Furunkel Pada Hidung

Furunkulosis dan Vestibulitis. Infeksi yang luas dan invasif dari kelenjar sebasea atau folikel
rambut, yang melibatkan pula jaringan subkutan - bisul atau furunkel. Biasanya disebabkan
Staphylococcus aureus (Gbr. 12-5). Analgesik dan kompres hangat dapat meredakan perasaan
tidak nyaman. Bilamana perlu berikan langsung antibiotik sistemik dan topikal melaawan
organisme, demikian pula insisi dan darinase abses. Staphylococctts ettreus juga merupakan
organisme penyebab vestibulitis hidung, yaifu suatu peradangan ringan dengan nyeri dan
krusta berulang. Salep antibiotik topikal dua sampai tiga kali sehari, biasanya mencukupi.

Infection of the skin of the nasal vestibule is termed nasal vestibulitis. It may be secondary to
constant rhinorrhea, nose picking, or viral infections such as herpes simplex and herpes
zoster. Foreign bodies frequently cause vestibulitis in children due to purulent discharge.
Nasal furunculosis is Staphylococcus aureus infection of the hair follicles. Nose picking is a
frequent cause of furunculosis. Topical and if necessary systemic antibiotics are prescribed.
The patient should be instructed not to squeeze out pus from this area. Since the veins
draining this area are valveless and directly join the cavernous sinus, there is a potential risk
of spreading infection to the cavernous sinus via these facial veins. Eczema may also mimic
vestibulitis. In these cases steroid base ointment may help the patient. In persistent
vestibulitis, neoplastic diseases such as basal cell or squamous cell carcinoma should be kept
in mind.

T. Metin nerci: Diagnosis in Otorhinolaryngology DOI: 10.1007/978-3-642-00499-5_2,

Springer-Verlag Berlin Heidelberg 2009

The Rudolph sign of nasal vestibular furunculosis: Questions raised by this

common but under-recognized nasal mucocutaneous disorder
Kevin W Dahle, Richard D Sontheimer
Dermatology Online Journal 18 (3): 6

A. EARLY DESCRIPTIONS

First, a comprehensive literature search was employed to identify previous descriptions and clinical
significance of the symptom complex we are referring to here as nasal vestibular furunculosis. Veach
described a patient with recurrent folliculitis that was resistant to treatment with antiseptics and
ultimately responded to topical aluminum chloride in 1940 [1]. Later in 1996, Conners described a
patient with uncomplicated nasal furunculosis originally treated with a warm compress and oral
cephalexin that had a recurrence of symptoms [2].

B. NOMENCLATURE

The lack of a consensus designation for the common symptom complex that we describe here as
nasal vestibular furunculosis was surprising to us. We would like to share our rationale for choosing
this particular terminology for this report.

This clinical entity has been described in modern textbooks under a variety of names including
vestibule furunculosis [3], nasal vestibulitis [4], and simply nasal infection [5]. We found the most
precise clinical description of this symptom complex in a current otolaryngology textbook:
Nasal furunculosis and vestibulitis are localized infections of the hair-bearing nasal vestibule. A
furuncle is a localized painful area of cellulitis surrounding a hair follicle; vestibulitis is a more diffuse
process, often with crusting. The causative organism is almost always S. aureus. Therapy includes
local heat compresses, elimination of digital manipulation, topical antibiotic ointments and systemic
antibiotics directed against S. aureus, such as dicloxacillin, second-generation cephalosporins, or
rifampin. Many of these patients are chronic carriers of S. aureus in the nasal vestibule [6].

We performed a comprehensive literature search using the Medline and Oldmedline databases
accessed via PubMed to identify previous clinical names for this symptom complex. Our PubMed
search keywords included nose furunculosis, nasal furunculosis, nose furuncule, nasal
furuncule, nose vestibule furunculosis, nasal vestibule furunculosis, nose vestibular furunculosis,
nasal vestibular furunculosis, nose folliculitis, nasal folliculitis, nose vestibule folliculitis, nasal
vestibule folliculitis, nose vestibular folliculitis, nasal vestibular folliculitis, nose vestibulitis and
nasal vestibulitis. In addition, similar searches were performed using the European Biomedical
Institute Literature Database and the Google search engine to identify publications not indexed by
PubMed.

