Nasal Vestibulitis: Definition and Clinical Characteristics
Nasal vestibulitis (NV) is an infection of the nasal vestibule—the skin-lined anterior portion of the nasal cavity just inside the nostrils—typically caused by bacterial infection of hair follicles and characterized by erythema, crusting, and tenderness of this area. 1, 2
Anatomic Location and Pathophysiology
- The nasal vestibule is the skin-lined entrance to the nasal cavity, distinct from the mucosa-lined nasal cavity proper that is involved in rhinosinusitis 3
- NV represents a superficial infection of the hair follicles and skin within this vestibular area 2
- This condition should not be confused with rhinosinusitis, which involves inflammation of the nasal mucosa and paranasal sinuses 3
Clinical Presentation
- Patients typically present with localized erythema, swelling, crusting, and tenderness at the nasal vestibule 1, 2
- Mid-facial cellulitis occurs in approximately 79% of cases requiring medical attention 1
- Abscess formation within the nasal vestibule develops in approximately 48% of cases 1
- When infection extends to involve the nasal tip with visible erythema and edema, this is termed the "Rudolph Sign" 4
Risk Factors and Etiology
The most common identifiable risk factors include nasal manipulation through:
- Nasal hair plucking (14.4% of cases) 1
- Nose blowing (9.3% of cases) 1
- Nose picking (8.5% of cases) 1
- Nose piercing (3.4% of cases) 1
Staphylococcus aureus is the predominant causative organism:
- Methicillin-sensitive S. aureus (MSSA) accounts for 81% of culture-positive cases 1
- Diabetes mellitus is present in approximately 10% of patients 1
- Immunosuppression is an additional risk factor 1
Distinction from Nasal Vestibular Furunculosis
- Nasal vestibular furunculosis (NVF) represents a deeper, more localized infection of a single hair follicle within the nasal vestibule, forming a discrete furuncle or boil 2, 4
- NVF and NV share common etiology and treatment approaches but remain distinct pathological entities 2
- NVF typically presents with acute focal swelling and erythema, often at the nasal tip, with symptom duration of 3-4 days before presentation 5
Management Approach
Topical antibiotics are the mainstay of treatment:
- Intranasal topical mupirocin is the most frequently reported effective treatment 4, 5
- Oral antibiotics (such as sodium fusidate) may be added for more extensive cases with cellulitis 4, 5
- Conventional treatment typically results in healing within 36 days, though this can be shortened to approximately 18 days with adjunctive therapies like topical basic fibroblast growth factor 6
- Resolution of NVF typically occurs within 7 days with appropriate antibiotic therapy 5
Complications and Prognosis
Despite the potential for serious complications, the actual risk is extremely low:
- Theoretical complications include ophthalmic vein thrombosis and cavernous sinus thrombosis due to venous drainage patterns 4
- In a series of 118 hospitalized cases (representing more severe presentations), no major complications were observed 1
- Complications appear to be infrequent in clinical practice 2
Diagnostic Approach
- Diagnosis is primarily clinical, based on visual inspection of the nasal vestibule showing erythema, crusting, and tenderness 2
- Bacterial cultures are obtained in only approximately 33% of cases and are not routinely necessary for diagnosis 1
- When cultures are performed, they help guide antibiotic selection in treatment-resistant cases 2
Common Pitfall
Do not confuse nasal vestibulitis with rhinosinusitis—the former involves the skin-lined vestibule and requires topical antibiotics, while the latter involves the mucosa-lined nasal cavity and sinuses with entirely different diagnostic criteria and management 3, 1, 2