Nostril or vestibular stenosis is a rare disease that causes nasal obstruction and can be classified as either congenital or acquired. Acquired nostril stenosis is mainly caused by trauma, infection, burns, and scarring from previous surgery [1]. The pathological feature of acquired stenosis is the proliferation of secondary fibrotic tissue after damage to the subcutaneous tissue beneath the vestibular skin, particularly a circumferential scar [2,3]. Pediatric patients can experience nostril stenosis as a result of iatrogenic causes, trauma, and very rarely birth-related trauma [4,5]. However, owing to the diverse causes and individual variations in structural or morphological features as well as the range and severity of disease, there is no established standard treatment [6].

Here, we present two pediatric cases of shallow post-traumatic nostril stenosis treated successfully by simple excision of the underlying redundant scar tissue, approximation of the skin and mucosal flap within the nasal tissue, and sharing of the surgical video.

Case 1

A 5-year-old boy visited the outpatient clinic with right nasal obstruction. The patient was admitted to the orthopedic department through the emergency room because of a fall from the 7th floor of a building 1 year and 9 months prior. Three months after the accident, the patient was evaluated by another otolaryngologist for epistaxis, and nostril stenosis was incidentally found. Nasal endoscopy revealed narrowing of the right nostril (internal diameter, approximately 3 mm) (Fig. 1A). Facial computed tomography (CT) performed at the time of the accident revealed no evidence of nasal bone or septal fractures (Fig. 2). The operation was performed as described below, and the vestibular scar was successfully epithelialized without recurrence or symptoms for up to 10 months postoperatively (Fig. 1B).

Figure 1. Endoscopic findings of case 1. (A) The preoperative assessment of the left nasal cavity reveals nostril stenosis with an internal diameter measuring 3 mm. (B) Postoperative right nasal cavity shows widened nasal orifice.

Figure 2. Facial computed tomography (CT) (non-enhanced) findings of case 1. (A) Axial, (B) and coronal. Preoperative CT shows no evidence of nasal bone or septal fracture.

Case 2

A 6-year-old boy visited the outpatient clinic with left nasal obstruction. The patient fell from the third floor into a garden and experienced facial trauma. The patient was admitted to the plastic surgery department of another hospital and paranasal CT revealed a left nasal bone fracture. In addition, fractures of the right medial and inferior walls of the orbit were observed (Fig. 3). The nasal bone fracture was reduced by a plastic surgeon; however, because there was no pediatric ophthalmologist, the patient was referred to our hospital, and the orbital walls were reduced. Seven months after the accident, the patient was referred for left nostril stenosis while planning a dacryocystorhinostomy as a second-stage operation. Nasal endoscopy showed narrowing of the left nostril (approximately 3 mm internal diameter) (Fig. 4A), which was repaired as described below, and the patient was followed up for more than 1 year without nasal obstruction (Fig. 4B). An exemption from review was obtained from the Institutional Review Board of Pusan National University Yangsan Hospital (05-2023-074).

Figure 3. Paranasal computed tomography (non-enhanced) findings of case 2. (A) Axial view shows nasal bone fracture (white filled arrow) on the left side. Blow out fracture of right side is shown in the (B) axial (white arrowheads), and (C) coronal view (white empty arrow).

Figure 4. Endoscopic findings of case 2. (A) The preoperative assessment of the left nasal cavity reveals nostril stenosis with an internal diameter measuring 3 mm. (B) Postoperative left nasal cavity shows widened nasal orifice.

After general anesthesia, incisions were made at the stenotic point near the transition between the nasal vestibule and nasal cavity in the superomedial (1 o’clock on the right side and 11 o’clock on the left side) and inferolateral (8 o’clock on the right side and 4 o’clock on the left side) directions. The superomedial incision was directed towards the upper nasal columella, whereas the inferolateral incision was directed towards the nasofacial groove [6]. The thickness of the vestibular stenosis was approximately 2–3 mm. The vestibular skin was retracted with Adson tooth forceps to determine the extent to which redundant skin and soft tissue around the incision area were removed with iris scissors. The nasal floor subcutaneous tissue in the inferolateral area was pulled in the inferomedial direction and fixed to the periosteum of the inferolateral pyriform aperture using a rapid vicryl 4-0 suture. The nasal floor mucosa was approximated using the inferolateral vestibular skin. The septal mucosa was advanced anteriorly to the lateral columellar skin and fixed using the same sutures. The nasal mucosa underneath the alar region was pulled to the superolateral position to cover the denuded area and was fixed to the superolateral vestibular skin using the same technique. Sufficient visibility inside the nasal cavity was achieved using this technique. To maintain the patency of the vestibule, silicone sheets were placed along the nasal valve area inside and over the alar skin and sutured together with a rapid vicryl 4-0 (Supplementary Video). The patient was discharged the following day. Cotton balls were packed on the affected side for three weeks until the silastic sheets were removed from the outpatient clinic.

