Dr. Davis Thomas

Atrophic Rhinitis

Definition• Atrophic rhinitis is defined as a chronic nasal disease

characterised by progressive atrophy of the nasal mucosa along with the underlying bones of turbinates.

• There is also associated presence of viscid secretion which rapidly dries up forming foul smelling crusts.

• This fetid odour is also known as ozaena. • The nasal cavity is also abnormally patent. • The patient is fortunately unaware of the stench emitting

from the nose as this disorder is associated with merciful anosmia.

AetiologyThe etiology of this problem still remains obscure.

Numerous pathogens have been associated with this condition, the most important of them are

• 1. Coccobacillus, • 2. Bacillus mucosus, • 3. Coccobacillus foetidus ozaenae,• 4. Diptheroid bacilli and • 5. Klebsiella ozaenae.

These organisms despite being isolated from the nose of diseased patients have not categorically been proved as the cause for the same.

TYPES OF ATROPHIC RHINITISPRIMARY ATROPHIC RHINITIS diagnosis of exclusionCAUSES:1. Hereditary2. Endocrine dysfunction3. Racial 4. Reflex sympathetic dystrophy syndrome5. Nutritional deficiency6. Autoimmune

SECONDARY ATROPHIC RHINITIS

CAUSES1. Iatrogenic - surgery (commonest)2. Trauma3. Radiation4. Granulomatous diseases5. Infection

COMMONEST CAUSE OF UNILATERAL ATROPHIC RHINITIS

GROSSLY DEVIATED SEPTUM

MECHANICAL THEORY OF ZAUFAL – It states that skeletal defects due to gross septal deviation to one side leads to unilateral atrophic rhinitis on the roomy side.

Pathology:1. Metaplasia of ciliated columnar nasal epithelium into

squamous epithelium.2. There is a decrease in the number and size of compound

alveolar glands3. Loss of cilia4. Atrophy of nerves5. Fibrosis of lamina propria

Type Iis characterised by the presence of endarteritis and

periarteritis of the terminal arterioles. This could be caused by chronic infections. These patients benefit from the vasodilator effects of

oestrogen therapy.

Type II is characterised by vasodilatation of the

capillaries, these patients may worsen with estrogen

therapy.

They also showed a positive reaction for alkaline phosphatase suggesting the presence of active bone resorption.

Triad of Atrophic Rhinitis

1. Fetor 2. Crusting 3. Atrophy.

Clinical features:Nasal obstruction - crust formation atrophic nerve endingsThick crustsEpistaxisAnosmiaOffensive smell perceived by othersHeadacheImpairment of hearingAssociated changes in pharynx & larynx

Clinical examinationClinical examination of these patients show that their

nasal cavities filled with foul smelling greenish, yellow or black crusts,

the nasal cavity appear to be enormously roomy. When these crusts are removed bleeding starts to occurSeptal perforations &external deformity

Why nasal obstruction even in the presence of roomy nasal cavity?

• The nasal cavity is filled with sensory nerve endings close to the nasal valve area.

• These receptors sense the flow of air through this area thus giving a sense of freeness in the nasal cavity.

• These nerve endings are destroyed in patients with atrophic rhinitis thus depriving the patient of this sensation.

• In the absence of these sensation the nose feels blocked.

INVESTIGATIONS

ROUTINE BLOOD & URINE INVESTIGATIONS

To R/O underlying causes

Radiographic findingsLateral bowing of nasal wallsThin or absent turbinates Hypoplastic maxillary sinuses

CT scan findings1. Mucoperiosteal thickening of paranasal sinuses2. Loss of definition of osteomeatal complex due to

resorption of ethmoidal bulla and uncinate process3. Hypoplastic maxillary sinuses4. Enlargement of nasal cavity with erosion of the lateral

nasal wall5. Atrophy of inferior and middle turbinates

Conservative Treatment1.Nasal douching - The patient must be asked to

douche the nose atleast twice a day with a solution prepared with:

Sodium bicarbonate - 28.4 gSodium biborate - 28.4 gSodium chloride - 56.7 g

mixed in 280 ml of luke warm water.

The crusts may be removed by forceps or suction. 2. 25% glucose in glycerin drops can be applied to the

nose thus inhibiting the growth of proteolytic organism.

Conservative• In patients with histological type I atrophic rhinitis

oestradiol in arachis oil 10,000 units/ml can be used as nasal drops.

