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Atrophic Rhinitis Alan L. Cowan, M.D. Faculty Advisor: Matthew Ryan, M.D. The University of Texas
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
Atrophic Rhinitis
Atrophic Rhinitis  Common Terms  Ozena Dry Rhinitis  Rhinitis Sicca 

Common Terms

Atrophic Rhinitis  Common Terms  Ozena Dry Rhinitis  Rhinitis Sicca 


Ozena Dry Rhinitis Rhinitis Sicca


Atrophic Rhinitis  Dr. Spencer Watson. Diseases of the nose and its associated cavities. London,
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
Atrophic Rhinitis
 Described in 1876 by Dr. Bernhard Fraenkel as a triad of:  Fetor 
 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
Atrophic Rhinitis
 Clinical Features Anosmia   Ozena, i.e. foul odor  Extensive nasal crusting 
 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
Atrophic rhinitis
 Primary 
 Primary
Atrophic rhinitis  Primary   History of prior sinus surgery, radiation, granulomatous disease, or nasal

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

and India Microbiology of primary AR is almost uniformly   Klebsiella ozenae.  Radiographic and
  Klebsiella ozenae.  Radiographic and clinical features similar to secondary AR.
Klebsiella ozenae.
 Radiographic and clinical features similar to secondary
AR.
Atrophic rhinitis
Atrophic rhinitis
Atrophic rhinitis  Secondary     Complication of sinus surgery (89%) Complication of radiation
 Secondary    
 Secondary
Complication of sinus surgery (89%)
Complication of sinus surgery (89%)

Complication of radiation (2.5%) Following nasal trauma (1%) Sequela of granulomatous diseases (1%)

nasal trauma (1%) Sequela of granulomatous diseases (1%) Sarcoid  Leprosy   Rhinoscleroma Sequlae of
Sarcoid  Leprosy  
Sarcoid
Leprosy
Rhinoscleroma Sequlae of other infectious processes  Tuberculosis  Syphilis 
Rhinoscleroma
Sequlae of other infectious processes
Tuberculosis
Syphilis

Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.

Surgical causes
Surgical causes
Surgical causes  Based on review of 242 cases from Mayo Clinic.  Procedures per patient

Based on review of 242 cases from Mayo Clinic.

causes  Based on review of 242 cases from Mayo Clinic.  Procedures per patient 2.3
causes  Based on review of 242 cases from Mayo Clinic.  Procedures per patient 2.3

Procedures per patient

2.3
2.3
  Partial middle or inferior turbinectomy  56%  Total middle and inferior turbinectomy
 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
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 
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
Radiographic Findings
Mucoperiosteal thickening of the paranasal sinuses. Loss of definition of the OMC secondary to resorption
Mucoperiosteal thickening of the paranasal sinuses.
Loss of definition of the OMC secondary to resorption
of the ethmoid bulla and uncinate process.
Hypoplasia of the maxillary sinuses.
Enlargement of the nasal cavities with erosion
and bowing of the lateral nasal wall.
Bony resorption and mucosal atrophy of the inferior
and middle turbinates.
Biopsy Findings
Biopsy Findings
 Normal Mucosa  Pseudostratified Columnar  Presence of serous and mucous glands  Atrophic
 Normal Mucosa
 Pseudostratified
Columnar
 Presence of serous
and mucous glands
 Atrophic Rhinitis
 Squamous metaplasia
 Atrophy of mucous
glands
 Scarce or absent cilia
 Endarteritis obliterans
Rhinitis  Squamous metaplasia  Atrophy of mucous glands  Scarce or absent cilia  Endarteritis
Rhinitis  Squamous metaplasia  Atrophy of mucous glands  Scarce or absent cilia  Endarteritis
Microbiology
Microbiology
Klebsiella ozenae
Klebsiella ozenae
 

Microbiology Klebsiella ozenae    May be found in almost 100% of primary AR No

May be found in almost 100% of primary AR No predominance in secondary AR

in almost 100% of primary AR No predominance in secondary AR Staphylococcus aureus   
Staphylococcus aureus
Staphylococcus aureus

  

Proteus mirabilis Escherichia coli Corynebacterium diphtheriae

in secondary AR Staphylococcus aureus     Proteus mirabilis Escherichia coli Corynebacterium diphtheriae
Current Therapies
Current Therapies
Current Therapies  Goals of therapy    Therapy options  Topical therapy  Saline
 Goals of therapy    Therapy options  Topical therapy  Saline irrigations
 Goals of therapy
 Therapy options
 Topical therapy
 Saline irrigations
 Antibiotic irrigations
 Systemic antibiotics
Closure of the nostrils
 Systemic antibiotics  Closure of the nostrils  Restore nasal hydration Minimize crusting and debris

Restore nasal hydration Minimize crusting and debris

 Closure of the nostrils  Restore nasal hydration Minimize crusting and debris Implants to fill
Implants to fill nasal volume
Implants to fill nasal volume
Local therapy  Irrigations  Saline  Mixtures  Sodium bicarbonate  Shehata: Sodium Carbonate
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
Systemic therapy
Oral antibiotics   Tetracycline  Ciprofloxacin  Aminoglycosides  Streptomycin injections Medication
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
Surgical therapies
Surgical therapies  Young procedure Modified Young procedure Turbinate reconstruction    Volume reduction


Young procedure Modified Young procedure Turbinate reconstruction

  
Volume reduction procedures Denervating operations 
Volume reduction procedures
Denervating operations
Nasal Closure
Nasal Closure
Young’s procedure  Circumferential flap elevation 1 cm cephalic to the alar rim.  
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
Advantages  Often provided relief of symptoms   Disadvantages Difficult to elevate circumferential flap
Advantages  Often provided relief of symptoms   Disadvantages Difficult to elevate circumferential flap
Advantages  Often provided relief of symptoms   Disadvantages Difficult to elevate circumferential flap

Disadvantages

Difficult to elevate circumferential flap
Difficult to elevate circumferential flap
 Breakdown of central suture area common  Does not allow for cleaning  Did
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
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
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
Modified Young
Modified Young
Modified Young
Modified Young
Volume reduction Plastipore implantation   Porus material allows tissue ingrowth.  Implants shaped then
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
Plastipore
Volume Reduction (cont) Triosite and Fibrin  Triosite (60% hydroxyapetite, 40% calcium triphosphate) mixed 
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
Triosite and Fibrin

Bertrand, Doyen, Eloy. Laryngoscope 106: May 1996. p 652-57.

Triosite and Fibrin
Triosite and Fibrin
Triosite and Fibrin
Other Therapies
Other Therapies
Non-surgical nasal closure Nasal vestibule impressions taken similar to hearing aid moulds.  Impressions are
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
Nasal Obturator
Nasal Obturator
Nasal Obturator
Nasal Obturator
Nasal Obturator
Other Therapies
Other Therapies
Other Implants   Acrylic  Silicone  Teflon  Silastic  Boplant Denervation 
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
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.