Atrophic Rhinitis

Atrophic Rhinitis

🌬 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.

📍 Key Features:

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

✨ 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.

🦠 Theories for Primary Atrophic Rhinitis:

Various theories have been proposed. [Mnemonic: HERNIAS]

• Hereditary

• Endocrinal

• Racial

• Nutritional

• Infective

• Autoimmune

• Surfactant Deficiency

📘 In my detailed notes, I’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.

🏥 Causes of Secondary Atrophic Rhinitis:

Develops secondary to another cause.

What are the causes of Secondary Atrophic rhinitis?

🔬 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

📋 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).

🔬 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).

💊 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

👉 There are several more clinically significant complications — including ones that affect the ears, lungs, and quality of life — all covered in detail in my ENT notes.

🏥 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?

🤔 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).