Atrophic RhinitisAtrophic RhinitisUTMB Dept of OtolaryngologyUTMB Dept of Otolaryngology

March 30, 2005March 30, 2005

Alan L. Cowan, M.D.Alan L. Cowan, M.D.

Matthew Ryan, M.D.Matthew Ryan, M.D.

Atrophic RhinitisAtrophic Rhinitis

Common TermsCommon Terms OzenaOzena Dry RhinitisDry Rhinitis Rhinitis SiccaRhinitis Sicca

Atrophic RhinitisAtrophic Rhinitis Dr. Spencer Watson. Dr. Spencer Watson. Diseases of the nose and its Diseases of the nose and its

associated cavitiesassociated cavities. London, 1875.. London, 1875. 1) 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 nasal easily dealt with by the frequent employment of the nasal

douche …”douche …” 2) Idiopathic or constitutional2) Idiopathic or constitutional

““commences in early childhood ... And remains during the commences in early childhood ... And remains during the early years or throughout the whole adult life.”early 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 The nature of the inflammatory process is very probably allied to that of lupus erythematosus of the face.”allied to that of lupus erythematosus of the face.”

3) Syphilitic Ozoena3) Syphilitic Ozoena ““the most common form”the most common form” ““These ulcers may be preceded or followed by caries or These ulcers may be preceded or followed by caries or

necrosis of the bones, and the stench is then more horribly necrosis of the bones, and the stench is then more horribly sickening than in any other form of this disgusting malady.”sickening than in any other form of this disgusting malady.”

Atrophic RhinitisAtrophic Rhinitis

Described in 1876 by Dr. Bernhard Fraenkel Described in 1876 by Dr. Bernhard Fraenkel as a triad of:as a triad of: FetorFetor CrustingCrusting Atrophy of nasal structuresAtrophy of nasal structures

Dr. Francke Bosworth. Dr. Francke Bosworth. A Manual of Diseases A Manual of Diseases of the Nose and Throat.of the Nose and Throat. 1881. 1881. ““the breath is often so penetrating as to render the breath is often so penetrating as to render

the near presence of the sufferer not only the near presence of the sufferer not only unpleasant but almost unendurable.”unpleasant but almost unendurable.”

Atrophic RhinitisAtrophic Rhinitis

Clinical FeaturesClinical Features AnosmiaAnosmia Ozena, i.e. foul odorOzena, i.e. foul odor Extensive nasal crustingExtensive nasal crusting Subjective nasal congestionSubjective nasal congestion Enlargement of the nasal cavityEnlargement of the nasal cavity Resorption or absence of turbinatesResorption or absence of turbinates Squamous metaplasia of nasal mucosaSquamous metaplasia of nasal mucosa DepressionDepression

Atrophic rhinitisAtrophic rhinitis

PrimaryPrimary History of prior sinus surgery, radiation, History of prior sinus surgery, radiation,

granulomatous disease, or nasal trauma are granulomatous disease, or nasal trauma are exclusions.exclusions.

Primary AR is rare in the USPrimary AR is rare in the US Most cases are reported in China, Egypt, and IndiaMost cases are reported in China, Egypt, and India Microbiology of primary AR is almost uniformly Microbiology of primary AR is almost uniformly

Klebsiella ozenaeKlebsiella ozenae.. Radiographic and clinical features similar to Radiographic and clinical features similar to

secondary AR.secondary AR.

Atrophic rhinitisAtrophic rhinitis

SecondarySecondary Complication 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%)

SarcoidSarcoid LeprosyLeprosy RhinoscleromaRhinoscleroma

Sequlae of other infectious processesSequlae of other infectious processes TuberculosisTuberculosis SyphilisSyphilis

Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.

