Infective atrophic rhinitis
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Infective & Atrophic Rhinitis. Dr. Vishal Sharma. Acute Infective Rhinitis. SPECIFIC NON-SPECIFIC Acute diphtheritic Common cold Acute syphilitic Influenza Erysipelas Exanthematous rhinitis. Common cold (coryza).

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Infective & Atrophic Rhinitis

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Infective & Atrophic Rhinitis

Dr. Vishal Sharma


Acute Infective Rhinitis

SPECIFIC NON-SPECIFIC

Acute diphtheritic Common cold

Acute syphilitic Influenza

Erysipelas

Exanthematous rhinitis


Common cold (coryza)

  • Highly contagious, viral infectious disease of upper respiratory system. Caused by rhino-virus, coronavirus, human parainfluenza virus, human respiratory syncytial virus, adenovirus.

    Transmission:

  • Aerosol generated by coughing, sneezing

  • Contact with saliva or nasal secretions


  • Symptoms: sore throat, runny nose, nasal congestion, sneezing, cough; pink eye, muscle aches, fatigue, malaise, headaches, muscle weakness, loss of appetite. Symptoms resolve after 1-2 week.

  • Opportunistic super infections:acute bronchitis, croup, pneumonia, sinusitis, otitis media, sore throat.


Treatment

  • Bed rest. Avoid exposure to cold weather.

  • Plenty of fluids. Avoid cola & alcoholic drinks.

  • Avoid tea & coffee (they cause dehydration)

  • Antihistamines + nasal decongestants

  • Non-aspirin analgesics

  • Antibiotics for secondary infection

  • Doubtful role: Vitamin C, Zinc, chicken soup, ginger, garlic, herbal tea, steam inhalation.


Chronic Infective Rhinitis

SPECIFIC NON-SPECIFIC

TubercularChronic simple

Chronic diphtheritic Chronic hypertrophic

Chronic syphiliticAtrophic rhinitis

LeprosyRhinitis sicca

RhinoscleromaRhinitis caseosa

Rhinosporidiosis


Atrophic Rhinitis


History

Dr. Spencer Watson, 1875:

  • Used the term “Ozaena”

    Dr. Bernhard Fraenkel, 1876:

  • Described triad of:

    1. Fetor

    2. Crusting

    3. Atrophy of nasal structures


Introduction

  • Chronic inflammation of nose with progressive atrophy of nasal mucosa & turbinate bones

  • Formation of scanty viscid secretion & green crusts which emit a foul odour (ozaena)

  • Removal of crusts reveals roomy nasal cavity

    Types: 1. Primary 2. Secondary


Primary Atrophic Rhinitis


 Developmental

 Hereditary

 Endocrine

 Racial

 Nutritional deficiency

 Infection

 Autoimmune Autonomic Imbalance

 Surfactant deficiency in nasal secretion

Aetiology


Developmental

Congenitally spacious nasal cavity

Poor pneumatization of maxillary antrum

Hereditary:30% cases autosomal inheritence

67% = Dominant, 33% = Recessive

Endocrine:Seen during puberty, menopause,

menstruation. Symptoms aggravated

due to oestrogen deficiency.


Racial: More in American Negroes & Latin

races (yellow race)

Nutritional deficiency:Iron deficiency,

Vitamin A deficiency, Vitamin D deficiency

Infection:Klebsiella ozaenae(Perez & Abel

bacillus), Coccobacillus foetides ozaena,

Bacillus mucosus, Diphtheroids,

Haemophilus influenzae


Autoimmune: viral infection / malnutrition / immune deficiency  trigger destructive autoimmune process on nasal mucosa

Autonomic Imbalance: Reflex Sympathetic Dystrophy Syndrome (R.S.D.S.) causes vasodilatation & hyperaemic decalcification of turbinates followed by vasoconstriction

Surfactant deficiency in nasal secretion: ciliary dysfunction + stasis of nasal secretions


Secondary Atrophic Rhinitis

  • Long-standing purulent sinusitis

  • Iatrogenic: Radical turbinectomy,

    maxillectomy, post-radiotherapy

  • Tuberculosis, Syphilis, Leprosy

  • Rhinoscleroma

  • Deviated nasal septum (atrophy in wider nasal

    cavity)


Symptoms

  • Nasal obstruction

  • Greenish-yellow nasal discharge

  • Offensive smell (ozaena) due to anaerobic infection, experienced by relatives

  • Merciful anosmia presentin the patient

  • Epistaxis on crust removal


Signs

  • Roomy nasal cavity with atrophy of mucosa & turbinates

  • Greenish-yellow nasal discharge with crust formation (begins posteriorly)

  • Foul smell (foetor)

  • Nasal septum perforation

  • Nasal myiasis


Nasal crusting


Nasal crusting


Normal Turbinates & Meati


Turbinate atrophy & roomy nasal cavity


D/D for ozaenaD/D for dry nose

1. Atrophic rhinitis1. Atrophic rhinitis

2. Purulent sinusitis2. Rhinitis sicca

3. Nasal foreign body3. Radiotherapy

4. Rhinitis caseosa4. Sjogren’s syndrome

5. Malignancy


Causes of Anosmia

1. Loss of olfactory neural elements

2. Thick secretion & crusts over olfactory area

3. Degeneration of secretory glands  scanty mucous for dissolving odoriferous materials

Causes of nasal obstruction

1. Blunting of sensory nerve endings

2. Crust formation

3. Lack of eddy current formation in roomy cavity


Pathology:

 Accumulation of lymphocytes & plasma cells.

