Diseases of the External Nose and Vestibule

Diseases of the External Nose

Cellulitis. The nasal skin can be invaded by Streptococcus or Staphylococcus bacteria, resulting in redness, swelling, and tenderness of the nose. Occasionally, this condition arises as an extension of infection from the nasal vestibule.
Treatment:

• Systemic antibacterials
• Hot fomentation
• Analgesics

Nasal Deformities

1.    Saddle Nose. A depressed nasal dorsum can involve the bony, cartilaginous, or both components of the nasal dorsum. The most common cause is nasal trauma leading to depressed fractures. Other causes include:

• Excessive removal of the nasal septum during submucous resection
• Septal cartilage destruction due to hematoma or abscess
• Diseases like leprosy, tuberculosis, or syphilis

Treatment: Correction involves augmentation rhinoplasty. The dorsum may be filled with cartilage, bone, or synthetic implants:

• Cartilaginous depression: Cartilage is harvested from the nasal septum or auricle and layered.
• Cartilage and bone depression: Cancellous bone from the iliac crest is preferred.
• Synthetic implants: Silicone or Teflon implants can be used but have a higher risk of extrusion.

2.    Hump Nose. This deformity involves excess bone, cartilage, or both. Correction is performed through reduction rhinoplasty, which includes:

• Exposing the nasal framework via a vestibular incision
• Removing the hump
• Narrowing the lateral nasal walls using osteotomies

3.    Crooked or Deviated Nose

• Crooked nose: The nasal dorsum curves in a “C” or “S” shape.
• Deviated nose: The midline is straight but shifted to one side.

Causes: These deformities are often traumatic and can result from injuries during birth, childhood, or unnoticed trauma. Treatment: Rhinoplasty or septorhinoplasty aims to correct both the external appearance and nasal function.  

Tumours of the Nose

Congenital Tumours

1. Dermoid Cyst

• Simple Dermoid: Appears as a midline swelling without an external opening.
• Dermoid with Sinus: Often seen in infants or children, presenting as a sinus with hair protrusion. These may have intracranial extensions, requiring combined neurosurgical and otolaryngological management.

2. Encephalocele/Meningoencephalocele
   • Herniation of brain tissue with meninges through a congenital bony defect.
   • Presents as a pulsatile swelling with a cough impulse.
     Treatment: Neurosurgical intervention to sever the tumour stalk and repair the bony defect.

1. Glioma

• A non-communicating remnant of encephalocele. Typically firm and encapsulated.
  Treatment: Surgical removal via an external nasal approach.

Benign Tumours

• Common types include papilloma, hemangioma, pigmented nevus, and seborrheic keratosis.
• Rhinophyma: A slow-growing tumor due to sebaceous gland hypertrophy, often linked to acne rosacea. Treatment involves surgical debulking or carbon dioxide laser excision.

Malignant Tumours

1. Basal Cell Carcinoma (Rodent Ulcer). Most common malignant tumor of nasal skin. Presents as a cyst, papule, or ulcer. Treatment: Options include cryosurgery, irradiation, or surgical excision with margins
2. Squamous Cell Carcinoma. The second most common malignancy. Presents as an infiltrative nodule or ulcer. Treatment: Early lesions respond to radiotherapy. Advanced cases require wide surgical excision and lymph node dissection.
3. Melanoma. Treatment is surgical excision.

 

Diseases of the Nasal Vestibule

Furuncle (Boil). An acute infection of a hair follicle, is commonly caused by Staphylococcus aureus. Predisposing factors include trauma from nose-picking or hair-plucking.
Symptoms: Severe pain and tenderness with swelling.
Treatment:

• Warm compresses
• Analgesics
• Topical and systemic antibiotics
• Incision and drainage if fluctuation is present

Note: Premature incision or squeezing can lead to cavernous sinus infection.  

Vestibulitis. Inflammation of the nasal vestibule due to nasal discharge (e.g., rhinitis, sinusitis) and trauma.

• Acute Form: Redness, swelling, and crusting.
• Chronic Form: Induration, painful fissures, and crusting.

Treatment:

• Cleaning with hydrogen peroxide
• Application of antibiotic-steroid ointment
• Cauterization of chronic fissures with silver nitrate

Stenosis and Atresia of the Nares

• Causes: Trauma, inflammation, or congenital anomalies.
  Treatment: Reconstructive plastic procedures.

Tumors of the Nasal Vestibule

1. Nasoalveolar Cyst. Presents as a smooth bulge in the vestibule. Treated by excision via a sublabial approach.
2. Papilloma (Wart). Treated by surgical excision under local anaesthesia.
3. Squamous Cell Carcinoma. Can metastasize to regional lymph nodes. Treatment involves surgical excision or irradiation.

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

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