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Self-inflicted destruction of nose and palate: report of case
Self-inflicted destruction of nose and palate: report of case
Russell Gigliotti, DDS H. Glenn Waring, DDS, Baltimore
A bizarre condition developed in which a female patient literally picked away her entire nose includ ing the nasal septum, much of the turbinate bone, the internal nasal structures, and most of the hard palate. Working with the medical and psychiatric staffs, the dental staff constructed a combination nasal and dental prosthetic appliance for the pa tient. This treatment improved her mental attitude and physical well-being to the point that she be came completely rehabilitated.
The case history described in this report illustrates the vital role played by the dental service o f a large, metropolitan hospital in the total rehabilita tion of a debilitated, geriatric patient. A most un usual and bizarre condition developed in which a patient literally picked away her entire nose in cluding the nasal septum, much of the turbinate bone, the internal nasal structures, and most of the hard palate. By joint efforts o f the medical, psychiatric, and dental staffs, a plan of treatment, that included the construction of a combination nasal and den tal prosthetic appliance, was instituted. In this way, the patient’s mental attitude and physical well-being were improved.
History and diagnosis A white, 61-year-old woman who needed a com plete upper denture and a nasal prosthesis was 593
referred to the dental clinic. She showed a massive excavation of the entire nasal region that caused her considerable discomfort while speaking or eating. Because of her difficulty in eating, she had chronic constipation and loss of weight. The nose and paranasal structures (Fig 1; 2, left) were com pletely eroded, leaving an aperture measuring about 4 or 5 cm in diameter. The skin that bor dered the cavity was reddened and scabbed, but clean, and it showed no signs of infection or ac tive erosion. From the frontal view of the patient, it was possible to see the maxillary antrum and the sphenoid bone (Fig 2, left). The hard palate was almost entirely eroded (Fig 2, right), but the soft palate was intact. The tongue, pharynx, lar ynx, and buccal mucosa were all normal. The pa tient showed no response to pain over the entire fifth cranial nerve region. The response to pres sure was slight. About ten years previously, the patient had experienced shooting, stabbing pains on both sides of her face from the upper lip to the supra orbital area. In 1955, at another hospital, a right trigeminal rhizotomy was performed on the pa tient; in 1959, a left trigeminal rhizotomy was performed on her that led to relief of pain. After the second operation, the patient, com plaining that it felt as though maggots were eating inside her face, began to pick her nose to such a degree that she gradually destroyed it. The trau ma of picking led to scab formation and to subse quent eradication of the scabs. The patient seemed fairly well oriented and showed few signs of hallucinations, delusions, or other psychotic tendencies. However, she would cry easily and complained she had no friends. She also appeared infantile and immature with respect to her nose and childishly put on the air of being a bad girl who deserved punishment. The psychi atric staff classified the patient as psychotic be cause of her present behavior patterns, the amount of self-destruction, and the obsessive, compulsive reaction with signs of depression. The course of treatment agreed on by the den tal staff was to construct both a denture and a na sal prosthesis to correct her physical deformity. She was unable to speak a single word clearly or eat properly. The patient’s old upper denture was now loose and ill-fitting because of the huge, palatal aperture (Fig 2, right) that she had made with the long, sharp nail of her right thumb. It was decided to use psychotherapy on the patient, after the prosthetic appliances were inserted, and to en courage her to have frequent, short periods of con594 ■ JADA, Vol. 76, March 1968
Fig 1 ■ Lateral view of face showing erosion o f nose.
versation with the medical and nursing staffs to improve her mental outlook. From the age of 7 until the age of 20, the pa tient had every summer what she reported to be St. Vitus’ dance (chorea). H er intelligence was slightly impaired because of her limited educa tion. She showed a disturbance of the sleep pat-
Fig 2 ■ Left: Frontal view o f face showing erosion o f nose and paranasal structures. Right: Frontal view showing de stru ctio n o f hard palate.
tern, and she bemoaned the fact that she was “alone in the world” and “had no friends.” Her self-inflicted destruction in the form of nasal and palatal eradication could be considered an in stance of direct aggression toward herself. The act of picking away her nose and palate may have been a result of inner frustrations formed during a rather unhappy childhood and married life that were being expressed by an unusual act of anti social conduct. T he patient was compulsive about scabs in her nose. She said she had been a good housekeeper with a strong aversion to dirt and claimed her mother was particularly compulsive about dirt, both on her children and in her house. T he patient could not wear a bandage over her nose when she ate because food came out of her nose and she was unable to wipe it clean. It was intolerable for her to be unable to keep her nose clean. This fact, with the history of chronic constipation and obsessive acts, made this a possi ble instance of anal symbolism. The extraordinary, obsessive, compulsive behavior seemed possibly to be a result of organic brain disease secondary to degenerative changes.
