Atrophic Rhinitis: Symptoms, Types, Causes and Treatment

Atrophic rhinitis is a chronic nasal disorder that can have a significant impact on quality of life. Characterized by the progressive atrophy of the nasal mucosa and underlying structures, it leads to symptoms that are both physically and socially distressing. Understanding its signs, forms, causes, and available treatments is crucial for patients and clinicians alike. In this article, we delve into the latest research to provide a thorough, evidence-based overview of atrophic rhinitis.

Symptoms of Atrophic Rhinitis

Atrophic rhinitis presents with a constellation of symptoms that can be both bothersome and socially stigmatizing. Early recognition is essential for effective management and the prevention of complications. Let's explore the typical clinical features of this condition.

Symptom	Description	Prevalence/Notes	Source(s)
Crusting	Formation of thick, dry nasal crusts	Most consistent finding; present in 100%	3 4 5 6
Fetor (Ozaena)	Foul-smelling nasal discharge or odor	Present in 70-100%	4 5 6 8
Nasal Obstruction	Sensation of blocked nose (paradoxical)	Reported in 48-80%	2 4 5 6 10
Epistaxis	Bleeding from the nose	Present in ~45%	2 5 12
Anosmia	Loss or reduction of smell (hyposmia)	Present in up to 95%	2 5 12
Purulence	Mucopurulent nasal discharge	Common	2 3 12
Nasal Myiasis	Infestation with nasal maggots	10-27% in advanced cases	3 5 12
Headache	Facial or head pain	45% in some cohorts	5

Table 1: Key Symptoms

The Symptom Triad

Atrophic rhinitis is classically defined by the triad of:

• Crusting: Thick, dry, often greenish crusts form within the nasal cavity. These are hard to remove and may bleed if dislodged.
• Fetor (Ozaena): A characteristically foul odor emanates from the nose, sometimes noticed more by others than the patient themselves due to olfactory loss.
• Atrophy: Thinning and shrinkage of the nasal mucosa and underlying bone, leading to a widened (roomy) nasal cavity 3 4 5 6 8 12.

Paradoxical Nasal Obstruction

Despite the nasal cavities becoming abnormally wide due to tissue loss, patients frequently report a sensation of nasal blockage. This is termed "paradoxical nasal obstruction" and is thought to result from altered airflow and reduced mucosal sensation 2 6 10.

Other Symptoms and Complications

• Epistaxis (nosebleeds) occurs due to fragile, atrophic mucosa.
• Loss of smell is common and can be profound.
• Secondary infections may lead to purulent discharge and, in advanced cases, nasal myiasis (infestation with maggots), particularly in hot climates or poor hygiene settings 3 5 12.
• Headache and general discomfort may also be present 5.

Types of Atrophic Rhinitis

Not all cases of atrophic rhinitis are alike. Understanding the distinction between primary and secondary forms is vital for guiding treatment and prognosis.

Type	Definition	Key Features / Causes	Source(s)
Primary	Occurs in a previously healthy nose	Etiology unclear; no antecedent disease or trauma	2 3 4 6 8 9
Secondary	Follows surgery, trauma, or chronic infection	Often due to surgical removal of turbinates, chronic infections, granulomatous disease	1 2 4 6 8 9

Table 2: Types of Atrophic Rhinitis

Primary (Idiopathic) Atrophic Rhinitis

Primary atrophic rhinitis, also known as "ozena," develops in individuals with no history of prior nasal trauma, surgery, or chronic disease. The precise cause remains elusive, but several mechanisms have been suggested, including genetic predisposition, chronic infection, and nutritional or vascular factors 3 8 9. It is more common in young to middle-aged females and often starts around puberty 4 7 12.

Secondary Atrophic Rhinitis

Secondary atrophic rhinitis arises as a consequence of an identifiable insult to the nose. Common scenarios include:

• Nasal Surgery: Particularly excessive turbinate removal (turbinectomy) or septal surgery 1 2 6.
• Chronic Granulomatous Diseases: Such as leprosy, tuberculosis, syphilis, sarcoidosis, and rhinoscleroma 4 8.
• Chronic Sinusitis: Long-standing infection may eventually cause mucosal atrophy 4 6.
• Other Causes: Radiation exposure, trauma, certain systemic diseases (e.g., diabetes mellitus) 4 6.

Secondary forms are now more common in clinical practice, especially in regions with advanced surgical interventions 6.

Causes of Atrophic Rhinitis

The underlying causes of atrophic rhinitis are complex and often multifactorial. Understanding these can help with prevention and targeted management.

Factor	Description / Role	Notes / Examples	Source(s)
Bacterial	Chronic infection with P. aeruginosa, K. ozenae, S. aureus	Culture positive in most cases; role in pathogenesis debated	3 8 9 14
Hereditary	Familial and genetic factors implicated	More common in certain families	3 8 7
Nutritional	Deficiencies in protein, iron, vitamins	Anemia and low total protein common	3 9
Hormonal	Fluctuations or disturbances in hormones	Worsens during pregnancy, menstruation	7
Vascular	Impaired blood supply to nasal mucosa	Endarteritis, periarteritis observed	7 16
Surgical/Trauma	Excessive turbinate removal, injury	Leading cause of secondary cases	1 2 4 6
Chronic Disease	Leprosy, TB, syphilis, rhinoscleroma	Granulomatous diseases	4 8
Environmental	Dry, dusty, or polluted climates	May exacerbate or predispose	1 12

Table 3: Etiological Factors

Infectious Agents

A high percentage of patients show colonization with Pseudomonas aeruginosa, Klebsiella ozenae, and Staphylococcus aureus. The role of these bacteria is debated—are they cause or consequence? However, their presence correlates with symptom severity and chronicity 3 8 9 14.

