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Nasal vestibular stenosis after birth trauma during caesarean section
International Journal of Pediatric Otorhinolaryngology Extra (2009) 4, 165—168
www.elsevier.com/locate/ijporl
CASE REPORT
Nasal vestibular stenosis after birth trauma during caesarean section§ Jagdeep S. Thakur a,*, Vijay K. Diwana b, Anamika Thakur c a
Department of Otolaryngology - Head & Neck Surgery, I. G. Medical College, Shimla, HP 171001, India Department of Plastic & Reconstructive Surgery, I. G. Medical College, Shimla, HP 171001, India c Department of Pharmacology, I. G. Medical College, Shimla, HP 171001, India b
Received 7 October 2008; received in revised form 28 November 2008; accepted 2 December 2008 Available online 9 January 2009
KEYWORDS Nose; Vestibule; Stenosis; Caesarean section; Complication
Summary Introduction: Iatrogenic trauma includes injury due to intubation, trauma during nasal examination, management of epistaxis or surgery of nose. As the maternal and child care is improving, the iatrogenic trauma during child birth is becoming very rare. We present a unique case that had nasal vestibular stenosis due to injury during caesarian section. As the treatment of vestibular stenosis is difficult, we reviewed the literature for the management of vestibular stenosis and present our surgical technique for managing this particular case. Patient and surgical method: A two and half year male child was brought to our department with complaint of left nostril obstruction since birth. The child had received multiple cut injuries on the face at the time of lower segment caesarian section of the mother at a peripheral hospital. This deformity was corrected by surgery and nasal stent. Discussion: We searched ‘Pubmed’ and ‘Scopus’ with no keywords limit and found only one case of iatrogenic nasal deformity due to birth trauma in English literature. The surgical correction of vestibular stenosis is very difficult due to small surgical field and high recurrence rate. There are number of techniques described in the literature for correction of vestibular stenosis. We reviewed them and compared our experience in managing this deformity. Conclusion: The very initial management in terms of proper suturing of flaps and nasal stents or referral to a specialist following nasal trauma can avoid this type of deformity. We concluded that the management of vestibular stenosis is very difficult and the result of surgery is influenced by not only the surgical technique but also by cooperation of the patient and family members. # 2008 Elsevier Ireland Ltd. All rights reserved.
Introduction §
All the authors stated above have participated sufficiently in the conception and design of the work, in the analysis of the data and in writing the manuscript to take public responsibility for it. * Corresponding author. Tel.: +91 177 2883444 (Off)/91 177 2800224 (Res). E-mail addresses: [email protected], [email protected] (J.S. Thakur).
Nose is one of the most important aesthetic unit of the face. However due to its projection, it is the most common anatomical structure of face to get injured. Nasal fractures and deviated nasal septum are common examples of trauma. Alar and
1871-4048/$ — see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2008.12.001
166
J.S. Thakur et al.
collumella generally escape injury due to their elasticity but sharp or lacerated injuries lead to disfigurement of the nose and disruption of normal physiology of respiration. Trauma to nose can be due to birth, assault, fall, games, infections, burns or iatrogenic. Birth trauma is well known for deviated nasal septum and is due to disproportionate fetal head and vaginal canal. Iatrogenic trauma includes injury due to intubation, trauma during nasal examination, management of epistaxis or surgery of the nose. As the maternal and child care is improving, the iatrogenic trauma during child birth is becoming very rare. We have found (Pubmed and Scopus search with no keywords limit) only one case [1] of iatrogenic nasal deformity due to birth trauma in English literature. We present a unique case that had nasal vestibular stenosis due to injury during caesarian section. This is the first case to be reported with this mode of injury. As the treatment of vestibular stenosis is difficult, we reviewed the literature for the management of vestibular stenosis and present our surgical technique for managing this particular case.
Patient and surgical method On 25 October 2007, a two and half year male child was brought to our department with complaint of left nostril obstruction since birth. The child had received multiple cut injuries on the face at the time of lower segment caesarian section of the mother at a peripheral hospital. The child did not have any surgical intervention and the wound was allowed to heal by secondary intention. On examination (Fig. 1), there were multiple scars on the face. One scar on the nose extended from the base of the collumella circumferentially and then
Fig. 1 nose.
