Granulomatous disorders of the nose and paranasal sinuses

To review granulomatous findings in sinus and nasal tissue as part of a diagnostic indicator of various disease states, focusing on the role of further testing and evaluation to clarify this diagnosis as well as the implications for patient care.

Inflammatory and infectious diseases as well as neoplasms, cocaine abuse and trauma may have rhinosinus granulomatous findings as part of the disease state. The need for careful histopathologic evaluation as well as the pitfalls and caveats of laboratory testing will be reviewed in this paper. Some infections such as invasive fungal rhinosinusitis and rhinoscleroma may have a chronic granulomatous course, which may require extensive surgical and pharmacologic treatment. Treatment options for Wegener's granulomatosis have shown a lack of effect of etanercept, but hopeful alternatives to prolonged cyclophosphamide use include methotrexate and leflunomide. Cocaine-induced midline destructive lesions unfortunately have a high prevalence of cytoplasmic antineutrophil cytoplasmic antibodies, limiting this test's usefulness in distinguishing this disorder from Wegener's granulomatosis.

The otorhinolaryngologist must be aware of the differential diagnosis of these chronic inflammatory states to formulate an optimal course of evaluation and longitudinal management for these patients.