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Atrophic Rhinitis

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Atrophic Rhinitis

๐ŸŒฌ What is Atrophic Rhinitis?

Atrophic Rhinitis is a chronic inflammatory condition of the nose characterized by:

  • Progressive atrophy (wasting away) of the nasal mucosa and the underlying turbinate bones.
  • Leading to the formation of greenish-yellow crusts.
  • Resulting in abnormally roomy nasal cavities.
  • Associated with a very characteristic foul-smelling odor.

๐Ÿ“ Key Features:

  • Starts around puberty.
  • Tends to regress around middle age (>40 years).
  • More common in females than males.

โœจ Types and Etiology of Atrophic Rhinitis

Atrophic Rhinitis is classified into two types based on the cause:

  1. Primary Atrophic Rhinitis: The underlying exact cause is unknown.

  2. Secondary Atrophic Rhinitis: Develops as a result of another specific underlying cause.

๐Ÿฆ  Theories for Primary Atrophic Rhinitis:

Various theories have been proposed. [Mnemonic: HERNIAS]

  • Hereditary

  • Endocrinal

  • Racial

  • Nutritional

  • Infective

  • Autoimmune

  • Surfactant Deficiency

๐Ÿ“˜ In my detailed notes, Iโ€™ve discussed in detail each of these theories.

Subtypes of Primary Atrophic Rhinitis (Based on Histology):

  • Type 1: Shows endarteritis and periarteritis. Benefits from estrogen therapy (vasodilation).
  • Type 2: Shows vasodilatation of capillaries. Estrogen therapy may worsen.

๐Ÿฅ Causes of Secondary Atrophic Rhinitis:

Develops secondary to another cause.

What are the causes of Secondary Atrophic rhinitis?


๐Ÿ”ฌ Histology of Atrophic Rhinitis

Examining nasal tissue reveals characteristic changes:

  • Epithelial Changes: Normal ciliated columnar epithelium with goblet cells is replaced by stratified squamous epithelium, and cilia are lost.
  • Glandular Atrophy: Atrophy of seromucinous glands.
  • Nerve Atrophy: Atrophy of nerve elements.
  • Vascular Changes: Obliterative endarteritis and periarteritis in arteries of mucosa, periosteum, and bone (prominent in Type 1).
  • Bone Resorption
  • Sinus Hypoplasia

๐Ÿ“‹ Clinical Features of Atrophic Rhinitis

Symptoms:

  • Foul Smell (Halitosis)

What is Merciful Anosmia?

  • Anosmia

What are the reasons behind Anosmia in Atrophic Rhinitis?

  • Nasal Obstruction

What are the reasons behind nasal obstruction in Atrophic Rhinitis?

  • Epistaxis

  • Thick Greenish yellow Crusts and Discharge

  • Foreign Body Sensation

  • Slavic Facies

What is Slavic Facies?

  • Myiasis

  • Impairment of Hearing

Signs (On Examination):

  • General: Foul smell emanating from the patient.

  • Anterior Rhinoscopy:

    • Nasal cavity full of greenish or grayish-black dry crusts covering turbinates and septum.
    • Bleeding on crust removal.
    • After cleaning, nasal cavities are very roomy.
    • Atrophy of turbinate bones (especially inferior and middle). Severe atrophy may allow visualization of the posterior nasopharyngeal wall.
    • Nasal mucosa is pale.
    • Septal perforation may be present.
    • In extreme cases, saddle nose deformity.
  • Pharynx/Larynx: May show similar atrophic changes (atrophic pharyngitis, laryngeal sicca).


๐Ÿ”ฌ Investigations of Atrophic Rhinitis

  • CT Scan of Nose & Paranasal Sinuses

What are CT Scan findings in Atrophic Rhinitis?

  • Nasal Swab: Culture & sensitivity (to identify secondary invaders).

  • Nasal Biopsy: Confirms diagnosis by histology (epithelial/vascular changes, glandular/nerve atrophy).

  • Investigations for Secondary Causes:

    • Chest X-ray, Sputum for AFB, Mantoux test (TB).
    • Serological tests (Syphilis, other granulomatous diseases).
    • Tests for Rhinoscleroma (complement fixation, biopsy).
    • Tests for SLE (urine/serum protein).

๐Ÿ’Š Complications of Atrophic Rhinitis

Atrophic rhinitis, if left untreated, can lead to several troublesome and even socially debilitating complications. Some key complications include:

  • Nasal deformities like saddle nose

  • Septal perforation

  • Foul-smelling crusts and secondary infections

  • Psychological distress due to social embarrassment

๐Ÿ‘‰ There are several more clinically significant complications โ€” including ones that affect the ears, lungs, and quality of life โ€” all covered in detail in my ENT notes.


๐Ÿฅ Management of Atrophic Rhinitis

There is no specific cure for primary atrophic rhinitis. Management aims to control symptoms, improve hydration and hygiene, and minimize crusting/odor.

Medical Treatment:

  • Nasal Irrigation & Crust Removal: Most important step. 2-3 times/day initially, reduced later.

    • Alkaline Nasal Douching

    • Buffered Hypertonic Saline.

What is the composition of Alkaline Nasal Douching?

What is the role of each component in Alkaline Nasal Douching?

  • Application of 25% Glucose in Glycerine: Paint the nasal cavity.

What is the amount of Glucose and Glycerine used?

What is the role of Glucose and Glycerine here?

  • Kemicetine Anti-Ozena Solution

  • Estradiol Spray

  • Submucosal injection of Placental Extract

  • Oral Potassium Iodide

  • Systemic Streptomycin

What is the dosage of Streptomycin in Atrophic Rhintis?

Surgical Management:

Aims to reduce the size of the roomy nasal cavities to improve airflow pattern and moistening, and sometimes reroute salivary ducts.

  • Young's Operation

  • Modified Young's Operation

  • Nasal Cavity Narrowing Procedures - Reduce chamber size.

    • Lautenslager Operation
    • Wilson's Operation
    • Submucosal/Subperiosteal Implants under floor/lateral wall/septum mucosa.
    • Plastipore Implantation.

What is Lautenslager operation?

What is Wilson's Operation?

What implants are used reducing the size of nasal cavity in Atrophic Rhinitis?

  • Wittmack Operation

  • Stellate Ganglion Block

  • Vestibuloplasty

What is Young's operation & Modified Young's Operation?

What are the advantages & disadvantages of Young's operation & Modified Young's Operation?

What is Wittmack Operation?

How does Stellate ganglion block help in Atrophic Rhinitis?

What is Vestibuloplasty?


๐Ÿค” Differential Diagnosis of Atrophic Rhinitis

When a patient presents with symptoms suggestive of Atrophic Rhinitis (crusting, odor, obstruction), consider:

  • Nasal or Paranasal Sinus Tumor.
  • Purulent Rhinitis or Sinusitis.
  • Nasal Diphtheria.
  • Tuberculosis of the Nose.
  • Gumma (Syphilis).
  • Intranasal Foreign Body.
  • Nasal Cholesteatoma (rare).

Prognosis of Atrophic Rhinitis

Atrophic Rhinitis persists for many years, typically starting around puberty. However, there is often spontaneous recovery or significant improvement around middle age (>40 years).

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