Atrophic Rhinitis-Part 2

8/14/2019 Atrophic Rhinitis-Part 2

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Atrophic RhinitisAtrophic Rhinitis

Dr. A. Karunagaran, MS,Dr. A. Karunagaran, MS,DLO.DLO.

Madras Medical collage,Madras Medical collage,Chennai-3Chennai-3


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Common TermsCommon TermsOzenaOzenaDry RhinitisDry RhinitisRhinitis SiccaRhinitis Sicca


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Atrophic RhinitisAtrophic Rhinitis1) Accidental or Simple Ozoena1) Accidental or Simple Ozoena

due to the retention of mucous.due to the retention of mucous. easily dealt with by the frequent employment of the nasaleasily dealt with by the frequent employment of the nasaldouche douche

2) Idiopathic or constitutional2) Idiopathic or constitutional commences in early childhood ... And remains during the earlycommences in early childhood ... And remains during the earlyyears or throughout the whole adult life.years or throughout the whole adult life. The patient is generally anosmic and he is, therefore, The patient is generally anosmic and he is, therefore,unaware of the offensive odor of his breath.unaware of the offensive odor of his breath. The nature of the inflammatory process is very probably allied The nature of the inflammatory process is very probably alliedto that of lupus erythematosus of the face.to that of lupus erythematosus of the face.

3) Syphilitic Ozoena3) Syphilitic Ozoena

the most common formthe most common form These ulcers may be preceded or followed by caries or These ulcers may be preceded or followed by caries ornecrosis of the bones, and the stench is then more horriblynecrosis of the bones, and the stench is then more horriblysickening than in any other form of this disgusting malady.sickening than in any other form of this disgusting malady.


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Described in 1876 by Dr. Bernhard FraenkelDescribed in 1876 by Dr. Bernhard Fraenkelas a triad of:as a triad of:

FetorFetorCrustingCrustingAtrophy of nasal structuresAtrophy of nasal structures

the breath is often so penetrating as to render thethe breath is often so penetrating as to render thenear presence of the sufferer not only unpleasantnear presence of the sufferer not only unpleasantbut almost unendurable.but almost unendurable.


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Clinical FeaturesClinical FeaturesAnosmiaAnosmia

Ozena, i.e. foul odorOzena, i.e. foul odorExtensive nasal crustingExtensive nasal crustingSubjective nasal congestionSubjective nasal congestionEnlargement of the nasal cavityEnlargement of the nasal cavityResorption or absence of turbinatesResorption or absence of turbinatesSquamous metaplasia of nasal mucosaSquamous metaplasia of nasal mucosaDepressionDepression


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Atrophic rhinitisAtrophic rhinitis

SecondarySecondaryComplication of sinus surgery (89%)Complication of sinus surgery (89%)Complication of radiation (2.5%)Complication of radiation (2.5%)Following nasal trauma (1%)Following nasal trauma (1%)Sequela of granulomatous diseases (1%)Sequela of granulomatous diseases (1%)

SarcoidSarcoidLeprosyLeprosyRhinoscleromaRhinoscleroma

Sequlae of other infectious processesSequlae of other infectious processes Tuberculosis TuberculosisSyphilisSyphilis


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Other suggested causesOther suggested causesInfectious (Ssali)Infectious (Ssali)

Case report of AR developed in 7 children of one familyCase report of AR developed in 7 children of one familyafter contact with another known AR child.after contact with another known AR child.

DietaryDietary(Bernat) Iron therapy found to benefit 50% of patients(Bernat) Iron therapy found to benefit 50% of patients

treatedtreated(Han-Sen) Hypocholesterolemia present in 50% of (Han-Sen) Hypocholesterolemia present in 50% of patients.patients.(Han-Sen) Vitamin A therapy showed symptomatic(Han-Sen) Vitamin A therapy showed symptomaticimprovement in 84%.improvement in 84%.

Hereditary (Barton, Sibert)Hereditary (Barton, Sibert)

Proposed autosomal dominant disease due to father andProposed autosomal dominant disease due to father and8 of 15 children contracting the disease.8 of 15 children contracting the disease.HormonalHormonal

Symptoms known to worsen with menstraution orSymptoms known to worsen with menstraution orpregnancy.pregnancy.


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Other suggested causesOther suggested causes

Developmental (Hagrass)Developmental (Hagrass)Radiologic evidence of poor maxillary antrumRadiologic evidence of poor maxillary antrumpneumatization and short nasal lengthspneumatization and short nasal lengths

Vascular (Ruskin)Vascular (Ruskin)Postulated overactivation of sympathetic activity.Postulated overactivation of sympathetic activity.

