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GranulomatousDiseases of the Nose
Department of ENT
KSHEMA
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GranulomatousDiseases
Bacterial Fungal UnspecifiedRhinoscleroma Rhinosporidiosis Wegener’s
granulomatosis
Syphilis Aspergillosis Non healing midline granuloma
Tuberculosis Mucormycosis Sarcoidosis
Lupus Candidiasis
Leprosy
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RhinoscleromaSyn: Scleroma
First reported in nasal cavity - HEBRA 1870Chronic granulomatous diseaseGm -ve bacillus
Klebsiella rhinoscleromatis ( Frisch bacillus)
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INCIDENCE
Northern India , North KarnatakaMale = FemaleAny Age
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Pathology
Starts in the Nose
NasopharynxOropharynxLarynxTrachaBronchi
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Clinical featuresAtrophic Stage
Catarrhal rhinitic stage
Granulomatous stageSubdermal infiltration of
lower external nose & upper lip
Woody feel – Hebra Nose deformity
Cicatricial stageStage of fibrosisStenosis
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DIAGNOSIS
Miculikz cells- large foam cells with central nucleus & vacuolated cytoplasm
Russell bodies- resemble plasma cells with eccentric nucleus & a pink staining cytoplasm
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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.
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Lupus Vulgaris
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RHINOSPORIDIOSIS
Malbran 1892
Rhinosporidium seeberi / Kinealyi? Fungus
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ClassificationBENIGN
NASALSEPTAL MUCUS MEMBRANEFLOOR OF NOSE / SPUR
NASOPHARYNGEALNASOPHARYNGEAL SURFACE OF SOFT PALATE
MIXEDNaso-Lacrimal
BIZARREConjunctivalCutaneous
MALIGNANT - Generallized
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Clinical features
Nasal dischargeEpistaxis
O/ELeafy , Polypoidal, PinkishPapillomatousVascular- Bleeds on touchStudded with white dots
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LIFE CYCLE
Liberated Spores
Trophic stage
Early Trophozoite
Late
Trophozoite
SPORANGIUM7 microns
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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.
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Aspergillosis
Aspergillus fumigatus ( 90%)Aspergillus nigerAspergillus flavus
Sudan & Saudi ArabiaSeen in Immunosuppressed
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Clinical Features
Rhino- sinusitisBlack/ greyish membrane on nasal mucosaPultaceous , cheesy , sludgy blackish mass (Fungal ball)
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Forms
AllergicHORA’S CLASSIFICATION
InvasiveNon-invasive (aspergilloma)Fulminant (Angio-invasive / Destructive)
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Aspergillus
Septate HyphaeDichotomous Branching at 45 deg angleHyphae stained by Grocott’s silver stain
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Treatment
Surgical DebridementItraconazoleAmphoterecin B
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Mucormycosis
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Mucormycosis
Aggressive opportunistic fungusMUCORELES
Rhizopus OryzaeMucor CircinelloidesMucor Javanicus
Immunocompromised Diabetics
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TYPESROWE JONES
NON INVASIVESEMI INVASIVEINVASIVE
TypesCerebralOccularPulmonarySuperficialDisseminated
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Cerebral & Orbital extension
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Pathogenesis
Rapid SpreadInvasiveInvade arteries – endothelial damage ThrombosisNecrotic Mass
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Treatment
Surgical debridementAmphoterecin B
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Oroantral fistula
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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.
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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.
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Wegener’s GranulomatosisSystemic disease - UNKNOWN
Upper airwaysLungsKidneysSkin
C/FPersistent coldCrustingGranulationsSeptal perforation /saddling
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Wegener’s GranulomatosisInvestigations
Chest Xray – single/multiple cavitySerum creatinine, Urine -RBC, casts, albumin +C –ANCA ↑↑
BiopsyEpitheloid granulomaNecrotizing vasculitis
Rx : Steroids & Cytotoxic agents
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Midline Lethal Granuloma
Synonyms Stewart’s granulomaNon-healing midline granulomaPolymorphic reticulosis
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Midline Lethal GranulomaSlowly progressive
F>M 5-6th decade
HPR – suggestive of lymphoma
3 stagesProdromal stage (nasal obstrucion)Fetor/ ulcerationToxemia
Rx – Sx + RT
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Department of ENT , K.S.H.E.M.A
Deralakatte, Mangalore
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DefinitionInfestation of the nose by maggots which are the larvae of a fly (genus “Chrysomia”)
Synonym: Maggots in the nose
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AETIOLOGY
Atrophic RhinitisLeprosyLarge roomy nasal cavities following removal of nasal polyps/ rhinosporidiosisFollowing surgery for ca. MaxillaPoor HygienePoor Nutritional status.
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PATHOGENESIS
Flies (Genus- “Chrysomia”) lays eggs in nasal cavityEggs hatch into larvae (maggots)Superadded secondary bacterial infectionPNS invaded by maggots
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•200 eggs at a time
•Hatch within 24 hrs
•1.5cm in length
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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
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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
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RHINOLITH
Department of ENT , K.S.H.E.M.A
Deralakatte, Mangalore
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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
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AETIOLOGY
Foreign body
Inspissated pus
Blood clots
Inspissated mucus
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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
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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
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INVESTIGATIONS
X-ray PNS water’s view –Radio-opaque lesion in the region of the nasal cavity.
Similar findings if CT is done
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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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