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Dr. Navin Kumaresan
Definition of Granuloma
Granuloma is a tumor like mass of nodular
granulation tissue with actively growing fibroblasts
and...
Classification of Granulomas
Bacterial

Fungal

 Rhinoscleroma

 Rhinosporidiosis  Wegener’s

 Syphilis
 Tuberculosis...
Respiratory Scleroma or
Mikulicz disease
Definition
Rhinoscleroma or scleroma is a chronic granulomatous
disease caused by gram negative bacillus Klebsiella

rhino...
Nasal involvement staging
1.

Catarrhal Stage: foul smelling purulent nasal
discharge (carpenter’s glue), not responding t...
Nasal involvement staging
3. Nodular/granulation stage: Non-ulcerative, painless

nodules which widen lower nose (Hebra no...
Rhinoscleroma nodules
Lesion in nose & palate
Hebra nose
Investigations
 X-ray PNS: Sinusitis + bone destruction
 Nasopharyngoscopy: Obliteration of nasopharynx due to

adhesion...
Histopathology
Granulomatous tissue characterized by:
1.

Mikulicz (foam) cells: histiocytes with foamy vacuolated

cytopl...
Histopathology
Histopathology (magnified)
Warthin-Starry stain: Mikulicz cell
Medical treatment
 Streptomycin 1 g OD im and Tetracycline 500 mg QID:

oral together for 4-6 weeks plus 1 month (till tw...
Radiotherapy & Surgery
 Radiotherapy: 3500 rad over 3 week
 Surgery: Removal of granulations & nodular lesions

with cau...
Tuberculosis
 Nose:
 C/F:

 Diagnosis:

Nasal Septum and ant. inferior
turbinate
Ulceration & Perforation of Nasal
Sept...
Syphilis
Acquired or Congenital
 Acquired:
Chancre of the vestibule of nose
Saddle Nose
 Congenital:
Saddle nose, cornea...
Leprosy
 Nose:

Nasal septum and ant. inferior turbinate

 C/F:

Nodular lesion
Atrophic rhinitis, dep. of nose,

destru...
Definition
 Chronic granulomatous infection of the mucous

membrane by Rhinosporidium seeberi, mainly
affecting nose & na...
Epidemiology
 88 – 95% cases in India, Pakistan & Sri Lanka
 Common in Kerala, Karnataka & Tamil Nadu

 Age:

20 – 40 y...
Incidence
 Nasal

78%

 Nasopharyngeal

16%

 Mixed (naso-nasopharyngeal, nasolacrimal)

05%

 Bizarre (Conjunctival /...
Clinical Presentation
 Epistaxis + nasal discharge + nose block
 Nasal mass: papillomatous or polypoid, granular,

friab...
Nasal Mass
Bleeding Nasal Mass
Nasal & Nasopharynx
Nasal & Nasopharynx
Oropharyngeal Mass
Mass in uvula
Cutaneous Granulomas
Mode of transmission
 Bathing in infected water; infective spores enter via

breached nasal mucosa
 Droplet infection by...
Life-cycle
Investigation
 Biopsy & Histopathological examination
 Microscopic examination of nasal discharge for spores

Sporangia ...
Haematoxylin & Eosin stain
Periodic Acid Schiff stain
Gomori Methenamine Silver stain
Medical Treatment
 Dapsone: arrests maturation of spores
 Dose: 100 mg OD orally (with meals) for one year

 Iron & Vit...
Surgical management
 General anesthesia with Oro-tracheal intubation
 2% Xylocaine with adrenaline infiltrated till

sur...
Fungal Sinusitis
A. Invasive (hyphae present in submucosa)
1.

Acute invasive

(< 4 weeks)

2.

