• Atrophic rhinitis is a chronic inflammatory disease of the nasal cavity that is characterised by atrophy of turbinates and nasal mucosa with foul smelling crusts
• It can be primary or secondary

Primary Atrophic Rhinitis

• Etiology (can be remembered with the mnemonic ‘HERNIA’)
  • Heriditary factors
  • Endocrine
    • Atrophic rhinitis is mostly seen in females, starts around puberty and decreases after puberty.
    • Hence a hormonal etiology is suggested
  • Racial – more in whites and yellow races
  • Nutritional
    • Atrophic rhinitis is more seen in the developing nations
    • It is rarely seen in people belonging to higher socioeconomic status
    • Hence deficiency of vitamins and nutrients is believed to be a causative factor
  • Infective
    • Various bacteria – Klebsiella ozaenae, streptococcus, staphylococcus, proteus and E.coli have been isolated from the crusts
    • It is suggested that these bacteria are in fact secondary pathogens, responsible for the foul smell\
  • Autoimmune
• Pathogenesis
  • The ciliated columnar epithelium is replaced by squamous epithelium
  • There is atrophy of the nasal mucosa and turbinates (with resorption of bone)
  • The venous sinusoids, the seromucinous glands and the nerves atrophy
  • Obliterative endarteritis of vessels occur
  • Arrested development of sinuses
• Clinical features
  • Symptoms
    • Nasal obstruction – even though the nasal cavity is roomy, there is deposition of crusts which cause obstruction to air flow
    • Foul smell from nose – Even though there is foul smell, the patient is unable to experience this, hence called merciful anosmia
    • Epistaxis – Occurs when the crusts get dislodged
  • Signs
    • Nasal cavity is filled with greenish / blackish crusts
    • On removal of crusts, there is bleeding and a roomy nasal cavity is revealed
    • Nasal mucosa is pale
    • Atrophy of turbinates, appear as ridges
    • Even the posterior wall of nasopharynx may be visible
    • Septal perforation and dermatitis of vestibule may be persent
    • Similar atrophic changes may be present in pharynx (atrophic pharyngitis) and larynx (cough and hoarseness may be present)
    • Serous otitis media may be present due to eustachian tube dysfunction
    • Sinus may not be well developed (X ray)
• Treatment
  • Medical
    • Removal of crusts with alkaline irrigation
      • Fluid for irrigation can be prepared by mixing one teaspoon full of powder (one part sodium bicarbonate, one part sodium biborate, two parts sodium  chloride) in 280ml of water
      • The fluid can be introduced through one nostril and drained out through the other nostril
      • Care should be taken so that the fluid does not enter the eustachian tube or gets aspirated
      • Irrigation can be done initially 2-3 times a day, later decrease the frequency to 2-3 times a week.
      • Hard to remove crusts can be removed by forceps once they are softened by irrigation
    • Painting the nasal mucosa with 25% glucose in glycerol – helps prevent growth of bacteria so that foul smell does not occur
    • Antibiotic sprays
    • Oestradiol spray – to improve vascularity
    • Submucosal injection of placental extract
    • Streptomycin orally 1g/day for 10 days
    • Potassium iodide orally helps liquefy nasal secretion
  • Surgical
    • Young’s operation
      • Both the nostrils are surgically closed by raising flaps in the vestibule region
      • Aims to give rest to nasal mucosa so that it may revert back to ciliated columnar epithelium
      • The nostrils are opened after 6 months
    • Modified young’s operation
      • In this, the nasal cavity is only partially closed
      • This is done to prevent the discomfort caused by complete nasal closure
      • It is also said to have same effect as that of young’s operation
    • Narrowing of the nasal cavity
      • Due to roomy nasal cavity, the air currents dry up secretions, causing crusting
      • Narrowing of nasal cavity aims to prevent crusting by decreasing the size of the airway
      • This can be done by the following techniques
        • Submucosal injection of teflon paste
        • Insertion of strips of cartilage, fat, bone or teflon
        • Medialisation of the lateral wall

Secondary Atrophic rhinitis

• This occurs secondary to certain conditions like
  • syphilis
  • lupus
  • leprosy
  • radiotherapy to nose
  • long standing purulent sinusitis
  • excessive surgical removal of turbinates

Unilateral atrophic rhinitis

• This occurs in case of long standing septal deviation
• The opposite side with the roomy nasal cavity is predisposed to development of crusts

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