1. Infective & Atrophic Rhinitis
Dr. Vishal Sharma

2. Acute Infective Rhinitis
SPECIFIC NON-SPECIFIC
Acute diphtheritic Common cold
Acute syphilitic Influenza
Erysipelas
Exanthematous rhinitis

3. 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

4. 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.

5. 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.

6. Chronic Infective Rhinitis
SPECIFIC NON-SPECIFIC
Tubercular Chronic simple
Chronic diphtheritic Chronic hypertrophic
Chronic syphilitic Atrophic rhinitis
Leprosy Rhinitis sicca
Rhinoscleroma Rhinitis caseosa
Rhinosporidiosis

7. 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

8. Atrophic Rhinitis

9. 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

10. 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

11. Primary Atrophic Rhinitis

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

13. 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.

14. 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

15. 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

16. 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)

17. 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

18. 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

19. Nasal crusting

20. Nasal crusting

21. Normal Turbinates & Meati

22. Turbinate atrophy & roomy nasal cavity

23. 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

24. 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

25. 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

26. Biopsy Findings
Normal
Atrophic rhinitis

27. 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

28. 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

29. 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

30. Medical Treatment

31. 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

32. 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.

33. 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

34. Surgical Treatment

35. 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 month with a
tri-radiate (Mercedes Benz) incision.

36. Pre-operative

37. Mucosal flaps sutured

38. Cutaneous flap sutured

39. Post-operative healed flaps

40. Modified Young’s operation

41. Tri-radiate incision

42. Modified Young’s (El Kholy)

43. 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

44. 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

45. 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

46. Pre-operative

47. Lautenslager’s operation

48. Submucosal Teflon paste

49. Sublabial Implants

50. Sublabial Implants

51. Vestibuloplasty

52. Antral mucosa transplant

53. 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

54. 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

55. Surgical Treatment Modified Young Young Lautenslager Lady Wilson Was
Vestibuloplasty Very
Sublabial implantation Sweet
Antral mucosal transplantation And
Parotid duct implantation Pretty

56. Nasal Obturator

57. Nasal Obturator Advantages Reversible & easily removed
Allows for irrigations & serial clinical exams
Avoids surgical morbidity
Disadvantages
Uncomfortable
Sore throat due to obligate mouth breathing

58. 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

59. 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

60. Thank You