(BQ) Par 1 book Self assessment and review ENT has contents: Granulomatous disorders of nose, nasal polyps and foreign body in nose, inflammatory disorders of nasal cavity, oral cavity, anatomy of pharynx, tonsils and adenoids, pharynx hot topics,... and other contents.
17 chapter Granulomatous Disorders of Nose, Nasal Polyps and Foreign Body in Nose GRANULOMATOUS DISEASES OF THE NOSE Bacterial Fungal Unspecified/Causes yySyphilis yyRhinosporidiosis yyWegener’s granulomatosis yyTuberculosis yyAspergillosis yyLupus yyMucormycosis yyNon-healing midline granuloma yyRhinoscleroma yyCandidiasis yySarcoidosis yyLeprosy yyHistoplasmosis yyBlastomycosis BACTERIAL INFECTIONS LUPUS VULGARIS yy It is an indolent and chronic form of tuberculous infection yy Female: Male ratio is 2:1 yy Most common site is the mucocutaneous junction of the nasal septum, the nasal vestibule and the ala yy Characteristic feature is the presence of apple-jelly nodules (Brown gelatinous nodules) in skin yy Cutaneous lesion involving external nose has a typical butterfly appearance yy Lupus can cause perforation of cartilaginous part of nasal septum yy Confirmation is by biopsy yy T/t = ATT SYPHILIS (FLOW CHART 17.1) Flow Chart 17.1: Types and clinical feature of syphilis 210 SECTION II Nose and Paranasal Sinuses RHINOSCLEROMA (MIKULCIZ DISEASE) It is chronic, progressive granulomatous disease commencing in the nose and extending into the nasopharynx and oropharynx, larynx (subglottic area), trachea and bronchi Organism Klebsiella rhinoscleromatis (Gram-negative Frisch bacillus) Features yy Scleroma can occur at any age and in either sex yy The disease has following stages: Atrophic Stage Resembles atrophic rhinitis and is characterized by foul smelling purulent nasal discharge and crusting Granulomatous Stage yy Proliferative stage yy The stage is characterized by granulomatous reactions and presence of ‘Mikulicz cells’ yy Painless nodules are formed in nasal mucosa yy Subdermal infiltration occurs in lower part of external nose and upper lip giving a woody feel yy Severe cases may lead to broadening of nose due to thickening of the skin with characteristic “Hebra-nose” Diagnosis yy Biopsy shows submucosal infiItrates of plasma cells, lymphocytes, eosinophils, mikulicz cells and russell bodies yy Mikulicz Cells: are large foam cells with a central nucleus and vacuolated cytoplasm containing the bacilli) yy Russell Bodies: are homogenous eosinophilic inclusion bodies found in plasma cells yy Both of them are characteristic features of Rhinoscleroma Treatment yy Streptomycin (2 g/day) + Tetracycline (2 g/day) for a minimum of 4–6 weeks (till consecutive samples are negative) yy Surgical dilatation of the cicatricial areas with polythene tubes for 6–8 weeks LEPROSY yy M/C in lepromatous leprosy yy M/C affected parts: Nasal septum (anterior part) and inferior turbinate Feature Leads to perforation of nasal septum and saddle nose deformity Treatment Dapsone, Isoniazid and Rifampin NEW PATTERN QUESTION Q N1 Tapir nose is seen in: a Leprosy b Syphilis c Rhinoscleroma d Lupus vulgaris FUNGAL INFECTIONS RHINOSPORIDIOSIS Fig 17.1: Nodular lesion of Rhino scleroma involving the vestibulo external nose and extending to upper lip This is “Hebra nose” Cicatricial Stage It is characterized by formation of: yy Adhesions fibrosis and stenosis of nose, nasopharynx and oropharynx yy Subglottic stenosis with respiratory distress may occur yy Pain is not a feature of this stage yy The fibrotic deformity of external nose in this stage is called as “Taper nose” Point to Remember ¾¾ M/C symptom of Rhinoscleroma is Nasal obstruction and crusting (94%) > Nasal deformity > Epistaxis yy It is a chronic granulomatous infection of mucous membranes yy Causative organism: Rhinosporidium seeberi Latest Concept Rhinosporodium seeberi was previously considered as fungus It is now taken as an aquatic protestan protozoa It belongs to class mesomycetozoea and is unicellular History It was first described by Guillermo Seeber in 1900 in a patient in Argentina yy Distribution: Endemic in India, Pakistan, Sri Lanka, Africa and South America yy Most commonly affected sites : Nose and nasopharynx yy Others: Lip, palate, uvula, maxillary antrum, epiglottis, larynx, trachea, bronchi, ear, scalp, penis, vulva, vagina CHAPTER 17 Granulomatous Disorders of Nose, Nasal Polyps and Foreign Body in Nose yy Mode of affection: Through contaminated water of pond (M/C route) It is common in farmers and people bathing in ponds The spores get deposited in traumatized part of nose and completes its life cycle there (Fig 17.2) MUCORMYCOSIS It is an aggressive opportunistic fungal infection Predisposing Factors yy Immunosuppressed patients yy Uncontrolled diabeties Features yy Mucormycosis differs from other fungi as it has a remarkable affinity for blood vessels and arteries leading to extensive endothelial damage and thrombosis yy The disease begins in the nose and paranasal sinus and spreads to orbit, cribiform plate, meninges and brain yy Typical finding: Black necrotic mass seen filling the entire nasal cavity yy Erosion of the nasal septum and the hard palate may be seen Investigations Fig 17.2: Life cycle of R seeberi Features yy Young males are more affected (15-40 years) yy Lesions are polypoid and papillomatous friable masses which bleed easily on touch yy They are strawberry (pink to purple) colored and studded with white dot’s representing the sporangia yy Patients complain of nasal discharge which is blood tinged Sometimes frank epistaxis is the only presenting complaint Diagnosis It is made by biopsy which shows several sporangia and spores Treatment yy Endoscopic excision of the mass followed by cauterization of its base yy Recurrence may occur after surgery yy Medical management with dapsone decrease the recurrence rate ASPERGILLOSIS yy Aspergillosis is the commonest fungal infection of the nose and sinuses yy Causative organism: A fumigatus (90%) > A niger and A flavus yy Spread: air-borne Features yy It can affect any age group yy Black or grayish membrane seen on nasal mucosa yy Maxillary sinus shows a fungal ball Treatment Surgical debridement and antifungal drugs yy Sinus radiographs show thickened sinus walls and spotty destruction of the bony walls yy MRI detects early vascular and intracranial invasion Treatment yy Systemic - Amphotericin B yy Surgical debridement of the affected tissues yy Orbital exenteration is mandatory in case of ophthalmoplegia and loss of vision Points to Remember yySyphilis affects the bone, while tuberculosis affects the cartilagenous framework of nose yyRhinoscleroma is caused by Frisch bacillus, i.e Klebsiella rhinoscleromatis Mikulicz cells and Russel bodies are typical of the histopathological examination yySarcoidosis resembles tuberculosis except for caseation, and Kveim test and biopsy are diagnostic NEW PATTERN QUESTIONS Q N2 Nasal polypoidal mass with subcutaneous nodules on skin are seen in: a Zygomycosis b Rhinosporidiosis c Sporotrichosis d Aspergillosis Q N3 Ideal treatment of rhinosporodiosis is: a Rifampicin b Excision with cautery at base c Tetracycline d Laser Q N4 Strawberry skin appearance of nasal mucosa is seen in: a Wegener’s granulomatosis b Sarcoidosis c Kawasaki disease d Rhinosporidiosis 211 212 SECTION II Nose and Paranasal Sinuses Q N5 Which of the following is a lethal midline granuloma of nose: a Wegener's granuloma b Rhinosporidium c Lupus d Stewarts granuloma Q N6 Mikulicz cells and Russell bodies are seen in: a Rhinoscleroma b Rhinosporidiasis c Scleroderma d Lupus vulgaris Q N7 Mitral cells are seen in: a Rhinoscleroma b Olfactory tract c Rhinosporidiosis d Optic nerve NASAL POLYPS yy Polyps are non-neoplastic pedunculated masses which are sparsely cellular and are covered by normal epithelium i.e columnar ciliated epithelium yy Features: They are soft, fleshy, pale, insensitive to pain and not shrink with the use of vasoconstrictors yy They not bleed on touch and are insensitive to probing and never present with epistaxis or bleeding from nose yy Types of nasal polyp are described in Table 17.1 Table 17.1: Types of nasal polyp Ethmoidal polyps Age group = 30–60 years Sex = Male > Female M/C Site – Ethmoid sinus (can also arise from middle turbinate and middle meatus) Etiology ; Allergy (M/C) On examination – B/L Multiple, smooth, glistening sessile or pedunculated polyps