Left vestibular stenosis and cut marks on the
towards floor of the left nostril and left alar base. Another scar was extending downwards from the tip of the nose and meeting the first scar at collumellar base. There were multiple superficial scars, one on the dorsum of the nose and two on the forehead. The anterior hygroscopic test was almost absent on the left side. The left nostril had a very small opening and hence anterior rhinoscopic examination was not possible. The complete heamogram, biochemistry and X-ray paranasal sinus were found to be normal. A reconstructive surgery was planned under general anesthesia.
Surgical technique Under general anesthesia, an incision was made on the first scar present on the collumellar base. The collumellar flap was raised upwards and then this incision was extended on the inner side of collumella on left side towards tip, like hemi-transfixion incision. Now the flap was raised further and we found that cartilage was not involved by scar tissue. The left nasal cavity was found normal. Multiple incisions were made on the inner side of the flap so as to lax this part of the flap. Now this flap was repositioned on the collumella and nostril so as to have normal patency of the left nostril. The collumellar end of the flap was sutured with vicryl 4-0 while inner side of the flap was reinforced by splint made of a suction catheter. The patient recovered well and discharged. After 6 weeks, patient reported with complete occlusion of the nostril (Fig. 2) and it was found that parents were not regular in keeping nasal stent in child. A revision surgery was planned similar to ‘Double crossplasty’ [2] as patient had complete occlusion of the nostril. A custom made acrylic nasal splint was used postoperatively (Fig. 3). Child and parents were encouraged for use of nasal stent for 3 months. Patient was kept on regular follow up and at 10
Fig. 2 Complete left nostril stenosis after 6 weeks of surgery.
Nasal vestibular stenosis after birth trauma
Fig. 3 Postoperative photograph with custom made nasal stent.
months after revision surgery, patient had normal vestibule with mild alar deformity (Fig. 4). The alar deformity had been planned for the correction at later stage (at the age of 18 years), if required.
Discussion Nasal vestibule of children gives a very small area to work for a surgeon. Trauma to this area carries a poor prognosis in terms of healing. The healing in the vestibule is by secondary intention due to presence of limited skin [3] and trauma to the cartilaginous area further add up to the scar tissue and leads to aesthetic disfigurement. In this case, the injury was by a surgical blade during a caesarian section. In ‘Pubmed’ and ‘Scopus’ search, we found that this is the first case of nasal trauma during caesarian section to be reported although injuries to other body parts during caesarian section are well known. As the mother of the patient did not have any hospital record of the caesarian section, we could not find the reason for
Fig. 4 Normal nostril and vestibule after revision surgery.
167 these cuts on the nose and it is assumed that the fetal distress and panicky of surgeon might have been the cause. The surgical correction of vestibular stenosis is very difficult due to small surgical field and high recurrence rate. There was a similarity in our case to the left nasal vestibule stenosis due to a complication of cleft lip repair (unilateral and complete). The repair techniques described above have also been described for the repair of alar narrowing after cleft lip repair. There are number of techniques described in the literature for the repair of nasal vestibular stenosis. The simple technique involves excision of the scarred tissue and application of the split or full thickness graft but due to their (grafts) tendency for secondary contraction, this technique requires nasal stent for a long postoperative period. To overcome this, the use of composite graft has been advocated by many authors. Karen et al. [3] found excellent results by using composite aural graft notably without any nasal stent postoperatively. They had few complications at donor site in terms of hematoma, notching and hypertrophic scar. Jablon and Hoffman [1] reported a case of nasal vestibular stenosis caused by obstetrics’ forceps. They treated this case by a mucosal graft from the hard palate and without any nasal stent. In 1992, Naasan and Page [2] described the ‘double cross plasty’ for the treatment of vestibular stenosis and Tiwari and Sarabahi [4,5] described similar technique for post-burn vestibular stenosis with a name ‘Starplasty’. Salvado and Wang [6] had reported the use of mitomycin C for the correction of vestibular stenosis with good results. Mitomycin C inhibits fibroblast proliferation and collagen synthesis which lead to less scarring. Smith and Roy [7] reported endoscopic lysis of the scar tissue with application of mitomycin C and nasal stents in pediatric patient. In our case, we managed the vestibular stenosis with almost similar technique as double crossplasty but there was failure initially as patient did not use the nasal stent (suction catheter) after discharge from the hospital but after revision surgery, we used a custom nasal stent and encouraged the mother and patient which lead to acceptable result. In the end, it is needless to states that the very initial management in terms of proper suturing of flaps and nasal stents or referral to a specialist following nasal trauma could have avoided this type of deformity. We concluded that the management of the vestibular stenosis is very difficult and the result of surgery is influenced not only by the surgical technique but also by cooperation of the patient and family members.
