ATROPHIC RHINITIS
DR SAJID RASHID NAGRA
MBBS MCPS FCPS
ENT, HEAD & NECK SURGEON
Synonyms:
• OZAENA
• MERCIFUL ANOSMIA
• DRY RHINITIS
DEFINITION
CHRONIC INFLAMMATORY DISEASE
ATROPHY
HISTORY
• Dr. Spencer Watson(1875)
• Dr. Bernhard Fraenkel(1876) : TRIAD of
atroph
y
fetor
crusts
Atrophic Rhinitis
Dr. Francke Bosworth. A Manual of
Diseases of the Nose and Throat. 1881.
“The breath is often so
penetrating as to render the near
presence of the sufferer not only
unpleasant but almost
unendurable.”
ETIOLOGICAL TYPES
•PRIMARY ATROPHIC
RHINITIS
•SECONDARY ATROPHIC
RHINITIS
ATROPHIC RHINITIS (OZAENA)
Chronic inflammation of nose
characterized by atrophy of nasal mucosa
and turbinate bones.
Primary atrophic rhinitis :
Aetiology : Exact cause is not known.
Various theories regarding its causation are:
a. Hereditary factors
b. Endocrinal disturbances :
Starts puberty,
Involves females more than males,
Tends to cease after menopause.
c. Racial factors – White.
d. Nutritional deficiency : Deficiency of
vitamin A, D or iron.
e. Infective : Klebsiella ozaenae, (Perez
bacillus), diphtheroids, [Link],
Esch. Coli, Staphylococci and
Streptococci but they are all
considered to be secondary
invaders.
f. Autoimmune process : The body
reacts by a destructive process to
the antigens released from the nasal
mucosa.
CAUSES OF PRIMARY ATROPHIC
RHINITIS
HERNIA
HERNIA
HEREDITY
HERNIA
ENDOCRINAL
DISTURBANCE
HERNIA
RACIAL FACTORS
HERNIA
NUTRITIONAL DEFICIENCY
HERNIA
INFECTIVE
HERNIA
AUTOIMMUNE
PROCESS
SECONDARY ATROPHIC
RHINITIS
[Link] specific infections
Lupus
vulgaris
syphilis
leprosy
SECONDARY ATROPHIC
RHINITIS
2. Extensive surgery of the nose
(turbinectomy)
SECONDARY ATROPHIC
RHINITIS
3. Severe deviated nasal
septum
Pathology
Ciliated columnar epithelium is
replaced by stratified squamous type.
Atrophy of seromucinous glands,
venous sinusoids and nerve elements.
Obliterative endarteritis.
The bone of turbinates undergoes
resorption.
Paranasal sinuses are small.
PATHOLOGY:
• Microscopic changes
NORMAL
squamous metaplasia
Absence of cilia
Atrophy of
muscosal
glands
Normal Atrophy of nerve endings
and olfactory nerve
Type 1: charecterised by
endarteritis and periarteritis of
terminal arterioles
-result of chronic infection
- benefits from vasodilator
effect of oestrogen therapy
Type 2: vasodilatation of
capillaries
- which might be made
SYMPTOMS
Clinical features
Commonly seen in females and starts around
puberty.
Foul smell from the nose.
Marked anosmia (merciful anosmia)
Nasal obstruction
Epistaxis when the crusts are removed.
Nasal cavity full of greenish or greyish black dry
crusts.
Nasal cavities appear roomy due to resorption or
absence of turbinates
Nasal mucosa appear pale & Squamous metaplasia
Septal perforation and dermatitis of nasal vestibule.
Nose shows saddle deformity.
Why nasal obstruction even in the
presence of roomy nasal cavity?
Why nasal obstruction even in the
presence of roomy nasal cavity?
PARADOXICAL NASAL
OBSTRUCTION
SIGNS :
EXTERNAL NOSE:
SIGNS :
ANTERIOR RHINOSCOPY:
ATROPHIED
TURBINATES
GREENISH
FOUL
SMELLING
CRUSTS
PALE & ATROPHIC
MUCOSA
Radiological findings
• Mucoperiosteal thickening of paranasal s
inuses
• Loss of definition of osteomeatal complex
• Enlargement of nasal cavity with erosion
and bowing of the lateral nasal wall
• Atrophy of inferior and middle turbinates
• Hypoplastic maxillary sinuses
• Bony resorption and mucosal atrophy of
the inferior and middle turbinates.
