Atrophic Rhinitis Alan L. Cowan, M.D.
Faculty Advisor: Matthew Ryan, M.D.
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
March 30, 2005
Atrophic Rhinitis
Common Terms
Ozena
Dry Rhinitis
Rhinitis Sicca
Atrophic Rhinitis
Dr. Spencer Watson. Diseases of the nose and its associated cavities. London, 1875. 1) Accidental or Simple Ozoena
“due to the retention of mucous.” “easily dealt with by the frequent employment of the nasal douche
…”
2) Idiopathic or constitutional “commences in early childhood ... And remains during the early
years or throughout the whole adult life.” “The patient is generally anosmic … and he is, therefore, unaware
of the offensive odor of his breath.” “The nature of the inflammatory process is very probably allied to
that of lupus erythematosus of the face.”
3) Syphilitic Ozoena “the most common form” “These ulcers may be preceded or followed by caries or necrosis of
the bones, and the stench is then more horribly sickening than in any other form of this disgusting malady.”
Atrophic Rhinitis
Described in 1876 by Dr. Bernhard Fraenkel as a triad of: Fetor
Crusting
Atrophy of nasal structures
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.”
Atrophic Rhinitis
Clinical Features Anosmia
Ozena, i.e. foul odor
Extensive nasal crusting
Subjective nasal congestion
Enlargement of the nasal cavity
Resorption or absence of turbinates
Squamous metaplasia of nasal mucosa
Depression
Atrophic rhinitis
Primary
History of prior sinus surgery, radiation, granulomatous disease, or nasal trauma are exclusions.
Primary AR is rare in the US
Most cases are reported in China, Egypt, and India
Microbiology of primary AR is almost uniformly Klebsiella ozenae.
Radiographic and clinical features similar to secondary AR.
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.
Surgical causes
Based on review of 242 cases from Mayo Clinic. Procedures per patient
2.3
Partial middle or inferior turbinectomy 56%
Total middle and inferior turbinectomy 24%
No turbinectomy 10%
Partial maxillectomy 6%
Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.
Other suggested causes
Infectious (Ssali) Case report of AR developed in 7 children of one family after contact with another known AR
child.
Dietary (Bernat) Iron therapy found to benefit 50% of patients treated (Han-Sen) Hypocholesterolemia present in 50% of patients. (Han-Sen) Vitamin A therapy showed symptomatic improvement in 84%.
Hereditary (Barton, Sibert) Proposed autosomal dominant disease due to father and 8 of 15 children contracting the
disease.
Hormonal Symptoms known to worsen with menstraution or pregnancy.
Developmental (Hagrass) Radiologic evidence of poor maxillary antrum pneumatization and short nasal lengths
Vascular (Ruskin) Postulated overactivation of sympathetic activity.
Environmental (Mickiewicz) Chronic exposure to phosphorite and apatide dust
Autoimmune (Ricci)
Physical findings
Crusting 100% Present
Inferior Turbinates 62% Partial absence 37% Total absence
Middle Turbinates 57% Absent
Discharge 52% Present
Septum 10% Perforations
Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.
Radiographic Findings
1. Mucoperiosteal thickening of the paranasal sinuses.
2. Loss of definition of the OMC secondary to resorption of the ethmoid bulla and uncinate process.
3. Hypoplasia of the maxillary sinuses.
4. Enlargement of the nasal cavities with erosion and bowing of the lateral nasal wall.
5. Bony resorption and mucosal atrophy of the inferior and middle turbinates.
Pace-Balzan, Shankar, Hawke. J Otolaryngol 1991; 20:428-32.
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 obliterans
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
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
Local therapy
Irrigations Saline Mixtures
Sodium bicarbonate Shehata: Sodium Carbonate 25g, Sodium Biborate 25g, and Sodium
Chloride 50g in 250ml water.
