Endoscopic views of choanal stenosis in secondary atrophic rhinitis.

Atrophic rhinitis is a chronic nasal disease characterized by mucosal atrophy, resorption of the underlying bone, the formation of thick crusts, and a distinctive fetid odor. This destructive process is usually associated with isolation of Klebsiella ozaenae in nasal cultures. (1-3) We describe two cases of atrophic rhinitis.

Patient 1 was a 25-year-old white woman who had sustained a nasal fracture 5 years earlier and a severe sinus infection approximately 6 months earlier. The infection had resulted in a saddle-nose deformity and septal perforation. She was treated with antibiotics at that time. She reported that since then, she bad experienced intranasal crusting, anosmia, and difficulty breathing through her nose. Nasal endoscopy confirmed the saddle-nose deformity and the subtotal perforation of the nasal septum, and it detected an almost complete obstruction of the nasal cavities by large fetid, yellowish and brownish crusts (figure, A). Following repeated endoscopic removal of crusts, daily nasal irrigations, and antibiotic therapy, nasal endoscopy revealed that her nasal passages had become more clear (figure, B). The large septal perforation and synechiae between the posterior septum and the posterior portion of the inferior turbinates became visible, as did the inferior meatus on both sides leading to the choanae. Her breathing improved, and she is being monitored every 3 months.

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Patient 2 was a 40-year-old white woman who had a history of intranasal cocaine use of many years' standing. She complained of difficult nasal breathing, nasal crusting, and recurrent sinus infections. Endoscopic nasal examination revealed an abnormally patent, empty nose anteriorly with a subtotal perforation of the nasal septum and atrophic inferior and middle turbinates (figure, C). However, when the telescope was further advanced posteriorly, it became obvious that the posterior ends of the nasal cavities were completely obstructed. There were no choanae or nasopharynx visible. These appeared to be obstructed with scarred tissues and dried crusts. After repeated endoscopic debridements and daily nasal moisturizing and irrigation over several weeks, she was able to resume breathing through her nose. Nasal endoscopy identified two distinct small openings in the inferior meatus leading to bilateral stenosed choanae (figure, D). Surgery to enlarge the choanae was recommended, but the patient declined because she was satisfied with the improvement in her airway. Small openings in the area of the anterior ethmoid were also noted. Her status was maintained during periodic check-ups.

Most authors classify atrophic rhinitis into two categories: primary and secondary. (1-3) The primary form is of spontaneous onset, slowly progressive, and occurs in a previously healthy nose. Secondary atrophic rhinitis results from chronic sinusitis, trauma, sinonasal surgery, granulomatous disease, radiation exposure, (1-3) and/or intranasal cocaine use. (4,5) Secondary atrophic rhinitis accounts for most cases encountered today. (1-3) Excessive turbinate surgery has been both implicated and acquitted in the literature as an etiology for secondary atrophic rhinitis. (1)

Diagnosis of atrophic rhinitis can usually be made on the basis of a thorough history and physical examination. Patients can manifest with nasal obstruction, crusting, epistaxis, anosmia, and/or headache. A strong permeating odor may dominate the clinical picture. Nasal endoscopy usually reveals the presence of thick, adherent crusts that are yellow-green to gray-brown on the turbinates. The use of an endoscope (4 mm, 0[degrees]) is critical for examining the posterior ends of the nasal cavities. Dried crusts may obstruct the small openings. Because there is a significant incidence of concurrent sinusitis, computed tomography (CT) is frequently included in the diagnostic evaluation. CT may reveal chronic sinusitis, resorption of the underlying soft tissue and bone, enlargement of the nasal cavities with atrophic turbinates, and a displacement or absence of the nasal septum.

Treatment is aimed at clearing secondary bacterial infections, reducing the amount of crusting, and alleviating the foul odor. Medical management usually suffices for most patients. The mainstay of treatment is continuous nasal hygiene, which can improve a patient's quality of life. Standard hygiene therapy entails vigorous and regular intranasal irrigations with a saline or sodium bicarbonate solution. In the event of purulent secretions or evidence of sinusitis, systemic antibiotic therapy is indicated and is guided by endoscopically obtained sinus cultures. In addition, periodic and regular debridement of the crusts may be helpful. Various surgical procedures, ranging from closure of the nostrils as suggested by Young (6) to endonasal microplasty, (2,7) have been employed.

In cases of difficult nasal breathing, the posterior end of the nasal cavity should be carefully examined. It may be completely obstructed. The choanae may be stenosed as a result of synechiae between the turbinates and the septum. In such an event, surgical correction of the stenosed choanae may improve the airway.

References

(1.) Moore EJ. Kern EB. Atrophic rhinitis: A review of 242 cases. Am J Rhinol 2001;15:355-61.

(2.) Goodman WS, De Souza FM. Atrophic rhinitis. Otolaryngol Clin North Am 1973;6:773-82.

(3.) Chand MS, MacArthur CJ. Primary atrophic rhinitis: A summary of four cases and review of the literature. Otolaryagol Head Neck Surg 1997;116:554-8.

(4.) Yanagisawa E, Latorre R. Endoscopic view of cocaine rhinitis. Ear Nose Throat J 1996;75:128-30.

(5.) Trimarchi M, Nicolai P, Lombardi D, et al. Sinonasal ostcocartilaginous necrosis in cocaine abusers: Experience in 25 patients. Am J Rhinol 2003;17:33-43.

(6.) Young A. Closure of the nostrils in atrophic rhinitis. J Laryngol Otol 1971;85:715-18.

(7.) Saunders WH. Atrophic rhinitis: Results of surgical treatment. Arch Otolaryngol 1958;68:342-5.

From the Section of Otolaryngology, Hospital of St. Raphael, New Haven, Conn., and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven (Dr. Yanagisawa), and the Section of Otolaryngology, Yale-New Haven Hospital and Yale University School of Medicine, New Haven (Dr. Yanagisawa and Dr. Scher).