Systematic identification and characterization of clinical and socio-economical correlates of granulomatous nasal and para-nasal sinuses: A large-scale study among patients of Odisha, India

Abstract

Granulomatous formation in the nose and paranasal sinuses still presents an unmet clinical challenge as it affects both the physical health and personality of patients, and the lack of a systematic diagnostic and disease management approach has further complicated the scenario. Occurrence of granulomatous nasal disorder in the rural Indian population is associated with several factors such as lack of proper medical care, lack of hygienic and clean working and living conditions, and limited financial abilities to access the already overburdened primary healthcare system. This study aims to understand the correlation disease incidence, manifestation of signs and symptoms and associated socio-epidemiological parameters for 104,000 patients over a period of 23 months in Odisha. Primarily the study used socio-epidemiological surveys collected, annotated, and curated independently for granulomatous nasal disorder patients and compared this with their clinical records for signs & symptoms and performed several statistical analyses to better understand the disease incidence correlation with age, socio-economic and gender based parameters. Overall results suggest that males from low socio-economic background living in rural areas are the most vulnerable population and commonly affected with granulomatous nasal disorder (commonly Rhinosporidiosis sub-type) with common origin of the disease reported at the nasal septum and floor. We also highlight that change in the mass of nose followed by bleeds on touch, nasal discharge and hanging mass in throat are the most common manifestations presented by patients with granulomatous nasal disorders. Together, this research work identifies and characterise clinical and socio-economic factors that lead to and exacerbate the incidence of granulomatous nasal disorders.

Keywords: Fungal granuloma; Granulomatous; Leprosy; Males; Nose; Paranasal sinuses; Poor living condition; Rhinoscleroma; Rhinosporidiosis; Rural area; Tuberculosis.

Figure 1

Epidemiological analysis of granulomatous nasal disorder cases identified at VIMSAR medical College, Odisha. Different forms of granulomatose nasal disorders analysed include Rhinosporidiosis (RSP), Fungal Granuloma (FG), Rhinoscleroma (RSC), Tuberculosis (TB) and Leprosy (LEP). (A) Relative Incidence of different granulamotous nasal disorders. Incidence rate (expressed in % of total) for each type of granulomatous disorder is shown as percentage of total confirmed granulomatous cases (n = 162). Each dot in the grid represents 1% of the total no. of granulomatous nasal disorders. (B) Heat-map depicting correlation of age and disease incidence in granulomatous nasal disorder patients. Results showed variable incidence rates in patients of different age groups (expressed in years). All patients (n = 162). included in the study were between 10-60 years, divided into 6 different age groups each spanning a decade. Color-scheme depicting percentages of total cases (between 0-30%, 30 being the highest incidence percentage) is depicted on the bottom. (C) Simple linear regression analysis of percentage (%) of disease incidence (y-axis) vs age of patient in years (x-axis) for different forms of granulomatous nasal disorders. (D) Normalised Q-Q plot analysis of % predicted incidence vs % actual incidence of granulomatous nasal disorders for male and female patients. (E) Percent incidence of granulomatous nasal disorders identified in males and females (total n = 162). Percentages are expressed for different forms of granulomatous nasal disorders. (F) Percent incidence of granulomatous nasal disorders in patients (n = 162) belonging to different habitats (HB), i.e. rural and urban and different socio-economic background (SEB), i.e. low, middle and high earning families.

Figure 2

Heat-map summary of symptoms and signs presented by granulomatous nasal disorder patients. Different forms of granulomatose nasal disorders- Rhinosporidiosis (RSP), Fungal Granuloma (FG), Rhinoscleroma (RSC), Tuberculosis (TB) and Leprosy (LEP) showed different frequencies of (A) symptoms and (B) signs in patients. All patients (n = 162). included in the study were between 10-60 years. Color-scheme depicting percentages of total cases (between 0-100%, 100 being the highest incidence percentage) is depicted on the right-hand side.

Figure 3

Correlation of epidemiological and clinical parameters associated with RSP infections. (A) Linear regression analysis of percentage (%) of incidence of granulomatous nasal disorder (y-axis) vs age of patient in years (x-axis) for male (M) and female (F) patients. (B) Percentage (%) incidence of RSP infections with gender and age of patient (in years), (C) occupation, and (D) source of bathing water expressed as percent incidence of total number of patients with granulomatous nasal disorders (n = 162). In panel C, C.D of farmer refers to dependent child of farmers. (E) Association of disease symptoms with percent incidence and recurrence among RSP patients (n = 162). Inferior M and T refer to inferior meatus and inferior turbinate, respectively. (E) Heat-map depicting correlation of signs and symptoms associated with incidence of RSP infections expressed as percent incidence of total RSP infections (n = 162). Color-scheme depicting percentages of total cases (between 0-87%, 87 being the highest incidence percentage) is depicted on the right-hand side.