Granulamatous diseases of nose
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Transcript of Granulamatous diseases of nose
DEPARTMENT OF OTORHINOLARYNGOLOGY
J.J.M. MEDICAL COLLEGE
CLASSIFICATION:(I) BACTERIAL: Rhinoscleroma Syphilis Tuberculosis Lupus Leprosy
(II) FUNGAL Rhinosporidiosis Aspergillosis Mucormycosis Candidiasis, Histoplasmosis,
Blastomycosis
(III) UNSPECIFIED CAUSES
RHINOSCLEROMA
Chronic granulomatous disease Caused by Gm –ve bacillus, Klebsiella
rhinoscleromatis or Frisch bacillus Seen more often in Northern India
PATHOLOGY: disease starts in the nose and extends to pharynx and tracheobronchial tree
CLINICAL FEATURES:
Atrophic stage: charecterised by foul smelling purulent nasal discharge and crusting
Granulomatous stage: granulomatous nodules form in nasal mucosa, subdermal infiltration of lower part external nose and upper lip giving a ‘woody feel’
Cicatricial stage: stenosis of nares, distortion of upper lip, adhesions in the nose and pharynx
DIAGNOSIS
Biopsy: infiltration of submucosa with plasma cells, lymphocytes, eosinophils, Mikulicz cells, Russel bodies
Mikulicz cells: large foam cells with a central nucleus and a vacuolated cytoplasm containing causative bacilli.
Russel bodies: homogenous eosinophilic inclusion bodies found in the plasma cells.
Causative organism can be cultured from biopsy material.
TREATMENT
Medical: Streptomycin (1g/day) + Tetracycline ( 2g/day) for 4-6 wks and repeated, if necessary, after 1 month.
Surgical: to establish the airway and correct nasal deformity
NASAL SYPHILISIt is of two types Acquired and Congenital (1) ACQUIRED
a) Primary: manifests as primary chancre of vestibule of nose
b) Secondary: simple rhinitis with crusting and fissuring in the nasal vestibule, mucous patches in pharynx, fever, skin rash and generalised lymphadenitis
c) Tertiary: nose is commonly involved, gumma on nasal septum, offensive nasal discharge with crusts, saddle nose deformity
(2) CONGENITAL
Early form: seen in first 3 months of life, manifests as “snuffles”, fissuring and excoriation of nasal vestibule and upper lip.
Late form: manifests around puberty, gummatous lesions destroy the nasal structures, other stigmata of syphilis are present.
DIAGNOSIS Serological tests (VDRL) Biopsy of the tissue with special stains to
demonstrate Trep.pallidum
TREATMENT: Benzathine penicillin 2.4 million units i.m every wk for 3 wks, nasal crusts removed by irrigation with alkaline solution,removal of bony and cartilaginous sequestra.
COMPLICATIONS: vestibular stenosis, saddle nose deformity, atrophic rhinitis, perforation of nasal septum
TUBERCULOSIS
Secondary to pulmonary TB Sites commonly involved: anterior part
of nasal septum and anterior end of inferior turbinate
Nodular infiltration is followed by ulceration and perforation of cartilaginous part of nasal septum.
Diagnosis: Biopsy and special staining of sections for AFB, culture of organisms, animal inoculation.
Treatment: Antitubercular drugs
LUPUS VULGARIS
Low grade tuberculous infection affecting nasal vestibule, skin of face and nose
Skin lesions- brown gelatinous nodules called “apple-jelly” nodules
Chronic vestibulitis and perforation of cartilaginous part of septum
Diagnosis: Biopsy of lesion Treatment: ATT
LEPROSY Caused by M.leprae Nose is involved as a part of systemic
disease, more often in lepromatous C/F: excessive nasal discharge, red and
swollen mucosa, crusting and bleeding, septal perforation.
Diagnosis: scraping of nasal mucosa and biopsy, lepra cells present
Treatment: Dapsone, Rifampicin, Isoniazid. Reconstructive procedures.
RHINOSPORIDIOSIS
FUNGAL INFECTIONS
Fungal granuloma caused by Rhinosporidium seeberi
Occurs along coastal areas of tropical countries like India, Sri Lanka
Acquired through Contact with contaminated water
PATHOLOGY:disease mostly affects nose and nasopharynx
Vascular Polypoidal masses are formed in the nose
sporangia are the chitinous cysts containing spores scattered in the mass.
RHINOSPORIDIOSIS
C/F Symptoms:blood tinged nasal discharge,
nasal stuffiness, frank epistaxis Signs: -pink to purple polypoidal mass
attached to nasal septum or lateral wall, may track backwards
-bleed on touch
-studded with white dots- sporangia
DIAGNOSIS: Biopsy- several sporangia filled with spores
TREATMENT: complete excision of mass with diathermy knife and cauterisation of it’s base.
Recurrence may occur.
ASPERGILLOSIS Causative organism: Aspergillus niger,
A. fumigatus, A. flavus Predisposing factor: immunosupression C/F: black or greyish membrane in nasal
mucosa, fungus ball in maxillary sinus on exploration
Diagnosis: special stains to demonstrate the fungus
Treatment: surgical debridement of involved tissue, Antifungal drugs eg. Amphotericin-B
MUCORMYCOSIS Predisposing causes: uncontrolled diabetes,
immunosupression Pathology: It shows rapid destruction of
involved structures due to affinity of fungus to invade arteries causing endothelial damage and thrombosis
C/F: black necrotic mass filling the nasal cavity, eroding septum and hard palate.
Diagnosis: demonstrate fungus using special stains.
Treatment: Amphotericin-B, surgical debridement of affected tissue, control of predisposing cause
WEGENER’S GRANULOMATOSISAetiology: Systemic disorder of unknown aetiology
C/F: clear or blood stained nasal diacharge - crusting, granulations, septal perforation and
saddle nose -general symptoms like migratory arthralgias,
fatigue, AnaemiaDiagnosis: Biopsy from nose- necrosis and ulceration
of mucosa, epitheloid granuloma, necrotising vasculitis
ESR-raised.Treatment: Systemic Steroids and cytotoxic drugs
NON-HEALING MIDLINE GRANULOMA (Polymorphic Reticulocytosis)
Slowly destructive disease of nose and midfacial region
Careful biopsies will show mixed population of cell having mature lymphocytes, plasma cells, large lymphoreticular cells resembling lymphoma
Treatment: Radiotherapy followed by surgical debridement and nasal prosthesis
SARCOIDOSIS Granulomatous disease, absence of caseation Systemic disorder C/F: nasal obstruction, nasal pain, epistaxis
submucosal nodules in the nasal septum and inferior turbinate.
Diagnosis: biopsy of the lesions Treatment: Steroids- used locally for nasal
symptoms