1. Dr. Navin Kumaresan

3. Definition of Granuloma
Granuloma is a tumor like mass of nodular
granulation tissue with actively growing fibroblasts
and capillary buds due to chronic inflammation
with vasculitis.

4. Classification of Granulomas
Bacterial
Fungal
 Rhinoscleroma
 Rhinosporidiosis  Wegener’s
 Syphilis
 Tuberculosis
 Lupus
 Leprosy
Unspecific cause
granulomatosis
 Non-healing midline
Mucormycosis
Granuloma
Candidiasis*
Histoplasmosis*  Sarcoidosis
Blastomycosis*
 Aspergillosis




* rare

5. Respiratory Scleroma or
Mikulicz disease

6. Definition
Rhinoscleroma or scleroma is a chronic granulomatous
disease caused by gram negative bacillus Klebsiella
rhinoscleromatis [von Frisch bacillus].

7. 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

8. Nasal involvement staging
3. 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.

9. Rhinoscleroma nodules

10. Lesion in nose & palate

11. Hebra nose

12. Investigations
 X-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.

13. 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

14. Histopathology

15. Histopathology (magnified)

16. Warthin-Starry stain: Mikulicz cell

17. Medical treatment
 Streptomycin 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

18. Radiotherapy & Surgery
 Radiotherapy: 3500 rad over 3 week
 Surgery: Removal of granulations & nodular lesions
with cautery or laser
 Plastic reconstructive surgery

19. Tuberculosis
 Nose:
 C/F:
 Diagnosis:
Nasal Septum and ant. inferior
turbinate
Ulceration & Perforation of Nasal
Septum cartilaginous part
 Treatment:
Biopsy & AFS
Anti-tubercular drugs
 Skin:
Lupus Vulgaris “apple-jelly”

20. Syphilis
Acquired or Congenital
 Acquired:
Chancre of the vestibule of nose
Saddle Nose
 Congenital:
Saddle nose, corneal opacities,
deafness and Hutchinson’s teeth
 Diagnosis:
 Treatment:
VDRL
Benzathine pencillin

21. Leprosy
 Nose:
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

23. Definition
 Chronic 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.

24. Epidemiology
 88 – 95% cases in India, Pakistan & Sri Lanka
 Common in Kerala, Karnataka & Tamil Nadu
 Age:
20 – 40 yrs.
 Sex ratio: Male : Female
4:1

25. Incidence
 Nasal
78%
 Nasopharyngeal
16%
 Mixed (naso-nasopharyngeal, nasolacrimal)
05%
 Bizarre (Conjunctival / Tarsal / Cutaneous)
rare

26. Clinical Presentation
 Epistaxis + 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

27. Nasal Mass

28. Bleeding Nasal Mass

29. Nasal & Nasopharynx

30. Nasal & Nasopharynx

31. Oropharyngeal Mass

32. Mass in uvula

33. Cutaneous Granulomas

34. Mode of transmission
 Bathing 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

35. Life-cycle

36. Investigation
 Biopsy & Histopathological examination
 Microscopic examination of nasal discharge for spores
Sporangia of different shapes oval to round and
bursting spores are present.

37. Haematoxylin & Eosin stain

38. Periodic Acid Schiff stain

39. Gomori Methenamine Silver stain

40. Medical Treatment
 Dapsone: arrests maturation of spores
 Dose: 100 mg OD orally (with meals) for one year
 Iron & Vitamin supplements

41. Surgical management
 General 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

43. Fungal Sinusitis
A. 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

44. Aspergillosis
 Etiology: 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

45. Fungal Sinusitis

46. Mucormycosis
 Acute 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

47. Black crusting

48. Investigations
 Biopsy & HPE
 X-ray PNS: Sinusitis & focal bone destruction
 CT scan: rule out orbital & intracranial extension
 MRI: for vascular invasion & intracranial extension

49. C.T. scan coronal cuts

50. C.T. scan axial cuts

51. Aspergillosis Mucormycosis

52. Microscopic Difference
Aspergillosis hyphae
Mucormycosis hyphae
 Narrow
 Broad
 Septate
 Non-Septate
 Branching at 45°
 Branching at 90°
 Dichotomous branching
 Singular branching

53. Immuno-fluorescent staining

54. Treatment
 Surgical debridement of necrotic debris
 Amphotericin B infusion: 1 mg / kg / day IV daily / on
alternate days
 Itraconazole: 100 mg BD for 6-12 months

55. Surgical debridement

57. Definition & Etiology
 Definition: Chronic systemic disease of unknown
etiology which may involve any organ with noncaseating(hard) granulomatous inflammation
 Etiology: Resembling Tuberculosis
Unidentified organism

58. Clinical Features
 Nasal 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

59. Lupus Pernio

60. Investigations
 Biopsy of nodule & HPE: Non-caseating hard
granuloma
 Kveim intradermal Test

61. Non-caseating granuloma

62. Non-caseating granuloma

63. Asteroid inclusion bodies

64. Chest X-ray findings
 Bilateral Hilar lymph
node enlargement with
or without diffuse
parenchymal infiltrates

65. Treatment
1.
Prednisolone
2. Chloroquine / Methotrexate + Prednisolone: In
patients not responding to steroids
3. Cutaneous lesions: Excised & skin grafted

67. Definition
Autoimmune condition
characterized by necrotizing
granulomas within nasal
cavity & lower respiratory
tract with generalised
vasculitis & focal
glomerulonephritis

68. Clinical Features
 Nose & 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

69. Crusting in nasal cavity

70. External nasal deformity

71. Destruction of orbit & nose

72. Investigations
 E.S.R.
 Urine: microscopic examination
 CT scan: PNS
 Chest X-ray & CT scan
 Serum urea & creatinine
 Biopsy & HPE

73. CT scan PNS: nasal destruction

74. CXR: nodular lesion with cavity

75. C.T. scan lungs
n

76. C - ANCA by Indirect
Immuno-fluorescence

77. Medical Treatment
1.
Triple therapy: Prednisolone + Cyclophosphamide
+ Cotrimoxazole
2. Plasma exchange & intravenous immunoglobulin
3. Alkaline nasal douche for crusts