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Necrotizing nasal lesions

Necrotization is the process of causing or undergoing necrosis or the death or decay, of part of an organ or tissue, due to disease, injury, or deficiency of nutrients; mortification). Trauma and infection are the most common causes of these lesions.

Excluding trauma, the differential diagnosis of necrotizing nasal lesions can be subdivided into four categories: infectious, vasculitic and autoimmune, idiopathic, and neoplastic. Common to all of these categories is the presence of granulomatous inflammation.

The differential diagnosis of necrotizing intranasal lesions is extensive, and accurate diagnosis is essential for determining the appropriate treatment. A thorough history and physical examination are mandatory, specifically looking for signs and symptoms of systemic disease.

Cocaine abuse can cause extensive midline nasal destruction, ranging from simple septal perforations to alar necrosis, saddle deformities, and massive, progressive osteocartilaginous necrosis of the sinonasal tract and palate. It is important to elicit information regarding trauma or septal surgery, recent travel, medications, and if possible, about cocaine abuse. Generally treated conservatively with debridement of necrotic tissues, antibiotics, saline irrigations, and abstinence from cocaine.

Skin testing and/or complement fixation titers for tuberculosis, histoplasmosis, coccidiodomycosis, and blastomycosis may be obtained.

Biopsies and Immunohistochemical studies are very helpful, and special stains and cultures for acid-fast bacilli, fungi, spirochetes, and rhinoscleroma should be performed.

A wide variety of infectious diseases can lead to necrotizing lesions of the nose. Mycobacteria, fungi, or spirochetes cause most of these. Rhinosporidiosis is a fungal infection that is quite prevalent in India. Nasal involvement in the lepromatous form of leprosy is universal.

Several fungal infections can be implicated in causing necrotizing, granulomatous lesions of the nose. Nasal lesions in histoplasmosis, coccidiodomycosis, blastomycosis, and cryptococcosis are almost invariably the result of systemic spread from a primary pulmonary infection.

Nasal disease secondary to syphilis can occur at any age, including in the neonate. Primary, secondary, and tertiary syphilis can all cause intranasal disease.

Of the bacterial causes of necrotizing nasal lesions, rhinoscleroma is of particular interest. It is endemic to Mexico, and Central and South America and is caused by Klebsiella rhinoscleromatis.

Wegener's granulomatosis is a distinct clinical entity that is classically defined by the presence of a necrotizing granulomatous vasculitis involving both the upper and lower respiratory tracts, and a focal necrotizing glomerulonephritis.

Relapsing polychondritis is felt to be an autoimmune disease that is characterized by recurrent inflammation with destruction of cartilaginous and other connective tissue structures. The cartilage of the ears, nose, and airway are the most frequently involved.

Churg-Strauss syndrome, or allergic granulomatosis and angiitis, is a fascinating clinical syndrome that is characterized by the presence of severe asthma, fever, and peripheral eosinophilia, along with signs and symptoms of vasculitis in other organ systems.

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology that most commonly strikes in young adulthood and is more frequently seen in the black population. Every organ system can be involved in the granulomatous process.

Idiopathic midline destructive disease is the ultimate diagnosis of exclusion for necrotizing intranasal lesions. It is a very rare disease that is defined as the progressive and relentless inflammatory destruction of the sinonasal tract and palate, with erosion of contiguous structures.

A variety of malignant neoplasms can cause ulcerative lesions of the nasal cavity, including squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, and lymphomas.

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