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