Atrophic rhinitis.ppt for MBBS STUDENTS YEAR 3 MINOR SUBJECT

This ppt is based on dhingra, scott.

1. Atrophic Rhinitis
Prof. Dr. Krishna Koirala

2. Questions
•Define Atrophic Rhinitis. What is the hallmark of
this condition? Write down its types.
•Write down the clinical features and
investigations of atrophic rhinitis.
•Discuss the medical and surgical treatment of
atrophic rhinitis.
• PBQ

3. •Defined as chronic inflammation of nose
characterized by progressive atrophy of
nasal mucosa, including the glands,
turbinate bones and the nerve elements
supplying the nose
• Hallmark: formation of scanty viscid
secretion & greenish crusts which emit a
foul odour (ozaena)
•Removal of crusts reveals roomy nasal cavity
•Types
−Primary
−Secondary

4. Primary Atrophic rhinitis
•Etiology:
−Hereditary : autosomal inheritance in 30% cases
−Developmental: congenital roomy nasal cavity, poor
pneumatization of maxillary antrum
−Endocrine : Seen during puberty, menopause,
menstruation (symptoms aggravate due to estrogen
deficiency)
−Racial : More in American Negroes & Latin (yellow race)
−Nutritional deficiency : Iron, Vitamin A, Vitamin D

5. •Infection : Klebsiella ozaenae (Perez & Abel bacillus),
Coccobacillus foetides ozaena, Bacillus mucosus,
Diphtheroids, Haemophilus influenzae
•Autoimmune : Viral infection / malnutrition / immune
deficiency trigger destructive autoimmune process on
nasal mucosa
•Autonomic Imbalance : Reflex Sympathetic Dystrophy
Syndrome (R.S.D.S.) causes vasodilatation & hyperemic
decalcification of turbinates followed by vasoconstriction
•Surfactant deficiency in nasal secretion
−Ciliary dysfunction + stasis of nasal secretions

6. Secondary Atrophic Rhinitis
•Long-standing purulent sinusitis
•Iatrogenic:
−Radical turbinectomy, post - RT
•Granulomatous lesions:
−Tuberculosis, syphilis, leprosy, rhinoscleroma
•Deviated nasal septum (atrophy in wider nasal
cavity)

7. Symptoms
•Nasal obstruction
•Greenish -yellow nasal discharge
•Offensive smell (ozaena) due to anaerobic
infection, experienced by relatives but not
by the patient (Merciful anosmia)
•Bleeding on crust removal

8. Signs
•Roomy nasal cavity with atrophy of mucosa
& turbinates
•Greenish-yellow nasal discharge with crust
formation (begins from posteriorly)
•Foul smell (fetor)
•Nasal Myiasis may be present

9. Nasal crusting

10. Turbinate atrophy & roomy nasal cavity

11. D/D for ozaena D/D for dry nose
1. Atrophic rhinitis 1. Atrophic rhinitis
2. Purulent sinusitis 2. Rhinitis sicca
3. Nasal foreign body 3. Radiotherapy
4. Rhinitis caseosa 4. Sjogren’s
syndrome
5. Malignancy

12. •Causes of Anosmia
−Loss of olfactory neural elements
−Thick secretion & crusts over olfactory area
−Degeneration of secretary glands  scanty mucus
for dissolving odoriferous materials
•Causes of nasal obstruction
−Blunting of sensory nerve endings
−Crust formation
−Lack of eddy current formation in roomy cavity

13. Pathology
•Accumulation of lymphocytes & plasma cells
•Metaplasia from ciliated columnar to squamous
epithelium
•Ciliary destruction & decrease in number & size of nasal
glands
•Bone resorption
•Type I: Endarteritis & periarteritis of terminal
arterioles :benefit from vasodilator effect of
estrogen therapy
•Type II: Dilated capillaries : worsened by estrogen

14. Specific Investigations
•Saccharine test : nasal muco- ciliary
clearance time
•Serum iron & protein levels: malnutrition
•Culture & sensitivity of nasal discharge
•X-ray P.N.S. : maxillary sinusitis

