ATROPHIC RHINITIS

By SREEJITH T

OZAENA Chronic inflammation of nose,

characterized by atrophy of nasal mucosa and turbinate bones.

nasal cavities are roomy ,filled with foul smelling crusts.

2 typesPrimary

Secondary

PRIMARY ATROPHIC RHINITIS

AETIOLOGY HERNIA

HEREDITARY FACTORS

ENDOCRINE DISTURBANCES

RACIAL FACTORS

NUTRITIONAL DEFICIENCY

INFECTIVE

AUTOIMMUNE PROCESS

PATHOLOGY

Ciliated columnar epithelium replaced by stratified squamous type.

Atrophy of seromucinous glands, venous blood sinusoids and nerve elements.

Arteries in the mucosa, periosteum and bone show obliterative endarteritis.

Bone of turbinates undergoes resorption causing widening of nasal chambers.

Paranasal sinuses are small due to arrested development.

CLINICAL FEATURES

MC females foul smell from the nose merciful anosmia nasal obstruction - crust formation. greenish or greyish black dry crusts

covering the turbinates and septum. Epistaxis – on removal of crust. nasal cavities appear roomy atrophy of turbinates

nasal mucosa –pale septal perforation dermatitis of nasal vestibule saddle deformity of nose atrophic pharyngitis – Pharyngeal mucosa

appear dry and glazed with crusts atrophic laryngitis – cough, hoarseness of

voice hearing impairment X-ray paranasal sinus - opaque

TREATMENT

MedicalNasal irrigation and removal of crusts

25% glucose in glycerine

Local antibiotics

Oestradiol therapy

Placental extract

Systemic use of streptomycin

Potassium iodide

Surgical

YOUNG’S OPERATION

• Modified Young’s operation

NARROWING THE NASAL CAVITIES• Submucosal injection of teflon paste• Insertion of fat, cartilage or teflon strips

under the mucoperiosteum of the floor, lateral wall of nose, mucoperichondrium of the septum.

• Section and medial displacement of lateral wall of nose

SECONDARY ATROPHIC RHINITIS

Syphilis Lupus Leprosy Rhinoscleroma Long standing purulent sinusitis Radiotherapy to nose Excessive surgical removal of turbinates

UNILATERAL ATROPHIC RHINITIS Extreme deviation of nasal septum accompanied

by atrophic rhinitis on the wider side

ALLERGIC RHINITIS

IgE mediated immunologic response of nasal mucosa to airborne allergens and is characterized by Watery nasal discharge Nasal obstruction Sneezing Itching in the nose

2 TypesSeasonal

Perennial

ETIOLOGY

Inhalent allergensSeasonal allergens – pollensPerennial allergens – molds, dust mite,

dander from animals

Genetic predisposition

PATHOGENESIS

Inhaled allergens IgE blood basophil / mast cell

Subsequent exposure Ag +IgE degranulation of mast cells release preformed & newly formed chemical mediators vasodilatation, mucosal edema, infiltration of eosinophils, excessive secretion from nasal glands, smooth muscle contraction.

PRIMING EFFECT - mucosa earlier sensitized to an allergen will react to smaller doses of subsequent specific allergen and also get primed to other nonspecific antigens to which patient was not exposed cause nonspecific nasal hyper -reactivity

• ALLERGIC RESPONSE- 2 phases

Acute or early phase

• Within 5–30 min after exposure

• Sneezing, rhinorrhoea, nasal blockage, bronchospasm

• Due to release of vasoactive amines

Late or delayed phase

• 2-8 hour after exposure

• Swelling, congestion, thick secretion

• Due to infiltration of inflammatory cells at the site of antigen deposition

CLINICAL FEATURES

Seasonal nasal allergy

Paroxysmal sneezing(10-20 sneezes at a time)

Nasal obstruction

Watery nasal discharge

Itching of eyes, palate or pharynx

Perennial allergy

Frequent colds

Persistently stuffy nose

Anosmia due to mucosal edema

Postnasal drip

Chronic cough

Hearing impairment

SIGNS OF ALLERGY

Nasal signs Transverse nasal crease Pale and edematous nasal mucosa: bluish Swollen turbinates Thin, watery or mucoid discharge

Ocular signs Edema of the lids Congestion and cobblestone appearance of the

conjunctiva Dark circles under the eyes(allergic shiners)

Otologic signs Retracted tympanic membrane Otitis media

Pharyngeal signs Granular pharyngitis

Laryngeal signs Hoarseness Edema of the vocal cords

NEW ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA (ARIA) CLASSIFICATION

Duration of disease

INTERMITTENT (symptoms are

present for)

• Less than 4 days a week OR

• For less than 4 weeks

PERSISTENT (symptoms are

present for)

• More than 4 days a week OR

• For more than 4 weeks

Severity of disease

MILD: None of the following symptoms are present• Sleep disturbances• Impairment of daily activities, leisure and

sport• Impairment of school or work• Troublesome symptoms

MODERATE TO SEVERE

• One or more of the above symptoms are present

INVESTIGATIONS Total and differential count

Peripheral eosinophilia Nasal smear

taken at the time of clinically active disease or after challenge test

shows large number of eosinophils present in non allergic rhinitis also eg:NARES

Skin test: helps to identify specific allergen Skin prick test: drop of conc. allergen solution volar

surface of forearm introduce to the dermis central wheal and surrounding zone of erythema within 10-15 min +ve test

Specific IgE measurement: in vitro test to find specific allergen

Radioallergosorbent test (RAST) invitro test measures specific IgE antibody concentration in serum

Nasal provocation test

COMPLICATIONS

Recurrent sinusitis Nasal polypi Serous otitis media Orthodontic problems Bronchial asthma

TREATMENT

Avoidance of allergen. Treatment with drugs

Antihistaminics Sympathomimetics (oral & topical) Corticosteroids Sodium cromoglycate Anticholinergics Leukotriene receptor antagonist Anti IgE

Immunotherapy allergen is given in gradually increasing doses till the

maintenance dose is reached suppresses IgE formation raise the titre of specific IgG antibody subcutaneous, nasal, sublingual routes

STEP CARE APPROACH RECOMMENDED BY ARIA

Mild intermittent disease oral antihistamines, intranasal cromolyn sodium

Moderate / persistent disease intranasal corticosteroids

Severe combination therapy (oral nonsedating antihistamines + intranasal steroids)

Severe and persistent combination therapy + short course of oral steroids & immunotherapy

Persistent nasal obstruction intranasal decongestants OR (oral decongestants + antihistamines)

Avoid allergens and irritants in all forms of disease.

THANK YOU !!!