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Abstract

Objective: Atrophic rhinitis (AR) is a rare clinical condition affecting the nasal mucosa. It is characterized by progressive nasal congestion and thick, bothersome nasal secretions. In this narrative review, pathogenesis, differences between the 2 types of AR, new management modalities, and the impact of management on lifestyle have been highlighted. Materials and Methods: An extensive literature search was conducted using PubMed, Web of Science, Google Scholar, and Saudi Digital Library databases. The articles were investigated to extract information on the pathogenesis, types, new treatment modalities, and the impact of management on lifestyle. Results: AR has primary and secondary types that affect different populations and have specific clinical presentations. Primary AR is common in women and countries with long, warm seasons. Secondary AR is the most common disease in the industrialized world. It is more common among adults who have systemic disease, have undergone extensive nasal surgery, and have experienced nasal trauma. Certain infections, autoimmune disorders, chronic sinusitis, hormonal imbalance, poor nutritional condition, and iron deficiency anemia have been suggested as etiological factors. Conservative treatment is safe, inexpensive, and effective. Hygiene, a well-balanced diet, smoking cessation, and early detection and treatment of nasal pathology can help prevent AR. Some interventions shown to improve quality of life was explained in detail. Conclusions: This paper reviewed published relevant literature on AR related to pathogenesis, types, new treatment modalities, and the impact of treatment on lifestyle, thus, providing a comprehensive view of the management and prevention of AR.

Keywords

atrophic rhinitis ozaena empty nose syndrome etiopathogenesis management quality of life

Introduction

Atrophic rhinitis (AR) is a chronic degenerative nasal disease characterized by a triad of symptoms and signs, including progressive atrophy of the nasal mucosa, the formation of the nasal crust, and a distinctive offensive odor.¹ AR is occasionally referred to as acute necrotizing rhinitis, rhinitis atrophicans, atrophic catarrh, coryza foetida, or rhinitis in a representative fetus (ozaena). AR is classified into primary and secondary types. Primary AR presents with spontaneous onset and progresses slowly with time. In contrast, the secondary type presents underlying causes such as nasal surgery, radiation therapy, and granulomatous disease.²

Previous articles have separately described the etiology, pathogenesis, and treatment of AR without much emphasis on the impact of AR on patient quality of life. Furthermore, recent advances in AR diagnostics and management strategies have not been reported comprehensively to help clinicians make the appropriate treatment decisions. Therefore, this article reviewed the pathogenesis, types, diagnostics, and new treatment modalities of AR and its impact on quality of life.

Materials and Methods

A comprehensive literature search was conducted using PubMed, Web of Science, Google Scholar, and Saudi Digital Library databases. The articles were examined to extract information on the pathogenesis, types, new treatment modalities of AR, and its impact on lifestyle.

Primary AR

Primary AR, also known as ozaena, is an age-old disease first described by Fraenkel in the late 19th century. The condition is characterized by a sclerotic change in the mucous membrane, abnormal patency of the nasal passages due to atrophic changes in the mucosa and underlying bones, and thick viscous secretions that emit a foul odor when dry.³ It affects all parts of the nasal cavity while rhinitis sicca affects only the anterior and caudal parts of the nasal cavity.⁴

Etiology of primary AR

Several theories have been proposed to explain the etiological factors that can contribute to the development of primary AR. These include heredity factors⁴, infections, and infectious agents,^5,6 developmental disorders,⁷ nutritional deficiencies,⁵ phospholipid deficiency,⁸ autonomic disorders,^5,9 endocrine imbalances,⁵ allergy, and immune disorders.^10,11

Clinical presentation of primary AR

Primary AR is characterized by a triad comprising widening of the nasal cavity, greenish crusts, and foul nasal odor (foeter). Progressive atrophic changes in the nasal cavity and turbinate can lead to paradoxical nasal obstruction.³ Paradoxical nasal obstruction describes a patient who perceives nasal congestion with a wide and patent and wide nasal cavity.⁵ Generally, AR tends to affect women more than men and presents with bilateral crusting and a foul smell due to superinfections.⁵ Atrophy in the olfactory epithelium of patients with AR can lead to the development of hyposmia or even anosmia.³

Diagnosis of primary AR

The diagnosis of primary AR is based on the appropriate symptoms and physical findings, along with consistent findings on computed tomography (CT) of the sinuses.¹² No specific investigation has been conducted on primary AR. Therefore, it was diagnosed to exclude other causes of secondary AR. There are many diagnostic tests to exclude secondary causes of AR, including a complete blood count to exclude anemia (low hemoglobin level) and infections (leukocytosis). A nasal swab should be taken for stains and culture if leukocytosis occurs. An elevated erythrocyte sedimentation rate is found in granulomatous infections, such as tuberculosis. Evaluating nutritional status by serum protein and plasma vitamin levels is necessary to exclude malnutrition.⁵ Evaluation of underlying systemic diseases, such as leprosy, sarcoidosis, granulomatosis with polyangiitis (GPA) (Wegener disease), GPA, or syphilis, should be considered if systemic symptoms, such as weight loss, shortness of breath, or chronic epistaxis, are present. In this case, laboratory evidence of a systemic disorder such as hematologic and renal abnormalities or an abnormal finding on chest radiography may also suggest an underlying inflammatory process.¹³ In addition, serological tests, such as venereal disease research laboratories test, can be performed to exclude syphilis in suspected patients. Radiological investigations such as chest radiographs and CT scans can also be used to exclude secondary causes of AR.

Histopathology

Normally, the nasal mucosa consists of 3 layers, beginning with the epithelium of the basal membrane, which separates it from the tunica propria or stroma. The nasal epithelial layer is formed by pseudostratified columnar epithelium, mainly of the ciliated type, with goblet cells attached by desmosomes. The stroma is divided into 3 sublayers starting superficially with a lymphoid layer, a glandular layer consisting of seromucinous glands, and a venous pseudo cavernous layer adherently attached to the periosteum and perichondrium.¹⁴ AR affects all layers of the nasal mucosa and has different levels of severity. Changes ranged from some abnormality in the pseudostratified columnar epithelium to metaplasia of the respiratory epithelium to stratified squamous epithelium with keratinization accompanied by a decrease in goblet cells.¹ The basement membrane, if present, usually appears thin. Stroma changes included normal-looking serous and mucinous glands with inflammatory cell infiltration in the lymphoid immediately under the epithelial layer. The periarteritis and endarteritis of terminal arterioles, inflammatory infiltration, and basement membrane thickening are all observed. However, Taylor and Young denied these changes.¹⁵