Lining epithelium initially is columnar, later due to trauma it undergoes squamous metaplasia Symptoms Presenting symptom B/L nasal blockage Others yyPartial/complete loss of smell yyPain over nasal bridge forehead/cheek yyPostnasal drip Broadening of nose (frog face deformity) Note: Polyps not present with Epistaxis/bleeding O/E yyAnterior Rhinoscopy—multiple, smooth, bluish gray grape-like masses yyOn probing – All polyps are insensitive to probing and donot bleed Investigation– X-ray of PNS IOC: NCCT of nose and paranasal sinus Treatment Surgical yyEffective only in 50% cases Drug used – Intranasal corticosteroids Medical T/t – Not done as it is recurrent Surgery yySimple polypectomy: Indicated in case of one/two polyps yyIntransal ethmoidectomy: Done when polyps are multiple and sessile Since it is a blind procedure it can give rise to orbital complications yyExtranasal ethmoidectomy: Indicated when polyps recurr after intranasal procedures [Howarth’s incision (Incision given medial to the inner canthus of the eye)] yyHorgans Transantral ethmoidectomy: When polypoidal changes are also seen in the maxillary antrum yyEndoscopic sinus surgery: It is the latest procedure for removal of small polyps under good illumination using 0° and 30° sinoscope i.e Functional endoscopic sinus surgery (FESS) Antrochoanal polyps (Killians polyp) yySeen in children and young adults (male > female) yyMaxillary antrum (floor and medial wall) Etiology = Allergy + Infection On examination – U/L, pale, white, translucent It has parts: yyAntral yyChoanal yyNasal U/L Nasal blockage (which can become bilateral when polyp grows into nasopharynx and obstructs opposite choana) yyHyponasal voice yyNasal discharge yyConductive deafness due to (blockage of Eustachian tube) Anterior Rhinoscopy: It is not visualized as they are posterior Posterior Rhinoscopy – Smooth, white spherical masses seen in choana IOC: NCCT nose and paranasal sinus Treatment Medical Surgical ↓ treatment No role (TOC) Surgical Management yyIntranasal polypectomy: Indicated in - young patients with incomplete dentition yyCaldwell-Luc operation (i.e opening the maxillary artrum through canine fossa by sublabial approach) It is done if there is recurrence and age of patient is more than 17 years yyNowadays Antrochoanal polyp is being treated by FESS CHAPTER 17 Granulomatous Disorders of Nose, Nasal Polyps and Foreign Body in Nose Point to Remember ¾¾ Samters triad – It is a triad of asthma, aspirin intolerance and nasal polyps Relation of Polyp to Bernoulli's phenomenon Bernoulli's theorem states that as velocity of air increases , lateral pressure decreases More the velocity, more is the drop in lateral pressure When air passes through nasal valve area—narrowest part, the velocity of air increases, which leads to drop in pressure such that negative pressure occurs This negative pressure facilitates accumulation of edematous fluid in the submucosa leading to polyp formation Q N9 Samter’s triad includes: a Nasal polyps b Aspirin sensitivity c Bronchiectasis d Bronchial asthma e Immunodeficiency Q N10 Most common nasal mass: a Polyp b Papilloma c Angiofibroma d None FOREIGN BODIES IN NOSE May be organic or inorganic and are mostly seen in childrenQ Clinical Features Unilateral foul smelling discharge in a child is pathognomic of a foreign body.Q Treatment yy Removal under LA/GA Q yy In children use of oral positive pressure technique called as ‘Parent’s Kiss’ technique is being practiced for removal of anterior nasal foreign body (Scott Brown) Fig 17.3: Bernoulli's phenomenon—Negative pressure seen at the stenotic site, facilitates accumulation of fluid in the submucosa Points to Remember Some important points to remember in a case of nasal polyp If a polypus is red and fleshy, friable and has granular surface, especially in older patients, think of malignancy Simple nasal polyp may masquerade a malignancy under neath Hence all polypi should be subjected to histology A simple polyp in a child may be a glioma, an encephalocele or a meningoencephalocele It shold always be aspirated and fluid examined for CSF Careless removal of such polyp would result in CSF rhinorrhoea and meningitis Multiple