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Pin hole nasal prosthesis: A clinical report
Pin hole nasal prosthesis: A clinical report Vidya Kamalaksh Shenoy, MDS,a Pratheek Shetty, MDS,b and Bhaskar Alva, MS, DIHc College of Dental Surgery and Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India Atrophic rhinitis is a debilitating nasal mucosal disease characterized by foul-smelling discharge of crusts and enlargement of the nasal cavity. Numerous surgical and nonsurgical methods have been advocated for its treatment. This article describes a noninvasive technique for partial occlusion of the dilated nasal cavity in a patient with atrophic rhinitis by use of a pinhole nasal prosthesis made from clear acrylic resin. (J Prosthet Dent 2002;88:359-61.)
A
trophic rhinitis is a chronic nasal disease characterized by progressive atrophy of the nasal mucosa and the underlying bones of the nasal turbinate, accompanied by the formation of foul-smelling thick, dry crusts in the greatly-enlarged nasal cavities.1-2 The disease presents either as a primary condition with periarterial fibrosis and obliterating endarteritis, or secondarily as a result of trauma, nasal surgery, granulomatous disease, infections, or radiation exposure.3,4 The main goal of the treatment is to induce reversibility of the nasal mucosa by reducing the size of the nasal cavity, reducing air entry through the nose, increasing the lubrication of the nasal mucosa, and keeping the nasal cavity clean and moist so that it is free from crusts and fetor. For many years, various medical5,6 and surgical7-9 methods for the treatment of this slowly progressive and disabling disease were attempted. The dominant clinical feature of atrophic rhinitis is a fetid odor emanating from the nose. Fortunately, patients with this condition are anosmic, so they are subjectively unaware of the stench. However, the odor is so offensive that it wreaks havoc on social and marital relationships. The medical management includes the treatment of infection with antibiotics and regular nasal douching with a solution of diluted sodium bicarbonate, sodium chloride, and sodium borate. Alternatively, application of nasal cotton wool tampons soaked in glycerin containing 25% glucose for 24 hours has also been recommended.6 Surgical treatment includes the complete closure of anterior nares by surgical intervention (Young’s operation),7 which causes patient discomfort because of the resultant mouth breathing and nasal voice. Surgery can also result in cosmetic nasal deformity. Another surgical This article was presented at the 29th Indian Prosthodontic Society Annual Conference held at Hyderabad, Andhra Pradesh, India, November 23-25, 2001. a Assistant Professor, Department of Prosthodontics and Maxillofacial Prosthetics, College of Dental Surgery. b Professor, Department of Prosthodontics and Maxillofacial Prosthetics, College of Dental Surgery. c Associate Professor, Department of ENT, Kasturba Medical College. OCTOBER 2002
approach is partial closure of anterior nares leaving a hole of 3 mm in the nostrils for gentle nasal breathing in patients who object to mouth breathing and nasal voice.8 Alar stents made of clear heat-polymerized acrylic resin have been used for the treatment of alar collapse and were reportedly well tolerated.10,11 Internal nares inserts were fabricated with heat-polymerized acrylic resin to restore nasal airways, which were lost after reconstructive nasal surgery for deviated nasal septum. These inserts would restore support for the lateral nasal tissues and allow free passage of air through the nasal cavities. Tissue acceptance of the prosthesis was excellent.10 Breathing was restored within the health and function of the surrounding tissues. The external prosthesis junction was established at the mucocutaneous junction from a cosmetic standpoint, because there is no bridge connecting the 2 sides of the prosthesis. However, this design may result in posterior displacement of the prosthesis. An effective noninvasive method for treating atrophic rhinitis by means of a pinhole nasal prosthesis made of clear acrylic resin is described. The advantages of the stent are that the technique is non-invasive, cost effective, tissue tolerant, esthetic to the patient, comfortable to use, easy to fabricate, and clean. It maintains the patency and the contour of the nasal cavities. The stent is designed with a bridge across columela to prevent its posterior displacement during inhalation.
