Atrophic Rhinitis
Prof. Dr. Krishna Koirala
Questions
• Define Atrophic Rhinitis. What is the hallmark
of this condition? Write down its types.
• Write down the clinical features and
investigations of atrophic rhinitis.
• Discuss the medical and surgical treatment of
atrophic rhinitis.
• PBQ
• Defined as chronic inflammation of
nose characterized by progressive
atrophy of nasal mucosa, including
the glands, turbinate bones and the
nerve elements supplying the nose
• Hallmark: formation of scanty viscid
secretion & greenish crusts which
emit a foul odour (ozaena)
• Removal of crusts reveals roomy nasal
cavity
• Types
− Primary
− Secondary
Primary Atrophic rhinitis
• Etiology:
− Hereditary : autosomal inheritance in 30% cases
− Developmental: congenital roomy nasal cavity,
poor pneumatization of maxillary antrum
− Endocrine : Seen during puberty, menopause,
menstruation (symptoms aggravate due to
estrogen deficiency)
− Racial : More in American Negroes & Latin
(yellow race)
− Nutritional deficiency : Iron, Vitamin A, Vitamin D
• Infection : Klebsiella ozaenae (Perez & Abel
bacillus), Coccobacillus foetides ozaena, Bacillus
mucosus, Diphtheroids, Haemophilus influenzae
• Autoimmune : Viral infection / malnutrition /
immune deficiency trigger destructive autoimmune
process on nasal mucosa
• Autonomic Imbalance : Reflex Sympathetic
Dystrophy Syndrome (R.S.D.S.) causes
vasodilatation & hyperemic decalcification of
turbinates followed by vasoconstriction
• Surfactant deficiency in nasal secretion
− Ciliary dysfunction + stasis of nasal secretions
Secondary Atrophic Rhinitis
• Long-standing purulent sinusitis
• Iatrogenic:
− Radical turbinectomy, post - RT
• Granulomatous lesions:
− Tuberculosis, syphilis, leprosy,
rhinoscleroma
• Deviated nasal septum (atrophy in
wider nasal cavity)
Symptoms
• Nasal obstruction
• Greenish -yellow nasal discharge
• Offensive smell (ozaena) due to anaerobic
infection, experienced by relatives but not
by the patient (Merciful anosmia)
• Bleeding on crust removal
Signs
• Roomy nasal cavity with atrophy of
mucosa & turbinates
• Greenish-yellow nasal discharge with
crust formation (begins from
posteriorly)
• Foul smell (fetor)
• Nasal Myiasis may be present
Nasal crusting
Turbinate atrophy & roomy nasal
cavity
D/D for ozaena D/D for dry nose
1. Atrophic rhinitis 1. Atrophic rhinitis
2. Purulent sinusitis 2. Rhinitis sicca
3. Nasal foreign body 3. Radiotherapy
4. Rhinitis caseosa 4. Sjogren’s syndrome
5. Malignancy
• Causes of Anosmia
− Loss of olfactory neural elements
− Thick secretion & crusts over olfactory area
− Degeneration of secretary glands scanty
mucus for dissolving odoriferous materials
• Causes of nasal obstruction
− Blunting of sensory nerve endings
− Crust formation
− Lack of eddy current formation in roomy
cavity
Pathology
• Accumulation of lymphocytes & plasma cells
• Metaplasia from ciliated columnar to squamous
epithelium
• Ciliary destruction & decrease in number & size of
nasal glands
• Bone resorption
• Type I: Endarteritis & periarteritis of terminal
arterioles :benefit from vasodilator effect of
estrogen therapy
• Type II: Dilated capillaries : worsened by
estrogen
Specific Investigations
• Saccharine test : nasal muco- ciliary
clearance time
• Serum iron & protein levels: malnutrition
• Culture & sensitivity of nasal discharge
• X-ray P.N.S. : maxillary sinusitis
C.T. Scan Nose and P.N.S.
