Eur Arch Otorhinolaryngol (2011) 268:17–26
DOI 10.1007/s00405-010-1391-z
REVIEW ARTICLE
Rhinitis sicca, dry nose and atrophic rhinitis: a review
of the literature
Tanja Hildenbrand • Rainer K. Weber •
Detlef Brehmer
Received: 25 July 2010 / Accepted: 16 September 2010 / Published online: 29 September 2010
 Springer-Verlag 2010
Abstract Despite the fact that many people suffer from
it, an unequivocal definition of dry nose (DN) is not
available. Symptoms range from the purely subjective
sensation of a rather dry nose to visible crusting of the
(inner) nose (nasal mucosa), and a wide range of combi-
nations are met with. Relevant diseases are termed rhinitis
sicca anterior, primary and secondary rhinitis atrophicans,
rhinitis atrophicans with foetor (ozena), and empty nose
syndrome. The diagnosis is based mainly on the patient’s
history, inspection of the external and inner nose, endos-
copy of the nasal cavity (and paranasal sinuses) and the
nasopharynx, with CT, allergy testing and microbiological
swabs being performed where indicated. Treatment con-
sists in the elimination of predisposing factors, moistening,
removal of crusts, avoidance of injurious factors, care of
the mucosa, treatment of infections and where applicable,
correction of an over-large air space. Since the uncritical
resection of the nasal turbinates is a significant and fre-
quent factor in the genesis of dry nose, secondary RA and
ENS, the inferior and middle turbinate should not be
resected without adequate justification, and the simulta-
neous removal of both should not be done other than for a
malignant condition. In this paper, we review both the
aetiology and clinical presentation of the conditions asso-
ciated with the symptom dry nose, and its conservative and
surgical management.
T. Hildenbrand
R. K. Weber
Division of Sinus and Skull Base Surgery, Traumatology,
Department of ENT, Hospital Karlsruhe, Moltkestr. 90,
76133 Karlsruhe, Germany
D. Brehmer (&)
Private ENT Clinic Goettingen, Faculty of Medicine, University
Witten/Herdecke, Friedrichstr. 3/4, 37073 Goettingen, Germany
e-mail: dr.d.brehmer@t-online.de
Keywords Dry nose
Rhinitis sicca
Rhinitis
atrophicans
Ozena
Nasal obstruction
One of the chief functions of the nose is to warm and
moisten the inspired air and another function is to recover
the moisture from the expired air [1].
The nature of the inflow and outflow of the air within the
nasal cavity is of decisive importance for this air-condi-
tioning feature. In this context, the optimal distribution of
the inspired air over the nasal turbinates while ensuring
intimate contact of the air with the surface-moist mucosal
membrane is essential.
The expression ‘‘dry nose’’ (DN) has not been unam-
biguously defined. Mainly, it is based on relevant anam-
nestic patient information. ENT specialists often employ
the term ‘‘rhinitis sicca’’ although here too a clear defini-
tion is lacking. Symptoms range from the purely subjective
sensation of a somewhat dry nose to visible crusting of the
nose; a wide range of combinations is possible:
• Sensation of dryness in the nose
• Itching, mild burning sensation
• Nasal obstruction
• Crusting, scabs and ‘‘bogies’’, possibly associated with
an (unpleasant) smell
• Epistaxis
• Diminished sense of smell
Possible causes of dry nose include a variety of diseases,
external and internal factors and environmental conditions:
• Local mechanical irritation
• Climatic or environmental factors
– Dry room or environmental air (relative humidity
\50%)
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– Heated room or hot environment • Reduced mucociliary clearance [7–10].

– Long-distance flights • Reduction in the number of goblet cells and elastic
fibres in the nasal mucosa [11].
• Workplace conditions
• Reduced sensitivity of the nasal mucosa [12].
– Dry air, clean-room condition [2] • Enlargement of the nasal cavity resulting from involu-
– Cold, heat tion atrophy of the nasal mucosa [13, 14].
– Dusty conditions (e.g. grinding/polishing of plaster, • Decrease in the body’s water content [15].
granite, chalk, cement, wood arsenic, nickel car-
Altered airflow due to changes in geometry, leads to
bonyl, tobacco smoke)
changes in the conditioning situation [14, 16], with the
• Drugs (cocaine) result that in over-60-year-olds, the air-conditioning
• Side effects of medications (see Table 1) capacity becomes impaired: both intranasal air temperature
• Supportive nasal administration of oxygen [3] and humidity decrease [17].
