23. Diseases, injuries, inflammations and tumors of the external nose.

What are the possible injuries of the external nose

• thermal injury

• nasal fractures

What is the thermal injury to the nose

• frostbite

• burns

What are the types of nasal fractures

• closed

• open

Describe closed nasal fracture

• nasal skeleton is covered completely by soft tissues with no external communication

• usually due to blunt trauma

Describe open fractures

• cartilaginous or body part of nasal skeleton is exposed

• usually due to abrasions, cuts or stab wounds

what are the clinical signs of nasal fractures

• visible deformity, lateral discoloiration, depression of nasal pyramid

• haematoma of the soft tissues, orbital/ septal haematoma

• swelling of the overlying soft tissues

• pain on application of pressure to nasal pyramid

• headaches, epistaxis, nasal obstruction and disorders of olfaction

What is the treatment of nasal fractures

• surgical treatment indicated due to potential for permanent nasal deformity

  • open fracture

    • immediate surgery + tetanus prophylaxis or booster

  • closed fracture

    • reduced manually or with instrument during 1st week → packed to provide internal splint or plaster cast externally

What are the skin diseases of the nose

• impetigo, acne vulgaris, trichophyton, rosacea

• lupus erythematous, lupus vulgaris

• leprosy, syphilis, rhinoscleroma, nasal sarcoidosis, nasal folliculitis/ furuncles

What is nasal folliculitis/ furuncles

• inflammation of hair follicles

• if deeper infection → furuncle + multiple fused furuncles → carbuncle

what is the cause of nasal folliculitis/ furuncles

• Staph aureus

What are the symptoms of nasal folliculitis/ furuncles

• pain, tenderness, erythematous swellings

• oedema of upper lip, fever

what is the treatment of nasal folliculitis/ furuncles

• topical antibiotics

• drainage

What is erysipelas

Bacterial skin infection involving upper dermis that extends into superficial cutaneous lymphatics

What are the symptoms of erysipelas

• early stage

  • high fever, feeling of tension in soft tissues

• later stage

  • erythema and swelling, sharply demarcated from unaffected skin

• tissue is warm

What is the treatment for erysipelas

• parenteral administration of penicillin

• moist compression soaked in an antiseptic solution can be applied locally

what are the causes of nasal eczema

• caused by abnormal nasal sections, can be contact allergy

What are the symptoms of nasal eczema

• early stage

  • moist with vesicles and pustules

• later stage

  • crusts, followe by painful cracks and scaling

• chronic stage

  • lichenification, xerosis, fissuring

What is the treatment of nasal eczema

• curst softened with mild greasy ointment followed by corticosteroid

What are the causes of impetigo

• strep pyogenes

• stapah aureus

what are the symptoms of impetigo

• early stage- micro pustules

• later stage- golden yellow lesions surrounded by erythema

• bullae can occur

What are the symptoms of rosacea

stages

1. facial flushing

2. non transient erythema and/ or oedema and occular symptoms

3. dome shaped papules and pustules

4. rhinophyma- swelling of nose caused by lymphoedema and hypertrophy of subcutaneous tissue

What is the treatment of rosacea

• avoid triggers

  • heat, cold, stress, hot fluids, alcohol

• avoid CS

• rhinophyma- treated by physical ablation or removal by paring, electrosurrgery, cryotherapy, laser

• antibiotics

  • 1st- oral tetracyclines, oral erythromycin, topical metronidazole

  • 2nd- topical clindamycin

  • 3rd- oral retinoids

What are teh precancerous lesions of the nose

• actinic keratosis

• Bowen’s disease- SCC in situ

• cutaneous horns

What are the benign tumours of the nose

• rhinophyma

  • skin disorder that causes the nose to enlarge and become red, bumpy and bulbous

What are the clinical signs of rhinophyma

• CT and sebaceous hyperplasia with angiectatic changes

• most patients have preexisting rosacea

• seen almost exclusive in older men

What is the treatment of rhinophyma

Surgical ablation

What are the types of malignant tumours

• basal cell carcinoma, squamous cell carcinoma

• malignant melanoma

• sarcomas, lymphomas

What are the clinical types of basal cell carcinoma

• nodulocerative

  • skin colour papule/ nodule with pearly telangiectatic

• pigmented

• superficial

• sclerosing

  • flesh/ yellowish coloured, shiny papule/ plaque

What is the etiology of BCC

• malignant proliferation of basal keratinocytes of epidermis

• due to UVB exposure

• can occur due to radiation, trauma, arsenic exposure or genetic predisposition

What is the treatment of BCC

• excision, electrodessication an curettage

• MOHS- microscopically controlled, minimally invasive

• radiotherapy- where surgical intervention is not possible

What is the etiology of squamous cell carcinoma

• malignant proliferation of keratinocytes- vertical growth

• preisposing factors

  • UV radiation, ionizing radiation, chemical carcinogens

  • HPV 16/18

  • immunosuppression

What are the clinical signs of SCC

• indurated erythematous nodule/ plaque with surface scale/ crust

• ulceration

What is the treatment of SCC

• surgical excision with primary closure. skin flaps or grafting

• MOHS surgery

What are the types of malignant melanoma

• lentigo maligna

• lentigo maligna melanoma

• superficial spreading melanoma

• nodular melalnoma

• acrolentiginous melanoma

Describe lentigo maligna

• Malignant melanoma in situ (normal + malignant melanocytes confined to epidermis)

= 2-6cm, brown/black uniformly flat macule or patch with irregular borders

• Lesion grows radially and produces complex colors

Describe lentigo maligna melanoma

• Malignant melanocytes invading into the dermis

• Associated with pre-existing solar lentigo, not pre-existing nevi

• Flat, brown, stain-like, gradually enlarging with loss of skin surface markings

• With time, color changes from uniform brown to dark brown with black and blue

• Found on all skin surfaces, especially those often exposed to sun

Describe superficial spreading melanoma

• Atypical melanocytes initially spread laterally in epidermis, then invade dermis

• Irregular, indurated, enlarging plaques with red/white/blue discoloration

• Focal papules or nodules

• Ulcerate and bleed with growth

Describe nodular melanoma

• Atypical melanocytes that initially grow vertically with little lateral spread

• Uniformly ulcerated, blue-black and sharply delineated plaque or nodule

• May be pink or have no color at all → amelanotic melanoma

• ‘’EFG’’ = elevated, firm, growing

Describe acrolentiginous melanoma

• Ill-defined, dark brown macule

• Palmar, plant, subungual skin

• Melanomas on mucous membranes have poor prognosis

What is the etiology of melanoma

• malignant proliferation of melanocytes and nevus cells

• risk factors

  • many moles, fair skin, red hair, positive personal/ family history, large congenital nevi, multiple dysplastic nevi

What are the clinical signs of melanoma

• Asymmetry

• Border (irregular and/or indistinct)

• Color (varied)

• Diameter (increasing or >6mm)

• Evolution (change in color, size, shape)

What is the treatment of melanoma

• surgical excision

• high dose IFN and chemotherapy for nodal and metastatic disease

• radiotherapy can be used as adjuvant treatment