Conditions involving external nose

Dr T Balasubramanian

Importance of nose

Nose is the most prominent portion of face

More prone for injuries Disorders of external

nose could be a indicator of a systemic disorder

Introduction

Disorders of external nose commonly involves skin Whole of dorsum of nose is skin lined The vestibule of the nose is skin lined Since the common problems involve the skin in this

area a recap of dermatological terms is a must

Dermatological terms

Macule – This is a flat lesion within the skin Papule – Circumscribed raised lesion of dermis /

epidermis less than 1 cm in diameter Nodule – This is a papule greater than 1cm in

diameter Plaque – Is a large superficial lesion whose surface

area is greater than that of its height and its margins are irregular

Acute nasal infections

Bacterial – Vestibulitis, Erysepelas, and impetigo Viral – Herpes, Warts, Molluscum contagiosum,

Measles

Acute vestibulitis

Infection of nasal vestibular skin

Commonly arises from hair bearing region of vestibule

Staph aureus is the commonly involved organism

Common in children due to nose picking

Acute vestibulitis symptoms

Severe pain Fever Swelling Tenderness In recurrent vestibulitis diabetes to be ruled out

Vestibulitis treatment

Broad spectrum antibiotics Antiinflammatory drugs Local application of antibiotic cream Squeezing to be avoided – could cause cavernous

sinus thrombosis

Dangerous area of face

Infection can traverse via the valveless facial vein

Via its supraorbital and superior ophthalmic branches spread to cavernous sinus

Impetigo

Superficial contageous infection involving the skin of the vestibule

Group A streptococcus is involved Two forms bullous and non bullous forms Staphylococcal infection leads to widespread

shedding of epidermis (scalded skin syndrome / Lyell's disease)

Erysipelas

Acute infection of skin lined vestibule Streptococcus implicated It enters via fissures in the skin Pain, heat, swelling and vesiculation Peau d ' orange appearance

Herpes simplex lesions

Type I Herpes virus is involved Lips, perioral region and cheek involved Infections from this area spreads to involve the

vestibule of the nose Antibiotics help in preventing secondary infections

Herpes zoster lesions

This virus is responsible for chicken pox lesion Involvement of maxillary division of V nerve causes

vesicles over cheek and nasal vestibule areas Infection gets transmitted via fluid present in the

vesicles

HPV infections

Warts Localised neoplastic growth of epidermis Self limiting Cryotherapy / cauterization

Lesions formed by HPV

Warts Three types of lesions are possible Hyperkeratotic lesions, verruca vulgaris, common

wart All these lesions appear raised Usually self limiting

Wart Verruca vulgaris

Molluscum contagiosum

DNA virus of Pox group is involved Appears as small papules white and waxy with a

dome Not contagious Self limiting Can be cauerized

Chronic infections

Vestibulitis Lupus vulgaris Syphilis Lupus erythematosis Acne rosacea

Chronic vestibulitis

Repeated fissuring of vestibule Crust formation Epistaxis is possible when the pt rubs the nose Diabetes to be excluded

Lupus vulgaris

This is a type of cutaneous tuberculosis involving the skin of the vestibule

Direct inoculation of skin causes scrofuloderma Post primary tuberculosis Initially lesions are nodular resembling apple jelly

hence the term apple jelly nodules Extensive tissue destruction is seen causing nasal

deformities. Nasal cartilages are predominantly destroyed

Syphilis

Primary syphilis involving the vestibule is common Firm painless nodule Rubbery cervical adenopathy Rhinitis ”syphlitic snuffles” Secondary syphilis causes vestibular skin fissuring Tertiary syphilis in the form of gumma is common

in the nose. There is extensive bony destruction. Tenderness over bridge of nose & nocturnal pain

Congenital syphilis

Presents within few weeks after birth Purulent rhinorrhoea ”Snuffles” Fissuring around vestibule Saddling of nose is seen at the age of 3-4

Yaws

Extragenital infection of T Pertenue Common in children of Africa Extensive disease can lead to midfacial destruction Gondou type of yaws causing bilateral rounded

swelling of nasal process of maxilla

Lupus erythematosis

Autoimmune disorder Multi organ disorder Involves skin in the vestibule Photosensitivity

Acne rosacea

Involves the skin over the face Skin lining of the nasal vestibule is also involved Skin shows reddish patches with ruptured

subcutaneous blood vessels Nose becomes red and bulbous Burning / stinging sensation over face + Avoid exposure to sun

Neoplasms

Benign – Papilloma, Kerata acanthoma Malignant – Rodent ulcer, sq cell carcinoma

Keratoacanthoma

Benign tumor arising from hair follicles of skin over the nose

Skin exposed to sun causes more problems Presents are firm, round, reddish / flesh colored

lesion Lesion may turn globular and may present with a

horny central keratotic plug Shedding of this plug signals recovery

Traumatic conditions

Fracture nose Septal hematoma Saddle nose

Fracture nose

May be with or without displacement Deformity of dorsum of nose Tenderness / Swelling over nasal bone area /

crepitus X-ray nasal bones may reveal # Closed reduction is preferred

Septal hematoma / abscess

May be caused by injuries / surgery in the nasal septal area

Bilateral swelling of nasal septum with nasal block Perichondrium stripped away from the cartilage Cartilage necrosis occur within 36 hours if not

drained Hematoma may give rise to septal abscess

Saddle nose

Occurs due to destruction of the bridge of nose Destruction of osseous / cartilagenous portion of the

bridge of nose Septal abscess / syphilis involving the nose may

cause this problem

Foreign bodies

Inanimate Animate Rhinolith

Conditions involving nasal septum

Deviated nasal septum Dislocation of anterior portion of nasal septum Septal perforatrion

Congenital conditions

Nasal dermoid Gliomas Choanal atresia

Thankyou