• Symptoms of other diseases (granulomatosis, infec- A familial, i.e. genetic, impairment of nasal air-condi-
tious, rheumatic and immunological disorders) tioning has been reported by Sahin-Yilmaz et al. [18], who
investigated 47 pairs of twins.
– Wegener’s granulomatosis, sarcoidosis, tuberculo-
sis, syphilis, leprosy
Relevant diseases besides ‘dry nose’ revealing similar
• Wound healing phase after endonasal sinus surgery and
findings and symptoms
surgery on the nose
• Anatomical changes to the outer and inner nose, with
In common with the symptom itself, a number of indi-
modification of normal airflow
vidual diseases associated with the symptom dry nose and
• Allergic rhinitis, in particular house dust mites and
crusting, is poorly defined, and the definitions also overlap.
moulds
This is illustrated by the following terms contained in the
• Permanent sequelae of surgery on the nose and
literature:
paranasal sinuses
• Sequelae of head and neck radiotherapy • Rhinitis sicca anterior,
• Obstructive sleep apnoea (OSA) or continuous positive • Primary rhinitis atrophicans/primary atrophic rhinitis
airway pressure (CPAP) treatment of OSA [4]. Moist- (PAR): rhinitis atrophicans with foetor (ozena),
ening led to a reduction in symptoms [5] • Secondary rhinitis atrophicans/secondary or diffuse
• Old age atrophic rhinitis (SAR).
Dry nose may be the first symptom of an incipient cold
with a runny nose; in such a case, however, it is of only
Rhinitis sicca anterior
limited duration.
Although an increased susceptibility for infections has
The term, rhinitis sicca anterior, defines a chronic inflam-
frequently been postulated, and is pathophysiologically
mation in the region of the anterior part of the nose usually
plausible, it has never been confirmed as the sole cause.
affecting the anterior and caudal septum and/or the corre-
The mechanical and functional integrity of the mucous
sponding lateral nasal vestibule. Due to irritation (mechan-
membrane is considered a major natural defence mecha-
ical—finger picking, toxic, persistent secretion, respiration,
nism against infection. Depending on the degree to which it
(air)flow characteristics, dry, hot and dusty environment),
dries out, mucociliary transport and even the epithelial
drying, superficial erosion and/or ulceration with (thin) crust
barrier, may be impaired.
formation occurs.
Epidemiological data on the prevalence of dry nose are
Patients experience a sensation of dryness, itching and
not available. However, in particular when questioned,
increased crust formation. The crusts are thin and dry and
many people confess to be sufferers and admit to the use of
do not extend into the posterior part of the nasal cavity, as
numerous therapeutic measures, mostly ointments and
is the case with atrophic rhinitis. Usually there is no foetid
sprays or nasal douches.
smell, only an occasional patient experiences mild foetor
In old age, anatomical changes and an involution atro-
caused by bacterial colonisation of the small crusts.
phy of the mucosa result in an increase in such complaints
Manipulations may give rise to a vicious circle of increased
as impairment of nasal breathing and dry nose, and the
crusting and persistent complaints. In the individual case,
following phenomena may occur:
continued irritation and manipulation may result in perfo-
• Hanging nasal tip and shortening of the columella [6]. ration of the nasal septum (Fig. 1).

