Abstract
Introduction
Nasal vestibular stenosis is a rare trauma-related nasal congestion.
Presentation of case
A 52-year-old man complained of right nasal obstruction for 2 weeks caused by hot metal fragments from a gas cylinder explosion 7 weeks before. The patient was diagnosed with right nasal vestibular stenosis due to nasal trauma based on physical examination and CT scan. The patient underwent right nasal vestibular stenosis repair for 2 h without complications. The patient was positioned with the head elevated 20° and received IVFD RD5 therapy at a rate of 1500 mL/day, ceftriaxone 2 × 1 g/day, metamizole 3 × 1 g/day, and ranitidine 2 × 50 mg/day. On the second day, there was no bleeding, pain, or nasal congestion, and an anterior rhinoscopy showed a silicone tube in place. The patient was discharged the same day and started on oral cefixime 2 × 200 mg/day, gentamicin ointment and nasal saline irrigation (NSI) 2 × 100 mL/day for both nostrils. Three months after surgery, the septal stitches and silicone tube were removed and no bleeding was found.
Discussion
The management of vestibular stenosis caused by trauma has a higher success rate than other types of vestibular stenosis. Prompt management plays a crucial role in successfully treating unilateral vestibular stenosis caused by trauma.
Conclusion
Prompt management is highly effective in treating unilateral vestibular stenosis.
Keywords: Nasal congestion, Surgery, Nasal vestibular stenosis
Highlights
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Nasal vestibular stenosis in adults caused by traumatic injury is a rare case.
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Immediate treatment following the identification of stenosis caused by trauma is crucial for successful management.
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The primary focus of stenosis management is to correct existing stenosis and prevent the development of new stenosis and scar tissue.
1. Introduction
Nasal vestibular stenosis is a narrowing in the area of the vestibule, caudal nasal valve, and posterior of the external nares. It may be caused by congenital anomalies, trauma, infection, or iatrogenic factors [1]. Nasal cavity stenosis, especially nasal vestibular stenosis, is a rare condition [2]. The management of nasal vestibular stenosis can be performed using various methods, including scar removal with stent placement, local flap from the surrounding area, split, and full-thickness skin graft with long-term stent placement, as well as composite grafts that can be taken from the earlobe [3]. Surgical procedures can be a challenge due to the tendency for scar contracture and recurrence. Its ability to withstand contraction eliminates the need for postoperative stenting and provides good results [1,4]. This paper aims to report the success of stenting a trauma-related nasal vestibular stenosis. This report follows the Surgical Case Report (SCARE) 2023 guidelines [5].
2. Presentation of case
A 52-year-old man complained of a closed right nostril for 2 weeks. This condition was caused by a hot metal fragment lodged in the patient's right nostril due to a gas cylinder explosion 7 weeks ago. Examination revealed a closed right nostril with a pinhole-sized hole in the center. The left nostril and nasal cavity were within normal limits (Fig. 1). Right vestibular stenosis due to nasal trauma was diagnosed. Computed tomography (CT) of the paranasal sinuses showed an enhancing solid lesion in the cutaneous-subcutaneous area of the right nasal vestibule without extension into the nasal cavity, the paranasal sinuses appeared normal bilaterally, and no fractures were observed (Fig. 2). Repair of the right-sided vestibular stenosis was planned and performed on the sixth week.
Fig. 1.
Condition of the patient's nose.
Fig. 2.
Axial and sagittal CT scan of the paranasal sinuses.
The procedure began with infiltration of the area around the right canal stenosis with Pehakain®. A wire was then passed through the nasal vestibular opening. An incision line was made in the shape of a triangular ellipse with the center at the opening of the stenosis and followed with a triangular elliptical incision. Finally, any scar tissue contractures were separated and removed. The mucosa was sutured to the skin with Vicryl 5/0. Silicone tubes (Nastent®) were inserted into both nostrils and secured to the septum with 2/0 suture (see Fig. 3).
Fig. 3.
Repair stenosis in the right vestibule of the nasal. (a) An iron wire was used to guide the direction of the rice vestibule hole. (b) An elliptical triangular incision line was made with the center at the stenosis hole. (c-d) Scar tissue contracture was separated and removed. (e) The mucosa was sutured to the skin with 5/0 Vicryl. (f) Silicone tubes (Nastent®) were inserted into both nostrils and secured to the septum with lateral 2/0 sutures.
The final results were evaluated, with a blood loss of approximately 10 cc, and the surgical wound was treated with gentamicin ointment. The surgery took 2 h and was uncomplicated. After surgery, the patient was advised to maintain a head elevation of 20°. The patient received IVFD RD5 therapy at a rate of 1500 mL/h, ceftriaxone at a dose of 2 × 1 g/day, metamizole at a dose of 3 × 1 g/day, and ranitidine at a dose of 2 × 50 mg/day. The patients were monitored for discomfort, vital signs, and bleeding. On the second day, there was no bleeding, pain, or nasal congestion. A silicone tube was observed in place during anterior rhinoscopy. The patient was discharged the same day and prescribed cefixime 2 × 200 mg/day orally, gentamicin ointment and nasal saline irrigation (NSI) 2 × 100 mL/day for both nostrils.
