Nasal Granulomas

1. Nasal Granulomas Dr. Vishal Sharma

2. Definition of granuloma Granulomas result from chronic inflammation & consist of:a. macrophages b. epithelioid cells (active macrophages resembling epithelial cells) c. multi-nucleated giant cells + d. vasculitis +e. necrosis

3. Classification of nasal granulomas

4. A. BacterialC. Fungal 1. Rhinoscleroma1. Mucormycosis 2. Tuberculosis2. Aspergillosis 3. Syphilis D. Non-specific: 4. Leprosy1.Sarcoidosis B. Aquatic parasite2.Wegener’s granuloma 1.Rhinosporidiosis3.Allergic granuloma 4. Sinonasal lymphoma ?

5. Rhinoscleroma or Respiratory Scleroma

6. Definition Rhinoscleroma or scleroma is progressive granulomatous disease caused by gram negative Klebsiella rhinoscleromatis [von Frisch bacillus] Commences in nose  nasopharynx, para nasal sinus, oropharynx, larynx, trachea & bronchi

7. Nasal involvement staging 1. Catarrhal Stage: foul smelling purulent nasal discharge (carpenter’s glue), not responding to conventional antibiotics2. Atrophic stage:foul smelling, honey-comb coloured crusting in stenosed nasal cavity (in contrast to roomy nasal cavity of atrophic rhinitis)

8. Nasal involvement staging 3. Nodular/ granulation stage: Non-ulcerative, painless nodules (soft & bluish–red  pale & hard)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.

9. Rhinoscleroma nodules

10. Lesion in nose & palate

11. Hebra nose

12. Tapir Hebra

13. Involvement of other sites Nasopharynx:Ear block & ed hearing (fibrosis of eustachian tube orifice). Nasal intonation & nasal regurgitation (fibrosis of soft palate).Oropharynx: Sore throatLarynx & tracheo-bronchial tree:Dry cough, hoarseness, respiratory distress

14. Investigations • X-ray PNS: sinusitis + bone destruction • Nasopharyngoscopy:obliteration of nasopharynx due to adhesions b/w deformed V-shaped soft palate & posterior pharyngeal wall (Gothic sign) • Flexible laryngoscopy: subglottic stenosis • Biopsy & H.P.E.:Mikulicz cell & Russel body • Complement fixation test: b/w pt’s serum & Frisch bacillus suspension. Done if biopsy is inadequate.

15. 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

16. Histopathology

17. Histopathology (magnified)

18. Warthin-Starry stain: Mikulicz cell

19. Medical treatment • Total duration= 6 wk to 6 months (or negative cultures from 2 consecutive biopsy materials) • Streptomycin: 1g OD intramuscularly + Tetracycline: 500 mg QID orally • Rifampicin: 450 mg OD orally • 2% Acriflavine solution: applied locally OD

20. Radiotherapy & Surgery • R.T.: 3500 cGy over 3 wk along with antibiotics halts progress of resistant cases • Removal of granulations & nodular lesions with cautery or laser • Dilatation of airway combined with insertion of Polythene tubes for 6 – 8 wk • Plastic reconstructive surgery: after 3 negative cultures from biopsies

21. Tuberculosis

22. Sino-nasal Tuberculosis • Rare. Usually due to spread from pulmonary TB • Ulcers, nodules, polypoid masses in cartilaginous part of septum, lateral wall & inferior turbinate • H.P.E.: epithelioid granulomas with Langhan’s multi-nucleate giant cells, caseating necrosis • AFB may be found on nasal smears • Treatment: INH + Rmp + Etb + Pzn X 6 – 9 mth

23. Acid Fast Bacillus

24. Histopathology

25. Histopathology magnified

26. Lupus Vulgaris • Tuberculosis of skin (of nose & face) • Can mimic a squamous cell carcinoma • Rapid course / indolent chronic form • Nodules have apple jelly appearanceon diascopy • Nodules ulcerate & crust  scarring + distortion of nasal alae, nasal tip & vestibule • Tx: A.T.T.  surgical reconstruction if required