• Kemecetine antiozaena solution - is prepared with chloramphenicol 90mg, oestradiol dipropionate 0.64mg, vitamin D2 900 IU and propylene glycol in 1 ml of saline.

• Potassium iodide can be prescribed orally to the patient in an attempt to increase the nasal secretion.

• Systemic streptomycin injection

• Systemic use of placental extracts have been attempted with varying degrees of success.

Surgical treatmentAims - to narrow the widened nasal cavity - diminish drying and crust formation - rest the mucosa and allow regeneration

Surgical management1. Submucous injections of paraffin, .2. Recently teflon strips, and autogenous

cartilages have been inserted along the floor and lateral nasal wall after elevation of flaps.

3. Wilson's operation - Submucosal injection of 50% Teflon in glycerin paste.

4. Witmack’s operation – rerooting of parotid duct

5. Lautenslager’s operation – medialisation of lateral wall

6. Repeated stellate ganglion blocks have also been employed with some success

7. Young's operation• This surgery aims at closure of one or both nasal

cavities by plastic surgery.• After a period of 6 to 9 months when these flaps

are opened up the mucosa of the nasal cavities have found to be healed.

• This can be verified by postnasal examination before revision surgery is performed.

8.Modifications of this procedure has been

suggested (modified Young's operation) where a 3mm hole is left while closing the flaps in the nasal vestibule. This enables the patient to breath through the nasal cavities

COMPLICATIONS

EpistaxsisSaddle nose deformityMyiasisMeningitisAnosmia

Rhinosporidiosis

It is a chronic granulomatous fungal disease of the nose caused by Rhinosporidium Seeberi/ Kinealyi.

Mode of Transmission:1. Exact mode is not known.2.Acquired by swimming in contaminated ponds.3.Inhaling the dust of dried cowdung.Malignant:- Deep seated and multiple, spreading

through systemic route. Generalised Rhinosporidiosis.

Incidence:- 95% from India & SrilankaMale: Female – 2:1Tamil Nadu – Hyperendemic areas –

madurai & Ramnad, Thirumangalam, Rajapalayam, Sivagangai (Large Ponds)

Affects –Nasal mucosa, Conjunctiva, Sclera, Tonsils, Genitalia and Skin

Trauma – Predisposing factor – infective spores enter through traumatised nasal mucosa and multiply in the submucosa forming sporangia.

Spores are discharged into tissues and cause reactive hyperplasia and lead to formation of vascular mass.

CLASSIFICATION – Anatomical Sites 1. Nasal (78%)

a. Mucous membrane of septumb. Spur in nasal floorc. Lateral wall

2. Nasopharyngeal (16%)a. Upper aspect of palate

3. Mixeda. Naso – nasopharyngeal (6.3%)b. Ethmoido – nasopharyngealc. Naso – lacrimal

4. Bizareea. Conjuntivalb. Tarsalc. Cutaneousd. Laryngeal

LIFE CYCLE – Ashworth (1923), Karunaratne (1964)

• Earliest stage ( Trophic stage or Trophocyte)

• Round or oval cell – Chitinous wall – smaller – RBC –vacuolated cytoplasm – vasicular nucleus – nucleolus

• First division – 50 µ - mitotic

• Cellulose layer – trophocyte - 100µ

• Free nuclei 2000 – sporangium – cytoplasm cleavage – spore -150µ - 1000 spores

• 8–16 spherical bodies – Feulgen pasitive material (Spherules)

• 250µ –300µ - sporangia ruptures

• Spherule – lipoprotein coat – protein matrix

Staining MethodSpherule is made up of liproprotein coat with

protein matrix and feulgen positive centreBromophenol blue – spherulesBismark brown – wall of spherulesSudan black B – Lipoprotein coat.

Clinical FeaturesSymptoms Nasal ObstructionNasal dischargeEpistaxisItchingSigns AR – An irregular, friable, red, granular mass

studded with sporangia showing as white spots, usually pedunculated.

InvestigationsRoutine Blood and Urine investigations.Histamine level to be estimated – Histamine

content of Rhinosporidiosis is increased so proliferates quickly and bleeds profusely.

X-Ray PNS.Microscopic (KOH) examination of nasal

discharge.DNE.HPE.

