6. Tuberculosis
• Associated with primary pulmonary tuberculosis
• Affects anterior septum and anterior part of inferior
turbinate
• C/F :
– Nasal obstruction, discharge, pain
– Red, nodular thickening, ulceration +/-
– Perforation /scarring of the cartilagenous septum
7. Lupus vulgaris (Cutaneous tuberculosis)
• Indolent and chronic form of
tuberculous lesions of the skin of
nose
• May cause epitheliomatous
reaction of squamous epithelium
• Apple jelly nodules on diascopy
• Scarring more severe
8. Diagnosis
• History of previous TB or active pulmonary TB
• Mantoux test : Skin test for delayed hypersensitivity
by injection of purified protein derivative
• Microscopy : Ziehl-Neelsen stain
• Culture (6-8 weeks) : Lowenstein -Jensen medium,
Middlebrook's medium
• Polymerase chain reaction (PCR)
• Histopathological examination of biopsy specimen
16. • Organism : Treponema
pallidum
• Endarteritis of small
blood vessels with
secondary hypertrophic
changes in endothelium
leads to endarteritis
obliterans and luminal
obliteration
17. Congenital syphilis
• Nose always involved
• In Infants :
– ‘Snuffles’ 3 weeks - 3 months
– Simple catarrhal rhinitis becomes purulent with
secondary fissuring and excoriation of nasal
vestibule, upper lip
– Nasal obstruction interferes with suckling and
nutrition
20. • At puberty
– Gummatous & destructive
lesions in the mucous
membrane, periosteum &
bone of nasal septum
– Ulceration & destruction
leads to secondary
atrophic rhinitis and
saddle nose deformity
21. Tertiary syphilis
• Most commonly involves the
nose
• Pathological lesion: Gumma
• Begins as a subcutaneous
nodule, progresses to involve
overlying skin and breaks
down to form punched out
destructive ulcer
22. • Posterior bony septal perforation and extensive
necrosis of nasal and facial tissues Saddle nose
deformity
• Early symptoms:
– Pain over the nasal bridge (worse at night), swelling
and obstruction
– Offensive discharge, bleeding, crusting, anosmia
(secondary atrophic rhinitis)
• Severe scarring of nose
24. Treatment
• Parenteral penicillin: drug of choice for all stages
– Benzathine penicillin G (2.4 IU IM, single dose)
• Local treatment
– Clearance of crusts and regular cleansing by
copious alkaline douches (1-3 times a day)
– Yellow mercury oxide ointment applied locally
• Reconstructive surgery
25. Rhinoscleroma (Respiratory scleroma)
• Progressive granulomatous disease commencing in nose and
extending into the nasopharynx, oropharynx, larynx ,
sometimes to trachea and bronchi caused by Klebsiella
rhinoscleromatis (Frisch bacillus)
26. Stages
• Catarrhal : Foul smelling purulent rhinorrhea persisting for
weeks to months
• Atrophic : Foul smelling large nasal plaques or crusts
(simulates atrophic rhinitis )
• Granulomatous (proliferative/nodular) :
– Granulomatous nodules enlarge and coalesce (Tapir nose)
– Pathologic changes most characteristic
– K. rhinoscleromatis most frequently isolated
• Cicatrizing : Adhesions and stenosis distort normal anatomy
(Hebra nose)
28. Diagnosis
• High index of suspicion : Coalescent, enlarged granulomatous
nodules at or near the nasal vestibule, diffuse and bilateral
• Microscopy : Silver impregnation stains, Wartin -Starry or
Giemsa stain
• Culture of infected tissue: K. rhinoscleromatis in 98%
• Complement fixation test
• Biopsy showing characteristic histological features
29. Histopathology
• Mikulicz cells
– Scattered large foam cells with a
central nucleus and vacuolated
cytoplasm containing bacilli
(transformed macrophages that
have ingested the bacillus)
• Russel bodies
– Resemble plasma cells with an
eccentric nucleus and deep eosin
staining cytoplasm
30. Treatment
• High dose of bactericidal antibiotics
– Minimum of 4-6 weeks , continued until 2 consecutive
cultures from biopsy material are proven negative
• Streptomycin (1 g/day), Tetracycline (2g/day)
• Rifampicin, Sulphamethoxazole – trimethoprim, Ciprofloxacin
• Local application of 2% acriflavin for 8 weeks
• Irradiation: 3000-3500 Gy over 3 weeks
• Surgical debridement
• Reconstructive surgery
31. Rhinosporidiosis
• Chronic granulomatous infection that affects the nasal mucosa
(70%), ocular conjunctiva and other mucosa
• Organism: Rhinosporidium seeberi
• Common in Eastern terai belt of Nepal (Janakpur, Rajbiraj)
• Contacted by immersion in contaminated water of ponds
containing animal dungs
32. Clinical Features
• Insidious onset of painless, gradual nasal obstruction
• Nose
– Large sessile or pedunculated lesions
– Leafy, papillomatous or proliferative lesions studded with
white dots
– Pink, red or purple in colour
• Vascular and bleed on touch
33.
