Nasal syphilis

Syphilis of the nose is divided into acquired and congenital. Acquired syphilis of the nose can appear in all three periods - primary, secondary and tertiary. Syphilis of the nose in the tertiary period has the greatest practical significance.

Acquired syphilis of the nose

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Cause of syphilis of the nose

The causative agent is the pale treponema, which has the appearance of a thin spiral thread from 4 to 14 microns long with small uniform curls.

Syphilis of the nose in the primary period (6-7 weeks) manifests itself as a hard chancre, is a very rare localization. According to statistics, in the 20th century, primary extragenital chancre occurred in 5% of cases of all infections, of these 5%, only 1% accounted for primary syphilis of the nose. Infection occurs mainly through digital transfer of infection when picking the nose, therefore the main localization of chancre is the vestibule of the nose.

Pathological anatomy

Three to four weeks after infection, a primary affect appears at the site of infection, including a hard chancre and regional (submandibular) lymphadenitis. A hard chancre, or primary syphiloma, is a small painless erosion (0.5-1 cm) or ulcer of a round or oval shape, with smooth edges and a dense infiltrate at the base, with a smooth, shiny, red surface. The infiltrate contains a large number of lymphocytes and plasma cells. Endarteritis that occurs at the site of the infiltrate causes narrowing of the blood vessels and, as a consequence, necrosis and ulceration of the affected tissue. Five to seven days after the appearance of a hard chancre, the lymph nodes closest to it, the ipsauricular or subangular mandibular, become enlarged. They are dense, up to 2-3 cm in diameter, painless, not fused with the skin or with each other, the skin above them is not changed.

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Symptoms of syphilis of the nose

The changes that occur at the site of infection are usually one-sided and initially have an acute inflammatory character: painful swelling in the nasal vestibule at the level of the anterior inferior part of the nasal septum. This is followed by an ulcer with raised edges, a dense bottom and painless to the touch. A week later, regional adenopathy occurs.

The diagnosis is established on the basis of the epidemiological anamnesis, characteristic pathological changes, as well as using the serological reactions of Wasserman, Kahn, Sachs-Vitebsky, and the immunofluorescence reaction, which become positive only 3-4 weeks after the appearance of the hard chancre.

Differential diagnostics are carried out with malignant tumors, furunculosis of the nasal vestibule, lupus and some other inflammatory-productive processes.

Treatment is carried out using the means and methods used in the primary period of syphilis. Yellow mercury ointment is prescribed locally.

Syphilis of the nose in the secondary period sometimes manifests itself as persistent bilateral catarrhal rhinitis, painful, weeping cracks in the skin in the nasal vestibule, which are not amenable to treatment. Syphilitic changes in the mucous membrane of the nose in this period are rare, but these changes can be observed in the mucous membrane of the oral cavity and pharynx, where they are surrounded by diffuse erythema.

Syphilis of the nose in the tertiary period occurs in 5-7% of cases after 3-4 years in patients who have not received full treatment. Sometimes nasal forms of tertiary syphilis can occur 1-2 years after the primary infection or 20 years after it. The tertiary period is characterized by damage to the skin and mucous membrane, internal organs (most often syphilitic aortitis), bones, and the nervous system (neurosyphilis: syphilitic meningitis, tabes dorsalis, progressive paralysis, etc.).

Pathological anatomy

In the tertiary period, the mucous membrane of the nasal septum is affected, the process spreads to the mucous membrane of the hard and soft palate with the formation of slightly painful gummatous infiltrates of a bluish-red color. These infiltrates quickly disintegrate and ulcerate, destroying bone and cartilaginous tissue. The disintegration of the gumma begins from its central part and leads to the formation of a deep ulcer with steep dense edges, the bottom of which is covered with necrotic decay. The formation of penetrating holes in the nasal septum, soft and hard palate causes severe breathing, speech and eating disorders. Necrosis and disintegration of the internal bone and cartilaginous tissues of the nose leads to the formation of sequesters. Subsequently, severe atrophic rhinitis and cicatricial disfigurement of the nasal pyramid develop.

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Clinical course of syphilis of the nose

Patients complain of nasal congestion, headaches that get worse at night. If the gumma is located in the upper part of the nasal septum, then hyperemia, swelling and pain on palpation are detected on the bridge of the nose. If the gumma is located in the lower parts of the nasal septum, then the infiltrate after some time appears in the palate along the midline in the form of a reddish swelling. The external signs of gumma are most noticeable when it is localized in the area of the nasal bones. In the area of the root of the nose, a rapidly increasing infiltrate appears, covered with hyperemic skin, the bridge of the nose expands, and fistulas form in the skin, through which bone sequesters and necrotic masses are released.

