Atrophic Rhinitis ’Ozena’ Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital.

Atrophic RhinitisAtrophic Rhinitis ’Ozena’’Ozena’

Bastaninejad, Shahin, MD, ORL & HNS, TUMSBastaninejad, Shahin, MD, ORL & HNS, TUMS

Amiralam HospitalAmiralam Hospital

Presentation OutlinesPresentation Outlines

DefinitionDefinition

Pathophysiology

Clinical presentations

Differential diagnosis

Investigations

Treatment

Atrophic rhinitis Atrophic rhinitis

(AR) (AR) is a chronic is a chronic

and degenerative and degenerative

disease of the nasal disease of the nasal

& paranasal & paranasal

mucosa & other mucosa & other

structuresstructures

Definition (Cont’)

triad of characteristic fetor, greenish crusts and roomy nasal cavities this this triad is diagnostic of the conditiontriad is diagnostic of the condition

Prevalence of Primary ARPrimary AR 0.3-1% in high prevalence countries

High Prevalence countries are: India, Pakistan, China, Philippines, Malaysia, Saudi Arabia, Egypt and South america


Primary AR: More common in females(*6), usually

bilateral, Prevalent in young and middle age adults

Often, no underlying etiology is discoveredOften, no underlying etiology is discovered,

although inheritable or infectious causes (58.7% K.

ozena) are proposed mechanisms

there is however little evidence to suggest

bacterial organisms cause the disease, they may

be secondary invaders


Secondary ARSecondary AR: : Complication of sinus surgery (89%)

1. FESS in CRS > FESS in Polypoid CRS

2. In Mayo clinic assay : Partial MT and/or IT resection was the most common cause

Complication of radiation (2.5%)

Following nasal trauma (1%)

Sequela of granulomatous diseases (1%) and other infections : TB, Sarcoidosis, Leprosy, Rhinoscleroma, Syphilis

OutlinesOutlines


PathophysiologyPathophysiology

Clinical presentationsClinical presentations

Differential diagnosisDifferential diagnosis

InvestigationsInvestigations

TreatmentTreatment

PathophysiologyNl. Respiratory epithelium (Pseudostratified Columnar) metaplastic changes cuboidal/stratified squamous epithelium

Atrophy of cilia and the mucosal and submucosal gland

Secondary bac. Infection produce a foetid odour

Osteitis of inferior turbinates and ethmoid turbinates

Vascular involvement (mainly endarteritis obliterans)

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TreatmentTreatment

Clinical Features Clinical Features (Symptoms)(Symptoms)

Nose emits a foul smell due to crusting and secondary infections (main characteristic).(main characteristic).

Anosmia, cacosmia

Nasal obstruction

Headache

Thick purulent discharge with a foul smell (due to the anaerobic bacteria)

Minor bleeds due to dislodgment of crusts

Complain of dryness in the nose and throat (pharyngitis sicca)

Clinical Features Clinical Features (signs)(signs)

Greenish yellow and black crusts (Crusts 100% present), bleeding and ulcerated mucosa is seen when crusts are separated

Patient is usually gloomy

Foetor (detected from distance)

Wide capacity of the nasal passages, Shrinkage of inferior and middle turbinates

Insensitivity of nasal mucosa (probe test)

Septal perforation, myiasis, saddle nose &… may be seen

OutlinesOutlines






TreatmentTreatment

Differential diagnosisDifferential diagnosisTB

Leprosy

Scleroma

Syphilis

Chronic sinus suppuration on its own

Suppurating adenoidal disease

Neglected FB / rhinoliths

Wegner’s disease

Chronic fungal rhinosinusitis

Empty nose syndrome (ENS)Kern & Stenkvist at 1994

What is What is ENSENS??

