Thursday, May 31, 2012

REGIONS OF THE NASAL MUCOSA

The nasal mucosa can be divided into three clear regions:
Vestibular region
This is a stratified squamous epithelium characterised by an epidermis that has lost its corneal covering and has no glands.

Olfactory region
This region has a thin, brownish-yellow mucosa called the locus luteus. It is poor in mucus glands and is characterised by the presence of olfactory receptor elements. It is located in the olfactory area and makes up the whole top part of the nasal fossa located above the olfactory groove.
Histologically it is comprised of a stratified cylinder-like epithelium and the chorion. The epithelium contains the olfactory or olfactory receptor cells, also known as Schultze's cells, the stable cells and the basal cells. The chorion is characterised by the presence of voluminous tubuloacinar glands called Bowman's capsules.
Respiratory region
The respiratory mucosa, or Schneider's membrane, takes up the greatest part of the nasal surface. Microscopically, it is comprised of a stratified cylindrical and ciliated epithelium and has three cell types: mucus-secreting, goblet and basal. The chorion has a considerable number of vascular elements, particularly venous, and glands in a single layer with mucous and serous cells.

Wednesday, May 30, 2012

Histology and morphology of the nasal mucosa


Skin
The skin that covers the nasal vestibule is rich in pilous follicles, sebaceous glands and sweat glands.



Epithelium
The respiratory epithelium is comprised of four different cell types: ciliated cells, goblet cells, brush cells and basal cells. 



Ciliated cells: These cells derive their name from the celia they contain, which are extracellular
finger-like extensions 5 microns high and 0.3 microns thick. Their function is to remove inhaled particles.

Goblet cells: These cells perform secreting activity. They are surrounded by the ciliated cells or are clustered, forming veritable intraepithelial glands. The goblet cells, together with the exocrine glands, maintain and renew the mucosa covering that is required for ciliary movement.

Brush cells: These line the surface of the mucosa and have microvilli (cytoplasm prolongations in the apical pole) to increase the exchange surface of the nasal respiratory mucosa. They play an important role in the phenomena of secretion and reabsorption of the nasal mucosa.

Basal cells: These are replacement cells that may give rise to one of the other three cell types.


Basal membrane 
This membrane guarantees cohesion between epithelial cells as well as adhesion between epithelium and chorion and controls the relationship between epithelium and chorion.



Chorion
The mucosal chorion consists of three layers: lymphoid, glandular and vascular.


Lymphoid layer: Comprised of lymphoid cells such as lymphocytes, which are responsible for late allergic response. It also contains plasmocytes, the main source of immunoglobulin; histiocytes or macrophages that eliminate foreign elements by phagocytosis and are also responsible for the synthesis of collagen and mucopolysaccharides; and polynuclear cells which appear in inflammatory states.

Glandular layer or stratum: Three types of glands may be distinguished according to the cell constitution of the acinus (group of cells specialised in secretion, which form the glands): the mucous glands, which secrete mucus; the serous glands, which produce a clear, aqueous secretion poor in mucin and the mixed seromucous glands.
Myoepithelial cells, contractile cells that facilitate excretion, surround the glandular acini. 

Deep vascular layer: This is comprised of the blood vessels of the nasal mucosa. The arteries that enter the nasal fossae in contact with the periosteum. The capillaries that have endothelial pores and grooves and permit rapid exchange between blood and the mucosa at subepithelial, glandular and periosteal level. The venous network that also extends throughout the same three layers.

Tuesday, May 29, 2012



Anatomy of the nasal cavity or nasal fossae

A. Entry Apertures
Nostrils: These are the entry apertures to the nasal fossae located at the front of the nose, which lead to the nasal vestibule.
Nasale: This is the most anterior part of the nasal fossae, limited laterally by the ala of nose and medially by the most anterior portion of the septum. This area extends in towards the fossae until the head of the middle and inferior turbinates. It is surrounded by the cartilages of the nose and covered by the skin of the nose. The piriform aperture is next, which then leads to the actual olfactory area of the nasal cavity, which extends to a space delimited by the lower edge of the middle turbinate on the outside and the tubercle of the septum on the inside, known as the olfactory groove.
Choanae or posterior nasal apertures : These are apertures at the back of the nasal cavity which connect it with the nasopharynx.


B. Lateral Wallsconnombreseningles
The lateral wall of thenasal fossae is comprised of the frontal process of the maxillary bone, the lacrimal bone, the ethmoidal labyrinth with its middle and superior turbinates, the inferior turbinate and the vertical process of the palatine bone.
The point where the palatine bone is joined to the body of the sphenoid has an aperture called the sphenopalatine foramen, through which blood vessels and nerves enter the nasal cavity.
Nasal turbinates
The lateral wall contains the 3 nasal turbinates (also called nasal conchae). They are structures comprised of spongy bone, coated with a thin and delicate nasal mucosa, with rich and abundant blood irrigation.
They are divided into the inferior, middle  and superior turbinates. They are well irrigated by intramucosal arterial networks that come from the carotid system through the maxillary and facial artery, the drainage veins and the lymphatic system.
Superior Turbinate: The superior nasal turbinate is formed by the rear part of the medial surface of the ethmoid labyrinth (ethmoid bone).
Middle turbinate: The middle turbinate is formed by a lamella that emerges from the end of the medial surface of the ethmoid labyrinth (ethmoid bone).
Inferior turbinate: The inferior turbinate (inferior nasal concha) is formed by a compact lamina of bone. It is in the lower portion of the nasal fossae.
Meatuses
Between each turbinate and the lateral wall of the nasal fossae there are three canals located in the anteroposterior direction, called the meatuses. There are three meatuses, the superior, middle and inferior, whose content drains to other structures.
Superior nasal meatus: The superior nasal meatus is the smallest of the three. It occupies the middle third of the lateral wall of the nasal cavity. It lies between the superior and middle nasal turbinates, between the posterior ethmoid cells at the front and the sphenopalatine foramen to the rear.
 Middle nasal meatus: The middle nasal meatus is a nasal aperture situated between the middle and inferior conchae. It communicates with the infundibulum through the hiatus semilunaris, and at the front through the anterior ethmoidal cells.
 Inferior nasal meatus: The inferior nasal meatus is the largest of the three. It is the space between the inferior turbinate and the floor of the nasal cavity. The entry to the nasolacrimal duct is located in its most anterior portion.
 All the nasal fossae are coated by ciliated respiratory epithelium that permits the removal of the mucus produced by the mucous glands.