Surgical causesSurgical causes

Based on review of 242 cases from Mayo Based on review of 242 cases from Mayo Clinic.Clinic. Procedures per patientProcedures per patient

2.32.3 Partial middle or inferior turbinectomyPartial middle or inferior turbinectomy

56%56% Total middle and inferior turbinectomyTotal middle and inferior turbinectomy

24%24% No turbinectomyNo turbinectomy

10%10% Partial maxillectomyPartial maxillectomy

6%6%

Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.

Other suggested causesOther suggested causes Infectious (Ssali)Infectious (Ssali)

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

Dietary Dietary (Bernat) Iron therapy found to benefit 50% of patients treated(Bernat) Iron therapy found to benefit 50% of patients treated (Han-Sen) Hypocholesterolemia present in 50% of patients.(Han-Sen) Hypocholesterolemia present in 50% of patients. (Han-Sen) Vitamin A therapy showed symptomatic improvement in 84%.(Han-Sen) Vitamin A therapy showed symptomatic improvement in 84%.

Hereditary (Barton, Sibert)Hereditary (Barton, Sibert) Proposed autosomal dominant disease due to father and 8 of 15 children Proposed autosomal dominant disease due to father and 8 of 15 children

contracting the disease.contracting the disease. Hormonal Hormonal

Symptoms known to worsen with menstraution or pregnancy.Symptoms known to worsen with menstraution or pregnancy. Developmental (Hagrass)Developmental (Hagrass)

Radiologic evidence of poor maxillary antrum pneumatization and short nasal Radiologic evidence of poor maxillary antrum pneumatization and short nasal lengthslengths

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)

Physical findingsPhysical findings Crusting Crusting

100% Present100% Present Inferior TurbinatesInferior Turbinates

62% Partial absence62% Partial absence 37% Total absence37% Total absence

Middle TurbinatesMiddle Turbinates 57% Absent57% Absent

Discharge Discharge 52% Present52% Present

SeptumSeptum 10% Perforations10% Perforations

Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.

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 Loss of definition of the OMC secondary to resorption of the ethmoid bulla and uncinate process.of 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 Enlargement of the nasal cavities with erosion and bowing of the lateral nasal wall.and bowing of the lateral nasal wall.

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

Pace-Balzan, Shankar, Hawke. J Otolaryngol 1991; 20:428-32.

Biopsy FindingsBiopsy Findings

Normal MucosaNormal Mucosa Pseudostratified Pseudostratified

ColumnarColumnar Presence of serous and Presence of serous and

mucous glandsmucous glands Atrophic RhinitisAtrophic Rhinitis

Squamous metaplasiaSquamous metaplasia Atrophy of mucous Atrophy of mucous

glandsglands Scarce or absent ciliaScarce or absent cilia Endarteritis obliteransEndarteritis obliterans

MicrobiologyMicrobiology

Klebsiella ozenaeKlebsiella ozenae May be found in almost 100% of primary May be found in almost 100% of primary

ARAR No predominance in secondary ARNo predominance in secondary AR

Staphylococcus aureusStaphylococcus aureus Proteus mirabilisProteus mirabilis Escherichia coliEscherichia coli Corynebacterium diphtheriaeCorynebacterium diphtheriae

Current TherapiesCurrent Therapies

Goals of therapyGoals of therapy Restore nasal hydrationRestore nasal hydration Minimize crusting and debrisMinimize crusting and debris

Therapy optionsTherapy options Topical therapyTopical therapy Saline irrigationsSaline irrigations Antibiotic irrigationsAntibiotic irrigations Systemic antibioticsSystemic antibiotics Implants to fill nasal volumeImplants to fill nasal volume Closure of the nostrilsClosure of the nostrils

Local therapyLocal therapy IrrigationsIrrigations

SalineSaline MixturesMixtures

Sodium bicarbonateSodium bicarbonate Shehata: Sodium Carbonate 25g, Sodium Biborate 25g, and Shehata: 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 agents

GlycerineGlycerine Mineral OilMineral Oil Paraffin with 2% MentholParaffin with 2% Menthol

