This document discusses types of granulomatous diseases of the nose, including bacterial, fungal, parasitic, and inflammatory/autoimmune diseases. It provides details on specific conditions like rhinoscleroma, tuberculosis, syphilis, leprosy, aspergillosis, mucormycosis, Wegener's granulomatosis, sarcoidosis, and T/NK-cell lymphoma. For each condition, it describes clinical features, diagnosis, and treatment approaches.

1. SEMINAR TOPIC –
GRANULOMATOUS
DISEASES OF NOSE
NAME - MAYANK SAH
MBBS BATCH 2020

2. TYPES -
BACTERIAL INFECTIONS
FUNGAL INFECTIONS
PARASITIC INFECTIONS
INFLAMMATORY / AUTOIMMUNE
NOTE - GRANULOMATOUS LESIONS OF NOSE ARE NOT SPECIFIC FEATURE OF
ALL MENTION DISEASE THEY CAN BE SECONDARY TO SYSTEMIC DISEASES

3.  BACTERIAL INFECTIONS
1) RHINOSCLEROMA –
It is a chronic granulomatous disease caused by Klebsiella
rhinoscleromatis /Frisch Bacillus
More common in north than in south
PATHOLOGY
• Starts from nose and extends to nasopharynx ,oropharynx, larynx
[subglottic region] trachea ,bronchi
• Ratio is 1:1 for male and female

4.  Clinical features-
Atrophic stage –
• Foul smell
• Nasal discharge
• Crusting
Granulomatous stage –
• Painless nodules
• Woody feel/hebra/Hard [due to granuloma] of external nose and
upper lip
Cicatricial stage
• Stenosis of nares [Tapir nose ]
• Subglottic stenosis and fibrosis[difficulty breathing]

5.  Diagnosis-
• Biopsy-shows MIKULICZ CELLS AND RUSSEL BODIES
• Mikulicz cells are macrophages that phagocytosed the bacteria forming large
foamy cells
• Russel bodies are plasma cells with eosinophilic inclusion bodies
• Culture of the organism isolated from biopsy
TREATMENT-
• Streptomycin 1g/day and Tetracycline 2g/day at least for 6 weeks
• Ciprofloxacin, rifampin, steroids [to avoid fibrosis]
Note –treatment is stopped only when two consecutive culture are negative
• Surgical establish airway and correct deformity –tracheostomy

6. 2)TUBERCULOSIS -
• It is rarely presented as primary tuberculosis of nose but more often
as secondary to lung tuberculosis
• Site involved-anterior nasal septum and anterior part of inferior
turbinate
• Nodal infiltration
• Ulceration
• Perforation of the nasal septum (cartilaginous part)

7.  Diagnosis-
• Biopsy
• Z-N Staining for Acid Fast Bacilli
 Treatment-
• Anti tubercular drugs like
• Isoniazid ,rifampicin ,ethambutol ,pyrazinamide
 Cutaneous lesions of Tuberculosis
 LUPUS VALGARIS –commonly seen in immunocompromised patients
 Like organ transplant ,HIV etc
 Characteristic features – apple jelly nodules [brown colour , no blanch on pressure]
 Presents as chronic vestibulitis
 Perforation of cartilaginous septum can be seen
 Treatment same as for tuberculosis

8. 3)SYPHILIS-( cause treponema pallidum)
Types –
a) Acquired –
• Primary –rare and presents with painless ulcer of vestibule
• Secondary-rarely recognize because presents as simple rhinitis ,snail
track ulcer can be seen
• Tertiary-Gummous lesions seen
• Features –septum destroy[bony part]
• Saddling of nose
• Crusting and offensive nasal discharge

9. B)congenital
• Two forms-
• a) early- in the first three months of life manifests as
‘snuffles’(catarrhal rhinitis )
• b)late –around puberty similar as tertiary stage of acquired gummous
lesions
Diagnosis –
• Serology test [ VDRL]
• Biopsy stain for treponema pallidum
Treatment
• Penicillin I.M every week for 3 weeks
• Nasal irrigation by alkaline solution

