Laryngotracheal manifestations of rhinoscleroma

A Myriad of Scleroma Presentations: The Usual and Unusual

To prospectively study a series of scleroma patients with a focus on socioeconomic status, clinical presentation, pathology, microbiology, and treatment. A total of 52 patients diagnosed with scleroma were included in the study. Demographic data of the patients were collected and clinical, radiographic, and histopathologic findings were analyzed. Biopsies from atypical patients were sent for electron microscopic examination. Patients were treated both medically and surgically with clinical follow-up to determine outcomes and the incidence of recurrence. Fifty-two patients were included in the study. There were 23 males (44.2%) and 29 females (55.8%). The highest incidence of scleroma was identified in individuals from poor, rural areas in the third to fourth decades of life. The nose was affected in all cases. Other affected sites included the nasopharynx, soft and hard palate, larynx and trachea, lacrimal passages, skin, and gingiva. Some patients had atypical presentations. Complete follow-up of all patients was hindered by non-compliance with clinic visits and the long duration of medical treatment. Recurrence or relapse of the granulomatous lesions after initial improvement occurred in 11 patients (21.2%) within 1 to 3 years. Scleroma is a stubborn, chronic, granulomatous bacterial disease. The diverse presentations may mimic neoplasms and other granulomatous conditions. We present cases with unusual presentations and demonstrate the transmission electron microscopic features of these lesions. Furthermore, we confirm the importance of achieving full eradication of the etiologic bacilli to prevent recurrent disease.

Identification and Management of Chronic Laryngitis

Chronic laryngitis is an inflammatory process of at least 3 weeks duration and affects phonation, breathing, and swallowing. This article describes the infectious, inflammatory, and autoimmune causes of chronic laryngitis. Symptoms of chronic laryngitis are nonspecific and may range from mild to airway compromise requiring emergent tracheostomy.

Airway scleromas and their extensions

BACKGROUND

Scleroma is a rare, chronic, granulomatous infectious disease of the respiratory tract mucosa which begins in the nose and spreads to the respiratory tract and adjoining structures. We report on the extensions and the management of 134 cases of scleroma in the Highlands region of Papua New Guinea.

METHODS

The charts and treatment records of 134 scleroma cases were retrospectively reviewed from 1995 to 2013. The staging, extensions, treatment and results of treatment were reviewed and analysed.

RESULTS

Of the 134 cases, 72 (53.7%) were females and the age ranged from 6 to 65 years. The disease was confined to the nose and nasopharynx in 71 (53.0%) cases. Extension of the disease from the nose to the Eustachian tube occurred in nine (6.7%) cases and into the middle ear in four (3.0%) cases. Further extensions to the larynx and trachea were seen in 17 (12.7%) cases each and the bronchus in three (2.2%) cases. Primary laryngoscleroma without involvement of the nose and nasopharyngeal stenosis without laryngeal involvement were managed in 11 (8.2%) and nine (6.7%) cases respectively. Others cases treated were ethmoid scleroma with proptosis and scleroma involving the upper lip in one (0.75%) case each. Ninety-nine (74.9%) patients were treated medically while 35 (26.1%) patients required surgery. Cure were achieved in 83 (61.9%) cases treated medically and 26 (19.4%) had successful surgical outcome.

CONCLUSION

Scleroma begins in the nose and when not arrested, extends causing obstruction to the airway and cosmetic deformity which requires surgical intervention.

The "forgotten zone": acquired disorders of the trachea in adults

The upper airway is generally defined as the air passage segment that extends between the naso- or oropharynx and the carina. The longest segment of the upper airway—the trachea—begins at the inferior portion of the larynx and extends to the branch point of the main carina. The trachea has the potential to be a “forgotten zone” in differential diagnoses, as pathological processes involving this portion may not receive prominent clinical consideration in disorders presenting with respiratory symptoms and signs. Unlike the oropharynx, this anatomical area is beyond visualization on routine inspection; unlike the mediastinum and lung fields, it is a potential “blind spot” on initial, plain radiographic examination of the chest. Nonetheless, the adult trachea is affected by a number of primary disorders and is also a target organ of a variety of systemic diseases. This review will focus on both primary and systemic diseases involving the adult trachea with specific attention to their clinical manifestations and diagnostic hallmarks.

Septal rhinoscleroma

Rhinoscleroma is a chronic granulomatous condition of the nose and other structures of the upper respiratory tract. Infection by the bacterium Klebsiella rhinoscleromatis is said to be the cause. A female patient aged 45 years, presented with a past history of trauma to the nose and swelling on her nose since last 1 year. There was nasal asymmetry and internal nasal examination showed a septal swelling protruding to the right nasal cavity with hypertrophied nasal mucosa and inferior turbinate. Open tip rhinoplasty approach was used to excise the mass, which examined pathologically revealing a rhinoscleroma, fibrotic infiltrative stage.