CLINICAL REPORT A 25-year-old man with atrophic rhinitis was referred to the Department of Prosthodontics, College of Dental Surgery, Mangalore, India. He had undergone surgery 3 years before, but the disease recurred. The patient underwent closure of anterior nares by surgical intervention (Young’s operation) to reduce air entry through the nose, thereby allowing the nasal cilia to rest. However, the surgical treatment resulted in patient discomfort, because he became a mouth breather and developed a nasal voice. The patient presented with discharge of greenish crusts from the nose suggesting the presence of THE JOURNAL OF PROSTHETIC DENTISTRY 359
THE JOURNAL OF PROSTHETIC DENTISTRY
SHENOY, SHETTY, AND ALVA
Fig. 1. A, Intranasal impression with modeling plastic impression compound. B, Extranasal impression, irreversible hydrocolloid reinforced with dental plaster.
infection, foul smell from the nasal cavity, and persistent headache. The headache was likely caused by inflammation of the underlying sinuses. Neurologic or any other medical cause for the headache in the patient was ruled out. Clinical examination revealed enlarged nasal cavities. The patient found it uncomfortable to douche the nose and declined further surgery. Hence, an alternative approach with pinhole nasal prosthesis was undertaken. An impression of the nasal cavity was made with modeling plastic impression compound (Pinacle; Dental Products of India Ltd, Mumbai, India), as the shape of the nasal concha is irregular. Plastic impression compound was stiff, moldable, and did not droop as a result of gravity.12 The prosthesis did not protrude beyond the cartilaginous pyramid of the nose, which is flexible and can accommodate the rigidity of the prosthesis. However, the modeling plastic impression compound had to be meticulously inserted, taking care not to damage the nasal mucosa. The compound was softened, molded into a cylindrical core of approximate length of the nasal cavity, and inserted into each nasal vestibule of the patient.10 A band of material was left across the columela to join the 2 sides (Fig. 1, A). An impression of the external nasal region was made with irreversible hydrocolloid (Imprint; Dental Products of India Ltd) reinforced with dental plaster (Fig. 1, B). The impression was removed (Fig. 2) and poured in dental stone. The prosthesis was waxed to form and evaluated on the patient to verify the fit. The wax form was processed in heat polymerizing clear acrylic resin (DPI-heatcure; Dental Products of India Ltd). A hole was drilled through the prosthesis to provide an airway followed by trimming and polishing (Fig. 3, A). The prosthesis was inserted into the nasal vestibule (Fig. 3, B) and the patient was instructed to wear it continuously, removing it only for a short period 360
Fig. 2. Retrieved intranasal impression.
of time for cleaning. The prosthesis was designed with a smooth outer surface for comfort and to prevent injury to the nasal mucosa. A 3-mm hole was drilled in the prosthesis to provide an airway for partial closure of the nasal cavity, as bilateral complete nasal closure was not well tolerated by the patient. The device was long enough to cover only the cartilaginous pyramid of the nose. The prosthesis had a bridge across the nasal columela to connect both sides to prevent its accidental posterior displacement and possible inhalation. Fabrication requirements of the prosthesis were biologic compatibility and tissue tolerance, made of inert and nontoxic substances. The device needed a smooth external surface that to prevent injury to the nasal mucosa and the growth of microorganisms. Easy removal, simple cleaning with soap and water, and durability were essential. Sedatives and antihistamines prescribed for atrophic rhinitis were discontinued. The patient was examined 2 VOLUME 88 NUMBER 4
SHENOY, SHETTY, AND ALVA
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. A, Processed intranasal prosthesis. B, Pinhole intranasal prosthesis in situ.
months later. The nasal cavities were clean and reduced in size with an absence of crusts and the associated foul odor. Tissue tolerance of the prosthesis was excellent. Patient had relief from nasal blockage and headache. The patient was disease free at 8 months follow-up.
thesis and resulted in significant relief from symptoms. This is recommended as an effective alternative form of treatment for atrophic rhinitis.
DISCUSSION
1. Zohar Y, Talmi YP, Strauss M, Finkelstein Y, Shvilli Y. Ozena revisited. J Otolaryngol 1990;19:345-9. 2. Weir N, Golding-Wood DG. Scott-Brown’s otolaryngology. 6th ed. Oxford: Butterworth - Heinemann; 1997. p. 4, 8, 26. 3. Moore E J, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol 2001;15:355-61. 4. Ruskin JL. A differential diagnosis and therapy of atrophic rhinitis and ozena. Arch Otolaryngol 1932;15:222-57. 5. Dudley JP. Atrophic rhinitis: antibiotic treatment. Am J Otolaryngol 1987; 8:387-90. 6. Shehata MA. Atrophic rhinitis. Am J Otolaryngol 1996;17:81-6. 7. Young A. Closure of the nostrils in atrophic rhinitis. J Laryngol Otol 1967; 81:515-24. 8. Sinha SN, Sardana DS, Rajvanshi VS. A nine years’ review of 273 cases of atrophic rhinitis and its management. J Laryngol Otol 1977;91:591-600. 9. Shehata M, Dogheim Y. Surgical treatment of primary chronic atrophic rhinitis (an evaluation of silastic implants). J Laryngol Otol 1986;100:803-7. 10. Young JM. Internal nares prosthesis. J Prosthet Dent 1970;24:320-3. 11. Davenport JC, Brain DJ, Hunt AT. Treatment of alar collapse with nasal prostheses. J Prosthet Dent 1981 ;45:435-7. 12. Sykes LM. An interim extraoral prosthesis used for the rehabilitation of a patient treated for osteoradionecrosis of the mandible: a clinical report. J Prosthet Dent 2001;86:130-4.
