| Abstract|| |
Nasal septal perforation is a common complication of many nasal diseases such as congenital, infectious, trauma, and iatrogenic, and rarely may occur as a complication of systemic diseases, etc. The symptoms of uncorrected nasal septal perforations include crusting, epistaxis, difficulty in breathing, nasal twang in speech, postnasal discharge, foul-smelling, rhinorrhea, and hyposmia. Large nasal defects cannot be closed by hard acrylic resin nasal septal obturators because of the problems in access and path of insertion. However, obturation can be achieved by fabrication of a nasal stent that engages one of the nasal cavities. This clinical report describes prosthetic management of a patient with large nasal septal defect following septal surgery complication with an intranasal heat-processed acrylic resin stent. The stent is rendered patent for comfortable breathing, improves speech, is esthetically acceptable, dense and hygienic. These nasal stents indirectly separate the two nasal cavities with effective obturation of large nasal septal defects.
Keywords: Acrylic resin, intranasal stent, nasal cavity, nasal septal defects, nasal septal perforation, nasal stent, obturation
|How to cite this article:|
Goyal MK, Goyal S. Prosthetic rehabilitation of large nasal septal defect with an intranasal stent: A clinical report. Indian J Dent Res 2011;22:719-22
Prosthodontics continues to be an integral part of total patient care in conjunction with other specialties on the medical team. Large nasal septal defect is defined as a defect that exceeds in size a stretched nostril. The etiology of nasal septal perforation is more often due to local factors than systemic complications.  Local complications after septal surgery or intranasal trauma , are among the most common causes of nasal septal perforation. Many patients have previously undergone submucous resection to correct a deviated septum.  Intranasal trauma includes nose picking and the use of cautery or caustic on both sides of the anterior nasal septum to treat epistaxis.  Local exposure to cocaine; irritants like lime, tar, and pitch; calcium nitrate; sulfuric acid; arsenicals; salt; glass; and chromic acid fumes may cause septal perforation. Rarely does nasal septal perforation occur as a complication of some systemic diseases. Systemic lupus erythematosus,  rheumatoid arthritis,  syphilis, tuberculosis, typhoid, and diphtheria are described as some of the underlying systemic diseases causing nasal septal perforation. In the field of rhinology, the symptom complex of septal perforation is one of the most troublesome. The symptom complex of uncorrected nasal septal defects include crusting, episodes of epistaxis, difficulty in breathing, air turbulence, nasal twang in speech, postnasal discharge, foul-smell, rhinorrhea, and hyposmia. ,,,,,
|How to cite this URL:|
Goyal MK, Goyal S. Prosthetic rehabilitation of large nasal septal defect with an intranasal stent: A clinical report. Indian J Dent Res [serial online] 2011 [cited 2020 Jan 21];22:719-22. Available from: http://www.ijdr.in/text.asp?2011/22/5/719/93464
Surgical or mechanical obturation of these defects will help to alleviate the symptoms and will add greatly to the comfort of patient. Attempts at surgical closure have included the use of mucosal flaps, septum shortening, a composite free graft from the anterior end of the middle turbinate and fascia, and free pericranium autografting with cranial periosteum.  The major disadvantage of the surgical closure is a significant breakdown of the repair site. Thus, prosthetic mechanical closure of the anterior nasal septal perforation is the treatment of choice in most of these cases over surgical intervention, especially in cartilaginous perforations with healed nasal margins. This clinical report describes a procedure for fabrication of heat-processed acrylic resin intranasal stent that fits into one of the nasal cavities for the management of a large nasal septal defect. The medial wall of the stent indirectly allows for the partition of the two nasal cavities.
| Clinical Report|| |
0A 25-year-old man with nasal septal perforation was referred to the Department of Prosthodontics, Manipal College of Dental Sciences, Manipal, Karanataka, India, for prosthetic fabrication of nasal stent. He had undergone submucous resection to correct a deviated nasal septum and a minor rhinoplasty procedure to correct alar deformity 6 months back. However, the surgical treatment resulted in nasal septal perforation which caused air turbulence, difficulty in breathing, nasal discharge, nasal voice, and patient discomfort. Patient was kept on hollow rubber tubing to prevent nasal stenosis and to maintain patency of nasal passage, to facilitate partition between two nasal cavities and to enhance nasal breathing after surgery, which was highly uncomfortable, unesthetic to the patient, and difficult to maintain hygiene led to foulsmell. The examination of the nasal defect was done by placing a nasal speculum in one nostril and a lightened otoscope in the other. The extent and configuration of the defect was determined and proper identification of the remaining structures was done before the impression was made. Patient revealed mild inflammation of the nasal mucosa and presented in a stage of healing [Figure 1]. The nasal septal defect was found to be smaller than the stretched nares. The use of a rigid, heat-processed, hollow, intranasal clear acrylic resin stent was considered, which could be inserted in one of the nasal cavities and medial wall of the stent would prosthetically replace the missing part of the nasal septum.
