Chronic Atrophic Rhinitis

Chronic atrophic rhinitis is divided into primary (genuinic), the etiology and pathogenesis of which is not entirely clear, and secondary, due to exposure to external hazards of the working environment (chemical, dust, temperature, radiation, etc.) and adverse climatic conditions.

[1], [2], [3], [4]

Causes of Chronic Atrophic Rhinitis

In the occurrence of chronic atrophic rhinitis, a role is played by upper respiratory tract infections, nasal injuries, previous hyperplastic and catarrhal processes in the nasal cavity. If secondary chronic atrophic rhinitis develops under the influence of harmful working conditions, all stages of this process can be followed - from catarrh of the nasal mucosa to dystrophy characterized by its atrophy, then at primary chronic atrophic rhinitis the causes of the disease largely remain unidentified. As for pathogenesis, several of his “theories” are distinguished: infectious (chronic inflammatory processes of the rhinosinus system), alterative (effects of dry hot air, dust production particles, ionizing studies, consequences of radical surgical interventions on endonasal structures, injuries of the nose).

According to V.I. Voyachek (1953), B.S. Preobrazhensky (1966), G.Z. Piskunov (2002) and other Russian rhinologists, primary chronic atrophic rhinitis refers to local manifestations of the systemic dystrophic process, during which the atrophic process undergoes the mucous membrane is not only the upper respiratory tract, but also internal organs. In connection with this situation, B. Preobrazhensky considered it more correct to call chronic atrophic rhinitis rhinopathia chronica atrophica. VI Voyachek believed that the extreme manifestation of chronic atrophic rhinitis is ozena. Many authors (especially foreign ones) do not secrete chronic atrophic rhinitis into an independent clinical form, but consider that the malnutrition of the nasal mucosa is only a symptom or consequence of more common diseases of the upper respiratory tract and the whole body, and associate this disease with metabolic disorders, chronic infections, ozone, lesion of the vegetative link of the nasal mucosa, resulting from viral, coccal and other infections. The factor of general constitutional (genetic) susceptibility to mucosal dystrophies of the body organism cannot be excluded, the triggering mechanism of which can be either external harmful factors or 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 of cells, tissues and organs expressed in varying degrees, and usually develops during various diseases, differing from hypoplasia (hypogenesis), that is, underdevelopment of tissue, organ, part of the body or the whole organism, which is based on a violation of embryogenesis (the extreme expression of hypoplasia is aplasia, or agenesis, - the absence of a whole organ or part of the body). Chronic atrophic rhinitis refers to pathological atrophies that differ from physiological (for example, senile atrophy of the SpO, 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: trophuroeurotic, hormonal, metabolic, functional, and from the effects 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 these processes and factors causing them take part to some extent.

Pathological changes in the nasal mucosa are manifested by a decrease in the volume and quantities of all its elements, including the glandular apparatus, vegetative and sensory nerve fibers, including the receptors of the olfactory organ. The cilia disappear, the cylindrical ciliated epithelium metaplasia into the flat epithelium, the blood and lymphatic vessels become thinner and lose elasticity, and in far-gone cases of atrophy, the bones of the rhinosinus system are also exposed.

[5], [6], [7]

Symptoms of chronic atrophic rhinitis

The main symptoms are a feeling of dryness in the nose, the presence of viscous, hardly excreted discharge, dries into yellowish-gray crusts, a decrease in sense of smell until it is completely absent. At anterior rhinoscopy, the mucous membrane of the nose appears pale, dry, with easily visible vessels translucent through it; the nasal conchae are reduced, the common and separate nasal passages are wide to the extent that the posterior 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 (years and decades), depending on the effectiveness of the complex treatment used.

[8]

Treatment of chronic atrophic rhinitis

Patients suffering from chronic atrophic rhinitis usually turn to an ENT specialist when the atrophic process has reached a pronounced 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 use of certain drugs. The effectiveness of treatment is increased if the cause of the atrophic (dystrophic) process is found and eliminated, for example, this or that hazard, bad habits, chronic focus of infection, etc.).

