Tugas THT Dr.khairan

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ATROPHIC RHINITIS Atrophic rhinitis is a chronic embarrassing debilitating disease involving nasal cavity and paranasal sinuses. It is characterized by foul smelling crusts (greenish) inside the nasal cavity. Nasal mucosa tends to bleed when these crusts are removed. Nasal cavity appears to be excessively roomy. Foul stench emanates from the patient. Patient is mercifully unaware of this stench because of the presence of anosmia. This article discusses the various features of this disease and th
  ATROPHIC RHINITIS Atrophic rhinitis is a chronic embarrassing debilitating disease involving nasal cavityand paranasal sinuses. It is characterized by foul smelling crusts (greenish) inside the nasalcavity. Nasal mucosa tends to bleed when these crusts are removed. Nasal cavity appears to be excessively roomy. Foul stench emanates from the patient. Patient is mercifully unawareof this stench because of the presence of anosmia. This article discusses the various featuresof this disease and the various management modalities available. INTRODUCTION  Atrophic rhinitis is defined as a chronic nasal disease characterised by progressiveatrophy of the nasal mucosa along with the underlying bones of turbinates. There is alsoassociated presence of viscid secretion which rapidly dries up forming foul smelling crusts.This fetid odor is also known as ozaena. The nasal cavity is also abnormally patent. The patient is fortunately unaware of the stench emitting from the nose as this disorder isassociated with merciful anosmia. This disease is rather rare in developed countries, but arerather common in developing countries . Now a days it is more common as a sequelae of medical interventions. Overzealous turbinate surgery has been implicated as a probableiatrogenic cause.  SYNONYMS The following are the various terminologies used to indicate the same condition:1. Rhinitis sicca2. Dry rhinitis3. Ozena4. Open nose syndrome5. Empty nose syndrome HISTORY A BRIEF REVIEW It was Spenser Watson of London who first coined the term Ozena to describe thiscondition. He was the first to describe clinical features of this disease. He classified thisdisease into mild, moderate and severe varieties. Mild variety of atrophic rhinitis according toWatson ischaracterizedby heavy crusting. These crusts can easily be removed by nasaldouching. Moderate variety features anosmia and stench emanating from the nasal cavity.Severe variety is invariably caused by syphilis. Bone destruction and cosmetic deformities of nose is rather common in this variety. In 1876 Dr Bernhard Fraenkel first described the  classic triad of symptoms which was virtually diagnostic of this disorder. This triad is still known as Fraenkel’s triad in his honor include: Fetor, Crusting and Atrophy of nasal structure s. Frank Bosworth in 1881 noted that ‘  Breath from these patients were not onlyunpleasant but virtually unbearable. The sufferer perse was mercifully unaware because of the presence of anosmia .”   ETIOLOGY The etiology of this problem still remains obscure. Numerous pathogens have beenassociated with this condition, the most important of them are:1. Coccobacillus2. Bacillus mucosus3. Coccobacillus foetidus ozaenae4. Diptheroid bacilli5. Klebsiella ozaenae.These organisms despite being isolated from the nose of diseased patients have notcategorically been proved as the cause for the same. Other predisposing factors include:   1.   Chronic sinusitis2.   Excessive surgical destruction of the nasal mucosa and turbiantes3.    Nutritional deficiencies: 50% of patients with atrophic rhinitis benefited with irontherapy and symptomatic improvement in majority of the patients with atrophicrhinitis when treated with vitamin A.4.   Syphilis5.   Endocrine imbalances (Disease is known to worsen with pregnancy / menstruation)6.   Heredity7.   Autoimmune disease8.   Developmental: Shortened antero posterior nasal lengths and poor maxillary antral pneumatization in patients with atrophic rhinitis.9.   Vascular: Excess sympathetic activity was observed in these patients. Age of onset:   Usually atrophic rhinitis commences at puberty. Sex prediliction:   Females are more commonly affected than males. CLASSIFICATION  Primary atrophic rhinitis: This classic form of atrophic rhinitis is supposed to arise denovo. This isin facta diagnosis of exclusion. This type of atrophic rhinitis is common inChina, India and Middle East. In almost all these patients Klebsiella ozenae has been isolated.Secondary atrophic rhinitis: This is the most common form of atrophic rhinitis seen indeveloped countries. In this type the predisposing cause is clearly evident. Common causes of secondary atrophic rhinitis include:1.   Surgical procedures involving nose and paranasal sinuses  –  They includeturbinectomies, sinus surgeries, maxillectomy etc.2.   Irradiation3.   Trauma4.   Granulomatous diseases: Include Sarcoidosis, Leprosy and Rhinoscleroma5.   Infections: This includes tuberculosis and syphilis CLINICAL FEATURES The presenting symptoms are commonly nasal obstruction and epistaxis. Anosmia i.e.merciful may be present making the patient unaware of the smell emanating from the nose.These patients may also have pharyngitis sicca. Choking attacks may also be seen due toslippage of detached crusts from the nasopharynx into the oropharynx. These patients alsoappear to be dejected and depressed psychologically.Clinical examination of these patients show that their nasal cavities filled with foul smellinggreenish, yellow or black crusts, the nasal cavity appear to be enormously roomy. When thesecrusts are removed bleeding starts to occur. Why nasal obstruction even in the presence of roomy nasal cavity?  This interesting question must be answered. The nasal cavity is filled with sensorynerve endings close to the nasal valve area. These receptors sense the flow of air through thisarea thus giving a sense of freeness in the nasal cavity. These nerve endings are destroyed in patients with atrophic rhinitis thus depriving the patient of this sensation. In the absence of these sensation the nose feels blocked. RADIOLOGIC FEATURES Radiologic features are similar for both types of atrophic rhinitis. Plain xrays showlateral bowing of nasal walls, thin or absent turbinates and hypoplastic maxillary sinuses. CT scan findings:    1.   Mucoperiosteal thickening of paranasal sinuses  2.   Loss of definition of osteomeatal complex due to resorption of ethmoidal bulla anduncinate process3.   Hypoplastic maxillary sinuses4.   Enlargement of nasal cavity with erosion of the lateral nasal wall5.   Atrophy of inferior and middle turbinatesHISTOPATHOLOGY1.   Metaplasia of ciliated columnar nasal epithelium into squamous epithelium.2.   There is a decrease in the number and size of compound alveolar glands3.   Dilated capillaries are also seen Pathologically atrophic rhinitis has been divided into two types:  Type I: is characterised by the presence of endarteritis and periarteritis of the terminalarterioles. This could be caused by chronic infections. These patients benefit from thevasodilator effects of oestrogen therapy. Type II: is characterised by vasodilatation of the capillaries, these patients mayworsen with estrogen therapy. The endothelial cells lining the dilated capillaries have beendemonstrated to contain more cytoplasm than those of normal capillaries and they alsoshowed a positive reaction for alkaline phosphatase suggesting the presence of active boneresorption. It has also been demonstrated that a majority of patients with atrophic rhinitis belong to type I category. MANAGEMENT Conservative:     Nasal douching  –  The patient must be asked to douche the nose atleast twice a day with asolution prepared with:Sodium bicarbonate  –  28.4 gSodium diborate  –  28.4 gSodium chloride  –  56.7 gMixed in 280 ml of luke warm water.The crusts may be removed by forceps or suction. 25% glucose in glycerin drops can beapplied to the nose thus inhibiting the growth of proteolytic organism.In patients with histological type I atrophic rhinitis oestradiol in arachis oil 10,000 units/mlcan be used as nasal drops.Kemecetine antiozaena solution  –  is prepared with chloramphenicol 90mg, oestradiol
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