The nasal mucosa starts anteriorly with a squamous epithelium in the vestibule and gradually changes to a pseudostratified columnar epithelium with numerous ciliated cells posteriorly.¹⁶ Garcia et al suggested that the flow of water and airflow in the anterior portion were more significant than in the posterior part due to the ciliary effect on the posterior lining mucosa. Thus, in the case of AR, water flow and airflow increase in the nasal cavity’s rear part, leading to mucous evaporation. The drying effect of airflow is believed to cause the respiratory mucosa’s metaplasia to the squamous type.¹⁷ Also, Bourne found that the capillary endothelial layer of AR tissue had more than a normal cytoplasm and strongly reacted with alkaline phosphatase, explaining the underlying bone’s thinning.¹⁸

Vascular involvement has 2 classic categories that Taylor and Young have reported. AR Type 1 is the most typical type (50-80% of cases) with periarteritis, endarteritis obliterans, and the terminal arterioles having periarterial fibrosis as an outcome of prolonged infections with plasma cell and round cell infiltration. By logic, these patients will be relieved from the influence of vasodilating action of estrogen treatment. AR Type 2, a less common type (20-50% of entire cases), has capillary vasodilatation. The dilated capillaries have endothelial cells that have more cytoplasm than usual and show a definite alkaline phosphatase reaction telling running bone resorption, which is a characteristic feature of this illness. This variety is not manageable by estrogen therapy. Nevertheless, in a single study, eighty percent of cases were consistent with the Type 2 histopathological grouping with capillary vasodilatation.¹⁵ Similarly, Bunnag et al’s study showed that 80% of patients had Type 2 capillary involvement.¹⁹

Management

The primary goal of AR management is to decrease crust formation, increase nasal hydration, and attempt to solve atrophy by managing the underlying causes, starting from prevention to medical management and even surgical intervention, if needed.²⁰ For primary AR, various management modalities have been suggested in the literature, as described below.

Medical management

The mainstay of the management of AR is conservative medical management, locally or systemically, which includes:

Nasal douches

A solution made of 28.4 g of sodium bicarbonate, 28.4 g of sodium diborate, which acts as an antiseptic and buffers the bicarbonate in the solution, 56.7 g of sodium chloride to make the solution isotonic, and 280 mL of warm water. Irrigation for both nostrils was performed with a 10 to 20 cc syringe or any other nasal irrigation device 3 to 4 times daily. During irrigation, the patient was advised to say “k k k” to close the velopharyngeal sphincter, thereby preventing aspiration.⁵

Sumaily et al compared homemade saline solutions used for nasal irrigation and their effect on mucociliary clearance (MCC). They found that saline with iodized table salt improved MCC in healthy people, similar to saline without iodized salt, with a significant decrease in saccharine clearance time (SCT), which was more pronounced in iodized saline solution.²¹ They evaluated the effect of diluted baby shampoo saline irrigation (1% concentration) on MCC in healthy subjects and found an increase in SCT after using the irrigation compared to SCT before using.²²

Nasal drops

Glucose glycerin drops consisting of 25% glucose were found to inhibit bacterial growth by fermentation, which produced local lactic acidosis and prevented bacterial growth. Glycerin is a lubricant that increases mucosal moisturization by absorbing atmospheric water. It is recommended to use it after nasal douches.⁵ Liquid paraffin nose drops are effective lubricants, but they are not recommended due to the risk of inhalant lipoid pneumonia.^5,23 Estradiol in Arachis oil drops can be used based on histopathological findings, and it was found to be beneficial in Type 1 but not recommended in Type 2 AR, as it may lead to a worsening of the condition.⁵ Topical antibiotic solutions, such as 80 mg of gentamicin sulfate dissolved in 1 L of normal saline solution, should be reversed in patients with purulent discharge and target the causative organism, mainly Klebsiella.²⁴ In one study, patients who received streptomycin and vasodilator medication orally or subcutaneously had satisfactory results.²⁵

Systemic medications

It is usually necessary from time to time and should be directed according to the nasal culture of purulent discharge. Tetracycline, aminoglycosides, and, more recently, ciprofloxacin (250-500 mg twice daily for 4 weeks) have been successful.³ Supplements are recommended for iron, zinc, protein, and vitamin (A and D) supplements for malnutrition patients with mineral deficiencies.⁵ Bernat found satisfactory results from iron therapy in 50% of patients, as they noticed improvements subjectively.²⁶

Nasal submucosal injections

Many materials have been used for nasal submucosal injection to treat patients with AR. A study using autologous fat and platelet-rich plasma injected into the inferior and middle turbinate, septum, and nose floor showed a significant improvement in subjective and objective aspects, as indicated by a decrease in the SNOT 20 score and the nasal MCC time, respectively.²⁷ The placental extract contains vitamins, nucleotides, and amino acids and has anti-inflammatory and wound-healing effects. It also causes vascularization, and vasodilation causes a decrease in the space of the roomy nasal cavity. Jaswal et al found that patients treated with systemic rifampicin were superior to those treated with a nasal injection of placenta extract in a subjective, objective, and histopathological study.²⁸ Vitamin E is an anti-inflammatory and antioxidant that prevents membrane lipid destruction. Testa et al used a nasal spray of pure α-tocopherol acetate, 2 puffs in each nostril, 3 times a day for 6 months, and found an improvement in nasal symptoms and perception of nasal airflow but no increase in nasal resistance.²⁹ Mitomycin C has an antiproliferative effect, inhibiting fibroblast activity and preventing nasal mucosa fibrosis. In one study, mitomycin C was added to nasal douches (0.2 mg/mL in 200 mL of warm water) as an adjuvant to oral rifampicin and showed a significant subjective and objective improvement along with the control group, who received oral rifampicin with nasal douches without mitomycin, with the superiority of the study group over the control group in decreasing crustation and softening thickened mucoid discharge.²⁰

Vaccine

In swine, AR is mainly caused by Bordetella bronchiseptica and Pasteurella multocida. Vaccines consisting mainly of toxoids against these organisms showed control of the situation, which must be evaluated in managing AR in humans.³⁰

Surgical management

Surgical approaches have been used to manage AR. They aim to decrease the size of the nasal cavities to increase nasal resistance. Therefore, the drying effect of air turbulence decreases. Second, regeneration of the normal nasal mucosa is promoted by temporary partial or complete closure of the nostril; third, increasing lubrication of the dry nasal mucosa by increasing the activity of the nasal mucosal glands or bringing secretions from other places. Furthermore, it improves the vascularity of the nasal cavities mainly by blocking the sympathetic system.⁵