OtherOther AcetylcholineAcetylcholine PilocarpinePilocarpine

Systemic therapySystemic therapy

Oral antibioticsOral antibiotics TetracyclineTetracycline CiprofloxacinCiprofloxacin AminoglycosidesAminoglycosides Streptomycin injectionsStreptomycin injections

Medication avoidanceMedication avoidance VasoconstrictorsVasoconstrictors Topical steroids *Topical steroids *

OtherOther Vitamin 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) VasodilatorsVasodilators Iron therapyIron therapy EstrogenEstrogen Corticosteroids *Corticosteroids *

VaccinesVaccines Antibacterial (Pasturella, Bordetella)Antibacterial (Pasturella, Bordetella) Autogenous Autogenous

Surgical therapiesSurgical therapies

Young procedureYoung procedure Modified Young procedureModified Young procedure Turbinate reconstructionTurbinate reconstruction Volume reduction proceduresVolume reduction procedures Denervating operationsDenervating operations

Nasal ClosureNasal Closure

Young’s procedureYoung’s procedure Circumferential flap elevation 1 cm cephalic to the alar Circumferential flap elevation 1 cm cephalic to the alar

rim.rim. Sutures placed in center of elevated flap to close the Sutures placed in center of elevated flap to close the

nostrilnostril Staged second side in 3 monthsStaged second side in 3 months

AdvantagesAdvantages Often provided relief of symptomsOften provided relief of symptoms

DisadvantagesDisadvantages Difficult to elevate circumferential flapDifficult to elevate circumferential flap Breakdown of central suture area commonBreakdown of central suture area common Does not allow for cleaningDoes not allow for cleaning Did not allow for periodic examinationDid not allow for periodic examination Recurrence after flap takedownRecurrence after flap takedownYoung. “Closure of the nostril in atrophic rhinitis.” Journal of

Laryngology and Otology, 81: 515-524.

Nasal ClosureNasal Closure Modified Young’sModified Young’s

Elevation of extended perichondrial flap through Elevation of extended perichondrial flap through contralateral hemitransfixion incision.contralateral hemitransfixion incision.

Short skin flap elevated from the intercartilaginous line Short skin flap elevated from the intercartilaginous line on 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 procedureTechnically easier than Young procedure No suture line breakdownNo suture line breakdown No vestibular stenosis on takedownNo vestibular stenosis on takedown

DisadvantagesDisadvantages Not possible with large septal defectsNot possible with large septal defects Does not allow for cleaningDoes not allow for cleaning Does not allow for periodic examinationDoes not allow for periodic examination Recurrence after flap takedownRecurrence after flap takedown

El Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial flap for El Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis.” Rhinology, 36, 202-203, 1998.closure of nostril in atrophic rhinitis.” Rhinology, 36, 202-203, 1998.

Modified YoungModified Young

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 Implants placed submucosally along the septum

and nasal floor.and nasal floor. AdvantagesAdvantages

Easier than other surgical options (Young’s)Easier than other surgical options (Young’s) Plastipore has low extrusion/complication ratePlastipore has low extrusion/complication rate May be done under local anesthesiaMay be done under local anesthesia

DisadvantagesDisadvantages Possibility 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)

Goldenberg, Danino, Netzer, Joachims. Oto HNS, Vol. 122 (6). pp. 794-97.

PlastiporePlastipore

Volume Reduction (cont)Volume Reduction (cont) Triosite and FibrinTriosite 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 vestibule Elevate 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)

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

DisadvantagesDisadvantages Leakage 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

Bertrand, Doyen, Eloy. Laryngoscope 106: May 1996. p 652-57.

Triosite and FibrinTriosite and Fibrin

Bertrand, Doyen, Eloy. Laryngoscope 106: May 1996. p 652-57.

