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Atrophic rhinitis
A review
March 3, 2012 Rhinology
Atrophicrhinitisisachronicembarrassingdebilitatingdiseaseinvolvingnasalcavityandparanasal
sinuses.Itischaracterizedbyfoulsmellingcrusts(greenish)insidethenasalcavity.Nasalmucosa
tendstobleedwhenthesecrustsareremoved.Nasalcavityappearstobeexcessivelyroomy.Foul
stenchemanatesfromthepatient.Patientismercifullyunawareofthisstenchbecauseofthe
presenceofanosmia.Thisarticlediscussesthevariousfeaturesofthisdiseaseandthevarious
managementmodalitiesavailable.
Introduction:
Atrophicrhinitisisdefinedasachronicnasaldiseasecharacterisedbyprogressiveatrophyofthe
nasalmucosaalongwiththeunderlyingbonesofturbinates.Thereisalsoassociatedpresenceof
viscidsecretionwhichrapidlydriesupformingfoulsmellingcrusts.Thisfetidodor isalsoknownas
ozaena.Thenasalcavityisalsoabnormallypatent.Thepatientisfortunatelyunawareofthestench
emittingfromthenoseasthisdisorderisassociatedwithmercifulanosmia .Thisdiseaseisrather
rareindevelopedcountries,butarerathercommonindevelopingcountries .Nowadaysitismore
commonasasequelaeofmedicalinterventions.Overzealousturbinatesurgeryhasbeenimplicated
asaprobableiatrogeniccause.
Synonyms:
Thefollowingarethevariousterminologiesusedtoindicatethesamecondition:
1.Rhinitissicca
2.Dryrhinitis
3.Ozena
4.Opennosesyndrome
5.Emptynosesyndrome
History:
ItwasSpenserWatsonofLondonwhofirstcoinedthetermOzenatodescribethiscondition.Hewas
thefirsttodescribeclinicalfeaturesofthisdisease.Heclassifiedthisdiseaseintomild,moderateand
severevarieties.MildvarietyofatrophicrhinitisaccordingtoWatsonischaracterizedbyheavy
crusting.Thesecrustscaneasilyberemovedbynasaldouching.Moderatevarietyfeaturesanosmia
andstenchemanatingfromthenasalcavity.Severevarietyisinvariablycausedbysyphilis.Bone
Abstract
Atrophic rhinitis a review
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Authors
BalasubramanianThiagarajan
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destructionandcosmeticdeformitiesofnoseisrathercommoninthisvariety. In1876DrBernhard
Fraenkelfirstdescribedtheclassictriadofsymptomswhichwasvirtuallydiagnosticofthisdisorder.
ThistriadisstillknownasFraenkelstriadinhishonorinclude:Fetor,CrustingandAtrophyofnasal
structures.FrankBosworthin1881notedthatBreathfromthesepatientswerenotonlyunpleasant
butvirtuallyunbearable.Thesuffererpersewasmercifullyunawarebecauseofthepresenceof
anosmia.
Etiology:
Theetiologyofthisproblemstillremainsobscure.Numerouspathogens havebeenassociatedwith
thiscondition,themostimportantofthemare:
1.Coccobacillus
2.Bacillusmucosus
3.Coccobacillusfoetidusozaenae
4.Diptheroidbacilli
5.Klebsiellaozaenae.
Theseorganismsdespitebeingisolatedfromthenoseofdiseasedpatientshavenotcategorically
beenprovedasthecauseforthesame.
Otherpredisposingfactorsinclude:
1.ChronicsinusitisSSali consideredatrophicrhinitistobeinfectiveinnature.Hereportedatrophic
rhinitisin7childrenofafamilyafterachildwithatrophicrhinitisspentanightintheirhouse.Common
organismisolatedfromnasalcavitiesofthesechildrenwasKlebsiellaozenae
2.Excessivesurgicaldestructionofthenasalmucosaandturbiantes
3.Nutritionaldeficiencies:Bernat in1965demonstratedthat50%ofpatientswithatrophic
rhinitisbenefitedwithirontherapy.Hansen demonstratedsymptomaticimprovementinmajorityof
thispatientswithatrophicrhinitiswhentreatedwithvitaminA.
