A Cure for Pains? A Novel Approach to Management of Proton-Associated Internal Nasal Stenosis (Pains)

Background: Acquired anterior nasal stenosis is a challenging problem. Stenosis as a result of direct trauma to the nasal valve region during nasal packing and instrumentation is well described in the literature. Indirect trauma, such as that occurring during thermal burns and radiotherapy treatment, is less well recognized but similarly difficult to correct.

Regardless of the etiology, surgical management is the mainstay of treatment. Repair can be difficult due to the tendency of the area to cicatrize and re-stenose. Several techniques have been proposed including excision and split skin grafting, CO2 laser resection with stenting, local flap rotation, Z-pasty techniques, and composite graft reconstruction. Balloon dilatation of congenital pyriform aperture stenosis has been described in the neonatal population but its utility in the setting of acquired anterior stenosis has never been reported.

Case Report: We describe the case of a 65-year-old female patient who developed complete anterior nasal stenosis following proton radiotherapy for treatment of a sinonasal undifferentiated carcinoma. She was treated with induction chemotherapy with cisplatin and etoposide and then following partial response was treated with concurrent cisplatin and proton radiation. She has been without evidence of disease for approximately two years but with anterior nasal stenosis related to treatment. She was interested in minimally invasive intervention to improve her nasal breathing. The patient underwent an endoscopic-assisted trans-nasal balloon dilatation using the Boston Scientific TM CRE endoscopic balloon dilation catheter, followed by silicone stenting of the region. The stenting was maintained for two weeks. The patient had complete resolution of obstructive symptoms without evidence of restenosis at last follow-up.

Conclusion: The balloon dilatation procedure offers a low-morbidity alternative to the management of acquired anterior nasal stenosis. It is of particular value in the irradiated patient, where poor tissue healing may be considered a relative contraindication to more involved reconstructive techniques.

Fig. 1 Preoperative photograph showing complete left-sided nasal stenosis.

Fig. 2 Intraoperative photograph showing the Boston Scientific CRE endoscopic balloon dilating the area of stenosis.

Fig. 3 Postoperative photograph showing a widely patent nasal passage.