Use of intranasal submucosal fillers as a transient implant to alter upper airway aerodynamics: implications for the assessment of empty nose syndrome.

BACKGROUND: Empty nose syndrome (ENS) is a debilitating condition associated with inferior turbinate tissue loss. Surgical augmentation of the inferior meatus has been proposed to treat ENS, although efficacy data with validated, disease-specific questionnaires is limited. Instead we evaluated submucosal injection of a transient, resorbable filler into the inferior meatus to favorably alter nasal aerodynamics in ENS patients. METHODS: Patients with a history of inferior turbinate reduction, diagnosed with ENS via Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) and cotton testing, were enrolled and underwent submucosal injection of carboxymethylcellulose/glycerin gel (Prolaryn®) into the inferior meatuses between July 2014 and May 2018. This material likely resorbs over several months. Outcomes included comparisons of preinjection and postinjection symptoms at 1 week, 1 month, and 3 months using the ENS6Q, 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-item scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). RESULTS: Fourteen patients underwent injections. Mean ENS6Q scores significantly decreased from baseline at 1 week (20.8 vs 10.5; p < 0.0001), and remained reduced but upward-trending at 1 month (13.7, p = 0.002) and 3 months (15.5, p > 0.05) following injections. Mean SNOT-22 scores significantly decreased at 1 week (p = 0.01) and 1 month (p = 0.04), mean GAD-7 at 1 month (p = 0.02) and 3 months (p = 0.02), and mean PHQ-9 at 1 week (p = 0.01) and 1 month (p = 0.004) postinjection. CONCLUSION: Transient, focal airway bulking via submucosal filler injection at sites of inferior turbinate tissue loss markedly benefits ENS patients, suggesting that aberrant nasal aerodynamics from inferior turbinate tissue loss contributes to (potentially reversible) ENS symptoms.

Successful management of primary atrophic rhinitis by turbinate reconstruction using autologous costal cartilage.

Initial management of primary atrophic rhinitis is conservative, with nasal ointments, saline irrigation, and antibiotics prescribed to relieve symptoms. However, in cases that show no improvement, a surgical approach is considered. Recently, many studies have reported successful surgical outcomes using various nasal implants. However, no study has reported implantation of autologous costal cartilage in PAR patients. We report here the case of a 63-year-old woman diagnosed with PAR that was intractable to medical therapy. Under general anesthesia, bilateral inferior turbinate reconstruction with autologous costal cartilage was successfully performed without any complications. One month after surgery, her symptoms improved dramatically. At the 2-year follow-up, her Sinonasal Outcome Test 25 (SNOT-25) score was 6, down from an initial score of 108. Her OMU CT showed improved sinonasal mucosal thickness and disappearance of thick mucosal secretion compared with preoperative CT image. Although this is a single case experience, it is suggested that turbinate reconstruction using autologous costal cartilage can serve as promising surgical modality for management of atrophic rhinitis.

Atrophic rhinitis: a CFD study of air conditioning in the nasal cavity.

Atrophic rhinitis is a chronic disease of the nasal mucosa. The disease is characterized by abnormally wide nasal cavities, and its main symptoms are dryness, crusting, atrophy, fetor, and a paradoxical sensation of nasal congestion. The etiology of the disease remains unknown. Here, we propose that excessive evaporation of the mucous layer is the basis for the relentless nature of this disease. Airflow and water and heat transport were simulated using computational fluid dynamics (CFD) techniques. The nasal geometry of an atrophic rhinitis patient was acquired from computed tomography scans before and after a procedure to narrow the nasal cavity. Simulations of air conditioning in the atrophic nose were compared with similar computations performed within the nasal geometries of four healthy humans. The excessively wide cavity of the patient generated abnormal flow patterns, which led to abnormal patterns of water fluxes across the wall. Geometrically, the atrophic nose had a much lower surface area than the healthy nasal passages, which increased water fluxes per unit area. Nevertheless, the simulations indicated that the atrophic nose did not condition inspired air as effectively as the healthy geometries. These simulations of water transport in the nasal cavity are consistent with the hypothesis that excessive evaporation of mucus plays a key role in the pathophysiology of atrophic rhinitis. We conclude that the main goals of a surgery to treat atrophic rhinitis should be 1) to restore the original surface area of the nose, 2) to restore the physiological airflow distribution, and 3) to create symmetric cavities.

