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 Tubercular Chronic simple Chronic diphtheritic Chronic hypertrophic Chronic syphilitic Atrophic rhinitis Leprosy Rhinitis sicca Rhinoscleroma Rhinitis caseosa Rhinosporidiosis

Chronic simple rhinitis Chronic hypertrophic rhinitis Early stage hypertrophy of glands in swollen turbinates Late stage hypertrophy + fibrosis Swollen turbinates pit on pressure No pitting Swollen turbinates shrink with topical decongestants Absent or minimal shrinking Tx: Antibiotics + Nasal decongestants Tx: Turbinate reduction or resection

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

Aetiology  Developmental  Hereditary  Endocrine  Racial  Nutritional deficiency  Infection  Autoimmune  Autonomic Imbalance  Surfactant deficiency in nasal secretion

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 present in 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 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

Causes of nasal obstruction 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 Oestradiol nasal spray (1%) Glucose (25%) in glycerin nasal drops Streptomycin injection Placental extract injection Autogenous vaccines Rifampicin Kemicetine solution: Estrogen, Vit. D, Chloramphenicol Mandl’s nasal paint (Potassium Iodide & oestradiol) Potassium Iodide 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 operation done 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 Young Young Lautenslager Lady Wilson Was Vestibuloplasty Very Sublabial implantation Sweet Antral mucosal transplantation And Parotid duct implantation Pretty

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

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