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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Acute infective rhinitis
Acute Infective Rhinitis

SPECIFIC NON-SPECIFIC

Acute diphtheritic Common cold

Acute syphilitic Influenza

Erysipelas

Exanthematous rhinitis


Common cold coryza
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


Infective atrophic rhinitis

  • 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.


Infective atrophic rhinitis

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
Chronic Infective Rhinitis

SPECIFIC NON-SPECIFIC

Tubercular Chronic simple

Chronic diphtheritic Chronic hypertrophic

Chronic syphilitic Atrophic rhinitis

Leprosy Rhinitis sicca

Rhinoscleroma Rhinitis caseosa

Rhinosporidiosis



History
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
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



Aetiology

Developmental

 Hereditary

 Endocrine

 Racial

 Nutritional deficiency

 Infection

 Autoimmune Autonomic Imbalance

 Surfactant deficiency in nasal secretion

Aetiology


Infective atrophic rhinitis

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.


Infective atrophic rhinitis

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


Infective atrophic rhinitis

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
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
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
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






Infective atrophic rhinitis

D/D for ozaena D/D for dry nose

1. Atrophic rhinitis 1. Atrophic rhinitis

2. Purulent sinusitis 2. Rhinitis sicca

3. Nasal foreign body 3. Radiotherapy

4. Rhinitis caseosa 4. Sjogren’s syndrome

5. Malignancy


Infective atrophic rhinitis

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


Infective atrophic rhinitis

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
Biopsy Findings

Normal

Atrophic rhinitis


Specific investigations
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
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 investigations1
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



Infective atrophic rhinitis

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
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
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



Infective atrophic rhinitis

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.









Advantages of modified young
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


Infective atrophic rhinitis

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


Infective atrophic rhinitis

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









Types of surgery
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
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 treatment1
Surgical Treatment

  • Modified Young Young

  • Lautenslager Lady

  • Wilson Was

  • Vestibuloplasty Very

  • Sublabial implantation Sweet

  • Antral mucosal transplantation And

  • Parotid duct implantation Pretty



Nasal obturator1
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
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
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