Similar to that in adults, pediatric nostril stenosis is often accompanied by impaired nasal valve function, leading to symptoms such as nasal obstruction. Severe narrowing can result in an external nasal deformity. Particularly in children, nasal obstruction can lead to mouth breathing, which can cause an adenoid face–a characteristic facial change associated with chronic mouth breathing–or even contribute to sleep-related disorders. Although these changes continue into the adolescent and adult stages, surgeons might delay operative correction, as they are not used to handling pediatric nostril stenosis cases because of the rarity or worry of secondary changes after the operation.

Here, we share our experiences with pediatric cases of shallow (less than 5 mm) nostril stenosis after trauma without postoperative complications. Considering the early adaptation of children and favorable outcomes, there is no need to delay early surgical correction of pediatric nostril stenosis.

Nostril stenosis can occur even in the absence of facial fractures following trauma, as in case 1. There is a possibility of subsequent progression to nostril stenosis because of the subcutaneous injury underneath, even in the absence of bony injury. In the absence of facial bone fractures, a child who has fallen and experienced pressure injuries to the entire body is better treated by an otolaryngologist. The causes of nostril stenosis in case 2 were trauma itself or iatrogenic trauma during the nasal bone reduction procedure. Gentle use of instruments inside the nasal cavity is mandatory, especially in cases of pediatric nasal bone fracture, as there is a higher risk of synechia, which might later develop into shallow stenosis. In addition, it is crucial to closely monitor the progression of nostril stenosis in children who have undergone reduction of nasal bone fractures.

Thorough evaluation is necessary for the diagnosis of nostril stenosis in children, and preoperative CT can be useful for determining the stenotic area and thickness. The surgical technique used depends on the range and severity of the disease.

A surgical technique involving scar tissue excision followed by advancement of local flaps within the nasal cavity, which is a relatively simple technique, has been successfully adapted for pediatric cases. This technique can be used for shallow nostril stenosis, especially at the junction of the nasal vestibule and nasal cavity. This technique has been described in adult patients [6], and we adapted it for pediatric cases with successful outcomes. Timely surgical intervention, rather than waiting until adulthood, can lead to better outcomes and alleviate symptoms in pediatric patients.

If stenosis and distortion of the surrounding anatomical components are severe, combined Z-plasty, W-plasty, or transplantation of composite grafts can be used for surgery [7-9]. These procedures are challenging and require a high level of surgical expertise. As the extent and complexity of the surgical procedure increases, the success rate of surgery may decrease. Other studies suggested adjunctive therapies such as nasal stents or postoperative drug injections can potentially increase the success rate of the surgical procedures [2,10]. In shallow nostril stenosis, as in our cases, a 3-week application of silastic sheets was sufficient to maintain the nasal cavity orifice.

A relatively simple surgical technique, including excision of the underlying redundant scar tissue and approximation of the skin and mucosal flap within the nasal tissue, is believed to be useful in achieving correction and improvement of symptoms in shallow pediatric post-traumatic nostril stenosis in a timely manner.

Although rare, soft tissue damage and secondary scar tissue formation are possible in pediatric patients regardless of the presence or absence of facial fractures after falling trauma. If the anatomical structure is not complex and shallow in pediatric nostril stenosis, it is believed that symptom improvement can be achieved through surgical treatment, such as excision of the underlying redundant scar tissue and approximation of the skin and mucosal flap at an appropriate time.

Supplementary materials can be found via https://doi.org/10.25056/JCM.2023.7.2.94.

This work was supported by a 2023 research grant from Pusan National University Yangsan Hospital.

The authors have nothing to disclose.