Empty nose syndrome.

Empty nose syndrome (ENS) is a rare, late complication of turbinate surgery. The most common clinical symptoms are paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea. Little is known about the pathogenesis of ENS, though it is speculated that anatomical changes leading to alterations in local environment, disruption of mucosal cooling, and disruption of neurosensory mechanisms are strongly implicated. The diagnosis is clinical, though often difficult to make due to the poor correlation between subjective and objective findings. Medical therapies include mucosal humidification, irrigations, and emollients. Surgical therapy should be reserved for refractory cases and may involve turbinate reconstruction, most commonly using implantable biomaterials. Ultimately, prevention of this feared complication through turbinate-sparing techniques is essential.

Regeneration of toxigenic Pasteurella multocida induced severe turbinate atrophy in pigs detected by computed tomography.

BACKGROUND: Atrophic rhinitis is a widely prevalent infectious disease of swine caused by Bordetella bronchiseptica and Pasteurella multocida. The course of the disease is considered to be different depending on the principal aetiological agents distinguishing B. bronchiseptica induced non-progressive and toxigenic P. multocida produced progressive forms. In order to compare the pathological events of the two forms of the disease, the development of nasal lesions has longitudinally been studied in pigs infected by either B. bronchiseptica alone or B. bronchiseptica and toxigenic P. multocida together using computed tomography to visualise the nasal structures. RESULTS: B. bronchiseptica infection alone caused moderately severe nasal turbinate atrophy and these lesions completely regenerated by the time of slaughter. Unexpectedly, complete regeneration of the bony structures of the nasal cavity was also observed in pigs infected by B. bronchiseptica and toxigenic P. multocida together in spite of seeing severe turbinate atrophy in most of the infected animals around the age of six weeks. CONCLUSIONS: B. bronchiseptica mono-infection has been confirmed to cause only mild to moderate and transient lesions, at least in high health status pigs. Even severe turbinate atrophy induced by B. bronchiseptica and toxigenic P. multocida combined infection is able to be reorganised to their normal anatomical structure. Computed tomography has further been verified to be a useful tool to examine the pathological events of atrophic rhinitis in a longitudinal manner.

Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature.

Despite the fact that many people suffer from it, an unequivocal definition of dry nose (DN) is not available. Symptoms range from the purely subjective sensation of a rather dry nose to visible crusting of the (inner) nose (nasal mucosa), and a wide range of combinations are met with. Relevant diseases are termed rhinitis sicca anterior, primary and secondary rhinitis atrophicans, rhinitis atrophicans with foetor (ozena), and empty nose syndrome. The diagnosis is based mainly on the patient's history, inspection of the external and inner nose, endoscopy of the nasal cavity (and paranasal sinuses) and the nasopharynx, with CT, allergy testing and microbiological swabs being performed where indicated. Treatment consists in the elimination of predisposing factors, moistening, removal of crusts, avoidance of injurious factors, care of the mucosa, treatment of infections and where applicable, correction of an over-large air space. Since the uncritical resection of the nasal turbinates is a significant and frequent factor in the genesis of dry nose, secondary RA and ENS, the inferior and middle turbinate should not be resected without adequate justification, and the simultaneous removal of both should not be done other than for a malignant condition. In this paper, we review both the aetiology and clinical presentation of the conditions associated with the symptom dry nose, and its conservative and surgical management.

Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms.

In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.

Atrophic rhinitis in a patient with anhidrotic ectodermal dysplasia.

We would like to present the rare case of a now 37-year old female patient with autosomal-recessively inherited anhidrotic ectodermal dysplasia being treated in our ENT department for atrophic rhinitis. The clinical appearance very much resembled the picture of an "empty nose" with distinct hypoplasia of the turbinates and extensively wide nasal cavities. We want to point out the possible existence of atrophic rhinitis against the background of an underlying syndromatic disease in adults and also the pediatric patient.

The aetiology and management of atrophic rhinitis.

Atrophic rhinitis is a chronic, debilitating and recalcitrant disease of the nasal cavities that is prevalent in several parts of the world. It has unique epidemiological features and clinical characteristics. Clinicians and researchers for decades have tried to postulate theories for the aetiology of the primary form of the disease. Management of the disease has seen several medical therapeutic regimens including alternative forms of medicine. Surgical options for the condition are also not completely satisfactory with a number of failures and recurrences. The authors provide here a comprehensive review of the existing literature as regards the aetiology and management of this refractory condition.

