The Fetid Rhinitis or Atrophic Ozena is a chronic illness characterized by yellowish secretion in the initial phase and the other phases with fetid crusts and atrophy of the mucous bone covering.
It was first described by Frankael in 1876(1). The anatomo-pathological alterations of the nasal mucosa include complete metaplasia of the ciliary epithelium in scams or stratified. The proper blade presents diffuse infiltrate of lymphocytes, histiocytes, plasmocytes and mastocytes. The mucous glands are atrophic and there is attrite in the adjacent arteries. A rarefied and fibrous osteitis is noticed. According to Methrota and collaborators, mucous atrophy, scam metaplasia and chronic inflammatory infiltrate characterize the illness(2). Barton and collaborators, in a study of electronic microscopy noticed in their patients the loss of epithelial cells and hair, irregularity of the cellular membrane, reduction of the cytoplasm and reduction of the mitochondrial number, which reflects low cellular local activity, in patients carrying atrophic rhinitis(3).
The ozenous atrophic rhinitis has greater incidence in countries of low social-economic development, mainly in women, aging between 15-35 years. Diverse theories exist that try to explain the appearance of this pathology, such as: sympathetic spasm (diminishing the sanguineous supplement), the reflected syndromes, immunological alterations, viral infection and nutritional lack. As well as the nasal hyperinfection caused by the Klebsiella azanae, leading to local ciliary immobility. Currently, its etiology remains unknown(4).
After the appearance of the ozena, there may be local infection due to: klebsiella ozenae, haemmophilus influenzae, Mooxarella (Branhamella) carrhalis, Corynebacterium diphtheriae, and Staphilococcus aureus. This hyperinfection aggravates ciliary stases and the epithelial destruction. A vicious cycle whose central elements are damages to the mucosa and the local sub mucosa, gradually established. Clinically, the ozenous atrophic rhinitis manifest with osteomucous atrophy, crusts and accented nasal fetidness. Ulceration does not exist, but a small bleed is present in the removal of the crusts(5).
The atrophic rhinitis remains as persistent illness and of difficult treatment. The best technique to be used is still argued, not existing consensus among authors.
The metilmetacrylate is a polymer that has been used in the cosmetic surgery to alleviate and to harmonize the face contour(8). This aloplastic implantation can equally be used in skull-face malformations as Crouzon or Apert Syndromes(9-11). The experience of some authors with long treatment of their patients showed great advantage of metilmetacrylate in comparison with autogenic grafts, with absence of complications in the long run and security in its use. On the other hand, the cellular toxicity of this material was described in experimental study with extrusion and local infection(9-13).
The objective of the present study was to evaluate the reasons of the almost complete ozena disappearance in current population. Moreover, it aimed to evaluate a new treatment for this pathology, the local infiltration of metacrill (polimetilcrylate), thus avoiding surgical procedures.
CASUISTRY AND METHODS
In 2005 and 2006 15 cases of ozenous atrophic rhinitis were evidenced. Such patients entered in a new protocol of treatment. The formula of metacrill is recognized by the health ministry, and has polimetilcrylate as base.
For the treatment, first anesthesia with xilocaine spray was carried through. A separator was introduced in the inferior meatus raising the turbinate to maximum.
Later 3ml of metacrill was infiltrated with aid of a needle, until the triplication of the atrophied turbinate dimension.
The patients were evaluated weekly, in the first month in a period of six months.
RESULT OF DISCUSSION
All patients related important clinical improvement, with significant reduction of the nasal fetidness. In the previous rhinoscopy evaluation, the 15 treated cases presented 100% of cure, with disappearance of crusts and of bad smell, and an apparent improvement of the local mucosa.
In the few still existing cases, the treatment of ozenous rhinitis was totally modified. The medicines are not used anymore because they are inefficacious. Niesel and collaborators report the ciprofloxacin pray use in a daily dose of 500-750mg in a period of 3 months in patients carrying ozena. A treatment of 74 months noticed a "significant clinical improvement" with the disappearance of the fetidness and klebsiella ozenae without cultures (5).
Several described surgical treatments exist in literature. They are classified in nasal surgeries for fossas narrowing and the denervation surgeries.
Between the first one we find the surgery of nasal closing. Young, in 1967, proposes the nasal closing total through the vestibular flap rotation and reopening one year after the first procedure. Currently, the bone part removal of the maxilla sinus lateral wall twirling it as flap on lower turbinate is used(14).
Chamber, in 2005, published a study histologically evaluating the nasal mucosa of rats, after unilateral nostril occlusion and exposition to pollutant agents. At the non-blocked side, presence of scam metaplasia and certain degree of local inflammation were noticed. At the non-blocked side, presence of scam metaplasia and certain degree of local inflammation were noticed. At the blocked side, the room which was created protected the mucosa, thus not presenting metaplasia, neither local inflammatory process with significance(15).
Several types of synthetic implantations, or not, are intranasally used, among which: silicon, septal cartilage, costal or tibia fragments, teflon, calcium silastic and hydroxyapatite, among others(16-18).
On denervation surgeries periarterial maxilar sympathectomy is performed leading to the increase of the nasal internal circulation, diminishing the drying and the crustal formation. Mocellin, M, described the technique of lateral cartilage rotation with the objective to promote the nasal fossa narrowing, having 42 operated cases(7).
