nasal granulomas13
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Nasal GranulomasDr. Navin Kumaresan
Definition of GranulomaGranuloma is a tumor like mass of nodular
granulation tissue with actively growing
fibroblasts and capillary buds due to
chronic inflammation with vasculitis.
Classification of GranulomasBacterial FungalRhinoscleromaSyphilisTuberculosisLupusLeprosy
RhinosporidiosisAspergillosisMucormycosisCandidiasis*Histoplasmosis*Blastomycosis*
Unspecific causeWegener’s
granulomatosisNon-healing midline
GranulomaSarcoidosis
* rare
Rhinoscleroma Respiratory Scleroma orMikulicz disease
Definition
Rhinoscleroma or scleroma is a chronic
granulomatous disease caused by gram
negative bacillus Klebsiella rhinoscleromatis
[von Frisch bacillus].
Nasal involvement staging
1. Catarrhal Stage: foul smelling purulent
nasal discharge (carpenter’s glue), not
responding to conventional antibiotics
2. Atrophic stage: foul smelling, honey-comb
colour crusting in stenosed nasal cavity
Nasal involvement staging3. Nodular/granulation stage: Non-ulcerative,
painless nodules which widen lower nose (Hebra
nose)
4. Cicatrizing stage: Adhesions & stenosis coarse
& distorted external nose (Tapir nose). Lower
external nose & upper lip have woody feel.
Rhinoscleroma nodules
Lesion in nose & palate
Hebra nose
InvestigationsX-ray PNS: Sinusitis + bone destruction
Nasopharyngoscopy: Obliteration of nasopharynx
due to adhesions between deformed V-shaped soft
palate & posterior pharyngeal wall (Gothic sign)
Flexible laryngoscopy: Subglottic stenosis
Biopsy & HPE: Mikulicz cell & Russel body
Complement fixation test: Between patient’s
serum & Frisch bacillus suspension.
Histopathology
Granulomatous tissue characterized by:
1. Mikulicz (foam) cells: histiocytes with foamy
vacuolated cytoplasm, central nucleus &
containing Frisch bacilli
2. Russel (Hyaline) body: degenerated plasma
cells with large round eosinophilic material
Histopathology
Histopathology (magnified)
Warthin-Starry stain: Mikulicz cell
Medical treatmentStreptomycin 1 g OD im and Tetracycline 500
mg QID: oral together for 4-6 weeks plus 1
month (till two consecutive negatives from
biopsy)
Rifampicin: 650 mg OD orally
Radiotherapy & SurgeryRadiotherapy: 3500 rad over 3 week
Surgery: Removal of granulations & nodular
lesions with cautery or laser
Plastic reconstructive surgery
TuberculosisNose: Nasal Septum and ant.
inferior turbinateC/F: Ulceration & Perforation of
Nasal Septum cartilaginous part
Diagnosis: Biopsy & AFSTreatment: Anti-tubercular drugs
Skin: Lupus Vulgaris “apple-jelly”
SyphilisAcquired or Congenital
Acquired: Chancre of the vestibule of nose
Saddle NoseCongenital: Saddle nose, corneal
opacities, deafness and Hutchinson’s teeth
Diagnosis: VDRLTreatment: Benzathine pencillin
LeprosyNose: Nasal septum and ant. inferior turbinate
C/F: Nodular lesion
Atrophic rhinitis, dep. of nose,
destruction of ant. nasal spine
Diagnosis: Scraping & Biopsy
Treatment: Dapsone, Rifampin and Isoniazid
Rhinosporidiosis
DefinitionChronic granulomatous infection of the mucous
membrane by Rhinosporidium seeberi, mainly
affecting nose & nasopharynx
Characterized by formation of friable, bleeding and
polypoidal lesions
Other sites: lips, palate, conjunctiva, epiglottis,
larynx, trachea, bronchi, skin, vulva, vagina, hand &
feet.
Epidemiology88 – 95% cases in India, Pakistan & Sri Lanka
Common in Kerala, Karnataka & Tamil Nadu
Age: 20 – 40 yrs.
Sex ratio: Male : Female 4 : 1
IncidenceNasal 78%
Nasopharyngeal 16%
Mixed (naso-nasopharyngeal, nasolacrimal) 05%
Bizarre (Conjunctival / Tarsal / Cutaneous) rare
Clinical PresentationEpistaxis + nasal discharge + nose block
Nasal mass: papillomatous or polypoid,
granular, friable, bleeds on touch,
pedunculated or sessile, pink surface studded
with white dots [Strawberry appearance],
involves septum & turbinates
Nasal Mass
Bleeding Nasal Mass
Nasal & Nasopharynx
Nasal & Nasopharynx
Oropharyngeal Mass
Mass in uvula
Cutaneous Granulomas
Mode of transmissionBathing in infected water; infective spores enter
via breached nasal mucosa
Droplet infection by cattle dung dust
Contact transmission: contaminated fingernails
are responsible for cutaneous lesions
Haematogenous: to other sites in infected patient
Life-cycle
InvestigationBiopsy & Histopathological examination
Microscopic examination of nasal discharge for
spores
Sporangia of different shapes oval to round
and bursting spores are present.
