with large round eosinophilic material Histopathology Histopathology (magnified) Warthin-Starry stain: Mikulicz cell
Medical treatment Total duration = 6 wk to 6 months (or negative cultures from 2 consecutive biopsy materials) Streptomycin: 1g OD intramuscularly + Tetracycline: 500 mg QID orally
Rifampicin: 450 mg OD orally Radiotherapy & Surgery R.T.: 3500 cGy over 3 wk along with antibiotics halts progress of resistant cases Removal of granulations & nodular lesions with cautery or laser
Dilatation of airway combined with insertion of Polythene tubes for 6 8 wk Plastic reconstructive surgery: after 3 negative cultures from biopsies Tuberculosis
Sino-nasal Tuberculosis Rare. Usually due to spread from pulmonary TB Ulcers, nodules, polypoid masses in cartilaginous part of septum, lateral wall & inferior turbinate H.P.E.: epithelioid granulomas with Langhans multi-nucleate giant cells, caseating necrosis AFB may be found on nasal smears
Treatment: INH + Rmp + Etb + Pzn X 6 9 mth Acid Fast Bacillus Histopathology Histopathology magnified
Lupus Vulgaris Tuberculosis of skin (of nose & face) Can mimic a squamous cell carcinoma Rapid course / indolent chronic form Nodules have apple jelly appearance on diascopy Nodules ulcerate & crust scarring + distortion of
nasal alae, nasal tip & vestibule Tx: A.T.T. surgical reconstruction if required Lupus vulgaris Apple jelly nodule
Syphilis Primary syphilis Lesions develop 3-4 wks after contact Chancre on external nose / vestibule Hard, painful, ulcerated papule Enlarged, rubbery, non-tender node
Spontaneous regression in 6-10 wks Primary syphilis chancre Secondary syphilis Most infectious stage Symptoms appear 6-10 wks after inoculation
Persistent, catarrhal rhinitis Crusting / fissuring of nasal vestibules Mucous patches in nose/pharynx Roseolar, papular rashes on skin Pyrexia, shotty enlargement of lymph nodes Secondary syphilis rashes
Rash of secondary syphilis Congenital syphilis Infants: snuffles, 3 wks to 3 mth after birth Fissuring / excoriation of upper lip / vestibule Mucosal rashes, atrophic rhinitis, saddle nose
Rhinosporidiosis Definition Chronic granulomatous infection by Rhinosporidium seeberi, mainly affecting mucous membranes of nose & nasopharynx; characterized by formation of
friable, bleeding or polypoidal lesions Other sites: lips, palate, antrum, conjunctiva, lacrimal sac, larynx, trachea, bronchus, ear, scalp, skin, penis, vulva, vagina, hand & feet. What is Rhinosporidium seeberi? Bizarre fungus: obsolete theory
Microcystis aeruginosa: a unicellular prokaryotic cyanobacterium (Karwitha Aluwalia) Aquatic parasite (Protoctistan Mesomycetozoa) according to recent 18S ribosomal ribonucleic acid (rRNA) gene analysis Epidemiology
88 95% cases are found in India & Sri Lanka Common in Kerala, Karnataka & Tamil Nadu Age : 20 40 yrs. Male: Female ratio = 4 : 1 People with blood group O more susceptible Classification
Benign a. Nasal ---------------------------------------------------- 78% b. Nasopharyngeal -------------------------------------- 16% c. Mixed (naso-nasopharyngeal, nasolacrimal) -- 05% d. Bizarre (Conjunctival / Tarsal / Cutaneous) --- rare Malignant ------------------------------------------------- rare Generalized, deep seated & difficult to eradicate
Clinical Presentation Epistaxis + viscid nasal discharge + nose block Nasal mass: papillomatous or polypoid, granular, friable, bleeds on touch, pedunculated or sessile, pink surface studded with white dots [Strawberry apperance], involves septum & turbinates
Nasal mucosa: edematous, hyperemic, covered with copious viscid secretions containing spores Lymph nodes: not affected Nasal mass Bleeding nasal mass
Nasal + Nasopharynx Nasal + Nasopharynx Oropharyngeal mass
Mass in uvula Cutaneous granulomas Mode of transmission 1. Bathing (head dipping) in infected water: infective
spores enter via breached nasal mucosa 2. Droplet infection by cattle dung dust 3. Contact transmission: contaminated fingernails are responsible for cutaneous lesions Life cycle
