SQUAMOUS CELL CARCINOMA
This man developed an ulcer in his left nostril. He ignored this for some time before presenting with an obvious carcinoma. He underwent surgical excision and reconstruction, producing an impressive cosmetic result. So far, there has been no sign of recurrence either locally or as metastases. This type of cancer can be associated with a range of exposure to inhaled irritants. This man had worked in the motor manufacturing industry and this may have been relevant to the aetiology.
Anticoagulation is increasingly used in general practice, with large numbers of patients having AF. This elderly man was taking warfarin and unfortunately experienced the obvious risk of anticoagulants, bleeding. His nosebleeds followed a URTI and were difficult to control. His Hb dropped to 64g/L. He required urgent referral to ENT for cautery.
This young man sustained an injury to his face playing rugby. It caused very obvious distortion to his nose. Although a cosmetic concern, this was more of a problem because it interfered with his nasal airway and hence his breathing. The patient was referred to the ENT surgeons to straighten out the deformity, which resolved the matter.
Acne rosacea is a common condition, seen most often in middle-aged and elderly patients, with a propensity for women. At the extreme end of long-standing rosacea can be the formation of a rhinophyma, as in this elderly man. Treatment with topical antibiotics may not be as effective as it is in inflammatory rosacea, and some patients require surgery. This can involve using laser techniques to reduce the excessive tissue. This case was relatively mild and did seem to respond fairly well to oral tetracyclines, so the patient did not require referral.
Nasal obstruction is quite commonly seen and proper examination of the nose may reveal polyps. They are not normally as obvious as this one. The treatment is primarily medical, with nasal corticosteroids being the choice. If the polyps are large, oral prednisolone may be required, but normally, steroid drops are effective. They will be required for a number of weeks before the patient can switch to a nasal steroid spray for longer-term use. Guidance on the correct technique for applying the drops and using the spray is important, but often omitted. Surgery is occasionally required, but the polyps often recur. In this case, the steroid drops were effective, so the patient did not require referral.
BASAL CELL CARCINOMA
The most common skin cancer seen on the face is basal cell carcinoma. The nose receives more than its fair share of UV exposure over the course of a lifetime, so it is not surprising that these tumours are often seen on the nose, as non-healing, scabbed lesions. As long as they are diagnosed early, treatment can be medical, with topical agents, but if surgery is required, modern techniques using flaps can produce very good cosmetic results. Recurrence is rare, but new lesions are always possible.
Cold sores are a common problem, caused by recurrent attacks of HSV-1. Patients are usually aware of an impending attack and should use topical or oral antivirals as early as possible, to try to reduce the severity and duration of the episode. When they are vesicular, patients should also be reminded that they are liable to transmit the virus to others by direct contact.
This man presented with concerns about his nose, because he admitted to a history of quite significant cocaine use. Examination revealed a large septal perforation caused by the long-standing vasoconstrictive effect of the drug, leading to the death of the cartilage cells that form a large part of the septum. The patient had long since given up his drug habit, so he was referred to the ENT surgeons, who agreed to repair the defect.
- Dr Phil Marazzi, GP, Surrey, UK