Abstract
Management of vestibular stenosis is always a challenge in rhinology, especially for patients with complete vestibular stenosis. Tip plasty (with columella strut) can be supplemented to the primary surgery, can ensure good functional and cosmetic outcomes in patients with complete vestibular stenosis.
Introduction
Nasal stenosis is a significant complication that can be resulted due to infection, burns, or after an iatrogenic trauma. It happens mostly due to the loss of vestibular lining because of scar contracture or direct injury to the lobule-ala-columella complex [1, 2]. Later can results in decreased nasal patency and deformity of the nasal tip due to fibrosis [3]. Surgical excision is usually offered as the primary modality of treatment to patients with vestibular stenosis to restore the functional and aesthetic effects of the nostril [4]. Various surgical techniques and use of different regional flaps have been described in the past for the effective reconstruction of the vestibular stenosis resulting in variable outcomes [5]. Despite that, it is always challenging to give both functional and cosmetic outcomes in patients presenting with complete vestibular stenosis. The later could be due to the weak and thin lower lateral cartilages [6], which are more vulnerable for the tractional force to fibrosis in the postoperative period, resulting in under projection of the nasal tip and restenosis. Hence, strengthening the medial crus of lower lateral cartilage with columellar strut can be a complementary step to the stenosis release to prevent restenosis in the postoperative periods in patients with recurrent and complete vestibular stenosis. In the present case, we have highlighted the utility of the tip plasty (with Columellar strut) in preventing restenosis in a patient presenting with complete vestibular stenosis.
Material and Methods
A 14-year-old child presented to the Department of Otolaryngology with complete nasal obstruction (Right side) for 6 months. The patient had a history of thermal injury during the excision of nasal Rhinosporidiosis in a peripheral hospital 6 months back. After 7 days in the postoperative period, the patient developed stenosis of the right vestibule, for which he was operated three times before coming to our hospital. During the treatment, he developed complete vestibular stenosis, significantly compromising the functional and aesthetic of the nose (Fig. 1). On examination, complete stenosis nose with organized fibrosis was detected in the right vestibule with the complete absence of the nasal patency.
Fig. 1.
Shows complete vestibular stenosis (Right side) with under projected nasal tip
The tip was found to be under projected with a pliable nasal tip. Diagnostic nasal endoscopy of the left nasal cavity was found normal. Non-contrast CT scan of the nose and paranasal sinus revealed soft tissue density in the right nasal cavity with normal paranasal sinuses. After the written and informed consent of the patient was planned for the elective surgery under general anaesthesia. Complete excision of the vestibular scar was performed with coblation, and the vestibular lumen was adequately widened comparing with the contralateral side. Then transcollumelar and marginal incisions were made in both sides of the nasal cavity. The soft tissue was elevated over the perichondrium, completely exposing the alar and the upper lateral cartilage. The septal cartilage was exposed after the elevation of the muco-perichondrial flap on the left side. Septal cartilage (25 mm × 10 mm) was harvested, preserving 10 mm of the dorsal and caudal rim. A pocket was made between the medial crura and later strengthened with the columellar strut harvested from the cartilaginous septum. Intradomal and intermodal sutures were placed to augment the nasal tip (Fig. 2). Mitomycin C was applied over the fresh wound in the right vestibule, which was kept for 5 min. Custom-made stents from endotracheal tube (8 mm diameter) was inserted in both the nasal cavity after careful measurement of the defect (Fig. 3). The incision was closed after maintaining complete hemostasis. The patient was discharged 24 h after the surgery. He is on close follow-up in the rhinology clinic for the past six months after surgery and was found to have adequate nasal patency and good aesthetics (Figs. 4, 5).
Fig. 2.
Placement of columellar strut between two medial crura
Fig. 3.
Insertion of custom-made stents from endotracheal tube (8 mm diameter) in both the nasal cavity
Fig. 4.
Photograph shows vestibular lumen 6 months after the primary surgery
Fig. 5.
Comparison of tip projection before and after the tip plasty
Discussion
Management of vestibular stenosis is always a challenge in rhinology, especially for patients with complete vestibular stenosis. Although partial stenosis can be encountered due to infection and iatrogenic injuries like nasogastric tube placement, nasotracheal intubation, poor surgical technique, and cauterization of the nasal mucosa, complete stenosis is very rare [6]. Stenosis not only creates functional disability to the patients but also significantly affects the aesthetics of the nasal tip due to traction of the healing tissue because of the repeated trauma.
As seen in the present case, the patient had complete stenosis, which could be due to the repeated iatrogenic trauma in the previous surgeries. Again, the lower lateral cartilage in the Asian nose is generally weak and thin [2], which is more susceptible to the tractional force caused by fibrosis. As evident in the present case, along with the stenosis, patients had an under projected nasal tip during the initial presentation to the rhinology clinic. The primary intention of the surgery is mostly aimed at providing adequate lumen for breathing and preventing restenosis in the postoperative period [7]. Various surgical techniques and use of regional flaps have been described in the past for the reconstruction of the vestibular stenosis, resulting in variable outcomes [5]. In the present case, we have used a custom-made stent from the endotracheal tube (No 8), which was placed in the stenosed nose and was kept for six weeks to enhance epithelialization. After maintaining adequate patency in the right nasal cavity, tip plasty was done. Columellar strut was placed between the medial crura, reinforced with intradomal and interdomal sutures. The aim of the tip plasty was directed towards the prevention of vestibular restenosis, and it was a supplemented surgical step along with the primary resection of the stenotic tissue. The postoperative functional and cosmetic outcomes were found quite satisfactory even after 180 days after the primary surgery.
Conclusion
Management of vestibular stenosis is always a challenge in rhinology, especially for patients with complete vestibular stenosis. Tip plasty (with columella strut) can be supplemented to the primary surgery, can ensure good functional and cosmetic outcomes in patients with complete vestibular stenosis.
Declarations
Conflict of interest
There are no conflicts of interest among the authors.
Ethical Approval
No part of the body has been demonstrated in the case report without the permission of the concerned patient.
Human or Animal Rights
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent
Written informed consent has been taken from each patient prior to the surgery and same has been informed to the institute reviewer board.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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