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Current Reviews

Atrophic RhinitisMostafa A. Shehata, MD

Atrophic rhinitis is a chronic nasal diseasecharacterized by progress ive atrophy of themucosa and underlying bone of the turbinatesand the presence of a viscid secretion, whichrapidly dries and forms c rusts that emit acharac teristic foul odor, sometimes calledozena (a stench). There is usually an abnormalpatency of the nasal passages.1-3HISTORY

This disease was known to ancient Egyp-tians, nearly 4,000 years ago as evidenced intheir medical papyri. The Edwin papyrus (1700BC) prescribed date wine and breast milk forthe treatment of this disease. The ancientGreeks and Indians were also familiar withatrophic rhinitis. The disease was first de-scribed as a separate clin ical entity of the noseby Fraenkel in 1876.4INCIDENCE

The disease appears to be endemic in sub-tropical and temperate countries, hence itsprevalence in South Asia, Africa, Eastern Eu-rope, and the Mediterranean. It is also foundin Egypt, Greece, Hungary, and Yugoslavia,4 aswell as in Brazil, Malaysia, the Philippines,and India.5

Heredity is an important factor, and thereappears to be a racia l influence in that theAsians, Latinos, and black Americans are moresuscept ible than natives of equatorial Africa.l

In affected areas, the general incidence is

From the Department of Otolaryngology, Faculty ofMedicine, Alexandria University, Alexandria, Egypt.

Address reprint requests to Mostafa Shehata, ENTDepartment, Faculty of Medicine, Alexandria, Egypt.Copyright 0 1996 by W.B. Saunders Company

0196-0709/96/l 702-0001$5.00/0

0.3% to 7.8% of the ear, nose and throatoutpatients in China,6 whereas it is about 1%in Egypt.7There i s also a strong family history amongpatients, who are usually poor and live inunhygienic conditions.7

The disease usual ly starts in childhood,espec ially in girls at the onset of puberty. Thissupports the hormonal theory that estrogenhas an etiologica l role in atrophic rhinit is.ETIOLOGY

The exact etiology is still uncertain, how-ever, many possibilit ies and suggestions havebeen described by investiga tors.

1. Chronic bacterial infection of the nose orthe sinuses has been suggested by Grunwald,8Adam,g Cullom,g Surgan,g Rosen et a1,g Henrik-sen and Gundersen,O and Zohar et a1.3 In thisrespect, many organisms have been cited asthe cause, including: Coccobacillus,l Bacillusmucosus,12 Coccobacillus foetidus ozaena,Diphtheroid bacilli, Bacillus pertussis,j andKlebs iella ozaena?O Although it is true thatthese organisms may be found in cultures,there is little evidence that they cause thedisease.13

2. Nutritional deficiencies,3 such as irondeficiency14 and Vitamin A deficiency.gJ53. Endocrine imbalance, mainly estrogen

deficiency , evidenced by the common occur-rence of the disease in girls at the onset ofpuberty and the aggravation of symptoms dur-ing menstruation and the improvement ofsome cases by estrogen therapy.3,gs15

4. Developmental disorder resulting in poorpneumatization of antra and wide nose.3,75. Autonomic imbalance resulting in exces-sive vasoconstriction was suggested by Ruskinin 1932 (overly sympathetic activity).

American Journal of Otolaryngology, Vol 17, No 2 (March-April), 1996: pp 81-86 61

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82 MOSTAFA A. SHEHATA

6. Collagen disorder as an auto-immunedisease was suggested by Ricc i.g

7. Hereditary disorder, as a racia l Mande-lian hereditary inhibition of development ofnasal mucosa, is a theory suggested by Fleish-man.78. Chronic exposure to irritant and toxicagents such as cocaine and others, which issupported by the report from Mick iewicz etall6 in which atrophic rhinit is was found inworkers exposed to phosphorite and apatidedusts.

