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Referral and warning signs
When to refer
Refer to ENT Specialist (HC4/H/RR) if: Diagnosis uncertain. No improvement after 2 weeks of appropriate douching and antibiotics. Complications develop. Consideration for surgery.
Red flags
- Suspicion of underlying malignancy or specific granulomatous disease.
- Significant epistaxis.
- Signs of orbital or intracranial extension (rare).
Signs and symptoms
- Nasal obstruction sensation (despite wide airway).
- Offensive nasal odour (Ozaena): Foul smell noticed by others, but usually NOT by the patient (due to anosmia).
- Thick, dry crust formation in the nasal cavity (greenish, yellow, or black).
- Epistaxis (nosebleeds) when crusts are removed.
- Anosmia (loss of sense of smell).
- Headache.
- Examination: Widened nasal cavities, visible posterior pharyngeal wall, extensive crusting, atrophic pale mucosa, potential septal perforation.
Risk factors
- Unknown cause (Primary Atrophic Rhinitis).
- Secondary causes: Chronic infections (Klebsiella ozaenae sometimes implicated), Syphilis, Leprosy, Tuberculosis, Rhinoscleroma. Post-surgical changes (aggressive turbinectomy). Radiation therapy. Chronic granulomatous diseases. Nutritional deficiencies (possibly Iron, Vit A/D). Autoimmune factors.
- Association with HIV/AIDS and poor socioeconomic status mentioned in UCG.
Diagnosis
Clinical assessment
Diagnosis based on characteristic clinical picture: wide nasal cavities, extensive crusting, foul odour (reported by others), and anosmia.
Investigations
- Nasal Endoscopy (specialist).
- CT Scan of Sinuses (shows bony atrophy, wide cavities).
- Swab/Biopsy of crusts/mucosa: For Culture & Sensitivity (bacterial/fungal), Histology (rule out malignancy/granulomatous disease), AFB stain (TB), specific tests (syphilis, leprosy).
- Consider VDRL/RPR (Syphilis), HIV test.
Diagnostic criteria
Clinical findings of nasal crusting, foul odour, anosmia, and wide nasal cavity on examination, supported by investigations ruling out other causes.
Differential diagnosis
- Chronic Sinusitis (usually purulent discharge, not foul crusts/atrophy).
- Nasal Tumour.
- Chronic Granulomatous Disease (Wegener's, Sarcoidosis).
- Fungal Sinusitis (allergic or invasive).
- Rhinoscleroma (early stages mentioned in UCG).
Management
Non-pharmacological management
- Nasal Douching/Irrigation (Mainstay): Regular, frequent (at least BID) nasal irrigation with large volumes of warm saline solution (e.g., Normal Saline 0.9%) or alkaline solution (e.g., Sodium Bicarbonate 5% - 1 tsp in 100ml warm water) to remove crusts and moisturize mucosa. (LOC: HC3)
- Manual removal of crusts if necessary.
- Humidification of inspired air.
Pharmacological treatment
- Topical Lubrication/Moisturization: Application of lubricant ointment (e.g., Tetracycline eye ointment 1% per UCG, Vaseline) or paraffin oil inside the nose BID after douching to prevent crusting. (LOC: HC3)
- Antibiotics (Target secondary infection, reduce odour/crusting):
- - UCG recommends empirical Amoxicillin 500mg TID for 14 days. (LOC: HC3)
- - Consider culture-directed therapy if specific organism identified.
- - Rifampicin sometimes used (anti-Klebsiella effect).
- - Prolonged courses may be needed.
- Treat Underlying Cause: (e.g., Anti-TB meds, Syphilis treatment).
- Glucose-in-glycerine drops (local preparation sometimes used).
- Systemic medications (e.g., Potassium Iodide, vasodilators) - limited evidence, specialist use.
Monitoring
Monitor crusting, odour, patient comfort. Reinforce regular nasal douching. Follow up every 2 weeks initially.
Complications
- Epistaxis.
- Secondary infections (sinusitis, otitis media).
- Septal perforation.
- Pharyngitis sicca / Laryngitis sicca.
- Social isolation due to odour.
- Depression.
Prevention
- Treat underlying infections (TB, Syphilis etc.).
- Conservative nasal surgery (avoiding excessive turbinate removal).
- Good nutrition.
Patient education
- Explanation of the chronic nature of the condition.
- Critical importance and technique of regular nasal douching/irrigation.
- How to apply topical lubricants.
- Need for long-term management.
- Reassurance regarding anosmia (patient often unaware of odour).
- Importance of treating secondary infections.
Uganda-specific notes
Condition seen, sometimes associated with specific infections or post-surgical changes. Nasal douching with saline/bicarbonate and topical lubrication are key practical measures. Access to specialist care/surgery limited.
Surgical Management
- Procedures aim to narrow nasal cavity / reduce crusting (e.g., Young's operation, partial turbinectomy implants) - specialist procedures with variable success.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.2.5