INTRODUCTION
The nasal airway is supported by a rigid framework consisting of the bony and cartilaginous septum and paired nasal bones. The bony septum is composed of the vomer, perpendicular plate of the ethmoid, and maxillary crest. The lateral nasal walls feature paired turbinates – inferior, middle, and superior, occasionally supplemented by supreme turbinates – which contain both bony and soft-tissue components, potentially causing fixed or variable nasal obstruction. The internal nasal valve, formed by the nasal septum, upper lateral cartilage (ULC), and head of the inferior turbinate, is the narrowest part of the nasal passage. Normally, the angle between the nasal septum and ULC is 10°–15°; even slight decreases in this angle can lead to nasal blockage symptoms.[1,2]
Nasal obstruction is a common issue, often caused by inflammatory conditions such as allergic rhinitis and chronic rhino sinusitis, as well as structural alterations such as a deviated nasal septum (DNS).[3] This condition frequently presents in primary care and is a leading reason for ENT referrals.[4-6] Nasal obstruction disrupts airflow dynamics and sinus aeration, leading to sinusitis and modifications such as mucociliary dysfunction, lymphocytic penetration, and squamous metaplasia.[7,8] A deviated septum can cause pressure on surrounding structures, impairing drainage and ciliary function, and leading to secondary infections. Symptoms can be alleviated with medication, but surgery (septoplasty) may be necessary if medication is ineffective. For patients who prefer nonsurgical options or are not candidates for surgery, devices such as nasal stents can be used to widen the valve area and improve breathing.[9] These stents have been successfully used to treat nostril stenosis and maintain nasal airflow and have also been incorporated into molding plates to correct nasal cartilage deformities in infants with cleft lip and palate.[10]
There are several prefabricated nasal dilators are available but the problems with prefabricated nasal dilators are theiradaptability and support to endonasal tissue.
This article illustrates the fabrication of a customized nasal breather for DNS patients which consists of a replaceable nasopharyngeal tube that fits accurately between the septum and the lateral endonasal tissue and helps the patient to breathe passively, especially during the night without dislodging. When worn, this device expands the nasal valve by pressing the depressor septum at the joint.
CASE REPORT
A 39-year-old male patient reported to ENT surgeon with the chief complaints of difficulty in breathing and the patient was diagnosed with unilateral DNS condition which was clinically confirmed using a handheld ENT device called speculum [Figure 1]. The diagnosis was made by the ENT surgeon after clinical examination. Unilateral nasal obstruction was present with partial anosmia. On further examination, it was founded an over-dried nasal epithelia was reported with nasal crusts on lateral wall of nose. It was also noted that DNS spur was pressing lateral nasal wall give rise to pressure headache which was experienced by the patient. Sinusitis was also reported due to poor ventilation. Frequent epistaxis was also present. On the basis of above clinical conditions, it was confirmed that the respective case is of DNS. The patient was advised to go for surgical correction of the defect, i.e., septoplasty but the patient was reluctant to do surgery. Then, the patient was reported to the prosthodontic department for his routine dental checkup and while recording his case history, the patient revealed about his difficulty in breathing due to blocked nostril, especially during night due to compression of the unaffected side of the nostril when the patient is sleeping on one side. After a detailed discussion, it was decided to fabricate a nasal dilator with nasopharyngeal tube so that the patient can wear it in night which keeps the nostril dilated and nasopharyngeal tube helps the patient to breathe passively with the device.