Decreasing the size of the nasal cavities

Many approaches have been used to decrease the nasal cavity, from Caldwell-Luc up to the endoscopic approach. Many materials have been used, including homologous autologous endings with synthetic materials.⁵ Shina et al implanted acrylic resin implants in 60 patients, with improvement in 80% of the patients. After 2 years of follow-up, 80% of the patients worsened due to implant extrusion, while the result was satisfactory for the remaining 20%. They also used a Dermo-fat implant, harvested from the anterior thigh and implanted on the nasal floor with a cure rate of 25% due to the risk of resorption.³¹ A graft is usually performed in empty nose syndrome (ENS) cases and implanted in the lateral nasal wall just below the inferior turbinate after the elevation of the mucoperiosteum starting at the level of the pyriform aperture. Park and Jang used it in a patient with primary AR with significant subjective and objective improvement.³²

Promoting regeneration of the normal nasal mucosa

Young operation: Young suggested complete closure of the unilateral nostrils or both to promote regeneration of healthy mucosa. His technique involved a circumferential incision at the mucocutaneous junction, and the skin was sutured together.³³ They believed that the closure of the nostril would stop air turbulence and increase CO₂ and pH, which would help in mucosal regeneration. In addition, they thought that closure would create negative pressure, which would promote revascularization. However, patients may develop scars and vestibular stenosis.⁴ Some modifications were applied to Young’s approach, targeting improving the results or preventing its disadvantages.

- Sinha modification: Instead of complete nostril closure, he did partial nostril closure with the same technique as the Young by leaving a small opening in the nostril. He achieved complete cure in cases with a 3 mm opening, while the percentage of cure dropped to 70% as the size increased to 5 mm.³¹

- Gadre modification: He suggested a modification that involves elevating the mucosal flap posterior to the incision rather than reflecting the nasal vestibular skin. The mucosal flap was then sutured together, forming the obliterating membrane.³⁴ The result was a three-layered membrane; the external epithelial layer continued with the skin externally, the internal epithelial layer continued with the mucous membrane internally, and fibrous tissue was found.³⁵ The advantage is the simplicity of raising the flap and aesthetic improvement because the obliterating membrane will not be evident.³⁵

- Ghosh’s vestibuloplasty: Ghosh hypothesized the etiopathogenesis of AR, namely that decalcification of the turbinate secondary to reflex sympathetic dystrophy, which makes them collapsible under the impact of the inspiratory stream, which hits them continuously, resulting in AR. His technique elevates the flap from the skin on the lateral wall from the ala 3 mm posterior to the nostril opening with its base to the vestibular lumen. Then fold it over itself with its base laterally and suture it together so the air stream hits it and is redirected to the septum. Thus, the lateral wall is kept without direct air turbulence. This technique will allow the lateral nasal wall to regenerate normal mucosa while the nasal cavity is opened and accessible for cleaning and the advantage of doing both nostrils at 1 stage.³⁶

- El Kholy modification: To prevent scar and vestibular stenosis, he modified by making a hemitransfixion incision in the contralateral nasal cavity, elevating the flap, and then making a cartilage incision to access the ipsilateral mucoperichondrial flap. Additionally, an incision was made at the posterior end of the elevated ipsilateral flap, which was then reflected and sutured with another flap raised on the lateral vestibular skin on the ipsilateral side.³⁷

Recanalization of the obturator membrane: Young admitted to having restenosis after recanalization and may need revision surgery for a satisfactory opening.³³ Gadre suggested a three-flap technique to prevent restenosis and applied a stent with a tube for 6 weeks with no documented restenosis.³⁵ Pavithran et al studied 3 types of stents after recanalization using 3 flap techniques: silicone suction tube tips, dental wax plates, and customized acrylic stents. The tips of the suction tube do not have restenosis, but superior blunting of the nasal valve, while the dental wax plate has a risk of restenosis and superior synechia. The custom acrylic stent had the best result, with no restenosis or blunting.³⁸

Increasing lubrication of the dry nasal mucosa

The described operations are technically challenging with no satisfactory results. Wittmaack’s operation was reimplanting the Stenson’s duct to the maxillary antrum. This technique will help moisturize the dry nasal cavity through parotid secretions.⁵ Sharan performed other operations using the Caldwell-Luc approach, in which the maxillary sinus mucosa was elevated from the sinus wall and then reflected through the antrum to the nasal cavity, filling the roomy nose and increasing secretion through the normal sinus mucosa.³⁹

Improving vascularity of the nasal cavities

Stellate ganglion injections: A local anesthetic agent (10–15 cc of 1% xylocaine) was injected into the stellate ganglion of the cervical sympathetic chain to block the sympathetic action that causes vasodilation. The effect of injection was confirmed by Horner syndrome and nasal mucosa congestion. The daily injection is recommended in unilateral cases, while in bilateral cases, injected separately on alternative days to avoid bilateral recurrent laryngeal nerve palsy.⁵ However, Sinha et al found that the effect is temporary, and patients relapse within 4 to 8 days.³¹ Cervical sympathectomies have the same concept as stellate ganglion injection but with permanent results.⁵

Secondary AR

The secondary type of AR is attributed to a known underlying cause. Causes can be traumatic or iatrogenic. This is called ENS. Other causes could be secondary to granulomatous diseases such as tuberculosis, leprosy, granulomatosis with polyangiitis, or sarcoidosis.⁵ This rare rhinologic disorder develops many years after sinonasal surgery. This was based on coronal CT showing a total or partial inferior and middle turbinectomy. Patients may have these conditions months to years after surgery.⁴⁰

ENS patients typically present with excessive nasal crusting, malodor emanating, and paradoxical nasal obstruction in the nasal cavity. Other associated symptoms include headache, facial pain, anosmia, mucosal dryness, dyspnea, sleep disturbances, epistaxis, and rarely mucopurulent rhinorrhea. ENS has an unusual symptom, aprosexia nasalis, where the patient becomes highly preoccupied with maintaining a breathing sensation, leading to a chronically reduced concentration. The sensation of not being airborne is not relieved by breathing in the mouth and mostly leads to a negative psychological impact in ENS patients, manifesting as depression, anxiety, anger, fatigue, frustration, and irritability.^2,41

ENS can be classified according to surgical intervention before presentation⁴⁰:

ENS due to inferior turbinectomy (most common)

ENS due to middle turbinectomy

ENS due to inferior and middle turbinectomy

ENS with remnant tissue of the turbinate

Pathophysiology of ENS

ENS is a poorly understood condition. Numerous studies have emphasized that the sensation of nasal obstruction is not correlated with anatomical nasal obstruction; therefore, these studies suggest that the perception of nasal patency is a neurosensory rather than an anatomical mechanism.⁴⁰ Consequently, in patients with ENS, when a large amount of inspired airstream has less contact with the surface area of the mucosal wall due to the lack of turbulence, this airflow pattern produces insufficient mucosal cooling, leading to a lesser perception of nasal patency.⁴⁰ In individuals with ENS, there were 3 consistent changes following inferior turbinate excision. The airflow patterns observed are laminar as opposed to turbulent. The velocity of the airflow vectors is increased rather than medium velocity. The compromised airflow to the inferior portion of the nasal cavity causes a shift in the airflow upward toward the middle meatus and nasopharynx region.⁴²