Other possible causes are chronic sinusitis;excessive surgical destruction of the nasalmucous membranel; healed chronic granulo-mata, such as scleroma, leprosy, syph ilis, andlupus vulgaris ; narcotic inhalations; repeatedcautery to nasal mucosa; and radiotherapy.

It seems likely that atrophic rhinitis resultsfrom a number of separate factors workingsimultaneously.PATHOLOGY

The initia l examination shows chronic non-specific inflammation with accumulation ofchronic inflammatory cells, such as lympho-cytes and plasma cells. Nasal exfoliation ischaracteristic with nearly absence of colum-nar and goblet cells . Ciliary destruction iscommon and crusts are formed on the nasalmucosa.4 There is excessive reduction in thesize and amount of the mucosal and submuco-sal structures (Fig 1).

Most investigators agree that there arepatches of metaplasia from columnar ciliatedto squamous epithelium, that there is a de-crease in the number and size of the com-pound alveolar glands, and that there aredilated capil laries and active bone absorp-tion.*J Some investigators such as Taylor andYoung,15 were unable to show end-arteritisand peri-arte ritis of the terminal arterioles,which were described by other investigators.

Therefore, it is possible that there are twotypes of atrophic rhinitis :

Type 1 is characterized by endarteritis andperiarte ritis of the terminal arterioles, whichare the result of chronic infection and mightbenefit from the vasodilator effect of estrogentherapy and,

Type 2 shows vasodilatation of the capillar-ies, which might be made worse with estrogentherapy.

The result of either type i s a scanty, thickmucous d ischarge, forming colored crusts thatmay harden into large casts obstructing thenose.?CLINICAL PICTURE

The disease usually manifests itself in child-hood, especial ly in girls. The onset may beginat puberty, and the symptoms worsen duringmenstruation.The presenting symptoms are most com-monly nasal obstruction, headache, and epi-stax is. Anosmia and halitos is may be present,

Fig 1. Atrophic mucosa,subepithelial fibrosis, chron-ic inflammatory cells, andedema of the lamina pro-pria (original magnificationx 120).

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and patients are often only made aware of thepresence of these symptoms by the reluctanceof others to come within their vic inity .

Sometimes the symptoms are mainly pha-ryngeal and are caused by the pharyngitissicca that often accompanies the condition orby the choking which occurs when detachedcrusts slip from the nasopharynx to the oro-pharynx.l

The cruel socia l rejection, beginning earlyin childhood, that is experienced by thosewith ozena, together with sleep disturbancescaused by nasal obstruction, often result inmarked psychotic behavior.4Examination confirms the presence of fetororis in all but in the earliest cases. The nasalcavi ties are found to be lined with green,yellow, and black crusts. Detachment of crustsshows a bleeding and ulcerated mucosa. Thenasopharynx can be clear ly seen through thewide nasal cavities.

Atrophy of the inferior turbinate, and occa-sionally the middle turbinate, is frequent andmay be complete (Fig 2).*

Fig 2. Radiograph of the nose and sinuses, occipito-frontal view, showing wide, roomy nose with markedatrophy of the inferior and middle turbinates.

INVESTIGATIONSThe following investigations are necessary

to study the cases:1. Nasal swab to be cultured and identi-fied, but the results are usually of little

value2. Sinus puncture is required to excludeconcomitant sinus infection3. Radiography of the sinuses to exclude

the presence of seps is4. Computed tomography has been re-

cently used for imaging of atrophicrhinitis17

5. Serological tests to exclude syphilis6. Blood picture, serum proteins, and ironleve ls should also be checked1

TREATMENTThere is no cure for atrophic rhinitis ; all

medical and surgical measures have short orprolonged palliative effect.Conservative Measures

Regular nasal cleaning was performed bysyringing the nasal cavi ties with a solution ofdiluted sodium bicarbonate (250 mL warmwater in which was dissolved 25 g sodiumbicarbonate, 25 g sodium biborate, and 50 gsodium chloride).l* Balanced physiological sa-line was also tried with good symptomaticrelief.lg

Applicat ion of nasal cotton wool tampons,soaked in 25% glucose in glycerine for 24hours, inhibit the proteolytic organisms andloosens dry, adherent crusts.

