From Stoke Mandeville Hospital, Aylesbury, Bucks.
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1 STENOSIS OF THE NOSTRILS: A REPORT OF THREE CASES By P. S. BAjAJ, M.S., F.R.C.S.(Ed.), F.R.C.S. and B. N. BAILEY, F.R.C.S. From Stoke Mandeville Hospital, Aylesbury, Bucks. ACQUIRED stenosis of the anterior nares is caused by loss of the vestibular lining which may result from infection or trauma. Syphilis, tuberculosis or smallpox may involve the nasal mucosa, while the trauma may be that of burns, lacerations or surgical misadventure. O'Connor in 1937 described in detail the pathogenesis and treatment of this condition. Since then only three cases have been reported in the English literature: one by Shaw (1967) from India and two by Soni (1961) from Burma. It is interesting to note that all three cases developed stenosis of the nostrils following smallpox, which is reported to lead to this condition only occasionally (Barsky et al., 1964). We wish to report three cases seen at Stoke MandeviUe Hospital in a period of less than one year, each resulting from a different cause. Case I.--N.B., aged 5 years, was admitted in November 1967 with stenosis of both nostrils. Chemical cauterisation with trichloracetic acid had been performed in a casualty department to stop epistaxis three months prior to admission. The right nostril was completely blocked and the left one was about one-fourth of its normal size (Fig. I). Scar tissue was excised by inserting the point of a number xi B.P. scalpel and coring out the aperture. The raw surfaces were covered by a split skin graft on a stent mould, and maximum over-correction was attempted. Later the child was fitted with a Perspex prosthesis to maintain the nostrils in their over-corrected position and the mother advised of its constant use. The prosthesis consisted of two linked nostril plugs with holes drilled in them to allow nasal breathing. Unfortunately, the prosthesis was not regularly used after the child was discharged from hospital and when he was seen six weeks post-operatively the right nostril had contracted again to a pinhole. We hoped that the left airway might still be salvaged by regular use of the prosthesis, but when the child came back for review after three months, the prosthesis had been lost. Both the nostrils had contracted down to their pre-operative size. A repeat operative correction has been carried out and this time a prosthesis attached to an upper dental cap splint is being used (Figs. 2 and 3). Case 2.--K.B., aged I I years, an old case of cleft lip and palate, was admitted in October 1967 with a pinhole left nostril (Fig. 4). His cleft lip and anterior palate had been repaired at 2 months and the palate at the age of one year. The left airway was partly obstructed by a fold of mucosa along its lateral wall. A Z-plasty of that fold carried out at the age of 4 years and repeated at 9 years failed to achieve a satisfactory result. Thinning of the lateral wall of the left nostril carried out a year later was not any more successful. The final stenosis was due in part to the natural flattening of the cleft nostril but mainly to repeated surgical interventions. Excision of all the scar tissue and split skin grafting of the raw surface on the inside of the nostril using a stent mould was carried out as in the first case. The nostril was maintained in its dilated position by a prosthesis (worn continuously except for normal cleaning) for six months. Nine months post-operatively the nostril aperture is still well maintained (Fig-. 5)- Case 3.--R.M., aged 15 years, was admitted in February I968 with stenosis of both nostrils following smallpox at the age of 6 while he was in West Pakistan. The left nostril was completely blocked and the right one stenosed to less than half its size (Fig. 6). A similar procedure to the first case was carried out and the patient fitted with a prosthesis. Both nostrils remain satisfactorily dilated six months after the operation and use of the prosthesis has now ceased (Figs. 7 and 8). 269
2 270 BRITISH JOURNAL OF PLASTIC SURGERY FIG. I Pre-operative photograph of Case r. Note complete occlusion of right nostril and stenosis of left nostril. FIGS. 2land 3 Same case three months after the second operative correction.