Another theory suggested that poor trigeminal nerve regeneration or damage after nasal surgeries may lead to poor input into the air-inspired perception pathway. Patients with ENS are strongly associated with conditions that affect mental health, such as depression and anxiety. This psychogenic effect affects nasal perception of airflow.⁴³ The study by Collins et al focused on the turbinate perimeter ratio in pigs. The findings suggest that this ratio could serve as a more reliable morphometric measure of AR. Additionally, the data collected from this ratio is suitable for quantitative analysis.⁴⁴

Clinical presentation of ENS

Patients with ENS usually present with paradoxical obstruction, indicating previous nasal surgery that led to a patent airway, while the patient complains of nasal obstruction. Other symptoms may include crusting, dryness, and even suffocation.⁴³ ENS differs from primary AR, which usually presents as Klebsiella ozaenae colonized in the nasal cavity with extensive crusting. Compared to other sinonasal conditions, such as chronic sinusitis and deviated nasal septum, patients with ENS have worse symptoms, according to 6-item ENS questionnaire (ENS6Q). This condition affects the individual’s cognitive ability and could lead to anxiety and depression.⁴³

Diagnosis of ENS

ENS was first introduced to describe patients with nasal obstruction and the absence of normal nasal tissue.⁴⁵ In contrast to primary AR, patients with ENS generally have an underlying cause of symptoms such as trauma, radiation therapy, and nasal surgery.² The diagnosis is based on the clinical symptoms of the patients and the clinical findings because several methods have been described to objectively assess nasal patency: anterior rhinomanometry, acoustic rhinometry, and peak nasal inspiratory flow, but they are not correlated with the severe symptoms of the patients.⁴⁰

CT scans of patients with ENS can reveal thickening of the mucosa in the septum and sinuses, enlargement of the sinuses of the nasal cavity, destruction of the lateral nasal wall, and partial or complete resection of the middle/inferior turbinate.² An ENS6Q containing 6 questions with a score of 0 to 5 is used to investigate common presenting symptoms of ENS. A score equal to 10.5 and more confirms the diagnosis of ENS.

Office-based cotton test: This is an office test to evaluate the effect of the placement of cotton moisturized with normal saline in the nose area with deficient tissue.⁴⁵ Cotton was left in place for 20 to 30 minutes, then a reassessment of patient symptoms was performed using EMS6Q to confirm diagnosis and results in the surgical management of those patients.⁴⁶

Histopathology of ENS

In the secondary type of AR, histopathology is based on the underlying causes. These include granulomatous sinonasal diseases such as sarcoidosis, tuberculosis, leprosy, and GPA. In the case of sarcoidosis, the histopathology shows noncaseating granulomata associated with progressive fibrosis due to a granulomatous response, and no vasculitis or cholesterol crystals can be detected.⁴⁷ In tuberculosis and leprosy, histopathology shows that caseating granulomas have submucosal fibrosis and decrease the number of submucosal glands. A biopsy study showed epithelioid cell granulomas associated with T lymphocytes and vasculitis in granulomatosis with polyangiitis.⁴⁸

In ENS, histopathological studies have shown decreased submucosal glands, submucosal fibrosis, and squamous metaplasia. At the same time, ciliated mucosa and goblet cells were preserved in the epithelial layers. In the same study, they found that 35% of patients with ENS had goblet cell metaplasia, indicating a change in ciliated cells to goblet cells rather than hyperplasia of the residual goblet cells due to the activation of epidermal growth factor receptors after surgical insult. Immunohistochemical staining revealed a decrease in transient receptor potential channel melastatin 8 “TRPM8” receptors in ENS patients, which ended with a sensation of nasal obstruction.⁴⁹

Management of ENS

Prevention of the disease is mandatory because the management options become restricted once the ENS manifests. Carefully examining the need for surgical turbinectomy and other strategies, such as medical management, in allergic patients to reduce tissue loss and allow fast restoration of nasal physiologic mechanisms is critical.^3,50

Other surgical approaches for the management of hypertrophied turbinate have been used to minimize the incidence of ENS, including electrical cauterization, laser surgery, submucosal turbinoplasty using microdebrider, partial turbinectomy, and submucosal resection using special techniques, including radiofrequency ablation or quantum molecular resonance (QMR) techniques.⁵¹ Maniaci et al found microdebrider-assisted turbinoplasty superior to the QMR technique in controlling the short and long-term obstructive symptoms, with QMR showing less postoperative complication.⁵² In another study, the QMR technique showed less postoperative complication than the coablation technique, which controls the obstructive symptoms more than the QMR technique.⁵³ ENS treatment can be classified into medical and surgical options. In some patients, a multidisciplinary approach may be needed that involves ear, nose, and throat surgeons, allergists, and psychiatrists to manage this challenging disease; surgical choices are usually attempted only after an adequate trial of medical management, counseling, and education has not been able to improve for a period of 6 to 12 months, taking into account the potential neurologic mechanisms of ENS development.⁵⁴

The medical treatment of ENS

Medical treatment includes hydration with saline or oil-based lubricants, mucosal moisturization, increased fluid intake, intermittent closure of the nostrils (to return humidity), and an aggressive regimen of nasal saline sprays.⁵⁴ For patients with psychological symptoms, cognitive behavioral therapy might help, and the careful use of newer-generation antidepressants might complement therapy.⁵⁵

Surgical management of ENS

Recently, surgical therapy for ENS has received excellent acceptance because evidence of beneficial outcomes in both nasal symptoms and the comorbid mental health sectors have been reported.^45,56. In a systematic review, Leong reported that corrective surgery improved ENS complaints, nasal symptoms, psychopathological conditions, and sleep function.⁵⁶

The general concept of surgical intervention is to restore nasal physiologic function.² Submucosal filler injections are ideal short-lived bulking agents to increase tissue deficit sites, and this procedure can be performed in the clinic. This measure provides time for total healing of the operated tissues, which may subside the patient’s initial complaints. Young’s approach to temporary nasal closure (either through fabricated plugs or tissue flaps) has been described as beneficial for AR disease.^37,57 This approach might also help patients with ENS due to the resemblance between AR and ENS.² Most surgical treatments for ENS involve reshaping nasal cavities to act as previously resected nasal tissue. These procedures are considered turbinate reconstruction procedures. Fortunately, reconstruction of the lower turbinate may be accomplished at the lateral nasal wall at the level of the inferior meatus. Several materials have been used for submucosal grafting:

temporary fillers,

autologous cartilage,

acellular dermal allografts, and

synthetic implants

Temporary Fillers

The submucosal filling of cross-linked hyaluronic acid has been described as a minimally invasive option in patients with ENS. In this description, the commercial product Juvéderm (Allergan, Dublin, Ireland) was used, but a variety of similar products are available; these alternatives are likely to offer similar usefulness.⁵⁸