C. Medial Wall
Nasal septum is an osteocartilaginous laminar structure located on the medial part of the nasal pyramid. It forms the internal wall of both nasal fossae.
Vomeronasal organ or Jacobson's organ, is an auxiliary organ of the sense of smell.

D.  Mucous Membrane
 The nasal or pituitary mucosa covers the perichondrium and periosteum of the walls of the nasal cavity, smoothing out their irregularities and covering vascular and nervous bone apertures. The mucosa continues with the mucosa of the sinuses and the lacrimonasal duct.
The nasal mucosa presents two very morphologically and functionally different areas: respiratory mucosa and olfactory mucosa.
The epithelium covering the mucosa varies in structure depending on the functions performed, to guarantee the filtration and drainage of the particles of inspired air.

Friday, May 25, 2012

Inflammation of the sinuses

Sinusitis is the inflammation of the sinuses. Inflammation leads to ostium (the opening that communicate the sinuses with nasal cavity) obstruction and cilia (small hairs that line the sinuses and function to remove mucus from the sinuses) impairment. When it happens mucus are stagnated in the sinuses and sinusitis symptoms appear. If mucus stagnated in the sinuses are infected we have sinus infection.


So, not all sinusitis sufferers have infection but all have inflammation, the starting point in this vicious circle of rhinosinusitis (inflammation favors infection and infection favors more inflammation). Activating the physiological defense mechanisms of the upper airways (increased mucus secretion, greater ciliary cleansing activity and increased arterial blood flow) that are impaired during rhinosinusitis, helps to reduce and prevent inflammation.
There are many causes that can produce inflammation of the mucosa of the nose and paranasal sinuses and must be considered and treated properly:

  • Environmental factors
  • Infectious microbial pathogens
  • Allergy/atopy/asthma
  • Air pollution
  • Anatomic factors
  • Septal deviation
  • Mucociliary impairment
  • Systemic disease
  • Genetic disorders
  • Immunodeficiency states
  • Endocrine disorders
  • Laryngopharyngeal reflux

Thursday, May 24, 2012

10 frequent Questions and Answer about Nasodren

  • What is Nasodren? What is the composition of Nasodren?
A cyclamen extract that gives a fast relief from rhinosinusitis symptoms
  • Why is Nasodren different?
The cyclamen extract activates natural/physiological pathways to clean and drain the nose and sinuses from accumulated mucus.
  • How does Nasodren work?
Nasodren it is not absorbed in the bloodstream, it acts activating natural/physiological pathways that are impaired during rhinosinusitis
  • Is Nasodren a saline solution?
No, the saline solution will only clean the mucus from the nose, Nasodren is a Cyclamen extract that cleans and drains mucus from the sinonasal area.
  • How many applications of Nasodren do I need to feel relieve?
After the 2nd day of application, symptoms as facial pain will be reduced significantly; the mucupurulent secretions will stop after the 4th day. We recommend you to use Nasodren daily during 8 to 10 days.
  • Does Nasodren work for chronic sinusitis?
Yes, of course
  • Is Nasodren an antibiotic?
No, Nasodren is from a natural extract of Cyclamen (a plant)
  • Does Nasodren work for cyst conditions?
No
  • Does Nasodren contain chemical substances?
No at all, the powder only contains Cyclamen extract after being lyophilized, a dehydration process, that you will mix with sterile water.
  • Can I be allergic to cyclamen?
Yes
  • Is Nasodren just a natural treatment?
Yes, Nasodren is a natural extract that will help your organism to clean and drain mucus in a natural way.

Wednesday, May 23, 2012

MECHANISM OF ACTION

Saponins are present in the plant world and most plants contain them in the form of triterpene and steroid glycosides. The term “saponin” comes from a Celtic word. It means soap and it is found in all the European languages. Saponins have some of the characteristic properties of soap, particularly detergent and surfactant properties, the ability to reduce surface tension and create a fairly stable film and, therefore, the property to form a foam. Due to these properties, the saponins adhere to surfaces, such as those of the mucous membranes.


The extract from the fresh tubers of Cyclamen europaeum in Nasodren® contains saponins. The main saponin component is cyclamin with a triterpenoid structure, which is accompanied by deglucocyclamine, hydrated cyclamine and other structurally related saponins.
However, this does not mean that the saponins themselves have an anti-inflammatory effect. There is no evidence in the scientific literature that proves any ability of the saponins to act directly on the inflammatory process, for example by inhibiting the formation of inflammation mediators, leukocyte migration, etc.
The aqueous extract obtained from the Cyclamen europaeum root-tuber is rich in saponins. These substances are known for their surfactant activity, which means they are adsorbed through the nasal mucosa without being absorbed into the bloodstream.
The surfactant action of the cyclamen saponins on the nasal mucosa reduces surface tension, facilitating humidification of the zone in addition to the secretion of mucin by goblet cells. This fluidifies the mucous accumulated in the nasal cavity, facilitating its elimination and thereby relieving congestion.
In addition, the saponins stimulate the sensitive receptors present in the nasal mucosa, inducing a nociceptive response transmitted by the trigeminal nerve. The nasal mucosa is entirely innervated by the trigeminal nerve, and therefore the cholinergic response generated in the nasal cavity is observed throughout the nasal mucosa, favouring opening of the ostium, increasing glandular secretions and increasing ciliar movement in the entire area. The accumulated secretions in the sinuses are consequently drained through the nose, providing rapid symptomatic relief of nasal congestion.

