Journal of
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Kingdom of Bahrain
- Rhinoscleroma: Rhinoscleroma is a chronic granulomatous condition of the nose and other structures of the upper respiratory tract.
- It is a result of infection by the bacterium Klebsiella rhinoscleromatis.
- Rhinoscleroma is contracted by means of the direct inhalation of droplets or contaminated material.
- The disease probably begins in areas of epithelial transition such as the vestibule of the nose, the subglottic area of the larynx, or the area between the nasopharynx and oropharynx.
- Rhinoscleroma usually affects the nasal cavity, but lesions associated with rhinoscleroma may also affect the larynx; nasopharynx; oral cavity; paranasal sinuses; or soft tissues of the lips, nose, trachea, and bronchi.
- Epidemiology
- It is endemic to regions of Africa (Egypt, tropical areas), Southeast Asia, Mexico, Central and South America, and Central and Eastern Europe.
- Rhinoscleroma tends to affect females somewhat more often than it does males.
- Typically, rhinoscleroma appears in patients aged 10-30 years.
- Disease may start as a single nodule or in groups in nasal cavity.
- The lesions do not suppurate or ulcerate
- They heal by dense cicatrization, almost cartilage like hardness
- Possible history findings
- Nasal obstruction (most common complaint)
- Rhinorrhea
- Epistaxis
- Dysphagia
- Nasal deformity
- Anesthesia of the soft palate
- Difficulty breathing that progresses to stridor
- Dysphonia
- Anosmia
Pathological development
- Diffuse stage resembling atrophic rhinitis
- Stage of localisation and organisation
- Stage of cicatrization
DD
- Atrophic rhinitis
- Tertiary syphilis
- Lupus
- Leprosy
- Cancer
Treatment
- Streptomycin
- Tetracyclines
- Chlorophenicol
- Steroids
- Locally
- Systemically
Wegner’s granulomatosis
- A condition characterized by granulomatous inflammation involving the respiratory tract and necrotizing vasculitis affecting small to medium sized vessels.
- The pathological hallmark is the co-existence of vasculitis and granulomas and classically involves a triad of airway, lungs and renal disease.
Age and Sex
- Significant number of patients below 25 years of age.
- Younger patients present with a generalized form.
Aetiology
- Aetiology remains unknown.
- Its inflammatory nature and resemblance to polyarteritis nodosa suggests that it represents some form of hypersensitivity reaction.
- It might be related to inhaled bacteria.
Clinical features
- Most patients start with minor ENT symptoms
- Variable degree of epistaxis
- Nasal Obstruction
- Bloody crusts
- Destruction of intranasal structures including septum may follow leading eventually to nasal collapse.
- Patients may complain of significant facial pain.
Pulmonary symptoms
- Cough
- Haemoptysis
- Pleuritic pain
- Cavitation
- Encapsulated lung abscess
Renal symptoms
- Between 30% to 90% patients develop renal symptoms.
- Microscopic haematuria
- Segmental or diffuse glomerulonephritis.
Ocular manifestations
- Conjuctiviitis
- Dacrocystitis
- Corneal ulceration
- Optic neuritis and retinal artery occlusion.
- Blindness unilateral or bilateral
Otologic symptoms
- Acute otitis media
- Otitis media with effusion
- Deafness
- Otalgia
Diagnosis
- cANCA test is positive in 95% of patients.
- A full blood count
- ESR
- Renal Profile
- Urine analysis
Biopsy from septum or turbinates
- Vasculitis
- Granulomas of epithelial cell type
- Multinucleated giant cells
- Mucosal thickening
- Bone destruction
- New bone formation
Treatment
- Steroids and a variety of cytotoxic drugs improve short term prognosis by 90%.
- Nasal symptoms managed by topical preparations.
- Augmentation rhinoplasty
Septal Perforation
Causes
- Trauma
- Surgical
- Repeated cautery
- Digital trauma
- Malignant disease
- Malignant tumours
- Malignant granuloma
- Chronic infections
- Syphilis
- Tuberculosis
- Leprosy
- Poisons
- Industrial
- Cocaine addicts
- Idiopathic
- Most are iatrogenic in origin
- Repeated cautery of the septum
- Occupational: Commonest cause is penetration of the nasal mucosa by one of the hexavalent forms of chromium.
- Other causes include exposure to soda ash, arsenic and its compounds, organic compounds of mercury, cocaine and snuff.
- There are often four well marked stages of development:
- Redness and congestion of mucosa
- Blenching and anaemia
- Necrosis and development of crusts
- Final extension of crusts in to cartilage and perforation
- There are often four well marked stages of development:
- Redness and congestion of mucosa
- Blenching and anaemia
- Necrosis and development of crusts
- Final extension of crusts in to cartilage and perforation
- There are often four well marked stages of development:
- Redness and congestion of mucosa
- Blenching and anaemia
- Necrosis and development of crusts
- Final extension of crusts in to cartilage and perforation
Symptoms
- Most septal perforations are asymptomatic.
- Development of large crusts may cause nasal obstruction
- Separation of crusts may lead to bleeding
- Whistling noise
- The larger the perforation more symptoms it would produce
Treatment
- Cure the causative disease process
- Perforations never heal spontaneously
- Less severe cases can be satisfactorily controlled by nasal douching
- Silastic Obturators can be used to close large perforations up to 4 cm in diameter.
- If obturators fail to deliver consider surgery
- Perforations larger than 2 cm are difficult to close
Acknowledgements
None.
Conflict of interest
None.
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