Chronic invasive

(> 4 wee...
Aspergillosis
 Etiology: Aspergillus niger, As. fumigatus & As. flavus
 C/F: Acute Rhinitis, sinusitis, black membrane n...
Fungal Sinusitis
Mucormycosis
 Acute invasive fungal sinusitis by Mucormycosis
 Unilateral nasal discharge and black crusts due to

ischa...
Black crusting
Investigations
 Biopsy & HPE
 X-ray PNS: Sinusitis & focal bone destruction
 CT scan: rule out orbital & intracranial e...
C.T. scan coronal cuts
C.T. scan axial cuts
Aspergillosis Mucormycosis
Microscopic Difference
Aspergillosis hyphae

Mucormycosis hyphae

 Narrow

 Broad

 Septate

 Non-Septate

 Branching...
Immuno-fluorescent staining
Treatment
 Surgical debridement of necrotic debris
 Amphotericin B infusion: 1 mg / kg / day IV daily / on

alternate da...
Surgical debridement
Definition & Etiology
 Definition: Chronic systemic disease of unknown

etiology which may involve any organ with noncase...
Clinical Features
 Nasal discharge, nasal obstruction, epistaxis
 Mucosal: Reveals yellow nodules surrounded by

hyperae...
Lupus Pernio
Investigations
 Biopsy of nodule & HPE: Non-caseating hard

granuloma
 Kveim intradermal Test
Non-caseating granuloma
Non-caseating granuloma
Asteroid inclusion bodies
Chest X-ray findings
 Bilateral Hilar lymph

node enlargement with
or without diffuse
parenchymal infiltrates
Treatment
1.

Prednisolone

2. Chloroquine / Methotrexate + Prednisolone: In

patients not responding to steroids
3. Cutan...
Definition
Autoimmune condition
characterized by necrotizing
granulomas within nasal

cavity & lower respiratory
tract wit...
Clinical Features
 Nose & Para-nasal sinus: Epistaxis, nasal block,

extensive crusting, septal destruction & nasal colla...
Crusting in nasal cavity
External nasal deformity
Destruction of orbit & nose
Investigations
 E.S.R.
 Urine: microscopic examination
 CT scan: PNS
 Chest X-ray & CT scan
 Serum urea & creatinine
...
CT scan PNS: nasal destruction
CXR: nodular lesion with cavity
C.T. scan lungs

n
C - ANCA by Indirect
Immuno-fluorescence
Medical Treatment
1.

Triple therapy: Prednisolone + Cyclophosphamide
+ Cotrimoxazole

2. Plasma exchange & intravenous im...
Nasal  Granulomas13
Nasal  Granulomas13
Nasal  Granulomas13
Nasal  Granulomas13
Nasal  Granulomas13
Nasal  Granulomas13
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Nasal Granulomas13