A comparison of different challenge methods for induction of atrophic rhinitis in pigs.

Transmission and development of atrophic rhinitis (AR) was studied in 5- to 15-week-old pigs (Groups 2-7) originating from a herd free of AR, and compared to unexposed healthy pigs (Group 1), and pigs from a herd with endemic AR (Group 8). At the start of the trial, pigs in Groups 2-5 were challenged intranasally twice a week for 3 weeks with pure cultures of bacteria originating from the endemic AR herd: Nontoxigenic Pasteurella multocida type A (PmA) plus Bordetella bronchiseptica phase I (Bb) (Group 2); PmA + toxigenic Pm type D (PmD) (Group 3); PmD only (Group 4); and PmD + Bb (Group 5). Group 6 pigs were challenged with nasal wash of pigs from the endemic AR herd, and Group 7 pigs were challenged by being housed together in the same pen with Group 8 pigs throughout the study. Nasal swabs of all pigs were cultured 5 times during the study. Serum was collected at 6 weeks post challenge. Average daily gain (ADG) and turbinate lesions (turbinate gross lesions by visual scoring and by Turbinate Perimeter Ratio, TPR, scoring, and histopathological lesions) were measured at the time of slaughter at 15 weeks of age. Mean TPR value for the Group 1 pigs was 1.64, which was significantly (P less than 0.05) different from the mean TPR value of 0.58 for the pigs from the endemic AR herd (Group 8), the 0.79 value for Group 6 pigs, and 1.03 value for Group 7 pigs. Of pigs challenged with pure bacterial cultures, only Group 5 (PmD + Bb) developed significant AR (mean TPR = 1.24). Only one pig in each of Groups 2 and 3, and two pigs in Group 4 showed TPR values indicative of AR (TPR less than 1.30). However, histopathological examination showed that those pigs were recovering from the infection 7 weeks post challenge. Constant exposure to certain bacteria or other factors in nasal washings, stress of crowding or poor environmental conditions might be required to experimentally produce AR in 5-week and older pigs similar to that in naturally infected pigs. There was no relationship between turbinate lesions and the isolation frequency or quantity of PmA, PmD, or Bb. Antibody levels against PmA or PmD had moderate to high correlation with TPR values (r = -0.694 and -0.503 respectively). ELISA values also corresponded well with the type of bacteria inoculated in each group of pigs and appeared to be a sensitive test for PmA, PmD, and Bb infections in pigs.(ABSTRACT TRUNCATED AT 400 WORDS)

Extended follow-up of total inferior turbinate resection for relief of chronic nasal obstruction.

Total inferior turbinectomy has been proposed as a treatment for chronic nasal airway obstruction refractory to other, more conservative, methods of treatment. Traditionally, it has been criticized because of its adverse effects on nasophysiology. In this study, patients who had previously undergone total inferior turbinectomy were evaluated with the use of an extensive questionnaire. It confirms that total inferior turbinectomy carries significant morbidity and should be condemned.

Effect of Klebsiella ozaenae on ciliary activity in vitro: implications in the pathogenesis of atrophic rhinitis.

Klebsiella ozaenae is a gram-negative rod that has been isolated with relative frequency from patients with atrophic rhinitis. The relationship of this bacterium to the pathogenesis of atrophic rhinitis is not understood, and whether this bacterium is simply an opportunistic colonizer of the injured nose or the etiologic agent of the disease is unclear. This study was designed to investigate a potential role for bacterially produced cilioinhibition as a mechanism for the pathogenesis of atrophic rhinitis.

Incidence of nasolacrimal injury and turbinectomy--associated atrophic rhinitis with Le Fort I osteotomies.

Injury to the lacrimal system can occur with trauma, craniofacial surgery, rhinoplasty and nasal antrostomy. Nasolacrimal duct injury may potentially occur with Le Fort I superior repositioning. Atrophic rhinitis is also a potential complication secondary to turbinectomy required during Le Fort I superior repositioning. A review of thirty-four cases over three years of Le Fort I osteotomies with superior repositioning found no postoperative lacrimal injury and no subsequent atrophic rhinitis associated with turbinectomy. An anatomical study relating the position of the nasolacrimal duct opening within the inferior meatus and the distance available for maxillary impaction is reviewed.

