Atrophic Rhinitis
’Ozena’
Bastaninejad, Shahin, MD, ORL & HNS, TUMS
Amiralam Hospital
Presentation Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment
Atrophic rhinitis
(AR) is a chronic
and degenerative
disease
of
the
nasal & paranasal
mucosa & other
structures
Definition (Cont’)
triad of characteristic fetor, greenish
crusts and roomy nasal cavities this
triad is diagnostic of the condition
Prevalence of Primary AR 0.3-1% in high
prevalence countries
High Prevalence countries are: India,
Pakistan, China, Philippines, Malaysia,
Saudi Arabia, Egypt and South america
Definition (Cont’)
Primary AR: More common in females(*6),
usually bilateral, Prevalent in young and middle
age adults
Often, no underlying etiology is discovered,
although inheritable or infectious causes (58.7%
K. ozena) are proposed mechanisms
there is however little evidence to suggest
bacterial organisms cause the disease, they may
be secondary invaders
Definition (Cont’)
Secondary AR:
Complication of sinus surgery (89%)
1. FESS in CRS > FESS in Polypoid CRS
2. In Mayo clinic assay : Partial MT and/or IT
resection was the most common cause
Complication of radiation (2.5%)
Following nasal trauma (1%)
Sequela of granulomatous diseases (1%) and
other infections : TB, Sarcoidosis, Leprosy,
Rhinoscleroma, Syphilis
Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment
Pathophysiology
Nl. Respiratory epithelium (Pseudostratified
Columnar)  metaplastic changes 
cuboidal/stratified squamous epithelium
Atrophy of cilia and the mucosal and
submucosal gland
Secondary bac. Infection produce a foetid
odour
Osteitis of inferior turbinates and ethmoid
turbinates
Vascular involvement (mainly endarteritis
obliterans)
Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment
Clinical Features (Symptoms)
Nose emits a foul smell due to crusting and
secondary infections (main characteristic).
Anosmia, cacosmia
Nasal obstruction
Headache
Thick purulent discharge with a foul smell (due
to the anaerobic bacteria)
Minor bleeds due to dislodgment of crusts
Complain of dryness in the nose and throat
(pharyngitis sicca)
Clinical Features (signs)
Greenish yellow and black crusts (Crusts
100% present), bleeding and ulcerated
mucosa is seen when crusts are separated
Patient is usually gloomy
Foetor (detected from distance)
Wide capacity of the nasal passages,
Shrinkage of inferior and middle turbinates
Insensitivity of nasal mucosa (probe test)
Septal perforation, myiasis, saddle nose &…
may be seen
Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment
Differential diagnosis
TB
Leprosy
Scleroma
Syphilis
Chronic sinus suppuration on its own
Suppurating adenoidal disease
Neglected FB / rhinoliths
Kern &
Wegner’s disease
Stenkvist
at 1994
Chronic fungal rhinosinusitis
Empty nose syndrome (ENS)
What is ENS?
ENS is an iatrogenic disorder most often recognized by the presence of
paradoxical nasal obstruction despite an objectively wide nasal fossa
ENS vs. Secondary AR
The resorption of the turbinate and adjacent
mucosal tissue that results from atrophic rhinitis
is reflective of the underlying pathophysiology of
the disease, whereas ENS is an iatrogenic
disorder
Secondary AR may also be the result of a
multitude of other factors, including trauma,
infection, or immunologic disorders.
Atrophic rhinitis has clear pathogenic links to
organisms isolated from nasal cultures, but as of
yet, there is no pathogen associated with ENS
Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment
Investigations
Hematologic study (CBC/diff)
ESR
FBS
C-ANCA, VDRL
PPD
CXR
PNS CT-Scan
Nasal swab for culture
Nasal Bx tested for bacteriological and
morphological indices
Outlines
Definition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment
Treatment (Medical)
Conservative
management
is
the
mainstay of the treatment
No cure available
Decongestants or antihistamines: strongly
contraindicates
Nasal irrigation and douches:
With Alkaline douches (preferred)
With N/S or antibiotic+N/S douches
Treatment (Medical)
An ideal alkaline nasal douche mixture:
1. Sodium bicarbinate
25g
2. Sodium biborate
25g
3. Sodium chloride
50g
One teaspoonful of this mixture in 250cc
lukewarm water, tds or qid, for 6wk, with a 10
to 20cc syringe
Instruct the patient to bend forward during the
procedure and keep saying K K K…
Treatment (Medical)
Glucose-glycerine nose drops
1. Anhydrous Glucose 25% (~15g)
2. Glycerine 60cc
Use this after nasal douching
You
can
also
Chloramphenicol
douching, too
use
drops
Gentamicin
after
or
nasal
Treatment (Medical)
Antibiotics:
Rifampicin 600mg daily for 12wk (generic cap.
is 300mg – take 2 every morning)
Recently: Cipro 500-750mg bid for 1-3mo
Vitamin A , 12,500 IU/day up to two
weeks.
Iron supplements
(if the patient is anemic)
Treatment (Surgical)
1) Young’s Procedure
2) Modified Young’s procedures
3) Modification of modified Young
4) Implantation
5) Other approaches
Treatment (Surgical)
Young’s procedure
Circumferential flap elevation 1 cm cephalic to
the alar rim
Complete closure of nostril
Staged second side in 3-6 months
Difficult to elevate circumferential flap
Modified Young
Staged second side with first side takedown
in 6 mo
No vestibular stenosis on takedown
Treatment (Surgical)
Modification of the modified young’s:
Treatment (Surgical)
Implantation:
uses
(Auto/homografts),
Bone
Cartilages,
...
Prostethic implants such as Plastipore, ...
Extrusion
of
the
prosthetic
implants
occured 1 in 8 in Plastipore series, but in
another prosthetic series it was occured as
high as 80%
Plastipore
Silastic Sheet - Case: Primary AR - 12mo postop result
(Otolaryngology–Head and Neck Surgery (2010))
Right
Left
Treatment (surgical)
Other approaches:
Transferring the Stensen duct to the maxillary
sinus antrum
Using a caldwell approach, translocating the
lateral nasal wall more medially
Silastic obturator
...
Presentation Conclusion
Endoscopic Sinus Surgery
2nd Atrophic Rhinitis
Primary Atrophic Rhinitis
Functional Endoscopic Sinus Surgery
...Try to save nasal structures and mucosal layer as much as you can