Historia del manejo de rinitis atrófica / The history of the treatment of atrophic rhinitis

La rinitis atrófica es una enfermedad crónica progresiva caracterizada por dilatación anormal de las cavidades nasales con atrofia de la mucosa, submucosa y cornetes nasales subyacentes. Los factores etiopatogénicos aún son desconocidos. Su presentación clínica consiste en congestión nasal paradójica asociado a secreciones viscosas, con presencia de costras secas de mal olor. La higiene nasal con irrigación de alto volumen y baja presión es el estándar de tratamiento médico. El tratamiento quirúrgico busca reducir el tamaño de las cavidades nasales y promover la regeneración de la mucosa nasal así como también su vascularización y lubricación. A lo largo de la historia se han descrito múltiples procedimientos quirúrgicos que han buscado estrechar la cavidad nasal para permitir el paso de aire de forma más fisiológica. Por otra parte, se han propuesto intervenciones radicales como el cierre de las fosas nasales para disminuir los síntomas y mejorar la calidad de vida. En este artículo se resumen los principales manejos y procedimientos propuestos junto con sus resultados y conclusiones. Si bien la mayoría de las técnicas descritas ya no se utilizan en la actualidad, es importante conocerlas ya que aún existen pacientes que fueron sometidos a ellas pudiendo presentar complicaciones y/o efectos adversos.

Atrophic rhinitis is a chronic progressive disease characterized by abnormal dilatation of the nasal cavities with atrophy of the mucosa, nasal submucosa and underlying nasal turbinates. The etiopathogenic factors are still unknown. Its clinical presentation consists of paradoxical nasal congestion associated with viscous secretions, usually with the presence of dry, bad-smelling crusts. Nasal hygiene with high pressure irrigation remains the standard of medical treatment. Surgical treatment seeks to reduce the size of nasal cavities and promote regeneration of nasal mucosa as well as its vascularization and lubrication. Throughout history, multiple surgical procedures have been described that have sought the narrowing of the nasal cavity to allow the passage of air more physiologically. On the other hand, radical interventions have been proposed such as the closure of the nostrils to reduce symptoms and improve quality. This article summarizes the main proposed procedures along with their results and conclusions. Although most of the techniques described are no longer used today, it is important to know them since there are still patients who were subjected to them and may present complications and / or adverse effects.

Triosite implants and fibrin glue in the treatment of atrophic rhinitis: technique and results.

Nine patients with primary or secondary atrophic rhinitis were treated by narrowing of the nasal fossae using a new surgical technique (derived from the Eryes procedure) in which a Triosite and fibrin glue mixture is implanted via the labial vestibule route. The results were good or excellent in seven patients. No rejections occurred. Osseocoalescence, as evaluated by computed axial tomography at 6 months, was good. Inspiratory intrasnasal pain in patients with postsurgical atrophic rhinitis improved following the operation. The surgical technique, which is quick and easy to perform, avoids the discomfort of nostril closure or the implantation of grafts from other parts of the body. Complicated flap procedures are also avoided.

Osteoperiosteal flap in the treatment of ozena. New technique.

An osteoperiosteal flap taken from the anterior wall of the maxilla and pedicled on its periosteum was developed to narrow the nasal cavity of 15 patients with ozena. Good results were obtained in over 80% of cases. Crusting, fetor, and epistaxis disappeared. The nasal mucosa appeared healthy. The bulge in the lateral nasal wall persisted. The method is not liable to graft rejection or shrinkage. The advantages of this new technique are discussed.

Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis.

The aetiology of primary atrophic rhinitis is still unknown. Treatment of this disease is conservative in the first place. Surgery is indicated if the medical treatment fails. The aim of surgery is either to narrow the nasal cavity or in special cases to close the nostril. Closure of the nostril (Young's operation), is achieved by raising a circular skin flap. Raising the skin flap is difficult, the suture line may break down and an excessive scar tissue may form resulting in vestibular stenosis. We therefore developed a septal mucoperichondrial flap to close the nostril. This new and easy technique has been used to treat 17 patients with excellent results. The description of this technique and the results of surgery will be discussed.