168
J.S. Thakur et al.
Conflict of interest There are no conflict of interest and no financial funding has been taken by any author.
References [1] J.H. Jablon, J.F. Hoffman, Birth trauma causing nasal vestibular stenosis, Arch. Otolaryngol. Head Neck Surg. 123 (1997) 1004—1006. [2] A. Naasan, R.E. Page, The double cross plasty: a new technique for nasal stenosis, Br. J. Plast. Surg. 45 (1992) 165—168.
[3] M. Karen, E. Chang, M.S. Keen, Auricular composite grafting to repair nasal vestibular stenosis, Otolaryngol. Head Neck Surg. 122 (2000) 529—532. [4] V.K. Tiwari, S. Sarabahi, Starplasty: an ideal method for correction of occluded external nares following burns, J. Plast. Reconstr. Aesthet. Surg. 59 (10) (2006) 1105—1109. [5] M. Sinha, A. Naasan, Correction of nasal stenosis: the double cross plasty, J. Plast. Reconstr. Aesthet. Surg. 60 (12) (2007) 1368—1369. [6] A.R. Salvado, M.B. Wang, Treatment of complete nasal vestibule stenosis with vestibular stents and mitomycin C, Otolaryngol. Head Neck Surg. 138 (2008) 795—796. [7] L.P. Smith, S. Roy, Treatment strategy for iatrogenic nasal vestibular stenosis in young children, Int. J. Pediatr. Otorhinolaryngol. 70 (8) (2006) 1369—1373.
Available online at www.sciencedirect.com
www.elsevier.com/locate/ijporl
CASE REPORT
Nasal vestibular stenosis after birth trauma during caesarean section§ Jagdeep S. Thakur a,*, Vijay K. Diwana b, Anamika Thakur c a
Department of Otolaryngology - Head & Neck Surgery, I. G. Medical College, Shimla, HP 171001, India Department of Plastic & Reconstructive Surgery, I. G. Medical College, Shimla, HP 171001, India c Department of Pharmacology, I. G. Medical College, Shimla, HP 171001, India b
Received 7 October 2008; received in revised form 28 November 2008; accepted 2 December 2008 Available online 9 January 2009
KEYWORDS Nose; Vestibule; Stenosis; Caesarean section; Complication
Summary Introduction: Iatrogenic trauma includes injury due to intubation, trauma during nasal examination, management of epistaxis or surgery of nose. As the maternal and child care is improving, the iatrogenic trauma during child birth is becoming very rare. We present a unique case that had nasal vestibular stenosis due to injury during caesarian section. As the treatment of vestibular stenosis is difficult, we reviewed the literature for the management of vestibular stenosis and present our surgical technique for managing this particular case. Patient and surgical method: A two and half year male child was brought to our department with complaint of left nostril obstruction since birth. The child had received multiple cut injuries on the face at the time of lower segment caesarian section of the mother at a peripheral hospital. This deformity was corrected by surgery and nasal stent. Discussion: We searched ‘Pubmed’ and ‘Scopus’ with no keywords limit and found only one case of iatrogenic nasal deformity due to birth trauma in English literature. The surgical correction of vestibular stenosis is very difficult due to small surgical field and high recurrence rate. There are number of techniques described in the literature for correction of vestibular stenosis. We reviewed them and compared our experience in managing this deformity. Conclusion: The very initial management in terms of proper suturing of flaps and nasal stents or referral to a specialist following nasal trauma can avoid this type of deformity. We concluded that the management of vestibular stenosis is very difficult and the result of surgery is influenced by not only the surgical technique but also by cooperation of the patient and family members. # 2008 Elsevier Ireland Ltd. All rights reserved.
