Atrophic rhinitis is a nasal condition characterized by symptoms such as foul odor, nasal crusting, and anosmia, which can arise from various causes including idiopathic factors, infections, and post-surgical changes. Treatment options range from nasal hydration therapies and antibiotics to surgical interventions aimed at improving nasal function. The condition is relatively rare in the US, but more prevalent in countries like China, Egypt, and India, with klebsiella ozenae often implicated in primary cases.

1. Atrophic RhinitisMOHAMMAD AMIR3rd Year MBBS(24/08/2009)JJMMC

2. Atrophic RhinitisCommon TermsOzenaDry RhinitisRhinitis Sicca

3. Atrophic Rhinitis1) Accidental or Simple Ozoena“due to the retention of mucous.”“easily dealt with by the frequent employment of the nasal douche …”2) Idiopathic or constitutional“commences in early childhood ... And remains during the early years or throughout the whole adult life.”“The patient is generally anosmic … and he is, therefore, unaware of the offensive odor of his breath.”“The nature of the inflammatory process is very probably allied to that of lupus erythematosus of the face.”3) Syphilitic Ozoena“the most common form”“These ulcers may be preceded or followed by caries or necrosis of the bones, and the stench is then more horribly sickening than in any other form of this disgusting malady.”

4. Atrophic Rhinitis Described in 1876 by Dr. Bernhard Fraenkel as a triad of:FetorCrustingAtrophy of nasal structuresThe breath is often so penetrating as to render the near presence of the sufferer not only unpleasant but almost unendurable.

5. Atrophic RhinitisClinical FeaturesAnosmiaOzena, i.e. foul odorExtensive nasal crustingSubjective nasal congestionEnlargement of the nasal cavityResorption or absence of turbinatesSquamous metaplasia of nasal mucosaDepression

6. Atrophic rhinitisPrimaryHistory of prior sinus surgery, radiation, granulomatous disease, or nasal trauma are exclusions.Primary AR is rare in the USMost cases are reported in China, Egypt, and IndiaMicrobiology of primary AR is almost uniformly Klebsiellaozenae.Radiographic and clinical features similar to secondary AR.

7. Atrophic rhinitisSecondaryComplication of sinus surgery (89%)Complication of radiation (2.5%)Following nasal trauma (1%)Sequela of granulomatous diseases (1%)SarcoidLeprosyRhinoscleromaSequlae of other infectious processesTuberculosisSyphilisMoore & Kern. Amer J Rhin. 2001 15(6): 355-361.

8. Surgical causesBased on review of 242 cases from Mayo Clinic.Procedures per patient2.3Partial middle or inferior turbinectomy56%Total middle and inferior turbinectomy24%No turbinectomy10%Partial maxillectomy6%Moore & Kern. Amer J Rhin. 2001 15(6): 355-361.

9. Other suggested causesInfectious (Ssali)Case report of AR developed in 7 children of one family after contact with another known AR child.Dietary (Bernat) Iron therapy found to benefit 50% of patients treated(Han-Sen) Hypocholesterolemia present in 50% of patients.(Han-Sen) Vitamin A therapy showed symptomatic improvement in 84%.Hereditary (Barton, Sibert)Proposed autosomal dominant disease due to father and 8 of 15 children contracting the disease.Hormonal Symptoms known to worsen with menstraution or pregnancy.Developmental (Hagrass)Radiologic evidence of poor maxillary antrum pneumatization and short nasal lengthsVascular (Ruskin)Postulated overactivation of sympathetic activity.Environmental (Mickiewicz)Chronic exposure to phosphorite and apatide dustAutoimmune (Ricci)

10. Physical findingsCrusting 100% PresentInferior Turbinates62% Partial absence37% Total absenceMiddle Turbinates57% AbsentDischarge 52% PresentSeptum10% PerforationsMoore & Kern. Amer J Rhin. 2001 15(6): 355-361.

11. Radiographic FindingsMucoperiosteal thickening of the paranasal sinuses.Loss of definition of the OMC secondary to resorption of the ethmoid bulla and uncinate process.Hypoplasia of the maxillary sinuses.Enlargement of the nasal cavities with erosion and bowing of the lateral nasal wall.Bony resorption and mucosal atrophy of the inferior and middle turbinates.Pace-Balzan, Shankar, Hawke. J Otolaryngol 1991; 20:428-32.

