General Medical Information

Atrophic Rhinitis

Shawn D. Newlands

Atrophic rhinitis, or rhinitis sicca, is characterized by atrophic mucosa on the septum, turbinates, or lateral nasal walls. Atrophic rhinitis can be associated with ozena (thick, foul-smelling, dry crust), although ozena is now more common in developing nations. Atrophic rhinitis is either primary or secondary. The symptoms are subjective nasal congestion and a constant foul-smelling odor despite lack of objective evidence of obstruction. Primary atrophic rhinitis occurs among elderly patients and is more prevalent in eastern Europe, Egypt, India, and China.

Atrophic rhinitis with ozena manifests as thick, adherent, green or yellow nasal crust that usually has a bad odor. Without ozena, this condition can be identified by dry, atrophied mucosa. Patients with atrophic rhinitis with or without ozena typically have some sinus disease that causes swelling of the ostial mucosa. Some patients with marked crusting describe nasal obstruction despite having a widely patent nasal cavity. This sensation of obstruction can be caused by decreased sensation of nasal airflow or an actual decrease in airflow due to higher levels of turbulent airflow within the nasal cavity. Intranasal crust may favor formation of turbulent airflow rather than the normal laminar airflow that occurs along the mucosal surface.

Although histologic findings are varied, mucosa with atrophic rhinitis usually is classified by the transformation of pseudostratified columnar epithelium into islands of keratinized squamous epithelium. This keratinized squamous epithelium can be sloughed off in large sheets from the mucosal surface as the characteristic nasal crust of ozena. Columnar and goblet cells are nearly absent from the mucosal epithelium, and glandular cells have a scarcity of secretory vesicles, possibly contributing to the absence of a protective mucous layer in this tissue. Inflammatory cells and mast cells usually infiltrate the mucosal lamina propria. Cytologic examination of nasal smears shows high numbers of neutrophils, bacteria, and metaplastic and squamous cells with few columnar and goblet cells. The patients have considerable nasal crusting, have atrophy of the nasal mucosa with squamous metaplasia, and may have atrophy of the bony turbinates, which enlarges the nasal airway. The disease often causes chronic sinusitis and headaches, confusing the diagnosis.

The abundance of cases of atrophic rhinitis with ozena in developing nations has led some physicians to suggest that iron or vitamin A deficiency, as well as poor hygiene, contributes to the pathogenesis of this condition. The primary form of the disease may be caused by infection with Klebsiella ozaenae. Bacterial strains (K. ozaenae and a toxic form of Corynebacterium diphtheriae) grow opportunistically in ozena nasal crust and may have roles in the pathogenesis of atrophic rhinitis. Ciliary beat studies have shown K. ozaenae to have ciliostatic properties that may facilitate establishment of bacterial colonies on healthy mucosa. An inherited disability in production of mucus can contribute to the establishment of ciliostatic bacteria and the development of atrophic rhinitis. The secondary form of the disease is caused by over-aggressive nasal surgery, chronic rhinosinusitis, granulomatous disease of the nasal cavity, or radiation by increasing the airflow and desiccation of the nasal mucosa.