- No unexpected or serious adverse events observed in clinical trials

18.- Similar treatment discontinuation between placebo and Cyclamen in study

19.- Benefit/risk assessment is clearly positive

 

 



Thursday, March 8, 2012

What can go wrong during a sinus surgery?

What can go wrong during a sinus surgery?

Several complications happen during a sinus surgery. For instance, bleeding, fat herniation, cerebrospinal fluid leak, retro-orbital hemorrhage, medial rectus damage or optic nerve lesion may require extra procedures and time. Minimizing these complications is however possible.
Bleeding



Proximity of the anterior ethmoidal and sphenopalatine arteries to the surgery site increases chances of cutting through these arteries, causing bleeding. The damaged anterior ethmoidal artery may retract into the orbit, increasing pressure in the rear part of the eye. If this condition is not treated, patient will loose eyesight. The bleeding and clotting disorder (coagulopathy) also triggers bleeding.  To minimize the bleeding, maximize medical treatment before the sinus surgery and use a shaver or through-cutting forceps for tissue removal.
CSF leak
The cerebrospinal fluid (CSF) may leak during the surgery because of proximity to thin skull base. The leak resembles to a stream flowing through a blood pool. The leak generally pulsates. Different types of grafts and an oxidized cellulose dressing are used to plug the leak. Prophylactic antibiotics are administered.
Correct positioning of surgical instruments help in avoiding the leak. Surgeon shall familiarize himself/herself with paranasal sinus area thoroughly before the surgery.  A CT scan aids in deciding the surgical area to be operated for aerating the sinuses. A “black halo” near the skull base on the scan ensures presence of normal cells that will protect the base. On the other hand, a “white-out” on the scan requires a very careful approach.
Fat hernia
Diplopia (An eye disorder in which single object appears as two different objects.) may or may not accompany the orbital fat hernia, sagging of the fat.
Medial rectus damage
Medial rectus, the eye muscle, controls eye movement.  Deep penetration into the eye area (orbit) damages the muscle. The damage causes diplopia and scarring. Surgeon shall avoid damaging the muscle.
Optic nerve lesion
If the surgeon penetrates into the orbit via the lamina papyracea, the optic nerve may damage. If the nerve is visible in the sphenoethmoid air cell, the nerve trauma may occur.
Retro-orbital hematoma
A supraorbital cell separates the frontal recess and the anterior ethmoid artery. The chances of damage to the cell increases with an increase in its penumatization. Some times the artery is dehiscent. If the artery is torn unknowingly during the surgery, the vessels retract to the orbit, causing retro-orbital hematoma (localized blood collection). A sizeable hematoma constricts the optic nerve and affects the vision.  

Wednesday, March 7, 2012

Types of non-allergic rhinitis

Types of non-allergic rhinitis

Non-infectious, non-allergic rhinitis implies watery, clear, non-purulent nasal discharge and negative results of the allergy tests. Itching, obstruction and sneezing may also occur. However, there are no specialized tests to diagnose non-allergic rhinitis. In some patients, both allergic and non-allergic rhinitis symptoms occur simultaneously. Non-allergic rhinitis develops in mid-age, whereas allergic rhinitis is common in young population. The non-contagious non-allergic rhinitis, a chronic form of rhinitis, is divided into the following categories:

Drug-induced non-allergic rhinitis is the result of acetylsalicylic acid, β-blockers, chlorpromazine, hydralazine, prazosin and many other medicines.
Changes in hormones may also cause non-allergic rhinitis. Especially, the changes occur during pregnancy, puberty, menstrual cycle and endocrine diseases, causing nasal symptoms. However, symptoms may disappear after these phases are over in some cases. For instance, post delivery, the nasal symptoms resolve completely.  
Common symptoms of non-allergic rhinitis with eosinophilia syndrome (NARES) include sudden sneezing (paroxysmal sneezing), excessive watery rhinorrhea and anosmia. The nasal smear features eosinophilia while the result of a skin-prick test is negative. Generally, NARES occur as an isolated disease, but some times, it may happen with nasal polyps, aspirin intolerance and asthma. NARES is called blood eosinophilia non-allergic rhinitis syndrome (BENARS) if amount of blood eosinophilia increases.
Smoke and other substances that create irritation in the respiratory tract’s mucosa may lead to rhinitis. Even emotions, such as stress and honeymoon related emotions, can trigger symptoms of rhinitis and / or aggravate the existing symptoms. Fatigue and spicy foods can also be the cause of the rhinitis.
Sjögren’s syndrome, too many surgical procedures and exposure to radiation can cause atrophic rhinitis.  The common symptoms of the atrophic rhinitis are nasal mucosal denudation, which may lead to nasal space expansion, hyposmia, fetor and crusting.  Secondary atrophic rhinitis due to surgery, trauma and infection is more common than the primary form.
If parasympathetic stimulation exceeds the required level, autonomic rhinitis symptoms may appear. The most commons symptom of the autonomic rhinitis is rhinorrhea.
Idiopathic rhinitis means hyper-reaction to tobacco smoke, alcohol, fluctuations in humidity or air temperature and the like. The nasal mucosa of the patients suffering from idiopathic rhinitis is generally normal. Polyposis, structural lesions, infection and allergy do not accompany this form of the rhinitis.
Occupational non-allergic rhinitis is ascribed to a broad spectrum of disease-causing agents present in the work environment. Over 200 chemicals and many compounds of these with low molecular weight trigger symptoms of rhinitis.