Tuesday, May 22, 2012

Paranasal sinus tumors may cause sinus headaches

The sinonasal tract comprises paranasal sinuses and nose. Tumors originating within the paranasal sinuses are uncommon. However, tumors of the tract may cause sinus headaches. The sinonasal tumors are more common in male patients of 50-70 years old. It is difficult to treat them because the sinonasal tract is located close to important organs like brain, carotid artery, skull base and orbit. Secondly, in initial stages, these tumors are asymptomatic.
Neoplasms of the tract could be benign as well as malign. For instance, squamous papilloma is benign, whereas squamous cell carcinoma (SCC) is malignant.


Squamous cell carcinoma, the most common sinonasal cancer, is mainly found in the maxillary and ethmoid sinuses. SCC having its source in the mucosa is the most common tumor of the maxillary sinus. On images, SCC may be identified with adenocarcinoma signs, calcification, hemorrhage or internal necrosis. This malignant tumor rarely occurs in the sphenoid and frontal sinuses. Its symptoms resembles to that of benign tumors. For example, nasal congestion and obstruction, and rhinorrhea. However, in advanced stages, sinus headaches, facial pain, proptosis or diplopia may develop. The lethal tumor is generally diagnosed in the advanced stages only.
However, its extension to the cranial base may be spotted in early stages. The stage of tumor influences the treatment. If tumor is detected in the advanced stage, the therapy consists of more than one method, such as chemotherapy, radiation therapy, radical en bloc resection and surgical salvage. In case of the patients who cannot be operated or do not want to be operated, only irradiation is done. Work is still in progress to decide a standardized treatment for the SCC associated with paranasal sinuses.

SCC, an epithelial tumor, is usually related to chronic sinusitis or it may lead to secondary sinusitis. It is thus necessary to distinguish between existing sinusitis inflammation and malignancy. SCC may involve the orbit. Primary SCC is rare.
Basaloid SCC, a rare condition of the sinuses, is extremely invasive. This aggressive tumor is multifocal. Another variant of SCC is verrucous carcinoma, a low-grade tumor.

The tumor may develop anywhere within the sinonasal tract. SCC can affect the neck nodes and local soft tissues. Unilateral purulent nasal discharge and dull pain may indicate the carcinoma. The SCC within the maxillary sinus may distort or cause swelling of the nearby structures, including eye, nose, gingivobuccal sulcus or cheeks.

Monday, May 21, 2012

Causes and types of facial Pain

Causes and types of facial Pain

Facial pain could be secondary to an array of diseases. For instance, pain in paranasal sinuses is one of the common causes of facial pain. Clinical examination and history of the patient aid in diagnosing the true cause of the pain. Temporal profile and pain origin are two important factors taken into account for the diagnosis. Based on these factors, facial pain could be divided into four categories: chronic, episodic, progressive and sudden.

Chronic

Chronic pain is benign facial pain. Chronic sinusitis, chronic tension and analgesic abuse headaches, giant cell arteritis and symptomatic trigeminal neuralgia may cause the pain.

Episodic

Episodic pain is also benign facial pain. The following disorders may cause the episodic pain:

  • Arteriovenous malformation
  • Chiari malformation
  • Classic trigeminal neuralgia
  • Cluster, exercise, post-coital and tension headaches
  • CSF hypotension
  • Migraine
  • Occipital neuralgia
  • Subacute angle closure glaucoma
  • Systemic hypertension
  • Third ventricle tumor

Progressive

Different diseases can lead to progressive pain, an intracranial process. For instance, abscess, chronic fever, chronic meningitis, idiopathic intracranial hypertension, subdural hematoma and tumor.

Sudden

Source of sudden pain includes the following:

  • Acute angle closure glaucoma
  • Acute obstructive hydrocephalus
  • Acute sinusitis may cause pain-sinus.
  • Cerebral infarction
  • Encephalitis
  • Fever
  • Intracranial hemorrhage
  • Meningitis
  • Pituitary apoplexy
  • Severe systemic hypertension
  • Subarachnoid hemorrhage
  • Thunderclap headache

Facial pain could be direct via the structures of the face or referred pain originating in surrounding structures. Pain-sinus may cause pain in the facial area because sinuses are located within the area. A sizeable number of patients who have undergone endoscopic sinus surgery complain about facial pain.

Headaches secondary to paranasal sinus problems are surrounded by several controversies and different terms are used to describe these headaches. For example, these headaches are called sinogenic facial pain, rhinosinusitis headache and sinus headache. Stress and psychological factors also contribute to the pain.

Analysis of facial pain

For a thorough understanding of the facial pain, including that of pain-sinus, analysis of the following is necessary:

  • Therapies used and their result
  • Signs and symptoms related to pain
  • Prodromes, symptoms before onset of the pain
  • Factors that precipitate the pain
  • Temporal profile: worsening of the pain in recent past and age at which pain started
  • Duration and frequency of the pain episodes
  • Level of pain
  • Pain types: throbbing, constant or dull
  • Side of pain: bilateral, unilateral, alternating
  • Pain location

Friday, May 18, 2012

Nasodren

Nasodren Prescribing information

1.NAME OF THE PRODUCT: NASODREN, Powder for the preparation of a nasal spray. 2.QUALITATIVE AND QUANTITATIVE COMPOSITION: Ingredient: Lyophilized powder from the juice and the natural aqueous extract from fresh tubers of Cyclamen europaeum L., 50 mg. The powder is porous, hygroscopic and cream-coloured. Excipients: No excipients, no preservatives or chlorides. Purified water 5 ml, as solvent for reconstitution of the lyophilized powder. Each dose of nasal spray releases 0.13 ml (2-3 drops) of solution (pH 5.3-6.8). This quantity corresponds to 1.3 mg powder. The finished solution produces 38 doses to be applied for a maximum of 16 days.