3 STENOSIS OF THE NOSTRILS 27I DISCUSSION Stenosis occurs in the outer and upper part of the nasal vestibule. This is because the septal cartilage and medial crus of the ala are rigid and provide support while the flaccid alar wing gradually contracts with the formation of scar tissue, obliterating the upper lateral portions of the vestibule. The nasal skin is pulled over the free border of the ala with a rolling effect causing an apparent thickening in that area. Since stenosis is brought about by loss of vestibular lining, the only way to restore the normal aperture is to replace it. We have provided lining by split skin grafts after all the scar tissue has been excised and the opening restored to its original shape. To FrG. 4 FIo. 5 Pre-operative photograph of Case 2. Note pinhole left nostril. Same case nine months after the operation. compensate for the tendency of graft to contract, the nasal openings must be overcorrected and maintained in that position by a prosthesis for six months. O'Connor (r937) described a technique in which a pocket lined by a skin graft is made outside the scarred nostril before it is excised in a serrated manner to avoid ring contracture. Use of a small flap along the medial part of the floor of the nostril has been advocated to keep the graft from being completely annular (Barsky et al, I964). This flap is fashioned from the obstructive curtain of the nostril. In a severe case of stenosis several factors militate against flap manipulations. I. If the obstructing web is due to a genuine excess of tissue, Z-plasty may effect a cure, but when the constriction is due to shortage of tissue, Z-plasty can never increase the amount of lining. 2. Placing of sutures to obtain perfect inlaying of flaps is almost impossible in these small nostrils unless their alar bases and columeua are separated from the face, and this procedure may make matters worse. 3. The tiny stiff flaps which must be transposed through 9 0 to break the" constricting ring" may or may not survive, much less sit comfortably. If they do not heal by
4 272 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 6 Pre-operative photograph of Case 3Note complete occlusion of left nostril and stenosis of right one. Fins. 7 and 8 Same case six months after the operation.
5 STENOSIS OF THE NOSTRILS 273 first intention, the raw area cicatrises and a vicious circle of (edema, fibrosis and scar contraction starts. 4- Tissue shortage must be treated by tissue replacement, and since a complete flap to line the vestibule tends to occlude its own orifice a graft must be used. 5- Split skin is the ideal resurfacing medium in a potentially infected cavity. Close contact and avoidance of ha:matoma formation will ensure IOO per cent. take. The natural tendency of grafts to contract is reduced at the end of six months but probably does not disappear completely for years. Over-correction should be maintained continuously for six months with the prosthesis removed only for the few seconds necessary to wash the nostril and the prosthesis. After six months night use only is suggested. As long as the prosthesis slips in easily it can be kept in reserve, but if there is any sign of difficulty its continuous use should be re-instituted. Over-correction is desirable in a child for there is little chance that even the softest and non-contracted graft will keep pace with surrounding development while it lines a concave surface. Full thickness skin has been used to cover the raw area in stenosis following excessive removal of the vestibular lining (Converse, 1964). This is supported by a small acrylic shell-like prosthesis worn inside the vestibule for long periods and even permanently. The Wolfe graft is less reliable than the Thiersch graft in obtaining IOO per cent. take, and both require prostheses. Whatever technique is used the crux of the problem is the use of a prosthesis. In the first case the child's parents did not realise the importance of constant use of the prosthesis, and rapid return of the stenosis occurred despite early correction. Cases 2 and 3 were co-operative and show excellent results. SUMMARY Three cases of stenosis of nostrils are reported. One of them was due to cicatrisation following chemical burns, the second one resulted from fibrosis following repeated surgical procedures on his left nostril, and the third was a sequel of smallpox. Treatment by excision of scar tissue and Thiersch grafting is described. The importance of the use of prosthesis to maintain the nostrils in an over-corrected position in the post-operative period is stressed. REFERENCES BARSKY, A. J., KAHN, S. and BERNARD, E. W. (1964). "Principles and Practice of Plastic Surgery". New York: Mccaraw-Hill. CONVERSE, J. M. (1967). "Reconstructive Plastic Surgery," Vol. II. Philadelphia: Saunders. O'CONNOR, B. Ca. (1947). Archs Otolar. 25, 208. SHAW, J. S. (1967). Plastic reconstr. Surg. 39, 57. SONI, R. L. (I961). Burma Ivied. J. 9, 179.
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