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Nose diseases

Category: Illness or disabilities

Type

Involuntary

Introduction and description

The nose consists of the visible nose on the face; the olfactory system [for smelling] and the sinuses. It is a part of the respiratory system; air is inhaled, warmed and moistened and carbon dioxide (CO₂) and other unwanted gases expelled along with water.

Visible nose - The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the nasal bones and the nasal cartilages, including the septal cartilage (which separates the nostrils) and the upper and lower lateral cartilages. On average the nose of a male is larger than that of a female [men are hunters needing lots of air, women are gatherers needing less]. It is also a part of the immune system and is the first line of defence against pathogens entering the body, particularly the lungs, via the nose. Hairs in the nose are used to trap the larger pathogens and mucus is then used to trap smaller pathogens.
Sinuses – The sinuses are a group of four paired spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphenoidal sinuses are behind the eyes. Through their copious mucus production, the sinuses are an essential part of the immune defense/air filtration carried out by the nose. Nasal and sinal mucosae are ciliated and move mucus to the choanae and finally to the stomach. The thick upper layers of nasal mucus trap pathogens and small particles in tissue abundantly provided with immune cells, antibodies, and antibacterial proteins [unless we interfere with this process by using pharmaceuticals]. The layers beneath are thinner and provide a substrate in which the cilia are able to beat and move the upper layer with its debris through the ostia toward the choanae.
Olfactory system - The nose has an area of specialised cells which are responsible for smelling. Smells inhaled through the nose impact the olfactory epithelium, which contains olfactory receptors. These receptors, rather than being ligand specific, accept a range of odour molecules. Olfactory neurons convert receptor activation into electrical signals. The signals travel along the olfactory nerve, which terminates in the olfactory bulb, which belongs to the central nervous system. That’s the hardware description. The software description says that we can recognise smells and the strength of smells and distinguish one smell from many

Diseases and illnesses

Rhinitis and sinusitis are among the most common medical conditions and are frequently associated. In Western societies an estimated 10% to 25% of the population have allergic rhinitis, with 30 to 60 million persons being affected annually in the United States. It is estimated that sinusitis affects 31 million patients annually in the United States. PMID: 20176255

The following list provides some examples of illness and diseases affecting the nose:

Anosmia - is the technical name for not being able to smell things - “an inability to perceive odours”. It may be either temporary or permanent. Loss of the sense of smell can also be partial or total, decreased ability to smell has the technical name, hyposmia. Follow the link for more details. The observations for anosmia are to be found with the entry.
Nosebleeds - The correct name for a nose bleed is ‘Epistaxis’. It is a hemorrhage from the nose, usually noticed when the blood drains out through the nostrils. There are two types: anterior which is the most common, and posterior which is less common, but is more likely to require medical attention. Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eyes. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting.
One cause of nose bleeds is the insufflation of drugs or ‘snorting’ drugs in the form of snuff. Nasal sprays can cause nose bleeds. They can also be caused by other sorts of inflammatory reactions to things like smoke or dust or other irritants. But Nose bleeds can be a side effect of spiritual experience. They can also occur to people who have an inherited ability to have experiences. They can be caused by the sudden changes in blood pressure caused by intense spiritual experience. As the emotions are extremely high, the emotions can cause the blood pressure to rise extremely fast.
Nasal polyps - are abnormal growths of tissue projecting from the mucous membranes of the nose and paranasal sinuses. They can cause nasal congestion, but they are in reality more of a symptom than a cause, as they act like cysts engulfing pathogens. The immune system traps larger pathogens engulfing them in tissue which is an overgrowth of the mucosa. “They may be removed by surgery, but are found to recur in about 70% of cases”. This is probably because the pathogen is still there.
Nasal septum disorders – The nasal septum is the bone and cartilage in the nose that separates the nasal cavity into the two nostrils. Disorders, in severe cases, can result in difficulty breathing, infections of the sinus and sleep apnea, snoring, repetitive sneezing, facial pain, nosebleeds, and mild to severe loss of the ability to smell. A deviated septum, for example, causes the cartilaginous ridge to lean to the left or the right, causing obstruction of the affected nasal passage. The condition can result in poor drainage of the sinuses.
Sinusitis - The paranasal sinuses are joined to the nasal cavity via small orifices called ostia. These become blocked easily by any inflammation caused by pathogens, or by swelling in the nasal lining. If this happens, normal drainage of mucus within the sinuses is disrupted, and sinusitis may occur. If you have any problems with your teeth, such as bacterial problems, gingivitis, tooth decay etc, then what is called secondary sinusitis can result as the bacteria or other pathogen from the mouth transfers to the maxillary sinus. Thus secondary sinusitis is inflammation of the sinuses from another source such as an infection of the adjacent teeth. Clearly the solution here is to get your teeth fixed!
Rhinitis - is irritation and inflammation of the mucous membrane inside the nose. Common symptoms are a stuffy nose, runny nose, itching, sneezing, coughing and post-nasal drip. The inflammation of the mucous membrane is caused by pathogens - viruses, bacteria, fungi, toxins, and other irritants.
Allergic rhinitis - is repeated rhinitis on exposure to a specific substance. It is part of the overall allergic response and thus more correctly is classified as Asthma and other allergic responses – many researchers are beginning to understand that sinusitis, rhinitis, asthma and various so called auto-immune responses are simply differing manifestations of the same pathological process, with considerable overlap

