Infective & Atrophic Rhinitis

Dr. Vishal Sharma

Acute Infective Rhinitis

SPECIFIC NON-SPECIFIC

Acute diphtheritic Common cold

Acute syphilitic Influenza

Erysipelas

Exanthematous rhinitis

Common cold (coryza)Highly contagious, viral infectious disease of

upper respiratory system. Caused by rhino-

virus, coronavirus, human parainfluenza virus,

human respiratory syncytial virus, adenovirus.

Transmission:

Aerosol generated by coughing, sneezing

Contact with saliva or nasal secretions

Symptoms: sore throat, runny nose, nasal

congestion, sneezing, cough; pink eye, muscle

aches, fatigue, malaise, headaches, muscle

weakness, loss of appetite. Symptoms resolve

after 1-2 week.

Opportunistic super infections: acute

bronchitis, croup, pneumonia, sinusitis, otitis

media, sore throat.

TreatmentBed rest. Avoid exposure to cold weather.

Plenty of fluids. Avoid cola & alcoholic drinks.

Avoid tea & coffee (they cause dehydration)

Antihistamines + nasal decongestants

Non-aspirin analgesics

Antibiotics for secondary infection

Doubtful role: Vitamin C, Zinc, chicken soup,

ginger, garlic, herbal tea, steam inhalation.

Chronic Infective Rhinitis

SPECIFIC NON-SPECIFIC

Tubercular Chronic simple

Chronic diphtheritic Chronic

hypertrophic

Chronic syphilitic Atrophic rhinitis

Leprosy Rhinitis sicca

Rhinoscleroma Rhinitis caseosa

Rhinosporidiosis

Chronic simple rhinitis Chronic hypertrophic rhinitis

Early stage hypertrophy of glands in swollen turbinates

Late stage hypertrophy + fibrosis

Swollen turbinates pit on pressure

No pitting

Swollen turbinates shrink with topical decongestants

Absent or minimal shrinking

Tx: Antibiotics + Nasal decongestants

Tx: Turbinate reduction or resection

Atrophic Rhinitis

HistoryDr. Spencer Watson, 1875:

Used the term “Ozaena”

Dr. Bernhard Fraenkel, 1876:

Described triad of:

1. Fetor

2. Crusting

3. Atrophy of nasal structures

Chronic inflammation of nose with progressive

atrophy of nasal mucosa & turbinate bones

Formation of scanty viscid secretion & green

crusts which emit a foul odour (ozaena)

Removal of crusts reveals roomy nasal cavity

Types: 1. Primary 2. Secondary

Introduction

Primary Atrophic

Rhinitis

Aetiology Developmental

Hereditary

Endocrine

Racial

Nutritional deficiency

Infection

Autoimmune Autonomic Imbalance

Surfactant deficiency in nasal secretion

Developmental

Congenitally spacious nasal cavity

Poor pneumatization of maxillary antrum

Hereditary: 30% cases autosomal inheritence

67% = Dominant, 33% = Recessive

Endocrine: Seen during puberty, menopause,

menstruation. Symptoms aggravated

due to oestrogen deficiency.

Racial: More in American Negroes & Latin

races (yellow race)

Nutritional deficiency: Iron deficiency,

Vitamin A deficiency, Vitamin D deficiency

Infection: Klebsiella ozaenae (Perez & Abel

bacillus), Coccobacillus foetides ozaena,

Bacillus mucosus, Diphtheroids,

Haemophilus influenzae

Autoimmune: viral infection / malnutrition /

immune deficiency trigger destructive

autoimmune process on nasal mucosa

Autonomic Imbalance: Reflex Sympathetic

Dystrophy Syndrome (R.S.D.S.) causes

vasodilatation & hyperaemic decalcification of

turbinates followed by vasoconstriction

Surfactant deficiency in nasal secretion: ciliary

dysfunction + stasis of nasal secretions

Secondary Atrophic Rhinitis

Long-standing purulent sinusitis

Iatrogenic: Radical turbinectomy,

maxillectomy, post-radiotherapy

Tuberculosis, Syphilis, Leprosy

Rhinoscleroma

Deviated nasal septum (atrophy in wider nasal

cavity)

Symptoms Nasal obstruction

Greenish-yellow nasal discharge

Offensive smell (ozaena) due to anaerobic

infection, experienced by relatives

Merciful anosmia present in the patient

Epistaxis on crust removal

Signs Roomy nasal cavity with atrophy of mucosa &

turbinates

Greenish-yellow nasal discharge with crust

formation (begins posteriorly)

Foul smell (foetor)

Nasal septum perforation

Nasal myiasis

Nasal crusting

Nasal crusting

Normal Turbinates & Meati

Turbinate atrophy & roomy nasal cavity

D/D for ozaena D/D for dry nose

1. Atrophic rhinitis 1. Atrophic rhinitis

2. Purulent sinusitis 2. Rhinitis sicca

3. Nasal foreign body 3. Radiotherapy

4. Rhinitis caseosa 4. Sjogren’s

syndrome

5. Malignancy

Causes of Anosmia

1. Loss of olfactory neural elements

2. Thick secretion & crusts over olfactory area

3. Degeneration of secretory glands scanty

mucous for dissolving odoriferous materials

Causes of nasal obstruction

1. Blunting of sensory nerve endings

2. Crust formation

3. Lack of eddy current formation in roomy cavity

Pathology: Accumulation of lymphocytes & plasma cells.

