AAtrophictrophic Rhinitis Rhinitis

RhinosporidiosisRhinosporidiosis

RhinoscleromaRhinoscleroma..

Atrophic RhinitisAtrophic Rhinitis

Chronic nasal disease characterized by Chronic nasal disease characterized by progressive atrophy of the mucosa and progressive atrophy of the mucosa and underlying turbinates forming dry crust and underlying turbinates forming dry crust and viscid secretions with characteristic foul viscid secretions with characteristic foul odour, Ozaena.odour, Ozaena.

Aetiology:Aetiology: Primary: cause unknownPrimary: cause unknown Secondary: due to specific aetiological factorSecondary: due to specific aetiological factor

Primary:Primary: InfectionInfection

Klebsiella ozaenaeKlebsiella ozaenae

Diptheroid bacilliDiptheroid bacilli

Cocccobacillus foetidus ozaenaCocccobacillus foetidus ozaena Hormonal imbalanceHormonal imbalance

at puberty at puberty

more common in femalesmore common in females NutritionalNutritional

common in poor socioeconomic status common in poor socioeconomic status

In Vit A / D and iron-deficiencyIn Vit A / D and iron-deficiency HeredityHeredity AutoimmuneAutoimmune

Altered cellular reactivityAltered cellular reactivity

Release of nasal mucosal antigen into systemic circulationRelease of nasal mucosal antigen into systemic circulation

Secondary:Secondary: Chronic RhinosinusitisChronic Rhinosinusitis Chronic granulomatous lesionsChronic granulomatous lesions

TuberculosisTuberculosis

SyphilisSyphilis

LeprosyLeprosy SurgerySurgery

Excessive destruction nasal tissuesExcessive destruction nasal tissues

Pathology:Pathology: Epithelium: Epithelium:

Patches of metaplasia Patches of metaplasia Transition from ciliated columnar to non kerainized Transition from ciliated columnar to non kerainized or keratinized squamous epitheliumor keratinized squamous epithelium

Lamina propria: Lamina propria: chronic cellular infiltration, granulation tissue and chronic cellular infiltration, granulation tissue and fibrosis.fibrosis.

Mucous glands: Mucous glands: decreased in size and numberdecreased in size and number

Vascular: Vascular: decreased vascularity, periarteritis and endarteritis decreased vascularity, periarteritis and endarteritis of terminal arteriolesof terminal arterioles

Clinical Features:Clinical Features: Merciful anosmia Merciful anosmia

because of atrophy of nerve elements (responsible for the because of atrophy of nerve elements (responsible for the perception of smell).perception of smell).

Nasal obstruction Nasal obstruction Bleeding from the nose when the dried discharge Bleeding from the nose when the dried discharge

(crusts) are removed. (crusts) are removed. Nasal cavities: Nasal cavities:

roomy, filled with dry foul smelling black or dark green crustsroomy, filled with dry foul smelling black or dark green crusts Septal perforation and dermatitis of Septal perforation and dermatitis of nasal vestibule Nose may show a saddly nose deformity.Nose may show a saddly nose deformity. Associated with similar atrophic changes in the Associated with similar atrophic changes in the

pharynx, , larynx producing symptoms pertaining to producing symptoms pertaining to these structures. these structures.

Hearing impairment due to Hearing impairment due to Eustachian tube blockage blockage causing causing middle ear effusion. effusion.

Permanent loss of smell and impairement of tastePermanent loss of smell and impairement of taste

TreatmentTreatment medical medical surgical.surgical.

Medical measures include:Medical measures include: Nasal irrigation using normal saline Nasal irrigation using normal saline Nasal irrigation and removal of crusts using alkaline Nasal irrigation and removal of crusts using alkaline

nasal douches (280ml of water, 28.4g of Sod nasal douches (280ml of water, 28.4g of Sod bicarbonate, 28.4 g of Sod diborate, 56.7g of bicarbonate, 28.4 g of Sod diborate, 56.7g of Sod.Chloride.)Sod.Chloride.)

25% glucose in glycerine, 25% glucose in glycerine, Local antibiotics like Kemicetine antiozaena solution Local antibiotics like Kemicetine antiozaena solution

(Chloramphenicol + Ostradiol + Vit D2 )(Chloramphenicol + Ostradiol + Vit D2 ) Ostradiol spray Ostradiol spray Systemic streptomycin / rifampicinSystemic streptomycin / rifampicin Oral potassium iodide Oral potassium iodide Human placental extract : systemicHuman placental extract : systemic

injected in the submucosa injected in the submucosa

Surgical Interventions include:Surgical Interventions include: Young's operation Young's operation Modified Young's operation Modified Young's operation Narrowing of nasal cavities, Narrowing of nasal cavities,

submucosal injection of Teflon paste, submucosal injection of Teflon paste,

section and medial displacement of lateral wall of section and medial displacement of lateral wall of nose nose

Transposition of parotid duct to maxillary Transposition of parotid duct to maxillary sinus or nasal mucosa. sinus or nasal mucosa.

