A 43-year-old woman, who had previously undergone prior surgery for a subungual glomus tumor on the fourth finger of the right hand with the same technique described below, but without preoperative ultrasound, attended the clinic with intense paroxysmal pain. The clinical examination was normal, with no evidence of recurrence of the subungual glomus tumor (Fig. 1A). A skin ultrasound with an 18MHz transducer was performed and tumor recurrence was detected in the nail bed. The tumor measured 3.1mm in diameter (Fig. 1B). Prior to surgery, the tumor was localized by ultrasound and the nail plate was marked using a homemade guide (Fig. 2A). For this, the ultrasound transducer was oriented longitudinally with respect to the nail apparatus and the ultrasound guide was introduced perpendicular to the transducer to generate a comet tail reverberation that would hide the tumor (Fig. 2B). At this point, we kept the ultrasound guide fixed, withdrew the transducer, and marked the nail plate (Fig. 2C).

Figure 1.

A, Normal clinical examination. B, B-mode ultrasound shows a well-defined, solid hypoechoic lesion with an oval form and regular borders measuring 3.1mm in diameter.

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Figure 2.

A, Homemade metallic ultrasound guide. B and C, Use of comet tale reverberation to create an ultrasound guide for preoperative localization.

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Subsequently, after peripheral nerve block anesthesia of the finger with mepivacaine 2%, minimally invasive surgery was performed with removal of the nail plate using a 5mm punch, tumor excision with 4mm punch, dissection with a no. 15 scalpel, electrocoagulation of the nail bed, and induction of hemostasis with Gelita and Monsel solution (ferric subsulfate 20%). Histological study confirmed diagnosis of glomus tumor recurrence. The outcome of surgery was favorable. Pain resolved after the procedure and no evidence of tumor persistence was detected by ultrasound (Fig. 3A-D).

Figure 3.

A, Outcome immediately after surgery. B, Ultrasound confirmation of tumor resolution. C, Clinical outcome 2 weeks after surgery. D, Ultrasound confirmation 2 weeks after tumor excision.

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The technique is suitable for treating subungual glomus tumors of difficult clinical preoperative localization or recurrent tumors. The procedure should be used preferably for small tumors (<3mm) with a distal subungual location, thus avoiding the classic transungual approach with a high risk of oncydystrophy.4 This approach is simple and less traumatic. A drawback of the technique to highlight is that the lesion cannot be well visualized during surgery compared with a transungual approach. With this technique, use of preoperative ultrasound and marking the exact site of the tumor on the nail plate with a guide avoided having to perform the surgery blind.