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 Table 1 Medications with the side effect dry nose (German Pharmacopoeia (Rote Liste 2010))
Substance group Generic name Trade name Indications

Retinoids (1–10%) Isotretinoin Aknefug, Aknenormin, Isoderm, Severe forms of acne

IsoGalen, Isotret Hexal, Isotretinoin-ratiopharm
Tretinoin Vesanoid Promyelocyte leukaemia
   
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Doxepine (tricyclic Aponal , Doneurin , Doxepin , Mareen Depressive conditions, anxiety syndrome, mild withdrawal symptoms in
antidepressive) alcoholics and drug-dependent persons, agitation, sleep disorders
Methyldopa (1%– Dopegyl, Methyl-Dopa Stada, Presinol (mite) Hypertension (of pregnancy)
1%)
Sympathomimetics Dipivefrin (eye) Glaucoma
(local)
Naphazolin Diverse forms of rhinitis, only short-term use recommended
Oxymetazolin
Phenylephrine
Tetryzolin
Tramazolin
Xylometazolin
Antihistaminics, Clemastine Tavegil Urticaria, allergic rhinitis
first generation
Dimenhydrinat Vomex Vertigo, nausea, vomiting

Dimetinden Fenistil Itching, itching dermatoses, allergies
Diphenhydramine Betadorm D, Diphenhydramin, Dolestan, Hevert Dorm, Difficulty getting to sleep, difficulty staying asleep
Moradorm, Nervo OPT N, Sediat Sedopretten, Vivinox
Promethazine Atosil, Closin, Promethazin, Proneurin, Agitation in underlying psychiatric illnesses,
 possibly vomiting, nausea and sleep disorders
Prothazin
Terfenadin Terfenadin Allergic rhinoconjunctivitis, allergic skin disorders
19

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Fig. 1 Rhinitis sicca anterior with dry skin in the nasal vestibule and
thin yellowish crusts
Treatment consists in the application of a protective film
to the skin of the nasal vestibule, to allow the chronic
inflammation disrupting its integrity to self-heal while
avoiding mechanical irritation. This is usually achieved by
the application of ointments. Nasal sprays containing
dexpanthenol have also been used with success [19].
Primary atrophic rhinitis
Primary atrophic rhinitis (PAR) is a gradually progressive
chronic degenerative condition of the nasal mucosa of
unknown aetiology. Progressive atrophy of all the constit-
uents of the mucosa (epithelium, glands and vessels)
together with osteoclasis, mainly affecting the turbinates.
The respiratory epithelium undergoes stepwise metaplastic
changes. Histologically, atrophy of the serous and mucous
glands, loss of the cilia and goblet cells, chronic infiltration
of the lamina propria with granulations and scar formation
are seen. Some publications also report diminished vas-
cular density together with peri- and endarteritis. The his-
tological changes explain the disturbance to mucociliary
transport. Thick secretion that is not transported away,
promotes the formation of bacterially contaminated crusts
that may then be a source of recurrent bacterial infection. If
rhinitis atrophicans is complicated by foetid crust forma-
tion then rhinitis atrophicans with föetor (stinking nose,
ozena) results. Microbiological investigation usually
detects Klebsiella ozaenae (100% of the 45 patients of
Moore and Kern 2001 [20]), but also Staphylococcus
aureus, Proteus mirabilis, E. coli and other bacteria (Bor-
detella bronchiseptica and Pasteurella multocida). Endo-
scopic examination reveals a markedly large and wide
nasal cavity and visibly dry mucosa. The turbinates are
clearly diminished in size. With ozena, yellowish-green
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Eur Arch Otorhinolaryngol (2011) 268:17–26
crusts are found on the mucosa. Apart from crusting, the
patient usually also suffers from hyposmia or anosmia.
Foetor may give rise to social problems.
The cause of PAR is unknown, but both genetic and
infectious causes are under discussion. The condition is
more commonly seen in association with low socioeco-
nomic status, a poor diet and iron deficiency. A much less
frequent use of antibiotics in countries with a higher inci-
dence of the condition may have a role to play. The fact
that women are more frequently affected suggests a pos-
sible endocrinal factor. Over the past years and decades the
prevalence of PAR has declined.
Ozena is seen much more frequently in pigs than in
humans and, even under the most modern conditions of
intensive pig farming, remains one of the chief infections
in swine. Epizootiological studies have shown that the
mixing of animals from different pig factories for the
purpose of cross-breeding or simple reproduction is always
fraught with the risk of an explosive outbreak of disease
[21]. The causal agents here are toxinogenic strains of
Pasteurella multocida that are responsible for progressive
atrophic rhinitis [22]. Progressive atrophic rhinitis has even
been diagnosed in a herd of wild boars [23].
Secondary atrophic rhinitis
Secondary atrophic rhinitis (SAR) develops on the soil of
an underlying disease or may result from previous thera-
peutic measures. It is thus a collective term for a number of
conditions with a variety of aetiologies that share the
clinical feature of a dry nose, crusting, possibly nasal
obstruction, a foul smell and epistaxis as outlined above. In
contrast to PAR there is no osteoclastic activity, so the term
diffuse atrophic rhinitis may be more appropriate. Patho-
genetic factors leading to SAR include:
• Prior radical endonasal surgery. Persistent chronic
rhinosinusitis in addition may increase the probability
of SAR developing [24].
• Prior radiotherapy of the head and neck.
• Sjögren’s syndrome.
• Prior trauma (extremely rare).