Acellular Dermis Xenografts and Allografts

The submucosal implantation of acellular dermis allografts is well-described for the surgical management of ENS.² Human acellular dermal matrix (such as Alloderm, Allergan, Inc.) and porcine submucosal intestine submucosa are outlined to integrate into surrounding soft tissues over time.⁵⁹ To place these grafts, submucosal pockets are made under GA in the target location (typically the lateral wall of the inferior meatus). The graft material can then be tightly rolled and packed inside the pocket to narrow the overly patent nasal passage. Multiple sites along the lateral wall of the nasal cavity can be targeted for external graft placement. The locations of obvious tissue loss guide the implant site. In general, the data show the great efficacy of this procedure with lasting benefits.⁴² Some users have noted resorption and failure rates of 10 to 30% for matrix materials. Fragmentation of the intestinal submucosal membrane with loss of neo-turbinate projection has been reported, making this xenograft unfavorable for this application.^23,59

Autologous Cadaver Cartilage and the Donor

The ease of harvest, biocompatibility, and reduced material cost of autologous cartilage make this an attractive option for ENS surgery. The objectives of cartilage grafting are similar to those of allograft placement, and the cartilage placement techniques are analogous to allograft placement techniques. However, cartilage has the upper hand of a semirigid consistency and thus can be formed and sized to achieve the desired 3D shape. Autologous cartilage harvested from the nasal septum, ear, or rib can be carved and built to form a cylindrical shape before placing it in a submucosal pocket to simulate the lost turbinate tissue and narrow the nasal airway. Because many patients with ENS do not have adequate septal cartilage due to previous septoplasty procedures, costal or auricular cartilage may be required if the surgeon wants to use an autologous cartilage graft.^60,61 The characteristics of the included studies on primary and secondary AR are shown in (Tables 1 and 2). The histologic features of primary and secondary AR are presented in (Table 3).

Table 1.

Characteristics of the Included Studies on Primary AR.

Title	Authors/year	Study types	Main findings
Atrophic Rhinitis: A review of 242 cases	Moore and Kern (2001)³	Review	Use of different treatment modalities needed in controlling AR.
The etiology and management of atrophic rhinitis	Dutt and Kameswaran (2005)⁴	Review	Surgical treatment for this condition remains an option for those who fail medical management.
Exogenous lipoid pneumonia due to nasal application of petroleum jelly	Brown et al (1994)²³	Case report	Some reports are against using intranasal petroleum jelly due to the risk of pneumonia.
Ozena in immigrants of differing backgrounds	Yelenich-Huss et al (2016)²⁴	Case report	Patients with AR caused by Klebsiella pneumoniae improved after use of Streptomycin and vasodilator medication.
Ozaena and iron deficiency	Bernát (1968) ²⁶	Case report	Iron supplements could be helpful in patients with low iron levels.
Platelet-rich plasma in otolaryngology.	Stavrakas et al (2016)²⁷	Review	PRP was proposed as a new treatment modality for patients with AR.
Topical mitomycin C can help as an adjunct to alkaline nasal wash and rifampicin in primary atrophic rhinitis	Abdel-Naby Awad and Hasan (2019)²⁰	A prospective randomized controlled study	Mitomycin C dissolved in an alkaline nasal wash as an adjuvant to oral rifampicin can give a better result than rifampicin and alkaline nasal wash alone in patients with primary AR.
Closure of the nostrils in atrophic rhinitis	Young (1967)³³	Case series	Complete closure of the nose appears to reduce the ozcena in a limited number of cases of AR.
A nine years review of 273 cases of atrophic rhinitis and its management	Sinha et al (1977)³¹	Case series	Intranasal injection of placental extract can be used as the first line of treatment.
Modification in the technique of closure of the nostrils	Gadre (1973)³⁴	Case study	Several aesthetic advantages were identified using the modified nostril closure technique.
Reopening of the closed nostril in atrophic rhinitis	Gadre et al (1988)³⁵	Case study	Three flaps techniques were proposed as a new and practical approach for opening the nostrils.
Successful management of primary atrophic rhinitis by turbinate reconstruction using autologous costal cartilage	Park and Jang (2018)³²	Case study	Autologous costal cartilage could be a viable surgical approach for treating primary AR.
Vestibuloplasty (a new one-stage operation for atrophic rhinitis)	Ghosh (1987)³⁶	Case study	The rechanneling of the respiratory stream through the medial sections of the nasal fossae and decreasing the force of the stream successfully prevents and/or reverses the reflex sympathetic dystrophy. Complete closure of the nostrils is unnecessary.
Transplantation of the maxillary sinus mucosa in atrophic rhinitis	Sharan (1978)³⁹	Original research	The result of transplantation of maxillary mucosa into the nasal cavity showed improvement in some cases.
Role of α-tocopherol acetate on nasal respiratory functions: Mucociliary clearance and rhinomanometric evaluations in primary atrophic rhinitis	Testa et al (2021)²⁹	Retrospective observational study	After topical management: - A greater hydration of the nasal mucosa and a decrease of crusts and mucus accumulation was revealed in the endoscopic examination. - A rhinomanometric examination showed increased airflows after medical treatment, while nasal resistances did not differ significantly. - The NMC test showed improved clearance after treatment in all patients.
The effect of dilute baby shampoo on nasal mucociliary clearance in healthy subjects	Isaacs et al (2011)²²	A prospective, non-randomized study	The nasal irrigations with dilute baby shampoo increase MCTs in healthy subjects.
Novel treatment of atrophic rhinitis: Early results	Jaswal et al (2008)²⁸	Randomized controlled trial	Patients treated with oral rifampicin showed superior results compared to submucosal placentrex injections.

Abbreviation: AR, atrophic rhinitis; MCT, mucociliary clearance time; NMC, nasal mucociliary clearance.

Table 2.

Characteristics of the Included Studies on ENS.

