Etiopathogenesis, Clinical features and Management

1. Rhinoscleroma

3. History

4. Rhinoscleroma
 Progressivegranulomatousdisease
 Commencing in the nose and later extending into
the nasopharynx and oropharynx, the larynx
and sometimes the trachea and bronchi.

5. Aetiology ismultifactorial and usually seen in low
socio economic statusand poor domestic hygiene
• Laryngeal involvement  designated as respiratory
scleroma, rather than rhinoscleroma
- Amoils and Shindo (1996) series of 22 pt with
rhinoscleroma. 13 had laryngeal involvement, of which 3
underwent tracheostomy

6. Etiopathology :
 Caused by gram negativebacilli Klebsiella rhinoscleromatis /
Frisch bacilli / diplo bacillus.
 F>M, any age
 Difficult to isolate
 Histology: Granulomatoustissue infiltrates in the
submucosa, characterized by thepresence of plasma
cells, lymphocytes and eosinophils
 Characteristic histological features= Mikulicz cells and
Russel body

7. Russel bodies
Miculicz cells

8. CLINICAL FEATURES
Threestages–
1.The atrophic stage
Thefeaturesresemblethat of atrophic rhinitis,
including crust formation and afoul smelling
discharge

9. 2. Granulomatous or proliferative (or nodular)
stage.
- Non-ulcerativenodules- bluish red and rubbery and
later becomepaler and indurated.
- Thesenodulesnever break down but fibrose and
decreasein size

11. Hebra Nose

12. 3. Cicatrizing stage:-
 Adhesions and stenosisdistort thenormal anatomy
 Extend to involvethelacrimal sac, maxillary sinus,
nasopharynx, hard palate, tracheaand main bronchi
 Boneinvolvement has also been reported
 “Tapir’s nose”
 Lymphatic spread isuncommon becauseof extensive
fibroustissuedeposition
 Occasionally, malignant change

13. Complications :
1. External nose deformity
2. Vestibular stenosis
3. Cicatrization of soft palate
4. Nasal regurgitation
5. Tracheal stenosis

14. Diagnosis :
1. Culture on Mac Conkey’s agar
2. Levin test (complement fixation test) :
- High titresof antibodiesagainst K. Rhinoscleromatishasbeen
demonstrated.
3. Microbiological examination and aconfirmatoryBiopsy

15. TreaTmenT :
- Usually self limiting courseof itsown accord
ending in thecicatrizing stage
- Bactericidal antibioticsin largedosesfor a
minimum of four to six weeks
Traditionally Used : streptomycin (1gm i.m)
and tetracycline(2 g/day) for 4-6wks

16. Recently used :
 Oral rifampicin(450mg for aperiod of 6
weeks), sulphamethoxazole-trimethoprim
combination, and ciprofloxacin.
 Local application of 2 % acriflavin for a
period of 8 weeks has been noted to be both
efficacious and nontoxic.
 Intralesional steroids havebeen tried

17. Kailasa Regime :
- Carbolic acid (0.2ml) + Glacial acetic acid
(0.2ml) + Glycerine(0.4ml) + 10ml distilled
water isinjected locally as1 to 2 ml twice
weekly at multiplesitesof thelesion.
- Usually 8-10 injections lead to complete
regression of granuloma and restoration of
normal nasal patency. This mixture causes
chemical necrosis of granuloma
-

18. Irradiation
- Total doseof 3000-3500 Gy over three weeks

19. References
1. Scott and Brown Otorhinolaryngology, Head
and Neck surgery 7th
edition
2. Cummings Otolaryngology Head and Neck
Surgery, 5th
edition
3. Diseases of ear, nose, throat. P.L. Dhingra 6th
edition
4. Amoils CP, Shindo ML. Laryngotracheal
manifestations of rhinoscleroma. Ann Otol Rhinol
Laryngol. 1996;105:336-340.