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1. RHIN OSCLE R
O M A
R A A F I U L B A S H E E R

2. • I N T R O D U C T I O N
• I N C I D E N C E
• E T I O PAT H O G E N E
S I S
• C L I N I C A L
F E AT U R E S
• D I A G N O S I S
• T R E AT M E N T
TABLE
OF
CONTENTS
OVERVIEW

3. INTRODUCTION
• COINED BY:- VON HEBRA IN 1870
DEFINITION
• Respiratory scleroma or rhinoscleroma is a
progressive granulomatous disease commencing
in the nose and later extending into the
nasopharynx and oropharynx, the larynx and
sometimes the trachea and bronchi.
• Respiratory scleroma or rhinoscleroma is a
progressive granulomatous disease commencing
in the nose and later extending into the
nasopharynx and oropharynx, the larynx and
sometimes the trachea and bronchi.

4. INCIDENCE

5. INCIDENCE
(INDIA)

6. ETIOPATHOGENESIS
ETIOLOGY
K l e b s i e l l a
r h i n o s c l e r o m a
t i s
• F r i s c h
b a c i l l u s
• G r a m
n e g a t i v e
• I n t r a c e l l u l a r

7. RISK FACTORS
MULTIFACTORIAL
LOW SOCIO ECONOMIC
STATUS
POOR DOMESTIC HYGIENE
OVERCROWDING
1
2
3
4

8. ROUTE OF ENTRY
• DROPLET
NUCLEI

9. ROUTE OF ENTRY
• DROPLET
NUCLEI
ENTRY INTO MUCOSA
• OF OROPHARYNX
&
LARYNGOPHARYN
X

10. ROUTE OF ENTRY
• DROPLET
NUCLEI
ENTRY INTO MUCOSA
• OF
OROPHARYNX
&
LARYNGOPHAR
YNX
INTRACELLULAR SURVIVAL
• ENGULFED BY
MACROPHAGES
• MUCKLICZ CELLS
• MUCOPOLYSACC
HARIDES
SUPPORT
INTRACELLULAR
SURVIVAL

11. CLINICAL FEATURES
• SUBDERMAL INFILTRATION
• PROGRESSES THROUGH 4 STAGES-
1. CATARRHAL STAGE
2. ATROPIC STAGE
3. GRANULOMATOUS STAGE
4. CICATRICIAL STAGE
STAGE-I
RPENTER’S
STAGE-II
STAGE-III
STAGE-IV

12. KEY POINTS
STAGES CLINICAL FEATURES
CATARRHAL CARPENTERS GLUE
ATROPHIC CRUST FORMATION
NODULAR HEBRA NOSE
CICATRICIAL STENOSIS+FIBROSIS

13. I N V E S T I G A T I O N S
• SUBMUCOSA INFILTRATED WITH
PLASMA CELLS, LYMPHOCYTES,
EOSINOPHILS, MIKULICZ CELLS
AND RUSSEL BODIES
• MIKCULICZ CELLS (DIAGNOSTIC)
• FOAM CELLS
• CONTAIN CAUSATIVE
ORGANISM
• RUSSEL BODIES (DIAGNOSTIC)
• FOUND IN PLASMA CELLS
• ACCUMULATION OF Ig’s
B I O P S Y

14. D I A G N O S I S
• BASED ON REACTION OF
PATIENT’S SERUM WITH
SUSPENSION OF Klebsiella
rhinoscleromatis.
• HIGH TITRES OF ANTIBODIES
AGAINST K. rhinoscleromatis
INDICATES INTACT HUMORAL
IMMUNITY.
C O M P L E M E N T F I X A T I O N
T E S T ( L E V I N T E S T )

15. D I A G N O S I S
• INTRACRANIAL EXTENSION
OF RHINOSCLEROMA INTO
ANTERIOR CRANIAL
CAVITY VIA DESTRUCTION
OF POSTERIOR BONY
WALL OF LEFT
SPHENOIDAL SINUS
C T S C A N

16. D I A G N O S I S
• T1-WEIGHTED
• NASAL MASS
EXTENDING INTO
NASOPHARYNX
M R I

17. D I A G N O S I S
• MUCOID
• DOME SHAPED
• STICKY
• PINK COLOURED
• LACTOSE FERMENTING
COLONIES
C U L T U R E ( M a c C o n k e y
A G A R )

18. D I A G N O S I S
1. PAS
2. GIEMSA
3. WARTHIN STARRY SILVER
S T A I N S
PAS STAIN
• INCLUSION BODIES
• CONTAIN CAUSATIVE ORGANISM

19. C O M P L I C AT I O N S
1. EXTERNAL NOSE DEFORMITY
2. VESTIBULAR STENOSIS
3. CICATRIZATION OF SOFT PALATE
4. NASAL REGURGITATION
5. TRACHEAL STENOSIS

20. • DISEASE FOLLOWS A PROTRACTED BUT
USUALLY SELF LIMITING COURSE
• ENDING IN CICATRIZING STAGE
• ORGANISM CAN BE EXTREMELY DIFFICULT
TO ERRADICATE BY ANTIMICROBIALS
• ONCE DIAGNOSIS IS CONFIRMED THE
TREATMENT SHOULD BE INTENSE AND
PROLONGED
• LINES OF TREATMENT
1. ANTIBIOTICS
2. STEROIDS
3. RADIOTHERAPY
4. SURGERY
TREATMENT
MEDICAL

21. • DRUGS
1. STREPTOMYCIN
• I.M 1GM FOR 4-6 WEEKS
2. TETRACYCLINE
• 500MG Q.I.D
3. RIFAMPICIN
• 400MG FOR 6 WEEKS ORALLY
• NASAL INSTILLATION
• NASAL INFILTRATIOMN
4. COTRIMOXAZOLE+CIPROFLOXACIN
5. ACRIFLAVIN
• 2% LOCALLY
• 8 WEEKS
B A C T E R I C I D A L
A N T I B I O T I C S
• LARGE DOSES GIVEN FOR
MIN. DURATION OF 4-6 WEEKS
• CONTINUED TILL 2
CONSECUTIVE CULTURES
FROM BIOPSY MATERIAL ARE
PROVEN NEGATIVE

22. • CONTENT
1. CARBOLIC ACID(0.2ML)
2. GLACIAL ACETIC ACID(0.2ML)
3. GLYCERIN(0.4ML)
4. D/W(10ML)
• ROUTE
• INJECTED LOCALLY
• MECHANISM
• CHEMICAL NECROSIS OF GRANULOMA
• 8-10 INJ. LEADS TO COMPLETE
REGRESSION OF GRANULOMAAND
RESTORATION OF NORMAL NASAL
PATENCY
K a l i s a r e g i m e n

23. • DOSE
• 3000-3500 GY
• DURATION
• 3 WEEKS
• MECHANISM
• DESTROYS SCLEROMA BY RADIATION
• CURRENTLY NOT REQUIRED
I R R A D I AT I O N

24. • COMBINED WITH ANTIBIOTICS TO REDUCE
FIBROSIS
I N T R A L E S I O N A L
S T E R O I D S

25. • REQUIRED IN 4TH STAGE OF FIBROSIS AND
STENOSIS
• PLASTIC RECONSTRUCTIVE SURGERY
• CARRIED OUT BY LASER AND NASAL
ENDOSCOPY
• SILASTIC STENT FACILITATES RE-
EPITHELISATION
• USES
• ESTABLISHES AIRWAY
• CORRECT THE NASAL DEFORMITY
S U R G E R Y