Introduction §
All the authors stated above have participated sufficiently in the conception and design of the work, in the analysis of the data and in writing the manuscript to take public responsibility for it. * Corresponding author. Tel.: +91 177 2883444 (Off)/91 177 2800224 (Res). E-mail addresses: [email protected], [email protected] (J.S. Thakur).
Nose is one of the most important aesthetic unit of the face. However due to its projection, it is the most common anatomical structure of face to get injured. Nasal fractures and deviated nasal septum are common examples of trauma. Alar and
1871-4048/$ — see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2008.12.001
166
J.S. Thakur et al.
collumella generally escape injury due to their elasticity but sharp or lacerated injuries lead to disfigurement of the nose and disruption of normal physiology of respiration. Trauma to nose can be due to birth, assault, fall, games, infections, burns or iatrogenic. Birth trauma is well known for deviated nasal septum and is due to disproportionate fetal head and vaginal canal. Iatrogenic trauma includes injury due to intubation, trauma during nasal examination, management of epistaxis or surgery of the nose. As the maternal and child care is improving, the iatrogenic trauma during child birth is becoming very rare. We have found (Pubmed and Scopus search with no keywords limit) only one case [1] of iatrogenic nasal deformity due to birth trauma in English literature. We present a unique case that had nasal vestibular stenosis due to injury during caesarian section. This is the first case to be reported with this mode of injury. As the treatment of vestibular stenosis is difficult, we reviewed the literature for the management of vestibular stenosis and present our surgical technique for managing this particular case.
Patient and surgical method On 25 October 2007, a two and half year male child was brought to our department with complaint of left nostril obstruction since birth. The child had received multiple cut injuries on the face at the time of lower segment caesarian section of the mother at a peripheral hospital. The child did not have any surgical intervention and the wound was allowed to heal by secondary intention. On examination (Fig. 1), there were multiple scars on the face. One scar on the nose extended from the base of the collumella circumferentially and then
Fig. 1 nose.
Left vestibular stenosis and cut marks on the
towards floor of the left nostril and left alar base. Another scar was extending downwards from the tip of the nose and meeting the first scar at collumellar base. There were multiple superficial scars, one on the dorsum of the nose and two on the forehead. The anterior hygroscopic test was almost absent on the left side. The left nostril had a very small opening and hence anterior rhinoscopic examination was not possible. The complete heamogram, biochemistry and X-ray paranasal sinus were found to be normal. A reconstructive surgery was planned under general anesthesia.
Surgical technique Under general anesthesia, an incision was made on the first scar present on the collumellar base. The collumellar flap was raised upwards and then this incision was extended on the inner side of collumella on left side towards tip, like hemi-transfixion incision. Now the flap was raised further and we found that cartilage was not involved by scar tissue. The left nasal cavity was found normal. Multiple incisions were made on the inner side of the flap so as to lax this part of the flap. Now this flap was repositioned on the collumella and nostril so as to have normal patency of the left nostril. The collumellar end of the flap was sutured with vicryl 4-0 while inner side of the flap was reinforced by splint made of a suction catheter. The patient recovered well and discharged. After 6 weeks, patient reported with complete occlusion of the nostril (Fig. 2) and it was found that parents were not regular in keeping nasal stent in child. A revision surgery was planned similar to ‘Double crossplasty’ [2] as patient had complete occlusion of the nostril. A custom made acrylic nasal splint was used postoperatively (Fig. 3). Child and parents were encouraged for use of nasal stent for 3 months. Patient was kept on regular follow up and at 10
Fig. 2 Complete left nostril stenosis after 6 weeks of surgery.
Nasal vestibular stenosis after birth trauma
Fig. 3 Postoperative photograph with custom made nasal stent.
months after revision surgery, patient had normal vestibule with mild alar deformity (Fig. 4). The alar deformity had been planned for the correction at later stage (at the age of 18 years), if required.
