Disorders of external nose
Introduction:
Nose is the most prominent portion of the face and hence is more prone for injuries. It should be stressed that disorders of external nose could be an indicator of a systemic disorder.
Disorders of external nose commonly involves skin. It should be pointed out that the entire dorsum of nose is skin lined. The vestibule of the nose is also skin lined. Nasal skin may be invaded by streptococci or staphylococci causing reddish, swollen and tender nose. Treatment of these skin infections is by antimicrobials, and analgesics.
Dermatological conditions involving the skin over the nose include:
Macule - This is a flat lesion within the skin
Papule - This is a circumscribed raised lesion of dermis / epidermis less than 1 cm in diameter
Nodule - This is a papule greater than 1 cm in diameter
Plaque - This is a large superficial lesion whose surface area is greater than that of its height and its margins are irregular.
Deformities involving the nose:
Saddle nose:
In this condition there is depression of dorsum of the nose. It can involve bony, cartilaginous or both components of nasal dorsum. Trauma to nose causing depressed fractures is the commonest etiology. This can also be caused due to excessive removal of nasal septal cartilage in submucosal resection of nasal septum. Saddle nose can also be caused due to destruction of septal cartilage in patients with tuberculosis and syphilis. This condition can be surgically corrected by augmentation rhinoplasty.
Hump nose:
This condition can be caused by deformities involving bony, cartilaginous, or both of the nasal framework. This condition can be corrected by reduction rhinoplasty.
Supratip deformity:
This is also known as polybeak deformity. This happens to be the most common complication following rhinoplasty necessitating revison surgery. According to Sheen this is caused due to excessive dorsal septal resection with inadequate tip support.
Crooked / deviated nose:
In this condition the midline of the dorsum of the nose is curved in a C or S shaped manner. In deviated nose, the midline is straight but deviated to one side.
These deformities are usually traumatic in origin. Birth injuries which are not recognized will accentuate these deformities as growth of the nose occurs. The crooked / deviated nose can be corrected by septorhinoplasty.
Acute infections:
Acute infections involving the skin lining of the nose can be caused by:
Bacterial infections - Vestibulitis, Erysepelas, and impetigo
Viral - Herpes, warts, molluscum contagiosum, measles
Acute vestibulitis:
This is acute infection of nasal vestibular skin caused by staph aureus. This is common in children due to nose picking. This commonly arises from the hair bearing region of the vestibule.
Symptoms include:
1. Severe pain 2. Fever 3. Swelling 4. Tenderness
If recurrent vestibulitis is present then diabetes should be ruled out.
Treatment:
Broad spectrum antibiotics can be used.
Antiinflammatory drugs can be used to reduce swelling and pain
Local application of antibiotic cream may be considered
Squeezing of the furuncle should be avoided as it could cause cvernous sinus thrombosis. Infections can traverse via the valveless facial vein via its supraorbital and superior ophthalmic branches to spread to the cavernous sinus.
Impetigo:
This is superficial contageous infection involving the skin of the vestibule. Group A streptococcus has been implicated. This condition may exist in two forms bullous and non bullous.
Scalded skin syndrome:
This is also known as Lyell's disease. It is caused by staphylococcal infection leading on to widespread shedding of epidermis.
Erysipelas:
This is acute infection of skin lined vestibule. Streptococcus has been implicated. Usually infection enters via fissures in the skin. There is localized pain, warmth, swelling and vesiculation. There may be associated Peau d ' orange appearance.
Herpes simplex lesions:
This commonly occurs in lips, perioral region and cheek areas. Type I Herpes virus is involved. Infections from this area spreads to involve the vestibule of the nose. Antibiotics help in preventing secondary bacterial infections.
Herpes zoster lesions:
This virus is responsible for chicken pox lesion. If the maxillary division of trigeminal nerve is involved it causes vesicles over cheek and nasal vestibule areas. Infection usually gets transmitted via fluid present in the vesicles.