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Nasal Granulomas13

  1. 1. Dr. Navin Kumaresan
  2. 2. Definition of Granuloma Granuloma is a tumor like mass of nodular granulation tissue with actively growing fibroblasts and capillary buds due to chronic inflammation with vasculitis.
  3. 3. Classification of Granulomas Bacterial Fungal  Rhinoscleroma  Rhinosporidiosis  Wegener’s  Syphilis  Tuberculosis  Lupus  Leprosy Unspecific cause granulomatosis  Non-healing midline Mucormycosis Granuloma Candidiasis* Histoplasmosis*  Sarcoidosis Blastomycosis*  Aspergillosis     * rare
  4. 4. Respiratory Scleroma or Mikulicz disease
  5. 5. Definition Rhinoscleroma or scleroma is a chronic granulomatous disease caused by gram negative bacillus Klebsiella rhinoscleromatis [von Frisch bacillus].
  6. 6. Nasal involvement staging 1. Catarrhal Stage: foul smelling purulent nasal discharge (carpenter’s glue), not responding to conventional antibiotics 2. Atrophic stage: foul smelling, honey-comb colour crusting in stenosed nasal cavity
  7. 7. Nasal involvement staging 3. Nodular/granulation stage: Non-ulcerative, painless nodules 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.
  8. 8. Rhinoscleroma nodules
  9. 9. Lesion in nose & palate
  10. 10. Hebra nose
  11. 11. Investigations  X-ray PNS: Sinusitis + bone destruction  Nasopharyngoscopy: Obliteration of nasopharynx due to adhesions between deformed V-shaped soft palate & posterior pharyngeal wall (Gothic sign)  Flexible laryngoscopy: Subglottic stenosis  Biopsy & HPE: Mikulicz cell & Russel body  Complement fixation test: Between patient’s serum & Frisch bacillus suspension.
  12. 12. 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
  13. 13. Histopathology
  14. 14. Histopathology (magnified)
  15. 15. Warthin-Starry stain: Mikulicz cell
  16. 16. Medical treatment  Streptomycin 1 g OD im and Tetracycline 500 mg QID: oral together for 4-6 weeks plus 1 month (till two consecutive negatives from biopsy)  Rifampicin: 650 mg OD orally
  17. 17. Radiotherapy & Surgery  Radiotherapy: 3500 rad over 3 week  Surgery: Removal of granulations & nodular lesions with cautery or laser  Plastic reconstructive surgery
  18. 18. Tuberculosis  Nose:  C/F:  Diagnosis: Nasal Septum and ant. inferior turbinate Ulceration & Perforation of Nasal Septum cartilaginous part  Treatment: Biopsy & AFS Anti-tubercular drugs  Skin: Lupus Vulgaris “apple-jelly”
  19. 19. Syphilis Acquired or Congenital  Acquired: Chancre of the vestibule of nose Saddle Nose  Congenital: Saddle nose, corneal opacities, deafness and Hutchinson’s teeth  Diagnosis:  Treatment: VDRL Benzathine pencillin
  20. 20. Leprosy  Nose: Nasal septum and ant. inferior turbinate  C/F: Nodular lesion Atrophic rhinitis, dep. of nose, destruction of ant. nasal spine  Diagnosis: Scraping & Biopsy  Treatment: Dapsone, Rifampin and Isoniazid
  21. 21. Definition  Chronic granulomatous infection of the mucous membrane by Rhinosporidium seeberi, mainly affecting nose & nasopharynx  Characterized by formation of friable, bleeding and polypoidal lesions  Other sites: lips, palate, conjunctiva, epiglottis, larynx, trachea, bronchi, skin, vulva, vagina, hand & feet.
  22. 22. Epidemiology  88 – 95% cases in India, Pakistan & Sri Lanka  Common in Kerala, Karnataka & Tamil Nadu  Age: 20 – 40 yrs.  Sex ratio: Male : Female 4:1
  23. 23. Incidence  Nasal 78%  Nasopharyngeal 16%  Mixed (naso-nasopharyngeal, nasolacrimal) 05%  Bizarre (Conjunctival / Tarsal / Cutaneous) rare
  24. 24. Clinical Presentation  Epistaxis + nasal discharge + nose block  Nasal mass: papillomatous or polypoid, granular, friable, bleeds on touch, pedunculated or sessile, pink surface studded with white dots [Strawberry appearance], involves septum & turbinates
  25. 25. Nasal Mass
  26. 26. Bleeding Nasal Mass
  27. 27. Nasal & Nasopharynx
  28. 28. Nasal & Nasopharynx
  29. 29. Oropharyngeal Mass
  30. 30. Mass in uvula
  31. 31. Cutaneous Granulomas
  32. 32. Mode of transmission  Bathing in infected water; infective spores enter via breached nasal mucosa  Droplet infection by cattle dung dust  Contact transmission: contaminated fingernails are responsible for cutaneous lesions  Haematogenous: to other sites in infected patient
  33. 33. Life-cycle