Treatment is divided into general, local, medical and surgical.

General treatment of chronic atrophic rhinitis

General treatment includes vitamin therapy, the use of general stimulant drugs (aloe extract in injections; aloe juice, aloe tablets, iron aloe, phytin, rutin, calcium glucoiat - per os, etc.). Apply also microcirculation enhancing agents and angioprotectors to improve the trophism of the nasal mucosa (xanthinol nicotinate, pentoxifylline, agapurin, etc.). As a result of a number of studies, it was found that many patients suffering from dystrophic processes in the mucous membrane of the upper respiratory tract and gastrointestinal tract, have an imbalance of iron metabolism. When this fact is established, patients with atrophic rhinitis are prescribed iron supplements - aloe vera extract with iron, Lek ferrum, various iron salts (monocomponent and with vitamins). In some cases, if there are appropriate general therapeutic indications, agents that activate the metabolism in tissues are prescribed for systemic use (inosine, orotic acid, trimetazidine, cytochrome C, etc.). To improve the microcirculation in the nasal mucosa, it is advisable, along with the above-mentioned drugs, to prescribe appropriate angioprotectors, which improve the supply of nutrients and drugs to the atrophic nasal mucosa (dipyridamole, calcium dobesilate, xanthineol nicotinate, pentoxifylline preparations). The general treatment includes climatic and balneotherapy, walks in coniferous forest conditions, etc. General treatment with these means must be carried out after a thorough laboratory examination and in consultation with the therapist and other specialists.

[9], [10]

Topical 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 a cylindrical epithelium, goblet cells, glandular apparatus, capillaries, lymphatic vessels, interstitial tissue and neurofibrillus ANS. However, the achievement of such a complex effect on the nasal mucosa is possible only with careful selection of drugs for local application and installation use (solutions, ointments, gels). For this purpose, in the last century, various forms of iodine, ichthyol, phenol, silver, and even diachilone patches were recommended. The basis of this dosage form is the smallest powder of lead oxide (10 parts), which is kneaded on pork fat (10 parts), olive or sunflower oil (10 parts) and water (Gebra ointment). The drug is proposed by the founder of the Austrian School of Dermatology F. Gebra (1816-1880) for the external treatment of a number of skin diseases as a protective and protective means. Some of these drugs have not lost their significance in the present, but not all of them have a positive effect. Thus, the preparations of iodine, silver, lead, exerting a beneficial effect in the initial stages of treatment, with long-term use aggravate the atrophic process in the nasal mucosa. Herbal preparations containing many vitamins and biologically active substances (sea buckthorn oil, rosehip oil, carotoline, tui oil, eucalyptus, etc.) are more effective and do not have an inhibiting effect on the nasal mucosa with prolonged use. Promising for the treatment of atrophic rhinitis, especially in the presence of trophic ulcerations in the area of the nasal septum, ointment and gel forms of the drug solcoseryl containing the standard deproteinized extract from the blood of calves with a high activity of the reticuloendothelial system. Solcoseryl contains factors that contribute to the improvement of metabolism in tissues and the acceleration of regeneration processes (solcoseryl gel, solcoseryl ointment).

A number of authors recommend using polymer-based ointments, for example sodium CMC, for the treatment of chronic atrophic rhinitis. So, S.Z. Piskunov and T.P.Kakrusheva offer ointments for the nose of the following composition:

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

Comprehensive treatment with these composite forms, according to these authors, leads to improvement of the mucous membrane, regeneration of its epithelium, revitalization of the secretory function of the mucous glands.

Before using active preparations, it is necessary to clean the nasal cavity from dry crusts and viscous mucus. To do this, apply solutions and ointments of proteolytic enzymes for washing the nasal cavity and application effects.

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.).

[11], [12], [13]