• Mucosal thickening
• Resorption of ethmoid
bulla & uncinate
process
• Hypoplasia of maxillary
sinuses
• Roomy nasal cavities
• Erosion & bowing of
lateral nasal wall
• Atrophy of turbinates
• Chest X-ray: T.B., bronchiectasis, lung
abscess
• Serology for syphilis: V.D.R.L., T.P.H.A., T.P.I.
• Sputum for AFB, Mantoux test: T.B.
• Nasal smear study: leprosy
• Complement fixation test & biopsy:
Rhinoscleroma
Medical
Treatment
• Douching alkaline nasal douche
• Oestradiol nasal spray (1%) /Placental extract
injection (increase the vascularity of nasal
mucosa, regenerates the submucosal glands)
• Glucose (25%) in glycerin nasal drops
• Streptomycin injection /Rifampicin tablet :
Effective against Klebsiella
• Kemicetine anti-ozaena nasal solution : contains
chloramphenicol, estradiol dipropionate, Vit D, propylene glycol
• Mandl’s nasal paint (Potassium Iodide &
estradiol)
• Potassium Iodide orally (liquifies the crusts)
Alkaline Nasal Douche
Sodium bicarbonate (28.4g) loosens nasal crusts
Sodium biborate (28.4g) Antiseptic
Sodium chloride (56.7g) makes solution isotonic
• Mixed in 280 ml of warm water to make the solution
• 5 cm long no.8 infant feeding tube fitted in 20 ml
plastic syringe
• Syringe the nasal cavity by bending forward & keep
saying K, K, K … to close nasopharyngeal isthmus
• Done twice daily till all crusts disappear
Surgical
Treatment
Aim of Surgery
• Decrease trauma of air turbulence (decrease the
roomy cavity)
− Young , Modified Young ,Lautenslager's ,Wilson ,
Sublabial implants ,Vestibuloplasty
• Increase nasal secretions
− Parotid duct implantation into maxillary sinus
• Increase vascularity of nasal mucosa
− Cervical sympathectomy
− Nasal implantation of maxillary sinus mucosa
• Young’s operation:
− Only 1 nostril closed completely by
raising 2 circumferential flaps (inner
mucosal & outer cutaneous) in nasal
vestibule & suturing them in midline
• Modified Young’s operation
− Done by similar way but keeping a 3 mm
opening on both sides
• Recanalization done after 12-18 months
with a tri-radiate (Mercedes Benz) incision
Pre-operative
Mucosal flaps sutured
Cutaneous flap sutured
Post-operative healed flaps
Tri-radiate incision
Modified Young’s operation
Advantages of Modified Young
operation
• Progress of disease can be monitored
with 2.7 mm nasal endoscope
• Glucose in glycerin drops can be instilled
• Both nostrils can be operated at one
sitting
• Nasal breathing preserved
• No complaints of de-nasal voice
• Better cosmetic result
• Lautenslager’s operation: Fracture &
medial displacement of lateral nasal wall
• Wilson’s operation: submucosal injection
of Teflon paste
• Antral mucosal transplantation into nasal
cavity through intranasal antrostomy
• Vestibuloplasty: raising a lateral shelf
from nasal vestibular flap to cover the
turbinates
Pre-operative
Lautenslager’s operation
Submucosal Teflon paste
Antral mucosal transplant
Ventriculoplasty
• Sympathectomy
−Stellate ganglion block /cervical chain
block
• Sublabial implantation
−Placental bits, bone, cartilage, fat, acrylic
resin, teflon, Silastic
• Parotid duct implantation into maxillary
sinus : Wittmack’s operation
Action of Placental extract
• Progesterone leads to hyperplasia of nasal
mucosa & glandular secretion
• Estrogen leads to vasodilatation
• Biogenic stimulator of metabolic &
regenerative process
• Intra-placental serum boosts up immunity
• Mechanical narrowing of nasal passage