T r e a tm e n t Since this patient would not tolerate a nasal ban dage and was suffering from constipation because she was unable to eat properly, it was decided to provide her with a nasal prosthesis that would be worn in apposition to her complete upper den ture. She refused to wear eyeglasses; therefore, the type of secondary retention for the nasal ap pliance that uses the frame of the eyeglasses as an auxiliary attachment had to be ruled out. Alginate impressions were obtained both for the nasal appliance and the complete upper den
ture. For the denture impression, it was necessary to pack the nasal fossa to limit the flow of the im pression material too far superiorly. The denture construction followed the routine steps of muscletrimming the tray, postdam, corrective impression, bitetaking, and try-in stages. On the wax trial den ture, a housing was waxed onto the superior bor der of the palatal region near the premolars and first molars. This housing was a hollow, square shaped attachment that measured about 2 by 2 by 3 cm in size (Fig 3, left). Onto the superior anterior border of this attachment was imbedded a rectangular-shaped magnet. The denture and attached housing with the magnet were cured in heat-cured methyl methacrylate acrylic resin. The dental staff decided that the nasal appliance would be better tolerated by the soft tissues of the paranasal region if it were constructed both of soft and hard acrylic resin. The external nasal res toration was made of elastic resin (Dicor).* The internal housing that fitted in apposition to the maxillary denture housing was constructed of hard acrylic resin. The internal housing had about the same dimensions as its counterpart on the denture. It was directed posteriorly (Fig 3, center), and on to its superior border was attached a magnet of size and shape similar to the one on the denture. It was necessary to obtain an alginate impres sion of the entire face in order to pour a stone mold on which to construct the nasal appliance. A tray was made from cardboard, and a large quantity of alginate impression material was placed on it. The region spanned by the impres sion was bounded superiorly by the hairline, inferiorly by the lower border of the mandible, and posteriorly on each side by the tragus of the ear. The nasal region was packed internally with abundant gauze to control the flow of the alginate. An endotracheal tube was inserted to maintain a patent airway.
Fig 3 ■ Left: Frontal view sketch o f denture w ith housing. Center: Lateral view sketch o f nasal ap pliance w ith housing. Right: Lateral view sketch of denture and nasal appliance in apposition. G ig lio tti—Waring: SELF-INFLICTED DESTRUCTION OF NOSE AND PALATE ■ 595
jàIP *"?•*. rrSif***4.
Fig. 4 ■ Left: Frontal view of face showing nasal appliance in place. Center: Frontal view showing denture and nasal appliance in position. R ight: Lateral view of face w ith nasal appliance.
As the impression began to set slightly, a wet plaster bandage was applied and the entire mass was then covered with plaster of paris to reinforce the entire area of the facial tray. The face model was poured in hard gypsum stone. A nose was made from modeling clay that ex tended about 4 mm over the entire diameter of the nasal aperture and that suited the patient esthetically. The internal housing was preformed in wax. Both were invested in a flask and elim inated in the usual manner. Elastic resin powder and liquid were mixed and packed into the part of the gypsum mold that contained the external nasal appliance. The internal housing part of the appliance was packed in hard acrylic resin. The entire mass was allowed to stand under pressure and was then closed tightly for processing at 212 F for one and a half hours. The correct shade was obtained by blending the pigments. Before the nasal appliance was inserted and fitted on the patient, a minimal amount of flash ing was removed and the appliance was finished.
596 ■ JADA, Vol. 76, March 1968
When both the nose appliance and upper den ture were in position (Fig 3, right), the magnetic field provided by the apposition of the magnets created supplemental force to help retain both de vices. The use of both appliances aided the pa tient in eating and considerably improved her personality and her ability to carry on normal conversation (Fig 4). With the medical and psychiatric therapy, this treatment improved the patient’s mental attitude and physical well-being to the point that she be came totally rehabilitated.
The authors th a nk Miss Susanne H u ltq u is t and Claude Taylor o f the audiovisual departm ent of th e U niversity of M aryland School o f Dentistry. Doctor G ig lio tti is associate professor o f operative den tis try , U niversity of M aryland School of D entistry and v is it ing dental surgeon, B altim ore C ity Hospitals. Doctor W aring is c h ie f o f the dental service, B altim ore C ity Hospitals, Baltim ore. *Vernon-Benshoff Co., P ittsburgh, Penn.