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.

Vestibuloplasty (a new one-stage operation for atrophic rhinitis).

It is proposed that primary atrophic rhinitis belongs to a group of conditions under the heading 'Reflex Sympathetic Distrophy Syndrome'. This leads to decalcification of the turbinals, as in Sudeck's atrophy. Collapse of the decalcified turbinals is brought about by the impact of the inspiratory stream, and this is followed by atrophic changes. Based on this hypothesis, a new operation ('Vestibuloplasty') has been devised in order to direct the stream away from the turbinals and to dissipate the force of the stream so that its impact on the turbinals is minimized. Following this operation, 92 per cent of the cases have benefitted; this is comparable to the result following Young's or a modified Young's operation. After vestibuloplasty the patient can breathe through the nose and clean the nose as normal persons do; a second-stage procedure for reopening the nostril is not necessary and the chances of recurrence are negligible as compared to those following Young's operation.

Reopening of the closed nostril in atrophic rhinitis.

Closure of the nostril in atrophic rhinitis is a simple operation. Opening the obturated nose by excising the obturator membrane very often causes stenosis. A new and effective method for opening the nostrils, by means of flaps, is suggested.

Fibre-optic endoscopy in atrophic rhinitis.

Primary atrophic rhinitis seems to have a high prevalence in the arid regions bordering the great deserts of Saudi-Arabia. Fibre-optic endoscopy was performed on 42 patients treated surgically. Fibre-optic endoscopy demonstrated the presence of crusts in the nasal cavities and their subsequent reduction following surgery. It also demonstrated ulceration of the cartilaginous nasal septum in some cases and this may explain the pathogenesis of septal perforation noted in a high number of our patients. Fibre-optic nasendoscopy was also helpful in demonstrating the reappearance of free mucus in the nasal cavity and helped to determine the optimal time for reversing Young's procedure. Fibre-optic nasendoscopy is a reliable tool for verifying the results of surgery and comparing the efficacy of various treatment modalities.

Endoscopic dacryocystorhinostomy in cases of dacryocystitis due to atrophic rhinitis.

Atrophic rhinitis is a chronic inflammatory disease of the nose, which is more common in India. Chronic dacryocystitis is its rare complication. The authors found four cases of chronic dacryocystitis from March 2002 to October 2003 due to atrophic rhinitis. It was diagnosed clinically by the regurgitation test and lacrimal syringing. These cases were treated conservatively for a period of six weeks to make the nasal mucosa healthier and were then subjected to endoscopic dacryocystorhinostomy (end-DCR) under local anaesthesia. The procedure was found to be more difficult due to bleeding and the healing time was prolonged as compared to other cases of end-DCR. After one to one and half years of follow-up the primary success rate was 75 per cent but after revision surgery in one case, all cases were successful. Hence it was concluded that atrophic rhinitis is no more a contraindication for end-DCR. However, meticulous initial preparation and post-operative follow-up is necessary to improve the result.

Primary atrophic rhinitis: a scanning electron microscopic (SEM) study.

The surface features of atrophic rhinitis are shown and it is suggested that these explain the majority of symptoms. It seems clear that any lesion preventing the formation or maturation of large numbers of motile cilia, or the production of mucus capable of forming confluent sheets suitable for continuous propulsion, may cause atrophic rhinitis. In both familial and idiopathic forms of the disease, both abnormalities are present. It would be most interesting to know the ultrastructure of the cilia in transverse section of this condition. Transverse electron microscopic studies in Retinitis Pigmentosa, Usher's syndrome and Kartagener's syndrome now becoming known as the low cilia motility diseases show clearly the primary lesions in the micro-tubules and dynein arms of the cilia. A similar transmission electron microscopic study in atrophic rhinitis may show the fundamental cilial lesions. Surgical closure of the nasal passages has much to offer the patient with severe symptoms as the clinical features of the disease improve with the increasing normal micro-anatomical features demonstrated in this paper as a result of closure. This improvement in structure is not in all cases sufficient to fulfil the above criteria so a complete cure is improbable in the majority of cases.

