Nasal tuberculosis

There are two forms of tuberculosis of the nose: primary (lupus and tuberculoma) and secondary (ulcerative-caseous tuberculosis of the nose and bone tuberculosis of the nose). The cause is mycobacteria.

Tuberculous lupus of the nose belongs to the class of extrapulmonary tuberculosis with lesions of the skin and subcutaneous tissue of various localizations.

Tuberculous lupus of the nose is more common in women (65%). The nose is affected in 63% of cases, cheeks - 58%, auricles and periocular surfaces - 14%, and the red border of the lips is affected in 13% of cases.

Pathogenesis and pathological anatomy

Tuberculous lupus of the nose occurs as a result of the spread of MBT by hematogenous and lymphogenous routes from endogenous foci in other organs. Sometimes, usually in childhood, exogenous infection is observed, caused by massive infection of damaged skin. Localized and disseminated forms of tuberculosis of the skin are distinguished. Tuberculous lupus of the nose refers to localized forms and affects the skin of the nose, its mucous membrane with spread to the mucous membrane of the oral cavity. The primary element is a tubercle (2-3 mm in diameter) - a rounded lupoma with clear boundaries, soft elastic consistency, brownish-pink color, painless on palpation. Flat and early infiltrative forms of tuberculous lupus of the nose are distinguished.

The flat form is an infiltrate formed by the fusion of lumps, located in the dermis and barely protruding above the skin level. The infiltrate has clear scalloped edges surrounded by a border of hyperemia. Its spread occurs due to the formation of new tubercles along the periphery. The surface of the infiltrate may be covered with silvery-white scales, warty growths, erosions and ulcers, or have other features.

The infiltrative form of tuberculous lupus of the nose is characterized by damage to the soft tissues of the cartilaginous part of the nose and nasolabial area, resulting in the formation of an infiltrate with unclear boundaries and peeling on the surface in the dermis and subcutaneous tissue. Healing of the infiltrate occurs with the formation of a deep disfiguring scar. With the long-term existence of a lupus lesion or scar, its maligation is possible: a dense, painful, pinkish-cyanotic infiltrate with necrosis in the center appears, often covered with a dense black crust (lupus carcinoma).

The favorite localization of tuberculous lupus of the nose is the face, mainly the skin of the nose and cheeks, and the resulting picture is very characteristic and represents the appearance of a flattened butterfly, the “body” of which is located on the bridge of the nose, and the “wings” are symmetrically on the cheeks.

Clinical course and symptoms of tuberculosis of the nose

Patients usually seek medical help when the disease acquires quite obvious symptoms. In the initial stage, they complain of itching and burning in the nasal area, nasal congestion, frequent nosebleeds, the presence of crusts in the nasal passages, which can spread to the skin of the entrance to the nose and to its surface. The mucous membrane of the nose is pale, atrophic, covered with crusts, under which soft yellow nodules with scalloped edges are determined, ulcers are visible around them, easily bleeding when touched. These ulcers lead to exposure of the cartilage of the nasal septum and its perforations with uneven edges covered with granulation tissue, lupoids and atrophic scars. Scar tissue can form intranasal synechiae, stenose the nostrils, pull the tip of the nose to the upper lip, giving it the appearance of a parrot's beak, and in destructive-necrotic forms, completely destroy the supporting elements of the internal nose, distort the shape of the pyramid, giving it the appearance of a "dead head".

The clinical course of tuberculous lupus of the nose is long, lasting for many years, interrupted by remissions, sometimes spontaneous recovery, but most often accompanied by spread to the mucous membrane of the adjacent respiratory and alimentary tract, lymphoid apparatus, auditory tube, up to the middle ear. The disease is accompanied by regional lymphadenitis.