Life cycle begins as oval / spherical Trophocyte [8 m] with single nucleus. m] with single nucleus. Nuclear + cytoplasmic division of Trophocyte results in intermediate Sporangium. This enlarges into a mature Sporangium [120 300 m] with single nucleus. m] with chitinous wall & contains 16,000 Endospores. Mature sporangium
ruptures during sporulation & releases infective endospores via its Germinal pore. Endospores Differential diagnosis 1. Infected antrochoanal polyp 2. Inverted papilloma 3. Other granulomas:
Rhinoscleroma Tuberculosis Leprosy Fungal (aspergillosis, mucormycosis) 4. Malignancy of nose / paranasal sinus Investigations
Gomori Methenamine Silver stain Medical Treatment Dapsone: arrests maturation of spores (inhibits folic acid synthesis) & increases granulomatous response with fibrosis
Dose: 100 mg OD orally (with meals) for one year Give Iron & Vitamin supplements Side effects: Methemoglobinemia & anemia Surgical management At least 2 pints blood to be kept ready General anesthesia with Oro-tracheal intubation
2% Xylocaine (with 1:2 lakh adrenaline) infiltrated till surrounding mucosa appears blanched Mass avulsed using Lucs forceps & suction After removal of mass, its base cauterized Avoid traumatic implantation during surgery Laser excision: minimal bleeding, no implantation
Fungal granulomas Fungal Sinusitis A. Invasive (hyphae present in submucosa) 1. Acute invasive or fulminant (< 4 weeks) 2. Chronic invasive or indolent (> 4 weeks) Granulomatous
Non - granulomatous B. Non-invasive 1. Allergic 2. Fungal ball
3. Saprophytic Aspergillosis & Mucormycosis are common Predisposing factors for invasive fungal infection
Uncontrolled diabetes mellitus Profound dehydration Severe malnutrition Severe burns Leukemia, lymphoma Chronic renal disease, septicemia Long term tx with (steroids, anti-metabolites,
broad spectrum antibiotics) Clinical Features Acute invasive fungal sinusitis by Mucormycosis Unilateral nasal discharge + black crusts due to ischaemic necrosis, proptosis, ophthalmoplegia Cerebral & vascular invasion may be present
Significant inflammation with fibrosis & granuloma formation seen in chronic invasive fungal sinusitis Locally destructive with minimal bone erosion Black crusting Treatment
Remove precipitating factors Surgical debridement of necrotic debris Amphotericin B infusion: 1 mg / kg / day IV daily / on alternate days (total dose of 3 g). Liposomal Amphotericin B less toxic & more effective Itraconazole: 100 mg BD for 6-12 months Hyperbaric oxygen: fungistatic + tissue survival
Refractory sinusitis with foul smelling cheesy material in maxillary sinus Tx: Surgical removal. No anti-fungal drugs. Saprophytic fungal sinusitis Seen after sino-nasal surgery due to proliferation of fungal spores on mucous crusts
Tx: Surgical removal. No anti-fungal drugs. Investigations Biopsy & HPE: Tissue invasion by broad, nonseptate, 900 branching hyphae. Fungal penetration of arterial walls with thrombosis & infarction. Staining by Periodic Acid Schiff or Grocott Gomori Methenamine Silver nitrate stain.
X-ray PNS: Sinusitis + focal bone destruction CT scan: rule out orbital & intracranial extension MRI: for vascular invasion & intracranial extension Aspergillosis Mucormycosis
Branching at 900 Dichotomous branching Singular branching Immuno-fluorescent staining
Sarcoidosis Definition & etiology Synonym: Boecks sarcoid or Besnier Boeck Schaumann syndrome Definition: chronic systemic disease of unknown
etiology which may involve any organ with noncaseating (hard) granulomatous inflammation Etiology: 1. Special form of Tuberculosis (?) 2. Unidentified organism Clinical features Nasal discharge, nasal obstruction, epistaxis Mucosal: reveals yellow nodules surrounded by
hyperaemic mucosa on anterior septum & turbinates Skin (Lupus Pernio or Mortimers malady): nasal tip shows symmetrical, bulbous, glistening violaceous lesion (resembling perniosis or cold induced injury) Similar lesions on cheeks, lips & ears [Turkey ears]. Diascopy reveals yellowish brown appearance.