The use of lubricating oily nasal drops asmenthol 2% in paraffin is also helpfuLl

Estrogen therapy, used systematically andloca lly, has been suggested by some investiga-tors with relief of symptoms.

Vitamin A, administered orally in large dosesof 12,500 to 15,000 U daily was claimed togive the best results, especially in mild andmoderately severe cases.6 Potassium iodidetaken orally helped to increase nasal secretionto moisten the mucosa.7

Autogenous vacc ines were tried by someinvestigators with very limited therapeuticeffect.

Antibacterial vaccines, made of formalin-

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a4 MOSTAFA A. SHEHATA

killed whole cells of toxigenic Pasteurellamultocida and Bordetella bronchiseptica, werealso tried with some immunoprotective im-provement.20-22

Sinha et al5 reported promising results bythe use of local and general tissue therapy inthe form of human placenta extract. Theyclaim 80% improvement for two years.Antibio tics were preferred by many inves ti-gators, espec ially streptomycin injections thatact on proteolytic organisms. Specific antibiot-ics, according to antibiotic susceptibility ofthe organisms, were also tried.2 Vasodilatorsand corticosteroids were also suggested andhave some palliation effect1

Acetylcholine, used locally, and pilocar-pine, injected subcutaneously, were men-tioned by Ballenge9 to be of some value fortheir vasodilatation and reactivation of mu-cosa glands.

Chen Han Sen6 advised the use of largedoses of vitamin A, combined with streptomy-cin injection. He claimed good results aftersuch therapy.Surgical Treatment

Many surgical techniques were described inthe past and many others are presently usedwith variable therapeutic results. None of themwere fully successfu l or cured the disease.

Cavity-narrowing operations. These op-erations include: 1. the displacement of thelateral wall of the nose medially to narrow thenasal cavit y (Lautenschlagers operation,1982),23 2. nasal closure operations, 3. pharyn-goplasty, and 4. nasal implants.Encouraging results have been obtained fol-lowing complete closure of one or both nos-trils by plastic surgery,24 using a skin flap ofthe nasal vestibule. Closure is maintained for aperiod of 6 months to 3 years. Th is gives goodcurative result but recurrence rate is high.24Sinha, Sardana, and Rajvanshi5 reported thatpartial closure of both nostrils is better toler-ated by patients than complete closure withsimilar results. Bela1 et alz5 advocated closureof the posterior choana with rubber foam for 6months and claimed good results. However,after removing the choanal plug, all symptomsrecur.25 Al l types of nasal occlusion gave goodamelioration results in which dryness of the

nasal mucosa disappears and formation ofnasal crusts stops. Histologically, the nasalmucosa shows an increase in the number ofgoblet cel ls and tunica glands, and improve-ment in the microc irculation of the nasalmucosa. There is also a return of ciliated,pseudo-stratified columnar epithelium inmany areas of the nasal mucosa.24 Ultrast ruc-tural study of nasal mucosa after the opera-tions also showed reverse change in its micro-anatomy.26 However, the recurrence of thesymptoms after nasal occlus ion indicates thatit is not the final treatment of ozena.

