ILLNESS ANXIETY DISORDER NOSE NO LIMITS: A CASE OF RHINOTILLEXOMANIA

Abstract

Background: Rhinotillexomania is defined as a pathological and compulsive nose-picking behavior. Rhinotillexomania is a form of body-focused repetitive behavior that has the potential to cause destruction to the nasal structures, palate, or orbital wall. Multiple psychiatric diagnoses may be comorbid with rhinotillexomania.

Case presentation: A woman in her 60s presented with a midline sinonasal destructive lesions. Her medical work-up ruled out sinister etiology. Endoscopic imaging revealed her using a cotton swab to palpate her Eustachian tube orifices, the face of the sphenoid sinus, the posterior limit of her inferior turbinate, the anterior and superior limit of the septal perforation, and the ulcerated lesion on her anterior skull base. Biopsy found granulation tissue and foreign body giant cell reaction to foreign material consistent with cotton fibers. In a psychiatric interview, the patient reported experiencing a chronic sensation of fullness and discomfort in her nose. She had long been concerned her symptoms were caused by either a cancer or a fungal infection which she worried would invade her eyes and potentially also her brain. She described compulsively checking her nose in the mirror and searching the internet for potential diagnoses. She reported rinsing her nose multiple times per day and using cotton swabs and bobby pins to manipulate her nose to scrape the septal wounds in order to remove possible cancer or fungal involvement. She was diagnosed with illness anxiety disorder and rhinotillexomania. To help her, cognitive behavioral therapy was recommended as well as treatment with duloxetine.

Conclusions: This is a biopsy-proven case of rhinotillexomania secondary to illness anxiety disorder. The following case illustrates the importance of a careful psychiatric evaluation to properly diagnose and treat the comorbid psychiatric disorders that occur in the context of rhinotillexomania.

Full text

ILLNESS ANXIETY DISORDER
NOSE NO LIMITS:
A CASE OF
RHINOTILLEXOMANIA
Javier Ortiz Orendain, MD1, Christopher Low,
MD2, Kristin Somers, MD1, FACLP, Erin O’Brien,
MD2 1Division of Psychiatry and Psychology,
2Division of ENT
Background: Rhinotillexomania is defined as a
pathological and compulsive nose picking
behavior. Rhinotillexomania is a form of body
focused repetitive behavior which has the
potential to cause destruction to the nasal
structures, palate, or orbital wall. Multiple
psychiatric diagnoses may be comorbid with
rhinotillexomania.
Case presentation: A woman in her 60s
presented with a midline sinonasal destructive
lesions. Her medical work-up ruled out sinister
etiology. Endoscopic imaging revealed her
using a cotton swab to palpate her Eustachian
tube orifices, the face of the sphenoid sinus, the
posterior limit of her inferior turbinate, the
anterior and superior limit of the septal
perforation, and the ulcerated lesion on her
anterior skull base. Biopsy found granulation
tissue and foreign body giant cell reaction to
foreign material consistent with cotton fibers. In
psychiatric interview, the patient reported
experiencing a chronic sensation of fullness and
discomfort in her nose. She had long been
concerned her symptoms were caused by either
a cancer or a fungal infection which she worried
would invade her eyes and potentially also her
brain. She described compulsively checking her
nose in the mirror and searching the internet for
potential diagnoses. She reported rinsing her
nose multiple times per day and using cotton
swabs and bobby pins to manipulate her nose to
scrape the septal wounds in order to remove
possible cancer or fungal involvement. She was
diagnosed with illness anxiety disorder and
rhinotillexomania. To help her, cognitive
behavioral therapy was recommended as well
as treatment with duloxetine.
Conclusions: This is a biopsy proven case
of rhinotillexomania secondary to illness anxiety
disorder. The following case illustrates the
importance of a careful psychiatric evaluation to
properly diagnose and treat the comorbid
psychiatric disorders that occur in the context of
rhinotillexomania.
Rhinotillexomania is defined as a pathological and
compulsive nose picking behavior.
Compulsive nose picking can lead to destructive
lesions as well as expensive evaluations and
surgeries. Psychiatrists should screen for
rhinotillexomania when evaluating patients for
body focused repetitive behaviors..
Figure 2.
Endoscopic image of the patient’s sinonasal cavity
showing inferior turbinates laterally (arrows),
absence of the nasal septum (triangle) and
ulcerated tissue at the anterior skull base
(asterisk). Seen here is the patient voluntarily
demonstrating her method for nasal cleaning with
a cotton swab.
Figure 1.
Hematoxylin and eosin stained tissue section of the
sinonasal lesion biopsy. Ulcerated squamous
mucosa and granulation tissue with necrosis is seen,
along with acute and chronic inflammation, and
foreign body giant cell reaction (pentagon) to
foreign material consistent with cotton fibers
(arrow).