# Severe Secondary Atrophic Rhinitis with Extensive Osteomyelitis Following COVID-19-Associated Necrotizing Rhinitis: A Case Report and Microbiological Analysis

## TL;DR

This case report describes a rare complication of severe atrophic rhinitis following a COVID-19 infection, managed successfully with a non-antibiotic approach.

## Contribution

The paper presents a novel case of secondary atrophic rhinitis following COVID-19 and introduces an effective non-antibiotic treatment strategy.

## Key findings

- Severe secondary atrophic rhinitis can develop as a complication of COVID-19-associated necrotizing rhinitis.
- A nasal rest protocol with surfactant cleansing effectively managed multi-drug resistant pathogen colonization and symptoms.
- Histopathology ruled out invasive fungal disease, confirming the non-fungal nature of the condition.

## Abstract

Background and Clinical Significance: Atrophic rhinitis (AR) is a rare, chronic inflammatory condition characterized by progressive atrophy of the nasal mucosa and underlying bone. The present report describes a case of severe secondary AR as a sequela of COVID-19-associated necrotizing rhinitis, highlighting the diagnostic and management challenges posed by multi-drug resistant pathogens and extensive anatomical destruction. Case Presentation: A 75-year-old female developed progressive necrotizing rhinosinusitis with osteomyelitis following a COVID-19 infection. Computed tomography (CT) confirmed an osteolytic process and subsequent profound anatomical destruction, while histopathology ruled out invasive fungal disease. The resulting cavity was colonized by multi-drug resistant Pseudomonas aeruginosa and Staphylococcus aureus. Management and Outcome: Management focused on preventing crust formation through a structured “nasal rest” protocol, supplemented by cleansing nasal douching with a surfactant (baby soap) and mechanical crust removal. This treatment led to significant clinical improvement, with reduced crusting and complete resolution of ozena symptoms. Conclusions: This case illustrates the potential for SARS-CoV-2 infection to precipitate severe necrotizing sinonasal complications leading to secondary AR. It demonstrates the efficacy of a management strategy focused on mechanical cleansing and nasal rest, particularly when conventional antibiotic therapy is limited by extensive drug resistance.