Pharyngoplasty , with caudally based pharyn-geal flap to reduce nasal airflow advocated byHuffstadt and Hoeksemaz7 and nasal implantsare also treatment options. Autogenous tissueimplants, such as fat, dermofat, bone, or carti-lage, were all tried, but because of their gradualabsorption, the symptoms recur.4,7J8-30 mplant-ing placental tissue was also tried by Rama-janeyulu in 19765 with limited cure results.An osteoperiostal flap taken from the anteriorwall of the maxilla to narrow the nasal cavitywas thought to give better results.31

Synthetic implants, such as submucosal in-jection of paraffin oil, were first suggested andperformed by Gersuny in 1990,28 who startedthe era of synthetic implants, but the resultswere unfavorable.28 Many other sorts of syn-thetic materials including acrylic, silicone,Teflon, polythene, and Silastic were later triedas implants under the mucoperichondrium ofthe septum, floor, or lateral wa11.5~32*33n 1964,Wilson34 reported better results from the sub-mucosal injection of a suspension of pow-dered Teflon in 50% glycerine paste. Proplast,a polytertra fluoroethylene carbon (Vitek , Inc,Houston, TX), was used by Whitehead for itsadvantage of enabling the tissue to growthrough the implant to stabilize it in situ withminimal extrusion. Boplant, or processed can-cellous calf bones (Squipp and Sons, Inc, NewYork] was used as small strips and implantedsubmucosally under the mucosa of septum,floor, and lateral wall. This was reported byHuizing36 to give more promising results. A lltypes of implants give immediate successfu lresults, but the cure rate decreases graduallybecause of the frequent gradual absorption ofthe tissue implant or the occasional extrusionof synthetic implants. The frequency of extru-

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ATROPHIC RHINITIS 85

sion was estimated by some investigators to beas high as 80%.37

Our own studies were performed to evaluatesurgical synthetic implants in treatment ofatrophic rhinitis. A research trial was per-formed in 1986 in which 30 patients of bothsexes and of different age groups were treatedsurgica lly.38 The material used for implanta-tion was Silastic, a polymer of dimethyl silox-ane (Dow Corning Corp, Midland, MI). Theimplant was placed subperiosteally or subperi-chondrially under the mucosa of the septumor the nasal floor. The obtained curative re-sults were very encouraging. After severalyears of follow-up, the success rate decreasedslight ly, but it remained higher than most ofthe previously mentioned surgical tech-niques.38

Denervation operations. A sympathec-tomy operation in the form of a cerv ical sympa-thectomy was performed by Bertein,3g whereasstellate ganglion block has been used withsome success by Bahl,40 and Sharma and Sar-dana. Sphenopalatine ganglion block or extir-pation was performed by Girgis7 with somesuccess. Parasympathectomy, in which thegreat superf icial petrosal nerve is cut, wasdescribed by Krmptotic and Sunoric41 whoclaimed it was also an effective method.

Other operations. There are a number ofother operations. Local injections of placentalextract was described and used by Sinha et al5with the some success. The salivary irrigationoperation as advocated by Wittmaak in 191g7entails the reimplantation of the parotid ductinto the maxi llary sinus. This has the advan-tage of continuous wetting of the nasal cavitybut carries the disadvantage of watery rhinor-rhea during food mastication.7 Rethi deviseda modified surgical technique in which aseptal flap is raised to act as a baffle to narrowthe nasal cavity , with amelioration of thesymptoms.42 Considering all these surgicaltechniques and their modifications that haveevolved over the last 50 years, it becomesevident that atrophic rhinit is has attracted theinterest of many investigators worldwide, buthas proved very resistant to therapy as evi-denced by the investigators disappointinglong-term results. Although there are over 100surgical techniques, none have proved to be

fully successful, and the disease still needsfurther study and research to discover a moreeffective curative method of treatment.

PROGNOSISThe disease manifests itself in childhood,

especially in girls at a very active stage in theirlives . The long-standing symptom of halitos isis very annoying and deeply affects the psycho-logica l condition of such young patients. Thecruel social rejection, beginning early in life,that is experienced by those with ozena, to-gether with sleep disturbances caused by na-sal obstruction and often result in markedpsychotic behavior that may lead to suicide.

Although the symptoms persist for manyyears, the disease does not affect the capabilityof the patient or endanger his life. A ll avail-able lines of treatment are sti ll symptomaticfor palliation of the disease, and there is noknown cure.