EMR Sinusitis is predominantly or completely related to a response to one or more fungi. In EMRS cases, disease was uniformly bilateral, combined with a significantly higher frequency of asthma, increased incidence of aspirin sensitivity, and frequently an immunoglobulin G1 deficiency.

Cancer - Malignancies of the paranasal sinuses comprise approximately 0.2% of all malignancies. About 80% of these malignancies arise in the maxillary sinus. Men are much more often affected than women. Tumours of the sphenoid and frontal sinuses are extremely rare.

Symptoms

Sneezing- is caused by foreign particles irritating the nasal mucosa. It is not a disease or illness, but is a useful symptom, as it indicates the presence of pathogens that if allowed to enter the lungs could cause more serious illness. One of the useful pieces of advice in ayurvedic medicine and yogic practises is to always breathe through the nose, in this way the mucus and nasal hairs trap the pathogens. Thus the two most foolish things one can do is to cut the hairs in your nose and to use nasal sprays, inhalers or tablets that dry up the mucus. Sneezing can transmit infections, because it creates aerosols in which the droplets can harbour microbes. Not good for others, but good for you because you've shot the little critters half way across the room never to bother you again.
Nasal congestion - the blockage of the nasal passages due to membranes lining the nose becoming swollen from inflamed blood vessels. It is also known as a blocked nose or stuffy nose. The inflammation always has a cause - dust, viruses, bacteria, fungi, parasites - the immune system has released histamine in order to open the blood vessels to enable it to fight the pathogen. Use of any form of nasal sprays or anti-histamines is thus extremely unwise, as it allows the pathogen to enter the body.
Hearing difficulties - all systems are connected and blockage of the nose can in turn cause hearing difficulties and earache
Runny nose - this is an extremely helpful symptom, the runnier the better, which is why copious fluids should be drunk to encourage more running. Diseases of the nose tend to be caused by a pathogen of some sort and the thick sticky mucus traps the pathogen so it does no damage, and does not enter the body. The mucus helps to bathe the lining of the nose, thus helping to soothe it and reduces inflammation. Furthermore, by trapping the pathogen in the mucus all you have to do is blow your nose and you have expelled the pathogen.
Headaches - the pressure in the nose may in turn cause pressure over the eyes leading to eye pain and head pain
Watering eyes - the eyes and the nose are connected via passages and the watery eyes may be an indication that the pathogen has reached these passages, or that the fluids from the eyes are being used by the body's immune defences to supplement the fluid in the nose and help the removal of the pathogens.