nasal polypi in children may be assoicated with mucoviscidosis Expistaxis and orbital symptoms associated with a polyp should always arouse the suspicion of malignancy NEW PATTERN QUESTIONS Q N8 Frog face deformity is seen in: a Nasal polyp b Syphilis of nose c Wegner's granulomatosis d TB of nose Complications yy Nasal infection (vestibulitis) and sinusitis yy Rhinolith formation yy Inhalation into the tracheobronchial tree RHINOLITH yy It is stone formation in the nasal cavity yy Rhinolith forms around the nucleus of a small exogenous foreign body or blood clot when calcium, magnesium and phosphate deposit around it Clinical Features yy More common in adults Presents as unilateral nasal obstruction and foul smelling discharge (often blood stained) yy Ulceration of the surrounding mucosa may lead to frank epistaxis and neuralgic pain Treatment Removal under GA Some hard and irregular rhinolitis may require lateral rhinotomy NASAL MYIASIS (MAGGOTS IN NOSE) yy It results from the prescence of ova of flies particularly Chrysomyia species in the nose which produce ulceration and destruction of nasal structure 213 214 SECTION II Nose and Paranasal Sinuses yy Mostly seen in atrophic rhinitis when the mucosa becomes insensitive to flies laying eggs inside yy Fistulae in nose and palate yy Death occurs due to meningitis Clinical features Treatment Initial Instillation of chloroform water and oil in nose and plugging the nose so that maggots not crawl out yy Patient should be isolated yy 3–4 days maggots produce yy Intense irritation Sneezing yy Lacrimation yy Headache yy Thin blood stained discharge Later Maggots may crawl out of nose and there is foul smell Complications yy Destruction of nose, sinuses, soft tissues of face, palate and eyeball ALSO KNOW For undergraduate students: VIVA for UG Causes of unilateral blood stained nasal discharge in a child ¾¾ Foreign body in nose ¾¾ Rhinolith ¾¾ Nasal diphtheria ¾¾ Nasal myiasis ¾¾ Acute/Chronic unilateral sinusitis 215 CHAPTER 17 Granulomatous Disorders of Nose, Nasal Polyps and Foreign Body in Nose EXPLANATIONS AND REFERENCES TO NEW PATTERN QUESTION N1 Ans is c i.e Rhinoscleroma Ref Textbook of ENT, Hazarika 3/e, p 308 Tapir nose and Hebra nose are seen in rhinoscleroma N2 Ans is b i.e Rhinosporidiosis Ref Dhingra 6/e, p 158,159 In Rhinosporiodiosis leafy, polypoidal mass of pink-purple color is seen attached to nasal septum or lateral wall Subcutaneous nodules may be seen on skin N3 Ans is b i.e Excision with cautery at base Ref Dhingra 6/e, p 159 Read the preceeding text N4 Ans is b i.e Sarcoidosis Ref Dhingra 6/e, p 160 Strawberry skin appearance of nasal mucosa is seen in sarcoidosis N5 Ans is d i.e Stewarts granuloma Ref Textbook of ENT, Hazarika, 3/e, p 313 Midline nonhealing granulomas of nose are: Wegners granuloma Stewarts granuloma Stewarts granuloma is also called as lethal midline granuloma or midfacial lymphoma It is a rare T-cell lymphoma which gradually ulcerates the cartilage and bone of the nose and midface It is strongly associated with Epstein Barr virus N6 Ans is a i.e Rhinoscleroma Ref Dhingra 6/e, p 156 See text for explanation N7 Ans is b i.e Olfactory tract Ref Essentials of ENT, Mohan Bansal, p 181 Mitral cells are present in olfactory bulb of the olfactory tract N8 Ans is a i.e Nasal polyp Ref Textbook of ENT, Hazarika 3/e, p 344 Frog face deformity is seen in ethmoidal polyp.There is widening of the intercanthal distance with frog face deformity in extensive ethmoidal polyposis N9 Ans is a, b and d i.e Nasal polyps; Aspirin sensitivity; and Bronchial asthma Ref Scott Brown 7th/ed Vol 2, p 1472; Internet search – wikipedia.org; Textbook of Mohan Bansal, p 307 Samter’s triad is a medical condition consisting of asthma, aspirin sensitivity, and nasal/ethmoidal polyposis It occurs in middle age (twenties and thirties are the most common onset times) and may not include any allergies yy Most commonly, the first symptom is rhinitis yy The disorder typically progresses to asthma, then polyposis, with aspirin sensitivity coming last yy The aspirin reaction can be severe, including an asthma attack, anaphylaxis, and urticaria in some cases Patients typically react to