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Surgical Pearl: Lateral rhinotomy for exposure of tumors of the nasal vestibule
PEARLS OF WISDOM Surgical Pearl: Lateral rhinotomy for exposure of tumors of the nasal vestibule Frederick W. Gourdin, MD Augusta, Georgia
The nasal vestibule is the space that lies just within the nasal aperture. It is bordered laterally by the soft tissues of the ala and the lateral crus of the alar cartilage, inferiorly by the floor of the nasal cavity, and medially by the columella and cartilaginous septum. Tumors arising within the vestibule are uncommon, but are often aggressive.1 Surgical resection can be compromised by limited exposure and the tendency for tumors arising medially to track submucosally along the septum.2 Lateral rhinotomy is an adjunctive maneuver that greatly facilitates visualization and resection of malignancies of the nasal vestibule. Fig. 1, A shows a recurrent squamous cell carcinoma of the columella in a patient referred for Mohs micrographic excision. The posterior extent of the gross tumor extension along the septum is not visible on external nasal examination. Lateral rhinotomy is performed under infraorbital nerve block supplemented by local infiltration of anesthetic. The incision is initiated at the base of the ala and then carried superiorly in the nasofacial sulcus. The incision is usually terminated a few millimeters above the posterior ala, but may be carried as high as the caudal edge of the nasal bone if wide exposure of the vestibule is required (Fig. 1, B). The incision is deepened through the fibrous tissues of the ala and connected to the vestibule by dividing the nasal mucosa near the juncture of the interior surface of the ala and the floor of the nose. Hemostasis is obtained by electrocautery. A suture may then be placed in the base of the ala and used to retract the ala to expose the tumor (Fig. 1, C). The ala may be left unattached until the Mohs excision is complete, in this instance, after two stages. At the conclusion of the From the Section of Dermatology, Department of Medicine, Medical College of Georgia. Reprints are not available from the author. J Am Acad Dermatol 1998;38:476-7. Copyright © 1998 by the American Academy of Dermatology, Inc. 0190-9622/98/$5.00 + 0 16/74/87479
476
Fig. 1. A, Recurrent squamous cell carcinoma of the columella and septum. B, Diagrammatic representation of incision for lateral rhinotomy. C, Retraction of ala to expose nasal vestibule. D, Restoration of normal alar contour after healing.
procedure the ala is reapproximated with deep Vicryl sutures in the fibrous portion of the ala. The mucosa is closed with gut or chromic absorbable sutures and the skin with nylon or polypropylene nonabsorbable sutures. The skin edges may be scored at the start of the procedure to facilitate precise alar reapproximation. The wound usually heals quickly and without a significant cosmetic defect.3,4 Fig. 1, D shows restoration of the normal alar contour. Because of the high-risk nature of this particular tumor, the wound was allowed to heal by second intention. Definitive reconstruction is planned after 12 to 18 months of observation. The patient has declined a nasal prosthesis in the interim. Stuart J. Salasche, MD Feature Editor Direct all submissions to Dr. Stuart J. Salasche, 5300 N. Montezuma Trail, Tucson, AZ 85750.
Journal of the American Academy of Dermatology Volume 38, Number 3
Pearls of wisdom 477
REFERENCES 1. Shockley WW. Special problems associated with carcinoma of the nose. Otolaryngol Clin North Am 1993;26:24764. 2. Panje WR, Ceilley RI. The influence of embryology of the mid-face on the spread of epithelial malignancies. Laryngoscope 1979;89:1914-20.
3. Hanke CW, Lingeman RE, Singer MI, et al. Chemosurgical reports: lateral rhinotomy in the treatment of nasal mucous membrane carcinomas. J Dermatol Surg Oncol 1983;9:344-6. 4. Zilinsky I, Borenstein A, Tsur H. Lateral rhinotomy approach for Mohs micrographic surgery of the anterior septum. J Dermatol Surg Oncol 1993;19:866-8
IOTADERMA #50 What is the name of the syndrome in which the ability to recall proper names and eponyms seems to be selectively impaired? Jeffrey D. Bernhard, MD Answer will appear in the April issue of the Journal.
FEBRUARY IOTADERMA (#49) What name has been eponymously attached to a benign, self-limiting syndrome characterized by easy bruising and hematoma formation of the palmar aspect of the hands? Answer: Achenbach syndrome. REFERENCE Parslew R, Verbov JL. Achenbach syndrome. Br J Dermatol 1995;132:319. I am indebted to Dr. John R. Person for recognizing this disgnosis and presenting a case report at a meeting of the Quinsigamond Dermatologic Society on Dec. 10, 1997.
