GranulomatousDiseases of the Nose

Department of ENT

KSHEMA

GranulomatousDiseases

Bacterial Fungal UnspecifiedRhinoscleroma Rhinosporidiosis Wegener’s

granulomatosis

Syphilis Aspergillosis Non healing midline granuloma

Tuberculosis Mucormycosis Sarcoidosis

Lupus Candidiasis

Leprosy

RhinoscleromaSyn: Scleroma

First reported in nasal cavity - HEBRA 1870Chronic granulomatous diseaseGm -ve bacillus

Klebsiella rhinoscleromatis ( Frisch bacillus)

INCIDENCE

Northern India , North KarnatakaMale = FemaleAny Age

Pathology

Starts in the Nose

NasopharynxOropharynxLarynxTrachaBronchi

Clinical featuresAtrophic Stage

Catarrhal rhinitic stage

Granulomatous stageSubdermal infiltration of

lower external nose & upper lip

Woody feel – Hebra Nose deformity

Cicatricial stageStage of fibrosisStenosis

DIAGNOSIS

Miculikz cells- large foam cells with central nucleus & vacuolated cytoplasm

Russell bodies- resemble plasma cells with eccentric nucleus & a pink staining cytoplasm

TreatmentStreptomycin 1g/day

Tetracycline 2g/dayFor 4-6 weeksTreatment stopped when two consecutive cultures from the biopsy material - negative

Steroids – reduce fibrosisAcroflavin 2% local application.

Lupus Vulgaris

RHINOSPORIDIOSIS

Malbran 1892

Rhinosporidium seeberi / Kinealyi? Fungus

ClassificationBENIGN

NASALSEPTAL MUCUS MEMBRANEFLOOR OF NOSE / SPUR

NASOPHARYNGEALNASOPHARYNGEAL SURFACE OF SOFT PALATE

MIXEDNaso-Lacrimal

BIZARREConjunctivalCutaneous

MALIGNANT - Generallized

Clinical features

Nasal dischargeEpistaxis

O/ELeafy , Polypoidal, PinkishPapillomatousVascular- Bleeds on touchStudded with white dots

LIFE CYCLE

Liberated Spores

Trophic stage

Early Trophozoite

Late

Trophozoite

SPORANGIUM7 microns

TREATMENT

Cauterization of base and excision of mass

Revision & Follow upDapsone

Prevents maturation of sporangium Promotes fibrosis50 mg bid 3 months pre-op & 6 months post-op.

Aspergillosis

Aspergillus fumigatus ( 90%)Aspergillus nigerAspergillus flavus

Sudan & Saudi ArabiaSeen in Immunosuppressed

Clinical Features

Rhino- sinusitisBlack/ greyish membrane on nasal mucosaPultaceous , cheesy , sludgy blackish mass (Fungal ball)

Forms

AllergicHORA’S CLASSIFICATION

InvasiveNon-invasive (aspergilloma)Fulminant (Angio-invasive / Destructive)

Aspergillus

Septate HyphaeDichotomous Branching at 45 deg angleHyphae stained by Grocott’s silver stain

Treatment

Surgical DebridementItraconazoleAmphoterecin B

Mucormycosis

Mucormycosis

Aggressive opportunistic fungusMUCORELES

Rhizopus OryzaeMucor CircinelloidesMucor Javanicus

Immunocompromised Diabetics

TYPESROWE JONES

NON INVASIVESEMI INVASIVEINVASIVE

TypesCerebralOccularPulmonarySuperficialDisseminated

Cerebral & Orbital extension

Pathogenesis

Rapid SpreadInvasiveInvade arteries – endothelial damage ThrombosisNecrotic Mass

Treatment

Surgical debridementAmphoterecin B

Oroantral fistula

RHINITIS SICCACrust forming disease

HOT, DRY, DUSTY surroundings – bakers, blacksmiths, goldsmiths.

