Author Archives: Daniel Todd

Rhinophyma

The term rhinophyma is derived from the Greek rhis (‘nose’) and phyma (‘growth’). Rhinophyma is a large, bulbous, ruddy nose caused by granulomatous infiltration, commonly due to untreated rosacea. It has often been referred to as “potatoe nose”. It is most common in white men with a mean age of 50.

Signs and symptoms
Rhinophyma is characterized by prominent pores and a fibrous thickening of the nose, sometimes with papules. It is caused by chronic overgrowth of the sebaceous glands and overgrowth of the colonizing bacteria Dermodex Folliculorum. It is associated with the common skin condition rosacea and can be thought of as the end stage of acne rosecea. It can carry a strong psychological impact due to its effect on one’s personal appearance.

Causes
Alcoholism is mistakenly attributed as a cause of this disease, but heavy alcohol consumption does aggravate the condition due its to chronic vasodilation effects. Rhinophyma may be diagnosed without testing, but a skin biopsy can confirm the diagnosis. Surgical treatment may be beneficial.

Rhinophyma is a slowly progressive condition due to hypertrophy of the sebaceous glands of the tip of the nose often seen in cases of long-standing acne rosacea; it is not a neoplasm. It presents as a pink, lobulated mass over the nose with superficial vascular dilation; it mostly affects men past middle age. Patients seek advice because of the perceived unsightly appearance of the enlargement, or obstruction in breathing and vision.

Treatment
Treating with topical Metrogel seems like a good idea in theory with its activity against Dermodex folliculorum, however, it really does very little in reality. Treatment consists of paring down the bulk of the tissue with a sharp instrument or carbon dioxide laser and allowing the area to re-epithelialise. Sometimes, the tissue is completely excised and the raw area skin-grafted. I personally have never tried putting a skin graft on this and many of my colleagues think this would be a bad idea. With the deep and ever present epithelial elements I would expect it to re epithelialize completely in less than a month with just conservative cares (H2O2 and bactroban applied TID). The painting on the right is from Domenico Ghirlandaio (1449 – 11 January 1494), he was an Italian Renaissance painter from Florence.

Nasal Alar Reconstruction

This was a large defect from a skin cancer. It was reconstructed with a superiorly based nasolabial flap wrapped around a conchal cartilage graft. The division and inset was at 3 weeks.

Moisturizing Nasal Measures

Our nose makes over a liter of secretions per day. To warm, filter and humidify the incoming air in preparation for the lungs is one of the major functions the nose is responsible for.

Bactroban (Mupirocin) ointment is a water miscible ointment that out performs all others in the anterior nose.

Ponaris Nasal Emmolient is also a staple of our practice. Pretz, Blairex, Nose Better, Nasal Moist, and Rhinaris are all moisturizing sprays. Entertainer’s Secret is a special formulation used as a throat spray that some have used as a nasal moisturizer. Some have advocated Conjugated Estrogens dissolved in saline. Mayo clinic has compounded rose geranium in sesame oil they say works well.

2 weeks after Lateral Canthotomy and Cantholysis and Medial Orbital Exploration

Amazingly, the Lateral Canthotomy almost completely healed itself in 2 weeks.

Recognition and management of Orbital Bleeding

Obviously the eyes need to be exposed during the case. Often what is going on intranasally gives little indication of the problem. The eye rapidly grows proptotic and tense. Immediate cantholysis and canthotomy is necessary to allow the globe to release anteriorly. The next move I made was to decompress the orbit a bit intranasaly. I also made an immediate Lynch incision and bipolared the offending artery. Some Arista was also used and the final ethmoid packing was fairly loose.

Anterior Ethmoid Artery Hemorrage

It is not unusual for recurrent polyps or papillomatous sinus disease to lead to dehissance of the Lamina Papyrecea. The Anterior Ethmoid Artery is in close proximitry to this region and injury is possible. I have probably done as many sinus surgeries as anyone alive and kind of felt that my super human skills left me immune to this complication, until now. The intranasal surgery showed little sign of any problem, but the exposed eye become immediately proptotic and tense.