Historia del manejo de rinitis atrófica / The history of the treatment of atrophic rhinitis

La rinitis atrófica es una enfermedad crónica progresiva caracterizada por dilatación anormal de las cavidades nasales con atrofia de la mucosa, submucosa y cornetes nasales subyacentes. Los factores etiopatogénicos aún son desconocidos. Su presentación clínica consiste en congestión nasal paradójica asociado a secreciones viscosas, con presencia de costras secas de mal olor. La higiene nasal con irrigación de alto volumen y baja presión es el estándar de tratamiento médico. El tratamiento quirúrgico busca reducir el tamaño de las cavidades nasales y promover la regeneración de la mucosa nasal así como también su vascularización y lubricación. A lo largo de la historia se han descrito múltiples procedimientos quirúrgicos que han buscado estrechar la cavidad nasal para permitir el paso de aire de forma más fisiológica. Por otra parte, se han propuesto intervenciones radicales como el cierre de las fosas nasales para disminuir los síntomas y mejorar la calidad de vida. En este artículo se resumen los principales manejos y procedimientos propuestos junto con sus resultados y conclusiones. Si bien la mayoría de las técnicas descritas ya no se utilizan en la actualidad, es importante conocerlas ya que aún existen pacientes que fueron sometidos a ellas pudiendo presentar complicaciones y/o efectos adversos.

Atrophic rhinitis is a chronic progressive disease characterized by abnormal dilatation of the nasal cavities with atrophy of the mucosa, nasal submucosa and underlying nasal turbinates. The etiopathogenic factors are still unknown. Its clinical presentation consists of paradoxical nasal congestion associated with viscous secretions, usually with the presence of dry, bad-smelling crusts. Nasal hygiene with high pressure irrigation remains the standard of medical treatment. Surgical treatment seeks to reduce the size of nasal cavities and promote regeneration of nasal mucosa as well as its vascularization and lubrication. Throughout history, multiple surgical procedures have been described that have sought the narrowing of the nasal cavity to allow the passage of air more physiologically. On the other hand, radical interventions have been proposed such as the closure of the nostrils to reduce symptoms and improve quality. This article summarizes the main proposed procedures along with their results and conclusions. Although most of the techniques described are no longer used today, it is important to know them since there are still patients who were subjected to them and may present complications and / or adverse effects.

Use of intranasal submucosal fillers as a transient implant to alter upper airway aerodynamics: implications for the assessment of empty nose syndrome.

BACKGROUND: Empty nose syndrome (ENS) is a debilitating condition associated with inferior turbinate tissue loss. Surgical augmentation of the inferior meatus has been proposed to treat ENS, although efficacy data with validated, disease-specific questionnaires is limited. Instead we evaluated submucosal injection of a transient, resorbable filler into the inferior meatus to favorably alter nasal aerodynamics in ENS patients. METHODS: Patients with a history of inferior turbinate reduction, diagnosed with ENS via Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) and cotton testing, were enrolled and underwent submucosal injection of carboxymethylcellulose/glycerin gel (Prolaryn®) into the inferior meatuses between July 2014 and May 2018. This material likely resorbs over several months. Outcomes included comparisons of preinjection and postinjection symptoms at 1 week, 1 month, and 3 months using the ENS6Q, 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-item scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). RESULTS: Fourteen patients underwent injections. Mean ENS6Q scores significantly decreased from baseline at 1 week (20.8 vs 10.5; p < 0.0001), and remained reduced but upward-trending at 1 month (13.7, p = 0.002) and 3 months (15.5, p > 0.05) following injections. Mean SNOT-22 scores significantly decreased at 1 week (p = 0.01) and 1 month (p = 0.04), mean GAD-7 at 1 month (p = 0.02) and 3 months (p = 0.02), and mean PHQ-9 at 1 week (p = 0.01) and 1 month (p = 0.004) postinjection. CONCLUSION: Transient, focal airway bulking via submucosal filler injection at sites of inferior turbinate tissue loss markedly benefits ENS patients, suggesting that aberrant nasal aerodynamics from inferior turbinate tissue loss contributes to (potentially reversible) ENS symptoms.