Pathology: Ciliated collumnar epithelium >Stratified squamous

C/F: Crusting - anterior 1/3rd of the nose- Septum

Removal - epistaxis/ ulceration/ septal perforation

Rx: correction of occupationApplication with antibiotic / steroid ointmentAlkaline nasal douching.

RHINITIS CASEOSAAKA: Nasal cholesteatoma

Chronic inflammation of the nose associated with granulation tissue formation & accumulation of offensive purulent discharge & cheesy material

Unilateral & Affects males

Soft tissue of the face - inflammed & abscesses burst out through skin.

Invg: Radiology( Bony wall destruction) Histopathology ( keratinous material, numerous organisms / cholesterol crystals

Rx: Debris removal by scooping ,irrigation & free drainage of affected sinus.

Wegener’s GranulomatosisSystemic disease - UNKNOWN

Upper airwaysLungsKidneysSkin

C/FPersistent coldCrustingGranulationsSeptal perforation /saddling

Wegener’s GranulomatosisInvestigations

Chest Xray – single/multiple cavitySerum creatinine, Urine -RBC, casts, albumin +C –ANCA ↑↑

BiopsyEpitheloid granulomaNecrotizing vasculitis

Rx : Steroids & Cytotoxic agents

Midline Lethal Granuloma

Synonyms Stewart’s granulomaNon-healing midline granulomaPolymorphic reticulosis

Midline Lethal GranulomaSlowly progressive

F>M 5-6th decade

HPR – suggestive of lymphoma

3 stagesProdromal stage (nasal obstrucion)Fetor/ ulcerationToxemia

Rx – Sx + RT

Department of ENT , K.S.H.E.M.A

Deralakatte, Mangalore

DefinitionInfestation of the nose by maggots which are the larvae of a fly (genus “Chrysomia”)

Synonym: Maggots in the nose

AETIOLOGY

Atrophic RhinitisLeprosyLarge roomy nasal cavities following removal of nasal polyps/ rhinosporidiosisFollowing surgery for ca. MaxillaPoor HygienePoor Nutritional status.

PATHOGENESIS

Flies (Genus- “Chrysomia”) lays eggs in nasal cavityEggs hatch into larvae (maggots)Superadded secondary bacterial infectionPNS invaded by maggots

•200 eggs at a time

•Hatch within 24 hrs

•1.5cm in length

CLINICAL FEATURES

Nasal ObstructionNasal painFoul smelling nasal dischargeH/O crawling sensation in the noseH/O maggots coming out of nasal cavityOn Exam – Anterior Rhinoscopy:

Maggots seen crawing in / out of nasal cavity.+/- cellulitis of nose & faceFever malaise , headache, toxaemia

TREATMENTRemoval of maggots with nasal dressing forcepsInstillation of liquid paraffin in the nasal cavities

Nasal cavities packed with ribbon gauze soaked in turpentine for 24 hrs

Antibiotics for control of secondary infection

Maintenance of nasal hygiene by alkaline nasal douches

RHINOLITH

Department of ENT , K.S.H.E.M.A

Deralakatte, Mangalore

DEFINITION

It is a concretion in the nasal cavity formed around a foreign body , clot or inspissated pus. It is the deposits of calcium and magnesium carbonate with phosphate salts

AETIOLOGY

Foreign body

Inspissated pus

Blood clots

Inspissated mucus

CLINICAL FEATURESNasal obstruction- unilateral

Rhinorrhea – unilateral, foul smelling and blood stained

Anterior rhinos copy – brownish / blackish mass obstructing one nasal cavity

Probing reveals a stony hard mass

PATHOLOGY

Occurs due to deposition of layers of carbonates and phosphates of calcium and magnesium around the foreign body

The rhinolith is usually becomes hard and sometimes friable

INVESTIGATIONS

X-ray PNS water’s view –Radio-opaque lesion in the region of the nasal cavity.

Similar findings if CT is done

TREATMENT

Removal of the entire mass under GAEither as a whole or in piece mealUsually by trans-nasal routeRarely through lateral rhinotomy , if too large

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