Scleroma of the upper respiratory passages: a CT study

Imaging of Large Airways Disorders

OBJECTIVE

Recent technical advances, including the routine use of CT thin sections and techniques such as 2D minimum-intensity-projection and 3D volume images, have increased our ability to detect large airways diseases. Furthermore, dedicated CT protocols allow the evaluation of dynamic airway dysfunction.

CONCLUSION

With diseases of the large airways more commonly seen in daily practice, it is important that radiologists be familiar with the appearances, differential diagnosis, and clinical implications of these entities.

Surgical management of scleromatous laryngotracheal stenosis

OBJECTIVE

Scleroma is a chronic specific granulomatous disease of the upper respiratory tract caused by Klebsiella Rhinoscleromatis. It usually affects the subglottic region and upper trachea resulting in various degrees of stenosis. Patients with laryngotracheal stenosis may present with stridor, shortness of breath or exercise intolerance and may be tracheostomy dependent. In this work, we presented the experience of our Institute in the management of patients with scleromatous laryngotracheal stenosis using the already designed procedures for traumatic laryngotracheal stenosis.

PATIENTS AND METHODS

The study was a non controlled prospective study. It was conducted in Oto-Rhino-Laryngology and Head and Neck Surgery Department of Zagazig University Hospitals, Egypt. It included 38 patients with scleromatous subglottic stenosis and/or upper tracheal stenosis. The patients were classified into four grades according to Myer-Cotton's scale. The surgical treatment modalities included endoscopic CO2 laser surgery with dilatation, laryngotracheal reconstruction, and partial cricotracheal resection with thyrotracheal anastomosis.

RESULTS

The average follow-up period was 32.1 months. Twenty four patients (63%) had an excellent outcome. Nine patients (24%) had a good outcome. Five patients (13%) were still tracheostomy dependent. Eleven patients (29%) developed postoperative granulation tissue. The overall success rate was 87%.

CONCLUSION

Scleromatous laryngotracheal stenosis is considered a challenging surgical problem. It requires a multidisciplinary approach by well-trained personnel. The surgical techniques designed for cases of laryngotracheal stenosis of a traumatic etiology can be applied for cases of scleroma with approximately the same success rates.

Imaging of scleroma in the head and neck

We review the appearance of scleroma in the head and neck on imaging. Scleroma is a chronic granulomatous disease that primarily affects the nasal cavity, but the pharynx and larynx may also be involved. On imaging, nasal scleroma appears as bilateral or unilateral expanded homogeneous nasal masses that may exhibit hyperintense signal on T(1) weighted images. Pharyngeal scleroma commonly narrows the pharyngeal lumen and may involve the soft and hard palate. Imaging is essential to detect the extent of subglottic stenosis in patients with laryngeal scleroma. Rarely, scleroma may involve the orbit or the middle ear. Imaging is essential for the early diagnosis of scleroma and for differentiating it from other granulomatous and neoplastic lesions. Also, imaging is important for treatment planning and follow-up of patients after therapy.

Airway management of an unusual case of recurrent rhinoscleroma

Rhinoscleroma is a rare entity encountered in anesthesia practice. We discuss the management of a patient after its recurrence, involving the upper respiratory tract i.e. nasopharynx and oropharynx, which compromised the airway. The pateint was referred for anesthesia on three different occasions with different presentations owing to the recurrence of symptoms.The presence of an oropharyngeal membrane with a small opening made airway management a challenge. The patient was successfully managed on all three occasions. Imaging facilitated assessment and subsequent airway management.

Rhinoscleroma: an updated experience through the last 10 years

CONCLUSION

Rhinoscleroma is a chronic, specific, granuloma of the nose and other parts of the respiratory system. The disease is endemic in Egypt and many other countries. The causative organism is Klebsiella rhinoscleromatis bacillus, proved by fulfilling Koch's postulates. The mode of infection is not known and its worldwide irregular geographical distribution is not understood. Lines of treatment are unsatisfactory and a tendency for recurrence is the rule.

OBJECTIVES

Our aim was to study the clinical presentation, microbiology, pathological staging, follow-up, and lines of treatment of new rhinoscleroma patients admitted or seen at Alexandria Main University Hospital from January 1999 until January 2009.