Surgery and nasal douching have been advocated as the primary treatment modalities for atrophic rhinitis. Surgical intervention in the event of primary atrophic rhinitis induces the reversibility of the nasal mucosa by reducing the size of the nasal cavity, reducing air entry through the nose, and increasing the lubrication of the nasal mucosa. However, surgery may be contraindicated if the patient is medically unfit for surgery or refuses surgical treatment. If there is recurrence after initial surgery, revision surgery is difficult because of exuberant scar/fibrosis tissue in the nasal vestibule. In the event of secondary atrophic rhinitis, nasal douching with an alkaline solution of diluted sodium bicarbonate, sodium biborate, and sodium chloride is often prescribed.6 The purpose of douching is to keep nasal cavities clean from crusts. Nasal douching must be performed twice daily for 6 weeks to provide relief and is uncomfortable to the patient. Treatment with a pinhole nasal prosthesis helps overcome the disadvantages of both surgery and nasal douching. In addition, the pinhole nasal prosthesis reduces the air entry through the nose, thereby providing rest to the nasal cilia and inducing reversibility of the nasal mucosa. It is easy to make, economical, well tolerated by the patients, and esthetically made from clear acrylic resin.
SUMMARY The prosthodontic rehabilitation of a patient with atrophic rhinitis was provided with a pinhole nasal pros-
OCTOBER 2002
REFERENCES
Reprint requests to: DR VIDYA K SHENOY DEPARTMENT OF PROSTHODONTICS COLLEGE OF DENTAL SURGERY MANGALORE ⫺ 575 001 KARNATAKA, INDIA PHONE: 91- 824- 423452 (OFFICE) 91-824-450438 (RES) E-MAIL: [email protected] Copyright © 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 ⫹ 0 10/1/128152
doi:10.1067/mpr.2002.128152
361
A
trophic rhinitis is a chronic nasal disease characterized by progressive atrophy of the nasal mucosa and the underlying bones of the nasal turbinate, accompanied by the formation of foul-smelling thick, dry crusts in the greatly-enlarged nasal cavities.1-2 The disease presents either as a primary condition with periarterial fibrosis and obliterating endarteritis, or secondarily as a result of trauma, nasal surgery, granulomatous disease, infections, or radiation exposure.3,4 The main goal of the treatment is to induce reversibility of the nasal mucosa by reducing the size of the nasal cavity, reducing air entry through the nose, increasing the lubrication of the nasal mucosa, and keeping the nasal cavity clean and moist so that it is free from crusts and fetor. For many years, various medical5,6 and surgical7-9 methods for the treatment of this slowly progressive and disabling disease were attempted. The dominant clinical feature of atrophic rhinitis is a fetid odor emanating from the nose. Fortunately, patients with this condition are anosmic, so they are subjectively unaware of the stench. However, the odor is so offensive that it wreaks havoc on social and marital relationships. The medical management includes the treatment of infection with antibiotics and regular nasal douching with a solution of diluted sodium bicarbonate, sodium chloride, and sodium borate. Alternatively, application of nasal cotton wool tampons soaked in glycerin containing 25% glucose for 24 hours has also been recommended.6 Surgical treatment includes the complete closure of anterior nares by surgical intervention (Young’s operation),7 which causes patient discomfort because of the resultant mouth breathing and nasal voice. Surgery can also result in cosmetic nasal deformity. Another surgical This article was presented at the 29th Indian Prosthodontic Society Annual Conference held at Hyderabad, Andhra Pradesh, India, November 23-25, 2001. a Assistant Professor, Department of Prosthodontics and Maxillofacial Prosthetics, College of Dental Surgery. b Professor, Department of Prosthodontics and Maxillofacial Prosthetics, College of Dental Surgery. c Associate Professor, Department of ENT, Kasturba Medical College. OCTOBER 2002
