Granulomatous Conditions of the Nose: Diagnosis and Differential Features

Study Notes

Acute Rhinosinusitis

Facial pain characteristics:
- Seen in Ethmoid sinusitis, Frontal sinusitis, Maxillary sinusitis, and Sphenoid sinusitis

Acute Invasive Fungal Sinusitis

Risk factors: All immunocompromised patients (e.g., DM patients on steroids)
Clinical features:
- Nasal obstruction
- Nasal discharge
- Facial pain
- Hyposmia
- Anesthesia (less than 12 weeks)
Endoscopy findings:
- Black necrotic areas in middle meatus or turbinates
Diagnosis and management:
- Biopsy and microscopy
- Rx: Mucormycosis (Aseptate hyphae, right angle branching) - IV Liposomal amphotericin B + Local debridement + Manage immunosuppression
- Rx: Aspergillosis (Septate hyphae, acute angle branching) - Voriconazole + Local debridement + Manage immunosuppression
Most common type: Rhino-ocular/rhino-oculo-cerebral
Cutaneous invasive fungal sinusitis occurs in immunocompetent hosts, with a history of injury with vegetative matter

Chronic Rhinosinusitis

Symptoms extend for more than 12 weeks
Chronic bacterial rhinosinusitis:
- Most common type
- Most common organisms: Mixed aerobic and anaerobic (e.g., Staphylococcus)
- Endoscopy findings:
  - Pus in middle meatus
  - Pus/edema/polyp in middle meatus
- Best investigation: NCCT
- Rx: Medical treatment for one month, followed by surgical treatment (FESS)
Chronic fungal rhinosinusitis:
- Occurs in immunocompetent individuals
- Endoscopy findings:
  - Cheesy/clay-like debris (Fungal ball) in middle meatus (most common: Aspergillus)

Granulomatous Conditions of Nose

Granulomatosis with Polyangitis (Wegener's):
- Diagnosed by:
  - B/L nasal symptoms
  - CHL (Strawberry gingiva)
  - Cough, hemoptysis, and obstruction
  - Dyspnea
  - Glomerulonephritis
  - Haematuria
- Differentiating features:
  - Perforation in bony septum
Sarcoidosis:
- Diagnosed by:
  - Lupus pernio
  - Strawberry nasal mucosa
- Differentiating features:
  - Violaceous affection of nose
Syphilis:
- Diagnosed by:
  - Painless indurated ulcer (chancre)
  - Snail track ulcers
- Differentiating features:
  - Nasal Gummas
  - Cough, hemoptysis, and night sweats
  - Fever
Leprosy:
- Diagnosed by:
  - Skin patches
  - Sensory loss
  - Paresthesia/numbness in extremities
- Differentiating features:
  - Brownish nodules that do not blanch on pressure
  - Perforation in granulomas with acid-fast bacilli
Lupus vulgaris:
- Diagnosed by:
  - Strawberry nasal mucosa
  - Crusting
  - Perforation in bony septum
- Differentiating features:
  - Caseating granulomas

Rhinoscleroma

Etiology: Klebsiella rhinoscleromatis/Frisch bacillus
Clinical features:
- B/L nasal obstruction
- Excessive nasal crusting
- Woody/hard nose
Three stages:
- Atrophic stage (similar to atrophic rhinitis)
- Granulomatous stage (hard woody nose)
- Cicatritial stage (Hebra/Tapir nose)
Management:
- Confirmation done on biopsy
- Rx: Ciprofloxacin (DOC), Streptomycin, Tetracycline, Rifampicin
- Steroids (to reduce fibrosis)

Lupus Vulgaris

Strawberry nasal mucosa
Lupus pernio

T-Cell Lymphoma (Midline Lethal Granuloma)

Virus associated: EBV
M > F; 40-70 years
Clinical features:
- B/L nasal obstruction
- Blood-tinged nasal discharge
- Ulceration, necrosis, and perforation of septum and midfacial structures
Management:
- Radiotherapy ± chemotherapy for lymphoma
- Surgical reconstruction of defect

Rhinitis

Allergic Rhinitis vs. Vasomotor Rhinitis:
- Allergic rhinitis:
  - Etiology: Type 1 HS reaction (IgE mediated)
  - Clinical features:
    - Nasal obstruction
    - Nasal discharge (watery)
    - Sneezing/itching
    - Family history of allergy
    - Allergic salute
    - Dennie Morgan lines
  - Anterior Rhinoscopy:
    - Pale boggy (swollen) sometimes bluish mucosa
    - Inferior turbinate hypertrophy
  - Rx: RAST or Skin prick test
- Vasomotor Rhinitis:
  - Etiology: Parasympathetic overactivity
  - Also known as idiopathic rhinitis

Description

Test your knowledge on various granulomatous conditions affecting the nose, including Granulomatosis with Polyangitis, Sarcoidosis, Syphilis, TB, Leprosy, and Lupus vulgaris. Learn about the differentiating features and symptoms of each condition.