METHODS

Demographic data and the results of clinical, bacteriological, and histological examinations were reviewed. Medical and surgical treatments were evaluated. Follow-up as regards the results of treatment and incidence of recurrence was assessed.

RESULTS

Fifty-six patients were included in the study. There were 26 males and 30 females, and 85% of patients presented in the third and fourth decades of life. The nose was affected in 100% of patients. Other regions affected were the nasopharynx in 13 patients, palate in 7 patients, skin in 2 patients, larynx in 3 patients, trachea in 17 patients, nasolacrimal duct in 2 patients, and premaxilla in 1 patient. No lymph node affection was reported. Klebsiella rhinoscleromatis strain III was isolated from 100% of patients. Antibiotics used were a combination of trimethoprim-sulfamethoxazole 400 mg and rifampicin 300 mg twice daily for 3 months. Since 2003, this was replaced by ciprofloxacin 500 mg twice daily for 3 months. Surgical procedures performed were removal of nasal granulations, bronchoscopic dilatation, bipolar coagulation of skin lesions, tracheostomy, and repair of pharyngeal stenosis. Results were disappointing, as a large number of patients did not attend for follow-up. A high incidence of recurrence was found, reaching up to 25% within 10 years.

Imaging appearance of granulomatous lesions of head and neck

We aim to review the imaging appearance of granulomatous lesions of the head and neck. Granulomatous lesions are seen in different regions of the head and neck and a difficult diagnostic challenge for the radiologist. Infective granulomas may be due to bacterial or fungal agents. Non-infective granulomas are Wegener's granulomatosis, sarcoidosis, amyloidosis, chemical granuloma and reparative giant cell granuloma. Familiarity with the clinical presentation and imaging features of these lesions can suggest diagnosis in some cases. CT and MR imaging demonstrate the exact location, extension and effect on surrounding structures. A thorough knowledge of age, gender, common location, clinical features and imaging appearance of granulomatous lesions are important for diagnosis.

Rhinoscleroma: eight Peruvian cases

Rhinoscleroma is a rare infection in developed countries; although, it is reported with some frequency in poorer regions such as Central Africa, Central and South America, Eastern and Central Europe, Middle East, India and Indonesia. Nowadays, rhinoscleroma may be erroneously diagnosed as mucocutaneos leishmaniasis, leprosy, paracoccidioidomycosis, rhinosporidiasis, late syphilis, neoplasic diseases or other upper airway diseases. From 1996 to 2003, we diagnosed rhinoscleroma in eight patients attended in the Dermatologic and Transmitted Diseases service of "Cayetano Heredia" National Hospital, in Lima, Peru. The patients presented airway structural alterations producing nasopharyngeal, oropharyngeal and, in one patient, laryngeal stenosis. Biopsy samples revealed large vacuolated macrophages (Mikulicz cells) in all patients. Ciprofloxacin 500 mg bid for four to 12 weeks was used in seven patients and oxytetracycline 500 mg qid for six weeks in one patient. After follow-up for six to 12 months the patients did not show active infection or relapse, however, all of them presented some degree of upper airway stenosis. These cases are reported because of the difficulty diagnosing the disease and the success of antibiotic treatment.

Rhinoscleroma in three siblings

Rhinoscleroma is a chronic, granulomatous infectious disease that responds poorly to treatment. In recent years an increasing number of cases have been reported in nonendemic areas, explained largely by major migratory movements. We describe rhinoscleroma in three siblings. They had ulcerated but painless lesions, which bled spontaneously, and hemorrhagic scabs or crusts in their noses. In one child, the lesions had destroyed the entire left nasal ala and alar cartilage and most of the right. Dermatopathologic study identified the Mikulicz macrophages that contained organisms. It is possible that disposing factors could have been the neutropenia common to the three children and their poor living conditions. They were treated with a combination of trimethoprim-sulfamethoxazole and cefalexin, for a period of 3 months. We present this unusual case history of three siblings affected by a process that is relatively infrequent in our area of practice and is not considered very contagious. It is important to recognize the clinical signs characteristic of this disease, the diagnosis of which is not easy. Improvements in living conditions, hygiene, and health standards are essential prerequisites for its control and prevention.