Successful management of primary atrophic rhinitis by turbinate reconstruction using autologous costal cartilage.

Initial management of primary atrophic rhinitis is conservative, with nasal ointments, saline irrigation, and antibiotics prescribed to relieve symptoms. However, in cases that show no improvement, a surgical approach is considered. Recently, many studies have reported successful surgical outcomes using various nasal implants. However, no study has reported implantation of autologous costal cartilage in PAR patients. We report here the case of a 63-year-old woman diagnosed with PAR that was intractable to medical therapy. Under general anesthesia, bilateral inferior turbinate reconstruction with autologous costal cartilage was successfully performed without any complications. One month after surgery, her symptoms improved dramatically. At the 2-year follow-up, her Sinonasal Outcome Test 25 (SNOT-25) score was 6, down from an initial score of 108. Her OMU CT showed improved sinonasal mucosal thickness and disappearance of thick mucosal secretion compared with preoperative CT image. Although this is a single case experience, it is suggested that turbinate reconstruction using autologous costal cartilage can serve as promising surgical modality for management of atrophic rhinitis.

Chronic rhinosinusitis in ex-lepromatous leprosy patients with atrophic rhinitis.

AIM: Rhino-sinus mucosal involvement is well documented in untreated lepromatous leprosy, but less understood in ex-leprosy patients (i.e. leprosy patients who have been treated and cured) with atrophic rhinitis. MATERIALS AND METHODS: Rhino-sinus abnormalities were investigated in 13 ex-lepromatous leprosy patients with atrophic rhinitis, using interviews enquiring about sinonasal symptoms, nasal endoscopy, nasal swab culture and computed tomography. Endoscopic sinus surgery had been performed in three patients. The clinical course, computed tomography findings and nasal biopsy results of these three patients were evaluated. RESULTS: All patients had turbinate atrophy and 6 of the 13 (46.2 per cent) had septal perforation. Paranasal sinus involvement was noted in 9 of 12 examined patients (75 per cent). The most commonly affected sinus was the maxillary sinus (in 8 of 12; 66.7 per cent). All three patients treated by endoscopic sinus surgery experienced relapse and required further surgery. Maxillary sinus irrigation was effective for reduction of persistent symptoms such as postnasal discharge and crusts. CONCLUSION: Ex-lepromatous leprosy patients with atrophic rhinitis had various rhino-sinus abnormalities and persistent symptoms. These patients had chronic rhinosinusitis because of underlying atrophic rhinitis. These patients required repeated otolaryngological observations together with combined surgery and conservative treatment.

Rhinoplasty in atrophic rhinitis.

Rhinoplasty in atrophic rhinitis is a difficult surgery because the dorsal skin is adherent to the underlying structures. There is also more chance of postoperative infection. The experience of various types of rhinoplasty in 15 atrophic rhinitis patients is presented here. The patients were from the age group 17 to 35 years. Most of the operations were done under local anaesthesia. Commonest graft used was conchal-cartilage. Bone graft was avoided for augmentation because of its high rate of absorption in atrophic rhinitis. Young's operation was done in 5 patients in one side along with rhinoplasty. Young's operation was done only with skin layer.

Customised acrylic nasal stents following recanalisation of modified Young's procedure.

INTRODUCTION: Maintaining the patency of the nasal vestibule following recanalisation of a modified Young's procedure can be a difficult task, as restenosis is quite common. MATERIALS AND METHODS: Sixteen patients underwent recanalisation of a modified Young's procedure, between January 2005 and December 2007, in the ENT--head and neck surgery department of a tertiary centre. Three different stent types were used following recanalisation: silicone suction tube tips, dental wax plate stents and customised acrylic stents. RESULTS: The silicone suction tube stents prevented restenosis. They were visible in the post-operative period, and there appeared to be some blunting of the nasal valve region, with no functional impairment. Dental wax plates had a high rate of restenosis and were uncomfortable and unsightly. The customised acrylic stents were more acceptable in the post-operative period, and enabled nasal valve angulation to be maintained. CONCLUSION: The customised acrylic stent described was a superior alternative to such stenting methods as repeated packing, silicone suction tubes and dental wax plates, following recanalisation of a modified Young's procedure.

