Subatrophic, trophic rhinitis and related pathologies

Understanding "Dry Runny Nose" and Related Nasal Pathologies (Subatrophic, Atrophic Rhinitis, and Mimics)

The terminology used by patients to describe nasal complaints can often be imprecise. Terms like "runny nose," "dry runny nose," or even "chronic rhinitis" are frequently used incorrectly or vaguely by laypersons. For a specialist, such terminology often indicates a superficial understanding of the underlying condition and highlights the need for a thorough diagnostic evaluation. While these terms might have been acceptable in earlier times when knowledge of rhinology was more limited, modern practice requires a more precise approach to define the specific symptom complex and underlying pathology.

 

The Ambiguity of Lay Terminology

The concept of a "runny nose" lacks strict definition in everyday life. One patient might use this term for nasal stuffiness, another for profuse nasal discharge. Conversely, some might consider insufficient discharge a sign of a "runny nose," while others associate it with repeated sneezing. These subjective interpretations underscore the importance of a detailed clinical history and examination.

 

Symptoms Associated with "Dry Runny Nose"

A common presentation often labeled by patients as a "dry runny nose" (which may correspond to conditions like subatrophic rhinitis, rhinitis sicca, or early atrophic changes) primarily involves a sensation of **dryness and nasal congestion**. Patients may report:

• Inability to breathe comfortably through the nose for extended periods.
• Headache or a feeling of heaviness in the head.
• Shortness of breath (subjective, due to nasal obstruction).
• Loss of smell (anosmia or hyposmia).
• Formation of nasal crusts.

Such symptoms may occur intermittently, for example, with temperature changes (moving from cold outdoor air to a warm room), after eating, or at night in bed (often affecting the dependent side when lying down). Some patients report these symptoms "at the slightest cold" or may experience them seasonally (e.g., regularly in summer, perhaps due to dry air or specific environmental factors).

To assess the degree of nasal blockage, a physician might alternately compress each nostril and ask the patient to exhale forcefully, evaluating the airflow strength (e.g., by feeling it with a finger, observing misting on a mirror, or a polished metal surface held under the nostrils). This provides a subjective measure of nasal patency.

 

Potential Underlying Causes of "Dry Rhinitis" Symptoms

The condition often termed "dry rhinitis" differs from typical acute rhinitis primarily by the absence or extremely negligible amount of nasal discharge. The etiology of true "dry rhinitis" (often referring to atrophic or subatrophic changes) can be complex, and the term itself is somewhat outdated from a precise diagnostic standpoint. Symptoms described as such can be due to a variety of underlying issues:

 

Structural Abnormalities

• Deviated Nasal Septum or Septal Protrusions (Spurs, Ridges): These can alter airflow, leading to localized drying and crusting, and a sensation of blockage.
• Hypertrophy of Nasal Mucosa/Turbinates: Diffuse or limited thickening of the nasal lining, particularly the turbinates, can cause obstruction. Paradoxically, altered airflow over hypertrophied tissue can sometimes lead to sensations of dryness in other areas.
• Congenital or Acquired Choanal Atresia/Stenosis: Complete or incomplete blockage of the posterior nasal apertures can cause significant nasal obstruction and secondary changes.

 

Inflammatory Conditions and Growths

• Atrophic Rhinitis (including Ozena) or Subatrophic Rhinitis: Characterized by thinning of the nasal mucosa, loss of glandular function, crusting, and often a foul odor (in ozena). Leads to a sensation of dryness and paradoxical obstruction despite widened airways.
• Rhinitis Sicca Anterior: Localized dryness and crusting in the anterior part of the nasal septum, often due to nose picking or dry environments.
• Nasal Polyps: While often associated with discharge, nasal polyps primarily cause obstruction. If they significantly alter airflow, areas of dryness can occur.
• Benign and Malignant Tumors: Nasal tumors can cause obstruction and altered sensation. Malignant neoplasms may also manifest with inflammation in the surrounding nasal area, involvement of adjacent bone (appearing swollen), cerebral or neurological symptoms, and nosebleeds not linked to anterior septal issues.
• Adenoid Enlargements (especially in children): A common cause of nasopharyngeal obstruction, leading to mouth breathing, sensation of nasal blockage, and secondary nasal symptoms. This is often misdiagnosed by parents as a simple "runny nose" and its significance underestimated, potentially leading to "irreparable harm to the child's body" if unaddressed (e.g., affecting facial growth, hearing, sleep).
• Nasal Foreign Bodies and Rhinoliths: Primarily cause unilateral obstruction and foul discharge, but can contribute to dryness and altered sensation.

 

Infectious Granulomatous Diseases (Historical Context and Modern Implications)

Finally, symptoms resembling a "runny nose" or nasal blockage can be created by serious underlying conditions, the delayed recognition of which is extremely important. These include specific chronic infectious processes affecting the nasal bones and mucosa, such as tuberculosis and syphilis, which cause infiltration, ulceration, and sequestration (bone death).