Russell Gigliotti, DDS H. Glenn Waring, DDS, Baltimore
A bizarre condition developed in which a female patient literally picked away her entire nose includ ing the nasal septum, much of the turbinate bone, the internal nasal structures, and most of the hard palate. Working with the medical and psychiatric staffs, the dental staff constructed a combination nasal and dental prosthetic appliance for the pa tient. This treatment improved her mental attitude and physical well-being to the point that she be came completely rehabilitated.
The case history described in this report illustrates the vital role played by the dental service o f a large, metropolitan hospital in the total rehabilita tion of a debilitated, geriatric patient. A most un usual and bizarre condition developed in which a patient literally picked away her entire nose in cluding the nasal septum, much of the turbinate bone, the internal nasal structures, and most of the hard palate. By joint efforts o f the medical, psychiatric, and dental staffs, a plan of treatment, that included the construction of a combination nasal and den tal prosthetic appliance, was instituted. In this way, the patient’s mental attitude and physical well-being were improved.
History and diagnosis A white, 61-year-old woman who needed a com plete upper denture and a nasal prosthesis was 593
referred to the dental clinic. She showed a massive excavation of the entire nasal region that caused her considerable discomfort while speaking or eating. Because of her difficulty in eating, she had chronic constipation and loss of weight. The nose and paranasal structures (Fig 1; 2, left) were com pletely eroded, leaving an aperture measuring about 4 or 5 cm in diameter. The skin that bor dered the cavity was reddened and scabbed, but clean, and it showed no signs of infection or ac tive erosion. From the frontal view of the patient, it was possible to see the maxillary antrum and the sphenoid bone (Fig 2, left). The hard palate was almost entirely eroded (Fig 2, right), but the soft palate was intact. The tongue, pharynx, lar ynx, and buccal mucosa were all normal. The pa tient showed no response to pain over the entire fifth cranial nerve region. The response to pres sure was slight. About ten years previously, the patient had experienced shooting, stabbing pains on both sides of her face from the upper lip to the supra orbital area. In 1955, at another hospital, a right trigeminal rhizotomy was performed on the pa tient; in 1959, a left trigeminal rhizotomy was performed on her that led to relief of pain. After the second operation, the patient, com plaining that it felt as though maggots were eating inside her face, began to pick her nose to such a degree that she gradually destroyed it. The trau ma of picking led to scab formation and to subse quent eradication of the scabs. The patient seemed fairly well oriented and showed few signs of hallucinations, delusions, or other psychotic tendencies. However, she would cry easily and complained she had no friends. She also appeared infantile and immature with respect to her nose and childishly put on the air of being a bad girl who deserved punishment. The psychi atric staff classified the patient as psychotic be cause of her present behavior patterns, the amount of self-destruction, and the obsessive, compulsive reaction with signs of depression. The course of treatment agreed on by the den tal staff was to construct both a denture and a na sal prosthesis to correct her physical deformity. She was unable to speak a single word clearly or eat properly. The patient’s old upper denture was now loose and ill-fitting because of the huge, palatal aperture (Fig 2, right) that she had made with the long, sharp nail of her right thumb. It was decided to use psychotherapy on the patient, after the prosthetic appliances were inserted, and to en courage her to have frequent, short periods of con594 ■ JADA, Vol. 76, March 1968
Fig 1 ■ Lateral view of face showing erosion o f nose.
versation with the medical and nursing staffs to improve her mental outlook. From the age of 7 until the age of 20, the pa tient had every summer what she reported to be St. Vitus’ dance (chorea). H er intelligence was slightly impaired because of her limited educa tion. She showed a disturbance of the sleep pat-
Fig 2 ■ Left: Frontal view o f face showing erosion o f nose and paranasal structures. Right: Frontal view showing de stru ctio n o f hard palate.
tern, and she bemoaned the fact that she was “alone in the world” and “had no friends.” Her self-inflicted destruction in the form of nasal and palatal eradication could be considered an in stance of direct aggression toward herself. The act of picking away her nose and palate may have been a result of inner frustrations formed during a rather unhappy childhood and married life that were being expressed by an unusual act of anti social conduct. T he patient was compulsive about scabs in her nose. She said she had been a good housekeeper with a strong aversion to dirt and claimed her mother was particularly compulsive about dirt, both on her children and in her house. T he patient could not wear a bandage over her nose when she ate because food came out of her nose and she was unable to wipe it clean. It was intolerable for her to be unable to keep her nose clean. This fact, with the history of chronic constipation and obsessive acts, made this a possi ble instance of anal symbolism. The extraordinary, obsessive, compulsive behavior seemed possibly to be a result of organic brain disease secondary to degenerative changes.
