Atrophic Rhinitis
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Atrophic Rhinitis
๐ฌ 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.
๐ Key Features:
- Starts around puberty.
- Tends to regress around middle age (>40 years).
- More common in females than males.
โจ Types and Etiology of Atrophic Rhinitis
Atrophic Rhinitis is classified into two types based on the cause:
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Primary Atrophic Rhinitis: The underlying exact cause is unknown.
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Secondary Atrophic Rhinitis: Develops as a result of another specific underlying cause.
๐ฆ Theories for Primary Atrophic Rhinitis:
Various theories have been proposed. [Mnemonic: HERNIAS]
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Hereditary
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Endocrinal
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Racial
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Nutritional
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Infective
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Autoimmune
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Surfactant Deficiency
๐ In my detailed notes, Iโve 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.
๐ฅ Causes of Secondary Atrophic Rhinitis:
Develops secondary to another cause.
What are the causes of Secondary Atrophic rhinitis?
๐ฌ 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
๐ 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?
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Epistaxis
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Thick Greenish yellow Crusts and Discharge
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Foreign Body Sensation
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Slavic Facies
What is Slavic Facies?
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Myiasis
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Impairment of Hearing
Signs (On Examination):
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General: Foul smell emanating from the patient.
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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.
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Pharynx/Larynx: May show similar atrophic changes (atrophic pharyngitis, laryngeal sicca).
๐ฌ Investigations of Atrophic Rhinitis
- CT Scan of Nose & Paranasal Sinuses
What are CT Scan findings in Atrophic Rhinitis?
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Nasal Swab: Culture & sensitivity (to identify secondary invaders).
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Nasal Biopsy: Confirms diagnosis by histology (epithelial/vascular changes, glandular/nerve atrophy).
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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).
๐ Complications of Atrophic Rhinitis
Atrophic rhinitis, if left untreated, can lead to several troublesome and even socially debilitating complications. Some key complications include:
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Nasal deformities like saddle nose
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Septal perforation
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Foul-smelling crusts and secondary infections
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Psychological distress due to social embarrassment
๐ 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.
๐ฅ 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:
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Nasal Irrigation & Crust Removal: Most important step. 2-3 times/day initially, reduced later.
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Alkaline Nasal Douching
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Buffered Hypertonic Saline.
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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?
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Kemicetine Anti-Ozena Solution
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Estradiol Spray
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Submucosal injection of Placental Extract
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Oral Potassium Iodide
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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.
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Young's Operation
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Modified Young's Operation
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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?
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Wittmack Operation
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Stellate Ganglion Block
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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?
๐ค 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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