Biopsy Findings
Normal Mucosa
Pseudostratified
Columnar
Presence of serous
and mucous glands
Atrophic Rhinitis
Squamous
metaplasia
Atrophy of mucous
glands
Scarce or absent
cilia
Endarteritis
Microbiology
Klebsiella ozenae
May be found in almost 100% of primary
AR
No predominance in secondary AR
Staphylococcus aureus
Proteus mirabilis
Escherichia coli
Corynebacterium diphtheriae
Differential diagnosis
Differential diagnosis
Current Therapies
Goals of therapy
Restore nasal hydration
Minimize crusting and debris
Therapy options
Topical therapy
Saline irrigations
Antibiotic irrigations
Systemic antibiotics
Implants to fill nasal volume
Closure of the nostrils
Prognosis :
Disease persists for years
Treatment :
1. Medical :
a. Nasal irrigation and removal of crusts.
b. 25% glucose in glycerine. – Inhibits the
growth of proteolytic organisms which are
responsible for foul smell.
c. Local antibiotics –
KemicetineTM antiozaena solution
contains chloromycetin, oestradiol and
vitamin D2.
d. Oestradiol spray – increase vascularity
of nasal mucosa and regeneration of
seromucinous glands.
e. Placental extract injected
submucosally.
f. Systemic use of streptomycin –
reducing crusting and odour. Effective
against Klebsiella organisms.
g. Potassium iodide by mouth promotes
and liquefies nasal secretion.
ALKALINE NASAL DOUCHE
Sodium biborate (28.4 g)
Sodium carbonate (28.4 g)
Sodium chloride (56.7 g)
mixed in 280 ml of luke warm water.
Nasal drops
• 25% glucose in glycerine
Chloramphenicol & oetradiol spray
streptomycin drops
Kemicetine(local antibiotic)
Placental Extracts
Potassium iodide
Systemic :
• Streptomycin (1 g/day)
• Vitamin A
• Vasodilators
Surgical therapies
Young procedure
Modified Young procedure
Turbinate reconstruction
Volume reduction procedures
Denervating operations
2. Surgical
a. Young’s operation
Both the nostrils are closed completely just within
the nasal vestibule by raising flaps. They are
opened after 6 months or later.
Modified young’s operation
Aims to partially close the nostrils.
Nasal Closure
Young’s procedure
Circumferential flap elevation 1 cm cephalic to the alar
rim.
Sutures placed in center of elevated flap to close the
nostril
Staged second side in 3 months
Advantages
Often provided relief of symptoms
Disadvantages
Difficult to elevate circumferential flap
Breakdown of central suture area common
Does not allow for cleaning
Did not allow for periodic examination
Recurrence after flap takedown
Young. “Closure of the nostril in atrophic rhinitis.” Journal of
Laryngology and Otology, 81: 515-524.
Nasal Closure
Modified Young’s
Elevation of extended perichondrial flap through
contralateral hemitransfixion incision.
Short skin flap elevated from the intercartilaginous line
on the ipsilateral side.
Suture lateral and medial flaps with vicryl.
Staged second side with first side takedown in 6 mon.
Advantages
Technically easier than Young procedure
No suture line breakdown
No vestibular stenosis on takedown
Disadvantages
Not possible with large septal defects
Does not allow for cleaning
Does not allow for periodic examination
Recurrence after flap takedown
El Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial flap for
closure of nostril in atrophic rhinitis.” Rhinology, 36, 202-203, 1998.
a. Narrowing the nasal cavities. Among the
techniques followed, some are :
Submucosal injection to teflon paste.
Insertion of fat, cartilage, bone or teflon
strips under the mucoperiosteum of the floor
and lateral wall of nose and the
mucoperichondrium of the septum.
Section and medial displacement of lateral
wall of nose
Young’s operation
Quick note for treatment of atrophic rhinitis
ATROPI In Young Girls
A- antibiotic spray
T- teflon paste
R- remove crust
O- oetradiol therapy
P-potassium iodide ,placental extracts
I- irrigation
In- insertion of fat,cartilage
Y- young’s operation
G-glucose in glycerine
Secondary Atrophic Rhinitis
Secondary
Complication of sinus surgery (89%)
Complication of radiation (2.5%)
Following nasal trauma (1%)
Sequela of granulomatous diseases (1%)
Sarcoid
Leprosy
Rhinoscleroma
Sequlae of other infectious processes
Tuberculosis
Syphilis
Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.
UNILATERAL ATROPHIC RHINITIS
Extreme deviation of nasal septum
Atrophic rhinitis on the wider side.
Complications
Differential diagnosis