Delivered by Ingenta to: UCL LIBRARY IP: 91.238.114.238 On: Fri, 10 Jun 2016 18:47:01 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm Z-Plasty Correction of Congenital Nasal Vestibular Stenosis CDR Kevin S. Kennedy, MC, USNR; Sherard A. Tatum, M.D.; and Michael J. Kelleher, M.D. A BSTRACf Stenosis of the nasal vestibule is a difficult problem to alleviate because surgical treatment of this area often results in cicatrix formation and restenosis. Surgery and otherforms of trauma are the most common cause of nasal vestibular stenosis. Posttraumatic vestibular stenosis involves primarily thefloor of the vestibule. An usual case of bilateral congenital vestibular stenosis involving primarily the soft tissues of the lateral aspects of the nasal vestibules is reported. The Z-plasty correction of this stenosis is outlined with pertinent photo- Rraphs and schematic drawings. S tenosis of the nasal vestibule is a frequent cause of nasal obstruction. Surgery and other forms of trauma are common causes of nasal vestibular stenosis. l Congenital nasal vestibular stenosis is an unusual form of the disorder but the symptomatology produced may equal that of its posttraumatic counterparts. 2 In dis- cussing nasal vestibular stenosis, it is important to differentiate this from nasal obstruction based on nasal valving problems. Although nasal vestibular stenosis and nasal valving problems may coexist, the discussion of nasal valve dysfunction will be left to previous The work reported herein was partly performed under the United States Navy Clinical Investigation Program, report number 89-08-I969-63. The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense. From the Departments of Otolaryngology-Head and Neck Surgery, Naval Hospital, Portsmouth, VA 23708; Eastern Virginia Medical School, Norfolk, VA; and the Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. American Journal of Rhinology reports 3 - 7 and the focus of this article will be on vestib- ular stenosis. REPORT OF A CASE A 24-year-old black man stated a lifelong history of bilateral nasal dyspnea that he reported had wors- ened gradually since he was approximately 14 years old and was now presenting problems, especially when completing his job-related physical fitness tests. There was no history of trauma or previous surgery. Anterior rhinoscopy revealed a vertical slitlike nar- rowing of the nasal vestibule, which was approximately 4mm wide bilaterally. This narrowing appeared to be from a soft-tissue band from superior to inferior at the level of the pyriform aperture bony framework (Figure 1).Palpation of this soft tissue indicated that it was soft and pliable and could be compressed laterally to the bony pyriform aperture, which was normal in its posi- tion and size. The turbinates were normal in their size, shape, and appearance, but the nasal septum showed a mild deviation to the right inferiorly and mildly prom- inent vomerine crests bilaterally. The rest of the physi- cal exam, as well as a CBC, PT, PTT, and urinalysis were normal. Release of the vestibular stenosis was accomplished by performing bilateral Z-plasties of the lateral vestib- ular soft tissues. Each Z-plasty was designed to excise the vertically oriented excess soft tissue as the central limb (Figure 2) and using 60· angles on the arms of the Z-plasty to maximize the release. This also attempted to produce a scar with a horizontal orientation (Figure 3) so that when contracture occurred it would not reproduce the original superior to inferior soft-tissue band. Septoplasty with a superiorly based swinging door technique removing an inferior strip of cartilage through a left hemitransfixion incision also was com- pleted. The vomerine crests were narrowed using a "V" 33