Granulomatous Disease and Faciomaxillary Trauma

Abstract

Three types of etiology behind the granulomatous disease are infective, inflammatory, and neoplastic. Among infective, they are bacterial like (tuberculosis, rhinoscleroma, syphilis, and leprosy) fungal (Rhinosporidiosis, aspergillosis, mucormycosis, histoplasmosis, and blastomycosis) protozoal (leishmaniasis) lymphoma (peripheral T-cell neoplasm/non-healing)midline granuloma and inflammatory vasclitidies like Wegener’s granulomatosis, sarcoidosis, and Churg–Strauss syndrome. Tuberculosis of the nose is usually secondary to pulmonary tuberculosis and involves the anterior part of the septum and anterior end of inferior septum, hence it causes perforation in the anterior cartilaginous part of the septum. Diagnosis is by biopsy and AFB stain ant treatment is anti-tubercular drugs. Lupus is a low grade tubercular infection of the nose. Rhinoscleroma is caused by Klebsiella rhinoscleromatis and Mikulicz cells and Russell bodies are diagnostic findings of biopsy. Acquired and congenital syphilis can be seen in the nose. Congenital syphilis either presents early after birth as snuffles or late as gummas. Among acquired tertiary syphilis is most common. Gummas are seen on the nasal septum and cause perforation in both the bony and cartilaginous septum. Antibiotics given are benzathine penicillin and doxycycline. Leprosy also involves the anterior part of nasal septum and anterior end of inferior turbinate and this leads to perforation in the cartilaginous part. The fungal infection of the nose (Aspergillus fumigates, Aspergillus flavus, Aspergillus niger, Mucor, and Rhizopus) can lead to granuloma formation. Rhinosporidiosis is caused by Rhinosporidium seeberi identified to be an aquatic protistan protozoa (unicellular) parasite. Nasal biopsy or smear shows sporangia. Treatment is wide excision and cauterization of the base. Dapsone is given in the postoperative period to decrease the chances of recurrence. Wegner’s granulomatosis vasculitis is affecting most commonly the upper and lower respiratory tract (multiple bilateral cavitary lesions in the lungs) and the kidneys. Nasal involvement may lead to perforation of both bony and cartilaginous part of septum and ultimately whole septal destruction, saddle nose, or nasal airway stenosis. The cytoplasmic antineutrophil cytoplasmic autoantibody test is highly sensitive for Wegener’s granulomatosis but negative test does not exclude the diagnosis. The main agents used to treat Wegener’s are cyclophosphamide, methotrexate, and/or glucocorticoids. Approximately 40% patients have granulomatous changes in extrapulmonary organs of patients with sarcoidosis. Diagnosis is made on biopsy along with serum Angiotensin-converting enzyme levels. Biopsy is necessary for the definitive diagnosis of T-cell lymphoma and radiotherapy and chemotherapy are used for treatment.