A rare case of nasal gout

Discussion

As the incidence of gout increases, so too does the variability of its clinical presentation, which extends beyond the characteristic joint arthropathy that is classically reported. The literature reports tophaceous lesions presenting in the breast, ears, spine, abdominal striae and even heart valves.7 Nasal tophi, however, remain a rare manifestation with fewer than 10 reported cases in the English language. This presentation fits with the tendency for crystals to precipitate in cool extremities.

All reported cases feature middle-aged males presenting with predominant symptoms of nasal obstruction and poor cosmetic appearance that improved following surgical management.8 As in this case, the nasal lesion is frequently tender, however a number of patients have reported painless lumps.9 10

All reported cases (bar one) have occurred in patients with known gouty arthritis and often poorly controlled serum urate levels.11 This reflects the natural progression of the condition as tophi typically develop during later stages. Thus, nasal tophi are unlikely to be the initial presentation of this systemic condition. Although this case demonstrated no features of bony invasion, Wu et al describe a 2×2×1.5 cm lesion on the nasal dorsum associated with nasal bone destruction which required repair with a titanium mesh plate.8 Similarly, CT imaging provided by Chen et al revealed a tophaceous lesion invading into the nasal bone and septal cartilage.10

CT scan proved the investigation of choice across all available literature reports. The majority of published cases were managed surgically and CT scan helped in operative planning. Chen et al advocated the role of ultrasound guided fine needle aspiration cytology (FNAC) and microscopy for diagnostics. This non-invasive option was particularly beneficial as their patient declined surgical management, electing to optimise medical therapy once reassured of the nature of the lesion.10 Papanicolaou (PAP) staining and polarised light microscopy may have a role in confirming pathology prior to surgical excision.10 Ultrasound has proven a useful investigation of tophi elsewhere in the body and is cost-effective, non-invasive and easy to perform.12 However, in our case, where no FNAC was performed, ultrasound provided little diagnostic assistance. Ultrasound FNAC therefore should be considered a safe and quick way to establish a diagnosis prior to definitive management. Flexible nasendoscopy is another relevant investigation, which to our knowledge was only explicitly reported by Chen et al.10 This easily accessible modality enables direct visualisation of nasal cavity to assess for underlying masses while awaiting further radiological imaging. Where nasal bone involvement is likely to require reconstruction, flexible nasendoscopy is indispensible to enable surgical planning.

Numerous management options have been described in the literature, owing to great variability in clinical presentation regarding the size of the lesion, involvement of underlying bone and structural issues such as deviated nasal septum following trauma.13 Management of nasal gout does not yet have a defined treatment protocol due to its rarity and variable presentation.

The main options available are an open biopsy or transnasal approach. In our case, an intercartilaginous approach was used as this allowed good access to the soft tissue of the dorsum without causing an external scar. This involves an incision between the upper and lower alar cartilages. It has the advantage of involving and preserving the interdomal ligaments and involves the least undermining. If the tophi were present within the nasal cavity, then a direct biopsy could have been performed for diagnosis. In contrast, an open approach that involves an infracartilaginous incision and a connecting transcolumellar incision involves extensive undermining and an external scar but allows for excellent exposure, which may be necessary for more extensive disease.14

Diagnostic confirmation of nasal gout in these cases derives from postoperative tissue analysis. Kwak et al advocate the importance of fresh samples, as formalin fixation can dissolve the monosodium urate crystals.13 Management of all reported cases have produced satisfactory cosmetic results and improvement in nasal obstruction. Although the maximum duration of reported follow-up is 2 years, no recurrences have thus far been reported.8 It remains to be seen what the long-term recurrence rates are for tophaceous nasal gout.

This case report, together with the available literature, supports the early management and control of serum urate levels in reducing the incidence of acute attacks of gout and the subsequent development of gouty tophi. Once developed, prompt diagnosis and management are needed to maintain and improve quality of life.15