Atrophic rhinitis (Ozaena)
- Atrophic rhinitis is a chronic inflammatory disease of the nasal cavity that is characterised by atrophy of turbinates and nasal mucosa with foul smelling crusts
- It can be primary or secondary
Primary Atrophic Rhinitis
- Etiology (can be remembered with the mnemonic ‘HERNIA’)
- Heriditary factors
- Endocrine
- Atrophic rhinitis is mostly seen in females, starts around puberty and decreases after puberty.
- Hence a hormonal etiology is suggested
- Racial – more in whites and yellow races
- Nutritional
- Atrophic rhinitis is more seen in the developing nations
- It is rarely seen in people belonging to higher socioeconomic status
- Hence deficiency of vitamins and nutrients is believed to be a causative factor
- Infective
- Various bacteria – Klebsiella ozaenae, streptococcus, staphylococcus, proteus and E.coli have been isolated from the crusts
- It is suggested that these bacteria are in fact secondary pathogens, responsible for the foul smell
- Autoimmune
- Pathogenesis
- The ciliated columnar epithelium is replaced by squamous epithelium
- There is atrophy of the nasal mucosa and turbinates (with resorption of bone)
- The venous sinusoids, the seromucinous glands and the nerves atrophy
- Obliterative endarteritis of vessels occur
- Arrested development of sinuses
- Clinical features
- Symptoms
- Nasal obstruction – even though the nasal cavity is roomy, there is deposition of crusts which cause obstruction to air flow
- Foul smell from nose – Even though there is foul smell, the patient is unable to experience this, hence called merciful anosmia
- Epistaxis – Occurs when the crusts get dislodged
- Signs
- Nasal cavity is filled with greenish / blackish crusts
- On removal of crusts, there is bleeding and a roomy nasal cavity is revealed
- Nasal mucosa is pale
- Atrophy of turbinates, appear as ridges
- Even the posterior wall of nasopharynx may be visible
- Septal perforation and dermatitis of vestibule may be persent
- Similar atrophic changes may be present in pharynx (atrophic pharyngitis) and larynx (cough and hoarseness may be present)
- Serous otitis media may be present due to eustachian tube dysfunction
- Sinus may not be well developed (X ray)
- Symptoms
- Treatment
- Medical
- Removal of crusts with alkaline irrigation
- Fluid for irrigation can be prepared by mixing one teaspoon full of powder (one part sodium bicarbonate, one part sodium biborate, two parts sodium chloride) in 280ml of water
- The fluid can be introduced through one nostril and drained out through the other nostril
- Care should be taken so that the fluid does not enter the eustachian tube or gets aspirated
- Irrigation can be done initially 2-3 times a day, later decrease the frequency to 2-3 times a week.
- Hard to remove crusts can be removed by forceps once they are softened by irrigation
- Painting the nasal mucosa with 25% glucose in glycerol – helps prevent growth of bacteria so that foul smell does not occur
- Antibiotic sprays
- Oestradiol spray – to improve vascularity
- Submucosal injection of placental extract
- Streptomycin orally 1g/day for 10 days
- Potassium iodide orally helps liquefy nasal secretion
- Removal of crusts with alkaline irrigation
- Surgical
- Young’s operation
- Both the nostrils are surgically closed by raising flaps in the vestibule region
- Aims to give rest to nasal mucosa so that it may revert back to ciliated columnar epithelium
- The nostrils are opened after 6 months
- Modified young’s operation
- In this, the nasal cavity is only partially closed
- This is done to prevent the discomfort caused by complete nasal closure
- It is also said to have same effect as that of young’s operation
- Narrowing of the nasal cavity
- Due to roomy nasal cavity, the air currents dry up secretions, causing crusting
- Narrowing of nasal cavity aims to prevent crusting by decreasing the size of the airway
- This can be done by the following techniques
- Submucosal injection of teflon paste
- Insertion of strips of cartilage, fat, bone or teflon
- Medialisation of the lateral wall
- Young’s operation
- Medical
Secondary Atrophic rhinitis
- This occurs secondary to certain conditions like
- syphilis
- lupus
- leprosy
- radiotherapy to nose
- long standing purulent sinusitis
- excessive surgical removal of turbinates
Unilateral atrophic rhinitis
- This occurs in case of long standing septal deviation
- The opposite side with the roomy nasal cavity is predisposed to development of crusts