The pathogenesis of atrophic rhinitis in pigs induced by toxigenic Pasteurella multocida.

The pathogenesis of atrophic rhinitis was studied in an experiment in which piglets were infected with a toxigenic type D Pasteurella multocida strain in the right half of the nasal cavity. Two days before inoculation the nasal mucosa on the right side had been subjected to mild irritation by intranasal instillation of a weak solution of acetic acid. The untreated (left) half of the nasal cavity served as an intrinsic control. Macroscopically, changes in the turbinates were already appreciable at 3 days p.i., and pronounced turbinate atrophy was noted at 7 days p.i. At 14 days p.i. deviation of the snout and almost complete turbinate atrophy was observed. The turbinates in the untreated half of the nasal cavity developed normally. Histologically, the changes were initially characterized by bone resorption mediated by an increased number of osteoclasts. Later osteoclasts were sparse, and there was an apparent disruption of osteoid synthesis. Ultrastructurally, the osteoblasts showed nuclear indentations and dilatation of the endoplasmic reticulum. Since no inflammatory reaction was observed, the hypothesis is advanced that atrophic rhinitis in pigs is caused by a P. multocida-produced factor which will stimulate bone resorption and suppress osteoid synthesis.

Ozena as presenting symptom of a rare and severe genetic disease: hypohidrotic ectodermal dysplasia.

Ozena is quite a common clinical finding in ENT practice in many countries, but even if the pathological picture is clear, its etiology is unknown. We report on two young females in which ozena was the presenting symptom of a rare and severe genetic disorder (hypohidrotic ectodermal dysplasia, HED). Etiopathogenetic theories on ozena and genetic problems of HED are discussed.

Serum haptoglobin concentration in growing swine after intranasal challenge with Bordetella bronchiseptica and toxigenic Pasteurella multocida type D.

The acute phase reaction, in association with progressive atrophic rhinitis (AR), was monitored for 3 wk using serum haptoglobin (HPT) quantification in thirty-six, 15 kg swine after intranasal challenge with varying doses of Pasteurella multocida type D (toxigenic strain) and Bordetella bronchiseptica. The challenge doses were administered alone or in combination with pigs divided into 9 isolated treatment groups. Increasing doses of B. bronchiseptica were associated with lower serum HPT (P < 0.05), whereas increasing doses of P. multocida tended to increase serum HPT (0.05 < P < 0.10). Significant and positive correlation of mean HPT and AR score was found in these pigs; increased AR scores were associated with elevated mean HPT concentration (r = 0.41, P < 0.01). A significant interaction between P. multocida and B. bronchiseptica dose indicated that increasing the dose of B. bronchiseptica, for a fixed P. multocida dose, was associated with less AR (P < 0.05). The AR scores were greater in pigs given P. multocida, than B. bronchiseptica alone. These results indicate that a complex interaction between Pasteurella multocida and Bordetella bronchiseptica causes progressive atrophic rhinitis and alters serum HPT concentration in swine.

Induction of nasal turbinate atrophy in germ-free pigs, using Pasteurella multocida as well as bacterium-free crude and purified dermonecrotic toxin of P multocida.

To establish the role of the dermonecrotic toxin (DNT) of Pasteurella multocida in the cause and pathogenesis of atrophic rhinitis, germ-free pigs were inoculated with several strains of P multocida, crude DNT, or purified DNT. In some experiments, the aforementioned inocula were combined with Bordetella bronchiseptica. All DNT-producing P multocida strains induced severe turbinate atrophy. Histologic examination of the remnants of the nasal turbinates revealed intact, but undulated, ciliated epithelium and numerous osteoclasts. Inflammation was minimal or absent. A DNT-producing B bronchiseptica strain induced only mild turbinate atrophy. The lesions were characterized histologically by loss of cilia and ciliated cells and by an infiltration of predominantly mononuclear cells. Bone formation seemed impaired. Turbinate lesions were most severe in pigs infected with a combination of B bronchiseptica and a DNT-producing P multocida strain. Intranasal administration of sterile DNT-containing culture filtrate of P multocida or purified DNT of P multocida did not result in turbinate atrophy. In contrast, turbinate atrophy developed when these preparations were injected IM or when intranasal administration of DNT was preceded by inoculation of B bronchiseptica.

Ciliary ultrastructure and nasal mucociliary clearance in chronic and allergic rhinitis.

