Disease of external nose
Cellulitis
• The nasal skin may be invaded by streptococci
or staphylcocci leading to a red, swollen and
tender nose sometimes, it is an extension of
infection from the nasal vestibule.
Treatment
• Systemic antibacterials hot fomentation and
analgesics.
Nasal deformities
Saddle nose
• Depressed nasal
dorsum may involve
bony, cartilaginous or
both bony and
cartilaginous
components of nasal
dorsum. Nasal trauma
causing depressed
fractures is the most
common aetiology.
• It can also result from excessive removal of septum in
submucous resection , destruction of septal cartilages
by haematoma or abscess, sometimes by leprosy,
tuberculosis or syphilis.
• The deformity can be corrected by augmentation
rhinoplasty by filling the dorsum with cartilage, bone or
a synthetic implant.
• If depression is only cartilaginous, cartilage is taken
from the nasal septum or auricle and laid in a single or
multiple layers.
• If deformity involves both cartilage and bone,
cancellous bone from the iliac crest is the best. Auto
grafts are preferred to allografts .
• Saddle deformity can also be corrected by synthetic
implants of silicone or Teflon but they are likely to be
extruded.
• Hump nose this may
also involve the bone or
cartilage or both bone
and cartilage.
• It can be corrected by
reduction rhinoplasty
which consists of
exposure of nasal
framework by careful
raising of the nasal skin
by a vestibular incision ,
removal of hump and
narrowing of the lateral
walls by osteotomies to
reduce the widening
left by hump removal.
Crooked or a deviated nose
• the midline of dorsum from frontonasal angle to
the tip , is curved in a C or S shaped manner. In a
deviated nose , themidline is straight but deviated
to one side.
• Usually ,these deformities are traumatic in origin .
injuries sustained during birth, neonatal period or
childhood, but not immediately recognized. Will
also develop into these deformities with the
growth of nose.
• The deviated or crooked nose can be corrected by
rhinoplasty or septorhinoplasty. Aim of these
operations is to correct not only the outer
appearance of nose but also its function .
TUMOURS
• THEY MAY BE CONGENITAL , BENIGN OR MALIGNANT
• 1.CONGENITAL TUMOURS
Dermoid cyst
• Simple dermoid:- it occurs as a midline swelling under the skin but
in front of the nasal bones. It does not have any external opening.
• That associated with a sinus:- it is seen in infants and children and
is represented by a pit or a sinus in the midline of the dorsum of
nose. Hair may be seen protruding through the sinus opening
these cases, the sinus track may lead to a dermoid cyst under the
nasal bone in front of upper part of the nasal septum a combined
neurosurgical otolaryngologic approach is required in those
extending intracranially so as to close simultaneously any bony
defect through which the fistulous tract passes
ENCEPHALOCELE OR NINGOENCEPHALOCELE.
• It is a herniation of brain tissue with meninges through
a congenital bony defect. An extranasal
meningoencephalocele presents as a subcutaneous
pulsatile swelling in the midline at root of nose ( naso
frontal variety ), side of nose (nasoethmoid variety ) or
on anteromedial aspect of the orbit ( naso-orbital
variety).
• Swellings show cough impulse and may be reducible.
Treatment is neurosurgical: severing the tumour stalk
from the brain and repairing the bony defect through
which herniation has taken
• Glioma- it is a nipped off portion of encephalocele
during embroyonic development. MOST OF THEM
(60% ) are extranasal and present as firm
subcutaneous swellings on the bridge, side of nose
or near the inner canthus. Some of them are
purely in tranasal (30%) while 10% are both intra
and extra nasal. Extranasal gliomas are
encapsulated and can be easily removed by
external nasal approach
Benign tumours
• They arise from the nasal skin and include
papillona , haemangioma, pigmented naevus
• Seborrhoeic keratios
• Neurofibroma
• Or tumour of sweat glands.
• Rhinophyma or potato tumour is a slow-growing
benign tumour due to hypertrophy of the
sebaceous glands of the tip of nose often seen in
cases of long-standing acne rosacea. It presents as a
pink , lobulated mass over the nose with superficilal
vascular dilation : mostly affects men past middle
age.
• Patient seeks advice because of unsightly
appearance of the tumour. Or obstruction in
breathing and vision due to the large size of the
tumour .
• Treatment consists of
paring down the bulk of
tumour with sharp knife
or carbon diaoxide laser
and the area allowed to
re-epithelialise.
Sometimes, tumour is
completely excised and
the raw area skingrafted.