Often, such severe forms of disease affecting the nasal skeleton are not initially accompanied by severe or alarming symptoms. The patient might only experience more or less significant swelling or obstruction, which they patiently endure, mistaking it for a simple "runny nose" and not attaching due importance. The process, however, can progress, leading to significant destruction within the nose and disfigurement of the external nose. Timely recognition and specific treatment of these conditions could save the patient from serious long-term consequences.

 

Syphilis of the Nose

This applies especially to syphilis. The bones of the nasal skeleton are a common site for gummatous processes (tertiary syphilis). A long period often passes between the initial infection (primary and secondary syphilis) and the appearance of gummas. The initial infiltrative phenomena in the nose during tertiary syphilis can be insignificant, leading neither the patient nor the physician to immediately connect them with a past infection. This can result in a misdiagnosis of "runny nose" and a missed critical window for initiating specific general (systemic) and local treatment.

Historically, some physicians neglected local treatment for active syphilitic processes (papular or gummatous) in the upper respiratory tract, believing that systemic therapy alone would suffice. This view is a significant error. Disorders caused by syphilitic processes in the pharynx and larynx at the stages of rash (secondary) and destruction (tertiary, gummatous) require not only systemic but also diligent local treatment. Without it, patients could suffer for months from excruciating pain during swallowing (odynophagia) due to pharyngeal papules, experience hoarseness or voicelessness (aphonia) from laryngeal involvement, and endure severe destruction of nasal mucosa, cartilage, and bone, which, even if eventually healed by systemic treatment over long years, would leave significant defects and scarring.

 

Tuberculosis of the Nose

Similar considerations apply to tuberculous diseases of the nose, although nasal tuberculosis is much rarer than sinopulmonary tuberculosis. Specific anti-tuberculous therapy combined with local care is essential.

 

Differentiating Syphilis and Tuberculosis of the Nose (Historical Notes)

While differentiating syphilis from tuberculosis definitively requires prolonged examination and specific auxiliary methods (e.g., serological tests for syphilis like RW - Wassermann reaction, now VDRL/RPR and treponemal tests; bacteriological and histological studies of tissue biopsies for tuberculosis - AFB stain, culture, PCR, granulomas), some characteristic clinical signs were historically used to aid in practical differentiation:

• Course: Tuberculosis often proceeds more torpidly (sluggishly), with inflammation in surrounding tissue being absent or weakly expressed. Syphilis (gummatous) often involves surrounding tissue, including the external nose (bridge/dorsum), leading to swelling and redness.
• Localization: Tuberculosis was thought to localize more in the cartilaginous part (anterior nasal septum). Late syphilitic forms (gummas) preferentially affected bone tissue (posterior nasal septum, hard palate).
• Pain: Tuberculosis was typically not associated with spontaneous pain or pain on pressure. Gummy syphilis of the nose often caused constant headache, neuralgia, and pain on pressure over the bony parts of the nose.
• Nasal Discharge: Pus secreted from the nose with tuberculosis was often odorless. With syphilis, the discharge frequently had a putrid odor due to tissue necrosis.

Historically, therapeutic trials were sometimes used (e.g., response to anti-syphilitic treatment like salvarsan, which was considered a quick and potent agent, though local treatment was still deemed necessary).

 

Diagnosis of Conditions Presenting as "Dry Runny Nose"

A thorough diagnostic workup is essential to identify the true cause of symptoms that a patient might describe as "dry rhinitis" or persistent nasal congestion without significant discharge. This includes:

1. Detailed Medical History: Onset, duration, nature of symptoms (dryness, crusting, obstruction, pain, loss of smell, odor), previous nasal trauma or surgery, history of systemic diseases (including STIs, tuberculosis exposure, autoimmune conditions), medication use (especially topical decongestants), and environmental exposures.
2. Comprehensive ENT Examination:
   • Anterior Rhinoscopy: To assess the anterior nasal passages, septal position, and appearance of turbinates and mucosa.
   • Nasal Endoscopy: Crucial for visualizing the entire nasal cavity, nasopharynx, sinus ostia, and detecting subtle mucosal changes, polyps, tumors, foreign bodies, or structural abnormalities.
3. Imaging Studies:
   • CT Scan of Paranasal Sinuses: To evaluate for sinusitis, polyposis, bony abnormalities, tumors, or atrophic changes (e.g., widened nasal cavity, turbinate bone resorption in ozena).
   • MRI: May be useful for soft tissue lesions, suspected tumors with intracranial or orbital extension, or complex inflammatory conditions.
4. Specific Tests Based on Suspicion:
   • Allergy Testing: If allergic rhinitis is suspected.
   • Biopsy: For any suspicious lesions, unexplained granulomatous tissue, or to confirm diagnoses like sarcoidosis, GPA, tuberculosis, syphilis, or malignancy. Histopathological examination is key.
   • Microbiological Cultures: From nasal discharge or crusts, especially if infection (including specific pathogens like *K. ozaenae* in ozena) is suspected.
   • Serological Tests: For syphilis (VDRL/RPR, treponemal tests), autoimmune markers (e.g., ANCA for GPA), or other systemic diseases.
   • Olfactory Testing: If loss of smell is a significant complaint.