The authors have studied nasal specimens collected by means of nasal brushing in eight patients affected by allergic rhinitis and in eight affected by chronic rhinitis, while in other four patients affected by allergic rhinitis a lower turbinate biopsy was performed. All twenty patients showed an increased mucociliary clearance time and a reduced velocity regardless to the pathology during a previously performed saccharin test. Different ultrastructural alterations have been observed, such as: both central and peripheral microtubules alterations; absence of dynein arms; absence of radial spokes; ciliary membrane alterations; "compound" cilia; disorientation of central tubules. These alterations have been observed variously associated in both allergic and chronic rhinitis patients groups. Basing on their data, the authors state that ciliary abnormalities cannot be considered specific of a particular pathology but they can coexist in different situations. They also think that the mucociliary clearance parameters determination represents the only method to evaluate, even if in an indirect fashion, the percentage of ciliary abnormalities, as no direct quantitative method has been described. Ciliary ultrastructural alterations can be of diagnostic value only if associated with mucociliary clearance time and velocity determination.

Porcine atrophic rhinitis: a model for studying nasal physiology and pathophysiology.

Porcine infectious atrophic rhinitis is a disease of swine which ought to be of considerable interest to rhinologists. We have reviewed some aspects of human atrophic rhinitis, and some aspects of etiology incidence, pathology and physiology of porcine infectious atrophic rhinitis. Swine with this nasal problem fail rather dramatically, to gain as much weight as unaffected animals. We have speculated on several reasons for this including altered nasal physiology and trigeminal reflexes and reduced olfaction. Photographs of infected pigs are included.

Application of endoscopic sinus surgery to primary atrophic rhinitis? A clinical trial.

The aetiology of primary atrophic rhinitis (AR) is still unclear. Based on the sinus infection theories, endoscopic sinus surgery (ESS) was applied to treat AR. ESS was performed on 14 patients following Stammberger's techniques along with middle turbinectomy. Patients were evaluated using clinical symptoms, radiological sinus images, saccharine time tests, bacterial cultures and mucosal ultrastructures, before and 2 years after ESS. Three patients had good recoveries, 6 had partial recoveries and another 5 had persistent disease. Good recovery patients showed clear nasal cavities and mucociliary transport system normalisation. Patients possess in meagre infectious signs or crusting extending to their nasopharynx had poor outcomes. Patients with evidence of obvious infections (cloudy sinus images, mucopus presence in the sinuses and positive culture for Klebsiella ozaenae) had good recoveries following ESS. Candidate selection is critical for the success of ESS treatment in AR. Although further clinical trials are required to prove this strategy.

Long-acting oxytetracycline for control of induced Pasteurella multocida rhinitis in swine.

A long-acting oxytetracycline formulation was evaluated for control of rhinitis induced experimentally in pigs with a capsular type A, toxin-negative, low-passage strain of Pasteurella multocida. The pigs were 6 to 7 weeks old and were naturally infected with Haemophilus parasuis. The H parasuis infection was thought to predispose to establishment of P multocida in the nasal cavity. A long-acting oxytetracycline formulation was given IM at the rate of 20 mg/kg, 4 times at 5-day intervals. Medication reduced (P less than 0.05) the severity of turbinate atrophy and the proportion of pigs with P multocida and H parasuis in their nasal cavities. Numbers of colonies of P multocida and H parasuis isolated were also less in medicated pigs.

Radiological and endoscopic study of the maxillary sinus in primary atrophic rhinitis.

The maxillary sinuses of 40 patients suffering from primary atrophic rhinitis (ozaena) were studied radiologically, antroscopically and histopathologically. Sixty per cent of the patients showed thick bony walls and a small cavity of the maxillary sinus on X-ray and on antroscopy. On the other hand, 25 per cent of the cases revealed signs of infection including mucopurulent secretion on antroscopy associated with corresponding histopathological changes. It is concluded that poor pneumatization of the antrum plays a more important role in the pathogenesis of ozaena than infection.

Leprosy of the upper respiratory tract. A clinical bacteriological, histopathological and histochemical study of twenty cases.

Twenty cases clinically diagnosed as leprosy were thoroughly examined for E.N.T. lesions. These lesions were subjected to bacteriological, histopathological and histochemical studies. The results have been tabulated and discussed with special stress on some findings which are of help in diagnosing the disease.