This document discusses granulomas and provides classifications and definitions. It defines a granuloma as a tumor-like mass of nodular granulation tissue due to chronic inflammation. Granulomas are classified as bacterial, fungal, or of unspecified cause. Examples of bacterial granulomas include rhinoscleroma, syphilis, tuberculosis, and leprosy. Fungal granulomas include rhinosporidiosis, aspergillosis, mucormycosis, and candidiasis. Unspecific granulomas include Wegener's granulomatosis, non-healing midline granuloma, and sarcoidosis. The document then provides further details on specific granulomas such as

1. Dr. Navin Kumaresan

3. 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.

4. 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

5. Respiratory Scleroma or
Mikulicz disease

6. Definition
Rhinoscleroma or scleroma is a chronic granulomatous
disease caused by gram negative bacillus Klebsiella
rhinoscleromatis [von Frisch bacillus].

7. 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

8. 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.

9. Rhinoscleroma nodules

10. Lesion in nose & palate

11. Hebra nose

12. 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.

13. 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

14. Histopathology

15. Histopathology (magnified)

16. Warthin-Starry stain: Mikulicz cell

17. 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

18. Radiotherapy & Surgery
 Radiotherapy: 3500 rad over 3 week
 Surgery: Removal of granulations & nodular lesions
with cautery or laser
 Plastic reconstructive surgery

19. 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”

20. 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

21. 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

23. 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.

24. 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

25. Incidence
 Nasal
78%
 Nasopharyngeal
16%
 Mixed (naso-nasopharyngeal, nasolacrimal)
05%
 Bizarre (Conjunctival / Tarsal / Cutaneous)
rare

26. 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

27. Nasal Mass

28. Bleeding Nasal Mass

29. Nasal & Nasopharynx

30. Nasal & Nasopharynx

31. Oropharyngeal Mass

32. Mass in uvula

33. Cutaneous Granulomas

34. 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

35. Life-cycle

36. Investigation
 Biopsy & Histopathological examination
 Microscopic examination of nasal discharge for spores
Sporangia of different shapes oval to round and
bursting spores are present.

37. Haematoxylin & Eosin stain

38. Periodic Acid Schiff stain

39. Gomori Methenamine Silver stain

40. Medical Treatment
 Dapsone: arrests maturation of spores
 Dose: 100 mg OD orally (with meals) for one year
 Iron & Vitamin supplements

41. 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

43. 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

44. 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

45. Fungal Sinusitis

46. 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

47. Black crusting

48. Investigations
 Biopsy & HPE
 X-ray PNS: Sinusitis & focal bone destruction
 CT scan: rule out orbital & intracranial extension
 MRI: for vascular invasion & intracranial extension

49. C.T. scan coronal cuts

50. C.T. scan axial cuts

51. Aspergillosis Mucormycosis

52. Microscopic Difference
Aspergillosis hyphae
Mucormycosis hyphae
 Narrow
 Broad
 Septate
 Non-Septate
 Branching at 45°
 Branching at 90°
 Dichotomous branching
 Singular branching

53. Immuno-fluorescent staining

54. 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

55. Surgical debridement

57. Definition & Etiology
 Definition: Chronic systemic disease of unknown
etiology which may involve any organ with noncaseating(hard) granulomatous inflammation
 Etiology: Resembling Tuberculosis
Unidentified organism

58. 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

59. Lupus Pernio

60. Investigations
 Biopsy of nodule & HPE: Non-caseating hard
granuloma
 Kveim intradermal Test

61. Non-caseating granuloma

62. Non-caseating granuloma

63. Asteroid inclusion bodies

64. Chest X-ray findings
 Bilateral Hilar lymph
node enlargement with
or without diffuse
parenchymal infiltrates

65. Treatment
1.
Prednisolone
2. Chloroquine / Methotrexate + Prednisolone: In
patients not responding to steroids
3. Cutaneous lesions: Excised & skin grafted

67. Definition
Autoimmune condition
characterized by necrotizing
granulomas within nasal
cavity & lower respiratory
tract with generalised
vasculitis & focal
glomerulonephritis

68. 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

69. Crusting in nasal cavity

70. External nasal deformity

71. Destruction of orbit & nose

72. Investigations
 E.S.R.
 Urine: microscopic examination
 CT scan: PNS
 Chest X-ray & CT scan
 Serum urea & creatinine
 Biopsy & HPE

73. CT scan PNS: nasal destruction

74. CXR: nodular lesion with cavity

75. C.T. scan lungs
n

76. C - ANCA by Indirect
Immuno-fluorescence

77. Medical Treatment
1.
Triple therapy: Prednisolone + Cyclophosphamide
+ Cotrimoxazole
2. Plasma exchange & intravenous immunoglobulin
3. Alkaline nasal douche for crusts