The concept of "dry rhinitis" being solely due to an unknown etiology is outdated. A specific underlying cause can usually be identified with modern diagnostic tools.

 

Treatment Principles

Treatment must be directed at the specific underlying cause identified during the diagnostic workup.

• Structural Abnormalities: Surgical correction (e.g., septoplasty for deviated septum, turbinate reduction for hypertrophy, repair of choanal atresia).
• Nasal Polyps: Medical management (topical/systemic corticosteroids, biologics) and/or surgical removal (polypectomy, FESS).
• Adenoid Hypertrophy: Adenoidectomy.
• Atrophic Rhinitis/Ozena: Symptomatic relief with regular nasal irrigation, lubricants, treatment of infections. Surgical procedures to narrow nasal passages may be considered in severe cases.
• Infectious Granulomatous Diseases: Specific antimicrobial therapy (e.g., anti-tuberculous drugs, penicillin for syphilis) combined with local nasal care. Systemic treatment is paramount.
• Tumors: Treatment depends on whether benign or malignant, involving surgery, radiation, chemotherapy, or a combination.
• Rhinitis Medicamentosa: Cessation of topical decongestants, often with a course of intranasal corticosteroids.

Historically, for symptoms of "dry rhinitis" without a clear structural cause, minor cauterization of hypertrophic areas or removal of small hypertrophic mucosal parts was sometimes attempted to provide relief. However, modern approaches prioritize identifying and treating the specific pathology.

 

Differential Diagnosis of Chronic Nasal Dryness and Obstruction

Conditions presenting with symptoms a patient might call "dry runny nose" (i.e., nasal dryness, crusting, obstruction, often without profuse discharge) need careful differentiation:

Condition	Key Differentiating Features
Atrophic Rhinitis (incl. Ozena)	Widened nasal passages, severe mucosal atrophy, thick foul-smelling crusts (ozena), anosmia, sensation of dryness and obstruction.
Subatrophic Rhinitis / Rhinitis Sicca Anterior	Localized or mild diffuse dryness, crusting often in anterior septum/vestibule. Nasal passages may not be significantly widened. No foul odor unless secondarily infected.
Chronic Rhinosinusitis (some forms)	Persistent inflammation; may have periods of dryness/crusting alternating with discharge. Facial pain/pressure, hyposmia. CT shows sinus disease.
Sjögren's Syndrome	Autoimmune; severe dryness of eyes (keratoconjunctivitis sicca) and mouth (xerostomia), can also affect nasal mucosa. Positive autoantibodies.
Granulomatous Diseases (GPA, Sarcoidosis, Tuberculosis, Syphilis)	Crusting, ulceration, septal perforation, saddle nose deformity. Systemic symptoms may be present. Biopsy and specific tests are diagnostic.
Rhinitis Medicamentosa	Chronic nasal congestion due to overuse of topical decongestants. Mucosa often appears boggy and hyperemic. History of decongestant abuse.
Post-Surgical Changes ("Empty Nose Syndrome")	History of aggressive turbinate surgery. Paradoxical nasal obstruction, dryness, crusting, pain, difficulty breathing despite objectively patent airways.
Environmental Factors / Medications	Exposure to very dry air, certain medications (e.g., anticholinergics, diuretics) can cause nasal dryness.

 

Importance of Accurate Diagnosis and Specialist Care

It is critical not to dismiss persistent nasal symptoms, even if seemingly minor or described vaguely like "dry runny nose." Delay in diagnosing serious underlying conditions such as granulomatous diseases (tuberculosis, syphilis) or malignant neoplasms can lead to significant morbidity, including extensive tissue destruction, facial disfigurement, and, in the case of malignancy, potentially fatal outcomes. Timely recognition and appropriate treatment by an ENT specialist, often in conjunction with other specialists (e.g., infectious disease, rheumatology, oncology), are essential to prevent such severe consequences and improve the patient's quality of life.

 

References

1. Mygind N. Nasal Allergy. 2nd ed. Blackwell Scientific Publications; 1979. (General rhinology context and historical perspectives).
2. Ballenger JJ, Snow JB Jr. Otorhinolaryngology Head and Neck Surgery. 15th ed. Williams & Wilkins; 1996. (Comprehensive ENT textbook with historical and evolving concepts).
3. Scott-Brown WG, ed. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 7th ed. Hodder Arnold; 2008. (Standard reference for ENT conditions).
4. Hitanay M, Kumar B, Singh NK. Primary atrophic rhinitis: a clinical profile. Indian J Otolaryngol Head Neck Surg. 2013 Jul;65(Suppl 1):149-53. (Focus on atrophic rhinitis/ozena).
5. Jahnke V, Tolsdorff P. Syphilis and tuberculosis in the head and neck. HNO. 1990 Jun;38(6):213-8. (German, abstract available, discusses specific infections).
6. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020). Rhinology. 2020 Feb 20;58(Suppl S29):1-464. (Modern classification and management of rhinitis/sinusitis).
7. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020 Oct;146(4):721-767. (Covers various forms of rhinitis).