Fortunately, after 40 years of age, a goodpercentage of patients show spontaneous ar-rest of the active disease, in which the dis-charge, crusts, and bad odor disappear, de-spite the wide nasal cavity.

REFERENCES1. Weir N: Acute and chronic inflamma tion of the nose,

in Mackay IS, Bull TR (eds): Scott-Browns Otolaryngol-ogy, ~013, (ed 5). London, United Kingdom Butterworths,1987, pp 115-1412. Dudlev JP: Atrophic rhinitis, antibiotic treatment.Am J Otolaryngol8:38?-390, 1987

3. Zohar Y, Talmi YP. Strauss M, et al: Ozaena revisited.J Otolaryngol19:345-349,199O

4. Goodman WS, de Souza FM: Atrophic rhinitis. JOtolaryngol Clin North Am 6:773-782,1973

5. Sinha SM, Sardana DS, Rajvanshi VS: A nine yearreview of 273 cases of atrophic rhinitis and its manage-ment. J Laryngol Otol91:591-600,1977

6. Sen HC: The ozaena problem , clinical analysis ofatrophic rhinitis in 100 cases. Acta Otolaryngol 93:461-464,19827. Girgis IH: Surgical treatment of ozaena by dermofatgraft. J Laryngol Otol80:615-627,19668. Ballenger JJ: Chronic atrophic rhinitis. Diseases ofthe Nose, Throat and Ear (ed 12). Philadelphia, PA, Lea &Febiger, 1977, pp 129-130

9. Barbary AS, Yassin A, Fouad H, et al: Histopathologi-cal and histochemical studies on atrophic rhinitis. JLaryngol Otol84:1103-1112,197O

10. Henricksen SD, Gundersen WB: The etiology ofozaena. APMIS 47:380,1959

11. Lewenberg B: La microbe de lozena. Ann InstitutPasteur 8:292, 189412. Ab el P: Die aet iologie der ozaena. Z HygieneInfektionskrankeiten 21:89, 188513. Ferguson JL, MC Caffrey TV, Kern EB, et al: Effect of

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Klebsiella ozaenae on ciliary activity in vitro, impl icationin the pathogenesis of atrophic rhinitis. J Head Neck Surg102:207-211,199O14. Bernat I: Ozaena, a manifestation of iron deficiency.Oxford, United Kingdom, Pergamon, 1965

15. Taylor M, Young A: Histological and histochemicalstudies on atrophic rhinitis. J Laryngol Otol 75:574-589,1961

16. Mickiewicz L, Mekluski T, Kuzna Grygrel W, et al:Assessment of the nasal mucosa in workers exposed toprolonged effect of phosphorite and apatite dusts. P ol JbccupMed Environ-Health 6:277-285, i993

17. Pace Balzam A. Shankar L. Hawke M: Comuutedtomographic findings in atrophic rhinitis. J Otolarngol20:428-432,1991

18. Emkart 0: Rhinitis review. Rev Chil Pediatr 60:48-53,1989

19. Nuutinen J, Holopainen E, Haahtela T, et al: Bal-anced physiological saline in the treatment of chronicrhinitis. J Rhinology 24:265-269,1986

20. Foged NT, Neilsen JP, Jorsal SE: Protection againstprogressive atrophic rhinit is by vaccination with Pasteu-rella multocida toxin, purified by monoclonal antibodies.Vet Ret 125:7-11, 1989

21. Nielsen JP, Foged NT, Sorensen V, et al: Vaccinationagainst progressive atrophic rhinitis with a recombinantPasteurella multocida toxin derivative. Can J Vet Res55:128-138,1991

22. Kabay MJ, Mercy AR, Lloyd JM, et al: Vaccineefficacy for reducing turbinate atrophy and improvinggrowth rate in piggeries with endemic atrophic rhinitis.Aust VetJ 69:1oi-i