14. Biopsy FindingsNormal MucosaPseudostratified ColumnarPresence of serous and mucous glandsAtrophic RhinitisSquamous metaplasiaAtrophy of mucous glandsScarce or absent ciliaEndarteritis obliterans

15. MicrobiologyKlebsiella ozenaeMay be found in almost 100% of primary ARNo predominance in secondary ARStaphylococcus aureusProteus mirabilisEscherichia coliCorynebacterium diphtheriae

16. Current TherapiesGoals of therapyRestore nasal hydrationMinimize crusting and debrisTherapy optionsTopical therapySaline irrigationsAntibiotic irrigationsSystemic antibioticsImplants to fill nasal volumeClosure of the nostrils

17. Local therapyIrrigationsSalineMixturesSodium bicarbonateShehata: Sodium Carbonate 25g, Sodium Biborate 25g, and Sodium Chloride 50g in 250ml water.Antibiotic solution Moore: Gentamycin solution 80mg/LAnti-drying agentsGlycerineMineral OilParaffin with 2% MentholOtherAcetylcholinePilocarpine

18. Systemic therapyOral antibioticsTetracyclineCiprofloxacinAminoglycosidesStreptomycin injectionsMedication avoidanceVasoconstrictorsTopical steroids *OtherVitamin A (12,500 to 15,000 Units daily)Potassium Iodide (Increases nasal secretions)VasodilatorsIron therapyEstrogenCorticosteroids *VaccinesAntibacterial (Pasturella, Bordetella)Autogenous

19. Surgical therapiesYoung procedureModified Young procedureTurbinate reconstructionVolume reduction proceduresDenervating operations

20. Nasal ClosureYoung’s procedureCircumferential flap elevation 1 cm cephalic to the alar rim.Sutures placed in center of elevated flap to close the nostrilStaged second side in 3 monthsAdvantagesOften provided relief of symptomsDisadvantagesDifficult to elevate circumferential flapBreakdown of central suture area commonDoes not allow for cleaningDid not allow for periodic examinationRecurrence after flap takedownYoung. “Closure of the nostril in atrophic rhinitis.” Journal of Laryngology and Otology, 81: 515-524.

21. Nasal ClosureModified Young’sElevation of extended perichondrial flap through contralateral hemitransfixion incision.Short skin flap elevated from the intercartilaginous line on the ipsilateral side.Suture lateral and medial flaps with vicryl.Staged second side with first side takedown in 6 mon.AdvantagesTechnically easier than Young procedureNo suture line breakdownNo vestibular stenosis on takedownDisadvantagesNot possible with large septal defectsDoes not allow for cleaningDoes not allow for periodic examinationRecurrence after flap takedownEl Kholy, Habib, Abdel-Monem, Safia. “Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis.” Rhinology, 36, 202-203, 1998.

22. Modified Young

23. Volume reductionPlastipore implantationPorus material allows tissue ingrowth.Implants shaped then fenestrated for ingrowth.Implants placed submucosally along the septum and nasal floor.AdvantagesEasier than other surgical options (Young’s)Plastipore has low extrusion/complication rateMay be done under local anesthesiaDisadvantagesPossibility of extrusion (occurred in 1/8 pts)Requires septal mucosa (not discussed)Goldenberg, Danino, Netzer, Joachims. Oto HNS, Vol. 122 (6). pp. 794-97.

24. Plastipore

25. Volume Reduction (cont)Triosite and FibrinTriosite (60% hydroxyapetite, 40% calcium triphosphate) mixed with Fibrin 1:1.Deglove the labial vestibuleElevate periosteum of the floor posteriorly to the end of the hard palate, extend medially onto the septum.Insert Triosite & Fibrin mixture (~3.3g per side)AdvantagesGood to excellent result (7/9 patients)Material can be molded easily DisadvantagesLeakage of material (4/9 patients)Infection of material (3/9 patients)Potential damage to lacrimal systemBertrand, Doyen, Eloy. Laryngoscope 106: May 1996. p 652-57.

26. Other TherapiesNon-surgical nasal closureNasal vestibule impressions taken similar to hearing aid moulds.Impressions are used to create a silastic obturator.AdvantagesReversibleEasily removedAllows for irrigationsAllows for serial clinical examsAvoids surgical morbidity DisadvantagesMay be uncomfortableMay cause sore throat due to obligate mouth breathing.Lobo, Hartley, Farrington. J of Laryn and Oto. June 1998, Vol 112, p 543-46.

27. Other TherapiesOther ImplantsAcrylicSiliconeTeflonSilasticBoplantDenervationCervical sympathectomy (Bertein)Stellate ganglion block (Bahl)Sphenopalatine ganglion block (Girgis)Parasympathectomy, i.e. GSPN section (Krmptotic)Salivary IrrigationInvolves reimplantation of parotid duct into the maxillary sinusAccupunctureTimeDisease often resolves spontaneously after age 40

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