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Atrophic Rhinitis,[object Object],MOHAMMAD AMIR,[object Object],3rd Year MBBS,[object Object],(24/08/2009),[object Object],JJMMC,[object Object]
Atrophic Rhinitis,[object Object],Common Terms,[object Object],Ozena,[object Object],Dry Rhinitis,[object Object],Rhinitis Sicca,[object Object]
Atrophic Rhinitis,[object Object],1) Accidental or Simple Ozoena,[object Object],“due to the retention of mucous.”,[object Object],“easily dealt with by the frequent employment of the nasal douche …”,[object Object],2) Idiopathic or constitutional,[object Object],“commences in early childhood ... And remains during the early years or throughout the whole adult life.”,[object Object],“The patient is generally anosmic … and he is, therefore, unaware of the offensive odor of his breath.”,[object Object],“The nature of the inflammatory process is very probably allied to that of lupus erythematosus of the face.”,[object Object],3) Syphilitic Ozoena,[object Object],“the most common form”,[object Object],“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.”,[object Object]
Atrophic Rhinitis,[object Object],	Described in 1876 by Dr. Bernhard Fraenkel as a triad of:,[object Object],Fetor,[object Object],Crusting,[object Object],Atrophy of nasal structures,[object Object],The breath is often so penetrating as to render the near presence of the sufferer not only unpleasant but almost unendurable.,[object Object]
Atrophic Rhinitis,[object Object],Clinical Features,[object Object],Anosmia,[object Object],Ozena, i.e. foul odor,[object Object],Extensive nasal crusting,[object Object],Subjective nasal congestion,[object Object],Enlargement of the nasal cavity,[object Object],Resorption or absence of turbinates,[object Object],Squamous metaplasia of nasal mucosa,[object Object],Depression,[object Object]
Atrophic rhinitis,[object Object],Primary,[object Object],History of prior sinus surgery, radiation, granulomatous disease, or nasal trauma are exclusions.,[object Object],Primary AR is rare in the US,[object Object],Most cases are reported in China, Egypt, and India,[object Object],Microbiology of primary AR is almost uniformly Klebsiellaozenae.,[object Object],Radiographic and clinical features similar to secondary AR.,[object Object]
Atrophic rhinitis,[object Object],Secondary,[object Object],Complication of sinus surgery (89%),[object Object],Complication of radiation (2.5%),[object Object],Following nasal trauma (1%),[object Object],Sequela of granulomatous diseases (1%),[object Object],Sarcoid,[object Object],Leprosy,[object Object],Rhinoscleroma,[object Object],Sequlae of other infectious processes,[object Object],Tuberculosis,[object Object],Syphilis,[object Object],Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.,[object Object]
Surgical causes,[object Object],Based on review of 242 cases from Mayo Clinic.,[object Object],Procedures per patient,[object Object],2.3,[object Object],Partial middle or inferior turbinectomy,[object Object],56%,[object Object],Total middle and inferior turbinectomy,[object Object],24%,[object Object],No turbinectomy,[object Object],10%,[object Object],Partial maxillectomy,[object Object],6%,[object Object],Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.,[object Object]
Other suggested causes,[object Object],Infectious (Ssali),[object Object],Case report of AR developed in 7 children of one family after contact with another known AR child.,[object Object],Dietary ,[object Object],(Bernat) Iron therapy found to benefit 50% of patients treated,[object Object],(Han-Sen) Hypocholesterolemia present in 50% of patients.,[object Object],(Han-Sen) Vitamin A therapy showed symptomatic improvement in 84%.,[object Object],Hereditary (Barton, Sibert),[object Object],Proposed autosomal dominant disease due to father and 8 of 15 children contracting the disease.,[object Object],Hormonal ,[object Object],Symptoms known to worsen with menstraution or pregnancy.,[object Object],Developmental (Hagrass),[object Object],Radiologic evidence of poor maxillary antrum pneumatization and short nasal lengths,[object Object],Vascular (Ruskin),[object Object],Postulated overactivation of sympathetic activity.,[object Object],Environmental (Mickiewicz),[object Object],Chronic exposure to phosphorite and apatide dust,[object Object],Autoimmune (Ricci),[object Object]