Environmental (Mickiewicz)Environmental (Mickiewicz)Chronic exposure to phosphorite and apatide dustChronic exposure to phosphorite and apatide dust

Autoimmune (Ricci)Autoimmune (Ricci)


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Physical findingsPhysical findings

CrustingCrusting100% Present100% PresentInferior TurbinatesInferior Turbinates

62% Partial absence62% Partial absence37% Total absence37% Total absence

Middle TurbinatesMiddle Turbinates57% Absent57% Absent

DischargeDischarge52% Present52% Present

SeptumSeptum10% Perforations10% Perforations


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InvestigationsInvestigations

HemogramHemogramVDRLVDRLMantouxMantouxNasal smear for Lepra bacilliNasal smear for Lepra bacilli

Xray PNSXray PNS


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Radiographic FindingsRadiographic Findings

1.1. Mucoperiosteal thickening of the paranasal sinuses.Mucoperiosteal thickening of the paranasal sinuses.

2.2. Loss of definition of the OMC secondary to resorption of Loss of definition of the OMC secondary to resorption of the ethmoid bulla and uncinate process.the ethmoid bulla and uncinate process.

3.3. Hypoplasia of the maxillary sinuses.Hypoplasia of the maxillary sinuses.

4.4. Enlargement of the nasal cavities with erosion andEnlargement of the nasal cavities with erosion andbowing of the lateral nasal wall.bowing of the lateral nasal wall.

5.5. Bony resorption and mucosal atrophy of the inferior andBony resorption and mucosal atrophy of the inferior andmiddle turbinates.middle turbinates.


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Biopsy FindingsBiopsy Findings

Normal MucosaNormal MucosaPseudostratified ColumnarPseudostratified ColumnarPresence of serous andPresence of serous andmucous glandsmucous glands

Atrophic RhinitisAtrophic RhinitisSquamous metaplasiaSquamous metaplasiaAtrophy of mucous glandsAtrophy of mucous glandsScarce or absent ciliaScarce or absent ciliaEndarteritis obliteransEndarteritis obliterans


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MicrobiologyMicrobiology

Klebsiella ozenaeKlebsiella ozenaeMay be found in almost 100% of primary ARMay be found in almost 100% of primary AR

No predominance in secondary ARNo predominance in secondary ARStaphylococcus aureusStaphylococcus aureusProteus mirabilisProteus mirabilis

Escherichia coliEscherichia coliCorynebacterium diphtheriaeCorynebacterium diphtheriae


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Current TherapiesCurrent Therapies

Goals of therapyGoals of therapyRestore nasal hydrationRestore nasal hydrationMinimize crusting and debrisMinimize crusting and debris

Therapy options Therapy options Topical therapy Topical therapySaline irrigationsSaline irrigations

Antibiotic irrigationsAntibiotic irrigationsSystemic antibioticsSystemic antibioticsImplants to fill nasal volumeImplants to fill nasal volumeClosure of the nostrilsClosure of the nostrils


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Local therapyLocal therapyIrrigationsIrrigations

SalineSalineMixturesMixtures

Sodium bicarbonateSodium bicarbonateShehata: Sodium Carbonate 25g, Sodium Biborate 25g, andShehata: Sodium Carbonate 25g, Sodium Biborate 25g, and

Sodium Chloride 50g in 250ml water.Sodium Chloride 50g in 250ml water.Antibiotic solutionAntibiotic solution

Moore: Gentamycin solution 80mg/LMoore: Gentamycin solution 80mg/L

Anti-drying agentsAnti-drying agentsGlycerineGlycerine

Mineral OilMineral OilParaffin with 2% MentholParaffin with 2% MentholOtherOther

AcetylcholineAcetylcholinePilocarpinePilocarpine


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Systemic therapySystemic therapy

OtherOtherVitamin A (12,500 to 15,000 Units daily)Vitamin A (12,500 to 15,000 Units daily)Potassium Iodide (Increases nasal secretions)Potassium Iodide (Increases nasal secretions)

VasodilatorsVasodilatorsIron therapyIron therapyEstrogenEstrogenCorticosteroids *Corticosteroids *

VaccinesVaccinesAntibacterial (Pasturella, Bordetella)Antibacterial (Pasturella, Bordetella)AutogenousAutogenous


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Surgical therapiesSurgical therapies

Young procedure Young procedureModified Young procedureModified Young procedure

Turbinate reconstruction Turbinate reconstructionVolume reduction proceduresVolume reduction proceduresDenervating operationsDenervating operations


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Nasal ClosureNasal Closure

Youngs procedure Youngs procedureCircumferential flap elevation 1 cm cephalic to the alarCircumferential flap elevation 1 cm cephalic to the alarrim.rim.Sutures placed in center of elevated flap to close theSutures placed in center of elevated flap to close thenostrilnostrilStaged second side in 3 monthsStaged second side in 3 months