15. C.T. Scan Nose and P.N.S.
•Mucosal thickening
•Resorption of ethmoid
bulla & uncinate process
•Hypoplasia of maxillary
sinuses
•Roomy nasal cavities
•Erosion & bowing of
lateral nasal wall
•Atrophy of turbinates

16. •Chest X-ray: T.B., bronchiectasis, lung abscess
•Serology for syphilis: V.D.R.L., T.P.H.A., T.P.I.
•Sputum for AFB, Mantoux test: T.B.
•Nasal smear study: leprosy
•Complement fixation test & biopsy:
Rhinoscleroma

17. Medical
Treatment

18. •Douching  alkaline nasal douche
•Oestradiol nasal spray (1%) /Placental extract
injection (increase the vascularity of nasal mucosa,
regenerates the submucosal glands)
•Glucose (25%) in glycerin nasal drops
•Streptomycin injection /Rifampicin tablet : Effective
against Klebsiella
•Kemicetine anti-ozaena nasal solution : contains
chloramphenicol, estradiol dipropionate, Vit D, propylene glycol
•Mandl’s nasal paint (Potassium Iodide & estradiol)
•Potassium Iodide orally (liquifies the crusts)

19. Alkaline Nasal Douche
Sodium bicarbonate (28.4g)  loosens nasal crusts
Sodium biborate (28.4g)  Antiseptic
Sodium chloride (56.7g)  makes solution isotonic
•Mixed in 280 ml of warm water to make the solution
•5 cm long no.8 infant feeding tube fitted in 20 ml
plastic syringe
•Syringe the nasal cavity by bending forward & keep
saying K, K, K … to close nasopharyngeal isthmus
•Done twice daily till all crusts disappear

20. Surgical Treatment

21. Aim of Surgery
•Decrease trauma of air turbulence (decrease the
roomy cavity)
−Young , Modified Young ,Lautenslager's ,Wilson ,
Sublabial implants ,Vestibuloplasty
•Increase nasal secretions
−Parotid duct implantation into maxillary sinus
•Increase vascularity of nasal mucosa
−Cervical sympathectomy
−Nasal implantation of maxillary sinus mucosa

22. •Young’s operation:
−Only 1 nostril closed completely by raising 2
circumferential flaps (inner mucosal & outer
cutaneous) in nasal vestibule & suturing
them in midline
•Modified Young’s operation
−Done by similar way but keeping a 3 mm
opening on both sides
•Recanalization done after 12-18 months with a
tri-radiate (Mercedes Benz) incision

23. Pre-operative

24. Mucosal flaps sutured

25. Cutaneous flap sutured

26. Post-operative healed flaps

27. Tri-radiate incision

28. Modified Young’s operation

29. Advantages of Modified Young
operation
•Progress of disease can be monitored with
2.7 mm nasal endoscope
•Glucose in glycerin drops can be instilled
•Both nostrils can be operated at one sitting
•Nasal breathing preserved
•No complaints of de-nasal voice
•Better cosmetic result

30. •Lautenslager’s operation: Fracture & medial
displacement of lateral nasal wall
•Wilson’s operation: submucosal injection of
Teflon paste
•Antral mucosal transplantation into nasal
cavity through intranasal antrostomy
•Vestibuloplasty: raising a lateral shelf from
nasal vestibular flap to cover the turbinates

31. Pre-operative

32. Lautenslager’s operation

33. Submucosal Teflon paste

34. Antral mucosal transplant

35. Ventriculoplasty

36. •Sympathectomy
−Stellate ganglion block /cervical chain block
•Sublabial implantation
−Placental bits, bone, cartilage, fat, acrylic
resin, teflon, Silastic
•Parotid duct implantation into maxillary
sinus : Wittmack’s operation

37. Action of Placental extract
•Progesterone leads to hyperplasia of nasal
mucosa & glandular secretion
•Estrogen leads to vasodilatation
•Biogenic stimulator of metabolic & regenerative
process
•Intra-placental serum boosts up immunity
•Mechanical narrowing of nasal passage