HPV infections:
These are known to cause warts involving the skin lining of the vestibule. Warts are localized neoplastic growth of epidermis. This is a self limiting condition. It can be managed by cryotherapy / cauterization.
Molluscum contagiosum:
This is a viral infection involving skin lining of nose. It is caused by DNA virus belonging to pox group. The lesions appear as small papules (white and waxy in nature iwth a dome). It is a self limiting lesion and not contagious. These lesions can be managed by cauterization.
Chronic infections:
These include:
Vestibulitis
Lupus vulgaris
Syphilis
Lupus erythematosis
Acne rosacea
Chronic vestibulitis:
This is associated with repeated fissuring of vestible with crust formation. Epistaxis is possible if patient rubs the nose. Diabetes should be excluded in these patients.
Lupus vulgaris:
This is a type of cutaneous tuberculosis that involve the skin lining of the vestibule. This is a chronic, progressive, paucibacillary form of cutaneous tuberculosis. Direct inoculation of skin causes scrofuloderma which is another manifestation of cutaneous tuberculosis. This condition belongs to the post primary tuberculosis category.
These lesions initially appear as nodules resembling apple jelly and hence the term apple jelly nodules is referred to indicate this condition. Tuberculosis can cause externsive destruction of nasal cartilages causing severe nasal deformities.
Clinical forms of lupus vugaris include:
1. Plaque form - These lesions have irregular / serpiginous edge with large plaques. Areas of irrgular scarring with islands of active lupus tissue can be seen. The edge of the lesion becomes thickened and hyperkeratotic. Majority of these patients have single plaque lesions.
2. Ulcerative & mutilating forms - Scarring and ulceration predominate in this type of lesion. Crusts are known to form over areas of necrosis. Deep lying cartilages are invaded with formation of contractures. This type cause the maximum nasal deformity.
3. Vegetating form - This is characterized by marked infiltration, ulceration and necrosis. Scarring is minimal in this type of lesion. Mucous membranes are invaded and the underlying cartilage is slowly destroyed. Destruction of cartilage leads to disfigurement of the nose.
4. Tumor like forms - This type present as soft tumor like nodules / epithelial hyperplasia with production of hyperkeartotic masses.
5. Papular & Nodular forms - Multiple lesions are known to occur and this condition is also known as disseminated lupus or miliary lupus. This occurs in patients after immunosuppression.
This condition can be managed medically by prescribing the standard four drug antituberculous therapy.
Syphilis:
Primary syphilis involving the vestibule of the nose is rather common entity. It begins as a firm and painless nodule. There is also associated with rubbery cervical adenopathy. This condition is seen often in children under the age of 2.
These patients present with rhinitis which is also known as syphilitic snuffles. Secondary syphilis involve vestibular skin causing fissuring. Tertiary syphilis in the form of gumma are often seen in the nose. They cause extensive bony destruction. Classic findings of tertiary syphilis of nose is tenderness over the bridge of nose and presence of nocturnal pain involving the nose.
Congenital syphilis - Usually presents within the first few weeks after birth. It often causes purulent rhinorrhoea also known as snuffles. Fissuring of the skin lining of the vestibule is seen. Saddling deformity of nose is seen in children in the age group of 3-4.
Yaws:
This is an extragenital infection caused by Treponema Pertenue. This condition is commonly seen in children in Africa. Extensive involvement of nose could lead to midfacial destruction. In Gondou type of Yaws there is bilateral rounded swelling of nasal process of maxilla.
Lupus erythematosis:
This condition involves the skin lining of the vestibule of the nose. It is an autoimmune disorder. It is also a multi organ disorder. Photosensitivity is rather common in these lesions.
Acne Rosacea:
This condition involves the skin over the face. Skin lining of the nasal vestibule can also be involved. The skin shows reddish patches with ruptured subcuteanous blood vessels. The affected nose becomes red and bulbous.
These patients complain of burning and stinging sensation in face. These patients should be advised to avoid exposure to sun.
Neoplasms involving the external nose:
Neoplasms involving external nose can be classified as Benign and malignant.
