Granuloma nose

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Granulomatous lesions of nose Dr T. Balasubramanian

Introduction <ul><li>Presence of granuloma

Macrophages, granulocytes and multinucleated giant cells

Presence of vasculitis

Systemic involvement is common </li></ul>

Types of granulomas <ul><li>Infective

Inflammatory

Neoplastix </li></ul>

Infective granulomas <ul><li>Bacterial – Tuberculosis, leprosy, Rhinoscleroma, syphilis and actinomycosis

Fungal – Aspergillus, zygomycosis, Dermatocietes, Blastomycosis, Histoplasmosis, Sporotrichiasis and coccididomycosis

Protozoa – Leishmaniais

Miscellaneous - Rhinosporidiosis </li></ul>

Neoplastic <ul><li>Non healing granulomas

Midline granulomas

T cell lymphomas </li></ul>

Inflammatory granulomas <ul><li>Wegner's granulomatosis

Sarcoidosis

Churg-Strauss syndrome

Cholesterol granuloma

Eosinophilic granuloma </li></ul>

Sarcoidosis <ul><li>Etiology unkonwn

Multisystem disorder

Commonly involved organs include: Lymph nodes, skin, lungs, eye, nose, liver and spleen

Cutaneous lesions are known as lupus pernio

Nasal involvement of sarcoidosis almost always indicate multisystem involvement of the disease </li></ul>

Sarcoidosis (features) <ul><li>Commonly affects adults

Affected age group 2 nd - 5 th decades

Females outnumber males 2:1 </li></ul>

Sarcoidosis (Etiology) <ul><li>Unknown

Infective agents

Chemicals (Beryllium, Zirconium etc)

Pine pollen

Peanut dust

Immunological </li></ul>

Sarcoidosis (Immunology) <ul><li>Type IV hypersensitivity reaction reduced in these patients

No depression of CMI

Humoral immunity normal </li></ul>

Sarcoidosis (current hypothesis)

Causes for persistent granuloma (sarcoidosis) <ul><li>Increased production of calcitriol by monocytes

Continued antigenic stimulation

Failure of supressor mechanism

Abormalities in the regulation of cytokine network </li></ul>

Sarcoidosis (Histology) <ul><li>Fromation of epitheloid cell tubercles

There is no evidence of caseation

Fibrinoid necrosis may be seen sometimes

Fibrinoid necrosis may be converted to hyaline fibrosis

Tubercles are surrounded by lymphocytes and fibroblasts

These histological features are not diagnostic </li></ul>

Nasal sarcoidosis (clinical features) <ul><li>Nasal stuffiness & obstruction

Crusting of nasal mucosa is commonly seen

Blood stained nasal discharge

Purulent nasal discharge

Facial pain

Sometimes mucoid discharge

Anosmia (rare) due to mechanical obstruction of the olfactory cleft by crusts </li></ul>

Nasal sarcoid clinical features (contd) <ul><li>Perforation of anterior portion of nasal septum

Nasal bridge collapse

Nasal bones may be thickened due to osteitis

Secondary infections of sinuses common

Adenoid / tonsillar enlargement

Secretory otitis media </li></ul>

Diagnostic features of nasal sarcoidosis <ul><li>Clinical acumen

Histology

Imaging

Hematology

Kveim test (cutaneous hypersensitivity test for sarcoidosis) withdrawn now

Angiotensin converting enzyme elevated during acute phase

ESR raised </li></ul>

Sarcoidosis (Radiology) <ul><li>X-ray nasal bones show rarefaction & osteolytic reaction

Punctate osteolysis of nasal bones may be seen

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