3.CLINICAL PARTICULARS: 3.1 Therapeutic indications: NASODREN is indicated for the symptomatic relief and treatment 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 purulent rhinosinusitis, accompanied by generalized infection or orbital complications. In case of orbital complications or generalized infection, NASODREN should be administered in combination with antibiotics. Acute exudative or purulent otitis media, chronic exudative, Acute secretory otitis media or purulent otitis media. In case of fever, NASODREN should be administered in combination with antibiotics. In postoperative care, after nasal or sinonasal surgery. 3.2 Posology and method of administration: Posology in adults and children 5 years and above:
The solution is 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. The treatment normally lasts 7-10 days when being used daily but may be extended to 12-16 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 which are complicated by purulent infection, concurrent systemic antibiotic treatment is recommended. If a second treatment is necessary in severe or chronic cases, this should only be initiated 7-10 days after completion of the previous course. If a dose of the treatment is forgotten, the patient should continue with the treatment the next day as recommended. 3.3 Contraindications: Individual hypersensitivity against Cyclamen, Primula and other Primulaceae.
Polyposis of the nose and the paranasal sinuses that can block the meatus and secretion. 3.4 Special warnings and special precautionsof use: Apply only one spray per day into each nostril. Avoid inhaling during application. Avoid eye contact. Contact of the Product with the eyes may result in irritation and symptoms of Acute conjunctivitis.

Take note of the section 3.5 Interaction with other Products and other forms of interaction. If necessary, other nasal Products can be administered 1.5-2h before or after NASODREN. Undesirable effects are related to the specific mechanism of action, and may include some itching, sneezing, a brief sensation of mild to moderate burning in the nasopharynx, reflex salivation and, more rarely, a brief lacrimation and flushing of the face (especially in patients treated with antihypertensive medication). However, these are manifestations of the positive response to the Product. When prescribing NASODREN, it is suggested that the physician explains these effects to the patients as being due to the stimulation of N. trigeminus and N. facialis. All these effects usually diminish during the course of treatment. In some isolated cases a mild temporary headache or pale pink discharge may appear. It is not necessary to stop treatment in these cases. Accidental use by patients allergic to Cyclamen, Primula and other Primulaceae, which could lead to swelling of the nasal mucosa, eyelids and/or face. 3.5 Interaction with other Products and other forms of interactions:
Simultaneously administered parasypa- thomimetic drugs acting either directly (e.g. carbachol, pilocarpine, betanechol), or indirectly (cholinesterase inhibitors like neostigmine, ambenonium etc) will potentiate the effect of NASODREN (due to amplification of released acetylcholine action in the respective synapses). After application of NASODREN, a slight issuing of red blood cells in the nose was observed in some patients. Therefore, treatment with anticoagulants(e.g. coumarin derivatives, acetylsalicylic acid) should be suspended and the application of NASODREN commenced, taking into account the rate of elimination of the particular anticoagulant. 3.6 Pregnancy and lactation: There is no experience regarding the administration of NASODREN during pregnancy and breast-feeding in humans. Therefore, NASODREN should not be administered during pregnancy and breastfeeding, especially during the first trimester. 3.7 Effects on ability to drive or to operate machinery: Driving or operating machinery is not recommended for 2 hours after using the spray. 3.8 Adverse Reactions: In very rare cases of prolonged lacrimation or salivation lasting more than 2 hours, give atropine or other anticholinergics such as scopolamine to stop the secretory response. 3.9 Overdose: Exceeding the required dose may cause a severe burning sensation in the nasal mucosa or nasopharynx, 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. 4. PRODUCT PROPERTIES: 4.1 Incompatibilities: NASODREN is incompatible with anticholinergics (such as atropine, tropicamide etc.). Date of revision: September 2010.

Thursday, May 17, 2012

Acute Rhinosinusitis and Cyclamen extract

Despite the fact that Acute Rhinosinusitis (ARS) shows an increasing prevalence in European countries, it remains enigmatic in terms of its physiopathology, reliability of diagnosis or even in elaborating an effective and optimal treatment strategy.
Perhaps even more surprising is the fact that direct and indirect costs for one episode of ARS treatment are extremely high, approximately €800 according to the PROSINUS study. Considering that more than 20m Europeans are deemed to be affected at least once a year by an episode of ARS, that brings the cost of ARS treatment for the Health Authorities to more than €16bn per year.



The main cause of ARS is a post-viral infection, and all lecturers agreed that ARS is an inflammatory disease, with the aim of treatment being symptom relief, thereby allowing sinus drainage and ventilation.
But how can ARS be diagnosed? An interesting study presented shows that practitioners essentially use the same diagnosis criteria as the EP3OS study recommendations. That is to say, symptoms are the basis for Rhinosinusitis diagnosis, while X-ray and CTscan are not recommended at daily practice.

Moving on to available treatments, European Position paper on Rhinosinusitis and Nasal Polyps 2007 (EP3OS) guidelines recommend use of oral antibiotics only for the most complicated cases, where high fever and pain are present.
In most patients, inflammation can be controlled if treated by topical corticosteroids. However, as , high doses of corticosteroids are required to achieve a significant effect and, moreover, EMA have not approved a Rhinosinusitis indication for them.


Of particular note is the fact that half of the prescriptions for antibiotics in European countries
are for Upper Respiratory Tract Infection. Unfortunately, antibiotics do not seem to prevent ARS complications. A Cochrane Review on antibiotics in ARS provides quite an indicative statistic: we have to treat 7 patients to, probably, make one better slightly earlier.


Increasingly, patients from around the world are looking for safer, more effective Products for managing their disease. Could that be one of the reasons why Cyclamen europaeum L. extract is being administered more and more to relieve the symptoms of ARS sufferers?
A number of studies, some of them highly pioneering, have been carried out to demonstrate the clinical effectiveness of Cyclamen europaeum L. extract. Said efficacy is mainly due to its high saponin content. Once sprayed into the nostrils, saponins, in addition to a
local surfactant effect, stimulate the nervous system of the nasal mucosa inducing both a nociceptive and cholinergic response, hence stimulating glandular secretion and cilia movement.
So, , there is finally an innovative and effective treatment option for Acute Rhinosinusitis.
Cyclamen europaeum L. extract will clean and drain mucus away from the sinonasal area in a physiological way. One final point, but by no means of lesser importance, we have heard how Cyclamen europaeum L. extract has generated some very positive feedback from patients.