  34. 34. Investigation  Biopsy & Histopathological examination  Microscopic examination of nasal discharge for spores Sporangia of different shapes oval to round and bursting spores are present.
  35. 35. Haematoxylin & Eosin stain
  36. 36. Periodic Acid Schiff stain
  37. 37. Gomori Methenamine Silver stain
  38. 38. Medical Treatment  Dapsone: arrests maturation of spores  Dose: 100 mg OD orally (with meals) for one year  Iron & Vitamin supplements
  39. 39. Surgical management  General anesthesia with Oro-tracheal intubation  2% Xylocaine with adrenaline infiltrated till surrounding mucosa appears blanched  Mass avulsed using Luc’s forceps & suction  After removal of mass, its base cauterized  Laser excision: minimal bleeding
  40. 40. Fungal Sinusitis A. Invasive (hyphae present in submucosa) 1. Acute invasive (< 4 weeks) 2. Chronic invasive (> 4 weeks)  Granulomatous Non-granulomatous B. Non-invasive 1. Allergic Fungal ball Saprophytic Aspergillosis & Mucormycosis are common
  41. 41. Aspergillosis  Etiology: Aspergillus niger, As. fumigatus & As. flavus  C/F: Acute Rhinitis, sinusitis, black membrane nasal mucosa, semi-solid cheesy white fungal balls  Treatment: Surgical debridement & anti fungal drugs like Amphotericin B
  42. 42. Fungal Sinusitis
  43. 43. Mucormycosis  Acute invasive fungal sinusitis by Mucormycosis  Unilateral nasal discharge and black crusts due to ischaemic necrosis, proptosis, ophthalmoplegia  Fibrosis & granuloma formation seen in chronic invasive fungal sinusitis  Locally destructive with minimal bone erosion
  44. 44. Black crusting
  45. 45. Investigations  Biopsy & HPE  X-ray PNS: Sinusitis & focal bone destruction  CT scan: rule out orbital & intracranial extension  MRI: for vascular invasion & intracranial extension
  46. 46. C.T. scan coronal cuts
  47. 47. C.T. scan axial cuts
  48. 48. Aspergillosis Mucormycosis
  49. 49. Microscopic Difference Aspergillosis hyphae Mucormycosis hyphae  Narrow  Broad  Septate  Non-Septate  Branching at 45°  Branching at 90°  Dichotomous branching  Singular branching
  50. 50. Immuno-fluorescent staining
  51. 51. Treatment  Surgical debridement of necrotic debris  Amphotericin B infusion: 1 mg / kg / day IV daily / on alternate days  Itraconazole: 100 mg BD for 6-12 months
  52. 52. Surgical debridement
  53. 53. Definition & Etiology  Definition: Chronic systemic disease of unknown etiology which may involve any organ with noncaseating(hard) granulomatous inflammation  Etiology: Resembling Tuberculosis Unidentified organism
  54. 54. Clinical Features  Nasal discharge, nasal obstruction, epistaxis  Mucosal: Reveals yellow nodules surrounded by hyperaemic mucosa on anterior septum & turbinates  Skin (Lupus Pernio): Nasal tip shows symmetrical, bulbous, glistening violaceous lesion
  55. 55. Lupus Pernio
  56. 56. Investigations  Biopsy of nodule & HPE: Non-caseating hard granuloma  Kveim intradermal Test
  57. 57. Non-caseating granuloma
  58. 58. Non-caseating granuloma
  59. 59. Asteroid inclusion bodies
  60. 60. Chest X-ray findings  Bilateral Hilar lymph node enlargement with or without diffuse parenchymal infiltrates
  61. 61. Treatment 1. Prednisolone 2. Chloroquine / Methotrexate + Prednisolone: In patients not responding to steroids 3. Cutaneous lesions: Excised & skin grafted
  62. 62. Definition Autoimmune condition characterized by necrotizing granulomas within nasal cavity & lower respiratory tract with generalised vasculitis & focal glomerulonephritis
  63. 63. Clinical Features  Nose & Para-nasal sinus: Epistaxis, nasal block, extensive crusting, septal destruction & nasal collapse.  Pulmonary: Cough, haemoptysis  Renal: Hematuria & oliguria  Otological: Otalgia, deafness, facial nerve palsy  Oral & Pharyngeal: Hyperplastic, granular lesions
  64. 64. Crusting in nasal cavity
  65. 65. External nasal deformity
  66. 66. Destruction of orbit & nose
  67. 67. Investigations  E.S.R.  Urine: microscopic examination  CT scan: PNS  Chest X-ray & CT scan  Serum urea & creatinine  Biopsy & HPE
  68. 68. CT scan PNS: nasal destruction
  69. 69. CXR: nodular lesion with cavity
  70. 70. C.T. scan lungs n
  71. 71. C - ANCA by Indirect Immuno-fluorescence
  72. 72. Medical Treatment 1. Triple therapy: Prednisolone + Cyclophosphamide + Cotrimoxazole 2. Plasma exchange & intravenous immunoglobulin 3. Alkaline nasal douche for crusts

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