Causes

Although a number of pathogens can cause problems with the nose there is one overriding problem that can be a culprit and that is Dehydration. We often work or live in very warm dry environments and may ourselves by inadequately hydrated. Thus the simple and obvious cure to many problems associated with the nose is simply to drink more water, more water than you might think you need. If your nose feels all dry inside, then this is probably the main cause. A wet nose in a human is just as good a sign of health as a wet nose in a dog!

Now we can turn to the pathogens.

Fungal infection

Houses that are built these days, without air vents and adequate ventilation because of double glazing; offices that are poorly cleaned; even shops that are also badly ventilated can harbour fungal spores and they are irritants as well as pathogenic in their effects. I have not shortened the following because it is not only useful in its own rather quirky way, but shows what happens when you use symptom and not cause based medicine. Names, names, names [and no cures]

Key conclusions reached were: rhinosinusitis is preferred to sinusitis; acute invasive fungal rhinosinusitis is preferred to fulminant, or necrotizing and should refer to disease of <4 weeks duration in immunocompromised patients; both chronic invasive rhinosinusitis and granulomatous rhinosinusitis were useful terms encompassing locally invasive disease over at least 3 months duration, with differing pathology and clinical settings; fungal ball of the sinus is preferred to either mycetoma or aspergilloma of the sinuses; localized fungal colonization of nasal or paranasal mucosa should be introduced to refer to localized infection visualized endoscopically; eosinophilic mucin is preferred to allergic mucin; and allergic fungal rhinosinusitis (AFRS), eosinophilic fungal rhinosinusitis, and eosinophilic mucin rhinosinusitis (EMRS) are imprecise and require better definition. In particular, to implicate fungi (as in AFRS and EMRS), hyphae must be visualized in eosinophilic mucin, but this is often not processed or examined carefully enough by histologists, reducing the universality of the disease classification. A schema for subclassifying these entities, including aspirin-exacerbated rhinosinusitis, is proposed allowing an overlap in histopathological features, and with granulomatous, chronic invasive, and other forms of rhinosinusitis. Recommendations for future research avenues were also identified. PMID: 19544383

it might just be better to call the problem by the fungus that is the cause - of which there are many - each producing their own symptoms.

Fungi behave in different ways in the nose. Some behave like bacteria and can result in symptoms that look like chronic bacterial sinusitis. This is why antibiotics should NEVER be prescribed unless tests have been done to find out the cause. Some fungi are very destructive, even invasive and the infection can result in a mass that behaves like a malignant neoplasm, eroding bone and spreading into adjacent tissue - cancer and tumours can thus result from fungi. Nasal polyps can result from the more invasive kinds. One major culprit is Aspergillus species, but there are others, for example the Mucorales fungi, sometimes called pin molds, are implicated.

Whilst A. flavus has been the cause of some very nasty infections seen in Sudan, India, Pakistan, and Saudi Arabia, Aspergillus fumigatus is one agent in for example fungal balls, which cause ‘mucopurulent cheesy or clay-like materials within the sinus’.

The fungi causing AFRS are diverse, and in a review of the English literature, Manning and Holman in 1998 reported 168 positive cultures, 87% of the cases due to dematiaceous fungi, and 13% yielded Aspergillus species ………… patients with CRS show exaggerated humoral and cellular responses, both Th1 and Th2 types, after exposure to common airborne fungi, particularly of the Alternaria species

“It is believed that fungal allergens elicit immunoglobulin E (IgE)-mediated allergic and possibly type III (immune complex)-mediated mucosal inflammation”. So that is why one gets the inflammation. Note that there is also a clear link with asthma and allergic responses here with the same pathogens producing all the effects.