MALIGNANT TUMOUR
• Basal cell carcinoma ( rodent ulcer )
• Squamous cell carcinoma
• Melanoma
Basal cell carcinoma
TYPES:• Nodular Papule or nodule, translucent or “pearly”
• Ulcerating Ulcer (often covered with a crust)with a
rolled border (rodent ulcer)
• Cicatricial BCCs appear as scars
• Superficial multicentric BCC appear as thin.Pink or
red; characteristic fine threadlike telangiectasia can
be seen with the aid of a hand lens.
• Pigmented BCC may be brown to blue or black
Smooth, glistening surface; hard, firm;cystic lesions
may occur, however. Round, oval,shape, depressed
center (“umbilicated”).
• Causes
• Skin cancer is divided into two major groups:
nonmelanoma and melanoma. Basal cell
carcinoma is a type of nonmelanoma skin cancer,
and is the most common form of cancer in the
United States. According to the American Cancer
Society, 75% of all skin cancers are basal cell
carcinomas.
• Basal cell carcinoma starts in the top layer of the
skin called the epidermis. It grows slowly and is
painless. A new skin growth that bleeds easily or
does not heal well may suggest basal cell
carcinoma. The majority of these cancers occur on
areas of skin that are regularly exposed to sunlight
or other ultraviolet radiation. They may also appear
on the scalp. Basal cell skin cancer used to be more
common in people over age 40, but is now often
diagnosed in younger people.
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Your risk for basal cell skin cancer is higher if you have:
Light-colored skin
Blue or green eyes
Blond or red hair
Overexposure to x-rays or other forms of radiation
Basal cell skin cancer almost never spreads. But, if left
untreated, it may grow into surrounding areas and
nearby tissues and bone.
Symptoms
• Basal cell carcinoma may look only slightly different than
normal skin. The cancer may appear as skin bump or growth
that is:
• Pearly or waxy
• White or light pink
• Flesh-colored or brown
• In some cases the skin may be just slightly raised or even flat.
• You may have:
• A skin sore that bleeds easily
• A sore that does not heal
• Oozing or crusting spots in a sore
• Appearance of a scar-like sore without having injured the area
• Irregular blood vessels in or around the spot
• A sore with a depressed (sunken) area in the middle
• Diagnosis - biopsy
Treatment
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Treatment varies depending on the size, depth, and location of the
basal cell cancer. It will be removed using one of the following
procedures:
Excision cuts the tumor out and uses stitches to place the skin
back together.
Curettage and electrodesiccation scrapes away the cancer and
uses electricity to kill any remaining cancer cells.
Surgery, including Mohs surgery, in which skin is cut out and
immediately looked at under a microscope to check for cancer. The
process is repeated until the skin sample is free of cancer.
Cryosurgery freezes and kills the cancer cells.
Radiation may be used if the cancer has spread to organs or lymph
nodes or for tumors that can't be treated with surgery.
Skin creams with the medications imiquimod or 5-fluorouracil may
be used to treat superficial basal cell carcinoma.
DIFFERENTIAL DIAGNOSIS
• Solar keratosis
• Bowen’s disease
• Viral warts
• Cutaneous horn
• Keratoacanthoma
• Basal cell carcinoma
• Leg ulcers
Prognosis
• The rate of basal cell skin cancer returning is about
1% with Mohs surgery, and up to 10% for other
forms of treatment. Smaller basal cell carcinomas
are less likely to come back than larger ones. Basal
cell carcinoma rarely spreads to other parts of the
body.
• You should follow-up and regularly examine your
skin once a month, using a mirror to check hard-tosee places.
• To be continueeeeeeeeeeeeeeeee………….