ENS is an iatrogeniciatrogenic disorder most often recognized by the presence of paradoxical nasal obstruction paradoxical nasal obstruction despite an objectively wide nasal fossa

ENS vs. Secondary ARENS vs. Secondary ARThe resorption of the turbinate and adjacent mucosal tissue that results from atrophic rhinitis is reflective of the underlying pathophysiology of the disease, whereas ENS is an iatrogenic disorder

Secondary AR may also be the result of a multitude of other factors, including trauma, infection, or immunologic disorders.

Atrophic rhinitis has clear pathogenic links to organisms isolated from nasal cultures, but as of yet, there is no pathogen associated with ENS

OutlinesOutlines






TreatmentTreatment

InvestigationsInvestigationsHematologic study (CBC/diff)

ESR

FBS

C-ANCA, VDRL

PPD

CXR

PNS CT-Scan

Nasal swab for culture

Nasal Bx tested for bacteriological and morphological indices

OutlinesOutlines






TreatmentTreatment

Treatment Treatment (Medical)(Medical)

Conservative management is the mainstaymainstay

of the treatment

No cure available

Decongestants or antihistamines: strongly

contraindicates

Nasal irrigation and douches:

With Alkaline douches (preferred)(preferred)

With N/S or antibiotic+N/S douches


An ideal alkaline nasal douche mixture:

1. Sodium bicarbinate 25g

2. Sodium biborate 25g

3. Sodium chloride 50g

One teaspoonful of this mixture in 250cc

lukewarm water, tds or qid, for 6wk, with a 10 to

20cc syringe

Instruct the patient to bend forward during the

procedure and keep saying K K K…


Glucose-glycerineGlucose-glycerine nose drops

1. Anhydrous Glucose 25% (~15g)

2. Glycerine 60cc

Use this after nasal douching

You can also use Gentamicin or

Chloramphenicol drops after nasal

douching, too


Antibiotics:

Rifampicin 600mg daily for 12wk (generic cap.

is 300mg – take 2 every morning)

Recently: Cipro 500-750mg bid for 1-3moCipro 500-750mg bid for 1-3mo

Vitamin A , 12,500 IU/day up to two

weeks.

Iron supplements (if the patient is anemic)

Treatment (Surgical)

1) Young’s Procedure

2) Modified Young’s procedures

3) Modification of modified Young

4) Implantation

5) Other approaches


Young’s procedureYoung’s procedure

Circumferential flap elevation 1 cm cephalic to the alar

rim

Complete closure of nostril

Staged second side in 3-6 months

Difficult to elevate circumferential flap

Modified YoungModified Young

Staged second side with first side takedown Staged second side with first side takedown in 6 moin 6 mo

No vestibular stenosis on takedownNo vestibular stenosis on takedown


Modification of the modified young’s:


ImplantationImplantation: uses Bone (Auto/homografts),

Cartilages, ... Prostethic implants such as

Plastipore, ...

Extrusion of the prosthetic implants occured

1 in 8 in Plastipore series, but in another

prosthetic series it was occured as high as

80%

PlastiporePlastipore

Silastic SheetSilastic Sheet - Case: Primary AR - 12 - Case: Primary AR - 12momo postop result postop result ((Otolaryngology–Head and Neck Surgery (Otolaryngology–Head and Neck Surgery (20102010))))

RightRight

LeftLeft

Treatment (surgical)

Other approaches:

Transferring the Stensen duct to the maxillary

sinus antrum

Using a caldwell approach, translocating the

lateral nasal wall more medially

Silastic obturator

...

Presentation ConclusionPresentation Conclusion

Prim

ary Atrophic R

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rimary A

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itisA

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Endoscopic

Endoscopic S

inus S

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Functional Endoscopic Sinus SurgeryFunctional Endoscopic Sinus Surgery...Try to save nasal structures and mucosal layer as much as you can...Try to save nasal structures and mucosal layer as much as you can

Atrophic Rhinitis ’Ozena’ Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital.

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Transcript of Atrophic Rhinitis ’Ozena’ Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital.