3. Definition
⢠Atrophic rhinitis is defined as a chronic nasal disease
characterised by progressive atrophy of the nasal mucosa
along with the underlying bones of turbinates.
⢠There is also associated presence of viscid secretion which
rapidly dries up forming foul smelling crusts.
⢠This fetid odour is also known as ozaena.
⢠The nasal cavity is also abnormally patent.
⢠The patient is fortunately unaware of the stench emitting
from the nose as this disorder is associated with merciful
anosmia.
4. Aetiology
The etiology of this problem still remains obscure.
Numerous pathogens have been associated with this condition,
the most important of them are
⢠1. Coccobacillus,
⢠2. Bacillus mucosus,
⢠3. Coccobacillus foetidus ozaenae,
⢠4. Diptheroid bacilli and
⢠5. Klebsiella ozaenae.
These organisms despite being isolated from the nose of
diseased patients have not categorically been proved as the
cause for the same.
7. COMMONEST CAUSE OF UNILATERAL
ATROPHIC RHINITIS
GROSSLY DEVIATED SEPTUM
MECHANICAL THEORY OF ZAUFAL â It
states that skeletal defects due to gross septal
deviation to one side leads to unilateral atrophic
rhinitis on the roomy side.
8. Pathology:
1. Metaplasia of ciliated columnar nasal epithelium into
squamous epithelium.
2. There is a decrease in the number and size of compound
alveolar glands
3. Loss of cilia
4. Atrophy of nerves
5. Fibrosis of lamina propria
9. Type I
ďis characterised by the presence of endarteritis and
periarteritis of the terminal arterioles.
ďThis could be caused by chronic infections.
ď These patients benefit from the vasodilator effects of
oestrogen therapy.
10. Type II
ď is characterised by vasodilatation of the capillaries,
ďthese patients may worsen with estrogen therapy.
They also showed a positive reaction for alkaline
phosphatase suggesting the presence of active bone
resorption.
12. Clinical features:
Nasal obstruction - crust formation
atrophic nerve endings
Thick crusts
Epistaxis
Anosmia
Offensive smell perceived by others
Headache
Impairment of hearing
Associated changes in pharynx & larynx
13. Clinical examination
ďClinical examination of these patients show that their
nasal cavities filled with foul smelling greenish, yellow or
black crusts,
ď the nasal cavity appear to be enormously roomy.
ď When these crusts are removed bleeding starts to occur
ďSeptal perforations &external deformity
14. Why nasal obstruction even in
the presence of roomy nasal
cavity?
⢠The nasal cavity is filled with sensory nerve endings close
to the nasal valve area.
⢠These receptors sense the flow of air through this area
thus giving a sense of freeness in the nasal cavity.
⢠These nerve endings are destroyed in patients with
atrophic rhinitis thus depriving the patient of this
sensation.
⢠In the absence of these sensation the nose feels blocked.
18. CT scan findings
1. Mucoperiosteal thickening of paranasal sinuses
2. Loss of definition of osteomeatal complex due to
resorption of ethmoidal bulla and uncinate process
3. Hypoplastic maxillary sinuses
4. Enlargement of nasal cavity with erosion of the lateral
nasal wall
5. Atrophy of inferior and middle turbinates
19.
20.
21. Conservative Treatment
1.Nasal douching - The patient must be asked to douche
the nose atleast twice a day with a solution prepared with:
Sodium bicarbonate - 28.4 g
Sodium biborate - 28.4 g
Sodium chloride - 56.7 g
mixed in 280 ml of luke warm water.
The crusts may be removed by forceps or suction.
2. 25% glucose in glycerin drops can be applied to the nose
thus inhibiting the growth of proteolytic organism.
22. Conservative
⢠In patients with histological type I atrophic rhinitis oestradiol
in arachis oil 10,000 units/ml can be used as nasal drops.
⢠Kemecetine antiozaena solution - is prepared with
chloramphenicol 90mg, oestradiol dipropionate 0.64mg,
vitamin D2 900 IU and propylene glycol in 1 ml of saline.
⢠Potassium iodide can be prescribed orally to the patient in an
attempt to increase the nasal secretion.
⢠Systemic streptomycin injection
⢠Systemic use of placental extracts have been attempted with
varying degrees of success.
23. Surgical treatment
Aims
- to narrow the widened nasal cavity
- diminish drying and crust formation
- rest the mucosa and allow regeneration
24. Surgical management
1. Submucous injections of paraffin, .
2. Recently teflon strips, and autogenous cartilages
have been inserted along the floor and lateral nasal
wall after elevation of flaps.
3. Wilson's operation - Submucosal injection of 50%
Teflon in glycerin paste.
4. Witmackâs operation â rerooting of parotid duct
5. Lautenslagerâs operation â medialisation of lateral
wall
6. Repeated stellate ganglion blocks have also been
employed with some success
25. 7. Young's operation
⢠This surgery aims at closure of one or both nasal cavities
by plastic surgery.
⢠After a period of 6 to 9 months when these flaps are
opened up the mucosa of the nasal cavities have found to
be healed.
⢠This can be verified by postnasal examination before
revision surgery is performed.
8.Modifications of this procedure has been suggested
(modified Young's operation) where a 3mm hole is left
while closing the flaps in the nasal vestibule. This enables
the patient to breath through the nasal cavities
28. ďIt is a chronic granulomatous fungal disease of the
nose caused by Rhinosporidium Seeberi/ Kinealyi.
ďMode of Transmission:
1. Exact mode is not known.
2.Acquired by swimming in contaminated ponds.
3.Inhaling the dust of dried cowdung.
Malignant:- Deep seated and multiple, spreading
through systemic route. Generalised
Rhinosporidiosis.
29. ďIncidence:- 95% from India & Srilanka
ďMale: Female â 2:1
ďTamil Nadu â Hyperendemic areas â madurai
& Ramnad, Thirumangalam, Rajapalayam,
Sivagangai (Large Ponds)
ďAffects âNasal mucosa, Conjunctiva, Sclera,
Tonsils, Genitalia and Skin
30. ďTrauma â Predisposing factor â infective spores
enter through traumatised nasal mucosa and
multiply in the submucosa forming sporangia.
ďSpores are discharged into tissues and cause
reactive hyperplasia and lead to formation of
vascular mass.
31. CLASSIFICATION â Anatomical Sites
1. Nasal (78%)
a. Mucous membrane of septum
b. Spur in nasal floor
c. Lateral wall
2. Nasopharyngeal (16%)
a. Upper aspect of palate
3. Mixed
a. Naso â nasopharyngeal (6.3%)
b. Ethmoido â nasopharyngeal
c. Naso â lacrimal
4. Bizaree
a. Conjuntival
b. Tarsal
c. Cutaneous
d. Laryngeal
33. Staining Method
ďSpherule is made up of liproprotein coat with protein
matrix and feulgen positive centre
Bromophenol blue â spherules
Bismark brown â wall of spherules
Sudan black B â Lipoprotein coat.
39. Investigations
ďRoutine Blood and Urine investigations.
ďHistamine level to be estimated â Histamine content
of Rhinosporidiosis is increased so proliferates quickly
and bleeds profusely.
ďX-Ray PNS.
ďMicroscopic (KOH) examination of nasal discharge.
ďDNE.
ďHPE.
40. Treatment
ďWide excision of the mass along with basal cautery.
ďDapsone 100 mg daily to prevent recurrence (arrest
the maturation of spores).
Side effects â Methaemoglobinemia
Hepatotoxicity
Recurrence â 1) Incomplete removal
2) Submucosal presence of spores
3) Multiple sites.
42. ďIt is a chronic granulomatous disease of the nose,
caused by Gram negative, non motile, encapsulated,
diplobacillus, Klebsiella Rhinoscleromatis (Frisch
Bacillus).
ďSite â Nose, nasopharynx, oropharynx, larynx, trachea
and bronchi.
ďCommon in females.
ďPredisposing factors â Poor hygiene and low socio
economic status.
43. ďPathogenesis:
Droplet infection
ďClinical features:
1) Atrophic stage.
2) Granulomatous stage â Tapir Nose (Subdermal
infiltration of the nodules in lower part of nose &
upper lip giving a woody feel).
3) Cicatricial stage â Hebra Nose (Scarring, enlargement
& disfigurement of the nose).
44. Histology
ďMikulicz cells â Presence of scattered large foam cells
with a central nucleus and vacuolated cytoplasm
containing the bacilli.
ďRussel bodies â Plasma cells with eosinophilic,
homogenous inclusion bodies .
45. Investigations
ďBiopsy & HPE
ďCulture of the organism in Mc-conkey agar medium
and staining by PAS and Giemsa stains.
ďX Ray skull lateral view â âVâ shaped soft palate
attachment â Palatal sign â Gothic arch deformity
47. Rhinitis Medicamentosa
ďThe prolonged usage of Sympathomimetic nasal
decongesant drops and sprays leads to Tachyphylaxis
resulting in rebound vasodilatation & engorgement of
nasal mucosa leads to nasal obstruction.
48. ďRhinitis Sicca :
ďIt is a form of rhinitis characterised by dryness of
nose, limited to the anterior part of nasal cavity. It
occurs in people who work in hot and dry
surroundings.
ďRhinitis Caseosa:
ďIt is a chronic nasal disease characterized by the
presence of caseous cholesteatoma like material with
granulations in the nose. It is also called nasal
cholesteatoma.
49. Stewartâs Granuloma
ďIt is also called peripheral sinonasal T-cell lymphoma.
ďIt presents as an indurated swelling of the nose, nasal
vestibule and septum.
ďHPE â dense collection of cells especially
lymphocytes.
ďTreatment : Radiotherapy.
50. Wegenerâs Granuloma
ďIt is an autoimmune disease of unknown aetilogy
characterised by necrotising granuloma and vasculitis
of the upper and lower airways, systemic vasculitis
and focal necrotising glomerulonephritis.
ďDiagnosis by nasal biopsy.
ďTreatment : Saline nasal douching
Cyclophosphamide 1-2 mg/kg/day
High dose of steroids.
53. Pathogenesis
Neglected foreign body/ blood clot /
inspissated mucus -nidus
â
Granulations formation
â
Calcium, mg CO 3 or PO4 gets deposited
â
Hard rhinolith
â
Enlarges & nerosis of septum
54. CLINICAL FEATURES
ď Unilateral nasal discharge
ďNasal obstruction
ďOccasional epistaxis
ďSometimes asymptomatic
ďAR â irregular , grey or greyish black mass along the
floor
ďOn probing â gritty sensation
55. Diagnosis
- History , examination
- X- ray PNS
Treatment
surgical excision â endoscopic
lateral rhinotomy
56. NASAL MYIASIS
ďSYNONYM â maggots in the nose
Suppurative conditions of nose / unhygenic living
condition
â
attracts flies â chrysomiya , lay eggs
â
hatch & grow into larvae
â
Crawl into nasal cavity & surrounding regions
58. Clinical features
ďIrritation of nose
ďWatering of eyes
ďSwelling & puffiness of eyelids, lips
ďThin blood stained nasal discharge to epistaxsis
ďFoul smell
ďFormication â Crawling sensation in the nose.
ďAR- multiple maggots with purulent, foul smelling
nasal discharge
60. Treatment
ďHandpicked with nasal dressing forceps
ďInstillation of 25% chloroform or turpentine oil
ďDouching with warm saline
ďTreat complications
ďTreat underlying cause