Tuberculosis of the nose

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 reason is mycobacteria.

Tuberculosis of the nose is a class of extrapulmonary tuberculosis with skin and subcutaneous tissue damage of various locations.

Lupus tuberculosis in the nose is more common in women (65%). Nose lesions are 63%, cheeks - 58%, ears and periocular surfaces - 14%, in 13% of cases the red border of the lips is affected.

Pathogenesis and pathological anatomy

Lupus erythematosus arises from the spread of MBT by hematogenous and lymphogenous pathways from endogenous foci in other organs. Sometimes, usually in childhood, there is an exogenous infection caused by massive infection of the damaged skin. There are localized and disseminated forms of skin tuberculosis. Lupus erythematosus 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) - round loboma with clear boundaries, soft-elastic consistency, brownish-pink coloration, painless on palpation. Allocate a flat and early infiltrative form of tuberculous lupus in the nose.

The flat form is an infiltrate formed by the fusion of lupus, located in the dermis and almost not protruding above the level of the skin. The infiltrate has distinct scalloped edges surrounded by a hyperemia band. Its distribution is due to the formation of new bumps on the periphery. The surface of the infiltrate can be covered with silvery-white scales, warty growths, erosions and ulcers or have other characteristics.

The infiltrative form of tuberculous lupus in the nose is characterized by the defeat of the soft tissues of the cartilaginous part of the nose and the nasolabial region, resulting in an infiltrate with indistinct boundaries and desquamation on the surface in the dermis and subcutaneous tissue. Healing of the infiltrate occurs with the formation of a deep disfiguring scar. With the prolonged existence of a lupus or scar, it is possible to malign it: a dense, painful, pinkish-bluish infiltrate appears with necrosis in the center, often covered with a black dense crust (lupus-carcinoma).

The favorite location of tuberculous lupus in the nose is the face, mainly the skin of the nose and cheeks, and the emerging picture is very characteristic and is a kind of a sprawling butterfly, whose "body" is located on the back of the nose, "wings" - symmetrically on the cheeks.

Clinical course and symptoms of tuberculosis of the nose

Usually, patients seek medical help when the disease acquires sufficiently clear signs. In the initial stage, they complain of itching and burning in the nose, nasal congestion, frequent nasal bleeding, the presence of crusts in the nasal passages, which can spread to the skin of the entrance to the nose and its surface. The mucous membrane of the nose is pale, atrophic, covered with crusts, under which soft nodules of yellow color with scalloped edges are defined, around them there are ulcers easily bleeding when touching. These ulcers lead to the exposure of the cartilage of the septum of the nose and its perforations with uneven edges covered with granulation tissue, lupoids and atrophic scars. Scar tissue can form intranasal synechia, stenose the nostrils, attract the tip of the nose to the upper lip, giving it the appearance of a parrot's beak, and destructively necrotic forms completely destroy the supporting elements of the inner nose, distort the shape of the pyramid, giving it the appearance of a "dead head".

The clinical course of tuberculous lupus in the nose of the nose is prolonged, lasting for many years, interrupted by remissions, sometimes spontaneous recovery, but most often accompanied by the spread of the mucosal layer of neighboring respiratory and esophagus pathways, lymphoid apparatus, auditory tube, down to the middle ear. The disease is accompanied by regional lymphadenitis.

A special clinical form of tuberculous lupus in the nose is bone tuberculosis of the axillary-nasal system. This form of tuberculous lupus in the nose is characterized by the appearance of a specific periostitis and osteitis, followed by the so-called cold abscesses, forming fistulas, caseous necrotic decay of tissues or the formation of pseudotumoral tuberculoma, localized most often in the region of the superior alveolar process. Patients complain of pain in the area of the base of the nose pyramid, the canine fossa and the brow ridges, according to which of the airway systems is affected, respectively the cells of the latticed labyrinth, the maxillary or frontal sinus.

In the initial period there is a blanching of the skin over the affected area, sometimes - submandibular lymphadenitis. On the mucous membrane of the nose, undefined tuberculous nodules and infiltrates are detected. When endoscopy of the maxillary or frontal sinus with the help of a universal endoscope, the mucosa looks spotted with alternating areas of hyperemia and caseous yellowish raids. The presence of these changes in the mucosa testifies to the transition of the inflammatory process to the mature stage.

The mature stage of the rhinosinus form of lupus is characterized by a caseous necrotic disintegration of the soft and bony 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 region of the alveolar process. The osteoperostitis arising here has extensive growth and is accompanied by bleeding and neuralgia of the second branch of the trigeminal nerve. With frontal lupus erythematosus, osteitis is localized in the area of the frontal-nasal suture or in the region of the trellis plate. When localized in the lattice, the process acquires a pseudotumorous form with the formation of caseous May and fistulas in the region of the internal angle of the orbit or in the lattice plate, which often leads to a terrible complication, tuberculous meningitis. The defeat of the sphenoid sinus is characterized by the same changes as the damage to the latticed bone, in this case the optic nerves, cavernous sinus and pituitary gland are under threat of damage. Lesions of the paranasal sinuses are accompanied by purulent-caseous discharge from the nose.

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Diagnosis of tuberculosis of the nose

The diagnosis is made on the basis of the presence of polymorphic changes in the nose and face skin, prolonged and progressive course, the possible presence of contact with a patient with tuberculosis or a distant outbreak.

Differential diagnosis in the initial stages of the disease is difficult, because often the local manifestations of tuberculous lupus in the nose may be similar to the banal dermatitis of the vestibule of the nose. At the same stages, the tuberculous lupus of the nose should be differentiated from the ozona and the so-called finger erosions in children. In a mature state, tubercular lupus of the nose should be differentiated from the trophic ulcer of the septum of Gaek's nose, tertiary syphilis, rhinoscleroma, leprosy, granulation tissue arising from foreign bodies of the nose and rhinolithiasis, benign tumors, and finally the pseudotumorous form of tuberculous lupus erythematosus should be differentiated from the malignant tumor. In doubtful cases, biopsies are made, implantation of pathological material with guinea pig, diagnostics of ex jubantibus (antibiotic treatment).

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Treatment of tuberculosis of the nose

Treatment of tuberculous lupus erythematosus is a long process, not always effective. Most commonly used common anti-tuberculosis treatment, which is combined with massive doses of vitamin D2, intake of vitamins A and C. Locally prescribed ointments with appropriate antibiotics, vitaminized oils of sea-buckthorn, dogrose, carotolin, etc., proteolytic enzymes, corticosteroids. With fluffy tuberculosis, chemical cauterization is carried out with salts of zinc, chromium, silver, trichloroacetic acid and lactic acid. Various physiotherapeutic agents are also used (galvanocaustic, UV, ionizing radiation, laser therapy), but the therapeutic effect of these methods can not be considered sufficient.

Surgical treatment is aimed mainly at excising scar tissue and restoring the respiratory function of the nose, eliminating cosmetic defects, for example restoring the tip of the nose. However, any surgical intervention performed to remove anatomical defects in tuberculous lupus erythematosus should be performed only after the process has stabilized or recovered.

Prognosis for tuberculosis of the nose

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