Introduction

Cornu cutaneum or cutaneous horn is a relatively uncommon clinical entity consisting of a compacted hyperkeratosis over a hyperproliferative lesion and it resembles an animal horn1. The base of the lesion may be flat, nodular or crateriform. Cutaneous horn most often arises on the sun-exposed skin surface in elderly men, usually after fifth decade2. The lesion is found on scalp, face, pinna, eyelids, nose, neck, shoulders, hands and penis. The possibility of malignancy at the base of the lesion increases in men when compared with the age-matched women. Various histological variants have been documented at the base of the keratin mound therefore histopathological confirmation is often necessary to rule out benign, premalignant and malignant changes.

Case report

A 32 year old female house wife with fair complexion attended the ENT out patient department with complains of projectile mass from the left nostril (Fig.1) associated with pain and a sense of embarrassment since 8 months duration. There was no history of epistaxis or respiratory obstruction.

Figure 1

Figure 1: Rhino cutaneous horn

The clinical examination showed a hard keratotic conical mass protruding from the left nostril, painful on palpation. On careful anterior rhinoscopy a sessile mass was seen arising from the lateral wall of the vestibule about one cm. from the free margin. No such lesion was detected in the right nostril or other parts of the body. Examination of the neck did not reveal any clinical positive lymph nodes. The mass was clinically diagnosed as Rhino cutaneous horn from a sun-protected area of the vestibule of the left nostril. The lesion was excised (Fig.2) under local anesthesia after infiltrating the surrounding area of the lesion with 1:200,000 adrenline in xylocain with sufficient depth and safety margin. There was a minimal; bleeding and the defect was closed primarily by undermining the margins with 3-0 silk. An anterior nasal dressing with ribbon gauge impregnated with Fusidin(R) (sodium fusidate BP 20mg) ointment was done and a bolster applied. The patient was given an injection of Voltran(R) (diclofanic sodium) 75 mg. I/M and advised to take tablet of Voltran three times a day after meals for a period of two days. The anterior nasal pack was removed after 48 hours and thereafter only Fucidin ointment was applied locally for 5 days. The stitches were removed on day 5. Follow up period was uneventful without signs of recurrence. The histopathological examination showed squamous epithelial cells with keratine debris indicating a benign lesion.

Figure 2

Figure 2: Excised specimen

Discussion

Rhino cutaneous horn consist of a superficial hyperkeratosis over a hyperproliferative skin lesion resembling an animal horn. But the difference between animal horns is the presence of a central bone which is not seen in cutaneous horns in human beings. The earliest well documented case of cornu cutaneum from London in 1588 is of Mrs. Margaret Gryffith, an elderly Welsh woman. A showman, who advertised it in a pamphlet, exhibited her for money. However, earliest observations on cutaneous horns in humans were described by the London surgeon Everard Home in 17913. Farris from Italy first described the gigantic horn in man as a well documented a case report with adequate histology4. According to a largest study by Yu et al,5 61% of cutaneous horns were derived from benign lesions and 39% were derived from malignant or premalignant epidermal lesions. The important consideration in these cases is not the horn, but the underlying pathology which may be benign (seborrheic keratosis, viral warts, histiocytoma, inverted follicular keratosis, verrucous epidermal nevus, molluscum contagiosum, etc.), premalignant (solar keratosis, arsenical keratosis, Bowen's disease) or malignant (squamous cell carcinoma, rarely, basal cell carcinoma, metastatic renal carcinoma, granular cell tumor, sebaceous carcinoma or Kaposi's sarcoma6 Histopathological examination, specially of the base of the lesion7,8is necessary to rule out associated malignancy and full excision and reconstruction whenever required is the treatment of choice.

Conclusion

Cutaneous horn is a rare clinical diagnosis and is frequently seen over the sun-exposed skin surface but is rarely present in the sun-protected site. Although 2/3rd cases are benign the rest are premalingant and malignant may require an aggressive management.

Correspondence to

Dr Rajesh Associate Professor Himalayan Institute of Medical Sciences, Jollygrant, Dehradun, Uttranchcal India E mail - drrajeshent@rediffmail.com