Atrophic rhinitis: a CFD study of air conditioning in the nasal cavity.

Atrophic rhinitis is a chronic disease of the nasal mucosa. The disease is characterized by abnormally wide nasal cavities, and its main symptoms are dryness, crusting, atrophy, fetor, and a paradoxical sensation of nasal congestion. The etiology of the disease remains unknown. Here, we propose that excessive evaporation of the mucous layer is the basis for the relentless nature of this disease. Airflow and water and heat transport were simulated using computational fluid dynamics (CFD) techniques. The nasal geometry of an atrophic rhinitis patient was acquired from computed tomography scans before and after a procedure to narrow the nasal cavity. Simulations of air conditioning in the atrophic nose were compared with similar computations performed within the nasal geometries of four healthy humans. The excessively wide cavity of the patient generated abnormal flow patterns, which led to abnormal patterns of water fluxes across the wall. Geometrically, the atrophic nose had a much lower surface area than the healthy nasal passages, which increased water fluxes per unit area. Nevertheless, the simulations indicated that the atrophic nose did not condition inspired air as effectively as the healthy geometries. These simulations of water transport in the nasal cavity are consistent with the hypothesis that excessive evaporation of mucus plays a key role in the pathophysiology of atrophic rhinitis. We conclude that the main goals of a surgery to treat atrophic rhinitis should be 1) to restore the original surface area of the nose, 2) to restore the physiological airflow distribution, and 3) to create symmetric cavities.

Power microdebrider-assisted modification of endoscopic inferior turbinoplasty: a preliminary report.

BACKGROUND: In this article, microdebrider-assisted modification of endoscopic inferior turbinoplasty is described. It has the advantage of superior visualization during elevation of the mucosal flap and allows precise tailoring of the resection to the needs of patients. METHODS: From November 2001 to December 2002, 29 patients with chronic hypertrophic rhinitis treated with power endoscopic inferior turbinoplasty were available for follow-up examinations. Questionnaires and rhinomanometric studies were performed for subjective and objective evaluations. These patients were followed up for an average of 15.3 months after the operation. RESULTS: The overall improvement in nasal obstruction was 91% in our study. Twenty-two patients received rhinomanometric studies 1 week preoperatively and 2 months postoperatively. The average nasal airflow was increased by 187 ml/min. In addition, complete relief of headaches was achieved. But the remission rates of persistent rhinorrhea and post-nasal dripping were less significant, at about 58% and 54%, respectively. Atrophic change and permanent synechiae had not yet been observed. CONCLUSIONS: Power endoscopic turbintoplasty is a safe, simple, and effective method for the treatment of chronic hypertrophic rhinitis. It is especially handy in adjunct to endoscopic septoplasty or sinosurgery, and appears to provide a surgical choice of a minimally invasive technique. However, further study with a prospective design is needed to strengthen the evidence.

Endoscopic dacryocystorhinostomy in cases of dacryocystitis due to atrophic rhinitis.

Atrophic rhinitis is a chronic inflammatory disease of the nose, which is more common in India. Chronic dacryocystitis is its rare complication. The authors found four cases of chronic dacryocystitis from March 2002 to October 2003 due to atrophic rhinitis. It was diagnosed clinically by the regurgitation test and lacrimal syringing. These cases were treated conservatively for a period of six weeks to make the nasal mucosa healthier and were then subjected to endoscopic dacryocystorhinostomy (end-DCR) under local anaesthesia. The procedure was found to be more difficult due to bleeding and the healing time was prolonged as compared to other cases of end-DCR. After one to one and half years of follow-up the primary success rate was 75 per cent but after revision surgery in one case, all cases were successful. Hence it was concluded that atrophic rhinitis is no more a contraindication for end-DCR. However, meticulous initial preparation and post-operative follow-up is necessary to improve the result.

[Implantation of complex tissue flap for atrophic rhinitis].