34. • Histopathology (Diagnostic)
– Pseudoepitheliomatous squamous cell metaplasia
overlies numerous multisized, microscopic globular
cysts called sporangia with thick wall and an
operculum
– Large sporangia filled with endospores
– Granulomatous reaction of fibrous tissue,
neutrophils, plasma cells, and lymphocytes
35. Treatment
• Complete surgical excision with cauterization of the base
• Dapsone
– 100mg/day for 6 months
– Arrest maturation of sporangia and accentuated
granulomatous response with fibrosis
• Amphotericin B
• Medical management is not very effective
37. • Triad of
–Granulomatous inflammation of the upper
and lower respiratory tract
–Necrotizing vasculitis affecting small to
medium sized vessels
–Necrotizing glomerulonephritis
39. Types
• Type 1: Limited to nose
– Chronic nonspecific rhinitis, serosanguinous
nasal discharge , nose pain, crusting , septal
perforation
• Type 2: More systemic symptoms
– Hemoptysis, cavity in chest
• Type 3: Widely disseminated
– Multiple organ failure
40. • C/F
– Progressive malaise, pyrexia, weight loss
– Nose and sinuses involved in > 80 %
• Mucosal edema , Nasal obstruction, sinusitis
• Crusting
• Septal perforation
• Saddle nose
– Palatal ulcers/ perforation
43. • Otological symptoms: Recurrent AOM, OME
• Laryngeal and tracheal symptoms: unusual, most
commonly subglottic & upper trachea
• Central nervous system: (10-15%)
• Others: ulceration of skin in distal arms & legs,
polymyalgia, poly arthritis
44. Investigations
• Erythrocyte sedimentation rate (ESR) : Raised
• C - reactive protein (CRP) : +ve
• C – ANCA : positive in 95% - 60% if localized disease
• Serum angiotensin converting enzyme (SACE): Raised
• Blood urea, Serum creatinine
• Urine RE /ME
• Chest X-ray/ CT chest : Nodular lesions with cavitation
• Tissue biopsy : typical histological features
45.
46. • CT / MRI :
– Non-specific mucosal thickening in nose or PNS
(86%)
– Evidence of bone destruction (75%)
– New bone formation in walls of sinus (50%)
– Orbit affected (30%)
– MRI shows fat signal from sclerotic sinus wall
– Chest may show progressive cavitation and fibrosis
47. • Histological features
– Fibrinoid vascular necrosis
– Granulomas are epithelial cell type (large, irregular
and lined with histiocytes)
– May show fibrinoid necrosis or be non-necrotic
– Multinucleated giant cells + eosinophils
48. Criteria for the diagnosis of Wegener's granulomatosis
Criteria Definition
Nasal or oral
inflammation
Painful or painless oral ulcers or purulent or
bloody nasal discharge
Abnormal chest x-ray
Presence of nodules, fixed infiltrates or cavities
Urinary sediment
Microhematuria (over 5 RBC /HPF) or red cell
casts in urine sediment
Granulomatous
inflammation on biopsy
Histology showing granulomatous inflammation
within wall of artery or in peri or extravascular
area
Any 2 or more of four criteria
49. Treatment
• Prednisone (1 mg/kg per day) + Cyclophosphamide (2 mg/kg
per day) for 1 month
– Prednisolone tapered to alternate days for 2 months
stopped after achievement of complete response
– Cyclophosphamide continued for 6 months to 1 year
tapered over a few months
• Trimethoprim - Sulphamethoxazole, Azathioprine (200
mg/day)
• Methotrexate, Cyclosporin, Rituximab