Title	Authors/year	Study types	Main findings
Closure of the nasal vestibule in atrophic rhinitis—A new non-surgical technique	Lobo et al (1998)⁵⁷	Case report	The nasal obturator is an easy and cheap method for treating and preventing secondary AR, particularly in patients with sinonasal neoplasms.
Hyaluronic acid gel in the treatment of empty nose syndrome	Modrzyński (2011)⁵⁷	Clinical trial	HA is easy, safe, and worth considering in less severe forms of ENS.
Clinical analysis of submucosal Medpor® implantation for empty nose syndrome	Yuan-YunTam et al (2014)⁶²	Retrospective clinical analysis	The sites of submucosal implantation are mainly the nasal floor and septum, bilaterally or unilaterally. There is a significant improvement of SNOT-22 preoperatively to 1 year postoperatively.
Treating empty nose syndrome as a somatic symptom disorder	Lemogne et al (2015)⁵⁵	Case report	ENS management using CBT as a somatic symptom disorder might constitute a first-line, safe alternative to surgical management.
Inferior meatus augmentation procedure (IMAP) to treat empty nose syndrome: A pilot study	Thamboo (2020)⁵⁶	A pilot study	IM augmentation through submucosal implantation of biomaterials generates dramatic improvement in the quality of life for patients with ENS.
Empty nose syndrome	Coste et al (2012)⁵¹	Observational study	Prevention of ENS: Conservative nasal surgery is fundamental in minimizing the risk of ENS. - The recommended techniques for turbinate-reducing surgery are laser surgery and electrical cauterization, partial turbinectomy, and submucosal turbinoplasty. Surgical treatment for ENS: The objectives of surgery are: to reduce nasal cavity volume, increase resistance to airflow, reduce airflow, increase air humidity, and deviate airflow from the surgical site toward a healthy or non-operated area. - Endonasal microplasty Use submucosal implantation of a turbinal or septal cartilage graft to restore inferior turbinate volume. - Exogenic materials (hydroxyapatite, goretex, teflon, plastipore) have also given satisfactory results in the small series. - Hyaluronic acid gel, an injectable composite, also improved symptoms without increasing complications. Medical treatment: - Medical treatment is less effective in ENS than in AR. - It can associate nasal lavage, nasal hydration ointment, directed antibiotic therapy, aerosols, and local corticosteroids - Adding menthol to the classical local treatments may provide benefits in terms of the nasal obstruction sensation.

Abbreviations: AR, atrophic rhinitis; CBT, cognitive behavior therapy; ENS, empty nose syndrome; HA, hyaluronic acid; IM, inferior meatus; SNOT, Sino Nasal Outcome Test.

Table 3.

Histological Features of PAR and SAR.

Article	Author	Type of study	Summary of study
Primary AR
Histopathological and histochemical studies on atrophic rhinitis	Taylor and Young (1961)¹⁵	Case series	Study denied the occurrence of periarteritis and endarteritis of terminal arterioles, inflammatory infiltration, and basement membrane thickening.
Radiological and endoscopic study of the maxillary sinus in primary atrophic rhinitis	Hagrass et al (1992)⁷	- Radiological and endoscopic study of cases of primary AR	Most of the patients had different stages of squamous metaplasia. Almost 40% showed tunica propria infiltration with lymphocytes
Atrophic rhinitis: A review of 242 cases	Moore and Kern (2001)³	- Case review - Case series	Squamous metaplasia of the nasal mucosa. Generalized atrophy of the serous and mucus glands. Loss of Cilia. Diffuse endarteritis obliterans.
The biochemistry and physiology of bone. Edited by Geoffrey H. Bourne	Cohen (1956)¹⁸	Textbook	Capillary endothelial layer had more than a normal cytoplasm and strongly reacted with alkaline phosphatase, which explains the thinning of the underlying bone
Secondary AR
Non-infectious inflammatory lesions of the sinonasal tract	Helliwell (2016)⁴⁷	Review	In sarcoidosis non-caseating granulomata associated with progressive fibrosis. No vasculitis or cholesterol crystals can be detected. In granulomatosis with polyangiitis epithelioid cell granulomas, T lymphocytes infiltrate and vasculitis was observed.
Chronic rhinosinusitis in ex-lepromatous leprosy patients with atrophic rhinitis	Suzuki et al (2013)⁴⁸	Clinical experiment	In tuberculosis and leprosy: caseating granulomas. Submucosal fibrosis and decrease in the number of submucosal glands is observed
Distinct histopathology characteristics in empty nose syndrome	Wu et al (2021)⁴⁹	A prospective case control study	There is decreased submucosal glands, submucosal fibrosis, and squamous metaplasia. A decrease in transient receptor potential channel melastatin 8 “TRPM8” receptors in patient

Abbreviation: AR, atrophic rhinitis; PAR, primary atrophic rhinitis; SAR, secondary atrophic rhinitis.

Synthetic Implants

The use of synthetic implants has been studied in ENS reconstructive surgery. These implant types include silicone perforated sheeting or porous polyethylene (MedPor, Stryker Corporation, Kalamazoo, MI, USA).⁶² These materials do not react and are designed to allow tissue growth to penetrate the material and improve long-term integration. Synthetic implants are generally inexpensive and easy to obtain in most practices. Since synthetic implants are foreign bodies by nature, infection, and extrusion are possible complications. After tissue ingrowth, implant removal due to scarring is challenging if such extraction is warranted.

Conclusions

The prevalence of AR varies between different populations with different etiology and clinical manifestations. The availability of a wide range of diagnostic procedures and newer treatment modalities could improve the quality of life of AR patients. This narrative review has comprehensively outlined the various aspects of RA, including the impact of newer treatment modalities on patient quality of life.

Footnotes

Author Contributions

I. A. Sumaily was involved in concept and supervision. N. A. Hakami was involved in concept. A. A. Alserhani was involved in design and literature review. A. D. Almutairi was involved in design and literature review. M. M. Abualgasem was involved in data collection and/or processing and literature review. E. A. Abulqusim was involved in data collection and/or processing, analysis and/or interpretation, and literature review. A. A. Alsudays was involved in data collection and/or processing, analysis and/or interpretation, literature review, and writing. A. A. Alghulikah was involved in writing.

Data Availability Statement

Data are available upon request to the corresponding author.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval and Consent to Participate

Ethical approval was waived from the institutional review board.

References

el-Barbary

el-S, Yassin

Fouad

el-Shennawy

. Histopathological and histochemical studies on atrophic rhinitis. J Laryngol Otol. 1970;84(11):1103-1112. doi:10.1017/s0022215100156506

Chhabra

Houser

. The diagnosis and management of empty nose syndrome. Otolaryngol Clin North Am. 2009;42(2):311-330, ix. doi:10.1016/j.otc.2009.02.001

Moore

Kern

. Atrophic rhinitis: a review of 242 cases. Am J Rhinol. 2001;15(6):355-361.