• The differential diagnostic workup must consider
granulomatous inflammation, the clinical presentation
of which may include crusting, yellow secretion and a
foul smell, and a dry nose (infectious: tuberculosis,
syphilis, leprosy; non-infectious: sarcoidosis, Wegen-
er’s disease).
In the largest collection of cases to date, 197 patients
with sRA, the following causes were identified [20]:
• Complete removal of the lower and middle nasal
turbinates (24%).
Eur Arch Otorhinolaryngol (2011) 268:17–26 21

Fig. 2 Empty nose syndrome after radical endonasal sinus surgery

with resection of the inferior and middle turbinate

• Partial removal of the lower and/or middle nasal

turbinates (56%).
• Endonasal sinus surgery without turbinectomy (10%).
• Partial maxillectomy to remove a tumour (6%).
• Nasal trauma requiring surgical reconstruction (1%).
• Granulomatous disease (1%).
Empty nose syndrome (ENS) is defined as a form of
iatrogenic SAR, occurring after radical endonasal surgery
in particular resection of the nasal turbinates (lower and/or
middle), usually in connection with an operation on the
nasal sinuses [25–27] (Figs. 2, 3). It is characterised by the
symptoms nasal and pharyngeal dryness, paradoxical
impairment of nasal respiration, dyspnoea and hyposmia,
in some cases associated with depression [28].
The disturbed sense of smell is the result of the changed
airflow. The dryness of the pharyngeal mucosa is due to the
fact that, in contrast to the normal situation, drier intranasal
air (no moisture since turbinate mucosa is lacking) results
in disrupted airflow in the region of the choanae, and also
impinges on the posterior wall of the nasopharynx at
increased velocity [27]. According to Houser, pain too, is a
typical symptom, caused by the action of cold air on the
mucosa covering the sphenopalatine ganglion [28].
Resection of the lower and middle turbinates reduces
the effectiveness of the acclimatisation function of the
nose by 23% [29, 30]. The paradoxical impairment of
nasal respiration is explained by the unphysiological air-
flow, the reduced nasal airway resistance, the lack of
areas of functional mucosa together with the simultaneous
enlargement of the nasal cavity, and the curtailed contact
between air and mucosa [27]. Enlargement of the nasal
cross-section reduces the airway resistance and thus the
pressure gradient at the air/mucosa surface. In turn, this
Fig. 3 Secondary rhinitis atrophicans in epidermolysis bullosa
acquisita with atrophy of the inferior nasal turbinates (CT, a) and
yellow crusts in the nasopharynx (b)
causes malfunction of the nasopulmonary reflexes, which
may lead to a worsening of pulmonary function. In con-
trast, optimal nasal airway resistance is important for the
dilatation of the peripheral bronchioles and for improved
alveolar gas exchange.
The risk of an SAR following extensive resection of the
nasal turbinates is apparently determined not only by the
extent of the resection, but also by patient-specific and
undefined other factors including environmental factors.
While a number of authors observed no SAR following
total removal of the inferior turbinates even after a period
of observation covering several years [31–34], in other case
series a of 2–22% probability of SAR developing was
reported [30, 35–39].
Diagnosis of dry nose and atrophic rhinitis
Extensive history-taking is always followed by inspection
of the outer and inner nose (Table 2). This should, for

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Table 2 Diagnostic workup of dry nose
Medical history
Inspection of the external and inner nose
Endoscopy of the nasal cavity and nasopharynx, where indicated,
also of (operated) paranasal sinuses
Where indicated, CT of the paranasal sinuses
Allergy testing
Microbiological swab
example, identify any anatomical deformations that might
cause dry nose by changing the flow of air through the
nose. For the purpose of detecting minor lesions in the
nasal vestibule in patients with rhinitis sicca anterior,
the use of a microscope may prove useful. Endonasal
inspection should look for septal deviation or perforation,
and note the size and shape of the turbinates, the presence
and nature of crusts, the humidity of the mucosa, polyps or
tumours, post-nasal secretion and the nasopharyngeal
status.
A CT of the nasal sinuses is indicated when signs of
chronic rhinosinusitis are found, or to obtain adjunctive
evidence of PAR. Typical signs of PAR in the CT include:
• Thickened mucosa in the paranasal sinuses.
• The osteomeatal complex can no longer be defined due
to destruction of the normal anatomy.
• Hypoplasia of the maxillary sinus.
