atrophic rhinitis ’ozena’ bastaninejad, shahin, md, orl & hns, tums amiralam hospital
TRANSCRIPT
Atrophic RhinitisAtrophic Rhinitis ’Ozena’’Ozena’
Bastaninejad, Shahin, MD, ORL & HNS, TUMSBastaninejad, Shahin, MD, ORL & HNS, TUMS
Amiralam HospitalAmiralam Hospital
Presentation OutlinesPresentation Outlines
DefinitionDefinition
Pathophysiology
Clinical presentations
Differential diagnosis
Investigations
Treatment
Atrophic rhinitis Atrophic rhinitis
(AR) (AR) is a chronic is a chronic
and degenerative and degenerative
disease of the nasal disease of the nasal
& paranasal & paranasal
mucosa & other mucosa & other
structuresstructures
Definition (Cont’)
triad of characteristic fetor, greenish crusts and roomy nasal cavities this this triad is diagnostic of the conditiontriad is diagnostic of the condition
Prevalence of Primary ARPrimary 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 discoveredOften, 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 ARSecondary 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
OutlinesOutlines
DefinitionDefinition
PathophysiologyPathophysiology
Clinical presentationsClinical presentations
Differential diagnosisDifferential diagnosis
InvestigationsInvestigations
TreatmentTreatment
PathophysiologyNl. 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)
OutlinesOutlines
DefinitionDefinition
PathophysiologyPathophysiology
Clinical presentationsClinical presentations
Differential diagnosisDifferential diagnosis
InvestigationsInvestigations
TreatmentTreatment
Clinical Features Clinical Features (Symptoms)(Symptoms)
Nose emits a foul smell due to crusting and secondary infections (main characteristic).(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 Clinical Features (signs)(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
OutlinesOutlines
DefinitionDefinition
PathophysiologyPathophysiology
Clinical presentationsClinical presentations
Differential diagnosisDifferential diagnosis
InvestigationsInvestigations
TreatmentTreatment
Differential diagnosisDifferential diagnosisTB
Leprosy
Scleroma
Syphilis
Chronic sinus suppuration on its own
Suppurating adenoidal disease
Neglected FB / rhinoliths
Wegner’s disease
Chronic fungal rhinosinusitis
Empty nose syndrome (ENS)Kern & Stenkvist at 1994
What is What is ENSENS??
ENS is an iatrogeniciatrogenic disorder most often recognized by the presence of paradoxical nasal obstruction paradoxical nasal obstruction despite an objectively wide nasal fossa
ENS vs. Secondary ARENS vs. Secondary ARThe 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
OutlinesOutlines
DefinitionDefinition
PathophysiologyPathophysiology
Clinical presentationsClinical presentations
Differential diagnosisDifferential diagnosis
InvestigationsInvestigations
TreatmentTreatment
InvestigationsInvestigationsHematologic 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
OutlinesOutlines
DefinitionDefinition
PathophysiologyPathophysiology
Clinical presentationsClinical presentations
Differential diagnosisDifferential diagnosis
InvestigationsInvestigations
TreatmentTreatment
Treatment Treatment (Medical)(Medical)
Conservative management is the mainstaymainstay
of the treatment
No cure available
Decongestants or antihistamines: strongly
contraindicates
Nasal irrigation and douches:
With Alkaline douches (preferred)(preferred)
With N/S or antibiotic+N/S douches
Treatment Treatment (Medical)(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 Treatment (Medical)(Medical)
Glucose-glycerineGlucose-glycerine nose drops
1. Anhydrous Glucose 25% (~15g)
2. Glycerine 60cc
Use this after nasal douching
You can also use Gentamicin or
Chloramphenicol drops after nasal
douching, too
Treatment Treatment (Medical)(Medical)
Antibiotics:
Rifampicin 600mg daily for 12wk (generic cap.
is 300mg – take 2 every morning)
Recently: Cipro 500-750mg bid for 1-3moCipro 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 procedureYoung’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 YoungModified Young
Staged second side with first side takedown Staged second side with first side takedown in 6 moin 6 mo
No vestibular stenosis on takedownNo vestibular stenosis on takedown
Treatment (Surgical)
Modification of the modified young’s:
Treatment (Surgical)
ImplantationImplantation: uses Bone (Auto/homografts),
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%
PlastiporePlastipore
Silastic SheetSilastic Sheet - Case: Primary AR - 12 - Case: Primary AR - 12momo postop result postop result ((Otolaryngology–Head and Neck Surgery (Otolaryngology–Head and Neck Surgery (20102010))))
RightRight
LeftLeft
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 ConclusionPresentation Conclusion
Prim
ary Atrophic R
hinitisP
rimary A
trophic Rhinitis
22n
dn
d Atrop
hic R
hin
itisA
troph
ic Rh
initis
Endoscopic
Endoscopic S
inus S
urge
ryS
inus S
urge
ry
Functional Endoscopic Sinus SurgeryFunctional Endoscopic Sinus Surgery...Try to save nasal structures and mucosal layer as much as you can...Try to save nasal structures and mucosal layer as much as you can