Lupus Pernio Heerfordts syndrome Synonym: Waldenstrms uveo-parotid fever Special form of sarcoidosis with: 1. Transient B/L Facial palsy 2. Parotid enlargement
3. Uveitis 4. Fever Probe test Probing of nodular lesion to look for penetration Negative in sarcoidosis: probe does not penetrate nodular swelling because of hard granulomas
Positive in Lupus vulgaris: probe penetrates up to soft granulation tissue in centre of nodule Investigations Biopsy of nodule & HPE: Non-caseating hard granuloma with ill-defined rim of surrounding lymphoid cells (naked tubercle). Giant cells
contain asteroid inclusion or Schaumann bodies Kveim Siltzbach Test: Intradermal injection of spleen extract from case of sarcoidosis followed 6 wks later by skin biopsy shows development of non-caseating nodules Non-caseating granuloma
Non-caseating granuloma Asteroid inclusion bodies Chest X-ray findings Stage I = B/L Hilar lymph node enlargement
Stage II = B/L Hilar lymph node enlargement + diffuse parenchymal infiltrates Stage III = Diffuse parenchymal infiltrates without Hilar lymph node enlargement Stage IV = Diffuse parenchymal infiltrates + fibrosis with cor pulmonale
Hilar lymphadenopathy Treatment 1. Prednisolone: 1 mg/kg/d x 6 wk, taper over 3 mth. Good response in mucosal disease only. 2. Chloroquine / Methotrexate + Prednisolone:
in pt not responding to steroids Chloroquine = 250 mg PO on alternate days x 9 mth Methotrexate = 5mg PO weekly x 3mth Wegeners granuloma
Definition Autoimmune (?) condition characterized by necrotizing granulomas within nasal cavity & lower respiratory tract,
generalised vasculitis & focal glomerulonephritis Clinical Features Nose & paranasal sinus: epistaxis, nasal block, extensive crusts, septal destruction & nasal collapse. Rule out nasal substance abuse.
Ophthalmological: scleritis, conjunctivitis, corneal ulceration, dacryocystitis, proptosis, optic neuritis, blindness Others: Skin ulceration, polymyalgia, polyarthritis If untreated: death within 6 mth due to renal failure Crusting in nasal cavity
External nasal deformity Destruction of orbit & nose Differential diagnosis VASCULITIS
CT PNS: bone destruction in nasal cavity Chest X-ray & CT scan: pulmonary nodules Serum urea & creatine: ed renal function Biopsy of lesion & HPE: Granulomas + Vasculitis + Fibrinoid vascular necrosis CT scan PNS: nasal destruction
CXR: nodular lesion with cavity C.T. scan lungs nodular lung infiltrate with cavitation
HPE: Granulomatous vasculitis L = small pulmonary artery lumen surrounded by inflammatory infiltrate including a giant cell (black arrow) Segmental glomerular necrosis
early crescent formation (black arrows) c-A.N.C.A. Anti-Neutrophil Cytoplasmic Antibody (ANCA) titre by immuno-fluorescence. c-ANCA = cytoplasmic fluorescence Raised c-ANCA titres = 65-96% sensitive in WG
Becomes -ve when disease is controlled p-ANCA = peri-nuclear fluorescence p-ANCA titres raised in Polyangitis C ANCA by indirect immuno-fluorescence
Medical Treatment 1. Triple therapy: Prednisolone: 1 mg/kg/d x 1 mth Taper over 3 mth + Cyclophosphamide: 2mg/kg / day x 6-12 mth + Cotrimoxazole: 960 mg OD X indefinitely 2. Plasma exchange & intravenous immunoglobulin 3. Alkaline nasal douche for crusts
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