Bacterial

1. Granulomatous Diseases of
Nose
By :
Ritu Rajan

2. The granulomatous conditions affecting the nose and sinuses can be classified as :
Infective
Bacterial
Rhinoscleroma
Syphilis
Tuberculosis
Lupus
Leprosy
Fungal
Rhinosporidiosis
Aspergillosis
Mucormycosis
Histoplasmosis
Candidiasis
Blastomycosis
Inflammatory
Wegener’s granulomatosis,
Sarcoidosis
Churg-Strauss syndrome
Cholesterol Granuloma
Eosinophilic Granuloma
Neoplastic
T-cell Lymphoma
(Non-healing midline
granuloma)

3. • It is a chronic granulomatous disease
caused by Gram-negative bacillus called
Klebsiella Rhinoscleromatis or Frisch
bacillus.
• It is also known as Mikulicz disease or Hebra
Nose.
Rhinoscleroma

4. Etiological Factors –
• It is more common in second and third decades of life, though any age can be affected.
• The disease is endemic in several parts of the world (like India, Africa and Middle East).
• There is a slight female preponderance throughout the world.
• In India, it equally affects men and women.
• In India, it is seen more often in the northern than in the southern parts.
Pathology -
• Mode of infection is unknown.
• The disease starts in the nose and extends to nasopharynx, oropharynx, larynx (mostly
subglottic region), trachea and bronchi.

5. Clinical Features-
The four stages of this disease are :
1.Catarrhal : Foul smelling purulent nasal
discharge for weeks to months.
2. Atrophic stage : The features resemble that
that of atrophic rhinitis, including crust formation
and a foul smelling discharge (carpenter's glue).

6. 3. Granulomatous stage :
• Multiple granulomatous nodules, which enlarge
and coalesce, are seen in nasal mucosa.
• Subdermal infiltration of lower part of external
nose and upper lip gives “woody” feel.
• These are painless and non-ulcerative nodules.
• They can be found in pharynx, larynx, trachea
and bronchi also.
• They are initially bluish red and rubbery and
later become pale and indurated.
• These nodules never break down but ultimately
fibrose and progressively decrease in size.
• Regional lymph node involvement is extremely
infrequent.

7. 4. Cicatricial stage :
Fibrosis leads to stenosis of nares, distortion of upper lip and adhesions in the
nose, nasopharynx, oropharynx and larynx .
The subglottic stenosis manifests as respiratory distress.

8. Diagnosis –
Diagnosis in the atrophic stage is extremely difficult and the disease is usually
recognized only in the granulomatous or cicatrizing stage.
1. Biopsy :
Submucosa is infiltration with plasma cells, lymphocytes, eosinophils,
Mikulicz cells and Russell bodies.
2. Cultures of infected tissue:
The causative organisms are cultured and are diagnostic.

9. 1) Mikulicz cells –
These are large foam cells with a
central nucleus and vacuolated
cytoplasm containing causative bacilli.
2) Russell bodies -
These are homogenous eosinophilic
inclusion bodies found in the plasma
cells. They occur due to accumulation
of immunoglobulins secreted by the
plasma cells.
 The two most characteristic histologic features found in biopsy are :

10. 3. Levin test (complement fixation test) :
High titres of antibodies against K. Rhinoscleromatis has been
demonstrated. This indicates humoral immunity to be intact in these
patients.
4. Radioimaging :
MRI in the hypertrophic stage shows a soft tissue mass with mild to
marked high signal intensity in both Tl- and T2-weighted images.

11. Treatment-
Antibiotics :
Both streptomycin (1 g/day) and tetracycline (2 g/day) for 4–6 weeks.
Repeat if necessary after 1 month.
Treatment is stopped only when two consecutive cultures from the biopsy material are
negative.
Steroids : They can be combined to reduce fibrosis.
Surgery : In fourth stage of fibrosis and stenosis, surgery is required to establish the airway
and correct nasal deformity. A silastic stent facilitates re-epithelialization.
Radiotherapy : It is not effective.

12. • Rifampicin :
Nasal Instillation - 1 Amp of rifampicin 125mg diluted in 20mL saline solution and 2mL of the
solution is applied twice daily locally for a period of 8 weeks.
Nasal Infiltration - 1 Amp of rifampicin 125mg infiltrated into granulomas every other day
• Kailasa Regime :
Carbolic acid (0.2ml) + Glacial acetic acid (0.2ml) + Glycerine (0.4ml) + 10ml distilled water is
injected locally as 1 to 2 ml twice weekly at multiple sites of the lesion. This mixture causes
chemical necrosis of granuloma.Usually 8-10 injections lead to complete regression of
granuloma and restoration of normal nasal patency.
• Local application of 2 % acriflavin for a period of 8 weeks has been noted to be both
efficacious and nontoxic.