When someone refers to furuncles, most think of boils on the skin of the trunk and/or extremities.
Typically, one does not think of boils on or inside the nose when the term furuncle is mentioned. The
term nasal furuncle is more specific to the nose, however it does not specify the anatomic part of the
nose that is affected. In the literature, this term often describes lesions on the exterior surface of the
nose [7, 8].

The term folliculitis is often used in dermatology to refer to conditions that have multiple follicles
targeted by inflammation concurrently that tend to be more pruritic than painful and tender. Common
forms of cutaneous folliculitis typically do not cause the acute focal symptoms of tenderness and pain
that was evident in our case. The term nasal folliculitis is often used to denote focal inflammation
around the base of multiple hairs at the orifice of the nasal vestibule, not within the vestibule itself.

While nasal vestibulitis is more specific to the nasal vestibule itself, it does not identify the hair
follicle as the nidus of symptomatic inflammation. As we will describe below, it is our hypothesis that
staphylococcal overgrowth and invasion of a nasal hair follicle is likely to be the primary source of the
mucocutaneous symptom complex that we describe here as nasal vestibular furunculosis. We prefer
this term because it is specific to the nasal vestibule and the acute focal symptoms that are present.
However, the authors look forward to further discussion concerning the most appropriate designation
and classification of this symptom complex (this was a major goal for the publication of this case
report).

C. EPIDEMIOLOGY

To our knowledge, there have been no published studies attempting to quantify the incidence and
prevalence of nasal vestibular furunculosis. Anecdotally, our experience suggests that it is a fairly
common condition encountered in clinical practice. There are reports in the literature of rare
complications of similar nasal infections leading to cavernous sinus thrombosis and necrotizing
pneumonia [9, 10]. Further epidemiologic studies are needed to clarify the epidemiology of nasal
vestibular furunculosis and the true rates of associated complications. It would be of interest to know
whether nasal vestibular furunculosis is seen more commonly in individuals who are intranasal
carriers of S. aureus, as was stated in the otolaryngology textbook passage cited above [6].

D. CLINICAL OBSERVATIONS

One of the authors (RDS) has personal experience with nasal vestibular furunculosis. At least three
members of his immediate family have intermittently experienced this symptom complex over a period
of three decades. None of those individuals has ever had other clinical patterns of cutaneous or
systemic staphylococcal infections. In addition, he has seen a number of such patients over his three-
decade career of dermatology practice. Management of such patients by previous other physicians
involved diverse treatment modalities including oral antibiotics, reflecting confusion about this clinical
entity.

Typically, the initial symptom is focal pain in the tissue overlying one of the two nasal vestibules
(simultaneous bilateral involvement with nasal vestibular furunculosis symptoms appears to be very
rare). When the skin overlying the area of pain is inspected, there is no perceptible surface change.
However, when the skin overlying the area of pain is palpated, it is often found to be tender. Later, the
painful focus of skin overlying the lateral tip of the nose can become reddened. At that point there is
exquisite tenderness on palpation.

However, pustules rarely develop within the area of painful, tender erythema at the surface of the
skin. In addition, frank abscess formation at the surface of the skin with fluctuance is rarely ever seen.
Systemic symptoms including fever and chills do not accompany this localized form of presumed
bacterial nasal hair follicular inflammation. Over a period of time if left untreated the intranasal focus
of pain and surface tenderness +/- skin surface erythema will spontaneously resolve. However, this
can be hastened considerably by treatment with an intranasal topical product. It is not uncommon for
an individual with this symptom complex to experience multiple similar recurrent episodes over
months to years.

Various triggers for nasal vestibular furunculosis have been described in the literature. Nose picking
and hair plucking have been implicated [2]. Additionally, Veach reported that there was a
predominance of symptoms in the winter months [1]. As stated above, our patient noticed a
recurrence of symptoms after plucking his nose hair with tweezers, trimming his nose hair with a small
trimmer or picking off a scab inside his nose.

E. TREATMENT

In 1940, Veach treated a patient with antiseptics, tincture of mercury, and eventually aluminum
chloride [1]. It is important to note that antibiotics were not readily available at that time. Connors
recommended using warm compresses and oral anti-staphylococcal antibiotics followed by drainage
of the furuncle. Further recurrences were treated with topical mupirocin ointment [2]. However, it has
been our personal experience that drainage is not necessary once topical intranasal mupirocin
applications are started. The senior author has observed one patient whose symptoms were
controlled initially with topical intranasal application of an over-the-counter topical antibiotic ointment
containing neomycin, polymyxin and bacitracin. Over time, recurrences of this symptom complex
ceased to respond to this combination topical antibiotic preparation. However, the patient quickly
responded to the institution of topical mupirocin, suggesting acquired bacterial resistance to the
topical triple antibiotic combination.

