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Rhinoscleroma Treatment & Management

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jun 09, 2016
 

Medical Care

Bronchoscopy has a role in the initial treatment of symptoms. Treatment should also include long-term antimicrobial therapy and surgical intervention in patients with symptoms of obstruction.

Bacterial overinfection responds to treatment with third-generation cephalosporins and clindamycin. Sclerotic lesions respond well to treatment with ciprofloxacin. Long-term antibiotic therapy often eradicates this infection.[25]

The choice of long-term antibiotic therapy should be guided by the patient's age and sex. Repeat biopsy can be performed to help determine the appropriate duration of the antibiotic therapy.

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Surgical Care

Surgery combined with antibiotic therapy is beneficial in patients with granulomatous disease and nasal or pharyngeal obstruction or nasal sinus involvement due to the proliferation of lesions.

Tracheotomy should be considered in patients with laryngeal obstruction of the second degree (granulomatous stage) and above (sclerotic stage).

Plastic surgery is necessary in patients with cicatricial stenosis or when imperforation remains in the nasal cavity, pharynx, larynx, or trachea.[26]

Extensive granulomatous lesions are treated by means of open excision by using the laryngofissure approach, which is the best method for a quick recovery in patients without evidence of subglottic stenosis.

Surgery and laser therapy are required to treat airway compromise and tissue deformity. Fiberoptic intubation[27] allows assessment of the pathology and subsequent passage of a cuffed tracheal tube to secure the airway. To overcome respiratory obstruction as the fiberscope passes through the opening in the membrane, either rapid intubation or a technique of preoxygenation and voluntary hyperventilation followed by breath holding during bronchoscopy is used. The thin caliber and maneuverability of the flexible fiberoptic bronchoscope makes fiberoptic intubation an excellent technique for airway management in cicatricial membranes of the pharynx.

Treatment of the advanced cicatrix with carbon dioxide laser vaporization yields excellent results. Obstructive lesions of the larynx and subglottic space are always a challenging problem for the endoscopist and anesthetist. At this level of the obstruction, the effectiveness and innocuous nature of carbon dioxide laser treatment are related to the degree of endoscopic exposure. Because of the transtracheal high-frequency jet ventilator, ensuring a free laryngeal endoscopic operative field is now possible.

The transtracheal catheter is introduced percutaneously through the cricothyroid membrane into the trachea under endoscopic control and connected to a high-frequency jet ventilator. Among many advantages of this technique, the most convincing include a clear operating field for the surgeon, complete relaxation of the patient, good respiratory gas exchange, elimination of the risk of igniting an endotracheal tube with the laser, decrease in the risk of aspiration of blood and debris, and the ability to provide oxygen and/or mechanical ventilation in the postoperative period.

Palatal symptoms may be relieved by means of uvulopalatopharyngoplasty.

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Consultations

Consultation with a plastic surgeon may be helpful in patients with cicatricial stenosis or in those with imperforation of the nasal cavity, pharynx, larynx, or trachea. An endoscopist and an anesthetist may be required to perform vaporization with a carbon dioxide laser.

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Complications

Rhinoscleroma is a rare cause of upper airway obstruction. Isolated tracheal obstruction.[28, 29] Subglottal stenosis may be a late sequela of rhinoscleroma.[30] Scleroma is known to cause slowly progressive asphyxia.

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Long-Term Monitoring

Owing to the high rate of recurrence, prolonged antibiotic therapy (months to years) is necessary.

Nasal cytology is an easy and noninvasive investigation. This method can be performed on an outpatient basis as an adjuvant to clinical and histopathologic studies, along with nasal endoscopy. Nasal cytology is a simple, reliable, and timesaving procedure that can be used with further therapy.

Bronchoscopy plays a role in the follow-up care of patients.

Relapses occur, and close observation is the key to the long-term follow-up care of the patient.

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Egle Goriniene, MD Staff Physician, Department of Infectious Diseases, New Jersey Medical School

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: XOMA; Biogen/IDEC; Novartis; Janssen Biotech, Abbvie, CSL pharma<br/>Received honoraria from UpToDate for author/editor; Received honoraria from JAMA Dermatology for associate editor and intermittent author; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for i inherited these trust accounts; for: Celgene; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Jacek C Szepietowski, MD, PhD Professor, Vice-Head, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University; Director of the Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Poland

Disclosure: Received consulting fee from Orfagen for consulting; Received consulting fee from Maruho for consulting; Received consulting fee from Astellas for consulting; Received consulting fee from Abbott for consulting; Received consulting fee from Leo Pharma for consulting; Received consulting fee from Biogenoma for consulting; Received honoraria from Janssen for speaking and teaching; Received honoraria from Medac for speaking and teaching; Received consulting fee from Dignity Sciences for consulting; .

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