|Figure 1: Post-surgical nasal septal defect with healing nasal mucosa and crusting|
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The septal wall of one of the nasal cavities was blocked with small wetted gauze pieces to prevent engagement of the impression material and easy retrieval. An impression of the opposing nasal cavity was made with high-viscosity putty impression material (Extrude XP; Kerr Corporation, Orange, CA, USA) supported with a polyethylene tube of appropriate diameter and length as the core for the impression. A band of material was left across the columela to enhance the retention of the prosthesis through the alar wings. This impression was relined with light-bodied polyvinyl siloxane impression material (Extrude; Kerr Corporation). During impression making, attempts were made to record only one nasal cavity and only the perimeter of the defect [Figure 2]. It is preferable not to record both sides of the septum in the impression, contrary to the impression technique used to construct nasal septal obturators. However, the impression material had to be meticulously inserted and removed, taking care not to damage the nasal mucosa. The impression was removed and mater cast was poured in a die stone (Kalabhai, Karskarson Pvt. Ltd.). The master die was cut into two pieces with the help of die-cutting saw to evaluate the internal morphology of the nasal cavity [Figure 3]a and b. On the external surface of the master cast, circumferential bevel was created to make prosthesis margins inconspicuous. The prosthesis was waxed carefully by keeping it hollow, and external surface duplicating the internal anatomy of the nasal cavity and external prosthesis junction was established at 2 mm from the mucocutaneous junction from a cosmetic standpoint and this simultaneously prevented posterior displacement of the prosthesis. The waxed form was evaluated on the patient to verify the fit. The waxed form was processed in clear heat-polymerizing acrylic resin (DPI-heat cure, Dental Products of India Ltd.) The alar part of the prosthesis was tinted with oil-based paint (Tri-Star Colman; Tri-Star Creative Products Pvt. Ltd., Noida, Uttar Pradesh, India), mixed and incorporated into the heat-polymerizing acrylic resin to match the skin color of the patient. The prosthesis was retrieved, trimmed, and polished. All sharp edges and projections were smoothened and the outer surface of the prosthesis was highly polished to prevent injury to the nasal mucosa and the growth of microorganisms. Care must be taken not to reduce the retentive extensions and the areas of the alar wing which prevent posterior displacement of the prosthesis. The acrylic resin extensions interfering with insertion and withdrawal of the stent were at the time of insertion [Figure 4].
|Figure 2: Master impression of the left nasal cavity. (Note the extranasal extension of the impression for recording of circumference of left nares|
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|Figure 3: (a) Two-piece master die. (b) Internal configuration of the left nasal cavity|
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|Figure 4: Finished, highly polished, heat-cured acrylic resin nasal septal stent|
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The stent was inserted into the nasal cavity and the patient was instructed to wear it continuously, removing it only for a short period of time for cleansing. The stent was extended 1 mm past the mucocutaneous junction of the external nares and beveled, which facilitated easy manipulation with better esthetic results and prevented posterior displacement and possible inhalation. Patient was instructed on how to insert and remove the stent. Proper orientation of the stent is highly emphasized during the insertion phase [Figure 5]. Removal of the stent can usually be achieved by digital pressure to the side of the nose. The patient was instructed on daily cleaning of the stent with mild soap and water. Patient was recalled on frequent appointments to eliminate pressure areas and adjustments and to ascertain proper tissue healing and patient comfort.
| Discussion|| |
Mechanical closure of the nasal septal defect by artificial means has proved to be a safer and more predictable approach than surgical treatment. Various techniques and materials like use of blotting paper and soft Silastic silicone button (Janeke's technique), use of cotton ball dipped in thimerosal and hand-carved medical grade Silastic silicone nasal button (Kern et al.), Sta-Seal paste for impression and Luxene plastic button (Dishoeck and Lashley), elasticon impression material and Silastic 382 elastomer nasal septal obturator (Gainsberg et al.), hollow reeds, rubber and metallic tubing, hollow plastics and even various packs are used for the surgical and post-surgical stenting and obturation of the nasal cavities. Constructing the nasal septal obturator from an accurate impression of the defect has proved to be the most logical approach in managing these defects.  Nasal septal obturators are constructed of either medical grade Silastic silicone rubber or heat-processed acrylic resin. Both materials are biocompatible; however, medical grade Silastic silicone rubber cannot be highly polished, and it is porous and friable which might lead to sorption of fluids, irritation of tissues from adhesion of mucus crust, and tearing of the material. In contrast, heat-processed acrylic resin can be highly polished, has lesser tendency for water sorption, and mucus crust seldom adheres to its highly polished surface. Meanwhile, this material has lack of flexibility, and thus cannot be used in small non-stretchable nostrils.  Intranasal stents are fabricated with heat-processed acrylic resin to restore nasal airways and to maintain patency of the passage, which were lost after reconstructive nasal surgery for deviated nasal septum. Large nasal defects cannot be closed by hard acrylic resin nasal septal obturators because of the problems in access and path of insertion. However, obturation can be achieved by fabrication of a nasal stent that engages one of the nasal cavities and medial wall of stent effectively separates two nasal cavities. These stents restore support for the nasal tissues and allow free passage of air through the nasal cavities. The alar portion of the prosthesis was tinted with skin-colored oil-based paints and margins were beveled from a cosmetic standpoint and established at 2 mm from mucocutaneous junction to create alar wing which prevents posterior displacement of the prosthesis during inhalation. The advantages of the stent are that technique is non-invasive, cost-effective, and easy to fabricate. Stent is tissue tolerant, esthetic to the patient, comfortable to use, maintains the patency and the contour of the nasal cavities, and effectively restores nasal septal perforation.
| Conclusion|| |
This article presents a simple method for the fabrication of heat-processed acrylic resin intranasal stent for the indirect obturation of large nasal septal defect created as a post-surgical complication for the correction of deviated nasal septum. The medial wall of the intranasal stent will allow for partition of the two nasal cavities and the patency of the stent will allow for comfortable breathing. Construction of conventional heat-processed nasal septal obturator is limited to small defects that occur in the anterior septum. The method yields an intranasal stent that fits accurately into place, allows comfortable nasal breathing, alleviates symptoms associated with nasal perforation, reduces nasal twang, and is retentive, esthetically acceptable and well tolerated by the patient.
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Mukesh Kumar Goyal
Department of Prosthodontics and Maxillofacial Prosthetics, Jan Nayak Ch. Devilal Dental College, Sirsa, Haryana
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]