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Auris Nasus Larynx xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Case report

Successful management of primary atrophic rhinitis by turbinate

reconstruction using autologous costal cartilage
Marn Joon Park, Yong Ju Jang *
Departments of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Article history: Initial management of primary atrophic rhinitis is conservative, with nasal ointments, saline
Received 21 November 2016 irrigation, and antibiotics prescribed to relieve symptoms. However, in cases that show no
Accepted 6 June 2017 improvement, a surgical approach is considered. Recently, many studies have reported successful
Available online xxx
surgical outcomes using various nasal implants. However, no study has reported implantation of
autologous costal cartilage in PAR patients. We report here the case of a 63-year-old woman
Keywords:
diagnosed with PAR that was intractable to medical therapy. Under general anesthesia, bilateral
Atrophic rhinitis
Primary atrophic rhinitis
inferior turbinate reconstruction with autologous costal cartilage was successfully performed
Autologous costal cartilage without any complications. One month after surgery, her symptoms improved dramatically. At the
Turbinate reconstruction 2-year follow-up, her Sinonasal Outcome Test 25 (SNOT-25) score was 6, down from an initial
Endonasal microplasty score of 108. Her OMU CT showed improved sinonasal mucosal thickness and disappearance of
thick mucosal secretion compared with preoperative CT image. Although this is a single case
experience, it is suggested that turbinate reconstruction using autologous costal cartilage can serve
as promising surgical modality for management of atrophic rhinitis.
© 2017 Elsevier B.V.. All rights reserved.

1. Introduction Radiological findings of primary atrophic rhinitis have been

Atrophic rhinitis is a chronic, gradually progressing
degenerative condition of the nasal cavity characterized by a
foul odor (ozena), nasal obstruction, dryness, and crusting
[1]. The etiology of primary atrophic rhinitis is mostly
unknown. Progressive metaplasia and atrophy of all mucosal
components (epithelium, vessels, and glands) takes place
because of increased osteoclastic activity, resulting in a
volumetric decrease of sinonasal structures. The turbinate
show shrinkage and the inferior turbinate is affected the most.
Endoscopic inspection reveals a large, wide nasal cavity with
dried mucosa [2].
* Corresponding author at: Department of Otolaryngology, Asan Medical
Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil,
Songpa-gu, Seoul 05505, Republic of Korea. Fax: +80 248 927 73.
E-mail address: jangyj@amc.seoul.kr (Y.J. Jang).
http://dx.doi.org/10.1016/j.anl.2017.06.003
0385-8146/© 2017 Elsevier B.V.. All rights reserved.
previously described. Pace-Balzan et al. [3] reported the
following features: (1) mucosal thickening of the paranasal
sinuses, (2) loss of definition of the ostiomeatal unit (OMU)
secondary to resorption of the ethmoid bulla and uncinate
process, (3) hypoplasia of the maxillary sinuses, (4) enlarge-
ment of the nasal cavities with erosion and bowing of the lateral
nasal wall, and (5) bony resorption and mucosal atrophy of the
middle and inferior turbinate. However, there have been no
studies comparing changes in radiological findings following
surgical management of primary atrophic rhinitis patients.
Classically, the management of patients with primary
atrophic rhinitis is aimed at alleviating symptoms using nasal
irrigation douche or ointment application. In 1971, Young [4]
proposed closure of the nostril (Young’s operation), and
Saunders [5] suggested endonasal microplasty (intranasal
implant insertion) for the surgical management of primary
atrophic rhinitis. However, Young’s operation has its demerit
on the possibility of decreased patient’s quality of life due to

Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003
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closure of the nostril. In addition, previous nasal implantation
techniques carry the risk for implant extrusion, absorption, and
moreover, there are insufficient long term follow-up results [6–
9]. The corresponding author (YJ Jang) have previously
reported promising outcomes following inferior turbinate
reconstruction using autologous costal cartilage in empty nose
syndrome (ENS) patients [10]. Inspired by the fact that primary
atrophic rhinitis and ENS share similar physical and symptoms,
we hypothesized that the turbinate reconstruction procedure
would be also beneficial for the primary atrophic rhinitis
patients as well. Hence, we report here the first case of primary
atrophic rhinitis successfully treated by turbinate reconstruction
using autologous costal cartilage.
2. Case report
2.1. Clinical history
maxillary sinus, and mucosal swelling of all paranasal sinuses
(Fig. 2B).
2.2. Surgical technique
Turbinate reconstruction was performed as described in our
previous report on treating patients with ENS [10]. After the
patient was placed under general anesthesia, the right sixth
costal cartilage was harvested. A cube of harvested cartilage
with dimensions of 2 cm  4 cm  2 cm (length, breadth,
thickness, respectively) was carved and designed into two
conical grafts (Fig. 3A). Turbinate reconstruction was then
performed by making an incision on pyriform apertures
bilaterally (Fig. 3B). After the submucosal flap was elevated,
the graft was inserted submucosally; the wound was closed by
the simple suture of the nasal mucosa. The inferior turbinate
were reinforced and reconstructed, thus narrowing nasal
cavities bilaterally.

A 63-year-old woman, previously healthy with no underly- 2.3. Surgical outcome

ing conditions or history of nasal surgeries, complained
bilateral nasal obstruction, foul odor, severe crusting, postnasal
drip, and dryness of both nasal cavities. These symptoms
persisted and bothered the patient for many years, which led her
to visit her local ENT clinic, where she received frequent nasal
dressings for the nasal crusting of nasal cavities. Despite those
therapies, the symptoms did not completely resolve; therefore,
she visited the Asan Medical Center to seek a second opinion.
Endoscopic examination revealed severe crusting of the
mucosa of nasal cavities bilaterally, along with bilateral atrophy
of the turbinate (Fig. 1). Her initial SNOT-25 score was
108. We diagnosed the patient with primary atrophic rhinitis
and prescribed an oral antihistamine, a mucolytic agent, and
clarithromycin, along with nasal irrigation with saline solution.
After 1 month, there was no improvement in her symptoms
and the severe crusting persisted (Fig. 2A). Computed
tomography of the OMU CT showed atrophy of the middle
and inferior turbinate, hypoplasia and obstruction of the
At 2 weeks after surgery, crusting was diminished, and
augmented new inferior turbinate below the native turinate was
observed bilaterally. At 3 months after surgery, the patient
reported she no longer had any sensation of crusting of her nasal
cavity and had a decrease in postnasal drip. At the 2-year
follow-up, both inserted implants were still in place without
resorption on gross (Fig. 2C), in addition to amelioration in the
patient’s initial symptoms. Her SNOT-25 scores had decreased
to 6 (Fig. 4). OMU CT showed resolved obstruction of the sinus
opening as well as decreased mucosal swelling (Fig. 2D). No
surgery-related complications were observed during the 2-year
follow-up period, including graft absorption or extrusion.
3. Discussion
We report here the first successful management of primary
atrophic rhinitis by surgical reconstruction of the turbinate

Fig. 1. Initial endoscopic nasal examination of the patient; pus-like thick, yellowish discharge with atrophied turbinate are seen. (For interpretation of the references to
colour in this figure legend, the reader is referred to the web version of this article.)

Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003
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Fig. 2. (A–B) After 1 month of conservative management with clarithromycin and nasal irrigation. (A) Showing worsening of crusting and mucosal dryness. (B)
OMU CT scan reveals atrophied turbinate with bilateral hypoplasia of maxillary sinus. In addition, diffuse swelling of nasal mucosal linings were observed, therefore
obliterating the natural ostium of both maxillary sinuses. (C–D) Two-years post-operative outcomes. (C) Showing neo-turbinate below the missing turbinate with no
extrusion of implanted costal cartilage graft. (D) Shows decreased swelling of nasal mucosa with improved patency of natural ostium of antrum, bilaterally.