On the 8th day after surgery, the patient complained of frequent sneezing. However, there was no nasal bleeding, pain, or sensation of congestion. The patient received NSI therapy and Kenacort® ointment 3×/day. One month after surgery, the patient reported no discomfort, pain, or nasal congestion. The patient received the same therapy as before, but the dosage was increased from 3×/day to 4×/day. Two months after surgery, there was improvement and the therapy was continued. Three months after surgery, the septal stitches and silicone tube were removed and no bleeding was observed (Fig. 4). Cauterization was performed because of granulation in the left nasal cavity. The patient received cefixime therapy at a dose of 2 × 100 mg/day and mefenamic acid at a dose of 3 × 500 mg/day.
Fig. 4.
Three months after surgery. (a) Post silicone tube removal. (b-c) Nasoendoscopy of the right vestibule was airy and granulation of the rice septum was found. (d) Nasoendoscopy of the left vestibule revealed granulation on the nasal septum and caustic was performed.
3. Discussion
Nasal vestibular stenosis is a rare occurrence that can pose challenges in its management. The main challenge is to correct the stenosis without creating new stenosis or scarring, while ensuring patient satisfaction both immediately after surgery and in the long term [1]. The most prominent symptom of vestibular stenosis is nasal congestion. Some reports suggest that nasal trauma may cause vestibular stenosis [6,7]. Vestibular stenosis may occur after direct trauma to the ala nasalis or injury to the vestibular mucosa. Since most of the nasal vestibule consists of fibrofatty or fibromuscular tissue, there is a tendency for healing and scarring to occur, causing this area to contract, and become smoother [6,8].
The diagnosis of vestibular nasal stenosis can be made based on physical examination, including anterior rhinoscopy and endoscopic examination to determine the location and severity of the stenosis. Areas affected by stenosis include the nasal floor, roof, and lateral wall of the vestibule. Complementary examinations such as CT scans can be used to determine the extent of the damage, the location of the stenosis, and potential complications that may arise from vestibular stenosis. A CT scan of the paranasal sinuses can rule out the possibility of a fracture [9]. The management of nasal vestibule stenosis involves repairing the stenosis through incision or resection of scar tissue, followed by support of the scar tissue to prevent contraction. Correction can be difficult because the scar tends to contract and recur. To prevent postoperative contracture and narrowing in rhinoplasty, some surgeons have used nasal stents as a mechanical barrier to scar tissue formation [1,2]. The use of stents is usually combined with a surgical procedure to relieve the stenosis, which is useful in preventing the recurrence of the stenosis. In this case, the stent expand the vestibule or act as a buffer. Stents may also be used temporarily before surgery, especially in cases of incomplete stenosis and congenital anomalies [10].
The primary goal of surgery is the creation of a nostril that will be conducive to the placement of a silicone stent. Ideally, stents are placed immediately after surgery and patients wear them until the tissue has consolidated, typically about 3 months. Stenting helps the scar tissue mature and makes the remodelled scar tissue more pliable [11]. The stabilised tip of the stent is shaped to fit the edge of the nostril, expanding the nostril, vestibule, and lateral nasal wall [2]. Intranasal stenting is a conservative method of expanding nasal tissue and has been reported to successfully maintain nasal diameter in both acquired and congenital nasal stenosis [12].
Trauma-induced vestibular stenosis has a good prognosis, as evidenced by previous case reports in which reconstruction was successful in 100 % of 2 unilateral cases [6]. Other case reports have shown similar findings, suggesting that the cause may be related to pre-existing nasal disease and prompt treatment of nasal vestibular stenosis. Prompt management of nasal vestibular stenosis is crucial for successful repair [13]. The limitation of this case is the low-resource setting and the need for more innovation in the treatment methods and approaches, so we have to search the literature for safe surgical techniques with improved outcomes.
4. Conclusion
Unilateral vestibular stenosis caused by trauma has a high success rate of repair due to the pre-existing airway and prompt treatment. Immediate treatment is critical for successfully managing vestibular stenosis because nasal obstruction is not yet established.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Ethical approval
Ethical approval is exempt/waived at our institution because the report only has one patient.
Funding
Nothing.
Author contribution
Yogi Putra Adhi Pradana: Data curation, investigation, formal analysis, funding acquisition, software, roles/writing - original draft, writing - review & editing; Muhtarum Yusuf: resource, investigation, methodology, project administration, validation; Boedy Setya Santoso: Data curation, investigation, validation, visualisation, supervision.
Guarantor
Yogi Putra Adhi Pradana.
Conflict of interest statement
Yogi Putra Adhi Pradana, Muhtarum Yusuf, and Boedy Setya Santoso declare no conflicts of interest.
Acknowledgements
We would like to thank “Fis Citra Ariyanto”, our editor.
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