Abstract
Nasal stents are frequently used to maintain corrected nostril shape following primary cleft lip and nasal repair. Various stents have been described, but they are often cumbersome to generate, expensive, or difficult to retain. The author describes a rapid, effective, and inexpensive alternative to previously described commercially available or molded nasal stents whereby a nasal stent is fabricated from a pediatric nasal oxygen cannula. All patients in whom this stent has been used to date tolerated it well with no complication and with good maintenance of nostril shape at a minimum of 6 months follow-up.
Complete unilateral cleft lip and alveolus results in a nasal deformity characterized by a lower and lateralized alar base, attenuated and warped ala, foreshortened and oblique columella, and deviated septum and nasal tip. Most of this deformity can be corrected at the time of primary repair. Indeed, many surgeons view nasal reconstruction at the time of the primary lip repair as the standard of care for infants with complete unilateral cleft lip and palate (Salyer et al., 2003). The main goal when correcting the cleft nasal deformity is translocation of the alar cartilage with its attached vestibular lining into a normal position, which establishes the normal vault and shape of the cartilage. Unfortunately, there is invariably some postoperative relapse in the position of the alar cartilage, which is attributed to soft tissue memory or scarring (McComb, 1985).
Retaining the corrected shape of the nostril in the postoperative period using a nasal stent has been recommended by a number of authors (Nakajima et al., 1990; Yeow et al., 1999; Uhm et al., 2000; Yuzuriha et al., 2001). Various stent designs have been described. Previously reported approaches have included fashioning splints from a hollow nasopharyngeal airway tube (Egan and Kim, 2005), acrylic tubing (Loftus and Neale, 1996), methylmethacrylate (Casey and Schaaf, 1997), polyvinyl dental bite registration material (Gregory et al., 1999), and soft denture reliner (Bajaj et al., 2012). These approaches are limited by a cumbersome fabrication process or poor pliability of the stent material, which leads to pressure ulcers. Application of commercially available soft silicone rubber stents (Porex, Newnan, GA, and Koken Co, Ltd, Tokyo, Japan) is an attractive option but is limited by considerable expense (Nakajima et al., 1990; Yeow et al., 1999; Yuzuriha et al., 2001; Salyer, 2003). Expandable stents have also been tried (Ramstad and Bretteville, 1994; Wolfe et al., 2008); however, their applicability is limited in infants because of the need for close compliance on the patient's part.
The technique described in this report marries the benefits of the aforementioned stent techniques without significant drawbacks: it is easy to fabricate from ready-made materials in the operating suite; effective in maintaining the corrected nasal contour; pliable, thus decreasing the risk of pressure ulcers; inexpensive; and well tolerated by patients.
Methods
Patients underwent primary cleft lip and nasal repair between 2 and 3 months old age using the anatomic subunit approximation technique of Fisher (2005) without presurgical orthodontics or nasoalveolar molding. For primary nasal repair, a closure of the nasal floor was performed, and intranasal plication sutures were placed to recreate the relationship between the cephalad border of the lower lateral cartilage and caudal border of the upper lateral cartilage. Intranasal and extranasal subcutaneous dissection of the lower lateral alar complex was also undertaken with the subsequent placement of McComb suspension sutures.
At the completion of the cleft lip and nasal repair, the nasal prong segment was cut from a conventional disposable, latex free, clear pediatric/small adult nasal oxygen cannula (Salter Labs, Arvin, CA) and then cut coronally (Fig. 1). A small lip of material was left lateral to each prong to prevent recession of the fabricated stent into each naris. A thin layer of petrolatum-based ointment was then applied to the stent and nostril, and the stent was then secured in place with a 3-0 Prolene trans-septal suture (Johnson & Johnson Ltd, Somerville, NJ) (Fig. 2). The permanent lip sutures were removed 1 week later, and the nasal stent was kept in place. The nasal stent and trans-septal suture were removed in clinic 1 month after the lip repair.
Intraoperative fabrication of nasal stent. A: The nasal prongs are shown attached to the nasal oxygen cannula tubing. B: The nasal prong segment is cut free. C: The nasal prong segment is then cut coronally.
Placement of nasal stent. A: A permanent trans-septal suture is used to secure the stent at completion of the repair. B: Immediate appearance of the nasal stent after placement.
Results
Ten consecutive patients underwent nasal stenting using the described technique. All patients tolerated the stent well, and there was no evidence of nasal floor dehiscence, skin necrosis/ulceration, or dislodgement. In two cases, the patient's parents described transient obstruction of one or both of the nares due to crusting that was cleared with the use of a conventional pediatric nasal bulb suction. At a minimum of 6 months after repair, patients demonstrated minimal relapse of intraoperative alar rim correction (Fig. 3).
Representative case. A: Immediate preoperative appearance. B: Postoperative appearance immediately before nasal stent placement. C: Postoperative appearance 7 months after primary lip and nasal repair.
Discussion
Postoperative nasal stent use after primary cleft lip and nasal repair serves to maintain alar rim correction by preventing scar contracture. Although most studies suggest 4 to 6 months of continuous postoperative stent use, the author has found that 1 month of stenting is optimally tolerated while still allowing adequate scar deposition to maintain the corrected contour of the nostril. This has been borne out by the appearance of the nose at the time of the cleft palate repair at 9 to 12 months. In the author's experience, additional retention of the stent using adhesive tapes has provided diminishing returns and increased frustration for families.
The author's use of nasal oxygen cannula prongs to serve as a nasal stent stemmed from dissatisfaction with commercially available nasal stents, namely the Koken and Porex stents. These options are often difficult to size, particularly in white children undergoing lip and nasal repair at 2 months of age or earlier. In order to firmly seat these off-the-shelf stents intranasally, the author has found that the narrow bar of silicone bridging the two nares invariably places pressure on the columella, raising concerns over potential necrosis with long-term retention. The use of a pediatric/young adult nasal cannula to serve as a nasal stent avoids this, as the bridging segment between the two prongs is longer, placing far less pressure on the columella when inserted. In addition, the described nasal stent design is cost-effective. Based on North American pricing, the unit cost of a nasal oxygen cannula is roughly 1/30 that of current commercially available nasal stents; in an environment of health care cost containment, this benefit should not be overlooked. Furthermore, given that the nasal oxygen cannula is a ubiquitous item in operating suites, it is an attractive option for use as a nasal stent both at home and abroad on humanitarian surgical missions.
Conclusion
The author's technique of using nasal prongs from a disposable nasal oxygen cannula to fabricate a postoperative nasal stent after unilateral cleft lip and nasal repair is rapid, reliable, convenient, and inexpensive.
Objective
This article offers an alternative technique for generating a postoperative nasal stent for unilateral cleft lip and nasal repair.