It is our experience that topical antibiotic treatments are the most effective treatment. Typically, the
pain and erythema start to improve within 12 hours after the initiation of topical therapy with an
antibacterial ointment or cream applied twice daily by cotton tip to the entire mucosal surface of the
nasal vestibule. This treatment is best continued for 2-3 days consecutively. Initially, over-the-counter
triple antibiotic creams or ointments containing neomycin, polymyxin, and bacitracin are effective.
However, as noted above some individuals who have experienced nasal vestibular furunculosis
intermittently for a longer period of time appear to become resistant to the therapeutic effect of over-
the-counter triple antibiotic topical preparations. Starting a prescription-strength topical antibiotic
preparation such as mupirocin or retapamulin ointment can provide further relief in such patients.

F. ETIOLOGY OF NASAL VESTIBULAR FURUNCULOSIS

It is the authors hypothesis based upon review of the literature and extrapolation from personal
observations that the nasal hair follicle is the portal of entry for staphylococcal tissue invasion in nasal
vestibular furunculosis. Whether a single or group of hair follicles is involved is unclear. The initial pain
and tenderness of nasal vestibular furunculosis is very localized, arguing against a more widespread
mucocutaneous surface infection. Inflammation within the follicles of nasal hair could account for such
localized, asymmetrical point tenderness and pain. This inflammation must then spread through
multiple tissue layers in order for erythema to be evident on the nasal skin. As such, cutaneous
erythema of the nasal tip may or may not be present, depending on the level of inflammation. When
cutaneous erythema is present, it typically follows the onset of focal, intranasal pain.

Ideally, the authors would have performed a nasal vestibule culture for S. aureus in the patient whose
case we are reporting. Based upon the senior authors past experience of successfully treating nasal
vestibular furunculosis empirically with intranasal topical antibiotic ointments, it was felt that the
results of performing a nasal vestibule culture for S. aureus would not have had a clinical impact on
our treatment decisions in this case. In any further studies of nasal vestibular furunculosis, such
cultures should be performed in a standard manner.

In our literature review we have been unable to find reports of the histopathological changes of nasal
vestibular furunculosis. In addition, the authors were unable to find a histopathologic description of the
cutaneous erythema of the nasal tip that may be seen with nasal vestibular furunculosis. While an
intranasal biopsy would be extremely helpful in elucidating the pathophysiology of nasal vestibular
furunculosis, it is important to note the impracticality of performing an intranasal biopsy. The
instruments required to perform such a biopsy are not readily available in a typical dermatology office
setting.

G. CLINICAL CORRELATIONS/IMPLICATIONS

Nasal vestibular furunculosis raises a number of important clinical questions. Do patients with nasal
vestibular furunculosis have greater S. aureus colony counts? Do they have higher rates of methicillin
resistance? Do they have more virulent strains of S. aureus? If S. aureus does form intranasal
biofilms, would such biofilm formation potentiate the development of nasal vestibular furunculosis?
The association between the Panton-Valentine Leukocidin (PVL) positive S. aureus and cutaneous
furunculosis has been well documented in the literature [11, 12, 13]. Is there a similar correlation
between PVL positive S. aureus and nasal vestibular furunculosis? Is there an association between
nasal vestibular furunculosis and recurrent herpes simplex virus type 1 (HSV-1) infection? Further
studies are needed to clarify these correlations.

Additionally, further work is needed to elucidate the most effective treatment for nasal vestibular
furunculosis. It is the authors preference to treat initially with topical antibiotics. Does this practice
differentially decrease staphylococcal carriage rates in individuals with nasal vestibular furunculosis
compared to those who do not have nasal vestibular furunculosis? The authors have observed a
number of patients that initially respond to over-the-counter antibiotic treatment but subsequently stop
responding. Does topical use of intranasal antibiotics potentiate the development of new staph-
resistant strains? Do oral antibiotic regimens designed to rectify MRSA colonization benefit patients
with recurrent nasal vestibular furunculosis? All of these questions need to be clarified in order to
better treat this common clinical condition.