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Chronic Specific Rhinitis

  1. Atrophic Rhinitis (OZAENA)
  • Progressive atrophy of the nasal mucosa and the underlying bone of the turbinate and the presence of viscid secretions which from foul smelling crusts. It is a chronic inflammatory disorder.
  1. Etiology (for primary atrophic rhinitis)
    1. Organisms:- Klebsiella ozaenae (Perez bacillus), Diphtheroids, coccobacillus and bacillus mucosus
    2. Racial factors:- Whites & Yellow races more
    3. Chronic sinusitis. excessive surgical destruction, and syphilis
    4. Endocrinal pathology:- Starts at puberty. Stops after menopause
    5. Nutritional deficiency:- deficiency of vitamin A,D,E & iron
    6. Autoimmune theory
    7. Heredity
  2. Mnemonic- HERNIA
  1. Hereditary
  2. Endocrinal Phatho logy
  3. Racial factors
  4. Nutritional deficiency
  5. Infective
  6. Auto Immune Process
  1. Features:-
    Usually starts in females, around puberty
    1. Nasal obstruction Inspite of roomy nasal avrities dlt large crusts filling the nose and epistaxis
    2. Anosmia called Merciful / Blissful arosmia
    3. Patient herself is anosmic but a foul smell comes from her nose making her a social outcast.
  2. Signs:-
    1. Roomy nasal cavities with large crusts with shriveled turbinates (including resorption of bone)
    2. Septal perforation may be present
    3. Nose may show saddle deformity
    4. Atrophic changes in the pharyngeal mucosa may be seen
    5. Atrophic change may be seen in the larynx: atrophic laryngitis
    6. Hearing impairment due to Eustachian tube obstruction
    7. Obliterative endarteritis may be seen
    8. Tendency to recover spontaneously by middle age or menupause
  1. Investigations:-
  1. X- Ray P.N.S (water’s ) view ]: Thickening of the walls of the sinus
  2. Tests for syphilis
  3. CT scan --> Atrophy of Nasal & sinus mucosa
  1. Medical Treatment
    1. Alkaline Douching
      (Alkaline solution :- 280 ml warm water + a teaspoonful of the following powder:-* Sodium bicarbonate (28.4g) + Sodium biborate (28.4g) Sodium chloride (56.7g) [Purpose:- to loosen and remove the crusts and to remove the thick tenacious secretions]
    2. 25 % glucose in glycerine
      Following removal of the crust  The nose is painted with 25% glucose in glycerin
      Glucose  Inhibits proteolytic organisms]
      Glycerine  hygroscopic agent ]
    3. Other local antibiotics:-
      1. Kemicetine antiozaena solution:-
        [1 ml contains chloramphenicol (90mg). estradiol dipropionate (0.64mg), vit D2 (9001 Iu) and propyleneglycol]
      2. Potassium Iodide: by mouth to increase the nasal secretion
      3. Human placental extract:- tissue therapy with systemic human placenta extract[success : 80 % in 2 yrs] in the form of Submvcosal injections.
Other Drugs
  1. Streptomycin: 1 gm / day for 10 days (decreases the odour and crusts) Ritampicin.
  2. Sprays of Estrogen Oestradiol spray to ↑ vascularity of nasal mucosa.
  1. Surgical Treatment
    1. Lautenslager’s Operation:-
      1. Surgical procedures aimed at medializing the lateral nasal wall
      2. Substance injected:- Paraffin , teflon, polythene , cartilage, Fat bone.
    2. Young’s operation:-
      - Closure ofnoth the nostril following elevation of the nasal vestibular folds
    3. Modified Young’s operation:-
      1. Partial closure of the nostril leaving behind a 3mm hole
      2. This remains for a period of 2 yrs

Extra Edge:

  1. Unilateral atrophic rhinitis may be seen with severe DNS
  2. Secondary atrophic rhinitis due to : syphilis, leprosy, radiotherapy, turbinectomy
  3. Rhinitis Sicca : seen in hot, dry & dusty environment e. bakers, ironsmiths. t/t like atrophic rhinitis.

Atrophic changes confined ot anterior third fnuse particularly nasal septum.

  1. Rhintis Caseosa [Nasal cholesteatoma]
    1. Definition:- Is a chronic inflammation of the nose characterized by accumulation of offensive cheesy material resembling cholesteatoma- Sinus mucosa is granulomatous.
    2. Features:- Usually U/L
      - Males > Females
      - The nose gets filled with whitish debris with invasion of the bony structures and polyps
    3. Treatment :-  - Removal of debris by scooping it out
      - Repeated irrigation
      - Obstructive lesions: to be corrected surgically
Rhinitis Meaicamentosa :-Caused by excessive use of topical decongestant nasal drops.