4.Syphilis.
5.Endocrineimbalances(Diseaseisknowntoworsenwithpregnancy/menstruation)
6.Heredity:ThiswasfirstreportedbyBartonandSibert (Autosomaldominentpatternofinheritance
identified).
7.Autoimmunedisease
8.Developmental:Hagrass reportedshortenedAnteroPosteriornasallengthsandpoormaxillary
antralpneumatizationinpatientswithatrophicrhinitis.
9.Vascular:ExcesssympatheticactivitywasobservedinthesepatientsbyRuskin
Ageofonset:
Usuallyatrophicrhinitiscommencesatpuberty.
Sexpredilection:
Femalesaremorecommonlyaffectedthanmales
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ClassificationofAtrophicrhinitis:
Primaryatrophicrhinitis:Thisclassicformofatrophicrhinitisissupposedtoarisedenovo.Thisisin
factadiagnosisofexclusion.ThistypeofatrophicrhinitisiscommoninChina,IndiaandMiddleEast.
InalmostallthesepatientsKlebsiellaozenaehasbeenisolated.
Secondaryatrophicrhinitis:Thisisthemostcommonformofatrophicrhinitisseenindeveloped
countries.Inthistypethepredisposingcauseisclearlyevident.Commoncausesofsecondary
atrophicrhinitisinclude:
1.SurgicalproceduresinvolvingnoseandparanasalsinusesTheyincludeturbinectomies,sinus
surgeries,maxillectomyetc.
2.Irradiation
3.Trauma
4.Granulomatousdiseases:IncludeSarcoidosis,LeprosyandRhinoscleroma
5.Infections:Thisincludestuberculosisandsyphilis
Clinicalfeatures:
Thepresentingsymptomsarecommonlynasalobstructionandepistaxis.Anosmiai.e.mercifulmay
bepresentmakingthepatientunawareofthesmellemanatingfromthenose.Thesepatientsmay
alsohavepharyngitissicca.Chokingattacksmayalsobeseenduetoslippageofdetachedcrusts
fromthenasopharynxintotheoropharynx.Thesepatientsalsoappeartobedejectedanddepressed
psychologically.
Clinicalexaminationofthesepatientsshowthattheirnasalcavitiesfilledwithfoulsmellinggreenish,
yelloworblackcrusts,thenasalcavityappeartobeenormouslyroomy.Whenthesecrustsare
removedbleedingstartstooccur.
Whynasalobstructioneveninthepresenceofroomynasalcavity?
Thisinterestingquestionmustbeanswered.Thenasalcavityisfilledwithsensorynerveendings
closetothenasalvalvearea.Thesereceptorssensetheflowofairthroughthisareathusgivinga
senseoffreenessinthenasalcavity.Thesenerveendingsaredestroyedinpatientswithatrophic
rhinitisthusdeprivingthepatientofthissensation.Intheabsenceofthesesensationthenosefeels
blocked.
Radiologicfeaturesofatrophicrhinitis:
Radiologicfeaturesaresimilarforbothtypesofatrophicrhinitis.Plainxraysshowlateralbowingof
nasalwalls,thinorabsentturbinatesandhypoplasticmaxillarysinuses.
CTscanfindings:
1.Mucoperiostealthickeningofparanasalsinuses
2.Lossofdefinitionofosteomeatalcomplexduetoresorptionofethmoidalbullaanduncinate
process
3.Hypoplasticmaxillarysinuses
4.Enlargementofnasalcavitywitherosionofthelateralnasalwall
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5.Atrophyofinferiorandmiddleturbinates
Fig.1:CTscannoseandsinusesinapatientwithatrophicrhinitis
Histopathologicalfeatures:
1.Metaplasiaofciliatedcolumnarnasalepitheliumintosquamousepithelium.
2.Thereisadecreaseinthenumberandsizeofcompoundalveolarglands
3.Dilatedcapillariesarealsoseen
Pathologicallyatrophicrhinitishasbeendividedintotwotypes:
TypeI:ischaracterisedbythepresenceofendarteritisandperiarteritisoftheterminalarterioles.This
couldbecausedbychronicinfections.Thesepatientsbenefitfromthevasodilatoreffectsof
oestrogentherapy.