T r e a tm e n t Since this patient would not tolerate a nasal ban dage and was suffering from constipation because she was unable to eat properly, it was decided to provide her with a nasal prosthesis that would be worn in apposition to her complete upper den ture. She refused to wear eyeglasses; therefore, the type of secondary retention for the nasal ap pliance that uses the frame of the eyeglasses as an auxiliary attachment had to be ruled out. Alginate impressions were obtained both for the nasal appliance and the complete upper den
ture. For the denture impression, it was necessary to pack the nasal fossa to limit the flow of the im pression material too far superiorly. The denture construction followed the routine steps of muscletrimming the tray, postdam, corrective impression, bitetaking, and try-in stages. On the wax trial den ture, a housing was waxed onto the superior bor der of the palatal region near the premolars and first molars. This housing was a hollow, square shaped attachment that measured about 2 by 2 by 3 cm in size (Fig 3, left). Onto the superior anterior border of this attachment was imbedded a rectangular-shaped magnet. The denture and attached housing with the magnet were cured in heat-cured methyl methacrylate acrylic resin. The dental staff decided that the nasal appliance would be better tolerated by the soft tissues of the paranasal region if it were constructed both of soft and hard acrylic resin. The external nasal res toration was made of elastic resin (Dicor).* The internal housing that fitted in apposition to the maxillary denture housing was constructed of hard acrylic resin. The internal housing had about the same dimensions as its counterpart on the denture. It was directed posteriorly (Fig 3, center), and on to its superior border was attached a magnet of size and shape similar to the one on the denture. It was necessary to obtain an alginate impres sion of the entire face in order to pour a stone mold on which to construct the nasal appliance. A tray was made from cardboard, and a large quantity of alginate impression material was placed on it. The region spanned by the impres sion was bounded superiorly by the hairline, inferiorly by the lower border of the mandible, and posteriorly on each side by the tragus of the ear. The nasal region was packed internally with abundant gauze to control the flow of the alginate. An endotracheal tube was inserted to maintain a patent airway.
Fig 3 ■ Left: Frontal view sketch o f denture w ith housing. Center: Lateral view sketch o f nasal ap pliance w ith housing. Right: Lateral view sketch of denture and nasal appliance in apposition. G ig lio tti—Waring: SELF-INFLICTED DESTRUCTION OF NOSE AND PALATE ■ 595
jàIP *"?•*. rrSif***4.
Fig. 4 ■ Left: Frontal view of face showing nasal appliance in place. Center: Frontal view showing denture and nasal appliance in position. R ight: Lateral view of face w ith nasal appliance.
As the impression began to set slightly, a wet plaster bandage was applied and the entire mass was then covered with plaster of paris to reinforce the entire area of the facial tray. The face model was poured in hard gypsum stone. A nose was made from modeling clay that ex tended about 4 mm over the entire diameter of the nasal aperture and that suited the patient esthetically. The internal housing was preformed in wax. Both were invested in a flask and elim inated in the usual manner. Elastic resin powder and liquid were mixed and packed into the part of the gypsum mold that contained the external nasal appliance. The internal housing part of the appliance was packed in hard acrylic resin. The entire mass was allowed to stand under pressure and was then closed tightly for processing at 212 F for one and a half hours. The correct shade was obtained by blending the pigments. Before the nasal appliance was inserted and fitted on the patient, a minimal amount of flash ing was removed and the appliance was finished.
596 ■ JADA, Vol. 76, March 1968
When both the nose appliance and upper den ture were in position (Fig 3, right), the magnetic field provided by the apposition of the magnets created supplemental force to help retain both de vices. The use of both appliances aided the pa tient in eating and considerably improved her personality and her ability to carry on normal conversation (Fig 4). With the medical and psychiatric therapy, this treatment improved the patient’s mental attitude and physical well-being to the point that she be came totally rehabilitated.
The authors th a nk Miss Susanne H u ltq u is t and Claude Taylor o f the audiovisual departm ent of th e U niversity of M aryland School o f Dentistry. Doctor G ig lio tti is associate professor o f operative den tis try , U niversity of M aryland School of D entistry and v is it ing dental surgeon, B altim ore C ity Hospitals. Doctor W aring is c h ie f o f the dental service, B altim ore C ity Hospitals, Baltim ore. *Vernon-Benshoff Co., P ittsburgh, Penn.