eMedicine Specialties > Dermatology > Bacterial Infections
Rhinoscleroma: Treatment & Medication
Updated: Jul 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
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.
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.15
- 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 intubation16 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.
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.
Medication
The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.
Antibiotic agents
Tetracycline is the drug of choice. Other antibiotics include ciprofloxacin and rifampin. Bacterial overinfection responds to treatment with clindamycin and third-generation cephalosporins. Sclerotic lesions respond well to treatment with ciprofloxacin. Ciprofloxacin has the following advantages: Its oral administration is convenient, it achieves good tissue penetration, it is concentrated in macrophages, and it may prove useful in the treatment of patients with rhinoscleroma.
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against Pseudomonas species, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.
Adult
250-500 mg PO bid for 7-14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after fluoroquinolone dose; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, periodically evaluate organ system (eg, renal, hepatic, hematopoietic) function; adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Cefixime (Suprax)
Third-generation cephalosporin. Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more penicillin-binding proteins.
Adult
200 mg PO q12h or 400 mg/d PO qd or divided q12h
Pediatric
<12 years: 8 mg/kg/d susp PO qd or 4 mg/kg PO bid
>50 kg or >12 years: Administer as in adults
Coadministration with aminoglycosides increases nephrotoxicity; probenecid may increase effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); prolonged or repeated use may cause superinfections and promote growth of nonsusceptible organisms
Rifampin (Rifadin, Rimactane)
Inhibits DNA-dependent bacteria by binding to beta subunit of DNA-dependent RNA polymerase, blocking RNA transcription.
Adult
600 mg/d PO/IV single daily dose
Pediatric
10-20 mg/kg PO/IV; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; coadministration with enalapril may increase BP; coadministration with isoniazid may increase rate of hepatotoxicity more than with either agent alone (discontinue 1 or both if LFT results change)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemical values prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy associated with thrombocytopenia (reversible if therapy discontinued as soon as purpura appears); if treatment continued or resumed after purpura appears, cerebral hemorrhage or death may occur
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes and causing arrest of RNA-dependent protein synthesis.
Adult
150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d
600-1200 mg/d IV/IM divided q6-8h depending on degree of infection
Pediatric
8-20 mg/kg/d (hydrochloride) PO divided tid/qid
8-25 mg/kg/d (palmitate) PO divided tid/qid
20-40 mg/kg/d (phosphate) IV/IM divided tid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Corticosteroid agents
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Meticorten, Orasone)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Pediatric
4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve
Coadministration with estrogens may decrease clearance; concurrent digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, connective tissue, or tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI tract disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
More on Rhinoscleroma |
| Overview: Rhinoscleroma |
| Differential Diagnoses & Workup: Rhinoscleroma |
 Treatment & Medication: Rhinoscleroma |
| Follow-up: Rhinoscleroma |
| References |
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Further Reading
Keywords
rhinoscleroma, respiratory scleroma, scleroma, Mikulich disease, rhinosclerosis, Klebsiella rhinoscleromatis, K rhinoscleromatis, scleroma respiratorium, nasal polyposis, scleroma respiratorium
