This is a fascinating first case report of rhinotillexomania associated with empty nose syndrome (ENS). Rhinotillexomania encompasses compulsive, pathological nose picking and is a variant of self-harm. Tranchito and Chhabra describe an elderly patient presenting with longstanding symptoms of nasal blockage associated with feelings of suffocation, and a medical history that includes a compulsive picking disorder. On clinical and radiological examination, the patient was found to have extensive septal and piriform aperture destruction. A widely patent nose associated with the subjective perception of nasal blockage is typical of empty nose syndrome, an iatrogenic condition causing significant loss of internal nasal architecture.

The authors review the rhinotillexomania literature and identify severe cases leading to extreme destruction of nasal anatomy, not only involving the nasal septum, but also causing unilateral ethmoidectomy, orbital wall and hard palate defects, middle turbinectomy and medial antrectomy.

None of these cases were associated with ENS, which makes this case so interesting. The patient described ultimately underwent management similar to that given to an ENS sufferer: nasal douching and aggressive moisturisation of the intranasal mucosa. In combination with psychiatric management, the patient improved dramatically fast, considering the long preceding history. Importantly, this paper highlights not only the as yet unreported association of rhinotillexomania with ENS, but that it should be managed with a multidisciplinary approach involving, in particular, our psychiatric colleagues. At the very least this paper will remind all ENT surgeons to advise patients to stop picking their nose. Those of us who are also parents might, in addition, become even more vigilant with our children.

Rhinotillexomania manifesting as Empty Nose Syndrome.
Tranchito E, Chhabra N.
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Lucy Dalton

QEH Birmingham, UK.

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