AdvantagesAdvantagesOften provided relief of symptomsOften provided relief of symptoms

DisadvantagesDisadvantages

Difficult to elevate circumferential flapDifficult to elevate circumferential flapBreakdown of central suture area commonBreakdown of central suture area commonDoes not allow for cleaningDoes not allow for cleaningDid not allow for periodic examinationDid not allow for periodic examinationRecurrence after flap takedownRecurrence after flap takedown


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Nasal ClosureNasal ClosureModified YoungsModified Youngs

Elevation of extended perichondrial flap throughElevation of extended perichondrial flap throughcontralateral hemitransfixion incision.contralateral hemitransfixion incision.Short skin flap elevated from the intercartilaginous lineShort skin flap elevated from the intercartilaginous lineon the ipsilateral side.on the ipsilateral side.Suture lateral and medial flaps with vicryl.Suture lateral and medial flaps with vicryl.Staged second side with first side takedown in 6 mon.Staged second side with first side takedown in 6 mon.

AdvantagesAdvantages Technically easier than Young procedure Technically easier than Young procedureNo suture line breakdownNo suture line breakdownNo vestibular stenosis on takedownNo vestibular stenosis on takedown

DisadvantagesDisadvantages

Not possible with large septal defectsNot possible with large septal defectsDoes not allow for cleaningDoes not allow for cleaningDoes not allow for periodic examinationDoes not allow for periodic examinationRecurrence after flap takedownRecurrence after flap takedown


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Modified YoungModified Young


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Volume reductionVolume reduction

Plastipore implantationPlastipore implantation

Porus material allows tissue ingrowth.Porus material allows tissue ingrowth.Implants shaped then fenestrated for ingrowth.Implants shaped then fenestrated for ingrowth.Implants placed submucosally along the septum andImplants placed submucosally along the septum andnasal floor.nasal floor.

AdvantagesAdvantagesEasier than other surgical options (Youngs)Easier than other surgical options (Youngs)Plastipore has low extrusion/complication ratePlastipore has low extrusion/complication rateMay be done under local anesthesiaMay be done under local anesthesia

DisadvantagesDisadvantagesPossibility of extrusion (occurred in 1/8 pts)Possibility of extrusion (occurred in 1/8 pts)Requires septal mucosa (not discussed)Requires septal mucosa (not discussed)


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PlastiporePlastipore


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Volume Reduction (cont)Volume Reduction (cont)

Triosite and Fibrin Triosite and Fibrin Triosite (60% hydroxyapetite, 40% calcium triphosphate) Triosite (60% hydroxyapetite, 40% calcium triphosphate)mixed with Fibrin 1:1.mixed with Fibrin 1:1.Deglove the labial vestibuleDeglove the labial vestibuleElevate periosteum of the floor posteriorly to the end of Elevate periosteum of the floor posteriorly to the end of the hard palate, extend medially onto the septum.the hard palate, extend medially onto the septum.Insert Triosite & Fibrin mixture (~3.3g per side)Insert Triosite & Fibrin mixture (~3.3g per side)

AdvantagesAdvantagesGood to excellent result (7/9 patients)Good to excellent result (7/9 patients)Material can be molded easilyMaterial can be molded easily

DisadvantagesDisadvantagesLeakage of material (4/9 patients)Leakage of material (4/9 patients)Infection of material (3/9 patients)Infection of material (3/9 patients)Potential damage to lacrimal systemPotential damage to lacrimal system


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Triosite and Fibrin Triosite and Fibrin


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Triosite and Fibrin Triosite and Fibrin


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Nasal ObturatorNasal Obturator


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Other TherapiesOther Therapies

Other ImplantsOther ImplantsAcrylicAcrylicSiliconeSilicone

Teflon TeflonSilasticSilastic

BoplantBoplantDenervationDenervationCervical sympathectomy (Bertein)Cervical sympathectomy (Bertein)Stellate ganglion block (Bahl)Stellate ganglion block (Bahl)Sphenopalatine ganglion block (Girgis)Sphenopalatine ganglion block (Girgis)Parasympathectomy, i.e. GSPN section (Krmptotic)Parasympathectomy, i.e. GSPN section (Krmptotic)

Salivary IrrigationSalivary IrrigationInvolves reimplantation of parotid duct into the maxillary sinusInvolves reimplantation of parotid duct into the maxillary sinus

AccupunctureAccupuncture Time Time

Disease often resolves spontaneously after age 40Disease often resolves spontaneously after age 40


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THANK YOU THANK YOU

Atrophic Rhinitis-Part 2

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