Wednesday, May 16, 2012

Useful facts about cromolyn and other nasal sprays

A cromolyn nasal spray stops the release of histamine from the mast cell. Chromolyn inhibits calcium transmembrane flux, prevents degranulation due to antigen and therefore stabilizes membranes of the mast cell. The cell stabilization prevents release of histamine responsible for inflammatory cell action.



Cromolyn sodium is derived from khellin, found in Ammi visnaga plant. The intranasal cromolyn sodium is used as a 4% topical nasal spray. The safe spray reduces release of allergy agents.

Chromolyn reduces nasal pruritus, rhinorrhea and sneezing.  This spray is used to treat perennial and seasonal allergic rhinitis. The cromolyn also helps in reducing asthma.
However, chromolyn does not resolve nasal polyps, non-allergic rhinitis and acute allergic rhinitis.

Chromolyn also has some side effects, such as bad aftertaste, headache, nasal burning and stinging, and sneezing. However, adverse effects are limited to some cases only. The cromolyn nasal sprays are sold without prescription in the U.S.A.
The cromolyn nasal sprays are prophylactic that means a preventive measure. Since the spray action is delayed, i.e. it takes some time to start working, start using the spray before pollen season begins for desired results. Moreover, continue to use the nasal spray during exposure period as well.
The intranasal cromolyn is less effective than the intranasal corticosteroids.  However, in some cases, intranasal cromolyn benefits patients.
The body absorbs a minimum amount of cromolyn and the remaining unchanged medication is excreted.  However, its multiple doses are required daily. The U.S. Food and Drug Administration (FDA) approved intranasal cromolyn as Pregnancy Category B medication.
Other sprays
In some cases, topical adrenergic agents are used before a  nasal spray administered to reduce inflammation for better delivery of the spray.
Before starting the maxillary sinus surgery based on the minimally invasive sinus technique (MIST), a number of doses of nasal sprays are given to the patient to cause vasoconstriction that will decrease bleeding and increase operative visibility.
Since sometimes sinusitis is confused with symptoms developed due to excessive use of over-the-counter (OTC) vasoconstrictor nasal sprays, diagnosis of acute sinusitis becomes difficult.
Children suffering from hay fever are prescribed nasal sprays. The sprays are given with oral antihistamines, as the spray does not treat associated eye problems.
A corticoid-nasal spray is used for nasal polyposis.

Tuesday, May 15, 2012

Chronic nasal congestion

Chronic nasal congestion means continuous swelling of the nose tissues owing to enlargement of the blood vessels.  It may lead to fatigue. A number of factors, such as recurrent infections, reaction to cow’s milk and dust may cause chronic or recurrent nasal congestion in children. The young population that catch cold repeatedly, or suffer from asthma may also have the congestion.



Dental deformities, overgrowth of pharyngeal lymphoid tissue, retrognathic facies, halitosis, slim palatal arch and wide nose dorsum may cause chronic nasal congestion in children. If parents smoke within the house, their children may develop chronic nasal congestion.
The patients having chronic nasal congestion that is not accompanied by intranasal mass, infection or allergy may be suffering from vasomotor rhinitis. Chronic sinusitis patients also have chronic nasal congestion. If chronic nasal congestion leads to excessive breathing from the mouth, malocclusion and orofacial dental problems may develop. Recurrent sinusitis and headaches are related to chronic nasal congestion. 
If allergies or cold symptoms linger for long, chronic nasal congestion may occur, causing enlargement and inflammation of tonsillar and adenoid tissues.  Chronic nasal congestion causes fluid accumulation in the lower eyelid region, causing hyper pigmentation, which is also called allergic shiners or dark circles.
Excessive use of topical nasal decongestant leads to chronic nasal congestion. If paranasal sinuses do not develop fully, chronic nasal congestion may occur.
Chronic nasal congestion, a cause of nasal obstruction, also affects the voice. The injuries secondary to the nasal obstruction may even damage nasal resonance required for healthy voice. Since both air cavities of the paranasal sinuses and the nose lend the resonance, clearing up and draining these organs restore the resonance.
Nasal congestion persisting for long may impair both taste and smell senses. The congestion may plug the Eustachian tubes, causing hearing disorders. Chronic nasal congestion may obstruct draining of tears.
Chronic nasal congestion can be secondary to several disorders. Therefore, a thorough examination is necessary to identify the cause. Chronic nasal congestion is a common symptom of cystic fibrosis. Hypothyroidism, malfunctioning of the thyroid gland, may cause the congestion. Untreated leprosy may lead to chronic nasal congestion.
The obstructive sleep apnea (OSA) patients commonly complain about breathing problems or chronic nasal congestion. Continuous positive airway pressure (CPAP) therapy helps in resolving OSA.

Monday, May 14, 2012

Fungal infections-sinus

A paranasal sinus fungal ball, a type of infections-sinus, is minimally invasive. The ball forms when fungus traps within the paranasal sinus. The trapped fungus grows, occupies most of the sinus and blocks the sinus drainage system. The ball may even affect the bone. This unilateral mass of fungus usually occurs only in one sinus. In rare cases, the ball may affect more than one sinus. Generally, the ball occurs in the maxillary sinus. The balls may rarely develop in the frontal and sphenoid sinuses. The balls are more commonly found in female patients in their mid-life.




Causes
The fungi found in the air cause the ball. The fungi may vary from geographic region to region. However, Aspergillus fumigatus is the most common cause of the fungus ball. Other species of Aspergillus and Scedosporium apiospermum also initiate the ball formation. Fungi may travel through the airway or odontogenic route to reach the sinus. The ball looks like an onion in the histology sections.