Radiological appearances of sinonasal abnormalities

The aim of this pictorial review is to present a variety of abnormalities of the sinonasal cavities to emphasize the diversity of lesions occurring in this region. These include congenital, neoplastic and granulomatous disorders and some allergic and inflammatory lesions with uncommon radiological appearances, as well as expanding lesions of the facial bones or of dental origin with secondary involvement of the related sinus(es).

Rhinoscleroma mimicking nasal polyposis

Rhinoscleroma is increasing in incidence in the United States. It should be considered in patients who are immigrants from endemic countries and present with nasal polyposis that exhibits significant adherence to the nasal septum and relative sparing of the sinuses. Fluoroquinolones are emerging as the adjunctive antibiotic treatment of choice to complement surgical extirpation of the disease.

Laryngotracheal manifestations of rhinoscleroma

Rhinoscleroma is a rare, chronic granulomatous disease of infective causation. It usually begins in the nose and may progress to involve the larynx and trachea and cause dysphonia, stridor, and airway obstruction. Early rhinoscleroma is usually successfully treated with oral tetracycline, yet laryngotracheal disease may require operative intervention. The disease is rare in the United States, but with an increase in immigration from endemic areas, otolaryngologists should be familiar with the management of this rare disease. Current literature contains only a few reports describing the manifestations of this disease, mostly in the form of case studies. This study is a retrospective review of our institutional experience with the management of 22 patients with rhinoscleroma, 13 of whom had laryngotracheal involvement. The focus of this report is on the clinical manifestations of laryngotracheal scleroma. All of the patients were treated with long-term antibiotics. Nine patients underwent endoscopy with or without dilation and laser excision. Three patients required emergency tracheostomy, all of whom were ultimately decannulated without any sequelae. A rational approach to management of this unusual disease is provided.

Rhinoscleroma with orbital extension: CT and MRI

We describe the MRI features of a rhinoscleroma with orbital extension. This benign bacterial and granulomatous lesion of the paranasal sinuses gave homogeneous low intensity on T2-weighted images and enhanced with gadolinium. It could simulate a malignant sinonasal tumour or a fungal sinusitis; the diagnosis must be considered in patients from endemic areas.

Scleroma of the lower respiratory tract: case report and review of literature

The case of a 46-year-old man who presented with acute respiratory distress due to a tracheal mass is reported. The patient underwent endoscopic resection of the mass and the histopathology revealed scleroma. No other sites of involvement by scleroma were found. This case is reported because laryngotracheal involvement by scleroma as the only manifestation of this disease is extremely rare.

Rhinoscleroma: a growing concern in the United States? Mayo Clinic experience

Rhinoscleroma is a chronic, progressive, granulomatous infection of the upper airways caused by the bacterium Klebsiella rhinoscleromatis. Although most cases occur in developing countries, recent immigration patterns have led to an increasing number of patients with rhinoscleroma in the United States. Rhinoscleroma may mimic various inflammatory and neoplastic processes, including leprosy, paracoccidioidomycosis, sarcoidosis, basal cell carcinoma, and Wegener's granulomatosis. Current therapy consists of a combination of surgical débridement and prolonged antimicrobial therapy. Rhinoscleroma should be added to the list of opportunistic infections that can occur in patients with human immunodeficiency virus.

Infectious granulomatous diseases of the head and neck

Infectious granulomatous diseases of the head and neck are very important entities that can mimic or hide malignant tumors and a wide variety of diseases. The frequency of these diseases is increasing with the wider use of immunosuppressive drugs and the increasing incidence of AIDS. The diagnosis is simple, and does not require sophisticated diagnostic procedures, but a high index of suspicion is necessary. Although other studies are helpful to suggest the diagnosis or define the extent of the disease, the microbiological and histopathological analyses are the most specific studies for the diagnosis. The therapy is usually combined: medical and surgical. The medical therapy involves treatment for a long period of time, usually between 3 and 6 months. The follow-up should be kept for at least 3 years. The tendency of some of these diseases to relapse makes the therapy discouraging, and some patients will need multiple therapies throughout their life. An accurate diagnosis and specific therapy for adequate amount of time is the best way to achieve a complete cure or at least a better chance for a good prognosis.