EN4.34 | Granulomatous Diseases of Nose — Summary & Reflection

KEY TAKEAWAYS

Granulomatous diseases of the nose share chronic nasal obstruction, bloody crusting, septal perforation, and saddle-nose deformity as common features. In India the differential is broad: infective causes (tuberculosis — caseating granuloma, ZN/CBNAAT positive; rhinoscleroma — Klebsiella rhinoscleromatis, Mikulicz cells + Russell bodies, treat with prolonged ciprofloxacin; rhinosporidiosis — Rhinosporidium seeberi, strawberry polyp with sporangia, treat with complete excision; leprosy; syphilis); and non-infective causes (GPA/Wegener's — c-ANCA positive, necrotising vasculitis, treat with cyclophosphamide/rituximab + steroids; sarcoidosis — non-caseating granuloma, BHL, elevated ACE, lupus pernio, treat with corticosteroids). The central investigation for all is biopsy and histopathology. Additional specific tests: c-ANCA (GPA), serum ACE (sarcoidosis), CBNAAT/Mantoux (TB), VDRL/TPHA (syphilis). Septal perforation differential includes granulomatous disease, cocaine inhalation, chromate exposure, and trauma. Correct diagnosis is essential because treatments differ fundamentally: immunosuppression for GPA, ATT for TB, surgery for rhinosporidiosis, antibiotics for rhinoscleroma.

REFLECT

A 40-year-old male from rural Rajasthan presents to your ENT clinic with a 3-year history of progressive nasal obstruction, crusting, and what he describes as a 'shrinking nose.' He has seen multiple practitioners and received repeated courses of antibiotics without benefit. He is visibly distressed and says he has been told his condition cannot be treated. Reflect on the diagnostic journey that leads to chronic undiagnosed granulomatous nasal disease in the Indian primary care context — what are the structural and knowledge barriers that result in years of misdiagnosis? How would you communicate a new diagnosis (e.g. rhinoscleroma requiring years of antibiotic therapy with uncertain outcome) to a patient who has already lost confidence in the medical system? What counselling points are essential for this specific patient?