Genetic and Familial Predisposition

Studies highlight a familial tendency, suggesting possible genetic susceptibility. Some cases occur in clusters or among siblings, and the disease is more common in certain ethnic groups and regions 3 4 7 8.

Nutritional and Systemic Health

Low hemoglobin and protein levels (indicative of anemia and malnutrition) are common in affected patients, implying that nutritional deficits may either predispose or worsen the disease 3 9.

Hormonal and Vascular Factors

Outbreaks and exacerbations during puberty, pregnancy, and menstruation point toward hormonal influences. Impaired blood supply (e.g., endarteritis) has also been documented, leading to tissue atrophy 7 16.

Surgical and Traumatic Causes

Secondary atrophic rhinitis is strongly associated with overzealous nasal surgeries, especially turbinate resections. Such procedures dramatically increase the risk by removing the structures responsible for humidifying and filtering inspired air 1 2 6.

Chronic Inflammatory and Infectious Diseases

Granulomatous diseases (leprosy, tuberculosis, syphilis, sarcoidosis) and chronic sinusitis can cause or contribute to secondary atrophic changes 4 8.

Treatment of Atrophic Rhinitis

Managing atrophic rhinitis is challenging due to its chronic nature and multifactorial causes. Treatment aims to relieve symptoms, control infection, and, where possible, restore nasal function.

Modality	Purpose	Examples / Notes	Source(s)
Conservative	Symptom relief, hygiene	Nasal irrigation, douches, lubrication	1 5 12
Antibiotics	Treat or reduce infection	Oral/topical aminoglycosides, rifampicin, address K. ozenae	13 14
Nutritional	Correct deficiencies	Iron, protein, vitamins	3 9
Vasodilators	Improve mucosal blood flow	Prostigmine, estrogenic substances	16
Surgical	Reduce cavity size, restore function	Young's operation, implant insertion, submucosal injections	1 10 12
Alternative	Complementary approaches	Traditional Chinese Medicine (e.g., Yiqi Qingre Ziyin)	15

Table 4: Treatment Approaches

Conservative Management

• Nasal Irrigation and Lubrication: Regular saline douches, oil-based drops (e.g., liquid paraffin, glucose-glycerine drops) help remove crusts and keep mucosa moist 1 5 12.
• Crust Removal: Gentle removal of crusts, sometimes under medical supervision, prevents secondary infection.
• Infection Control: Topical or systemic antibiotics (gentamicin, tobramycin, rifampicin) are used to reduce bacterial load. Topical therapy may be more effective and better tolerated 13 14.

Nutritional and Supportive Measures

• Address iron deficiency anemia and protein malnutrition with dietary supplements and supportive care 3 9.
• Improve general health and hygiene.

Vasodilators and Hormonal Therapy

• Agents like prostigmine and estrogenic preparations have been tried to enhance blood flow and improve mucosal health. These may induce hyperemia and tissue regeneration in some cases 16.

Surgical Interventions

• Young’s Operation: Surgical closure of the nostrils to promote mucosal healing; reserved for severe cases, with variable success 12.
• Implants/Prostheses: Insertion of materials (e.g., cartilage, bone, synthetic implants) to reduce the size of the nasal cavity and redirect airflow 1 10 12.
• Submucosal Injections: Agents like placentrex have been investigated for their regenerative effects, though evidence remains limited 13.

Alternative and Complementary Therapies

• Traditional Chinese Medicine: Herbal formulations such as the Yiqi Qingre Ziyin method are being studied for their immunomodulatory and neuropeptide-regulating effects 15.
• Other complementary approaches may be considered, especially in regions where conventional treatments are limited.

Evidence and Challenges

Despite the variety of available treatments, high-quality evidence from randomized controlled trials is lacking, and most regimens are based on clinical experience and observational studies. Long-term disease control remains a challenge, often requiring ongoing multimodal therapy 12 11.

Conclusion

Atrophic rhinitis is a multifaceted nasal disorder that demands careful, individualized management. While its symptoms can be severe and stigmatizing, a combination of conservative, medical, and sometimes surgical approaches can provide relief.

Key Takeaways:

• Atrophic rhinitis is defined by crusting, fetor, and mucosal atrophy, often with paradoxical nasal obstruction.
• Primary and secondary forms differ by underlying cause, with secondary cases frequently linked to surgery or chronic disease.
• Multiple factors contribute to disease development, including bacterial infection, genetics, nutritional status, hormonal and vascular influences, and prior nasal trauma.
• Treatment is primarily conservative, focusing on symptom management, infection control, and nutritional support, with surgery reserved for refractory cases.
• There remains a pressing need for high-quality research to determine the most effective long-term interventions.

With early recognition and a tailored therapeutic strategy, many patients can achieve improved quality of life despite the chronic nature of this challenging condition.