If sinuses are inadequately ventilated and exposed to the fungus, the ball may develop.
The ball, a common form of fungal sinusitis, is one of the principal causes of chronic unilateral infections-sinus.

Signs and symptoms

The fungal ball comprises many fungal hyphae layers. Inflammation is very little within or around the ball. 
In many cases, there may be no symptoms at all. However, some patients with fungus ball may complain about strange facial fullness or may suffer from any other sinonasal tract disorder. 
Allergic symptoms are rare in patients with the ball. However, fetid smells, congestion, and pressure and pain in the face may appear. The expanding ball obstructs and worsens the symptoms.

Diagnosis criteria
The ball is an incidental finding in diagnosing different types of sinusitis. The following criteria may help in diagnosing the ball:

Radiological scans of the sinus display opacification with / without calcification.
Materials resembling to clay or mucopurulent cheesy are present in the sinus.
The sinus mucosa is separate from the dense ball.
Chronic inflammation is non-specific.
Allergic mucin and granuloma are absent.
There is no evidence of invasion of the bone, blood vessels or mucosa.

Treatment
As the ball is mostly asymptomatic, radiography is necessary for diagnosis. Since the ball neither attaches nor invades the tissue / sinus cavity blood supply, medication does not help. This ball should be removed surgically. Moreover, sinus drainage and ventilation should be restored. No antifungal drugs are given, as the ball rarely reoccurs.

Friday, May 11, 2012

7 Important information in Rhinosinusitis that you should know


• We know, that in the long term a specific form of inflammation can cause asthma. So if you
have sinus disease, which is a severe form of inflammation, you will be more susceptible to
having asthma. Evidently, there is a clear need for more research, so we can have at least a
hypothesis, indicating the importance of treating chronic inflammation in sinusitis.
The primary problem that affects the quality of life of the patient is that they are unable to sleep,
or to concentrate, so their work performance drops and their social life also suffers. So, it is extremely clear that diseases that affect the sinuses, whether or not they become chronic, can have a major effect on daily life conditions.

• Antibiotics are only to be used in severe cases, which means if the disease is longer than 5 days
or more. Moreover, in Chronic Rhinosinusitis antibiotics are also used, as well as anti-NFkB
activity or anti-metalloproteins. The objective in the treatment of these diseases is mainly the anti-inflammatory component, restoring ventilation and drainage, especially in Chronic Rhinosinusitis, but also in Acute Rhinosinusitis, and opening the ostia.
• Since the Nasodren has been on the market, it has been administered for the treatment of Acute and Chronic Rhinosinusitis, based on the evidence of
two studies we have performed. The first study shows that Cyclamen extract
works as a Product that stimulates mucusdrainage, and even increases blood flow in the
nasal area. In the second study we saw how it stimulates the parasympathetic system, opening
the ostia and improving sinus drainage. The study group and the control group were using
typical antibiotics and Cyclamen extract. We showed that the results of the adjunct
treatment with Cyclamen extract significantly improved the Total Symptom Score
of the patient.
• It is important to be aware of, and pay special attention to, symptoms like rhinorrea or those
of nasal blockage in patients, as they could progress in to serious disease.
The use of Cyclamen extract , will probably be a good adjunct treatment of Acute
Rhinosinusitis to reinforce, or to stimulate, the natural defences, mainly improving clearance
or producing new antibacterial products from secretory glands that will help, combined with
other products, to reduce the duration of the disease.
Cyclamen extract can cure Acute Rhinosinusitis, so that when you stop the Acute
phase, there is no chronic stage.

Thursday, May 10, 2012

Tips to avoid frontal sinus trephination complications

Frontal sinus trephination is traditionally performed to treat acute frontal sinusitis that does not respond to an antibiotic therapy. In complicated acute frontal sinusitis, trephination is used to drain pus and irrigate the sinus, preventing intracranial problems. Acute frontal sinusitis accompanied by orbital or intracranial extensions can be treated with trephination. The trephination, the simplest method for the frontal sinus entry, is used to explore frontal sinus and conduct biopsy. This surgery-sinus may however cause some complications, such as intracranial entry, osteomyelitis, scarring, sinocutaneous fistula formation, supraorbital hypesthesia and trochlea damage.  



Since frontal sinus hypoplasia (incomplete or underdevelopment of an organ or a tissue) occurs in a number of patients, chances of intracranial entry during small frontal sinus trephination are high. While accessing a small frontal sinus, loss of direction can cause intracranial entry. Stimulation of the body organs or sensory nerves causes sensation. Reduction in this sensation is medically called hypesthesia. These complications can however be avoided. Read on to learn useful tips to minimize the surgery-sinuscomplications.
  • Accurate evaluation of the penumatization pattern of the patient’s sinus is necessary.

  • Coronal and axial computed tomography (CT) scans will help in measuring height and depth of the sinus accurately. With the coronal CT scan, it is possible to asses how much bone has to be removed for entering into the sinus.
  • Incise medially, which means near the median plane of the supraorbital notch to prevent supraorbital nerve trauma.

  • Rounded burr gives more control while accessing the sinus than the perforating burr. So, operation with rounded burr is safer.
  • Enter the sinus through its floor instead of the anterior wall’s diploic bone to reduce the chances of osteomyleitis.

  • To place trephine, the surgical instrument, precisely in the correct position, especially in small frontal sinuses, image guidance is required.
  • During this surgery-sinus, avoid anterior wall’s cancellous bone containing marrow space. Osteomyleitis may develop if the marrow space is contaminated.

  • If fibrosis obliterates the frontal recess, trephination facilitates visualization of the sinus from both below and above.
  • If the trephine is inserted via the anterior wall, damage to supra-orbital nerve occurs, causing paresthesia or numbness.

  • Excessively laterally placed bony trephine can damage the supratrochlear neurovascular bundle.
  • Now-a-days a mini-trephination system is available to enter the sinus. It minimizes the incision size. From the incision, cultures can be collected.