Squamous metaplasia from ciliated columnar

Ciliary destruction & decrease in nasal glands

Bone resorption

Type I: Endarteritis & periarteritis of terminal

arterioles. Benefit from estrogen therapy

Type II: Dilated capillaries worsened by estrogen

Biopsy Findings

Normal Atrophic rhinitis

Specific Investigations

Saccharine test: ed nasal muco-ciliary

clearance time

Serum iron & protein levels: malnutrition

Culture & sensitivity of nasal discharge

Diagnostic Nasal Endoscopy

X-ray P.N.S.: maxillary sinusitis

C.T. scan P.N.S.Mucoperiosteal thickening Resorption of ethmoid

bulla & uncinate process Hypoplasia of maxillary

sinuses Roomy nasal cavities Erosion & bowing of

lateral nasal wall Atrophy of turbinates

Specific Investigations

Chest X-ray: T.B., bronchiectasis, lung abscess

Serology for syphilis: V.D.R.L., T.P.H.A., T.P.I.

Sputum for AFB, Mantoux test: T.B.

Nasal smear study: Leprosy

Complement fixation test & biopsy: Rhinoscleroma

Medical Treatment

Douching alkaline nasal douche

Oestradiol nasal spray (1%)

Glucose (25%) in glycerin nasal drops

Streptomycin injection

Placental extract injection

Autogenous vaccines

Rifampicin

Kemicetine solution: Estrogen, Vit. D, Chloramphenicol

Mandl’s nasal paint (Potassium Iodide & oestradiol)

Potassium Iodide orally

Alkaline Nasal DoucheSodium bicarbonate (28.4g) loosens nasal crusts

Sodium biborate (28.4g) Antiseptic

Sodium chloride (56.7g) makes solution isotonic

Mixed in 280 ml of warm water to make the solution.

20 ml plastic syringe with 6” long rubber tubing taken.

Syringe nasal cavity while pt bends forward & keeps

saying K, K, K … to close nasopharyngeal isthmus.

Done B.D. till all crusts disappear.

Action of Placental extractProgesterone leads to hyperplasia of nasal

mucosa & glandular secretion

Oestrogen leads to vasodilatation

Biogenic stimulator of metabolic & regenerative

process

Intra-placental serum boosts up immunity

Mechanical narrowing of nasal passage

Surgical Treatment

Young’s operation: Only 1 nostril closed

completely by raising 2 circumferential

flaps (inner mucosal & outer cutaneous) in nasal

vestibule & suturing them in midline.

Modified Young’s operation done by similar

way but keeping a 3 mm opening on both sides.

Recannalisation done after 12-18 month with a

tri-radiate (Mercedes Benz) incision.

Pre-operative

Mucosal flaps sutured

Cutaneous flap sutured

Post-operative healed flaps

Modified Young’s operation

Tri-radiate incision

Modified Young’s (El Kholy)

Advantages of Modified Young

Progress of disease can be monitored with 2.7

mm nasal endoscope

Glucose in glycerine drops can be instilled

Both nostrils can be operated at one sitting

Nasal breathing preserved

No complaints of de-nasal voice

Better cosmetic result

Lautenslager’s operation: Fracture & medial

displacement of lateral nasal wall

Wilson’s operation: submucosal injection

of Teflon paste

Antral mucosal transplantation into nasal cavity

through intranasal antrostomy: Raghav Sharan

Vestibuloplasty: raising a lateral shelf from

nasal vestibular flap to cover turbinates

Sympathectomy: Stellate ganglion block /

cervical chain block

Sublabial implantation: bone, cartilage, fat,

placental bits, hydroxyapatite + fibrin paste,

Plastipore, acrylic resin, silastic

Parotid duct implantation into maxillary sinus:

Wittmack’s operation

Pre-operative

Lautenslager’s operation

Submucosal Teflon paste

Sublabial Implants

Sublabial Implants

Vestibuloplasty

Antral mucosa transplant

Types of surgeryNasal closure: Young Modified Young

Volume reduction: Lautenslager Wilson

Sublabial implants Vestibuloplasty

Denervation: Cervical sympathectomy

Stellate ganglion block

Sphenopalatine ganglion block

Salivary irrigation: Parotid duct implantation

Aim of SurgeryDecrease trauma of air turbulence:

Nasal closure

Volume reduction

Increase nasal secretions:

Parotid duct implantation into maxillary sinus

Increase vascularity of nasal mucosa:

Denervation procedures

Nasal implantation of maxillary sinus mucosa

Surgical TreatmentModified Young Young

Lautenslager Lady

Wilson Was

Vestibuloplasty Very

Sublabial implantation Sweet

Antral mucosal transplantation And

Parotid duct implantation Pretty

Nasal Obturator

Nasal ObturatorAdvantages

Reversible & easily removed

Allows for irrigations & serial clinical exams

Avoids surgical morbidity

Disadvantages

Uncomfortable

Sore throat due to obligate mouth breathing

Rhinitis SiccaMild form of atrophic rhinitis

Seen in hot, dry, dusty places (bakers,

goldsmiths); alcoholics & anaemics

Crusting present anteriorly only

Bone atrophy & foetor are absent

Tx: Nasal douching + change of surrounding

Rhinitis CaseosaSynonym: Nasal cholesteatoma

Chronic inflammation with deposition of foul

smelling cheesy material in nasal cavity.

Nasal obstruction stasis of secretions &

exfoliated cells putrefaction caseation

Treatment: 1. Removal of cheesy debris

2. Correction of nasal obstruction

Thank You