10. 4)LEPROSY-(Not isolated to nose but systemic disease)
• Common in tropical areas
• Loss of sensations , neuropathies
• Cause –Mycobacterium leprae
• Sites – from anterior part of septum
• Feature –initial
• Nasal discharge
• Red swollen mucosa
-Late
Perforation and ulceration
Destruction of nasal spine

11.  Diagnosis
• Biopsy –scrapings of nasal mucosa
• Histological finding lepra cells acid fast bacilli can be seen
Treatment –
• Dapsone ,rifampin, isoniazid
• Reconstruction is done once disease is subsided

12.  PARASITIC INFECTIONS -
RHINOSPORIDIOSIS-
• Chronic infection caused byRHINOSPORIDIUM SEEBERI
• It is an aquatic protistan parasite earlier it was considered as fungus
• More common in southern part of India
• Acquired through contaminated water and ponds frequented by
animals
CLINICAL FEATURES-
• Not confined to any part can be seen any ware
• Leafy , polypoidal ,pink ,Strawberry with white dots/mulberry type
presentation
• Recurrent Epistaxis is associated with the disease
• Skin nodules and hypertrophy of turbinate is seen

13.  Diagnosis-
• Biopsy is not preferred as it is a very vascular structure instead
• Smear is prepared to visualize the round shaped sporangia
under microscope
Treatment –
• Surgical excision of complete mass and cauterization on base is
done ,may reoccur (wide excision )
• Medication –dapsone but not very effective

14.  FUNGAL INFECTIONS -
ASPERGILLOSIS-
• Caused by Aspergillus niger in immunocompromised patient
• Systemic or intracranial involvement can be fatal either due to
infection or due to side effects of the drugs
Clinical features –
• Black/ grey membrane seen over nasal mucosa
• Sinus examination shows semisolid cheesy-white material
Treatment –
• Antifungal drugs like Amphotericin B

15.  MUCORMYCOSIS-
• Involve cribriform plate , brain ,meninges, nose and sinuses
• Rapid destruction of structure thrombosis and invades artery
due to which the fatality rate is high if not treated
• Was commonly seen during COVID-19 in immunosuppressive
patient and long term use of steroids
• “Black fungus” name was given due to black necrotic material
seen areas (rhino-orbito-cerebral)
Treatment –
• Amphotericin B
• Surgical debriment

16.  INFLAMMATORY/AUTOIMMUNE -
WEGENER’S GRANULOMATOSIS/GRANULOMATOSIS WITH
POLYANGITIS
• Systemic disease involve mainly upper airways ,lungs ,kidney and skin
Clinical features-
• 80% of the patient will present with problem –
• Nasal obstruction due to crusting
• Perforation of septum (bony+cartilage)
• Saddling of nose and blood tinged discharge ,hemoptysis
• Renal failure is the main cause of death in patients
• Gingival hyperplasia –strawberry like –pathognomonic rare

17.  Diagnosis-
• Done by c-ANCA
• X-Ray may show single or multiple cavity lesions
• CT scan will show pulmonary infiltration and nodules
• Biopsy is diagnostic showing necrotizing granulomatous vasculitis
Treatment –
• Immunosuppressive drugs –cyclophosphamide
• Steroids both are found effective

18.  SARCOIDOSIS-( Rare nasal involvement 1-4%)
• Resembles TB on histology but with absence of caseation
• Involves lungs, lymph nodes and skin
• Heerfordt syndrome –It is a rare subacute version
• B/L parotid enlargement ,facial palsy , anterior uveitis
• Patient presents with nasal obstruction ,pain, sometime epistaxis ,saddling
of nose (bony) ,perforation septum
• Strawberry appearance of nasal mucosa
• Lupus pernio-violaceous affection of skin of nose and cheek
Treatment-
• Systemic steroids
• Nasal sprays, Hydroxychloroquine

19.  T/NK –cell Lymphoma-
• Neoplastic lesion with granulomas
• Features-midline malignant lesion , lethal granuloma
• Unlike Wegener’s it do not involve lung and kidneys
• Diagnostic –biopsy and CD-56 marker
• Treatment –
• Chemotherapy
• Radiation therapy
• Calcium supplement as calcium is washed out in this disease