Wednesday, May 9, 2012

Epistaxis (Nosebleed)



Epistaxis, an otolaryngologic emergency, means to bleed from the nasal cavity or nostrils. However, only a small percentage of cases are fatal and serious. The cause and form of the bleeding depends on the patient’s age. Since epistaxis is attributed to other diseases, a complete medical examination is necessary to find the appropriate cause.



Causes
Symptoms of sinus infectionsmay cause nosebleed in both children and adults.  Some of the patients are more prone to nose bleeding than others. Both systemic and local agents cause nosebleed. Systemic factors include hemophilia, hereditary hemorrhagic telaniectasia, liver disease, sarcoidosis and Wegener granulomatosis. Local factors comprise atrophic rhinitis, chronic inflammation, external and internal trauma, foreign bodies, low humidity and neoplasma.
Types of epistaxis
Nosebleed is divided into tow categories: anterior and posterior. The source of anterior nosebleed lies in the nostrils and that of posterior in the back of the nose.
Anterior nosebleed
The wall separating the nostrils contains several blood vessels susceptible to injuries. On many occasions, factors causing nosebleed may not be evident. However, a number of factors can trigger the bleeding. For instance,
  • a minor nose injury,
  • congenitally crooked nose,
  • crooked nose due to deviated septum,
  • influenza,
  • nasal congestion due to an infection
  • hay fever (allergic rhinitis)
  • overuse of nasal decongestants to treat symptoms of sinus infections
  • picking the nose,
  • blowing the nose,
  • high altitude, and
  • snorting drugs.
Children are more susceptible to anterior nosebleed.
Posterior nosebleed
Posterior nosebleed, heavy bleeding from the back of the nose, is more serious condition than the anterior. The bleeding starts from the artery branches supplying blood to the area located between the nasal cavity and the mouth’s roof. Head injuries, head fall, nasal surgery, hypertension and nasal cavity tumor may cause posterior nosebleed. The posterior condition is more common in adult patients than the younger. It requires a visit to the physician.
Prevention
Nosebleed can be prevented. Try the following:
Do not pick the nose.
Do not blow the nose hard when it is blocked owing to hay fever or cold.
Wear protective gear while playing rugby, boxing and other sports, where chances of the nose injury are high.
While using nasal decongestants, follow all the instructions.
When nosebleeds turn into “a crust” causing irritation within the nose, do not scratch the nose. Otherwise, bleeding will start again.
Humidify your home and work space, and moisturize the nose. This will prevent the dryness that is another cause of nosebleed.
Treat the Symptoms of sinus infections  well in time.

Tuesday, May 8, 2012

What are the benefits and challenges regarding the use of Cyclamen europaeum L.as a potential treatment option for Acute Rhinosinusitis

On examining the pros and cons of the extract of Cyclamen europaeum L. for ARS treatment, one othe main advantages of this treatment is that it offers therapeutically multi-action functions, opening the ostiomeatal complex, and activating the mucociliary system. Consequently, it increases the drainage of mucus retained in the sinonasal area; produces fast dehydration
and a detumescent effect (calms and relieves swelling). Unlike other products used in Rhinosinusitis treatment, Nasodren is not indicated for a specific etiology, but rather aimed at improving the symptomatology regardless of the cause that produces it.
This Product has no systemic effect while producing positive effects when treating Acute Rhinosinusitis. To understand how this is possible, it is necessary to look at the way that Cyclamen europaeum L. extract acts.



Without being dispersed through the entire mucosa of the nose, and possibly not even entering the sinuses at all, the Cyclamen europaeum L. extract produces a positive effect. The main secret that may be behind Cyclamen europaeum L. is the saponins, which produce a nociceptive response from the trigeminal nerve. A type of reflex is produced, thereby stimulating secretion and also ciliary transport
In actual fact, the saponins stimulate the lipid membranes of the neuronal cells in the sinuses, thereby producing a reflex that stimulates secretion. Additional advantages the action of this extract offers in treating Acute and Chronic Rhinosinusitis are helping to dilute secretions, as well as increasing the transport of said secretions. So, finally there are some innovative new treatment options in Rhinosinusitis.
There have already been a number of studies carried out on this new Product, the most interesting of which have been selected for this presentation to illustrate the effectiveness of Cyclamen europaeum L. One study (Trial code 4334-083) was conducted in the US, in accordance with all the criteria you would expect from a modern trial - randomized, double-blind, placebo-controlled - using Cyclamen europaeum L. nasal spray on patients with mild to moderate Acute Rhinosinusitis. For this reason, the Cyclamen europaeum L. extract was used as a monotherapy, without any other medication whatsoever.
The study concludes that Cyclamen europaeum L. nasal spray improved both subjective & objective measurements of sinusitis. Cyclamen europaeum L. shows an important reduction in the percentage of sinus occlusion in Total Symptom Score, and a significant reduction in Sinus Occlusion when Cyclamen europaeum is compared to placebo in patients with ARS. The placebo effect observed with patient-reported symptom score is not supported by objective measurements. No serious or unexpected adverse events were observed in the study. Despite the relatively small number of patients, the data indicates that there is indeed a clear benefit from treatment with the Cyclamen europaeum L. extract Nasodren® can contribute to reducing disease progression time, to decreasing the need for antibiotics or to boosting their effects, as well as reducing the number of complications and chronification. Nasodren® is indicated as a first line treatment for rhinosinusitis symptoms in monotherapy, and in combined treatments has shown to be at least of the same efficacy as standard combined treatment.
Neither of the studies reported any serious adverse events, or indeedunexpected events, with the new Product displaying excellent safety aspects.

Monday, May 7, 2012

Frontal sinus trephination

Frontal sinus trephination, also called mini-anterior frontal sinusotomy, is a traditional method of sinusitis surgery. An array of problems of the frontal sinus and recess can be treated with trephination. For example, the trephination is used for chronic or persistent frontal sinusitis, patients who need revision surgery for the frontal sinus and patients who have undergone functional endoscopic sinus surgery (FESS).