Septoplasty in unilateral atrophic rhinitis with deviated nasal septum.

Eight cases of atrophic rhinitis with DNS towards the opposite side were treated by septoplasty with reversal of the DNS. All the cases showed satisfactory results.

[Cytological evaluation of nasal mucosal variability in surgically treated patients with ozena]. / Ocena cytologiczna zmiennosci nablonka nosa u chorych na ozene leczonych operacyjnie.

The cytologic examination of nasal mucosa before and after the operation of ozaena were described. Significant changing of cytological images was found. In preoperative examinations the squamous metaplasia was seen, the postoperative examinations the squamous metaplasia was seen, the postoperative findings were various. From the prognostic point of view most positive was the recovery of the cylindric epithelium. The worst in the prognosis was the persisting of squamous metaplasia in all postoperative smears.

[Instrument for cryogenic surgery of subatrophic and atrophic rhinitis and pharyngitis]. / Ustroistvo dlia kriovozdeistviia pri subatroficheskikh i atroficheskikh rinitakh i faringitakh

To treat cryogenically the nasal and pharyngeal mucosa an instrument has been devised in which the supply of cold carrier is regulated by changing pressure in the reservoir and by using interchageable needles of different diameter. The direction of the cold carried stream is changed depending upon the needle chamfer angle and the arrangement of holes in its wall. The procedure used in applying cryogenic action is simple and may be used in treating outpatients.

[Various aspects of endonasal corrective surgery]. / Nekotorye aspekty éndonazal'noi korrigiruiushchei khirurgii.

This paper discusses the results of 649 rhinoseptoplastic and 139 rhinoconchoplastic operations performed according to modified methods of Killian and Cottle. The surgical intervention led to the following complications: 1) deformation of the nasal septum in the vestibule area (11 patients); 2) perforation of the nasal septum of atrophic origin (15 patients); 3) saddle-like deformation of external nose (7 patients); 4) vibration of the nasal septum which occurred in most patients after total resection of the cartilage and vomer. The author elaborated methods of plastic operations of: the vestibule of the nose in order to prevent its postoperative deformation, the vomerine zone in order to preserve intraosseous vessels in the foramen incisivum area, the ridge of the nose in order to avoid the saddle-like nose, and implantation of the zigzag cartilage graft in order to prevent vibration of the nasal septum. Analysis of the rhinoconchoplastic operations allowed the author to propose medial positioning of the nasal concha in the case of hypotrophic rhinitis and implantation of autocartilage into the nasal concha in order to enlarge it in the case of hypotrophy.

Chronic rhinosinusitis in ex-lepromatous leprosy patients with atrophic rhinitis.

AIM: Rhino-sinus mucosal involvement is well documented in untreated lepromatous leprosy, but less understood in ex-leprosy patients (i.e. leprosy patients who have been treated and cured) with atrophic rhinitis. MATERIALS AND METHODS: Rhino-sinus abnormalities were investigated in 13 ex-lepromatous leprosy patients with atrophic rhinitis, using interviews enquiring about sinonasal symptoms, nasal endoscopy, nasal swab culture and computed tomography. Endoscopic sinus surgery had been performed in three patients. The clinical course, computed tomography findings and nasal biopsy results of these three patients were evaluated. RESULTS: All patients had turbinate atrophy and 6 of the 13 (46.2 per cent) had septal perforation. Paranasal sinus involvement was noted in 9 of 12 examined patients (75 per cent). The most commonly affected sinus was the maxillary sinus (in 8 of 12; 66.7 per cent). All three patients treated by endoscopic sinus surgery experienced relapse and required further surgery. Maxillary sinus irrigation was effective for reduction of persistent symptoms such as postnasal discharge and crusts. CONCLUSION: Ex-lepromatous leprosy patients with atrophic rhinitis had various rhino-sinus abnormalities and persistent symptoms. These patients had chronic rhinosinusitis because of underlying atrophic rhinitis. These patients required repeated otolaryngological observations together with combined surgery and conservative treatment.