Chronic atrophic rhinitis

Chronic atrophic rhinitis is divided into primary (genuine), the etiology and pathogenesis of which are not entirely clear, and secondary, caused by the influence of external harmful factors of the industrial environment (chemical, dust, temperature, radiation, etc.) and unfavorable climatic conditions.

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Causes of chronic atrophic rhinitis

In the development of chronic atrophic rhinitis, a certain role is played by upper respiratory tract infections, nasal trauma, previous hyperplastic and catarrhal processes in the nasal cavity. If in secondary chronic atrophic rhinitis, developing under the influence of harmful industrial conditions, it is possible to trace all stages of this process - from catarrh of the nasal mucosa to dystrophy, characterized by its atrophy, then in primary chronic atrophic rhinitis, the causes of the disease remain largely unidentified. As for the pathogenesis, several of its "theories" are distinguished: infectious (chronic inflammatory processes of the rhinosinus system), alterational (effects of dry hot air, dust industrial particles, ionizing radiation, consequences of radical surgical interventions on endonasal structures, nasal trauma).

According to V.I. Voyachek (1953), B.S. Preobrazhensky (1966), G.Z. Piskunov (2002) and other domestic rhinologists, primary chronic atrophic rhinitis refers to local manifestations of a systemic dystrophic process, in which the atrophic process affects not only the mucous membrane of the upper respiratory tract, but also the internal organs. In connection with this position, B.S. Preobrazhensky considered it more correct to call chronic atrophic rhinitis rhinopathia chronica atrophica. V.I. Voyachek believed that the extreme manifestation of chronic atrophic rhinitis is ozena. Many authors (especially foreign ones) do not distinguish chronic atrophic rhinitis as an independent clinical form, but believe that hypotrophy of the nasal mucosa is only a symptom or consequence of more general diseases of the upper respiratory tract and the whole body, and associate this disease with metabolic disorders, chronic infections, ozena, damage to the vegetative link of the nasal mucosa, which arose as a result of viral, coccal and other infections. It is also impossible to exclude the factor of general constitutional (genetic) predisposition to dystrophies of the mucous membrane of the body, the trigger mechanism of which can be both external harmful factors and endogenous primary diseases, such as rhinoscleroma, syphilis, etc.

There is also an opinion that simple atrophic rhinitis in some cases and under certain conditions is the initial stage of ozena.

Pathological physiology and pathological anatomy of chronic atrophic rhinitis. Atrophy as a whole as a pathological process is characterized by a decrease in volume and size, as well as qualitative changes in cells, tissues and organs expressed to varying degrees, and usually develops during various diseases, differing in this from hypoplasia (hypogenesis), i.e. underdevelopment of tissue, organ, body part or the whole organism, which is based on a violation of embryogenesis (the extreme expression of hypoplasia is aplasia, or agenesis, the absence of an entire organ or body part). Chronic atrophic rhinitis refers to pathological atrophies that differ from physiological ones (for example, senile atrophy of the spinal cord, retina, olfactory nerve, etc.) by the presence of a contributing pathological process and certain qualitative features. Depending on the cause of occurrence, several forms of atrophy are distinguished: trophoneurotic, hormonal, metabolic, functional and from the impact of harmful external physical, chemical and mechanical factors. Probably, in the etiology and pathogenesis of chronic atrophic rhinitis, as well as in chronic atrophic processes in other ENT organs, most of the above processes and factors that cause them are involved to one degree or another.

Pathological changes in the nasal mucosa are manifested by a decrease in the volume and quantity of all its elements, including the glandular apparatus, vegetative and sensory nerve fibers, including the receptors of the olfactory organ. Cilia disappear, the cylindrical ciliated epithelium metaplasizes into flat epithelium, blood and lymphatic vessels become thinner and lose elasticity, and in advanced cases, the bone tissue of the rhinosinus system is also subject to atrophy.

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Symptoms of chronic atrophic rhinitis

The main symptoms are a feeling of dryness in the nose, the presence of viscous, difficult to blow out discharge, drying into yellowish-gray crusts, decreased sense of smell to its complete absence. During anterior rhinoscopy, the nasal mucosa appears pale, dry with easily vulnerable vessels shining through it; the nasal turbinates are reduced, the general and individual nasal passages are wide to such an extent that the back wall of the nasopharynx becomes visible. One of the varieties of chronic atrophic rhinitis is anterior dry rhinitis.

The clinical course of chronic atrophic rhinitis is long-term (years and decades), depending on the effectiveness of the complex treatment used.

