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Auris Nasus Larynx xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Case report

Successful management of primary atrophic rhinitis by turbinate

reconstruction using autologous costal cartilage
Marn Joon Park, Yong Ju Jang *
Departments of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea


Article history: Initial management of primary atrophic rhinitis is conservative, with nasal ointments, saline
Received 21 November 2016 irrigation, and antibiotics prescribed to relieve symptoms. However, in cases that show no
Accepted 6 June 2017 improvement, a surgical approach is considered. Recently, many studies have reported successful
Available online xxx
surgical outcomes using various nasal implants. However, no study has reported implantation of
autologous costal cartilage in PAR patients. We report here the case of a 63-year-old woman
diagnosed with PAR that was intractable to medical therapy. Under general anesthesia, bilateral
Atrophic rhinitis
Primary atrophic rhinitis
inferior turbinate reconstruction with autologous costal cartilage was successfully performed
Autologous costal cartilage without any complications. One month after surgery, her symptoms improved dramatically. At the
Turbinate reconstruction 2-year follow-up, her Sinonasal Outcome Test 25 (SNOT-25) score was 6, down from an initial
Endonasal microplasty score of 108. Her OMU CT showed improved sinonasal mucosal thickness and disappearance of
thick mucosal secretion compared with preoperative CT image. Although this is a single case
experience, it is suggested that turbinate reconstruction using autologous costal cartilage can serve
as promising surgical modality for management of atrophic rhinitis.
© 2017 Elsevier B.V.. All rights reserved.

1. Introduction Radiological findings of primary atrophic rhinitis have been

previously described. Pace-Balzan et al. [3] reported the
Atrophic rhinitis is a chronic, gradually progressing following features: (1) mucosal thickening of the paranasal
degenerative condition of the nasal cavity characterized by a sinuses, (2) loss of definition of the ostiomeatal unit (OMU)
foul odor (ozena), nasal obstruction, dryness, and crusting secondary to resorption of the ethmoid bulla and uncinate
[1]. The etiology of primary atrophic rhinitis is mostly process, (3) hypoplasia of the maxillary sinuses, (4) enlarge-
unknown. Progressive metaplasia and atrophy of all mucosal ment of the nasal cavities with erosion and bowing of the lateral
components (epithelium, vessels, and glands) takes place nasal wall, and (5) bony resorption and mucosal atrophy of the
because of increased osteoclastic activity, resulting in a middle and inferior turbinate. However, there have been no
volumetric decrease of sinonasal structures. The turbinate studies comparing changes in radiological findings following
show shrinkage and the inferior turbinate is affected the most. surgical management of primary atrophic rhinitis patients.
Endoscopic inspection reveals a large, wide nasal cavity with Classically, the management of patients with primary
dried mucosa [2]. atrophic rhinitis is aimed at alleviating symptoms using nasal
irrigation douche or ointment application. In 1971, Young [4]
proposed closure of the nostril (Young’s operation), and
Saunders [5] suggested endonasal microplasty (intranasal
* Corresponding author at: Department of Otolaryngology, Asan Medical
Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil,
implant insertion) for the surgical management of primary
Songpa-gu, Seoul 05505, Republic of Korea. Fax: +80 248 927 73. atrophic rhinitis. However, Young’s operation has its demerit
E-mail address: jangyj@amc.seoul.kr (Y.J. Jang). on the possibility of decreased patient’s quality of life due to
0385-8146/© 2017 Elsevier B.V.. All rights reserved.

Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003
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closure of the nostril. In addition, previous nasal implantation maxillary sinus, and mucosal swelling of all paranasal sinuses
techniques carry the risk for implant extrusion, absorption, and (Fig. 2B).
moreover, there are insufficient long term follow-up results [6–
9]. The corresponding author (YJ Jang) have previously 2.2. Surgical technique
reported promising outcomes following inferior turbinate
reconstruction using autologous costal cartilage in empty nose Turbinate reconstruction was performed as described in our
syndrome (ENS) patients [10]. Inspired by the fact that primary previous report on treating patients with ENS [10]. After the
atrophic rhinitis and ENS share similar physical and symptoms, patient was placed under general anesthesia, the right sixth
we hypothesized that the turbinate reconstruction procedure costal cartilage was harvested. A cube of harvested cartilage
would be also beneficial for the primary atrophic rhinitis with dimensions of 2 cm  4 cm  2 cm (length, breadth,
patients as well. Hence, we report here the first case of primary thickness, respectively) was carved and designed into two
atrophic rhinitis successfully treated by turbinate reconstruction conical grafts (Fig. 3A). Turbinate reconstruction was then
using autologous costal cartilage. performed by making an incision on pyriform apertures
bilaterally (Fig. 3B). After the submucosal flap was elevated,
the graft was inserted submucosally; the wound was closed by
2. Case report the simple suture of the nasal mucosa. The inferior turbinate
were reinforced and reconstructed, thus narrowing nasal
2.1. Clinical history cavities bilaterally.