13. (1) Acquired Syphilis :
It occurs in three stages -
 Primary syphilis
 Secondary syphilis
 Tertiary syphilis
1) Primary syphilis :
It is also known as chancre.
It is rarely seen at external nose or inside the vestibule.
It appears as a hard, non painful ulcerated papule & is always associated with enlarged,
rubbery, and non-tender lymphadenopathy.
A sore or chancre develops at the site of inoculation 10-90 days following infection.
These lesions undergo spontaneous resolution within 6-10 weeks.
It should be differentiated from malignant neoplasms and furunculosis.
• Malignant neoplasms usually affect older ages and undergoes relentless
progression
• Furunculosis is a painful condition and it progresses to suppuration.

14. 2) Secondary Syphilis :
Most infectious of all the three stages
Symptoms 6-10 weeks after inoculation
Secondary syphilis is rarely recognized in the nose, as mucous patches hardly
ever occur on such a thin, attenuated mucous membrane.
The symptoms include:
 Simple catarrhal rhinitis (persistent)
 Crusting & fissuring of nasal vestibule
 Mucous patches in the pharynx
 Roseolar / papular skin rashes
 Shotty, enlarged,non-tender lymph nodes.
 The scar of the primary lesion in the genitals or elsewhere may be visible.

15. 3) Tertiary Syphilis :
Only one-third of secondary syphilis cases progress to show clinical manifestations of tertiary
syphilis.
This stage is commonly encountered in the nose.
Lesion is also known as gumma.
The lesion invades the mucous membrane, periosteum and bone.
The bony portion of the nasal septum is frequently affected causing septal perforation.
 The symptoms include:
 Pain / headache (worse during night)
 Swelling/obstruction of nose - swelling may be diffuse
or localized , is associated with offensive discharge,
bleeding and crusting of the nose
 Olfactory acuity diminishes
 Perforation of bony portion of nasal septum and
associated collapse of the bridge of the nose can
cause structural damage to the nasal architecture
(saddle nose deformity)
 There may also be associated secondary atrophic
rhinitis

16. DIAGNOSIS
• It is made on the basis of serological tests.Serological tests for syphilis
include – VDRL, TPHA, FTA-ABS.
The VDRL is a nontreponemal test and is relatively nonspecific
but becomes positive early (four to five weeks) and correlates well
with disease activity.
• Dark-field examination of moist or intentionally abraided dry lesions
may demonstrate the organism.
• Lymph node aspirates or tissue specimens (lymph nodes, liver, skin or
mucous membrane) may also be examined by silver stains or
immunofluorescence for detection of spirochaetes

17. TREATMENT
• Penicillin is the drug of choice : benzathine penicillin 2.4 million
units i.m. every week for 3 weeks with a total dose of 7.2 million
units.
• Nasal crusts are removed by irrigation with alkaline solution.
• Bony and cartilaginous sequestra should also be removed.
• Local yellow mercury oxide ointment or Dilute mercuric nitrate
ointment should be applied freely to the nasal vestibules.
• Cosmetic deformity is corrected after disease becomes inactive.

18. (2) Congenital syphilis -
Treponema pallidum pass from the infected mother to
the fetus through the placenta.
The primary stage is not evident in Congenital syphilis.
Any of the lesions of secondary and tertiary forms of
syphilis of nose can occur.
It classically begin during the 3rd week of life though it
may appear around the 3rd month also,
Mucous batches may be seen on the nose, mouth,
throat and larynx.
Radiating fissures form at the angle of mouth.
Blood-stained, thick, purulent nasal discharge block the
nostrils and produce a bubbling sound during breathing
termed as “syphilitic snuffles”.

19. Feeding problem results due to nasal obstruction.
Chronic rhinitis, septal perforation, palatal
perforation is common.
Gummatous and destructive lesions occur most
commonly at puberty.
Other stigmata of syphilis like Hutchinson's incisors,
Moon's molars, interstitial keratitis and corneal
opacities may be present
Nerve deafness can develop due to the
involvement of the 8th cranial nerve endings. It
presents as bilateral progressive loss of hearing
which may become total.
Serologic tests for syphilis will invariably be negative

20. Management :
• In snuffles, the airway must be restored for feeding.
• The nasal discharge is removed by gentle suction and irrigation
and the use of local drops of 0.5 percent ephedrine solution or
simple normal saline, and by hyper extending the head before
feeding.
• In the tertiary forms, simple nasal toilet by syringing with
isotonic alkaline douche solution will remove the crusts and
discharge.
• Yellow mercuric oxide ointment may be applied frequently to the
nasal vestibules.