Tuesday, March 6, 2012

Barosinusitis

Barosinusitis

The paranasal sinuses contain a fixed amount of water vapor, mucus and air. The sinus pressure is generally in equilibrium with the ambient pressure. The sinus pressure changes with the changes in the ambient air pressure to achieve the equilibrium. If the equilibrium is not attained, pain in the sinus may start. This imbalance generally happens while descending from altitude. However, if the free air passage of the sinuses is obstructed, airflow from and to the sinuses is interrupted, disturbing the equilibrium. An injury to the sinus tissues, therefore, may occur. These injuries are referred to as barotraumas. The medical condition is commonly experienced by flyers and scuba divers. Barotrauma could be of ascent and descent.



Barotrauma of ascent may develop in flyers when the airplane ascends. The airflow obstruction may cause pressure or pain behind the eyes.  
Barotrauma of descent is also popularly called ‘squeeze’ by divers. As they descend into the water, the ambient pressure rises and the air in enclosed spaces, like sinuses, compresses. While descending, sinus pressuremay not equalize with the ambient pressure, causing barosinusitis or a sinus squeeze. Barosinusitis means inflammation or pain of the nasal sinuses because of change in the pressure.  The squeeze has a direct effect on the maxillary and frontal sinuses.  Barosinusitis may also develop in the patients already having nasal inflammation or pathology. If the sinus blockage occurs while descending during flying or diving, the intra sinus pressure decreases substantially, causing even mucosa hemorrhage.
Symptoms and signs
  • Pain in the sinus affected
  • The pain will be above the eyes in case of the frontal sinus squeeze and below the eyes if the maxillary sinus is affected.
  • Nose bleeding
  • Blood may come out from the mouth. 
  • Tenderness over the sinus affected when it is tapped lightly.
  • Vertigo
  • Tinnitus
  • Vomiting and / or nausea

Treatment
  • Stop diving until problem is fully resolved.
  • Use analgesics and decongestants.
  • Administer antibiotics for treating the frontal sinus squeeze.
  • Try Valsalva technique as it offers temporary relief.
  • Use systemic and topical vasoconstrictor agents to heal the swollen nasal mucosa and open the sinus ostia.
  • Avoid changes in atmospheric pressure until the condition improves.

Recovery from barosinusitis requires at least one to two weeks. A word of caution, do consult the physician before starting any treatment.

Monday, March 5, 2012

Bacteria associated with chronic maxillary sinus infections symptoms

Bacteria associated with chronic maxillary sinus infections symptoms

The chronic maxillary sinusitis is multi-factorial as compared to the acute maxillary sinusitis. For instance, an inflammatory process may initiate the colonization of bacteria in some patients instead of the bacterial infection causing the inflammation. However, the principal pathogens causing the chronic form of the disease are bacteria.



Staphylococcus aureus, gram-negative enteric and anaerobes are the most common pathogens triggering chronic maxillary sinusitis in both adults and children. However, S. aureus, normally found in the nasal passages, is the main cause of the disease. S. aureus-associated sinus infections symptoms may be attributed to changes in the sinus mucosa or the bone beneath it. S. epidermidis contaminates the nasal cavity. Gram-negative rods commonly associated with chronic maxillary sinusitis include Escherichia coli, Enterobacter species, Proteus mirabilis, Klebsiella penumoniae and Pseudomonas aeruginosa.
The chronic sinusitis associated with S. pyogenes is more common in children than in the adults.  S. pyogenes is also a major cause of skin infections in children and bacterial pharyngitis.
Chronic maxillary sinusitis’ acute exacerbation involves a sudden change in condition of the patient due to development of new symptoms or worsening of the existing ones. However, microbiology in both acute exacerbation and baseline cases is quite similar. Gram-negative enteric and anerobes are the major cause of the acute exacerbation of the chronic maxillary sinusitis. However, some pathogens exclusively related to acute infections may also be present in case of acute exacerbations. The number of acute sinusitis aerobes may be high in the patients suffering from acute exacerbations of chronic maxillary sinusitis than in those having the baseline form of chronic maxillary sinus infections symptoms.
Recurrent and / or chronic bacterial infections may be found in the chronic maxillary sinusitis patients though the chronic condition is non-infectious.  Predominance of anaerobic bacteria growing in the oral flora is also found in chronic maxillary sinusitis and untreated subacute maxillary sinusitis. Chronic maxillary sinusitis patients also have polymicrobial infection that requires antibiotics for treatment.
Although clinical symptoms are absent in chronic maxillary sinusitis, facial pain, fever, headache or stuffiness in face may be felt some times. During chronic maxillary sinusitis, several polyps may form and epithelium may degenerate.  The maxillary sinus’ mucous membrane may change: atrophy or hyperplasia. Changes in the ostium may block the opening. Recent allergic sinusitis or viral infection of the upper respiratory tract may predispose you to chronic maxillary sinusitis.