Expect the unexpected.

Sir,

Internal defects of nose arise from congenital abnormalities, trauma or surgical intervention. The intranasal splint, stent or prosthetic devices have been developed to improve nasal form and function. These serve the purpose to support nasal alae to avoid collapse during respiration, expand the nasal vestibule against scar band, avoid synechia and maintain airway patency by supporting graft in reconstructive surgery. Impression for the fabrication of intranasal prosthesis is made using impression materials of varying viscosities. Making intranasal impression in infants is a critical procedure. The aspiration of the fragments of the impression material that inadvertently tear during the procedure may cause airway obstruction. I present an atypical case of a rare complication in an infant that arose due to tear and lodgment of the highly elastic rubber base impression material in the nose during the process of impression making for intranasal splint required for nasal burns.

A 21-day-old infant reported with a history of facial burns by steam 10 days back due to some negligence by parents, while use of the steamer for nasal blockage in infant. There was scalding of the skin of the upper lip and perialar area and contractures were present in the alae reducing the size of the nasal openings to a great extent [Figure 1]. Considering the condition of the patient the objective of the treatment was to preserve air flow through nares by preventing their occlusion and to prevent further facial disfigurement. Impression was made using rubber base impression material in low viscosity and an intranasal acrylic hollow splint was fabricated to keep the nasal openings distended and to minimize the contracture to assist the child in breathing.

Figure 1

Infant with burn injury to perialar area

After 8 months, patient reported with fractured intranasal splint. It was planned to fabricate a new splint to accommodate the growth. A complication of such nature was encountered during impression making that was unexpected during the use of the impression material of highly elastic nature. It was planned to make the impression using light body polyvinyl siloxane. As a precautionary measure, the external nares were blocked with gauge piece coated with local anesthetic jelly and tied to the thread, so that impression material does not get pushed in the posterior nares [Figure 2]. After nasal packing with gauge, light body polyvinyl siloxane was syringed into both nares. Material was added over the external surface to record external surface of the nose. After the impression material was set, the impression was carefully removed pulling the thread and impression out simultaneously.

Figure 2

Nasal cavities packed with gauge pack tied to thread

The impression was washed and inspected. It appeared that the impression was not retrieved in totality. Direct intranasal examination did not reveal any fragment of impression material in the nasal cavity. However, there was suspicion of lodgment of impression material deep inside the nasal cavity beyond direct vision. Patient did not show any signs of discomfort, breathing problem, nasal secretion or any other symptom.

Purely on the suspicion basis and to rule out any fragment lodged in the nasal cavity, the patient was immediately rushed to otorhinolaryngology department of the adjoining medical institute. Radiograph and CT scan was advised to confirm the presence or absence of fragment. The radiographs did not reveal any abnormality. However, CT scan suggested a radiopaque line (foreign body) deep inside the nose [Figure 3]. Patient had undergone general anesthesia for complete removal of the impression after a failed attempt of removing it in the outpatient clinic. The removal of impression material was planned with the help of pediatric endoscope with a diameter of 2.75 mm through anterior nares. During removal, the rubber base impression material came out in small fragments unlike the expected single large fragment of elastic material [Figure 4]. The recovery was uneventful. Later, intranasal splint was fabricated in a conventional manner and was retained with adhesive tapes and patency of airways was maintained.

Figure 3

CT scan image showing linear foreign body in the nose

Figure 4

Fragments of the impression material removed from the nose

Narrow cavities like ear canal and nasal cavity in infants are difficult to record and pose the risk of foreign body lodgment during impression making. Use of cotton or gauge plugs tied to string and otostop are crucial in preventing iatrogenic complication of aspiration or lodgment of impression material. The otological complications caused by hearing aid mold impression material in the middle ear cavity have been reported in the literature,[1234] but to the best of my knowledge, no case of impression material lodgment in the nasal cavity has been reported. Such complications might have happened, but are not evident in the literature may be due to underreporting. The zinc oxide eugenol impression material has remained asymptomatic for 20 years in the maxillary sinus.[5]

Every attempt should be directed to rule out presence of any foreign material inside the body cavities. When asymptomatic, no immediate intervention is required. However, acute phase demands immediate surgical debridement. Sneezing and positive-pressure technique have been the ancient methods for nasal foreign body removal in children.

Authors suggest that the impressions of nasal or oral cavities in infants should be made when the infant is fully awake and in a hospital setting to remain prepared to handle airway emergencies.