The nasal vestibule is the space that lies just within the nasal aperture. It is bordered laterally by the soft tissues of the ala and the lateral crus of the alar cartilage, inferiorly by the floor of the nasal cavity, and medially by the columella and cartilaginous septum. Tumors arising within the vestibule are uncommon, but are often aggressive.1 Surgical resection can be compromised by limited exposure and the tendency for tumors arising medially to track submucosally along the septum.2 Lateral rhinotomy is an adjunctive maneuver that greatly facilitates visualization and resection of malignancies of the nasal vestibule. Fig. 1, A shows a recurrent squamous cell carcinoma of the columella in a patient referred for Mohs micrographic excision. The posterior extent of the gross tumor extension along the septum is not visible on external nasal examination. Lateral rhinotomy is performed under infraorbital nerve block supplemented by local infiltration of anesthetic. The incision is initiated at the base of the ala and then carried superiorly in the nasofacial sulcus. The incision is usually terminated a few millimeters above the posterior ala, but may be carried as high as the caudal edge of the nasal bone if wide exposure of the vestibule is required (Fig. 1, B). The incision is deepened through the fibrous tissues of the ala and connected to the vestibule by dividing the nasal mucosa near the juncture of the interior surface of the ala and the floor of the nose. Hemostasis is obtained by electrocautery. A suture may then be placed in the base of the ala and used to retract the ala to expose the tumor (Fig. 1, C). The ala may be left unattached until the Mohs excision is complete, in this instance, after two stages. At the conclusion of the From the Section of Dermatology, Department of Medicine, Medical College of Georgia. Reprints are not available from the author. J Am Acad Dermatol 1998;38:476-7. Copyright © 1998 by the American Academy of Dermatology, Inc. 0190-9622/98/$5.00 + 0 16/74/87479
476
Fig. 1. A, Recurrent squamous cell carcinoma of the columella and septum. B, Diagrammatic representation of incision for lateral rhinotomy. C, Retraction of ala to expose nasal vestibule. D, Restoration of normal alar contour after healing.
procedure the ala is reapproximated with deep Vicryl sutures in the fibrous portion of the ala. The mucosa is closed with gut or chromic absorbable sutures and the skin with nylon or polypropylene nonabsorbable sutures. The skin edges may be scored at the start of the procedure to facilitate precise alar reapproximation. The wound usually heals quickly and without a significant cosmetic defect.3,4 Fig. 1, D shows restoration of the normal alar contour. Because of the high-risk nature of this particular tumor, the wound was allowed to heal by second intention. Definitive reconstruction is planned after 12 to 18 months of observation. The patient has declined a nasal prosthesis in the interim. Stuart J. Salasche, MD Feature Editor Direct all submissions to Dr. Stuart J. Salasche, 5300 N. Montezuma Trail, Tucson, AZ 85750.
Journal of the American Academy of Dermatology Volume 38, Number 3
Pearls of wisdom 477
REFERENCES 1. Shockley WW. Special problems associated with carcinoma of the nose. Otolaryngol Clin North Am 1993;26:24764. 2. Panje WR, Ceilley RI. The influence of embryology of the mid-face on the spread of epithelial malignancies. Laryngoscope 1979;89:1914-20.
3. Hanke CW, Lingeman RE, Singer MI, et al. Chemosurgical reports: lateral rhinotomy in the treatment of nasal mucous membrane carcinomas. J Dermatol Surg Oncol 1983;9:344-6. 4. Zilinsky I, Borenstein A, Tsur H. Lateral rhinotomy approach for Mohs micrographic surgery of the anterior septum. J Dermatol Surg Oncol 1993;19:866-8
IOTADERMA #50 What is the name of the syndrome in which the ability to recall proper names and eponyms seems to be selectively impaired? Jeffrey D. Bernhard, MD Answer will appear in the April issue of the Journal.
FEBRUARY IOTADERMA (#49) What name has been eponymously attached to a benign, self-limiting syndrome characterized by easy bruising and hematoma formation of the palmar aspect of the hands? Answer: Achenbach syndrome. REFERENCE Parslew R, Verbov JL. Achenbach syndrome. Br J Dermatol 1995;132:319. I am indebted to Dr. John R. Person for recognizing this disgnosis and presenting a case report at a meeting of the Quinsigamond Dermatologic Society on Dec. 10, 1997.