A 63-year-old woman, previously healthy with no underly- 2.3. Surgical outcome

ing conditions or history of nasal surgeries, complained
bilateral nasal obstruction, foul odor, severe crusting, postnasal At 2 weeks after surgery, crusting was diminished, and
drip, and dryness of both nasal cavities. These symptoms augmented new inferior turbinate below the native turinate was
persisted and bothered the patient for many years, which led her observed bilaterally. At 3 months after surgery, the patient
to visit her local ENT clinic, where she received frequent nasal reported she no longer had any sensation of crusting of her nasal
dressings for the nasal crusting of nasal cavities. Despite those cavity and had a decrease in postnasal drip. At the 2-year
therapies, the symptoms did not completely resolve; therefore, follow-up, both inserted implants were still in place without
she visited the Asan Medical Center to seek a second opinion. resorption on gross (Fig. 2C), in addition to amelioration in the
Endoscopic examination revealed severe crusting of the patient’s initial symptoms. Her SNOT-25 scores had decreased
mucosa of nasal cavities bilaterally, along with bilateral atrophy to 6 (Fig. 4). OMU CT showed resolved obstruction of the sinus
of the turbinate (Fig. 1). Her initial SNOT-25 score was opening as well as decreased mucosal swelling (Fig. 2D). No
108. We diagnosed the patient with primary atrophic rhinitis surgery-related complications were observed during the 2-year
and prescribed an oral antihistamine, a mucolytic agent, and follow-up period, including graft absorption or extrusion.
clarithromycin, along with nasal irrigation with saline solution.
After 1 month, there was no improvement in her symptoms 3. Discussion
and the severe crusting persisted (Fig. 2A). Computed
tomography of the OMU CT showed atrophy of the middle We report here the first successful management of primary
and inferior turbinate, hypoplasia and obstruction of the atrophic rhinitis by surgical reconstruction of the turbinate

Fig. 1. Initial endoscopic nasal examination of the patient; pus-like thick, yellowish discharge with atrophied turbinate are seen. (For interpretation of the references to
colour in this figure legend, the reader is referred to the web version of this article.)

Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003
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Fig. 2. (A–B) After 1 month of conservative management with clarithromycin and nasal irrigation. (A) Showing worsening of crusting and mucosal dryness. (B)
OMU CT scan reveals atrophied turbinate with bilateral hypoplasia of maxillary sinus. In addition, diffuse swelling of nasal mucosal linings were observed, therefore
obliterating the natural ostium of both maxillary sinuses. (C–D) Two-years post-operative outcomes. (C) Showing neo-turbinate below the missing turbinate with no
extrusion of implanted costal cartilage graft. (D) Shows decreased swelling of nasal mucosa with improved patency of natural ostium of antrum, bilaterally.

using autologous costal cartilage. Because the etiology and In addition, no standard surgical approach has been
pathophysiology of primary atrophic rhinitis are not fully established for managing patients with primary atrophic
understood, patients with primary atrophic rhinitis are usually rhinitis. In a Cochrane review, Mishra et al. proposed a
managed by symptomatic treatment [2]. Nevertheless, no single randomized controlled trial comparing the effectiveness of
method is accepted as standard treatment because no method Young’s operation to nasal lubrication in primary atrophic
provides permanent relief. rhinitis patients. In 2012, interim results were published,
As mentioned in the introduction, many attempts have been showing a lack of evidence of long-term benefits or risks in
made to treat primary atrophic rhinitis with surgery comparisons of the two treatment methods because of the short
[2,5,6,8,9,11–13]. Despite these attempts, there is insufficient observation period [14].
evidence that surgery is superior to conservative management For many decades, costal cartilage was favored by many
of primary atrophic rhinitis, making surgeons hesitant to rhinoplasty surgeons to provide adequate amounts of harvested
perform surgery. Despite many decades of clinical experience cartilage. In 2013, the senior author of this report (YJ Jang) had
with primary atrophic rhinitis, no randomized control trials published a paper on turbinate reconstruction in ENS patients
have been conducted comparing surgical versus conservative using autologous cartilage. Patients whose inferior turbinate
management. were reconstructed using costal cartilage showed greater

Fig. 3. (A) 6th costal cartilage was harvested from the patient during surgery, and designed as above. (B) Schematic illustration of turbinate reconstruction; atrophied
inferior turbinate is seen (asterisk), and an incision and mucosal flap elevation was made at piriform aperture (arrowhead) followed by designed costal cartilage
implantation at the submucosal space (arrow).

Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003
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using Autologous Costal Cartilage” was written in accordance

with the Code of Ethics of the World Medical Association
(Helsinki Declaration).
We authors have consulted the Institutional Review Board
(IRB) of Asan Medical Center (AMC) about the IRB approval
before the initiation of the manuscript. Considering the fact that
this article is a case report, the Asan Medical Center IRB
approved an exemption of deliberation for IRB approval. If the
certification for exemption of deliberation for IRB approval by
AMC IRB is needed, we would be pleased to attach the proof of
certification. We have obtained written informed consent from
the participant. The patient’s anonymity was preserved during
the entire publishing process.

Sources of funding

Fig. 4. Pre-operative SNOT-25 score rated 108, which dramatically decreased
to 6 at two-years post-operative period.
improvement in their SNOT-25 scores than patients in which
conchal cartilage was used [15]. Round, long, ovoid costal None.
cartilage has its strength than thin, small conchal cartilage when
reconstructing the turbinate.
Moore and Kern [13] reported total number of 7 cases in References
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Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003