 Squamous metaplasia from ciliated columnar

 Ciliary destruction & decrease in nasal glands

 Bone resorption

Type I: Endarteritis & periarteritis of terminal

arterioles. Benefit from estrogen therapy

Type II:Dilated capillaries worsened by estrogen


Biopsy Findings

Normal

Atrophic rhinitis


Specific Investigations

Saccharine test:ed nasal muco-ciliary

clearance time

Serum iron & protein levels: malnutrition

Culture & sensitivity of nasal discharge

Diagnostic Nasal Endoscopy

X-ray P.N.S.: maxillary sinusitis


C.T. scan P.N.S.

  • Mucoperiosteal thickening

  • Resorption of ethmoid bulla & uncinate process

  • Hypoplasia of maxillary sinuses

  • Roomy nasal cavities

  • Erosion & bowing of lateral nasal wall

  • Atrophy of turbinates


Specific Investigations

Chest X-ray: T.B., bronchiectasis, lung abscess

Serology for syphilis: V.D.R.L., T.P.H.A., T.P.I.

Sputum for AFB, Mantoux test: T.B.

Nasal smear study: Leprosy

Complement fixation test & biopsy: Rhinoscleroma


Medical Treatment


Douching  alkaline nasal douche

Oestradiolnasal spray (1%)

Glucose(25%) in glycerin nasal drops

Streptomycininjection

Placentalextract injection

Autogenousvaccines

Rifampicin

Kemicetinesolution: Estrogen, Vit. D, Chloramphenicol

Mandl’s nasal paint(Potassium Iodide & oestradiol)

PotassiumIodide orally


Alkaline Nasal Douche

Sodium bicarbonate (28.4g)  loosens nasal crusts

Sodium biborate (28.4g)  Antiseptic

Sodium chloride (56.7g)  makes solution isotonic

Mixed in 280 ml of warm water to make the solution.

20 ml plastic syringe with 6” long rubber tubing taken.

Syringe nasal cavity while pt bends forward & keeps

saying K, K, K … to close nasopharyngeal isthmus.

Done B.D. till all crusts disappear.


Action of Placental extract

  • Progesterone leads to hyperplasia of nasal mucosa & glandular secretion

  • Oestrogen leads to vasodilatation

  • Biogenic stimulator of metabolic & regenerative process

  • Intra-placental serum boosts up immunity

  • Mechanical narrowing of nasal passage


Surgical Treatment


Young’s operation: Only 1 nostril closed

completely by raising 2 circumferential

flaps (inner mucosal & outer cutaneous) in nasal

vestibule & suturing them in midline.

Modified Young’s operationdone by similar

way but keeping a 3 mm opening on both sides.

Recannalisation done after 12-18 month with a

tri-radiate (Mercedes Benz) incision.


Pre-operative


Mucosal flaps sutured


Cutaneous flap sutured


Post-operative healed flaps


Modified Young’s operation


Tri-radiate incision


Modified Young’s (El Kholy)


Advantages of Modified Young

  • Progress of disease can be monitored with 2.7 mm nasal endoscope

  • Glucose in glycerine drops can be instilled

  • Both nostrils can be operated at one sitting

  • Nasal breathing preserved

  • No complaints of de-nasal voice

  • Better cosmetic result


Lautenslager’s operation: Fracture & medial

displacement of lateral nasal wall

Wilson’s operation:submucosal injection

of Teflon paste

Antral mucosal transplantation into nasal cavity

through intranasal antrostomy: Raghav Sharan

Vestibuloplasty:raising a lateral shelf from

nasal vestibular flap to cover turbinates


Sympathectomy: Stellate ganglion block /

cervical chain block

Sublabial implantation:bone, cartilage, fat,

placental bits, hydroxyapatite + fibrin paste,

Plastipore, acrylic resin, silastic

Parotid duct implantation into maxillary sinus:

Wittmack’s operation


Pre-operative


Lautenslager’s operation


Submucosal Teflon paste


Sublabial Implants


Sublabial Implants


Vestibuloplasty


Antral mucosa transplant


Types of surgery

  • Nasal closure: Young  Modified Young

  • Volume reduction: Lautenslager  Wilson

     Sublabial implants  Vestibuloplasty

  • Denervation: Cervical sympathectomy

     Stellate ganglion block

     Sphenopalatine ganglion block

  • Salivary irrigation:Parotid duct implantation


Aim of Surgery

Decrease trauma of air turbulence:

 Nasal closure

 Volume reduction

Increase nasal secretions:

 Parotid duct implantation into maxillary sinus

Increase vascularity of nasal mucosa:

 Denervation procedures

 Nasal implantation of maxillary sinus mucosa


Surgical Treatment

  • Modified YoungYoung

  • LautenslagerLady

  • WilsonWas

  • VestibuloplastyVery

  • Sublabial implantationSweet

  • Antral mucosal transplantationAnd

  • Parotid duct implantationPretty


Nasal Obturator


Nasal Obturator

Advantages

  • Reversible & easily removed

  • Allows for irrigations & serial clinical exams

  • Avoids surgical morbidity

    Disadvantages

  • Uncomfortable

  • Sore throat due to obligate mouth breathing


Rhinitis Sicca

  • Mild form of atrophic rhinitis

  • Seen in hot, dry, dusty places (bakers, goldsmiths); alcoholics & anaemics

  • Crusting present anteriorly only

  • Bone atrophy & foetor are absent

  • Tx: Nasal douching + change of surrounding


Rhinitis Caseosa

  • Synonym:Nasal cholesteatoma

  • Chronic inflammation with deposition of foul smelling cheesy material in nasal cavity.

  • Nasal obstruction  stasis of secretions & exfoliated cells  putrefaction  caseation

  • Treatment: 1. Removal of cheesy debris

    2. Correction of nasal obstruction


Thank You


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