• Enlargement of the nasal cavity with destruction of the
lateral nasal wall.
• Bony destruction of the inferior and middle turbinates.
Testing for allergy is important, for example in order to
diagnose a house mite allergy, which may be associated
with the symptom dry nose. When endoscopic examination
reveals purulent streaks or crusting, swabs should be taken
for a microbiological examination.
The diagnosis is based on the case history, endo-
scopic findings and, where necessary, adjunctive diagnostic
measures.
Treatment of dry nose
Treatment of dry nose comprises:
• Elimination or amelioration of triggering or promoting
factors.
• Moisturisation.
• Sufficient daily drinking amount
• Cleansing (when crusts are present) and
• Care of the mucosa.
• Treatment of obvious infections and
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Table 3 Basic rules for the treatment of dry nose
Elimination of promoting factors
Environmental, workplace situation
Diet, iron-, vitamin deficiency (?)
Moistening
Local (nasal irrigation, Inhalation, nasal spray)
Environment (elevated air humidity)
Systemic: sufficient liquid intake
Removal of crusts (nasal irrigation, instrumental removal by ENT
clinician)
Avoidance of injurious factors
Local (nose-picking, cotton carrier, decongestant nose drops,
Ointments containing potentially injurious substances—
imidazoline derivatives, cortisone applied to the skin of the nasal
vestibule,…).
Systemic (drugs, see Table 1)
Care of the mucosa
Oils
Ointments
Occlusion
Treatment of infections
Allergic rhinitis
Ozena
Chronic rhinosinusitis
Correction of an over-large air space
Occlusion
Augmentation
• where applicable, the elimination of an over-large
endonasal air space
The individual may have only limited control over
environmental factors. The importance of the latter is
obvious when dry nose is no longer experienced during a
holiday, but reappears when this is over.
By far the most common complaint is a subjective dry
nose with no endoscopic findings with the possible
exception of a somewhat dry mucosa in the anterior nose.
This is the case in almost all those patients exposed to
unfavourable climatic or workplace conditions and also the
large group of patients with obstructive sleep apnoea syn-
drome undergoing CPAP treatment. Patients operated on
the nose prior to normalised acclimatisation are affected
too.
Apart from strictly avoiding local manipulation, these
patients require humidification and care of the dry areas.
For this purpose the market offers a wide range of oint-
ments, oils, sprays and nasal irrigation (Table 3).
The nose should be humidified, viscous mucus flushed
and liquefied; all inflammation-inducing and promoting
substances should be cleared out. A protective film should
be applied to prevent drying. Transepithelial water loss can
Eur Arch Otorhinolaryngol (2011) 268:17–26
Table 4 Substances for moistening the nose and mucosal care
Nasal douches with saline solution
NaCl solution
Special saline solution
Isotonic–hypertonic, with and without buffering (alkaline)
Nasal ointments
Dexpanthenol
Salt-containing nasal ointments
Diverse other formulations
Nasal oils
Sesame oil
Vitamin-A oil
Salt water sprays
Hyaluronic acid nasal spray
Dexpanthenol nasal spray
be countered by the nasal application of saline solutions or
other substances [40]. The application of a hypertonic 10%
saline solution led to a 40% elevated transepithelial water
loss [40]. Problematic is the fact that most preparations do
not have a high evidence level for efficacy (Table 4).
Nasal irrigation, nasal saline spray and inhalation
Nasal irrigations are recommended for a large number of
diseases of the nose and nasal sinuses [41]. How nasal
irrigation works is precisely not clear. It is postulated that
the improvement in mucosal function is due to:
• Direct physical cleansing by flushing out thick mucus,
crust, debris, allergens, environmental toxins, etc. [42,
43].
• Removal of inflammation mediators, and
• improvement of mucociliary clearance by improving
the ciliary beat frequency [44, 45].
In a recent review article published in 2009 [46] nasal
irrigation is recommended:
• As an adjunctive treatment for chronic rhinosinusitis
(Grade A evidence: consistent study results of good
quality),
• as adjunctive treatment for allergic rhinitis, viral ARS,
follow-up treatment after nasal sinus surgery, (Grade B
evidence: inconsistent results or limited quality),
• for rhinitis of pregnancy, acute bacterial RS, also
sarcoidosis or Wegener’s disease. (Grade C evidence:
consensus recommendations, usual practice, expert
opinion, results of case series).