The frontal sinus areas that cannot be accessed during endoscopic procedure can be accessed using trephination.  For example, lateral and superior parts of the sinus are not accessible with endoscopes. If trephination is accurately placed over the frontal sinus pathology site, better views of the sinus are possible, reducing the need for dissection. Skull base defects, fibro-osseous lesions and neoplasms related to the frontal sinus cannot be managed just with endoscopic approaches.
The surgery prevents the infection from spreading into the frontal bone and intracranial region. Since advanced antibiotics can treat acute frontal sinusitis, the trephination is more popular for chronic frontal sinusitis than acute conditions. If a tiny catheter is left within the trephine, corticosteroids and topical antibiotics can be instilled and irrigation is possible every day, as a result, chronic inflammation resolves faster.
The sinusitis surgery can be used with endoscopic surgery methods in case of frontal sinus mucoceles and chronic frontal sinusitis. In this combined approach, trephination enables to place a catheter and stent within the frontal recess and prevents chances of stenosis. This combined method gives easy and quick entry to the sinus.
The trephination method uses a trephine for making a small burr hole in the frontal bone to enter into the frontal sinus(s). The surgeons use a trephine, drill, gouge, chisel, trocar and needle for trephination. A trephine with an endoscope can be used to examine the mucosa of the sinus. After trephination process is complete, nasal decongestants and intravenous antibiotics are administered.
The sinusitis surgery can be completed using any of two approaches: antero-inferior and anterior. The antero-inferior method, developed by Silcock, is the most popular approach, which is performed under general or local anesthesia. Ogston pioneered the median anterior trephination technique. The median anterior trephination uses a trephine to remove bony part, giving access to both the frontal sinuses.

Friday, May 4, 2012

Nasodren / Sinuforte

Nasodren is a natural product indicated for the treatment of acute and chronic rhinosinusitis, postoperative care after sinonasal surgery, and otitis media with effusion.
Its active ingredient are saponins, a cyclamen extract that gives a fast relief from rhinosinusitis symptoms, like nasal blockage, obstruction, congestion or nasal discharge.



Nasodren acts activating the physiological defense mechanisms of the upper airways (increased mucus secretion, greater ciliary cleansing activity and increased arterial blood flow) that are impaired during rhinosinusitis. Nasodren stimulates the trigeminal nerve endings of the nasal mucosa, which leads to a seromucus discharge, reduction of the inflammation of the mucosa and opening of the ostiums (the passages that communicate the sinuses to the nasal cavity), and therefore cleaning sinuses and nasal cavity. This specific mechanism of action can produce some itching, sneezing, brief sensation of mild to moderate burning sensation in the nasopharynx and more rarely, a brief lacrimation and flushing of the face. These are manifestations of the positive response to the product. All these effects usually diminish during the course of treatment.
Nasodren has demonstrated its efficacy, safety and tolerability, both in monotherapy and in combination, in 34 clinical trials and more than 2.000.000 consumer worldwide have benefit from its use since Nasodren was launched 10 years ago.

Wednesday, May 2, 2012

2 staging systems for chronic signs of sinus infection

Staging systems group different chronic rhinosinusitis phases, enabling treatment comparison.  An array of staging systems has been developed to record chronic sinusitis and outcome of medication. A standardized reporting system and staging system would enhance reliability of scientific communication. However, the standardized staging system is still a dream.
In the past, staging systems tried to measure severity of disease and took into account related conditions such as polyposis, allergy and asthma. These systems have been revised and improved. For instance, in the beginning of 1990s, Kennedy proposed an improved staging system.




Kennedy’s staging system
The system emphasizes on postoperative endoscopic follow-up to collect patient data. Since recurrent signs of sinus infection can be observed during nasal endoscopy, the recurrent disorder can be treated in the initial stage by using medication or surgical debridement. The system was rated high for its predictive and prognostic merits. With this system, the patients’ conditions can be compared without considering miscellaneous agents.
The system is mainly based on extent of the disease. Kennedy used intra-operative and radiographic data to measure the extent of the disease while defining the staging system. The system consists of four patient categories and stages based on severity of the disease. The Stage I incorporates anatomic defects, unilateral sinus disorders and bilateral disorder of the ethmoid sinuses. The Stage II focuses on bilateral ethmoid sinus disorder, in which one dependent sinus is involved. The Stage III covers bilateral ethmoid sinus problems, in which at least two dependent sinuses are involved. The Stage IV represents diffuse sinonasal polyposis.
Lund-MacKay staging system
Recently, the Rhinosinuistis Task Force approved revised version of the Lund-MacKay staging system to document research work. Initially, the Lund system used quantitative results of the computed tomography (CT) scan. However, the Task Force suggested incorporating endoscopic appearance, symptom score, surgery score, information about variation in anatomy and demographic data.  Radiological staging score of all four pairs of the sinuses and ostiomeatal complex is taken into account in the Lund system.
The endoscopic appearance measures characteristics at baseline, after 3 and 6 months, and 1 and 2 years. The characteristics evaluated include left and right polyp, edema, discharge, scarring and crusting. Anatomic variants, including agger nasi cells, Haller cells, everted uncinate process, paradoxic middle turbinate, concha bullosa and absent frontal sinus, are graded radiologically. The demographic data suggested by the Task Force includes anesthetic duration, systemic and nasal diagnosis, complications, surgery date, surgeon details, operation, and patient’ name, gender, age and date of birth.
Kennedy vs. Lund
The Kennedy System is based on the extent of disease, assessed using endoscopic surgical and CT findings.  The Lund Mackay system uses findings of the objective endoscopy and CT scans, and visual analogue scale, which is subjective.
Therapy’s compatibility with endoscopic methods, extent of operative and radiological disorder, comorbidity and several other prognostic factors have been suggested for objective assessment of chronic signs of sinus infection and selecting the best management method and therapy.