Haematoxylin & Eosin stain
Periodic Acid Schiff stain
Gomori Methenamine Silver stain
Medical TreatmentDapsone: arrests maturation of spores
Dose: 100 mg OD orally (with meals) for one
year
Iron & Vitamin supplements
Surgical managementGeneral anesthesia with Oro-tracheal
intubation
2% Xylocaine with adrenaline infiltrated till
surrounding mucosa appears blanched
Mass avulsed using Luc’s forceps & suction
After removal of mass, its base cauterized
Laser excision: minimal bleeding
Fungal granulomas
Fungal SinusitisA. Invasive (hyphae present in submucosa)
1. Acute invasive (< 4 weeks)
2. Chronic invasive (> 4 weeks)
Granulomatous Non-granulomatous
B. Non-invasive
1. Allergic Fungal ball Saprophytic
Aspergillosis & Mucormycosis are common
AspergillosisEtiology: Aspergillus niger, As. fumigatus & As.
flavus
C/F: Acute Rhinitis, sinusitis, black membrane
nasal mucosa, semi-solid cheesy white fungal balls
Treatment: Surgical debridement & anti fungal
drugs like Amphotericin B
Fungal Sinusitis
MucormycosisAcute invasive fungal sinusitis by Mucormycosis
Unilateral nasal discharge and black crusts due to
ischaemic necrosis, proptosis, ophthalmoplegia
Fibrosis & granuloma formation seen in chronic
invasive fungal sinusitis
Locally destructive with minimal bone erosion
Black crusting
InvestigationsBiopsy & HPE
X-ray PNS: Sinusitis & focal bone destruction
CT scan: rule out orbital & intracranial
extension
MRI: for vascular invasion & intracranial
extension
C.T. scan coronal cuts
C.T. scan axial cuts
Aspergillosis Mucormycosis
Microscopic DifferenceAspergillosis hyphae
Mucormycosis hyphae
Narrow
Septate
Branching at 45°
Dichotomous
branching
Broad
Non-Septate
Branching at 90°
Singular branching
Immuno-fluorescent staining
TreatmentSurgical debridement of necrotic debris
Amphotericin B infusion: 1 mg / kg / day IV
daily / on alternate days
Itraconazole: 100 mg BD for 6-12 months
Surgical debridement
Sarcoidosis
Definition & EtiologyDefinition: Chronic systemic disease of
unknown etiology which may involve any
organ with non- caseating(hard)
granulomatous inflammation
Etiology: Resembling Tuberculosis
Unidentified organism
Clinical FeaturesNasal discharge, nasal obstruction, epistaxis
Mucosal: Reveals yellow nodules surrounded
by hyperaemic mucosa on anterior septum &
turbinates
Skin (Lupus Pernio): Nasal tip shows
symmetrical, bulbous, glistening violaceous
lesion
Lupus Pernio
InvestigationsBiopsy of nodule & HPE: Non-caseating hard
granuloma
Kveim intradermal Test
Non-caseating granuloma
Non-caseating granuloma
Asteroid inclusion bodies
Chest X-ray findingsBilateral Hilar lymph
node enlargement
with or without
diffuse parenchymal
infiltrates
Treatment
1. Prednisolone
2. Chloroquine / Methotrexate + Prednisolone:
In patients not responding to steroids
3. Cutaneous lesions: Excised & skin grafted
Wegener’s granuloma
Definition Autoimmune condition
characterized by
necrotizing granulomas
within nasal cavity &
lower respiratory tract
with generalised
vasculitis & focal
glomerulonephritis
Clinical FeaturesNose & Para-nasal sinus: Epistaxis, nasal block,
extensive crusting, septal destruction & nasal
collapse.
Pulmonary: Cough, haemoptysis
Renal: Hematuria & oliguria
Otological: Otalgia, deafness, facial nerve palsy
Oral & Pharyngeal: Hyperplastic, granular lesions
Crusting in nasal cavity
External nasal deformity
Destruction of orbit & nose
InvestigationsE.S.R.
Urine: microscopic examination
CT scan: PNS
Chest X-ray & CT scan
Serum urea & creatinine
Biopsy & HPE
CT scan PNS: nasal destruction
CXR: nodular lesion with cavity
C.T. scan lungs
n
C - ANCA by Indirect Immuno-fluorescence
Medical Treatment
1. Triple therapy: Prednisolone +
Cyclophosphamide + Cotrimoxazole
2. Plasma exchange & intravenous
immunoglobulin
3. Alkaline nasal douche for crusts
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