Physical findings,[object Object],Crusting ,[object Object],100% Present,[object Object],Inferior Turbinates,[object Object],62% Partial absence,[object Object],37% Total absence,[object Object],Middle Turbinates,[object Object],57% Absent,[object Object],Discharge ,[object Object],52% Present,[object Object],Septum,[object Object],10% Perforations,[object Object],Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.,[object Object]
Radiographic Findings,[object Object],Mucoperiosteal thickening of the paranasal sinuses.,[object Object],Loss of definition of the OMC secondary to resorption of the ethmoid bulla and uncinate process.,[object Object],Hypoplasia of the maxillary sinuses.,[object Object],Enlargement of the nasal cavities with erosion and bowing of the lateral nasal wall.,[object Object],Bony resorption and mucosal atrophy of the inferior and middle turbinates.,[object Object],Pace-Balzan, Shankar, Hawke. J Otolaryngol 1991; 20:428-32.,[object Object]
Atrophic Rhinitis
Atrophic Rhinitis
Biopsy Findings,[object Object],Normal Mucosa,[object Object],Pseudostratified Columnar,[object Object],Presence of serous and mucous glands,[object Object],Atrophic Rhinitis,[object Object],Squamous metaplasia,[object Object],Atrophy of mucous glands,[object Object],Scarce or absent cilia,[object Object],Endarteritis obliterans,[object Object]
Microbiology,[object Object],Klebsiella ozenae,[object Object],May be found in almost 100% of primary AR,[object Object],No predominance in secondary AR,[object Object],Staphylococcus aureus,[object Object],Proteus mirabilis,[object Object],Escherichia coli,[object Object],Corynebacterium diphtheriae,[object Object]
Current Therapies,[object Object],Goals of therapy,[object Object],Restore nasal hydration,[object Object],Minimize crusting and debris,[object Object],Therapy options,[object Object],Topical therapy,[object Object],Saline irrigations,[object Object],Antibiotic irrigations,[object Object],Systemic antibiotics,[object Object],Implants to fill nasal volume,[object Object],Closure of the nostrils,[object Object]
Local therapy,[object Object],Irrigations,[object Object],Saline,[object Object],Mixtures,[object Object],Sodium bicarbonate,[object Object],Shehata: Sodium Carbonate 25g, Sodium Biborate 25g, and Sodium Chloride 50g in 250ml water.,[object Object],Antibiotic solution,[object Object], Moore: Gentamycin solution 80mg/L,[object Object],Anti-drying agents,[object Object],Glycerine,[object Object],Mineral Oil,[object Object],Paraffin with 2% Menthol,[object Object],Other,[object Object],Acetylcholine,[object Object],Pilocarpine,[object Object]
Systemic therapy,[object Object],Oral antibiotics,[object Object],Tetracycline,[object Object],Ciprofloxacin,[object Object],Aminoglycosides,[object Object],Streptomycin injections,[object Object],Medication avoidance,[object Object],Vasoconstrictors,[object Object],Topical steroids *,[object Object],Other,[object Object],Vitamin A (12,500 to 15,000 Units daily),[object Object],Potassium Iodide (Increases nasal secretions),[object Object],Vasodilators,[object Object],Iron therapy,[object Object],Estrogen,[object Object],Corticosteroids *,[object Object],Vaccines,[object Object],Antibacterial (Pasturella, Bordetella),[object Object],Autogenous ,[object Object]
Surgical therapies,[object Object],Young procedure,[object Object],Modified Young procedure,[object Object],Turbinate reconstruction,[object Object],Volume reduction procedures,[object Object],Denervating operations,[object Object]
Nasal Closure,[object Object],Young’s procedure,[object Object],Circumferential flap elevation 1 cm cephalic to the alar rim.,[object Object],Sutures placed in center of elevated flap to close the nostril,[object Object],Staged second side in 3 months,[object Object],Advantages,[object Object],Often provided relief of symptoms,[object Object],Disadvantages,[object Object],Difficult to elevate circumferential flap,[object Object],Breakdown of central suture area common,[object Object],Does not allow for cleaning,[object Object],Did not allow for periodic examination,[object Object],Recurrence after flap takedown,[object Object],Young. “Closure of the nostril in atrophic rhinitis.” Journal of Laryngology and Otology, 81: 515-524.,[object Object]