Hildenbrand

Weber

Brehmer

. Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature. Eur Arch Oto-Rhino-Laryngol Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol – Head Neck Surg. 2011;268(1):17-26. doi:10.1007/s00405-010-1391-z

Dutt

Kameswaran

. The aetiology and management of atrophic rhinitis. J Laryngol Otol. 2005;119(11):843-852. doi:10.1258/002221505774783377

Bist

Bisht

Purohit

. Primary atrophic rhinitis: a clinical profile, microbiological and radiological study. ISRN Otolaryngol. 2012;2012:404075. doi:10.5402/2012/404075

Hagrass

Gamea

el-Sherief

el-Guindy

el-Tatawi

. Radiological and endoscopic study of the maxillary sinus in primary atrophic rhinitis. J Laryngol Otol. 1992;106(8):702-703. doi:10.1017/s0022215100120626

Sayed

Abou-Elhamd

Abdel-Kader

Saleem

. Study of surfactant level in cases of primary atrophic rhinitis. J Laryngol Otol. 2000;114(4):254-259. doi:10.1258/0022215001905508

Raman

. Vasomotor rhinitis–atrophic rhinitis: two ends of an autonomic spectrum. Singapore Med J. 1989;30(1):94-96.

10.

Fouad

Afifi

Fatt-Hi

El-Sheemy

Iskander

Abou Saif

. Altered cell mediated immunity in atrophic rhinitis. J Laryngol Otol. 1980;94(5):507-514. doi:10.1017/s0022215100089180

11.

Medina

Benazzo

Bertino

, et al. Clinical, genetic and immunologic analysis of a family affected by ozena. Eur Arch Oto-Rhino-Laryngol Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol – Head Neck Surg. 2003;260(7):390-394. doi:10.1007/s00405-002-0571-x

12.

deShazo

Olivier

Stringer

Daley

Stodard

. Diagnostic criteria for atrophic rhinosinusitis. Am J Med. 2009;122(8):747-753. doi:10.1016/j.amjmed.2008.12.025

13.

deShazo

Stringer

Feldweg

. Atrophic rhinosinusitis: upto date. In: Atrophic Rhinosinusitis. 2023. Accessed May 17, 2023. https://medilib.ir/uptodate/show/7531

14.

Gelardi

Cassano

. The role of nasal cytology in the diagnosis of atrophic rhinitis. In: Di Girolamo

, ed. Atrophic Rhinitis. Springer; 2020:67-76. doi:10.1007/978-3-030-51705-2_6

15.

Taylor

Young

. Histopathological and histochemical studies on atrophic rhinitis. J Laryngol Otol. 1961;75:574-590. doi:10.1017/s0022215100058138

16.

Mygind

Pedersen

Nielsen

. Morphology of the Upper Airway Epithelium. The Nose: Upper Airway Physiology and the Atmospheric Environment. Elsevier Biomedical Press;1982.

17.

Garcia

GJM

Bailie

Martins

Kimbell

. Atrophic rhinitis: a CFD study of air conditioning in the nasal cavity. J Appl Physiol Bethesda Md 1985. 2007;103(3):1082-1092. doi:10.1152/japplphysiol.01118.2006

18.

Cohen

. Primary constituents of bony tissue. In: Bourne

, ed. The Biochemistry and Physiology of Bone. Academic Press, Inc.; 1956:5-12.

19.

Bunnag

Jareoncharsri

Tansuriyawong

Bhothisuwan

Chantarakul

. Characteristics of atrophic rhinitis in Thai patients at the Siriraj Hospital. Rhinology. 1999;37(3):125-130.

20.

Abdel-Naby Awad

Hasan

. Topical Mitomycin-C can help as an adjunct to alkaline nasal wash and rifampicin in primary atrophic rhinitis. Am J Otolaryngol. 2019;40(2):137-142. doi:10.1016/j.amjoto.2019.01.007

21.

Sumaily

Alarifi

Alsuwaidan

Alsiwat

Alsaleh

. Impact of nasal irrigation with iodized table salt solution on mucociliary clearance: proof-of-concept randomized control trial. Am J Rhinol Allergy. 2020;34(2):276-279. doi:10.1177/1945892419892172

22.

Isaacs

Fakhri

Luong

Whited

Citardi

. The effect of dilute baby shampoo on nasal mucociliary clearance in healthy subjects. Am J Rhinol Allergy. 2011;25(1):e27-29. doi:10.2500/ajra.2011.25.3583

23.

Brown

Slocum

Putthoff

Wallace

Foresman

. Exogenous lipoid pneumonia due to nasal application of petroleum jelly. Chest. 1994;105(3):968-969.

24.

Yelenich-Huss

Boyer

Alpern

Stauffer

Schmidt

. Ozena in immigrants of differing backgrounds. Am J Trop Med Hyg. 2016;95(1):35-37. doi:10.4269/ajtmh.15-0885

25.

Sternstein

. The use of antibiotics and vasodilators in atrophic rhinitis (ozena); preliminary report. N Engl J Med. 1951;245(5):165-171. doi:10.1056/NEJM195108022450502

26.

Bernát

. Ozaena and iron deficiency. Br Med J. 1968;3(5613):315. doi:10.1136/bmj.3.5613.315

27.

Stavrakas

Karkos

Markou

Grigoriadis

. Platelet-rich plasma in otolaryngology. J Laryngol Otol. 2016;130(12):1098-1102. doi:10.1017/S0022215116009403

28.

Jaswal

Jana

Sikder

Nandi

Sadhukhan

Das

. Novel treatment of atrophic rhinitis: early results. Eur Arch Oto-Rhino-Laryngol Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol – Head Neck Surg. 2008;265(10):1211-1217. doi:10.1007/s00405-008-0629-5

29.

Testa

Marcuccio

Lombardo

Cocuzza

Guerra

Motta

. Role of α-tocopherol acetate on nasal respiratory functions: mucociliary clearance and rhinomanometric evaluations in primary atrophic rhinitis. Ear Nose Throat J. 2021;100(6):NP290-NP295. doi:10.1177/0145561319870483

30.

Haesebrouck

Pasmans

Chiers

Maes

Ducatelle

Decostere

. Efficacy of vaccines against bacterial diseases in swine: what can we expect? Vet Microbiol. 2004;100(3-4):255-268.

31.

Sinha

Sardana

Rajvanshi

. A nine years’ review of 273 cases of atrophic rhinitis and its management. J Laryngol Otol. 1977;91(7):591-600. doi:10.1017/s0022215100084097

32.

Park

Jang

. Successful management of primary atrophic rhinitis by turbinate reconstruction using autologous costal cartilage. Auris Nasus Larynx. 2018;45(3):613-616. doi:10.1016/j.anl.2017.06.003

33.

Young

. Closure of the nostrils in atrophic rhinitis. J Laryngol Otol. 1967;81(5):515-524. doi:10.1017/s0022215100067426

34.

Gadre

. Modification in the technique of closure of the nostrils. J Laryngol Otol. 1973;87(9):903-904. doi:10.1017/s0022215100077793

35.

Gadre

Savant

Gadre

Bhargava

Juvekar

. Reopening of the closed nostril in atrophic rhinitis. J Laryngol Otol. 1988;102(5):411-413. doi:10.1017/s0022215100105225

36.