  1. DNS
    1. Etiology:
      1. Trauma: At birth - during labour
      2. After birth Blows - lateral/crushing
      3. Developmental error: Unequal growth between the palate and the skull base cause buckling of the    nasal septum e.g. cleft palate.
      4. Radical factors: Caucasians > Negroes
      5. Hereditary factors
  1. Types:
    1. Anterior dislocation
    2. C-shaped dislocation
    3. S-shaped
    4. 4. Spurs: Sharp shelf like projection at the junction of the bone & the cartilage (may occur at the Junction of vomer below and septal cartilage and or ethmoid bone)
    5. Cause: Vertical compression forces
    6. Thickening
  2. Symptoms:
    1. Nasal obstruction (Ipsilateral or may be bilateral)
    2. Mucosal changes [mucosa around the deviated septum is oedematous] (principle-Bernoulli’s principle)
    3. Neurological changes: Sluder’s Neuralgia (anterior Ethmoidal nerve syndrome)
    4. Sinusitis
    5. Anosmia
    6. Middle ear problems
    7. Epistaxis
      Pain around the nasal bridge of the nose radiating into the foreheads [cause: middle turbinate pressing on to the septum]
  3. Signs;                                                                                            
    1. Paradoxical nasal obstruction may be there (disturbed airflow)
    2. Cottle’s test: To confirm whether the obstruction is in the nasal valve area, which is the narrowest part of the nasal cavity.
      Method: The patient pulls the cheeks outwards and this opens up the internal nares reducing the blockade.
  4. Treatment: Septoplasty (SMR is NOT recommended anymore)
  1. Septal Hematoma:
    1. Etiology:
      1. Trauma (Most common cause)
      2. Bleeding disorders
    2. Most common presentation: B/L septal bulge or swelling.
      1. Treatment: Early surgical drainage (or aspiration) and a tight intranasal packing
      2. Complications: Large haematomas can cause septal cartilage necrosis
      3. Small haematomas: can cause thickening of the septum
      4. Septal abscess formation
  2. Septal Perforation:
    1. Etiology
      1. Trauma
        1. Surgical            
        2. Repeated cautery        
        3. Nose picking
      2. Malignant disease
      3. Chronic inflammation (Wegener’s, Syphilis, T.B, Leprosy)
      4. Poisons (cocaine, topical steroids and decongestants)
      5. Idiopathic
      6. Myiasis/rhinolith
    2. Symptoms:
      1. Small anterior perforation : Causes whistling during inspiration or expiration
      2. Large perforation:
        1. Crusts
        2. Nasal obstruction
        3. Severe epistaxis
    3. Treatment:
      1. Encourage natural healing
      2. If it does not occur: Surgical repair
      3. If perforation asymptomatic : no treatment
      4. Small and medium sized perforation (< 2 cm in Diameter): Closure surgically
      5. Large perforation (> 2 cm in diameter): Obturators or Silastic buttons   
  1. Nasal Obstruction
Common causes of unilateral nasal obstruction
  1. Furuncle                           
  2. Vestibulitis                       
  3. Stenosis of nares
  4. Atresia                              
  5. Nasoalveolar cyst            
  6. Papilloma
  7. Squamous cell carcinoma
Nasal cavity
  • Foreign body                       
  • DNS                                        
  • Hypertrophic turbinates
  • Concha bullosa                    
  • Antrochoanal polyp            
  • Synechia
  • Rhinolith                               
  • Bleeding polypus of septum
  • Benign and malignant tumours of nose and paranasal sinuses
  • Sinusitis, unilateral
  • Unilateral choana I atresia
Common causes of bilateral nail obstruction
  • Bilateral vestibulitis :  Collapsing nasal alae
  • Stenosis of nares :  Congenital atresia of nares
Nasal cavity
  • Acute rhinitis (viral, bacterial) : Chronic rhinitis & sinusitis
  • Rhinitis medicamentosa : Allergic rhinitis
  • Hypertrophic turbinates : DNS
  • Nasal polypi : Atrophic rhinitis
  • Rhinitis sicca : Septal haematoma
  • Septal abscess : Bilateral choanal atresia
    Adenoid hyperplasia
    Large choanal polyp
    Thornwaldt’s cyst
    Adhesions between soft palate and posterior pharyngeal wall
    Large benign and malignant tumours

Extra Edge. Pouch of douglar. During development, notochord is attached to the endoderm in the area of nasopharynx producing an invagination pouch. Persistence of this pouch causes Thornwaldt’s cyst which may get infected to form an abscess.

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