Pharmaceuticals

Anyone who is taking immunosuppressants, who is on chemotherapy, or who has been given any medicine with anti-histamines in it - from nasal sprays to cough medicines - is at risk from the more severe forms of fungal infection, as they are in effect immunocompromised, for example:

The disease is described by a time course of <4 weeks with predominant vascular invasion occurring in patients with immunocompromised status. The histopathology demonstrates hyphal invasion of blood vessels, which may include the carotid arteries and cavernous sinuses, vasculitis with thrombosis, hemorrhage, tissue infarction, and acute neutrophilic infiltrates. The disease has also been termed acute necrotizing FRS, as a necrotizing pathological reaction may be seen in some patients with only minimal inflammation, with plenty of fungi in the necrotic tissue. …. Although this type of infection is reported occasionally in apparently immunocompetent hosts. Aspergillus species, or members of the class zygomycetes are the most frequent etiological agents PMID: 19544383

Physical hurt and surgery

Damage to any parts of the nose can lead to infection:

The purpose of this study was to investigate whether a delay in operative management of frontal sinus fractures is associated with increased risk of serious infections….. Retrospective chart review was performed of 242 consecutive patients with surgically managed frontal sinus fractures who presented to the R Adams Cowley Shock Trauma Center between 1996 and 2011. …. Serious infections included meningitis, encephalitis, brain abscess, frontal sinus abscess, and osteomyelitis. ….There were 14 serious infections (5.8 percent). All patients with serious infections had both involvement of the posterior table and nasofrontal outflow tract injury. The cumulative incidence of serious infection in these patients was 10.8 percent. After adjustments for confounding, multivariable regression showed that operative delay beyond 48 hours was independently associated with a 4.03-fold (p < 0.05) increased risk for serious infection; …. Antibiotic use beyond 48 hours postoperatively was not associated with fewer infections. PMID: 23806917

Broken noses from sports injuries or accidents [or fights!], as well as surgery itself can damage the nose, but what is often not realised is that it can lead the way to infection, or increased risk of later infection, because it has compromised the structure of the nose and its ability to defend itself. For example:

Asymptomatic colonization of mucous crusts within the nasal cavity, often in patients who had previous sinus surgery, has been described as saprophytic fungal infestation. The possibility of extension of this growth leading to the formation of fungal ball has been predicted PMID: 19544383

Bacterial infection

The role of bacteria in sinusitis as the major pathogen is being increasingly questioned. Although bacterial infection can be detected, research has now established that the bacteria is in many cases not the cause and instead the cause is either viral or fungal. Thus again, treating a person with antibiotics without knowing the real cause is extremely unwise.

Ponikau et al. further progressed their hypothesis by demonstrating high levels of toxic major basic protein (MBP) from eosinophils in the mucus of patients with CRS, and postulated that MBP damages the nasal epithelium from the luminal side, permitting secondary bacterial infection on the damaged epithelium. Increasingly the role of bacteria in CRS is questioned PMID: 19544383

Rhinitis, on the other hand, may have bacterial origins and the bacteria implicated include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. But again there is some question as to whether the bacterial infection is not secondary to other infection. In the first place there is a significant time lag between getting bacterial infections and the symptoms appearing:

An acute upper respiratory illness of less than approximately 7 days' duration is most commonly caused by viral illness (viral rhinosinusitis), whereas acute bacterial sinusitis becomes more likely beyond 7 to 10 days. PMID: 20176255

furthermore some of these bacteria harbour bacteriophage, which may prove to be the actual culprit.

Viral infection

Rhinitis is commonly caused by a viral infection, more so than by bacteria, thus a test is essential before anti-biotics are given. The viruses implicated include Rhinoviruses, Coronaviruses, and influenza viruses, adenoviruses, human parainfluenza viruses, human respiratory syncytial virus, enteroviruses other than rhinoviruses, metapneumovirus, and measles virus.

The following paper shows that the herpes simplex virus can also infect the nose and travel through the olfacory bulb to cause encephalitis:

Herpes simplex encephalitis (HSE), targeting the limbic system, is the most common cause of viral encephalitis in the Western world. Two pathways for viral entry to the central nervous system (CNS) in HSE have been suggested: either via the trigeminal nerve or via the olfactory tract. This question remains unsettled, and studies of viral spread between the two brain hemispheres are scarce. Here, we investigated the olfactory infection …. After nasal instillation, HSV-1 infected mitral cells of the olfactory bulb (OB) on the right side only, followed by limbic encephalitis. As a novel finding, the anterior commissure (AC) conveyed a rapid transmission of virus between the right and the left OB, acting as a shortcut also between the olfactory cortices. …. We conclude that the olfactory route and the AC are important for the spread of HSV-1 PMID: 25604497

and it is not the only virus able to do this, other viruses can also do the same thing - the olfactory bulb is generally a weak spot