27. Lupus vulgaris

28. Apple jelly nodule

29. Syphilis

30. Primary syphilis • Lesions develop 3-4 wks after contact • Chancre on external nose / vestibule • Hard, painful, ulcerated papule • Enlarged, rubbery, non-tender node • Spontaneous regression in 6-10 wks

31. Primary syphilis chancre

32. Secondary syphilis • Most infectious stage • Symptoms appear 6-10 wks after inoculation • Persistent, catarrhal rhinitis • Crusting / fissuring of nasal vestibules • Mucous patches in nose/pharynx • Roseolar, papular rashes on skin • Pyrexia, shotty enlargement of lymph nodes

33. Secondary syphilis rashes

34. Rash of secondary syphilis

35. Congenital syphilis • Infants: snuffles, 3 wks to 3 mth after birth • Fissuring / excoriation of upper lip / vestibule • Mucosal rashes, atrophic rhinitis, saddle nose deformity, palatal perforation • Prenatal h/o syphilis, stillbirths, miscarriages • Hutchinson’s incisors, Moon’s mulberry molars, interstitial keratitis, corneal opacities, SNHL

36. Congenital syphilis: palatal rash & perforation

37. Tertiary syphilis • Commonest manifestation of nasal syphilis • Gumma: red, nodular, submucous swelling with infiltration. Ulcerates with putrid discharge / crusting. Ulcer margins irregular, overhanging, indurated, bare bone underneath. • Sites: mucosa, periosteum, bony septum, lateral wall, floor of nose, nasal dorsum, nasal bones

38. Tertiary syphilis gumma

39. Investigations • Dark-ground illumination examn of nasal smear • Venereal Disease Research Laboratory test • Rapid Plasma Reagin • Fluorescent Treponemal Antibody Absorption • Treponema Pallidum Haem-agglutination Assay • H.P.E.: peri-vascular cuffing by lymphocytes & plasma cells. Endarteritis: narrowing of vascular lumen, necrosis, ulceration.

40. Sensitivity of serological tests

41. Treatment 1. Benzathine penicillin G, IM, 2.4 MU single dose 2. If penicillin allergic: Doxycycline or Tetracycline  Doxycycline: 100 mg orally BD for 2 weeks  Tetracycline: 500 mg orally QID for 2 weeks 3. Sequestrectomy 4.Augmentation Rhinoplastyfor nasal deformity

42. Complications of untreated syphilis • Secondary infection with pyogenic organisms • Sequestration of bone • Perforation & collapse of bony nasal septum • Perforation of hard palate • Scarring / stenosis of choanae • Atrophic rhinitis • Meningitis

43. Leprosy

44. Leprosy • Etiology: Mycobacterium leprae • Types:a. tuberculous b. lepromatous c. borderline • C/F: nodules, inflammation of nasal mucosa, nasal obstruction, septal cartilage perforation • X-ray:erosion of anterior nasal spine • Sequelae: saddle nose, atrophic rhinitis, stenosis

45. Tuberculous Lepromatous

46. Saddle nose in leprosy

47. Erosion of anterior nasal spine

48. W.H.O. treatment regimen A. Tuberculoid (pauci-bacillary) leprosy: for 6 mth Dapsone: 100 mg daily, unsupervised + Rifampicin: 600 mg monthly, supervised B. Lepromatous (multi-bacillary) leprosy: for 1–2 yr Dapsone: 100 mg daily unsupervised + Clofazimine: 50 mg daily unsupervised + Rifampicin: 600 mg monthly supervised + Clofazimine: 300 mg monthly supervised

49. Rhinosporidiosis

50. Definition Chronic granulomatous infection by Rhinosporidium seeberi, mainly affecting mucous membranes of nose & nasopharynx; characterized by formation of friable, bleeding or polypoidal lesions • Other sites: lips, palate, antrum, conjunctiva, lacrimal sac, larynx, trachea, bronchus, ear, scalp, skin, penis, vulva, vagina, hand & feet.