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. [39]
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.
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. Rhinoplasty may be effective for external nasal deformities. [40]
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. [41]
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 [42] 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.
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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Very high magnification micrograph of rhinoscleroma. Hematoxylin and eosin stain. Silver staining demonstrates the presence of microorganisms consistent with Klebsiella rhinoscleromatis. Courtesy of Nephron (own work), via Wikimedia Commons.
