Rhinoscleroma: A case report and update on medical and surgical management

Abstract

Objectives: Rhinoscleroma is a chronic, progressive, granulomatous infection caused by Klebsiella rhinoscleromatis. The bacteria can infect the upper and/or lower airways, with the sinonasal cavity being affected 95%-100% of the time. We present the case of a 42-year-old Hispanic man who presented with Stage 3 rhinoscleroma, resulting in nasopharyngeal, glottic, and subglottic stenosis. Methods: The patient was taken to the operating room for direct microlaryngoscopy. A posterior cordotomy of the left vocal fold and laser radial incisions/dilation of the subglottis were performed along with topical application of Mitomycin-C. Results: Biopsies of the nasopharygeal and subglottic lesions showed inspissated mucin with foamy histiocytes, gram negative bacilli, and acute and chronic inflammation with fibrosis. Cultures were positive for Klebsiella rhinoscleromatis, sensitive to gatifloxacin. These pathological findings were consistent with Stage 3 rhinoscleroma. The patient was treated with a 6-month course of gatifloxacin. Purulent rhinorrhea and airway difficulties were improved at 6 weeks and resolved at 6 months. Conclusion: We report a case of synchronous rhinoscleromatous lesions. A combination treatment of surgical laser debridement, Mitomycin-C and long-term fluoroquinolones appears to be effective in treating this condition. There are 3 stages of rhinoscleroma and with prompt recognition and early treatment, the natural history of the disease can be halted. The advantages of fluoroquinolones over traditional antibiotic treatment for this condition (tetracycline) include low incidence of side effects, once daily dosing and concentration within the macrophages, the region of bacterial replication. When surgical treatment is necessary, stenosis can be effectively managed with CO 2 laser treatments and Mitomycin-C.