Triosite and FibrinTriosite and Fibrin

Other TherapiesOther Therapies

Non-surgical nasal closureNon-surgical nasal closure Nasal vestibule impressions taken similar to hearing aid Nasal vestibule impressions taken similar to hearing aid

moulds.moulds. Impressions are used to create a silastic obturator.Impressions are used to create a silastic obturator.

AdvantagesAdvantages ReversibleReversible Easily removedEasily removed Allows for irrigationsAllows for irrigations Allows for serial clinical examsAllows for serial clinical exams Avoids surgical morbidity Avoids surgical morbidity

DisadvantagesDisadvantages May be uncomfortableMay be uncomfortable May cause sore throat due to obligate mouth breathing.May cause sore throat due to obligate mouth breathing.

Lobo, Hartley, Farrington. J of Laryn and Oto. June 1998, Vol 112, p 543-46.

Nasal ObturatorNasal Obturator

Other TherapiesOther Therapies

Other ImplantsOther Implants AcrylicAcrylic SiliconeSilicone TeflonTeflon SilasticSilastic BoplantBoplant

DenervationDenervation Cervical 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 Irrigation Involves reimplantation of parotid duct into the maxillary sinusInvolves reimplantation of parotid duct into the maxillary sinus

AccupunctureAccupuncture TimeTime

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

BibliographyBibliography Lobo, Hartley, Farrington. “Closure of the nasal vestibule in Lobo, Hartley, Farrington. “Closure of the nasal vestibule in

atrophic rhinitis – a new non-surgical technique.” atrophic rhinitis – a new non-surgical technique.” The Journal of The Journal of Laryngology and OtologyLaryngology and Otology. June 1998, Vol. 112, pp. 543-46.. June 1998, Vol. 112, pp. 543-46.

Moore, Kern. “Atrophic Rhinitis: A Review of 242 cases.” Moore, Kern. “Atrophic Rhinitis: A Review of 242 cases.” American American Journal of RhinologyJournal of Rhinology. November-December 2001, Vol. 15, No. 6, p . November-December 2001, Vol. 15, No. 6, p 355-61.355-61.

Shehata. “Atrophic Rhinitis.” Shehata. “Atrophic Rhinitis.” American Journal of OtolaryngologyAmerican Journal of Otolaryngology, , Vol. 17, No. 2. March-April, 1996: pp 81-86.Vol. 17, No. 2. March-April, 1996: pp 81-86.

Chand, MacArthur. “Primary atrophic rhinitis: A summary of four Chand, MacArthur. “Primary atrophic rhinitis: A summary of four cases and review of the literature.” Otolaryngology – Head and cases and review of the literature.” Otolaryngology – Head and Neck Surgery. Vol. 116, No. 4: pp 554-57.Neck Surgery. Vol. 116, No. 4: pp 554-57.

Bertrand, Doyen, Eloy. “Triosite Implants and Fibrin Glue in the Bertrand, Doyen, Eloy. “Triosite Implants and Fibrin Glue in the Treatment of Atrophic Rhinitis: Technique and Results.” Treatment of Atrophic Rhinitis: Technique and Results.” Laryngoscope (106): May 1996: pp 652-57.Laryngoscope (106): May 1996: pp 652-57.

Goldenberg, Danino, Netzer, Joachims. “Plastipore implants in the Goldenberg, Danino, Netzer, Joachims. “Plastipore implants in the surgical treatment of atrophic rhinitis: Technique and results.” surgical treatment of atrophic rhinitis: Technique and results.” Otolaryngology Head and Neck Surgery. Vol 122 No 6: pp 794-97.Otolaryngology Head and Neck Surgery. Vol 122 No 6: pp 794-97.

Watson, Spencer. Watson, Spencer. Diseases of the nose and its accessory cavitiesDiseases of the nose and its accessory cavities. . London: 1875.London: 1875.

El Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial El Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis.” flap for closure of nostril in atrophic rhinitis.” RhinologyRhinology, 36, 202-, 36, 202-203, 1998.203, 1998.