Atrophic Rhinitis UTMB Dept of Otolaryngology March 30, 2005

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Atrophic RhinitisUTMB Dept of
OtolaryngologyMarch 30, 2005

• Alan L. Cowan, M.D.
• Matthew Ryan, M.D.

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Atrophic Rhinitis

• Common Terms
• Ozena
• Dry Rhinitis
• Rhinitis Sicca

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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.

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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.

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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

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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.

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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.
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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.
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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)

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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.
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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
20428-32.
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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

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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

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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

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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

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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

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Surgical therapies

• Young procedure
• Modified Young procedure
• Turbinate reconstruction
• Volume reduction procedures
• Denervating operations

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Nasal Closure

• Youngs 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.
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Nasal Closure

• Modified Youngs
• 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.
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Modified Young
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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 (Youngs)
• 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.
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Plastipore
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Volume Reduction (cont)

• Triosite and Fibrin
• Triosite (60 hydroxyapetite, 40 calcium
  triphosphate) mixed with Fibrin 11.
• 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.
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Triosite and Fibrin
Bertrand, Doyen, Eloy. Laryngoscope 106 May
1996. p 652-57.
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Triosite and Fibrin
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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.
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Nasal Obturator
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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

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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.