The above recommendations show that on the one hand
nasal irrigation is a common recommendation, while on the
23
other hand the indication of dry nose is not explicitly
included in the recommendation, since informative studies
that can be integrated into the evidence-based recommen-
dations are very rare.
Nevertheless, nasal irrigations are an important thera-
peutic option in patients with dry nose. In the case of
recurrent crust formation, it is virtually indispensable as an
adjunctive aid to instrumental clearing by the ENT
physician.
The most commonly employed nasal sprays are salt
solutions. In addition to household salt, iodised or non-
iodised, pharmaceutical grade salts as well as special nasal
spray salts and brines are used [42, 43]. These solutions
may be isotonic, hypotonic, hypertonic, unbuffered or
buffered. Mildly hypertonic saline solutions (up to
approximately 3%), with or without buffering, are all
suitable for nasal irrigation. However, it is currently not
clear which saline solution is best for what indication.
For isotonic saline solutions (isotonic unbuffered, buf-
fered Emser saline solution) numerous investigations have
shown that daily application over the long term produces
positive results (prevention and treatment of upper airway
infection/rhinosinusitis, aftercare following surgery on
nasal sinuses) with no relevant side effects.
In principle, saline sprays serve the same purpose as
nasal irrigation. Although no systematic comparison has
been reported in rhinitis sicca, it is known from investi-
gations regarding endonasal sinus surgery that low-volume
sprays and drops have a worse distribution than high-vol-
ume devices [47]. So, the potential therapeutic effect of
saline sprays must therefore be considered smaller. For the
present, the extent to which the admixture of other sub-
stances results in a real benefit in the treatment of dry nose
remains uncertain.
Inhalation with saline solutions with the aim of moist-
ening the mucosa is also recommended and applied. In
view of the resulting diffuse moistening of the mucosa, this
can be considered positive in the case of dry nose.
Unfortunately, no meaningful studies are available.
Nasal ointments
Despite the fact that many patients often use nasal oint-
ments no meaningful studies on their uses in dry nose are
available.
A moistening effect is achieved with intranasal use: the
application of a nasal ointment reduces nasal water loss as
does the application of glycerol 10% [40].
Elberg [48] reported on the effect of Emser salt applied
in the form of Nisita Nasal Ointment in 1,500 cases
including pre- and post-operative applications in patients
undergoing operations on the nose and nasal sinuses.
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Neither pain nor infections were observed with regular
application, despite the fact that no antibiotic was given.
Follow-up care was reportedly considerably facilitated and
abbreviated.
However, as is generally the case with company-spon-
sored application studies (with which our review is not
concerned herein) the above is merely Grade V evidence.
In comparison with dexpanthenol nasal ointment, dex-
panthenol nasal spray proved just as effective, or even
somewhat superior, in terms of its effect on mucociliary
transport (saccharine test) reported Verse et al. in an pro-
spective, randomised, open, cross-over study [49]. Its
advantage vis-a-vis the ointment is presumably the fact that
it reaches the upper parts of the nasal cavity.
Topical dexpanthenol is said to reduce transepidermal
water loss, to activate in vivo and in vitro fibroblast pro-
liferation, and accelerate the re-epithelialisation process
[50].
Nasal oils
Oils in a not-too-high concentration bring about an
improvement in the nasal ciliary beat frequency (CBF). In
contrast to Miglyol 840 and thyme oil, sesame oil, soy oil,
peanut oil, lavender oil, eucalyptus oil and menthol
increased the CBF, the effect being higher at a concen-
tration of the oils of 0.2% than at 2% [51]. According to
Riechelmann et al. [52] a mixture of menthol, eucalyptus
oil and pine needle oil in concentrations up to 5% had no
major negative effect on CBF, but did at concentrations of
between 7.5 and 10 g/m3. With conventional inhalation,
concentrations of max 1% are to be expected.
In a randomised cross-over study involving 79 patients
with dry nasal mucosa Johnsen et al. [53] showed that, in
comparison with a sodium chloride solution, treatment with
sesame oil resulted in a superior moistening effect. Dryness
and subjectively impaired nasal respiration were improved
significantly better by sesame oil in comparison with saline
irrigation. Björk-Eriksson et al. [54] also reported a sig-
nificant effect of sesame oil (3 9 3 puffs of 25 ll spray
daily for 30 days) on the symptoms impaired nasal respi-
ration, dryness (burning sensation, itching, irritation) and
crust formation in 20 patients with dry nose and 15 patients
post-radiation treatment. A total of 5 patients reported side
effects (one each: unpleasant odour, itching, disturbed
nasal respiration; and runny nose in two).