using autologous costal cartilage. Because the etiology and
pathophysiology of primary atrophic rhinitis are not fully
understood, patients with primary atrophic rhinitis are usually
managed by symptomatic treatment [2]. Nevertheless, no single
method is accepted as standard treatment because no method
provides permanent relief.
As mentioned in the introduction, many attempts have been
made to treat primary atrophic rhinitis with surgery
[2,5,6,8,9,11–13]. Despite these attempts, there is insufficient
evidence that surgery is superior to conservative management
of primary atrophic rhinitis, making surgeons hesitant to
perform surgery. Despite many decades of clinical experience
with primary atrophic rhinitis, no randomized control trials
have been conducted comparing surgical versus conservative
management.
In addition, no standard surgical approach has been
established for managing patients with primary atrophic
rhinitis. In a Cochrane review, Mishra et al. proposed a
randomized controlled trial comparing the effectiveness of
Young’s operation to nasal lubrication in primary atrophic
rhinitis patients. In 2012, interim results were published,
showing a lack of evidence of long-term benefits or risks in
comparisons of the two treatment methods because of the short
observation period [14].
For many decades, costal cartilage was favored by many
rhinoplasty surgeons to provide adequate amounts of harvested
cartilage. In 2013, the senior author of this report (YJ Jang) had
published a paper on turbinate reconstruction in ENS patients
using autologous cartilage. Patients whose inferior turbinate
were reconstructed using costal cartilage showed greater

Fig. 3. (A) 6th costal cartilage was harvested from the patient during surgery, and designed as above. (B) Schematic illustration of turbinate reconstruction; atrophied
inferior turbinate is seen (asterisk), and an incision and mucosal flap elevation was made at piriform aperture (arrowhead) followed by designed costal cartilage
implantation at the submucosal space (arrow).

Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003
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Fig. 4. Pre-operative SNOT-25 score rated 108, which dramatically decreased
to 6 at two-years post-operative period.
improvement in their SNOT-25 scores than patients in which
conchal cartilage was used [15]. Round, long, ovoid costal
cartilage has its strength than thin, small conchal cartilage when
reconstructing the turbinate.
Moore and Kern [13] reported total number of 7 cases in
which implantation of autologous cartilage or irradiated
homologous rib cartilage along submucosal space of nasal
floor was performed. However, it has not clearly mentioned
whether this procedure was done in primary atrophic rhinitis
patients, and which autologous cartilage was harvested.
Additionally, the place in which the graft was inserted in our
case differs from Moore's study. Therefore, we report that it is
the first attempt to perform a bilateral inferior turbinate
reconstruction using autologous costal cartilage in primary
atrophic rhinitis patient.
As well as dramatic improvement in the patients’ symptoms
shown in SNOT-25 scores, two year post-operative OMU CT
have proven decreased swelling of sinus mucosal lining with
improved patency of natural ostium of both maxillary sinuses.
Since no previous studies have compared changes in
radiological findings after surgical treatment in primary
atrophic rhinitis patient, our report gives promising clinical
usefulness of our technique in management of primary atrophic
rhinitis patients.
4. Conclusions
We report the first case of intractable primary atrophic
rhinitis successfully managed by turbinate reconstruction using
autologous costal cartilage. Therefore, we suggest inferior
turbinate reconstruction using the autologous costal cartilage
may serve as useful surgical option for treatment of primary
atrophic rhinitis.
Ethical statement
All authors state that this manuscript “Successful Manage-
ment of Primary Atrophic Rhinitis by Turbinate Reconstruction
Please cite this article in press as: Park MJ, Jang YJ. Successful management of primary atrophic rhinitis by turbinate reconstruction using
autologous costal cartilage. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.06.003
using Autologous Costal Cartilage” was written in accordance
with the Code of Ethics of the World Medical Association
(Helsinki Declaration).
We authors have consulted the Institutional Review Board
(IRB) of Asan Medical Center (AMC) about the IRB approval
before the initiation of the manuscript. Considering the fact that
this article is a case report, the Asan Medical Center IRB
approved an exemption of deliberation for IRB approval. If the
certification for exemption of deliberation for IRB approval by
AMC IRB is needed, we would be pleased to attach the proof of
certification. We have obtained written informed consent from
the participant. The patient’s anonymity was preserved during
the entire publishing process.
Sources of funding
None.
Acknowledgments
None.
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