Benign lesions of external nose:
Congenital lesions:
Dermoid cyst:
Also known as simple dermoid. It occurs as a midline swelling under the skin. It lies in front of the nasal b ones. It does not show any external opening.
Dermoid cyst with a sinus:
This condition is seen in infants and children and is represented by a pit or a sinus in the midline of the dorsum of the nose. Hair could be seen protruding through the sinus opening. A sinus tract may be seen leading to the cyst lying under the nasal bone in front of the upper part of nasal septum. There may also be intracranial extension.
In patients with intracranial extension, meningitis can occur if infection travels along this pathway. Treatment of these cysts involve splitting of nasal bones to remove any extensions involving the upper portion of the nasal bones.
Encephalocele / Meningomyelocele:
In this condition there is herniation of brain tissue along with its meninges through the congenital bone defect. Extranasal meningoencephalocele would present as a subcutaneous pulsatile swelling in the midline near the root of the nose (nasofrontal variety), side of the nose (naso ethmoid variety) or on the anteromedial aspect of orbit (naso orbital variety).
These swellings typically exhibit cough impulse and may in some patients be reducible also. Treatment is usually neurosurgical.
Glioma:
This is a nipped off portion of encephalocele during embryonic development. Majority of these lesions are extranasal and present as firm subcutaneous swellings on the bridge, side of nose or near the inner canthus of the eye. Some of these lesions could purely be intranasal while some of them could have both intranasal and extranasal components. These lesions are encapsulated and are easy to remove.
Benign lesions:
Keratoacanthoma:
This is a benign tumor arising from the hair follicles of skin over the nose. The problem would be more if the skin is exposed to sun. Usually these lesions present as firm, round, reddish / flesh colored lesions. These lesions could eventually turn globular and may present with a horny central keratotic plug. If this plug gets shedded then it is a sign of recovery.
Rhinophyma:
Rhynophyma is a progressive disfiguring soft tissue hypertrophy of the tip of nose. This is usually caused by hyperplasia of the cells of sebaceous glands. It has been accepted as the end stage of chronic acne rosacea. In addition to the obvious cosmetic disfigurement it can also cause obstruction to vision. It can also become infected and may bleed.
Surgical management:
This involves shaving of the lesion with cauterization of the bleeding vessels. Surgery should aim at removing the diseased tissue while conserving the normal underlying sebaceous glands which could facilitate in normal re-epithelization.
Microdebriders have been used with varying degrees of success in removing the diseased tissue. The bleeders if any can be controlled using flowseal.
Carbondioxide lasers have been used to manage this condition. Major advantage of laser is that the depth of excision is really precise and excess tissue removal is rare. There is very minimal risk of scar tissue formation.
Currently radiofrequency devices like coablators have been used in the management of this condition. Using this device there is very little risk of thermal damage to underlying tissue.
Numerous treatment modalities have been attempted to manage this condition. Oral antibiotics has shown excellent promise during early phases of this disease. Surgery will have to be resorted to in order to manage advanced rhinophymas.
Malignant tumors:
Basal cell carcinoma:
This condition is also known as rodent ulcer. This is the commonest malignant lesion involving the skin of the nose. It equally affects both males and females in the age group of 40-60. Common sites involved include the nasal tip and ala of the nose. It is a very slow growing tumor and it remains confined to the skin for a very long time. The underlying cartilage and bone can also be destroyed. Treatment depends on the size and depth of the lesion. Early lesions can be managed by cryosurgery. Advanced lesions can be managed by a combination of wide field excision and irradiation.
Squamous cell carcinoma:
This is the second commonest malignant tumor involving the nose. Nodal metastais is common unlike basal cell carcinoma. Early lesions can be managed by irradiation while advanced lesions wold need wide excision with irradiation.
Melanoma:
This is a rare malignancy involving the nasal skin, Clinical it could present as superficial spreading type (slow growing) or nodular (invasive type). Treatment is by surgical excision.