Ghosh

. Vestibuloplasty (a new one-stage operation for atrophic rhinitis). J Laryngol Otol. 1987;101(9):905-909.

37.

el Kholy

Habib

Abdel-Monem

Abu Safia

. Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis. Rhinology. 1998;36(4):202-203.

38.

Pavithran

Pujary

Mahesh

Parul

Aziz

. Customised acrylic nasal stents following recanalisation of modified Young’s procedure. J Laryngol Otol. 2010;124(8):864-867. doi:10.1017/S0022215110000642

39.

Sharan

. Transplantation of the maxillary sinus mucosa in atrophic rhinitis. Indian J Otolaryngol. 1978;30(1):14-16.

40.

Sozansky

Houser

. Pathophysiology of empty nose syndrome. The Laryngoscope. 2015;125(1):70-74. doi:10.1002/lary.24813

41.

Houser

. Surgical treatment for empty nose syndrome. Arch Otolaryngol Head Neck Surg. 2007;133(9):858-863. doi:10.1001/archotol.133.9.858

42.

Talmadge

Nayak

Yao

Citardi

. Management of postsurgical empty nose syndrome. Facial Plast Surg Clin N Am. 2019;27(4):465-475. doi:10.1016/j.fsc.2019.07.005

43.

Kanjanawasee

Campbell

Rimmer

, et al. Empty nose syndrome pathophysiology: a systematic review. Otolaryngol–Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2022;167(3):434-451. doi:10.1177/01945998211052919

44.

Collins

Bäckström

Brim

. Turbinate perimeter ratio as an indicator of conchal atrophy for diagnosis of atrophic rhinitis in pigs. Am J Vet Res. 1989;50(3):421-424.

45.

Leong

. The clinical efficacy of surgical interventions for empty nose syndrome: a systematic review. The Laryngoscope. 2015;125(7):1557-1562. doi:10.1002/lary.25170

46.

Gill

Said

Tollefson

Steele

. Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies. Curr Opin Otolaryngol Head Neck Surg. 2019;27(4):237-242. doi:10.1097/MOO.0000000000000544

47.

Helliwell

. Non-infectious inflammatory lesions of the sinonasal tract. Head Neck Pathol. 2016;10(1):32-39. doi:10.1007/s12105-016-0689-6

48.

Suzuki

Oshima

Watanabe

Suzuki

Kobayashi

Hashimoto

. Chronic rhinosinusitis in ex-lepromatous leprosy patients with atrophic rhinitis. J Laryngol Otol. 2013;127(3):265-270. doi:10.1017/S0022215113000030

49.

Lee

. Distinct histopathology characteristics in empty nose syndrome. Laryngoscope. 2021;131(1):E14-E18. doi:10.1002/lary.28586

50.

Scheithauer

. Surgery of the turbinates and “empty nose” syndrome. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010;9:Doc03. doi:10.3205/cto000067

51.

Coste

Dessi

Serrano

. Empty nose syndrome. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(2):93-97. doi:10.1016/j.anorl.2012.02.001

52.

Maniaci

Lechien

La Mantia

, et al. Effectiveness of submucosal turbinoplasty in refractory obstructive rhinitis: a prospective comparative trial. Eur Arch Oto-Rhino-Laryngol Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol – Head Neck Surg. 2022;279(9):4397-4406. doi:10.1007/s00405-022-07267-0

53.

Cocuzza

Maniaci

Di Luca

, et al. Long-term results of nasal surgery: comparison of mini-invasive turbinoplasty. J Biol Regul Homeost Agents. 2020;34(3):1203-1208. doi:10.23812/19-522-L-4

54.

Kuan

Suh

Wang

. Empty nose syndrome. Curr Allergy Asthma Rep. 2015;15(1):493. doi:10.1007/s11882-014-0493-x

55.

Lemogne

Consoli

Limosin

Bonfils

. Treating empty nose syndrome as a somatic symptom disorder. Gen Hosp Psychiatry. 2015;37(3):273.e9-10. doi:10.1016/j.genhosppsych.2015.02.005

56.

Thamboo

Dholakia

Borchard

, et al. Inferior meatus augmentation procedure (IMAP) to treat empty nose syndrome: a pilot study. Otolaryngol–Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2020;162(3):382-385. doi:10.1177/0194599819900263

57.

Lobo

Hartley

Farrington

. Closure of the nasal vestibule in atrophic rhinitis–a new non-surgical technique. J Laryngol Otol. 1998;112(6):543-546. doi:10.1017/s0022215100141040

58.

Modrzyński

. Hyaluronic acid gel in the treatment of empty nose syndrome. Am J Rhinol Allergy. 2011;25(2):103-106. doi:10.2500/ajra.2011.25.3577

59.

Velasquez

Huang

Humphreys

Nayak

. Inferior turbinate reconstruction using porcine small intestine submucosal xenograft demonstrates improved quality of life outcomes in patients with empty nose syndrome. Int Forum Allergy Rhinol. 2015;5(11):1077-1081. doi:10.1002/alr.21633

60.

Chang

Watson

. Inferior turbinate augmentation with auricular cartilage for the treatment of empty nose syndrome. Ear Nose Throat J. 2015;94(10-11):E14-15.

61.

Jung

Baguindali

Park

Jang

. Costal cartilage is a superior implant material than conchal cartilage in the treatment of empty nose syndrome. Otolaryngol–Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2013;149(3):500-505. doi:10.1177/0194599813491223

62.

Tam

Lee

, et al. Clinical analysis of submucosal Medpor implantation for empty nose syndrome. Rhinology. 2014;52(1):35-40. doi:10.4193/Rhino13.086

An Updated Review on Atrophic Rhinitis and Empty Nose Syndrome

Abstract

Keywords

Introduction

Materials and Methods

Primary AR

Etiology of primary AR

Clinical presentation of primary AR

Diagnosis of primary AR

Histopathology

Management

Medical management

Nasal douches

Nasal drops

Systemic medications

Nasal submucosal injections

Vaccine

Surgical management

Decreasing the size of the nasal cavities

Promoting regeneration of the normal nasal mucosa

Increasing lubrication of the dry nasal mucosa

Improving vascularity of the nasal cavities

Secondary AR

Pathophysiology of ENS

Clinical presentation of ENS

Diagnosis of ENS

Histopathology of ENS

Management of ENS

The medical treatment of ENS

Surgical management of ENS

Temporary Fillers

Acellular Dermis Xenografts and Allografts

Autologous Cadaver Cartilage and the Donor

Synthetic Implants

Conclusions

Footnotes

Author Contributions

Data Availability Statement

Declaration of Conflicting Interests

Funding

Ethics Approval and Consent to Participate

References