21. The nose is involved as a part of systemic disease, more often in the lepromatous than
tuberculoid or dimorphous forms of disease.
Nasal involvement in :
Tuberculoid Leprosy -
 Solitary skin lesions with cutaneous anaesthetic patches.
 There can be vestibule skin involvement, but there is no mucosal involvement.
Leprosy
Tuberculoid Leprosy Lepromatous Leprosy
Strong host resistance
Non-infective
Localized
Poor host resistance
Infective
Systemic with widespread
involvement of tissues
2 distinct polar forms of disease with the entire spectrum in between :

22. Lepromatous Leprosy -
 There is skin, nerve & mucosal involvement
 Nasal mucosa scraping microscopy shows typical cigar pattern Lepra bacilli
 Early Cases -
 Infection starts in the anterior part of nasal septum and anterior
end of inferior turbinate.
 Initially, there is excessive nasal discharge with red and swollen
mucosa.
 Later , there is
o nodular thickening of nasal mucosa (Nodules are paler than the
surrounding mucosa with a yellowish tinge)
o crust formation
o Blood stained discharge

23.  Advanced cases -
 Nodular lesions on the septum may
ulcerate and cause perforation.
 Both the bony and cartilaginous
portions of nasal septum are destroyed
due to perichondritis and periosteitis
(nasal bridge collapse).
 There can be sequelae like Atrophic
Rhinitis, septal perforation & dorsal
saddling.
 Anterior nasal spine destruction is
seen.
 Radiographs showing the absence or
erosion of anterior nasal spine are
virtually diagnostic of Lepromatous
leprosy.
 Hyposmia is seen in 40% of cases.

24. Diagnosis :
 Microscopy of nasal discharge and nasal mucosa scrapings from the anterior end of
the inferior turbinate for acid-fast bacilli.
Quantitative estimation of the bacterial count is obtained by noting the density of the
bacilli in the smear which is recorded as the bacterial index. In addition, the
morphology of the bacilli enables the observer to assess their viability.
 Histology of nasal mucosa : Lepra cells seen.
 Radiology: X-ray of paranasal sinuses in Waters view and lateral view reveals erosion of
the anterior nasal spine and alveolar maxillary process and thick sinus mucosa.

25. General Treatment :
 Improve general hygiene.
 Regular nasal douching to clear the discharge and the crusts.
 Treat secondary infection.
Specific Treatment :
• For multi-bacillary disease , the World Health Organization recommends a triple oral
drug-regimen of :
• rifampin, 600 mg once a month;
• dapsone, 100 mg daily; and
• clofazimine, 300 mg once a month and 50 mg daily for 12 months,
• For pauci-bacillary disease, the recommendation is :
• rifampin, 600 mg once a month, and
• dapsone, 100 mg daily for 6 months.

26. Primary tuberculosis of nose is rare. More often it is
secondary to lung tuberculosis.
Anterior part of nasal septum and anterior end of inferior
turbinate are the sites commonly involved.
First, there is nodular infiltration followed later by
ulceration and perforation of nasal septum in its
cartilaginous part.
Tuberculosis

27. Symptoms -
• Nasal discharge
• Nasal obstruction
• Pain
• Epistaxis
• H/O haemoptysis
• Evening rise of temperature
• Cough
Signs -
• Bright, red nodular thickening of septum with or without ulceration, bilaterally
• Septum—Cartilaginous part is affected.
• Septum—Ulceration, perforation
• Fibrosis seen in late stages

28. Lupus vulgaris (also known as Tuberculosis luposa) are painful cutaneous
tuberculosis skin lesions with nodular appearance, most often on the face
around the nose, eyelids, lips, cheeks, ears and neck.
Indolent and Chronic from of Tuberculosis infection
F:M = 2:1 (young adults)
It is mostly prevalent in Temperate Climate.
Starts at Vestibule, extends to adjoining skin and mucosa.
Most common location is the mucocutaneous junction.
Lupus vulgaris

29. Symptoms
• Nasal obstruction
• Nasal discharge (foul smelling)
• Epistaxis
• Deformity of the nose
Signs -
• Early stage—reddish, firm nodule
• Late stage—superficial ulceration
• Crusting
• Butterfly appearance
• Ulceration followed by fibrosis
• Perforation of the cartilaginous part of the nasal septum

30. Complications :
• Pulmonary tuberculosis may develop
• Dacryocystitis
• Nasopharyngeal lupus
• Atrophic rhinitis
• Epithelioma in the infected tissue
• Lupus of the face and nasopharynx
• Malignant transformation

31. Investigations –
• Blood examination
• Bacteriological examination of the discharge may show tubercle
bacilli
• Biopsy—Typical tubercle with sparse caseation necrosis
• Chest X Ray—Pulmonary tuberculosis may develop
• Mantoux test—strongly positive
• Diascopy –
o Diascopy is a test for blanchability performed by applying
pressure with a finger or glass slide and observing color
changes.
o In lupus, upon diascopy, thr reddish brown nodule become
more prominent by contrast— Apple jelly nodules

32. Treatment :
• Anti-tubercular treatment therapy for 6-9 months.
• Improve general hygiene.
• Regular nasal douching to clear the discharge and the crusts.
• Calciferol (Vitamin Da) I ,50,000 units daily for 6-9 months
• Reconstructive surgery of the residual nasal deformity after arrest of
the disease.