Infective & Atrophic Rhinitis

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

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

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 presentin 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 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 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

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 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.

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