Antibiotic solution Moore: Gentamycin solution 80mg/L
Anti-drying agents Glycerine Mineral Oil Paraffin with 2% Menthol
Other Acetylcholine Pilocarpine
Systemic therapy
Oral antibiotics Tetracycline Ciprofloxacin Aminoglycosides Streptomycin injections
Medication avoidance Vasoconstrictors Topical steroids *
Other Vitamin A (12,500 to 15,000 Units daily) Potassium Iodide (Increases nasal secretions) Vasodilators Iron therapy Estrogen Corticosteroids *
Vaccines Antibacterial (Pasturella, Bordetella) Autogenous
Surgical therapies
Young procedure
Modified Young procedure
Turbinate reconstruction
Volume reduction procedures
Denervating operations
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.
Modified Young
Volume reduction
Plastipore implantation Porus material allows tissue ingrowth. Implants shaped then fenestrated for ingrowth. Implants placed submucosally along the septum and
nasal floor.
Advantages Easier than other surgical options (Young’s) Plastipore has low extrusion/complication rate May be done under local anesthesia
Disadvantages Possibility of extrusion (occurred in 1/8 pts) Requires septal mucosa (not discussed)
Goldenberg, Danino, Netzer, Joachims. Oto HNS, Vol. 122 (6). pp. 794-97.
Plastipore
Volume Reduction (cont)
Triosite and Fibrin Triosite (60% hydroxyapetite, 40% calcium triphosphate) mixed
with Fibrin 1:1.
Deglove the labial vestibule
Elevate periosteum of the floor posteriorly to the end of the hard palate, extend medially onto the septum.
Insert Triosite & Fibrin mixture (~3.3g per side)
Advantages Good to excellent result (7/9 patients)
Material can be molded easily
Disadvantages Leakage of material (4/9 patients)
Infection of material (3/9 patients)
Potential damage to lacrimal system
Bertrand, Doyen, Eloy. Laryngoscope 106: May 1996. p 652-57.
Triosite and Fibrin
Bertrand, Doyen, Eloy. Laryngoscope 106: May 1996. p 652-57.
Triosite and Fibrin
Other Therapies
Non-surgical nasal closure Nasal vestibule impressions taken similar to hearing aid moulds.
Impressions are used to create a silastic obturator.
Advantages Reversible
Easily removed
Allows for irrigations
Allows for serial clinical exams
Avoids surgical morbidity
Disadvantages May be uncomfortable
May cause sore throat due to obligate mouth breathing.
Lobo, Hartley, Farrington. J of Laryn and Oto. June 1998, Vol 112, p 543-46.
Nasal Obturator
Other Therapies
Other Implants Acrylic Silicone Teflon Silastic Boplant
Denervation Cervical sympathectomy (Bertein) Stellate ganglion block (Bahl) Sphenopalatine ganglion block (Girgis) Parasympathectomy, i.e. GSPN section (Krmptotic)
Salivary Irrigation Involves reimplantation of parotid duct into the maxillary sinus
Accupuncture Time
Disease often resolves spontaneously after age 40
Bibliography Lobo, Hartley, Farrington. “Closure of the nasal vestibule in atrophic rhinitis
– a new non-surgical technique.” The Journal of Laryngology and Otology. June 1998, Vol. 112, pp. 543-46.
Moore, Kern. “Atrophic Rhinitis: A Review of 242 cases.” American Journal of Rhinology. November-December 2001, Vol. 15, No. 6, p 355-61.
Shehata. “Atrophic Rhinitis.” American Journal of Otolaryngology, Vol. 17, No. 2. March-April, 1996: pp 81-86.
Chand, MacArthur. “Primary atrophic rhinitis: A summary of four cases and review of the literature.” Otolaryngology – Head and Neck Surgery. Vol. 116, No. 4: pp 554-57.
Bertrand, Doyen, Eloy. “Triosite Implants and Fibrin Glue in the Treatment of Atrophic Rhinitis: Technique and Results.” Laryngoscope (106): May 1996: pp 652-57.
Goldenberg, Danino, Netzer, Joachims. “Plastipore implants in the surgical treatment of atrophic rhinitis: Technique and results.” Otolaryngology Head and Neck Surgery. Vol 122 No 6: pp 794-97.
Watson, Spencer. Diseases of the nose and its accessory cavities. London: 1875.
El Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis.” Rhinology, 36, 202-203, 1998.