Anterior rhinoscopy reveals a hyperemic, edematous mucous membrane covered with mucous-serous discharge. As the gumma disintegrates, the amount of discharge increases, it acquires a dirty-gray color with an admixture of blood, contains bone and cartilaginous sequesters, and has a strong putrid odor. When palpating the gummatous decay zone with a button probe, exposed bone is determined. The development of the tissue decay process leads to the total destruction of the endonasal structures and lateral walls of the nose with the formation of a single huge cavity connecting the nasal cavity with the maxillary sinus. By this time, the patient develops irreversible anosmia. The process of gummatous decay is painless, which is an important sign of diagnosing syphilis of the nose in the tertiary period, as well as the fact that syphilis of the nose in the tertiary period is not accompanied by adenopathy.

The most dangerous form of syphilis of the nose is the localization of the gummatous process in the area of the vault of the nasal cavity. The decay of gumma in this area can lead to intracranial complications. The same complications can occur with the localization of the syphilitic infiltrate in the area of the ethmoid bone or in the sphenoid sinus.

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Diagnosis of syphilis of the nose

Diagnosis is difficult in the initial stage of syphilis of the nose in the tertiary period, since the inflammatory phenomena that arise in the nose have similar features to acute common cold, therefore, in the case of unreasonably prolonged acute or subacute catarrhal rhinitis with a tendency to the appearance of an unusual infiltrate in the nasal cavity, one should always remember the "French shepherd's disease Syphilus". The final diagnosis at this stage is made using specific serological reactions.

Syphilis of the nose in the third period is differentiated from hypertrophic rhinitis, hematoma of the nasal septum. It should also be known that necrosis of the nasal bones occurs only in the presence of syphilitic infection and only in the third period of this disease. The resulting sequesters should be differentiated from a foreign body in the nose or rhinoliths. The presence of a disgusting odor of crusts secreted from the nasal cavity and the expansion of its cavities makes one think of ozena. However, the "syphilitic" odor differs from the ozenous one, which is easy to establish with appropriate clinical experience, moreover, with ozena there are never ulcerations, disintegrating infiltrates and sequestration. These same differences are characteristic of rhinoscleroma, for which ulceration of the infiltrate is not at all characteristic, although narrowing of the nasal passages is observed. The greatest difficulties arise in differentiating tertiary nasal syphilis from a disintegrating malignant tumor (almost always a unilateral lesion) and lupus of the nose. In the first case, the final diagnosis is established after a biopsy and serological diagnostics. In the second case, the difficulty lies in the fact that sometimes tertiary nasal syphilis acquires the features of pseudolupus and proceeds without gummatous decay and sequestration. It should also be borne in mind that in all cases of spontaneous perforation of the nasal septum that has arisen against the background of an unidentified infiltrate, one should always assume the presence of a syphilitic infection and carry out appropriate diagnostic measures. In all doubtful cases, a biopsy is performed and, without exception, serological tests. Trial antisyphilitic treatment occupies an important place in the diagnosis of syphilis of the nose.

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Congenital syphilis of the nose

In newborns, a typical manifestation of congenital syphilis of the nose is a persistent runny nose, which usually appears 2-6 weeks after birth. At first, this runny nose is no different from a common catarrhal inflammation, then the discharge from the nose becomes purulent, bleeding cracks appear in the vestibule of the nose, and excoriations appear on the upper lip. Nasal breathing is impaired, which greatly complicates sucking. Diagnosis is facilitated when cutaneous syphilides and specific lesions of the internal organs are observed simultaneously. Early manifestations of congenital syphilis of the nose leave behind synechiae in the vestibule of the nose, atrophy of the mucous membrane of the nose and characteristic scars in the area of the corners of the mouth.

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Diagnosis of congenital syphilis of the nose

Late manifestations of congenital syphilis of the nose are practically no different from those of tertiary syphilis of the nose.

Diagnosis is facilitated by establishing the Hutchinson triad of symptoms, characteristic of late congenital syphilis:

1. deformations of the upper middle incisors (the teeth taper downwards like a chisel, the lower edge is in the form of an arc concave upwards; permanent teeth are prone to early caries and enamel hypoplasia;
2. parenchymatous keratitis;
3. sensorineural hearing loss caused by damage to the ear labyrinth.

In the latter case, with satisfactory air conduction, bone conduction of sound may be absent or significantly reduced. In some cases, the nystagmus reaction from the semicircular canals of the vestibular apparatus may also be absent. Diagnosis is also facilitated by the fact that all women in labor undergo serological tests to exclude syphilitic infection.

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Treatment of congenital syphilis of the nose

Treatment of nasal syphilis includes a set of measures provided for by the relevant provisions and instructions for the treatment of patients suffering from congenital syphilis.