other NSAIDs such as ibuprofen, although paracetamol is generally considered safe yy Anosmia (lack of smell) is also typical, as the inflammation reaches the olfactory receptors in the nose N10 Ans is a i.e Polyp Remember: M/C Nasal masses are polyps 216 SECTION II Nose and Paranasal Sinuses QUESTIONS A 68-year-old Chandu is a diabetic and presented with black, foul smelling discharge from the nose Examination revealed blackish discoloration of the inferior turbinate The diagnosis is: [AIIMS 99] a Mucormycosis b Aspergillosis c Infarct of inferior turbinate d Foreign body IDDM patient presents with septal perforation of nose with brownish black discharge probable diagnosis is: [Al 97; RJ 06] a Rhinosporidiosis b Aspergillus c Leprosy d Mucormycosis Rhinosporidiosis is caused by: [PGI 99; UP 00] a Fungus b Virus c Bacteria d Protozoa True statement about Rhinosporidiosis is: [AI 99] a Most common organism is klebsiella rhinoscleromatis b Seen only in immunocompromised patients c Presents as a nasal polyp d Can be diagnosed by isolation of organism In rhinosporidiosis, the following is true: [PGI 99] a Fungal granuloma b Grayish mass c Surgery is the treatment d Radiotherapy is treatment Ideal treatment of rhinosporidiosis is: [AIIMS 97] a Rifampicin b Excision with cautery at base c Dapsone d Laser Rhinoscleromatis is caused by: [PGI 99] a Klebseilla b Autoimmune c Spirochetes d Rhinosporidium Mikulicz cell and russel bodies are characterisitc of: [JIPMER 02; Bihar 06] a Rhinoscleroma b Rhinosporidiosis c Plasma cell disorder d Lethal midline granuloma Atrophic dry nasal mucosa, extensive encrustations with woody’ hard external nose is suggestive of [MH 05] a Rhinosporidiosis b Rhinoscleroma c Atrophic rhinitis d Carcinoma of nose 10 Apple-jelly nodules on the nasal septum are found in case of: [MP 05] a Tuberculosis b Syphilis c Lupus vulgaris d Rhinoscleroma 11 About nasal syphilis the following is true: [PGI 02] a Perforation occurs in septum b Saddle nose deformity may occur c In newborn, it presents as snuffles d Atrophic rhinitis is a complication e Secondary syphilis is the common association 12 Killian term is used for which of the following polyp: a Ethmoidal b Antrochoanal [UP 05] c Tonsillar cyst d Tonsillolith 13 All the following are true of antrochoanal polyp except: [Al 94] a Common in children b Single and Unilateral c Bleeds on touch d Treatment involves Avulsion 14 All of the following are true about antrochonal polyp, except: [TN 07] a Single b Unilateral c Premalignant d Arises from maxillary antrum 15 Antrochoanal polyp is characterized by: [PGI Dec 03] a Usually bilateral b It is of allergic origin c It arises from maxillary antrum d Caldwell-Luc operation is treatment of choice in recurrent cases e Recurrence is common 16 The most appropriate management for antrochoanal polyp in children is: [AIIMS 02] a Caldwell-Luc operation b Intranasal polypectomy c Corticosteroids d Wait and watch 17 A patient presents with antrochoanal polyp arising from the medial wall of the maxilla Which of the following would be the best management for the patient? [AIIMS May 2014] a FESS with polypectomy b Medial maxillectomy (TEMM) c Caldwell-Luc procedure d Intranasal polypectomy 18 Treatment for recurrent atrochoanal polyp: [MP 2007] a Caldwell Luc operation b FESS c Simple polypectomy d Both a and b 19 The current treatment of choice for a large antrochoanal polyp in a 10-year-old is: [AIIMS Nov 2005, 2002, May 2014] a Intranasal polypectomy b Caldwell Luc operation c FESS d Lateral rhinotomy and excision 20 The current treatment of choice for a large antrochoanal polyp in a 30-year-old man is: [AIIMS Nov 05] a Intranasal polypectomy b Caldwell-Luc operation c FESS (Functional Endoscopic Sinus Surgery) d Lateral rhinotomy and excision 21 Which of the following statements is not correct for Ethmoidal polyp: [AIIMS 02] a Allergy is an etiological factor b Occur in the first decade of life c Are bilateral d Are often associated with bronchial asthma CHAPTER 17 Granulomatous Disorders of Nose, Nasal Polyps and Foreign Body in Nose 22 Regarding ethmoidal polyp, which one of the following is true: [Kolkata 05] a Epistaxis b Unilateral c