A special clinical form of tuberculous lupus of the nose is bone tuberculosis of the sinonasal system. This form of tuberculous lupus of the nose is characterized by the occurrence of specific periostitis and osteitis, followed by so-called cold abscesses that form fistulas, caseous-necrotic tissue decay or the formation of pseudotumoral tuberculoma, localized most often in the area of the upper alveolar process. Patients complain of pain in the area of the base of the nasal pyramid, canine fossa and superciliary arches, depending on which of the air systems is affected - the cells of the ethmoid labyrinth, the maxillary or frontal sinus, respectively.

In the initial period, the skin above the affected area becomes pale, sometimes - submandibular lymphadenitis. Non-ulcerated tuberculous nodules and infiltrates are detected on the nasal mucosa. During endoscopy of the maxillary or frontal sinus using a universal endoscope, the mucosa appears spotty with alternating areas of hyperemia and caseous yellowish deposits. The presence of these changes in the mucosa indicates the transition of the inflammatory process to a mature stage.

The mature stage of the rhinosinus form of lupus is characterized by caseous-necrotic decay of the soft and bone tissues of the affected area, the formation of fistulas and the release of purulent and caseous masses from them. Most often, the maxillary sinus is affected in the area of the alveolar process. The osteoperiostitis that occurs here has an extensive growth and is accompanied by bleeding and neuralgia of the second branch of the trigeminal nerve. With frontal localization of lupus, osteitis is localized in the area of the frontal-nasal suture or in the area of the ethmoid plate. When localized in the ethmoid bone, the process acquires a pseudotumorous form with the formation of caseous masses and fistulas in the area of the inner angle of the orbit or in the ethmoid plate, which often leads to a formidable complication - tuberculous meningitis. The defeat of the sphenoid sinus is characterized by the same changes as the defeat of the ethmoid bone, in this case the optic nerves, cavernous sinus and pituitary gland are at risk of defeat. The defeat of the paranasal sinuses is accompanied by purulent-caseous discharge from the nose.

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Diagnosis of tuberculosis of the nose

The diagnosis is established based on the presence of polymorphic changes in the mucous membranes of the nose and facial skin, a long and progressive course, and possible contact with a patient with tuberculosis or one's own distant source of infection.

Differential diagnostics at the initial stages of the disease is difficult, since local manifestations of tuberculous lupus of the nose can often be similar to banal dermatitis of the nasal vestibule. At these stages, tuberculous lupus of the nose should be differentiated from ozena and so-called digital erosions in children. In a mature state, tuberculous lupus of the nose should be differentiated from Haek's trophic ulcer of the nasal septum, tertiary syphilis, rhinoscleroma, leprosy, granulation tissue arising from foreign bodies in the nose and rhinolithiasis, benign tumors, and finally, the pseudotumorous form of tuberculous lupus of the nose should be differentiated from a malignant tumor. In doubtful cases, a biopsy is performed, pathological material is implanted in a guinea pig, and ex jubantibus diagnostics (antibiotic treatment) is performed.

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Treatment of tuberculosis of the nose

Treatment of tuberculous lupus of the nose is a long process, not always effective. General anti-tuberculosis treatment is mainly used, which is combined with massive doses of vitamin D2, intake of vitamins A and C. Ointments with appropriate antibiotics, vitaminized oils of sea buckthorn, rose hips, carotolin, etc., proteolytic enzymes, corticosteroids are prescribed locally. In case of lush tuberculomas, chemical cauterization is carried out with zinc, chromium, silver salts, trichloroacetic and lactic acids. Various physiotherapeutic means (galvanocautery, ultraviolet irradiation, ionizing radiation, laser therapy) are also used, however, the therapeutic effect of these methods cannot be considered sufficient.

Surgical treatment is mainly aimed at excising scar tissue and restoring the respiratory function of the nose, eliminating cosmetic defects, such as restoring the position of the tip of the nose. However, any surgical intervention performed to eliminate anatomical defects in tuberculous lupus of the nose should be performed only after stabilization of the process or recovery.

Prognosis for tuberculosis of the nose

The prognosis depends on the severity of the pathological process and its localization. The prognosis is most serious when the paranasal sinuses are affected.