Chronic atrophic rhinitis

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Chronic atrophic rhinitis
Specialty	Otorhinolaryngology

Chronic atrophic rhinitis, or simply atrophic rhinitis, is a chronic

Signs and symptoms

• It is most commonly seen in females.
• It is reported among patients from
  lower socioeconomic groups.^[1][2]
• The nasal cavities become roomy and are filled with foul smelling crusts which are black or dark green and dry, making expiration painful and difficult.
• Microorganisms are known to multiply and produce a foul smell from the nose, though the patients may not be aware of this, because the nerve endings (responsible for the perception of smell) have become atrophied. This is called merciful anosmia.
• Patients usually complain of nasal obstruction despite the roomy nasal cavity, which can be caused either by the obstruction produced by the discharge in the nose, or as a result of sensory loss due to atrophy of nerves in the nose, so the patient is unaware of the air flow. In the case of the second cause, the sensation of obstruction is subjective.
• Bleeding from the nose, also called epistaxis, may occur when the dried discharge (crusts) are removed.
• nasal vestibule
  can occur. The nose may show a saddle-nose deformity.
• Atrophic rhinitis is also associated with similar atrophic changes in the pharynx or larynx, producing symptoms pertaining to these structures. Hearing impairment can occur due to Eustachian tube blockage causing middle ear effusion.

Etiology

Causes can be remembered by the mnemonic HERNIA:

• Hereditary factors: the disease runs in families
• Endocrine
  imbalance: the disease tends to start at puberty and mostly involves females
• Racial
  factors: white people are more susceptible than natives of equatorial Africa
• Nutritional deficiency: vitamins A or D, or iron^{[citation needed]}
• Infection: Klebsiella pneumoniae subsp. ozaenae, diphtheroids, Proteus vulgaris, E. coli, etc.
• Autoimmune
  factors: viral infection or some other unidentified insult may trigger antigenicity of the nasal mucosa.

Secondary atrophic rhinitis

Specific infections, such as

Extreme deviation of nasal septum may be accompanied by atrophic rhinitis on the wider side.

Pathology

• The ciliated columnar epithelium of the nasal mucosa is replaced by stratified squamous epithelium.
• Atrophy of mucosa, turbinal bones and seromucinous glands tends to occur, due to obliterative endarteritis and periarteritis causing decreased blood supply, hence the supplying area atrophies.^[5]
• Arrested development of paranasal sinuses.

Diagnosis

Diagnosis is based on clinical history and examination. Examination is clinical, via anterior rhinoscopy and fibreoptic, using nasendoscopy. A CT scan can be used to confirm the diagnosis and review disease extent.

Treatment

Treatment of atrophic rhinitis can be either medical or surgical.

Medical measures include:

• Nasal irrigation using normal saline^[3]
• Nasal irrigation and removal of crusts using alkaline nasal solutions.
• 25% glucose in glycerine can be applied to the nasal mucosa to inhibit the growth of proteolytic organisms which produce foul smell.
• Local antibiotics, such as Chloromycetin.
• Vitamin D₂ .
• Estradiol spray for regeneration of seromucinous glands and vascularization of mucosa.
• Systemic streptomycin (1g/day) against Klebsiella organisms.
• Oral potassium iodide for liquefaction of secretion.
• Placental extract injected in the submucosa.^[6]
• Rifampicin 600 mg once daily for 12 weeks.^[5]

Surgical interventions include:

• Young's operation.
• Modified Young's operation.
• Narrowing of nasal cavities, submucosal injection of Teflon paste (William's operation), section and medial displacement of the lateral wall of the nose.
• Transposition of parotid duct to maxillary sinus or nasal mucosa (Wittmack's operation)
• Complete inversion of mucoperiosteum of maxillary antrum to create a neo-turbinate (Raghav Sharan's operation)
• Repeated Stellate ganglion block (Sardana's operation)
• Vestibuloplasty

History

This disorder was known since the time of ancient Egypt, almost 4,000 years ago, and descriptions of it are found in the historical

• Empty nose syndrome

References