Atrophic Rhinitis Alan L. Cowan, M.D.

Faculty Advisor: Matthew Ryan, M.D.

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

March 30, 2005

Atrophic Rhinitis

Common Terms

Ozena

Dry Rhinitis

Rhinitis Sicca

Atrophic Rhinitis

Dr. Spencer Watson. Diseases of the nose and its associated cavities. London, 1875. 1) Accidental or Simple Ozoena

“due to the retention of mucous.” “easily dealt with by the frequent employment of the nasal douche

…”

2) Idiopathic or constitutional “commences in early childhood ... And remains during the early

years or throughout the whole adult life.” “The patient is generally anosmic … and he is, therefore, unaware

of the offensive odor of his breath.” “The nature of the inflammatory process is very probably allied to

that of lupus erythematosus of the face.”

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

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

Atrophic Rhinitis

Described in 1876 by Dr. Bernhard Fraenkel as a triad of: Fetor

Crusting

Atrophy of nasal structures

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

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

Atrophic Rhinitis

Clinical Features Anosmia

Ozena, i.e. foul odor

Extensive nasal crusting

Subjective nasal congestion

Enlargement of the nasal cavity

Resorption or absence of turbinates

Squamous metaplasia of nasal mucosa

Depression

Atrophic rhinitis

Primary

History of prior sinus surgery, radiation, granulomatous disease, or nasal trauma are exclusions.

Primary AR is rare in the US

Most cases are reported in China, Egypt, and India

Microbiology of primary AR is almost uniformly Klebsiella ozenae.

Radiographic and clinical features similar to secondary AR.

Atrophic rhinitis

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

Sarcoid Leprosy Rhinoscleroma

Sequlae of other infectious processes Tuberculosis Syphilis

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

Surgical causes

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

2.3

Partial middle or inferior turbinectomy 56%

Total middle and inferior turbinectomy 24%

No turbinectomy 10%

Partial maxillectomy 6%

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

Other suggested causes

Infectious (Ssali) Case report of AR developed in 7 children of one family after contact with another known AR

child.

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

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

disease.

Hormonal Symptoms known to worsen with menstraution or pregnancy.

Developmental (Hagrass) Radiologic evidence of poor maxillary antrum pneumatization and short nasal lengths

Vascular (Ruskin) Postulated overactivation of sympathetic activity.

Environmental (Mickiewicz) Chronic exposure to phosphorite and apatide dust

Autoimmune (Ricci)

Physical findings

Crusting 100% Present

Inferior Turbinates 62% Partial absence 37% Total absence

Middle Turbinates 57% Absent

Discharge 52% Present

Septum 10% Perforations

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

Radiographic Findings

1. Mucoperiosteal thickening of the paranasal sinuses.

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

3. Hypoplasia of the maxillary sinuses.

4. Enlargement of the nasal cavities with erosion and bowing of the lateral nasal wall.

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

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

Biopsy Findings

Normal Mucosa

Pseudostratified Columnar

Presence of serous and mucous glands

Atrophic Rhinitis

Squamous metaplasia

Atrophy of mucous glands

Scarce or absent cilia

Endarteritis obliterans

Microbiology

Klebsiella ozenae

May be found in almost 100% of primary AR

No predominance in secondary AR

Staphylococcus aureus

Proteus mirabilis

Escherichia coli

Corynebacterium diphtheriae

Current Therapies

Goals of therapy Restore nasal hydration

Minimize crusting and debris

Therapy options Topical therapy

Saline irrigations

Antibiotic irrigations

Systemic antibiotics

Implants to fill nasal volume

Closure of the nostrils

Local therapy

Irrigations Saline Mixtures

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

Chloride 50g in 250ml water.

Antibiotic solution Moore: Gentamycin solution 80mg/L

Anti-drying agents Glycerine Mineral Oil Paraffin with 2% Menthol

Other Acetylcholine Pilocarpine

Systemic therapy

Oral antibiotics Tetracycline Ciprofloxacin Aminoglycosides Streptomycin injections

Medication avoidance Vasoconstrictors Topical steroids *

Other Vitamin A (12,500 to 15,000 Units daily) Potassium Iodide (Increases nasal secretions) Vasodilators Iron therapy Estrogen Corticosteroids *

Vaccines Antibacterial (Pasturella, Bordetella) Autogenous

Surgical therapies

Young procedure

Modified Young procedure

Turbinate reconstruction

Volume reduction procedures

Denervating operations

Nasal Closure

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

Sutures placed in center of elevated flap to close the nostril

Staged second side in 3 months

Advantages Often provided relief of symptoms

Disadvantages Difficult to elevate circumferential flap

Breakdown of central suture area common

Does not allow for cleaning

Did not allow for periodic examination

Recurrence after flap takedown

Young. “Closure of the nostril in atrophic rhinitis.” Journal of Laryngology and Otology, 81: 515-524.

Nasal Closure Modified Young’s

Elevation of extended perichondrial flap through contralateral hemitransfixion incision.

Short skin flap elevated from the intercartilaginous line on the ipsilateral side.

Suture lateral and medial flaps with vicryl. Staged second side with first side takedown in 6 mon.

Advantages Technically easier than Young procedure No suture line breakdown No vestibular stenosis on takedown

Disadvantages Not possible with large septal defects Does not allow for cleaning Does not allow for periodic examination Recurrence after flap takedown

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

Modified Young

Volume reduction

Plastipore implantation Porus material allows tissue ingrowth. Implants shaped then fenestrated for ingrowth. Implants placed submucosally along the septum and

nasal floor.

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

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

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

Plastipore

Volume Reduction (cont)

Triosite and Fibrin Triosite (60% hydroxyapetite, 40% calcium triphosphate) mixed

with Fibrin 1:1.

Deglove the labial vestibule

Elevate periosteum of the floor posteriorly to the end of the hard palate, extend medially onto the septum.

Insert Triosite & Fibrin mixture (~3.3g per side)

Advantages Good to excellent result (7/9 patients)

Material can be molded easily

Disadvantages Leakage of material (4/9 patients)

Infection of material (3/9 patients)

Potential damage to lacrimal system

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

Triosite and Fibrin

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

Triosite and Fibrin

Other Therapies

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

Impressions are used to create a silastic obturator.

Advantages Reversible

Easily removed

Allows for irrigations

Allows for serial clinical exams

Avoids surgical morbidity

Disadvantages May be uncomfortable

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 Obturator

Other Therapies

Other Implants Acrylic Silicone Teflon Silastic Boplant

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

Salivary Irrigation Involves reimplantation of parotid duct into the maxillary sinus

Accupuncture Time

Disease often resolves spontaneously after age 40

Bibliography Lobo, Hartley, Farrington. “Closure of the nasal vestibule in atrophic rhinitis

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

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

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

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

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

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

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

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