Atrophic Rhinitis

Ozena

Bastaninejad, Shahin, MD, ORL & HNS, TUMS

Amiralam Hospital

Presentation Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment

Atrophic

rhinitis

(AR) is a chronic
and

degenerative

disease of the nasal

&

paranasal

mucosa

&

structures

other

Definition (Cont)
triad of characteristic fetor, greenish
crusts and roomy nasal cavities this
triad is diagnostic of the condition
Prevalence of Primary AR 0.3-1% in high
prevalence countries
High Prevalence countries are: India,
Pakistan, China, Philippines, Malaysia,
Saudi Arabia, Egypt and South america

Definition (Cont)
Primary AR: More common in females(*6), usually
bilateral, Prevalent in young and middle age adults
Often, no underlying etiology is discovered,
discovered
although inheritable or infectious causes (58.7%
K. ozena) are proposed mechanisms
there is however little evidence to suggest
bacterial organisms cause the disease, they may
be secondary invaders

Definition (Cont)
Secondary AR:
Complication of sinus surgery (89%)
1. FESS in CRS > FESS in Polypoid CRS
2. In Mayo clinic assay : Partial MT and/or IT
resection was the most common cause

Complication of radiation (2.5%)

Following nasal trauma (1%)
Sequela of granulomatous diseases (1%) and
other infections : TB, Sarcoidosis, Leprosy,
Rhinoscleroma, Syphilis

Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment

Pathophysiology
Nl. Respiratory epithelium (Pseudostratified
Columnar) metaplastic changes
cuboidal/stratified squamous epithelium
Atrophy of cilia and the mucosal and
submucosal gland
Secondary bac. Infection produce a foetid
odour
Osteitis of inferior turbinates and ethmoid
turbinates
Vascular involvement (mainly endarteritis
obliterans)

Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment

Clinical Features (Symptoms)

Nose emits a foul smell due to crusting and
secondary infections (main characteristic).
Anosmia, cacosmia
Nasal obstruction
Headache
Thick purulent discharge with a foul smell (due to the
anaerobic bacteria)
Minor bleeds due to dislodgment of crusts
Complain of dryness in the nose and throat
(pharyngitis sicca)

Clinical Features (signs)

Greenish yellow and black crusts (Crusts
100% present), bleeding and ulcerated
mucosa is seen when crusts are separated
Patient is usually gloomy
Foetor (detected from distance)
Wide capacity of the nasal passages,
Shrinkage of inferior and middle turbinates
Insensitivity of nasal mucosa (probe test)
Septal perforation, myiasis, saddle nose &
may be seen

Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment

Differential diagnosis

TB
Leprosy
Scleroma
Syphilis
Chronic sinus suppuration on its own
Suppurating adenoidal disease
Neglected FB / rhinoliths
Wegners disease
Chronic fungal rhinosinusitis
Empty nose syndrome (ENS)

Kern &
Stenkvist
at 1994

What is ENS?

ENS is an iatrogenic disorder most often recognized by the presence of

paradoxical nasal obstruction despite an objectively wide nasal fossa

ENS vs. Secondary AR

The resorption of the turbinate and adjacent
mucosal tissue that results from atrophic rhinitis
is reflective of the underlying pathophysiology of
the disease, whereas ENS is an iatrogenic
disorder
Secondary AR may also be the result of a
multitude of other factors, including trauma,
infection, or immunologic disorders.
Atrophic rhinitis has clear pathogenic links to
organisms isolated from nasal cultures, but as of
yet, there is no pathogen associated with ENS

Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment

Investigations

Hematologic study (CBC/diff)

ESR
FBS
C-ANCA, VDRL
PPD
CXR
PNS CT-Scan
Nasal swab for culture
Nasal Bx tested for bacteriological and
morphological indices

Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment

Treatment
(Medical)
Conservative management is the

mainstay

of the treatment
No cure available
Decongestants

or

antihistamines:

contraindicates
Nasal irrigation and douches:
With Alkaline douches (preferred)
With N/S or antibiotic+N/S douches

strongly

Treatment (Medical)

An ideal alkaline nasal douche mixture:

1. Sodium bicarbinate

25g

2. Sodium biborate

25g

3. Sodium chloride

50g

One teaspoonful of this mixture in 250cc

lukewarm water, tds or qid, for 6wk, with a 10 to
20cc syringe
Instruct the patient to bend forward during the
procedure and keep saying K K K

Treatment (Medical)
Glucose-glycerine nose drops
1. Anhydrous Glucose 25% (~15 )
g

2. Glycerine 60cc

Use this after nasal douching

You

can

also

Chloramphenicol
douching, too

use
drops

Gentamicin
after

or

nasal

Treatment (Medical)
Antibiotics:
Rifampicin 600mg daily for 12wk (generic cap.
is 300mg take 2 every morning)
Recently: Cipro 500-750mg bid for 1-3mo

Vitamin A , 12,500 IU/day up to two

weeks.
Iron supplements

(if the patient is anemic)

Treatment (Surgical)
1) Youngs Procedure
2) Modified Youngs procedures
3) Modification of modified Young
4) Implantation
5) Other approaches

Treatment (Surgical)
Youngs procedure
Circumferential flap elevation 1 cm cephalic to the
alar rim
Complete closure of nostril
Staged second side in 3-6 months
Difficult to elevate circumferential flap

Modified Young

Staged second side with first side takedown

in 6 mo
No vestibular stenosis on takedown

Treatment (Surgical)
Modification of the modified youngs:

Treatment (Surgical)
Implantation:
Implantation

uses

Bone

(Auto/homografts), Cartilages, ... Prostethic

implants such as Plastipore, ...
Extrusion of the prosthetic implants occured
1 in 8 in Plastipore series, but in another
prosthetic series it was occured as high as
80%

Plastipore

Silastic Sheet - Case: Primary AR - 12mo postop result

(OtolaryngologyHead and Neck Surgery (2010))

Right

Left

Treatment (surgical)
Other approaches:
Transferring the Stensen duct to the maxillary
sinus antrum
Using a caldwell approach, translocating the
lateral nasal wall more medially
Silastic obturator
...

Presentation Conclusion

Endoscopic Sinus Surgery

2nd Atrophic Rhinitis

Primary Atrophic Rhinitis

Functional Endoscopic Sinus Surgery

...Try to save nasal structures and mucosal layer as much as you can