TreatmentWide excision of the mass along with basal

cautery.Dapsone 100 mg daily to prevent recurrence

(arrest the maturation of spores). Side effects – Methaemoglobinemia HepatotoxicityRecurrence – 1) Incomplete removal 2) Submucosal presence of spores 3) Multiple sites.

Rhinoscleroma

It is a chronic granulomatous disease of the nose, caused by Gram negative, non motile, encapsulated, diplobacillus, Klebsiella Rhinoscleromatis (Frisch Bacillus).

Site – Nose, nasopharynx, oropharynx, larynx, trachea and bronchi.

Common in females.Predisposing factors – Poor hygiene and low

socio economic status.

Pathogenesis:Droplet infection

Clinical features:1) Atrophic stage.2) Granulomatous stage – Tapir Nose (Subdermal

infiltration of the nodules in lower part of nose & upper lip giving a woody feel).

3) Cicatricial stage – Hebra Nose (Scarring, enlargement & disfigurement of the nose).

Histology

Mikulicz cells – Presence of scattered large foam cells with a central nucleus and vacuolated cytoplasm containing the bacilli.

Russel bodies – Plasma cells with eosinophilic, homogenous inclusion bodies .

Investigations

Biopsy & HPECulture of the organism in Mc-conkey agar

medium and staining by PAS and Giemsa stains.

X Ray skull lateral view – ‘V’ shaped soft palate attachment – Palatal sign – Gothic arch deformity

Treatment

Tetracycline – 6 weeksSteroids – prevent recurenceExcision of cicatrized tissue.

Rhinitis Medicamentosa

The prolonged usage of Sympathomimetic nasal decongesant drops and sprays leads to Tachyphylaxis resulting in rebound vasodilatation & engorgement of nasal mucosa leads to nasal obstruction.

Rhinitis Sicca :It is a form of rhinitis characterised by

dryness of nose, limited to the anterior part of nasal cavity. It occurs in people who work in hot and dry surroundings.

Rhinitis Caseosa:It is a chronic nasal disease characterized by

the presence of caseous cholesteatoma like material with granulations in the nose. It is also called nasal cholesteatoma.

Stewart’s Granuloma

It is also called peripheral sinonasal T-cell lymphoma.

It presents as an indurated swelling of the nose, nasal vestibule and septum.

HPE – dense collection of cells especially lymphocytes.

Treatment : Radiotherapy.

Wegener’s GranulomaIt is an autoimmune disease of unknown

aetilogy characterised by necrotising granuloma and vasculitis of the upper and lower airways, systemic vasculitis and focal necrotising glomerulonephritis.

Diagnosis by nasal biopsy.Treatment : Saline nasal douching Cyclophosphamide 1-2

mg/kg/day High dose of steroids.

TuberculosisSyphilisLeprosy

RHINOLITHSynonym – nasal calculus

Defined as concretion or calcareous mass in the nose

PathogenesisNeglected foreign body/ blood clot / inspissated mucus -nidus ↓Granulations formation ↓Calcium, mg CO 3 or PO4 gets deposited ↓Hard rhinolith ↓Enlarges & nerosis of septum

CLINICAL FEATURES

Unilateral nasal dischargeNasal obstructionOccasional epistaxis Sometimes asymptomaticAR – irregular , grey or greyish black mass

along the floorOn probing – gritty sensation

Diagnosis - History , examination - X- ray PNS

Treatment surgical excision – endoscopic lateral rhinotomy

NASAL MYIASISSYNONYM – maggots in the nose

Suppurative conditions of nose / unhygenic living condition

↓ attracts flies – chrysomiya , lay eggs ↓ hatch & grow into larvae ↓Crawl into nasal cavity & surrounding regions

Predisposing factors

atrophic rhinitis chronic suppurative rhinosinusitis syphilis & leprosy fungating malignant masses

Clinical featuresIrritation of noseWatering of eyesSwelling & puffiness of eyelids, lipsThin blood stained nasal discharge to

epistaxsisFoul smellFormication – Crawling sensation in the nose.AR- multiple maggots with purulent, foul

smelling nasal discharge

complicationsDestruction of surronding structures – nose ,

palate , orbitInhalation into tracheobronchial treeIntracranial spreadPsychological

TreatmentHandpicked with nasal dressing forcepsInstillation of 25% chloroform or turpentine

oilDouching with warm salineTreat complicationsTreat underlying cause

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