approach is partial closure of anterior nares leaving a hole of 3 mm in the nostrils for gentle nasal breathing in patients who object to mouth breathing and nasal voice.8 Alar stents made of clear heat-polymerized acrylic resin have been used for the treatment of alar collapse and were reportedly well tolerated.10,11 Internal nares inserts were fabricated with heat-polymerized acrylic resin to restore nasal airways, which were lost after reconstructive nasal surgery for deviated nasal septum. These inserts would restore support for the lateral nasal tissues and allow free passage of air through the nasal cavities. Tissue acceptance of the prosthesis was excellent.10 Breathing was restored within the health and function of the surrounding tissues. The external prosthesis junction was established at the mucocutaneous junction from a cosmetic standpoint, because there is no bridge connecting the 2 sides of the prosthesis. However, this design may result in posterior displacement of the prosthesis. An effective noninvasive method for treating atrophic rhinitis by means of a pinhole nasal prosthesis made of clear acrylic resin is described. The advantages of the stent are that the technique is non-invasive, cost effective, tissue tolerant, esthetic to the patient, comfortable to use, easy to fabricate, and clean. It maintains the patency and the contour of the nasal cavities. The stent is designed with a bridge across columela to prevent its posterior displacement during inhalation.
CLINICAL REPORT A 25-year-old man with atrophic rhinitis was referred to the Department of Prosthodontics, College of Dental Surgery, Mangalore, India. He had undergone surgery 3 years before, but the disease recurred. The patient underwent closure of anterior nares by surgical intervention (Young’s operation) to reduce air entry through the nose, thereby allowing the nasal cilia to rest. However, the surgical treatment resulted in patient discomfort, because he became a mouth breather and developed a nasal voice. The patient presented with discharge of greenish crusts from the nose suggesting the presence of THE JOURNAL OF PROSTHETIC DENTISTRY 359
THE JOURNAL OF PROSTHETIC DENTISTRY
SHENOY, SHETTY, AND ALVA
Fig. 1. A, Intranasal impression with modeling plastic impression compound. B, Extranasal impression, irreversible hydrocolloid reinforced with dental plaster.
infection, foul smell from the nasal cavity, and persistent headache. The headache was likely caused by inflammation of the underlying sinuses. Neurologic or any other medical cause for the headache in the patient was ruled out. Clinical examination revealed enlarged nasal cavities. The patient found it uncomfortable to douche the nose and declined further surgery. Hence, an alternative approach with pinhole nasal prosthesis was undertaken. An impression of the nasal cavity was made with modeling plastic impression compound (Pinacle; Dental Products of India Ltd, Mumbai, India), as the shape of the nasal concha is irregular. Plastic impression compound was stiff, moldable, and did not droop as a result of gravity.12 The prosthesis did not protrude beyond the cartilaginous pyramid of the nose, which is flexible and can accommodate the rigidity of the prosthesis. However, the modeling plastic impression compound had to be meticulously inserted, taking care not to damage the nasal mucosa. The compound was softened, molded into a cylindrical core of approximate length of the nasal cavity, and inserted into each nasal vestibule of the patient.10 A band of material was left across the columela to join the 2 sides (Fig. 1, A). An impression of the external nasal region was made with irreversible hydrocolloid (Imprint; Dental Products of India Ltd) reinforced with dental plaster (Fig. 1, B). The impression was removed (Fig. 2) and poured in dental stone. The prosthesis was waxed to form and evaluated on the patient to verify the fit. The wax form was processed in heat polymerizing clear acrylic resin (DPI-heatcure; Dental Products of India Ltd). A hole was drilled through the prosthesis to provide an airway followed by trimming and polishing (Fig. 3, A). The prosthesis was inserted into the nasal vestibule (Fig. 3, B) and the patient was instructed to wear it continuously, removing it only for a short period 360
Fig. 2. Retrieved intranasal impression.