Encephalitis is a hallmark of Nipah virus (NiV) infection in humans. The exact route of entry of NiV into the central nervous system (CNS) is unknown. Here, we performed a spatio-temporal analysis of NiV entry into the CNS of hamsters. NiV initially predominantly targeted the olfactory epithelium in the nasal turbinates. From there, NiV infected neurons were visible extending through the cribriform plate into the olfactory bulb, providing direct evidence of rapid CNS entry. Subsequently, NiV disseminated to the olfactory tubercle and throughout the ventral cortex. Transmission electron microscopy on brain tissue showed extravasation of plasma cells, neuronal degeneration and nucleocapsid inclusions in affected tissue and axons, providing further evidence for axonal transport of NiV. NiV entry into the CNS coincided with the occurrence of respiratory disease, suggesting that the initial entry of NiV into the CNS occurs simultaneously with, rather than as a result of, systemic virus replication. PMID: 23071900

I hope that it goes without saying that delivering any vaccine with live virus or bacteria, via the nasal route is a very unwise move given the findings of the papers above.

Treatments

Find the cause. Treat the cause not the symptoms.

Although there are a number of over the counter medicines available which treat the symptoms, they may do harm not good, as many seek to dry the runny nose - the very runny nose which is helping to get rid of the pathogens

Nasal sprays are used to deliver drugs and as local treatments for conditions affecting the nose itself such as nasal congestion and allergic rhinitis. The use of nasal sprays is increasing simply because substances can be assimilated extremely quickly and directly through the nose. They are, however, not without their problems. Please follow the link for more details.

A number of the nasal sprays used to relieve the symptoms of sinusitis, hay fever, allergic rhinitis and non-allergic (perennial) rhinitis contain corticosteroids. Corticosteroids are immunosuppressants, thus they reduce our natural defences against any pathogens that have lodged there.

Based on the available evidence, sinonasal saline irrigation …is recommended in the topical treatment of CRS. ….The evidence recommends against the use of topical antifungal therapy and topical antibiotic therapy delivered using nebulized and spray techniques in routine cases of CRS. PMID: 23044832

References and further reading

Laryngoscope. 2009 Sep;119(9):1809-18. doi: 10.1002/lary.20520. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Chakrabarti A1, Denning DW, Ferguson BJ, Ponikau J, Buzina W, Kita H, Marple B, Panda N, Vlaminck S, Kauffmann-Lacroix C, Das A, Singh P, Taj-Aldeen SJ, Kantarcioglu AS, Handa KK, Gupta A, Thungabathra M, Shivaprakash MR, Bal A, Fothergill A, Radotra BD.
J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S103-15. doi: 10.1016/j.jaci.2009.12.989. Rhinitis and sinusitis. Dykewicz MS1, Hamilos DL.
["Of snakes and crocodiles": central side effects of nose drops and facts about rhinitis medicamentosa]. Bielenberg J. Kinderkrankenschwester. 2011 Oct;30(10):406-8. German. The snakes and crocodiles refers to the hallucinations caused PMID: 22029138
Plast Reconstr Surg. 2013 Jul;132(1):154-62. doi: 10.1097/PRS.0b013e3182910b9b. Severe infectious complications following frontal sinus fracture: the impact of operative delay and perioperative antibiotic use. Bellamy JL1, Molendijk J, Reddy SK, Flores JM, Mundinger GS, Manson PN, Rodriguez ED, Dorafshar AH. 1Johns Hopkins School of Medicine, Baltimore, MD, USA.
Sci Rep. 2012;2:736. doi: 10.1038/srep00736. Epub 2012 Oct 15. Rapid Nipah virus entry into the central nervous system of hamsters via the olfactory route. Munster VJ1, et al 1Laboratory of Virology, Microscopy Unit, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA.

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