Discussion Nasal vestibule of children gives a very small area to work for a surgeon. Trauma to this area carries a poor prognosis in terms of healing. The healing in the vestibule is by secondary intention due to presence of limited skin [3] and trauma to the cartilaginous area further add up to the scar tissue and leads to aesthetic disfigurement. In this case, the injury was by a surgical blade during a caesarian section. In ‘Pubmed’ and ‘Scopus’ search, we found that this is the first case of nasal trauma during caesarian section to be reported although injuries to other body parts during caesarian section are well known. As the mother of the patient did not have any hospital record of the caesarian section, we could not find the reason for
Fig. 4 Normal nostril and vestibule after revision surgery.
167 these cuts on the nose and it is assumed that the fetal distress and panicky of surgeon might have been the cause. The surgical correction of vestibular stenosis is very difficult due to small surgical field and high recurrence rate. There was a similarity in our case to the left nasal vestibule stenosis due to a complication of cleft lip repair (unilateral and complete). The repair techniques described above have also been described for the repair of alar narrowing after cleft lip repair. There are number of techniques described in the literature for the repair of nasal vestibular stenosis. The simple technique involves excision of the scarred tissue and application of the split or full thickness graft but due to their (grafts) tendency for secondary contraction, this technique requires nasal stent for a long postoperative period. To overcome this, the use of composite graft has been advocated by many authors. Karen et al. [3] found excellent results by using composite aural graft notably without any nasal stent postoperatively. They had few complications at donor site in terms of hematoma, notching and hypertrophic scar. Jablon and Hoffman [1] reported a case of nasal vestibular stenosis caused by obstetrics’ forceps. They treated this case by a mucosal graft from the hard palate and without any nasal stent. In 1992, Naasan and Page [2] described the ‘double cross plasty’ for the treatment of vestibular stenosis and Tiwari and Sarabahi [4,5] described similar technique for post-burn vestibular stenosis with a name ‘Starplasty’. Salvado and Wang [6] had reported the use of mitomycin C for the correction of vestibular stenosis with good results. Mitomycin C inhibits fibroblast proliferation and collagen synthesis which lead to less scarring. Smith and Roy [7] reported endoscopic lysis of the scar tissue with application of mitomycin C and nasal stents in pediatric patient. In our case, we managed the vestibular stenosis with almost similar technique as double crossplasty but there was failure initially as patient did not use the nasal stent (suction catheter) after discharge from the hospital but after revision surgery, we used a custom nasal stent and encouraged the mother and patient which lead to acceptable result. In the end, it is needless to states that the very initial management in terms of proper suturing of flaps and nasal stents or referral to a specialist following nasal trauma could have avoided this type of deformity. We concluded that the management of the vestibular stenosis is very difficult and the result of surgery is influenced not only by the surgical technique but also by cooperation of the patient and family members.
168
J.S. Thakur et al.
Conflict of interest There are no conflict of interest and no financial funding has been taken by any author.
References [1] J.H. Jablon, J.F. Hoffman, Birth trauma causing nasal vestibular stenosis, Arch. Otolaryngol. Head Neck Surg. 123 (1997) 1004—1006. [2] A. Naasan, R.E. Page, The double cross plasty: a new technique for nasal stenosis, Br. J. Plast. Surg. 45 (1992) 165—168.
[3] M. Karen, E. Chang, M.S. Keen, Auricular composite grafting to repair nasal vestibular stenosis, Otolaryngol. Head Neck Surg. 122 (2000) 529—532. [4] V.K. Tiwari, S. Sarabahi, Starplasty: an ideal method for correction of occluded external nares following burns, J. Plast. Reconstr. Aesthet. Surg. 59 (10) (2006) 1105—1109. [5] M. Sinha, A. Naasan, Correction of nasal stenosis: the double cross plasty, J. Plast. Reconstr. Aesthet. Surg. 60 (12) (2007) 1368—1369. [6] A.R. Salvado, M.B. Wang, Treatment of complete nasal vestibule stenosis with vestibular stents and mitomycin C, Otolaryngol. Head Neck Surg. 138 (2008) 795—796. [7] L.P. Smith, S. Roy, Treatment strategy for iatrogenic nasal vestibular stenosis in young children, Int. J. Pediatr. Otorhinolaryngol. 70 (8) (2006) 1369—1373.
Available online at www.sciencedirect.com