Nasal Closure,[object Object],Modified Young’s,[object Object],Elevation of extended perichondrial flap through contralateral hemitransfixion incision.,[object Object],Short skin flap elevated from the intercartilaginous line on the ipsilateral side.,[object Object],Suture lateral and medial flaps with vicryl.,[object Object],Staged second side with first side takedown in 6 mon.,[object Object],Advantages,[object Object],Technically easier than Young procedure,[object Object],No suture line breakdown,[object Object],No vestibular stenosis on takedown,[object Object],Disadvantages,[object Object],Not possible with large septal defects,[object Object],Does not allow for cleaning,[object Object],Does not allow for periodic examination,[object Object],Recurrence after flap takedown,[object Object],El Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis.” Rhinology, 36, 202-203, 1998.,[object Object]
Modified Young,[object Object]
Volume reduction,[object Object],Plastipore implantation,[object Object],Porus material allows tissue ingrowth.,[object Object],Implants shaped then fenestrated for ingrowth.,[object Object],Implants placed submucosally along the septum and nasal floor.,[object Object],Advantages,[object Object],Easier than other surgical options (Young’s),[object Object],Plastipore has low extrusion/complication rate,[object Object],May be done under local anesthesia,[object Object],Disadvantages,[object Object],Possibility of extrusion (occurred in 1/8 pts),[object Object],Requires septal mucosa (not discussed),[object Object],Goldenberg, Danino, Netzer, Joachims. Oto HNS, Vol. 122 (6). pp. 794-97.,[object Object]
Plastipore,[object Object]
Volume Reduction (cont),[object Object],Triosite and Fibrin,[object Object],Triosite (60% hydroxyapetite, 40% calcium triphosphate) mixed with Fibrin 1:1.,[object Object],Deglove the labial vestibule,[object Object],Elevate periosteum of the floor posteriorly to the end of the hard palate, extend medially onto the septum.,[object Object],Insert Triosite & Fibrin mixture (~3.3g per side),[object Object],Advantages,[object Object],Good to excellent result (7/9 patients),[object Object],Material can be molded easily ,[object Object],Disadvantages,[object Object],Leakage of material (4/9 patients),[object Object],Infection of material (3/9 patients),[object Object],Potential damage to lacrimal system,[object Object],Bertrand, Doyen, Eloy. Laryngoscope 106: May 1996. p 652-57.,[object Object]
Other Therapies,[object Object],Non-surgical nasal closure,[object Object],Nasal vestibule impressions taken similar to hearing aid moulds.,[object Object],Impressions are used to create a silastic obturator.,[object Object],Advantages,[object Object],Reversible,[object Object],Easily removed,[object Object],Allows for irrigations,[object Object],Allows for serial clinical exams,[object Object],Avoids surgical morbidity ,[object Object],Disadvantages,[object Object],May be uncomfortable,[object Object],May cause sore throat due to obligate mouth breathing.,[object Object],Lobo, Hartley, Farrington. J of Laryn and Oto. June 1998, Vol 112, p 543-46.,[object Object]
Other Therapies,[object Object],Other Implants,[object Object],Acrylic,[object Object],Silicone,[object Object],Teflon,[object Object],Silastic,[object Object],Boplant,[object Object],Denervation,[object Object],Cervical sympathectomy (Bertein),[object Object],Stellate ganglion block (Bahl),[object Object],Sphenopalatine ganglion block (Girgis),[object Object],Parasympathectomy, i.e. GSPN section (Krmptotic),[object Object],Salivary Irrigation,[object Object],Involves reimplantation of parotid duct into the maxillary sinus,[object Object],Accupuncture,[object Object],Time,[object Object],Disease often resolves spontaneously after age 40,[object Object]
Thanks for your ,[object Object],Patient listening &viewing.,[object Object]

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Atrophic Rhinitis

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