ATrophic Rhinitis Granulomatous disease of nose

1. Atrophic Rhinitis
• Characterised by wide roomy nasal cavities
mostly secondary to destruction caused by
granulomatous condition of nose or due to
excessive tissue destructive surgery (empty
nose syndrome – excessive resection of
turbinates).
• Rarely Primary atrophic rhinitis following
an infection by Klebsiella ozaenae.
• Atrophic rhinitis also known as ozaena (foul smell)

2. Clinical presentation
1. Patient – main complaint is nasal obstruction
despite wide roomy nasal cavities because of
excessive crusting due to drying effect of air,
atrophy of glands nerves and blood vessels
which leads to infection in nose . Common in
poor socioeconomic patients.
2. Relatives- complains of foul smelling nasal
discharge from the patient
• Merciful for relatives and blissful anosmia for
patient as patient is not aware of it (Anosmia
due atrophy of nerves).

3. Medical Management
1. Alkaline Nasal Douching for remove the nasal crust 1st
part.
Method– Nacl,NaHco3, sodium biborate in a ratio of 2:1:1 in
distilled water. Filled in 20ml syringe and pushed in to the
nose. (loosen the crust)
2. Treat local infection that is 2nd part with Kemicetine solution
(spray/paint)—antibiotic solution which contains
chloroemphinicol, estradiol, propylene glycol and vitamin
D for nutritional deficiency (COPD).
3. 25% glucose in glycerine solution– glycerine (hrgroscopic)
lubricate the nose and glucose convert in to lactic acid
(proteolytic) which destroys bacterial proteins.
Investigate patient for any granulomatous disease if present.

4. Surgical Management
• Young’s Operation—Closure of nasal cavity for
6 month after remove crusting – till then
atrophic nasal mucosa regeneration occur.
Method- raise a flap of mucosa from lateral wall
and septum and suture the flaps.
• Modified Young’s operation– A gap of 3mm
opening is left in the centre that avoids the
discomfort of nasal obstruction.

5. Nowdays, atrophic rhinitis (secondary) is seen
mostly as a result of aggressive surgery for nasal
obstruction (Empty Nose Syndrome-excessive
resection of turbinate), trauma, manifestations of
granulomatous diseases, chronic cocaine abuse,
trauma and radiation therapy, these causes lead to
destructive effect in nose. It is also associated with
increasing age.
 Prior to the availability of antibiotics, primary
atrophic rhinitis in westernized countries was
commonly associated with infection from bacteria
such as Klebsiella pneumoniae subsp ozaenae which is
rare now.

6. Wide Roomy Patent nasal cavities are seen in patients
who complain of nasal Congestion/Obstrution because of
crusting formation due to drying effect of air .
The nasal mucosa in atrophic rhinitis gradually changes
from a functional, ciliated respiratory epithelium to a
nonfunctional lining of nonciliated squamous metaplasia,
with a loss of mucociliary clearance/humidification lead to
infection and foul smelling nasal discharge(ozaena)
Patient have anosmia due to decrease olfaction (nerve
atrophy) which is mercyful for others and blissful for
patient
Mostly seen in females who have estrogen and nutritonal
deficiency.

7. Management
Removal of crust by Alkaline Nasal Douching
sodium chloride, sodium bicarbonate, sodium biborate
solution in 2:1:1 in 50ml distilled water.
Local infection treated with Kemicitine solution which
contain (antibiotic solution)
C-chloroamphenicol
O-oestrdiol
P-propylene glycon – lubricant
D-VITAMIN D
25% GLUCOSE IN GLYCERINE SOLUTION-glucose change
in lactic acid which is proteolytic for bacterial proteins
and glycerine is a hygroscopic agent which help in nasal
lubrication.

8. SURGERY
• YOUNG’S OPERATION- only one nostril closed
by raising flaps from lateral wall of nose and
septum and suturing them midline.
• MODIFIED YOUNG’S OPERATION- keeping a
3mm central opening on both sides.

9. Rhinosporidiosis is an infectious disease caused by an aquatic protozoan previously considered
to be a fungus.
The aetiologic agent of rhinosporidiosis, Rhinosporidium seeberi, is closely related to several
protoctistiae fish pathogens. The infection affects nasal mucous membranes and ocular
conjunctivae of humans and animals, producing slowly growing masses that degenerate into
polyps.

10. Granulomatous disease of Nose
Syphilis and wegner’s granulomatosis can do
perforation in bony part of septum along with
cartilagenous septum.
Wegner granulomatosis is granulomatosis with
polyangitis. Autoimmune disease antibody
formerd against neutophils leads to vasculitis af
small and medium vessels. Affect upper and
lower airway along with Kidney.
Rhinophyma is tumour of nose not a
granulomatous disease of nose.

11. Rhinoscleroma
• Caused by klibesella form bacterial granulomas.
• Presentation like atrophic rhintis later forms
granulomas in nose present as Hard woody nose aka
Hebra nose.
• Diagnosis—Biopsy –macrophages with
intracytoplasmic bacilli (miculkics cells) and plasma
cells with inclusion bodies aka Russel bodies seen.
• T/t –Rifampicine
• Streptomycine
• Tetracycline
• Ciprofoxacin for 6 weeks.

12. Rhinosporidiosis
• Rhinosporidiosis is an infectious disease caused by an
aquatic protozoan previously considered to be a fungus.
• The aetiologic agent of rhinosporidiosis, Rhinosporidium
seeberi present in dung of cattle.
• Form granuloma in body skin and nose which are very
vascular form ripen strawberry and mulberry mass with
white dots (red and fleshy mass, bleeding polypoidal mass)
leads to epistaxis frequently which make it a differential
diagnosis of JNA.
• Diagnosis- nasal swab or biopsy which shows multiple
sporangias
• T/T- Wide Excision of mass with cauterisation of base
followed by Dapsone