of time for cleaning. The prosthesis was designed with a smooth outer surface for comfort and to prevent injury to the nasal mucosa. A 3-mm hole was drilled in the prosthesis to provide an airway for partial closure of the nasal cavity, as bilateral complete nasal closure was not well tolerated by the patient. The device was long enough to cover only the cartilaginous pyramid of the nose. The prosthesis had a bridge across the nasal columela to connect both sides to prevent its accidental posterior displacement and possible inhalation. Fabrication requirements of the prosthesis were biologic compatibility and tissue tolerance, made of inert and nontoxic substances. The device needed a smooth external surface that to prevent injury to the nasal mucosa and the growth of microorganisms. Easy removal, simple cleaning with soap and water, and durability were essential. Sedatives and antihistamines prescribed for atrophic rhinitis were discontinued. The patient was examined 2 VOLUME 88 NUMBER 4
SHENOY, SHETTY, AND ALVA
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. A, Processed intranasal prosthesis. B, Pinhole intranasal prosthesis in situ.
months later. The nasal cavities were clean and reduced in size with an absence of crusts and the associated foul odor. Tissue tolerance of the prosthesis was excellent. Patient had relief from nasal blockage and headache. The patient was disease free at 8 months follow-up.
thesis and resulted in significant relief from symptoms. This is recommended as an effective alternative form of treatment for atrophic rhinitis.
DISCUSSION
1. Zohar Y, Talmi YP, Strauss M, Finkelstein Y, Shvilli Y. Ozena revisited. J Otolaryngol 1990;19:345-9. 2. Weir N, Golding-Wood DG. Scott-Brown’s otolaryngology. 6th ed. Oxford: Butterworth - Heinemann; 1997. p. 4, 8, 26. 3. Moore E J, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol 2001;15:355-61. 4. Ruskin JL. A differential diagnosis and therapy of atrophic rhinitis and ozena. Arch Otolaryngol 1932;15:222-57. 5. Dudley JP. Atrophic rhinitis: antibiotic treatment. Am J Otolaryngol 1987; 8:387-90. 6. Shehata MA. Atrophic rhinitis. Am J Otolaryngol 1996;17:81-6. 7. Young A. Closure of the nostrils in atrophic rhinitis. J Laryngol Otol 1967; 81:515-24. 8. Sinha SN, Sardana DS, Rajvanshi VS. A nine years’ review of 273 cases of atrophic rhinitis and its management. J Laryngol Otol 1977;91:591-600. 9. Shehata M, Dogheim Y. Surgical treatment of primary chronic atrophic rhinitis (an evaluation of silastic implants). J Laryngol Otol 1986;100:803-7. 10. Young JM. Internal nares prosthesis. J Prosthet Dent 1970;24:320-3. 11. Davenport JC, Brain DJ, Hunt AT. Treatment of alar collapse with nasal prostheses. J Prosthet Dent 1981 ;45:435-7. 12. Sykes LM. An interim extraoral prosthesis used for the rehabilitation of a patient treated for osteoradionecrosis of the mandible: a clinical report. J Prosthet Dent 2001;86:130-4.
Surgery and nasal douching have been advocated as the primary treatment modalities for atrophic rhinitis. Surgical intervention in the event of primary atrophic rhinitis induces the reversibility of the nasal mucosa by reducing the size of the nasal cavity, reducing air entry through the nose, and increasing the lubrication of the nasal mucosa. However, surgery may be contraindicated if the patient is medically unfit for surgery or refuses surgical treatment. If there is recurrence after initial surgery, revision surgery is difficult because of exuberant scar/fibrosis tissue in the nasal vestibule. In the event of secondary atrophic rhinitis, nasal douching with an alkaline solution of diluted sodium bicarbonate, sodium biborate, and sodium chloride is often prescribed.6 The purpose of douching is to keep nasal cavities clean from crusts. Nasal douching must be performed twice daily for 6 weeks to provide relief and is uncomfortable to the patient. Treatment with a pinhole nasal prosthesis helps overcome the disadvantages of both surgery and nasal douching. In addition, the pinhole nasal prosthesis reduces the air entry through the nose, thereby providing rest to the nasal cilia and inducing reversibility of the nasal mucosa. It is easy to make, economical, well tolerated by the patients, and esthetically made from clear acrylic resin.
SUMMARY The prosthodontic rehabilitation of a patient with atrophic rhinitis was provided with a pinhole nasal pros-
OCTOBER 2002
REFERENCES
Reprint requests to: DR VIDYA K SHENOY DEPARTMENT OF PROSTHODONTICS COLLEGE OF DENTAL SURGERY MANGALORE ⫺ 575 001 KARNATAKA, INDIA PHONE: 91- 824- 423452 (OFFICE) 91-824-450438 (RES) E-MAIL: [email protected] Copyright © 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 ⫹ 0 10/1/128152
doi:10.1067/mpr.2002.128152
361