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)
  • 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
    • 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

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

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