Describe nasal vestibulitis and furuncle of the nose.

Vestibulitis and Furuncle

• Nasal vestibulitis is inflammation of the skin-lined nasal vestibule, and a furuncle (boil) is a staphylococcal abscess of a hair follicle there.
• Both are conditions of skin, not of mucosa — which is why the vestibule behaves like skin elsewhere on the face.
• The usual organism is staphylococcus aureus
• Predisposing factors — nose-picking and plucking of vibrissae.
• Vestibulitis presents with pain, tenderness, redness, swelling, crusting and fissuring of the vestibular skin, often with recurrent episodes
• A furuncle presents with severe, throbbing, well-localised pain out of proportion to the visible swelling, a tender red swelling in the vestibule, and later pointing with pus
• The critical point, and the reason this small condition IS taught AT all, IS the risk OF cavernous sinus thrombosis
• The nose and upper lip form the "danger area of the face".
• Infection can therefore spread retrogradely and intracranially, causing cavernous sinus thrombosis.
• Hence the absolute rule: a furuncle of the nose or upper lip must never be squeezed, picked or prematurely incised
• Management of a furuncle — systemic anti-staphylococcal antibiotics (flucloxacillin, or as guided by culture and local resistance); analgesia, which is needed and often underprescribed; local heat to encourage pointing; and NO manipulation
• Incision and drainage only when the abscess has pointed, and then gently under antibiotic cover
• Management of vestibulitis — topical antibiotic ointment (mupirocin or fusidic acid); an emollient; and treating the underlying nasal discharge, without which it recurs
• Advise the patient to stop nose-picking and plucking hairs, and to trim rather than pluck vibrissae
• For recurrent disease — test the blood glucose, since recurrent boils may be the presentation of diabetes; take nasal swabs for staphylococcal carriage and eradicate it with mupirocin to the nares and chlorhexidine washes; and consider immunodeficiency
• The warning signs OF spread.
• Such a patient requires immediate admission, intravenous antibiotics, imaging with MR venography and joint management
• The vestibule is skin, so it behaves like skin, which is why furuncles and fissuring occur there and not deeper in the nose
• Never squeeze a boil on the nose or upper lip; the valveless veins lead directly to the cavernous sinus
• Pain out of proportion to the swelling is characteristic of a furuncle in the tight vestibular skin
• Incise only when it has pointed, and then gently and under antibiotic cover
• Test the blood glucose in recurrent boils; they may be the presenting feature of diabetes