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
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.
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
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.
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.
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,