Procedure
- The patient was made to sit in an upright position and the inner surfaces of both nostrils were gently coated with petroleum jelly. The left nostril was blocked with a gauze piece to prevent the flow of impression material into that nostril
- A nasopharyngeal airway tube [Figure 2] 4 mm in thickness (Medisafe International India Pvt. Ltd.) was inserted in the patient’s nostril within the patient’s tolerable limit. The tube is oriented inside the nostril in such a way that the pointed end of the bevel is kept toward the tissue and opening toward the septum. A lateral cephalogram was taken to check the extent of the tube, although cone-beam computed tomography will give better view of the tube inside the nostril. Then, the overall length of the tube is marked with an OHP marker
- A bobby pin was used as a stopper over the mark obtained by the lateral cephalogram and placed at the marking to prevent accidental insertion of the airway while making the impression. An addition silicone impression material (Express Putty and Light Body 3M ESPE US) material was taken and loaded around the tube and inserted on the affected side till the marking. Moreover, the same material is inserted on another side. The patient was instructed to breathe through the mouth during the impression-making procedure [Figure 3]
- After setting the impression material, the whole impression is removed along with the tube and rinsed it with running water and disinfected by immersing in 2% glutaraldehyde solution for 10 min and then rinsed under tap water[11] [Figure 4]
- The hollow portion of the tube was blocked out using putty impression material (Express Putty and Light Body 3M ESPE US), and the impression was directly flasked using three-pour techniques with Type II and III gypsum [Figure 5]
- After dewaxing, the heat-cure acrylic resin was mixed and packed into the mold and sufficient time was given for bench curing. A long curing cycle was employed to prevent the presence of any residual monomer
- After deflasking, the prosthesis was finished and polished, another nasopharyngeal tube of the same length and width was taken and replaced in the prosthesis with the same orientation and a plastic stopper [Figure 6] was placed to prevent the accidental insertion of the tube inside the nostril
- A hole on the nonaffected side was created; elastic was used on either side of the prosthesis which can be worn around the head to keep the prosthesis in place [Figures 7-9]
DISCUSSION
This prosthesis is a nasal dilator that consists of nasopharyngeal airway tube on one side. A nasopharyngeal airway tube is made up of a hollow plastic/soft rubber that can be used by a health-care provider for assisting oxygenation and providing ventilation in patients where there is difficulty to oxygenate or ventilate through bag-mask ventilation. Here, in this article, we have used the nasopharyngeal airway tube, which is made of soft and elastic medical plastics, with good biocompatibility, without skin damage and allergy.
The nasopharyngeal airway tube comes with different widths and lengths; the width of the airway was selected according to the severity of nasal septum deviation, availability of the space between the septum and lateral endonasal tissue, and patient’s tolerable limit.
This customized nasal dilator and breather helps the endonasal tissue to keep in place and dilated which helps in passive breathing, especially during the night even if the patient sleeps on the affected side, this device contains an elastic band that can be worn around the head which helps the device to keep in position without dislodging.
The nasal septal or dilator prosthesis is 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.[12]
On the other hand, the heat-processed acrylic resin can be highly polished, has a lesser tendency for water sorption, and the mucus crust seldom adheres to its highly polished surface.[12] These devices should not be thought of as curative for nasal obstruction but rather should be considered adjuncts to treatment.
In those adult patients with significant improvement in breathing with nasal dilators, but who cannot tolerate the devices, nasal surgery or septoplasty may be considered, therapeutic implications for patients who can tolerate and do receive benefits.
The advantages of this prosthesis are its cost-effective, nonirritating to the tissue, non-invasive, it is very easy to wear and process and the patient will easily adapted to this. Moreover, on the other hand, there are limitations of the prosthesis that includes this device cannot be used as permanent treatment of the condition, not indicated for long-term use as can cause some adverse affects such as nasal aphthous ulcers, proper hygiene has to be maintained, breathing tube is sterilizable but it has to be changed on repeated intervals (it can last upto 2 months) and not indicated in patients with nasal polyps.
Summary
This article presents a simple method for the fabrication of a heat-processed acrylic resin nasal dilator with a nasopharyngeal airway tube for a DNS patient, the patency of the nasal dilator will allow for comfortable breathing. The method yields an intranasal dilator and a nasopharyngeal airway that fits accurately into place, allows comfortable nasal breathing, eliminates symptoms associated with nasal obstruction, and is comfortable, retentive, and well-tolerated by the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Keywords:
Deviated nasal septum; nasal dilator; nasal dilator cum breather; night breather