Rhinoscleroma of the Larynx: First case report in the State of Qatar

Rhinoscleroma is a chronic slowly progressive inflammatory condition of the upper airways mostly caused by infection with Klebsiella pneumoniae subspecies rhinoscleromatis and less frequently subspecies ozaenae. The disease is uncommon in developed countries but it still exists in Africa and South America. The disease usually takes a chronic course and diagnosis, which might be delayed, depends on the isolation of the organism from the tissue and the characteristic histopathologic features. We report here a case of rhinoscleroma of the upper airways that presented as a laryngeal mass in a young Egyptian man living in Qatar. The methods of diagnosis and treatment are discussed and the relevant literature reviewed.

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.

[Tracheal scleroma and rhinoscleroma: a case report]

Scleroma is a specific granlomatous disease caused by an enterobacteria of the Klebsiella family (Klebsiella rhinoscleromatis), localized electively in the upper airways, particularly the nasal fossae, leading to the term "rhinoscleroma". Tracheal involvement is exceptional. The disease progresses slowly, leaving mutilating and stenosing scar tissue. Medical treatment using antibiotics and corticosteroids is the basic approach although surgical treatment may be needed for fibrosclerosis unresponsive to medical treatment. We report a case of rhinoscleroma which extended to the trachea. In light of this case, we examine the demographic, diagnostic, therapeutic and evolutive aspects of this disease.

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.

Laryngeal scleroma associated with Klebsiella pneumoniae subsp. ozaenae

Klebsiella pneumoniae subsp. ozaenae was isolated from the pharynx of a woman with laryngeal scleroma. K. pneumoniae subsp. ozaenae is rarely isolated from clinical infections and has never been reported in laryngeal scleroma, which is usually caused by K. pneumoniae subsp. rhinoscleromatis.

Granulomatous Diseases and Chronic Rhinosinusitis

Chronic rhinosinusitis often fails to respond to standard medical or surgical treatment. In some of these cases, the underlying disease may be a chronic granulomatous process that requires aggressive topical, local, and in some instances, systemic therapy. Diseases that can present in this manner include autoimmune vasculitis, sarcoidosis, indolent infections, neoplastic processes, and various other miscellaneous conditions. This article reviews the typical presentations for some of these unusual conditions and discusses the appropriate evaluations that will lead to clinical identification and effective medical management.

Nonneoplastic lesions of the tracheobronchial wall: radiologic findings with bronchoscopic correlation

Nonneoplastic diseases of the central airways are uncommon but can be categorized as either focal or diffuse, although there is some overlap. Focal diseases include postintubation stenosis, postinfectious stenosis, posttransplantation stenosis, and various systemic diseases that may involve the airways and lead to focal stenosis (eg, Crohn disease, sarcoidosis, Behçet syndrome). Diffuse diseases of the central airways include Wegener granulomatosis, relapsing polychondritis, tracheobronchopathia osteochondroplastica, amyloidosis, papillomatosis, and rhinoscleroma. Conventional radiography is often the first step in the evaluation of suspected central airway disease and may be adequate in itself to identify the abnormality. However, computed tomography (CT) improves both the detection and characterization of central airway disease. Bronchoscopy remains the primary procedure for the diagnostic work-up of these disease entities. Nevertheless, a thorough radiologic evaluation with radiography and CT may demonstrate specific imaging findings (eg, calcification) that can help narrow the differential diagnosis and aid in the planning of bronchoscopy or therapeutic intervention.

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.

Laryngotracheobronchial involvement in a patient with nonendemic rhinoscleroma

We report the first case of rhinoscleroma in an Israeli citizen, a former sailor with a transatlantic shipping company. Characteristic histologic changes from a tracheal biopsy and isolation of Klebsiella rhinoscleromatis from a blood culture after diagnostic bronchoscopy confirmed the diagnosis. Extreme delay in the diagnosis, a not uncommon feature in nonendemic areas, was associated with severe advanced laryngotracheobronchial disease. Treatment with quinolones was followed by significant improvement, but the patient died 1 month after presentation, apparently from upper airway obstruction.

Scleroma of the larynx and associated squamous cell carcinoma: a causal relationship?

The known risk factors for development of laryngeal carcinoma are smoking, alcohol drinking, air pollution, laryngeal keratosis, single adult papillomas, and previous irradiation. Laryngeal scleroma as a risk factor for the development of laryngeal carcinoma has not been mentioned in the English-language literature, to my knowledge. This is a report of 2 cases of proven long-term rhinolaryngoscleroma that have changed to laryngeal carcinoma.

Laryngeal inflammation mimicking laryngeal carcinoma

A case of severe inflammation with an exuberant granulation lesion of the larynx that mimicked laryngeal tumour is presented. A patient who was a chronic smoker, with a history of hoarse voice underwent multiple endoscopies and biopsies, confirmed histopathologically as acute and, subsequently, as chronic inflammation. The tumour-like tissue in the larynx responded dramatically to prolonged antibiotic treatment. We emphasize the importance of histological confirmation before embarking on removal of an essential organ or part of the body which could lead to physical or emotional scarring.