Atrophic Rhinitis

Atrophic rhinitis is chronic nasal disease with atrophy of the mucosa and turbinate bone, wide nasal cavities, thick dry crusts, foul smell (ozaena) and loss of the sense of smell. The paradoxical sensation of nasal blockage is common.

Primary atrophic rhinitis is rare in developed countries but frequent in parts of Asia, Africa and the Middle East, where it is associated with Klebsiella ozaenae, poor hygiene, malnutrition and iron deficiency. It affects young women in the second to fourth decades more often. Secondary atrophic rhinitis follows excessive turbinate surgery, radiotherapy, trauma, chronic infection (tuberculosis, syphilis, leprosy), granulomatous disease and cocaine use.

Pathophysiology.

Progressive loss of ciliated epithelium, squamous metaplasia, thinning of seromucous glands and endarteritis reduce blood supply. Crusting, infection and mucosal damage maintain the cycle, and sensory nerve loss explains the blocked sensation despite wide airways.

Nasal crusting, foul odour noticed by others (but not the patient), epistaxis, nasal obstruction, dryness, anosmia, headache and pharyngeal dryness. The nasal cavity looks wide with pale, thin mucosa.

Red flags.

• Saddle nose deformity or septal perforation (granulomatosis with polyangiitis, syphilis, cocaine).
• Epistaxis with a mass.
• Orbital complications.
• Weight loss, night sweats (tuberculosis).

Clinical examination and nasal endoscopy show a wide cavity with atrophic turbinates and green crusts. Swab for culture and sensitivity, and take biopsy if atypical. CT of the sinuses shows reduced turbinate volume and widened passages. Test for iron deficiency, syphilis serology, HIV, antineutrophil cytoplasmic antibodies, chest radiograph and tuberculosis tests when a secondary cause is suspected.

Differential diagnosis.

• Empty nose syndrome.
• Granulomatosis with polyangiitis.
• Sarcoidosis.
• Nasal tuberculosis, syphilis or leprosy.
• Cocaine induced midline destruction.
• Nasal vestibulitis.

Treatment is symptomatic and aims to keep the nose moist and free of crusts. Surgery to narrow the nasal cavity (submucosal implants, medialisation, or closure of the nostrils by the Young operation) is for severe disease.

• Saline irrigation: 240 mL isotonic saline into each nostril two to three times daily, with removal of crusts; long term; monitor crusting and epistaxis; use boiled or sterile water.
• Mupirocin 2% nasal ointment (infection): applied to each nostril three times daily for 7 to 10 days; maximum 10 days; monitor for local irritation and resistance.
• Ciprofloxacin (Klebsiella or other Gram negative infection, severe): 500 mg orally twice daily for 2 to 3 weeks; maximum 1.5 g daily; monitor tendon pain, QT interval and glucose; reduce to 250 to 500 mg once daily when creatinine clearance is under 30 mL/min; avoid in pregnancy and children.
• Ferrous sulphate (iron deficiency): 200 mg (65 mg elemental iron) orally once daily for 3 months after haemoglobin normalises; maximum 400 mg daily; monitor ferritin and haemoglobin.

Use humidification and avoid dry environments.

Monitoring. Review each 2 to 4 weeks at first, then every 3 months; smell testing yearly.

Referral and escalation. ENT for surgery and for suspected secondary causes; rheumatology for granulomatous disease.

Special groups. Pregnancy: avoid ciprofloxacin and use saline, ointment and iron.