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

The study titled "Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature" by Tanja Hildenbrand, Rainer K. Weber, and Detlef Brehmer provides a comprehensive overview of the various conditions associated with the symptom of a dry nose (DN), such as rhinitis sicca, atrophic rhinitis, and Empty Nose Syndrome (ENS). The study examines the etiology, symptoms, diagnosis, and treatment options for these conditions, highlighting the complexity and variability in clinical presentation.

### Summary of Findings:

**1. Lack of Clear Definitions:**

The term "dry nose" lacks a precise definition and is used to describe a range of symptoms from a subjective sensation of dryness to visible crusting of the nasal mucosa. The term "rhinitis sicca" is commonly used by ENT specialists, though it too lacks a clear and consistent definition. The conditions discussed include rhinitis sicca anterior, primary and secondary atrophic rhinitis, and ENS, each with its own set of symptoms and underlying causes.

**2. Symptoms:**

Symptoms of dry nose can vary widely and may include:

- Sensation of dryness in the nose.

- Itching or a mild burning sensation.

- Nasal obstruction.

- Crusting or scabbing inside the nose, often accompanied by an unpleasant smell.

- Epistaxis (nosebleeds).

- Diminished sense of smell (hyposmia or anosmia).

**3. Causes:**

The causes of dry nose are multifaceted, involving various diseases, environmental factors, and physiological changes. Some common factors include:

- Mechanical irritation or trauma.

- Climatic or environmental factors such as dry air.

- Workplace conditions involving exposure to dust or chemicals.

- Side effects of medications, including those used to treat nasal congestion.

- Aging, which leads to anatomical changes and reduced mucociliary clearance.

- Anatomical changes due to surgery or trauma.

- Infections and systemic diseases like Wegener’s granulomatosis, sarcoidosis, or tuberculosis.

- The wound healing phase following nasal surgery.

**4. Empty Nose Syndrome (ENS):**

ENS is a particularly severe and complex condition resulting from over-resection of the nasal turbinates, which are crucial for proper airflow and humidification of the air we breathe. The study emphasizes that uncritical resection of these turbinates, particularly the inferior and middle turbinates, can lead to ENS, a form of secondary atrophic rhinitis (SAR). ENS is characterized by symptoms such as paradoxical nasal obstruction (a sensation of blocked nasal airflow despite having a physically enlarged nasal cavity), dry nose, pharyngeal dryness, dyspnea (difficulty breathing), and a disturbed sense of smell. Psychological symptoms like depression can also occur due to the chronic and distressing nature of the condition.

**5. Diagnosis:**

Diagnosing dry nose and its associated conditions requires a thorough patient history and a detailed examination of the external and internal nose using endoscopy and, if necessary, imaging techniques like CT scans. Allergies and infections should also be ruled out through appropriate tests.

**6. Treatment Approaches:**

The treatment of dry nose and associated conditions is primarily conservative and focuses on symptom management. Key recommendations include:

- **Moisturization:** Using nasal sprays, ointments, or saline solutions to keep the nasal mucosa hydrated.

- **Environmental Control:** Reducing exposure to dry air, dust, and other environmental irritants.

- **Cleansing:** Regular removal of crusts to prevent infection.

- **Avoidance of Irritation:** Patients are advised to avoid unnecessary manipulation of the nasal mucosa to prevent further irritation.

- **Surgical Correction:** In cases where there is an excessively large nasal cavity due to previous surgery, reconstructive procedures may be considered to restore normal airflow and improve symptoms.

**7. Importance of Nasal Turbinates:**

The study underscores the critical role of nasal turbinates in maintaining nasal health. These structures are essential for proper air conditioning (humidifying and warming the air) and should not be removed unless absolutely necessary, as their removal can lead to severe and often irreversible complications such as ENS.

**8. Recommendations for Medical Practice:**

The study advises against radical resection of nasal turbinates and emphasizes the importance of careful surgical planning and execution. It also highlights the need for more research into effective treatments for dry nose and ENS, as current therapeutic options are largely symptomatic and do not address the underlying pathophysiology.

### Conclusion:

The research provides a detailed exploration of the conditions associated with dry nose, particularly ENS, which is identified as a severe consequence of aggressive nasal surgery. The study concludes that preventive measures, particularly in surgical practice, are essential to avoid the development of these debilitating conditions. Moreover, while current treatments offer symptomatic relief, there is a clear need for more effective therapeutic strategies to manage and prevent these disorders. The study serves as a critical reminder of the delicate balance required in ENT surgery and the significant impact that nasal structure can have on overall respiratory health.