1. Conditions involving external nose Dr T Balasubramanian

2. 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

3. 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

4. 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

5. Acute nasal infections Bacterial – Vestibulitis, Erysepelas, and impetigo Viral – Herpes, Warts, Molluscum contagiosum, Measles

6. 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

7. Acute vestibulitis symptoms Severe pain Fever Swelling Tenderness In recurrent vestibulitis diabetes to be ruled out

8. Vestibulitis treatment Broad spectrum antibiotics Antiinflammatory drugs Local application of antibiotic cream Squeezing to be avoided – could cause cavernous sinus thrombosis

9. Dangerous area of face Infection can traverse via the valveless facial vein Via its supraorbital and superior ophthalmic branches spread to cavernous sinus

10. 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)

11. 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

12. 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

13. 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

14. HPV infections Warts Localised neoplastic growth of epidermis Self limiting Cryotherapy / cauterization

15. 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

16. Wart Verruca vulgaris

17. 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

18. Chronic infections Vestibulitis Lupus vulgaris Syphilis Lupus erythematosis Acne rosacea

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

20. 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

21. 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

22. 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

23. 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

24. Lupus erythematosis Autoimmune disorder Multi organ disorder Involves skin in the vestibule Photosensitivity

25. 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

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

27. 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

28. Traumatic conditions Fracture nose Septal hematoma Saddle nose

29. 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

30. 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

31. 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

32. Foreign bodies Inanimate Animate Rhinolith

33. Conditions involving nasal septum Deviated nasal septum Dislocation of anterior portion of nasal septum Septal perforatrion

34. Congenital conditions Nasal dermoid Gliomas Choanal atresia

35. Thankyou