The theories which were previously proposed to explain the ozenous rhinitis as the endogenous or exogenous causes, much previously discussed, have become obsolete.
In 50 years of study on ozenous atrophic rhinitis, we present a new theory on the significant reduction of the number of ozena cases. To raise this hypothesis the occurrence of pathology in Curitiba was used as example. It has been some years that the city had pure air. Today air is polluted by some causes:
1. Existence of Industrial City nearby;
2. Use of agriculture pesticides in farms next to the city
3. Known as "Ecological City" with pollen in all the squares and parks
4. Exaggerated increase in the number of automobiles, bus and trucks, that release carbon monoxide contributing for the pollution increase.
In a research carried through in colleges and otorhinolaryngology clinics it was evidenced that 60% of the population present some kind of rhinitis, allergic or not, that causes turbinate hypertrophies due to vessel dilatation. The exposition of vessel-dilatators agents as caused by the environmental pollution induces to a reduction of ozenous rhinitis. Patient with allergic rhinitis does not have ozena. As more than the half of the population presents some kind of rhinitis, is obvious that the ozena has almost disappeared.
Metacrill has been widely used in the therapeutical treatment of the face lift. It promotes improvement of the face contours, reduction of wrinkles, increase of volume, fulfilling and labial increase (8-3). The duration of its action varies from 6 months up to a permanent action, depending on the product.
This material can be used in patients suffering from face traumas in the skull-face surgeon supply. Amaral et al described 5 cases of cranioplasty using metacrill in trauma patients with sequels in frontal and parietal regions. Such patients had good postoperative evolution without complications in 4 years of treatment (8).
We conclude that metacrill provides a significant improvement in the crusts and bad-smell in patients carrying ozenous rhinitis. However, future studies will be necessary for the evaluation of this product.
1. Zohan Y, Talmi P. Ozena revised. J. Otolaryngol. 1990, 19(5):345-349.
2. Mehrotra R, Singhal J, Kawatra M, Gupta SC, Singh M. Pre and post-treatment histopathological changes in atrophic rhinits. Microsc. Res. Tech. 2006, 69(7):585-94.
3. Barton R, Gray JL, Wright W, Dilly P. Familial atrophic rhinits: a scanning electron microscopic study. J. Laryngol. Otol. 1980, 94:993-996.
4. Shehata M. Atrophic Rhinitis. American Journal of Otolaryngoglogy, 1996, 17(2):81-86.
5. Nielsen BC, Olinder-Nielsen AM, Malmborg AS. Successuful treatment of ezena with ciprofloxacin. Rhinology. 1995, 33(2):57-60.
6. Mocellin L. Tratamento de Rinite Atrófica Fétida. Tese para professor catedrático da Universidade Federal do Paraná: Curitiba, 1964.
7. Mocellin M. Rotação cartilagem lateral para o tratamento da renite atrófica ozenosa. Tese para Professor Titular da Universidade Federal do Paraná, 1992.
8. Amaral CER, Pereira CLC, Ajub J, Mariotto R, Lappin GA, Chagas Q, Guidi MC. Cranioplastia com implante de metacrilato. Ver. Soc. Brás. Cir. Craniomaxilofacial 2004, 7(2):1-4.
9. Ousterhout DK, Zlotow I. Aesthetic improvement of the forehead utilizing Methylmetacrilate onlay implants. Aesthetic Plast. Surg. 1990, 14(4):281-5.
10. Passy S. Use of PMMA for treatment of nasal defects, Congresso Mundial de Estética. Tóquio, 2000.
11. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with artecoll: 10 year history, indications, techniques and complications. Dermatol. Surg. 2003, 29:573-587.
12. Alcalay J, Alcalay R, Gat A, Yorav S. Late-onset granulomatous reaction to artecoll. Dermatol. Surg. 2003, 29: 859-862.
13. Neto S, Pereira G. Histoquímica do Metacril. Santa Casa, RJ, 1998.
14. Elwany, S. Ultrastructural observations on primary atrophic rhinitis. Effects of partial closure of the nostril. ORL 1988, 50:389-396.
15. Câmara JA, Garrosa M, Gayoso MJ. Histological changes in rat nasal epithelia after unilateral neonatal naris occlusion. Microsc. Res. Tech. 2006, 69(7):585-94.
16. Soccol A, Bettega S, Noronha L, Sass S, Soccol V, Mocellin M. Comparação entre os enxertos de hidroxiapatita sintética de cálcio e submucosa de intestino delgado porcino. RBORL. 2006, 72:195-199.
17. Murakami A, Craig S. Nasal Reconstruction Using the Inferior Turbinate Mucosal Flap. Archives of facial plastic surgery. 1990, 1(2):97-100.
18. Moore EJ, Kern EB. Atrophic rhinitis: a review of 242 cases. Am. J. Rhinol. 2001, 15(6):355-61.
Professor. And Professor Emeritus of the Federal University of Parana.
Institution: Federal University of Parana - Hospital de Clinicas.
Mailing address: Leonidas Mocellin - Rua General Carneiro, 181 - Centre - Curitiba / PR - Brazil - CEP 80060-900 - Fax: (41) 3314-1521 - E-mail: email@example.com
Article received on November 21, 2006. Article accepted on May 9, 2007.