RhinosporidiosisRhinosporidiosis

Endemic in southern India and Sri Lanka.Endemic in southern India and Sri Lanka.In Nepal: Rajbiraj and Janakpur.In Nepal: Rajbiraj and Janakpur.Chronic infection of the upper respiratory tract – Chronic infection of the upper respiratory tract – most commonly in the inferior turbinate of the most commonly in the inferior turbinate of the nasal cavity. nasal cavity. Causative agent:Causative agent: the ? fungus Rhinosporidium seeberithe ? fungus Rhinosporidium seeberi the waterborne organism Cyanobacterium microcystis the waterborne organism Cyanobacterium microcystis

aeruginosaaeruginosa

Other sites of involvement include:Other sites of involvement include: ears, larynx, esophagus, conjunctiva, and ears, larynx, esophagus, conjunctiva, and

tracheobronchial tree, any part of body tracheobronchial tree, any part of body

RhinosporidiosisRhinosporidiosis

Causative agent present in water and dust,Causative agent present in water and dust,

readily infects the nasal mucosa. readily infects the nasal mucosa.

matures into a sporangium matures into a sporangium

subsequently bursts to release multiple subsequently bursts to release multiple endospores, endospores,

infects surrounding tissues. infects surrounding tissues.

RhinosporidiosisRhinosporidiosis

Clinical Presentation:Clinical Presentation: Patients with nasal involvement present withPatients with nasal involvement present with

nasal obstruction, nasal obstruction,

epistaxis, and epistaxis, and

rhinorrhea. rhinorrhea. Systemic dissemination rareSystemic dissemination rare On Examination:On Examination:

Unilateral beefy-red granulomatous lesion with Unilateral beefy-red granulomatous lesion with white spots. (Strawberry appearance)white spots. (Strawberry appearance)

RhinosporidiosisRhinosporidiosis

Treatment:Treatment: Medical therapy with antibiotics or anti-fungal Medical therapy with antibiotics or anti-fungal

(not proven to be helpful)(not proven to be helpful) Treatment of choice : Treatment of choice :

Wide excision with electrocauterization of the Wide excision with electrocauterization of the lesional base. lesional base.

surgical excision of the lesion, (recurrence ~10%)surgical excision of the lesion, (recurrence ~10%) Dapsone Dapsone

RhinoscleromaRhinoscleromaProgressive granulomatous disease commencing in Progressive granulomatous disease commencing in nose and extending into other areas of airwaynose and extending into other areas of airway

occurs in regions of poor standard of domestic hygiene. occurs in regions of poor standard of domestic hygiene.

Causative organism:Causative organism: K. rhinoscleromatis (Gm –ve bacillus) K. rhinoscleromatis (Gm –ve bacillus)

Histology:Histology:

marked cellular infiltrates consisting of lymphocytes and plasma cells.  There marked cellular infiltrates consisting of lymphocytes and plasma cells.  There are many macrophages with clear to foamy cytoplasm (Mikulicz cells) Plasma are many macrophages with clear to foamy cytoplasm (Mikulicz cells) Plasma cells eccentric nucleus with deep eosin-staining cytoplasm (Russel Bodies.)cells eccentric nucleus with deep eosin-staining cytoplasm (Russel Bodies.)

RhinoscleromaRhinoscleroma

Clinical stages:Clinical stages: 1) rhinitic (Atrophic)1) rhinitic (Atrophic) 2) florid (Granulation)2) florid (Granulation) 3) fibrotic (Cicatrizing). 3) fibrotic (Cicatrizing).

Symptoms :Symptoms : vary with the location of the infection. vary with the location of the infection. nasal cavity (septum): most common site, nasal cavity (septum): most common site, other sites of infection include: other sites of infection include:

paranasal sinuses, orbit, larynx, tracheobronchial tree, and middle paranasal sinuses, orbit, larynx, tracheobronchial tree, and middle ear. ear.

Treatment :Treatment : Tetracycline Streptomycin x 6 weeksTetracycline Streptomycin x 6 weeks Acriflavine solution ( in vitro killed K. rhinoscleromatisAcriflavine solution ( in vitro killed K. rhinoscleromatis)) Significant airway obstruction requires surgical excision.Significant airway obstruction requires surgical excision. RadiotherapyRadiotherapy Laser treatment.Laser treatment.

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