Squamous Cell Carcinoma
• From keratinizing or malpighian (spindle)
cell layer of epithelium
• Older, men, fair, blue-eyed, North European
• Solar radiation (occupations) > chemicals,
chronic ulcers, cytotoxic drugs,
immunosuppressant drug treatment,
dermatoses, discoid lupus, hidradenitis
suppurativa
• Xeroderma pigmentosum, albinism
Squamous Cell Carcinoma
• Sun-exposed areas
• Inflammation and induration with thickening beyond the
clinical lesion presage the malignant transformation of a
precancerous lesion into SCC
• Types:
– Slow-growing: Verrucous, exophytic, metastasizes
– Rapid growing: Nodular, indurated, ulceration, invasive
Squamous Cell Carcinoma
• Squamous epithelial cells invade the dermis with welldifferentiated keratinization
• Keratin pearls surrounded by epithelial cells
• If poorly differentiated keratinization and inflammation are
minimal or absent
• Intercellular bridges are absent
• Poorly differentiated lesions may have a pseudoglandular
appearance
Squamous Cell Carcinoma
• Small, isolated skin ulcerations treated
conservatively for 2-3 weeks (ointment)
• Treatment depends on size and patient age
• Treatment options as for BCC (surgery/MMS)
• Older patients treated conservatively
• Recurrent lesion best treated by excision and
grafting instead of a flap
Squamous Cell Carcinoma
• MMS good for difficult or recurrent lesions
especially in medial canthal and alar regions
• Radiation can be effective in patients > 55
especially around eyes, nose and lips
• ELND are not necessary
Squamous Cell Carcinoma
• Mohs Micrographic Surgery
– Good for genital tumors (v. amputation)
– Early SCC of digits without bony involvement
especially in periungual region to avoid
amputation without compromising cure
– Good for SCC in scar or radiation site due to high
recurrence rate
– Good for SCC in perineural or scalp
Squamous Cell Carcinoma
Prognosis
• 5-10% metastasize
• Marjolin’s ulcer or xeroderma lesions more
• Scalp lesions where there was previous
radiation are prone to metastasize
• Tendency for recurrence treated by any
technique is twice that of BCC
Follow-up Treatment SCC
• Clinically examined every 6 months for 5 years
• 36% will develop second BCC in 5 years
• Early diagnosis and treatment are important in
recurrent lesions
• SCC should be examined every 3 months for
the first several years then indefinitely at 6
month intervals
Periodic Self Exam
• Prevention is the best weapon
• Curable disease if diagnosed early
• Full-length mirror, hand mirror, well-lit room
– Examine body front and back in mirror then R
and L sides
– Bend elbows and look at forearms, back of upper
arms and palms
– Back of legs and feet, b/w toes, soles
– Neck, scalp, back and buttocks with hand mirror
melanoma
• Least common variety
– May be nodular or superficial spreading type .
This is an example of melanoma or malignant
melanoma. This is the most dangerous form,
and also the most rare.
The ABCD Rule of Melanoma
• A = Asymetry – one half of the mole does not
match the other
• B = Border Irregularity – the edges of the mole
are uneven, notched or blurred
• C = Color – the pigment is not even. Cancerous
moles may have several colors in one mole (blue,
red, brown or black)
• D = diameter - watch moles the size of a pencil
eraser or larger for changes.
This melanoma grew under this man’s
fingernail. The nail has been removed to
facilitate removal of the tumor.
The large brown mass
on the side of this
woman’s nose is a
malignant melanoma.
This is the same
woman. Her
melanoma has been
removed. If you look
closely, you can see
the depression where
the tumor once was
located.
This is a further closeup of the woman’s
scar.
Doctors found that her
cancer had spread, so
she underwent
chemotherapy to try
to obliterate all of the
cancerous cells. The
differences in the
woman’s appearance
are side effects of the
chemotherapy.
This woman has a small melanoma on her neck.
It’s hard to see what is
wrong with this
woman. There is a
melanoma on the
right side of her nose
in this picture.
Although it’s not dark,
the tumor is still
melanoma.
The woman’s nose
had to be
removed because
the cancer was so
advanced. The
pen marks are
guides for
radiation, while
the mouth cork is
to keep her airway
open.
Historical Comparison of Melanoma Cases
This is not a color
enhanced photo. This
woman did not read
the warnings on her
medicine. She went
to the tanning bed
while taking
tetracycline. This
antibiotic amplifies
the effects of UV light.
Immunological factors and UV light: normal
epidermal Langerhans cells on the left; there
are fewer cells on the right after being treated
with UV light.
FURUNCLE OR BOIL IN THE NOSE
• Fairly common condition.
• Cause– nose picking causing infection of the the hair follicle of
the nasal vestibule.
– This is common in dry climate where the secretions of
the nose get dried up and cause irritation in the nose
forcing the person to introduce finger in the nose to
remove the crust.
– The skin over that area becomes painful and swelling
starts appearing over the area which spreads very fast.
– The patient can have fever .
– The area over the tip of nose and central part of upper
lip is calleddangerous area of the face as infection from
this area can spread to the brain (cavernous sinus)
• So never press or squeeze a boil over this areaor
you will land yourself in grave trouble.
• Give plenty of hot fomentation and take
appropriate antibiotics and anti inflammatory
drugs. Local application of antibiotic cream is also
effective. With this treatment the recovery takes
place in a couple of days. This disease is not to be
taken lightly and early medical help is always
rewarding and advocated.
Nasal Vestibulitis
• Nasal vestibulitis is infection of the area just inside
the opening of each nostril (the nasal vestibule).
• Minor infections at the opening of the nose may
result in pimples at the base of nasal hairs
(folliculitis) and sometimes crusts around the
nostrils. The cause is usually the
bacteria Staphylococcus.
• The infection may result from nose picking or
excessive nose blowing and causes annoying crusts
and bleeding when the crusts slough off.
• Bacitracin ointment or mupirocin