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Treatment of chronic atrophic rhinitis

Patients suffering from chronic atrophic rhinitis usually consult an ENT specialist when the atrophic process has reached an advanced stage, often incurable, so in such cases the treatment is quite long and with minimal effect, bringing relief to the patient only for the period of using certain drugs. The effectiveness of the treatment increases if the cause of the atrophic (dystrophic) process is found and eliminated, for example, one or another occupational hazard, bad habits, a chronic source of infection, etc.).

Treatment is divided into general, local medication and surgical.

General treatment of chronic atrophic rhinitis

General treatment includes vitamin therapy, the use of general stimulating drugs (aloe extract in injections; aloe juice, aloe in tablets, aloe with iron, phytin, rutin, calcium glucaniate - per os, etc.). Also used are agents that improve microcirculation, and angioprotectors to improve the trophism of the nasal mucosa (xanthinol nicotinate, pentoxifylline, agapurin, etc.). A number of studies have shown that many patients suffering from dystrophic processes in the mucous membrane of the upper respiratory tract and gastrointestinal tract have a disorder of iron metabolism. When this fact is established, patients with atrophic rhinitis are prescribed iron preparations - aloe extract with iron, ferrum Lek, various iron salts (monocomponent and with vitamins). In some cases, if there are appropriate general therapeutic indications, agents that activate tissue metabolism are prescribed for systemic use (inosine, orotic acid, trimetazidine, cytochrome C, etc.). To improve microcirculation in the nasal mucosa, it is advisable to prescribe, along with the above-mentioned drugs, appropriate angioprotectors that improve the flow of nutrients and medications into the atrophic nasal mucosa (dipyridamole, calcium dobesilate, xanthinol nicotinate, pentoxifylline preparations). General treatment includes climatotherapy and balneotherapy, walks in coniferous forests, etc. General treatment with the above-mentioned agents must be carried out after a thorough laboratory examination and in agreement with the therapist and other specialists.

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Local treatment of chronic atrophic rhinitis

Against the background of general treatment, local treatment is carried out, which is aimed at activating metabolic processes in the nasal mucosa, regenerating it into cylindrical epithelium, goblet cells, glandular apparatus, capillaries, lymphatic vessels, interstitial tissue and neurofibrils of the VNS. However, achieving such a complex effect on the nasal mucosa is possible only with a careful selection of drugs for local application and installation (solutions, ointments, gels). For this purpose, in the last century, various forms of iodine, ichthyol, phenol, silver and even diachilon plaster were recommended. The basis of this dosage form is the finest lead oxide powder (10 parts), which is mixed with pork fat (10 parts), olive or sunflower oil (10 parts) and water (Gebra ointment). The drug was proposed by the founder of the Austrian dermatological school F. Gebra (1816-1880) for external treatment of a number of skin diseases as a protective and covering agent. Some of the above drugs have not lost their significance even now, but not all of them give a positive effect. Thus, iodine, silver, lead preparations, having a beneficial effect at the initial stages of treatment, with prolonged use aggravate the atrophic process in the nasal mucosa. More effective, not having an inhibitory effect on the nasal mucosa with prolonged use, are preparations of plant origin containing many vitamins and biologically active substances (sea buckthorn oil, rosehip oil, carotolin, thuja oil, eucalyptus, etc.). Solcoseryl ointment and gel forms containing a standard deproteinized extract from calf blood with high activity of the reticular endothelial system are promising for the treatment of atrophic rhinitis, especially in the presence of trophic ulcers in the nasal septum area. Solcoseryl contains factors that improve tissue metabolism and accelerate regeneration processes (solcoseryl gel, solcoseryl ointment).

A number of authors recommend using polymer-based ointments, such as sodium CMC, for the treatment of chronic atrophic rhinitis. Thus, S.Z. Piskunov and T.A. Pankrusheva suggest nasal ointments of the following composition:

1. riboflavin 0.1 g, glucose 0.3 g, sodium salt of CMC 2.9 g, distilled water 94 ml;
2. 1% sodium adenosine triphosphate solution 50 ml, sodium salt of CMC 3 g, distilled water 47 ml;
3. 1% solution of humisol 97 ml, sodium salt CMC 3 g.

According to the data of the indicated authors, complex treatment with these composite forms leads to an improvement in the condition of the mucous membrane, regeneration of its epithelium, and revitalization of the secretory function of the mucous glands.

Before using active drugs, it is necessary to clear the nasal cavity from dry crusts and viscous mucus. For this purpose, solutions and ointments of proteolytic enzymes are used to wash the nasal cavity and for application.

Surgical treatment of chronic atrophic rhinitis

Surgical treatment for simple chronic atrophic rhinitis is rarely used (narrowing of the common nasal passages, plastic surgery of the nasal septum defect, etc.).

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