nasal granuloma

Nasal GranulomasDr. Navin Kumaresan

Definition of GranulomaGranuloma is a tumor like mass of nodular

granulation tissue with actively growing

fibroblasts and capillary buds due to

chronic inflammation with vasculitis.

Classification of GranulomasBacterial FungalRhinoscleromaSyphilisTuberculosisLupusLeprosy

RhinosporidiosisAspergillosisMucormycosisCandidiasis*Histoplasmosis*Blastomycosis*

Unspecific causeWegener’s

granulomatosisNon-healing midline

GranulomaSarcoidosis

* rare

Rhinoscleroma Respiratory Scleroma orMikulicz disease

Definition

Rhinoscleroma or scleroma is a chronic

granulomatous disease caused by gram

negative bacillus Klebsiella rhinoscleromatis

[von Frisch bacillus].

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

Nasal involvement staging3. 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.

Rhinoscleroma nodules

Lesion in nose & palate

Hebra nose

InvestigationsX-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.

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

Histopathology

Histopathology (magnified)

Warthin-Starry stain: Mikulicz cell

Medical treatmentStreptomycin 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

Radiotherapy & SurgeryRadiotherapy: 3500 rad over 3 week

Surgery: Removal of granulations & nodular

lesions with cautery or laser

Plastic reconstructive surgery

TuberculosisNose: Nasal Septum and ant.

inferior turbinateC/F: Ulceration & Perforation of

Nasal Septum cartilaginous part

Diagnosis: Biopsy & AFSTreatment: Anti-tubercular drugs

Skin: Lupus Vulgaris “apple-jelly”

SyphilisAcquired or Congenital

Acquired: Chancre of the vestibule of nose

Saddle NoseCongenital: Saddle nose, corneal

opacities, deafness and Hutchinson’s teeth

Diagnosis: VDRLTreatment: Benzathine pencillin

LeprosyNose: 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

Rhinosporidiosis

DefinitionChronic 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.

Epidemiology88 – 95% cases in India, Pakistan & Sri Lanka

Common in Kerala, Karnataka & Tamil Nadu

Age: 20 – 40 yrs.

Sex ratio: Male : Female 4 : 1

IncidenceNasal 78%

Nasopharyngeal 16%

Mixed (naso-nasopharyngeal, nasolacrimal) 05%

Bizarre (Conjunctival / Tarsal / Cutaneous) rare

Clinical PresentationEpistaxis + 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

Nasal Mass

Bleeding Nasal Mass

Nasal & Nasopharynx

Nasal & Nasopharynx

Oropharyngeal Mass

Mass in uvula

Cutaneous Granulomas

Mode of transmissionBathing 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

Life-cycle

InvestigationBiopsy & Histopathological examination

Microscopic examination of nasal discharge for

spores

Sporangia of different shapes oval to round

and bursting spores are present.

Haematoxylin & Eosin stain

Periodic Acid Schiff stain

Gomori Methenamine Silver stain

Medical TreatmentDapsone: arrests maturation of spores

Dose: 100 mg OD orally (with meals) for one

year

Iron & Vitamin supplements

Surgical managementGeneral 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

Fungal granulomas

Fungal SinusitisA. 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

AspergillosisEtiology: 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

Fungal Sinusitis

MucormycosisAcute 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

Black crusting

InvestigationsBiopsy & HPE

X-ray PNS: Sinusitis & focal bone destruction

CT scan: rule out orbital & intracranial

extension

MRI: for vascular invasion & intracranial

extension

C.T. scan coronal cuts

C.T. scan axial cuts

Aspergillosis Mucormycosis

Microscopic DifferenceAspergillosis hyphae

Mucormycosis hyphae

Narrow

Septate

Branching at 45°

Dichotomous

branching

Broad

Non-Septate

Branching at 90°

Singular branching

Immuno-fluorescent staining

TreatmentSurgical debridement of necrotic debris

Amphotericin B infusion: 1 mg / kg / day IV

daily / on alternate days

Itraconazole: 100 mg BD for 6-12 months

Surgical debridement

Sarcoidosis

Definition & EtiologyDefinition: Chronic systemic disease of

unknown etiology which may involve any

organ with non- caseating(hard)

granulomatous inflammation

Etiology: Resembling Tuberculosis

Unidentified organism

Clinical FeaturesNasal 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

Lupus Pernio

InvestigationsBiopsy of nodule & HPE: Non-caseating hard

granuloma

Kveim intradermal Test

Non-caseating granuloma

Non-caseating granuloma

Asteroid inclusion bodies

Chest X-ray findingsBilateral Hilar lymph

node enlargement

with or without

diffuse parenchymal

infiltrates

Treatment

1. Prednisolone

2. Chloroquine / Methotrexate + Prednisolone:

In patients not responding to steroids

3. Cutaneous lesions: Excised & skin grafted

Wegener’s granuloma

Definition Autoimmune condition

characterized by

necrotizing granulomas

within nasal cavity &

lower respiratory tract

with generalised

vasculitis & focal

glomerulonephritis

Clinical FeaturesNose & 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

Crusting in nasal cavity

External nasal deformity

Destruction of orbit & nose

InvestigationsE.S.R.

Urine: microscopic examination

CT scan: PNS

Chest X-ray & CT scan

Serum urea & creatinine

Biopsy & HPE

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

immunoglobulin

3. Alkaline nasal douche for crusts