Others
Home remedies and self-treatments recommended in the
Internet are mostly concerned with achieving moisturising,
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Eur Arch Otorhinolaryngol (2011) 268:17–26
the application of oils and the prevention of drying, but
the efficacy of the respective measures remains unclear.
Homoeopathy always recommends an individual constitu-
tional approach to treatment.
In the elderly patient with dry nose, Slavin recommends
moistening the nasal mucosa, and looking out for medi-
cament side effects (in particular avoidance of first gener-
ation anti-histamines and decongestive nose drops) [15].
A rough topographical endoscopically-oriented classifi-
cation may be useful for the differential treatment of the
dry nose symptom:
• In the case of problems localised in the anterior nose
(rhinitis sicca anterior in the widest sense) with a
visible lesion and possibly crusting, the first indication
is the local application of ointment. Relevant compar-
ative studies are not available. Potentially injurious
substances (decongestant medications, cortisone, aller-
genic substances) should be avoided.
• Vague complaints of dry nose in the absence of visible
changes to the nasal mucosa would appear the most
likely indication for moisturising measures (nasal
irrigation, inhalation, moisturising sprays). The ques-
tion as to whether admixed medicaments can diminish
the water loss on expiration needs further investigation.
• Dry nose with visible intranasal crust formation is the
domain of nasal irrigation, which is better able to
remove crusts than inhalation or sprays.
Treatment of atrophic rhinitis
Basic treatment comprises the measures outlined above for
dry nose. In the case of atrophic rhinitis, moistening
measures must be accompanied by removal of any crusts
and scabs. For this purpose, not only the commonly
employed instrumental removal by the ENT specialist, but
also nasal irrigation is used. As suitable solutions, the lit-
erature mentions not only the classical irrigation solutions
(buffered and unbuffered solutions of common salt or
special salts), but also solutions of 25% glucose in glyc-
erine, and antibiotics [55]. Tap water and other hypotonic
solutions are to be rejected.
Bacterial superinfections are treated with specific anti-
biotics. For ozena antibiotic treatment is reported to
achieve long-lasting results, e.g. Rifampicin 600 mg daily
for 12 weeks [54], Ciprofloxacin 2 9 500–750 mg for
8 weeks [56].
Surgical measures aim to reduce the size of, or tempo-
rarily occlude, the nasal cavity. Although occlusion can
resolve the problem of crusting and the considerable social
stigma of foetor, it also impairs nasal breathing and the
sense of smell. For the diminishment of nasal cavity size
Eur Arch Otorhinolaryngol (2011) 268:17–26
using submucosal implantation of tissue, foreign material
should not be used despite some authors describe promis-
ing result [57, 58]. In 2000 Goldenberg et al. [57]
implanted Plastipore, a high-density polyethylene sponge
containing micropores, and reported excellent results in six
patients, good results with only minor crusting in two
patients and one extrusion after 18 months. In a single case
Rice used hydroxyapatite for augmentation purposes, and
reported good results [58]. According to Houser [28] more
suitable materials are the patient’s own cartilage (e.g. rib
cartilage) or acellular dermis (AlloDerm). He implanted
lloDerm in eight patients and achieved a significant
improvement in symptom scores (SNOT 20) after a follow-
up period of at least 3 months. For treatment planning the
cotton test is suggested: moistened cotton is applied to the
area to be augmented for 20–30 min. If the test is positive,
the patient can be offered the augmentation. Friedman et al.
[59] and Moore and Kern [20] reported some success with
acellular dermis and autogenous cartilage or irradiated rib
[20] in 5 of 10 and 7 of 7 patients, respectively.
Prophylaxis
Since the uncritical resection of the nasal turbinates rep-
resents a significant and frequent factor in the genesis of
dry nose, secondary RA and ENS, the following points
must be strongly emphasised:
• The main objective of nasal turbinate surgery must be
the preservation of functional mucosa, while creating
an adequately large volume capable of ensuring
acclimatisation and the cleansing of the respired air,
and also preserving physiological airway resistance
[27].
• Without adequate justification the middle turbinate
should not be resected. Reduction of the lower nasal
turbinate should first be given careful consideration,
simultaneous removal of both the lower and middle
turbinates should not be done for a non-tumourous
condition [60].
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