TypeII:ischaracterisedbyvasodilatationofthecapillaries,thesepatientsmayworsenwithestrogen
therapy.Theendothelialcellsliningthedilatedcapillarieshavebeendemonstratedtocontainmore
cytoplasmthanthoseofnormalcapillariesandtheyalsoshowedapositivereactionforalkaline
phosphatasesuggestingthepresenceofactiveboneresorption.Ithasalsobeendemonstratedthat
amajorityofpatientswithatrophicrhinitisbelongtotypeIcategory.
Management:
Conservative:
NasaldouchingThepatientmustbeaskedtodouchethenoseatleasttwiceadaywithasolution
preparedwith:
Sodiumbicarbonate28.4g
Sodiumdiborate28.4g
Sodiumchloride56.7g
mixedin280mloflukewarmwater.
Thecrustsmayberemovedbyforcepsorsuction.25%glucoseinglycerindropscanbeappliedto
thenosethusinhibitingthegrowthofproteolyticorganism.
InpatientswithhistologicaltypeIatrophicrhinitisoestradiolinarachisoil10,000units/mlcanbeused
asnasaldrops.
Kemecetineantiozaenasolutionispreparedwithchloramphenicol90mg,oestradioldipropionate
0.64mg,vitaminD2900IUandpropyleneglycolin1mlofsaline.
Potassiumiodidecanbeprescribedorallytothepatientinanattempttoincreasethenasalsecretion.
Systemicuseofplacentalextractshavebeenattemptedwithvaryingdegreesofsuccess.
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Surgicalmanagement:
1.Submucousinjectionsofparaffin,andoperationsaimedatdisplacingthelateralnasalwall
medially.ThissurgicalprocedureisknownasLautenslaugersoperation.
2.Recentlyteflonstrips,andautogenouscartilageshavebeeninsertedalongthefloorandlateral
nasalwallafterelevationofflaps.
3.WilsonsoperationSubmucosalinjectionof50%Tefloninglycerinpaste.
4.Repeatedstellateganglionblockshavealsobeenemployedwithsomesuccess
5.Youngsoperation Thissurgeryaimsatclosureofoneorbothnasalcavitiesbyplasticsurgery.
Youngsmethodistoraisefoldsofskininsidethenostrilandsuturingthesefoldstogetherthus
closingthenasalcavities.Afteraperiodof6to9monthswhentheseflapsareopenedupthe
mucosaofthenasalcavitieshavefoundtobehealed.Thiscanbeverifiedbypostnasalexamination
beforerevisionsurgeryisperformed.Modificationsofthisprocedurehasbeensuggested(modified
Youngsoperation)wherea3mmholeisleftwhileclosingtheflapsinthenasalvestibule.This
enablesthepatienttobreaththroughthenasalcavities.Itisbetterifthesesurgicalproceduresare
doneinastagedmanner,whilewaitingforonenosetohealbeforeattemptingontheotherside.
Atrophicrhinitisendoscopicview
1. ZoharY,TalmiYP,StraussM,etal.Ozenarevisited.JOtol19:3459,1990
2. http://www.drtbalu.co.in/atro_rhinitis.html
3. http://www.utmb.edu/otoref/grnds/AtrophicRhinitis050330/AtrophicRhinitis050330.htm
4. Atrophicrhinitisareviewof242casesMoore,EricJ.Kern,EugeneBAmericanJournalof
Rhinology,Volume15,Number6,NovemberDecember2001,pp.355361(7)
5. DudleyJP.Atrophicrhinitis:antibiotictreatment.AmJOtolaryngol8:38790,1987
6. SsaliCH.Atrophicrhinitis.Anewcurativesurgicaltreatment.JLaryngolOtol197387:397403.
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8. HansenC.Theozenaproblem:clinicalanalysisofatrophicrhinitisin100cases.ActaOtolaryngol
198293:4614
9. Primaryatrophicrhinitis:aninheritedcondition?R.P.E.Bartona1a3andJ.R.Siberta2The
JournalofLaryngology&Otology(1980),94:pp979983CopyrightJLO(1984)Limited1980DOI:
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