OBJECTIVE: To improve the treatment effect of atrophic rhinitis. METHOD: Twenty-one cases (thirty-one sides) of atrophic rhinitis were treated by implantation of complex tissue flap to narrow the nasal cavity. RESULT: Short-term effective treatment results were 100% (21/21), long-term effective treatment results were 90.5% (19/21). CONCLUSION: Implantation of complex tissue flap offers a simple and effective way and can be recommended for the treatment of atrophic rhinitis.

[Empty nose syndrome].

OBJECTIVE: The aim of this article is to present the concept of empty nose syndrome(ENS) and help ENT doctors take care of regular nasal turbinate surgery. METHODS: Fourteen patients who was diagnosed as ENS in our department were reviewed retrospectively. All patients had undergone various forms of nasal surgery (all had had turbinectomy). Their age ranged from 13 to 52 years. All patients were treated conservatively, among these patients 5 subjects who had more serious symptoms received submucous and subperiostal nasal implantation with ilium. RESULTS: All patients had nasal obstruction and dryness of nasal cavity, nasopharynx and oto-pharynx in 6 months--5 years after their first nasal surgery, some presented symptoms of depression. Nasoscope examination showed all patients had a cylindrically enlarged nasal cavity. Conservative treatment was effective in most cases. The effectiveness of operative treatment was encouraging during short-term follow-up. CONCLUSION: Extensive turbinectomy may cause secondary nasal mucosal atrophy and a series of subsequent symptoms. The presentation of this concept is to remind the ENT doctors prudently performing turbinectomy to avoid the occurrence of irreversible injury to the nasal cavity.

[Toxic shock syndrome related to the operation of nose].

OBJECTIVE: To study the clinical features of Toxic shock syndrome. METHOD: The clinical information of two cases was analysed. RESULT: It indicates that this disease is caused by TSST-1 which is created by staphylococcus-aureus. The clinical features are acute toxic-shock syndrome with many complications and high mortality. CONCLUSION: More attention should be payed for it.

Application of endoscopic sinus surgery to primary atrophic rhinitis? A clinical trial.

The aetiology of primary atrophic rhinitis (AR) is still unclear. Based on the sinus infection theories, endoscopic sinus surgery (ESS) was applied to treat AR. ESS was performed on 14 patients following Stammberger's techniques along with middle turbinectomy. Patients were evaluated using clinical symptoms, radiological sinus images, saccharine time tests, bacterial cultures and mucosal ultrastructures, before and 2 years after ESS. Three patients had good recoveries, 6 had partial recoveries and another 5 had persistent disease. Good recovery patients showed clear nasal cavities and mucociliary transport system normalisation. Patients possess in meagre infectious signs or crusting extending to their nasopharynx had poor outcomes. Patients with evidence of obvious infections (cloudy sinus images, mucopus presence in the sinuses and positive culture for Klebsiella ozaenae) had good recoveries following ESS. Candidate selection is critical for the success of ESS treatment in AR. Although further clinical trials are required to prove this strategy.

Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis.

The aetiology of primary atrophic rhinitis is still unknown. Treatment of this disease is conservative in the first place. Surgery is indicated if the medical treatment fails. The aim of surgery is either to narrow the nasal cavity or in special cases to close the nostril. Closure of the nostril (Young's operation), is achieved by raising a circular skin flap. Raising the skin flap is difficult, the suture line may break down and an excessive scar tissue may form resulting in vestibular stenosis. We therefore developed a septal mucoperichondrial flap to close the nostril. This new and easy technique has been used to treat 17 patients with excellent results. The description of this technique and the results of surgery will be discussed.

Triosite implants and fibrin glue in the treatment of atrophic rhinitis: technique and results.

Nine patients with primary or secondary atrophic rhinitis were treated by narrowing of the nasal fossae using a new surgical technique (derived from the Eryes procedure) in which a Triosite and fibrin glue mixture is implanted via the labial vestibule route. The results were good or excellent in seven patients. No rejections occurred. Osseocoalescence, as evaluated by computed axial tomography at 6 months, was good. Inspiratory intrasnasal pain in patients with postsurgical atrophic rhinitis improved following the operation. The surgical technique, which is quick and easy to perform, avoids the discomfort of nostril closure or the implantation of grafts from other parts of the body. Complicated flap procedures are also avoided.