1. Base of nose

Formed by the palatine process of the maxilla and the horizontal process of the palatine bone. Roof of the nose consists of from cartilage superior lateral And inferior, and the bones nasal bone, frontal bone laminate cribrosa, os etmoidale, And corpus os sphenoidale. The medial wall of the nasal cavity is the nasal septum. The nasal septum consists of on cartilage september Nasi, laminate perpendicular OS etmoidale, and the vomer bone. Meanwhile, in the apex of the nose, the nasal septum is completed by

skin, network subcutaneous, And cartilage alaris major. 2,3

2. Wall lateral

The lateral wall can be divided into three parts, namely anteriorly there is the frontal process of the maxillary bone, medially there is the ethmoid bone, maxillary bone and concha, and posteriorly there is the perpendicular plate of the palatal bone, and the medial pterygoid plate. The most important part of the lateral wall is the four conchae. The largest and lowest conchae is the inferior conchae, then the smaller conchae are the medial conchae, the inferior conchae, and the inferior conchae. superior And Which most small  is  concha  supremacy. Konka

supremacy usually will experiencing rudimentary. ¹⁵ Between the conchae and wall lateral nose there is cavity narrow Which named with

meatus. There are three meati, namely inferior, middle and superior meatus. ^2.3 The superior meatus or ethmoid fissure is a narrow gap between the septum and the lateral mass of the ethmoid bone above the middle concha. The sphenoethmoidal recess is located posterosuperior to the superior concha and in front of the sphenoid concha. The sphenoethmoidal recess is the opening of the sphenoid sinus . 2,3

The middle meatus is one of the gaps in which there are the openings of the maxillary sinus, frontal sinus and the anterior part of the ethmoid sinus. Behind the anterior part of the middle concha which is hanging, on its lateral wall there is a crescent-shaped gap called the infundibulum. Estuary or fissure shaped month sickle Which connecting the middle meatus with the infundibulum is called the hiatus semilunaris. The inferior and medial walls of the infundibulum form a drawer-like projection known as the uncinate process. The frontal sinus ostium, antrum maxilla, And cells ethmoid front culminate in infundibulum. Sine frontal And cells ethmoid front usually culminate in part front above, and the maxillary sinuses open posteriorly to the frontal sinus opening. 2,3

The front and upper part of the nasal cavity receives sensory innervation from the anterior ethmoidal nerve, which is a branch of the nasociliary nerve, which originates from the ophthalmic nerve (N.V1). The rest of the nasal cavity receives sensory innervation from the maxillary nerve via the sphenopalatine ganglion. The sphenopalatine ganglion, in addition to providing sensory innervation, also provides vasomotor or autonomic innervation to the nasal mucosa. This ganglion receives sensory fibers from the maxillary nerve (N.V2), parasympathetic fibers from the greater superficial petrosal nerve and sympathetic fibers from n.petrosus deep. Ganglion sphenopalatine located in behind And slightly above the posterior end of the middle concha. ^2,3,4

The olfactory nerve descends from the lamina cribrosa of the undersurface of the olfactory bulb and terminates on the olfactory receptor cells in the olfactory mucosa in the upper third of the nose. ^2,3,4

In children there are differences in size, shape and structure that support the cartilage and bone framework of the nose. The anatomy of the nasal framework of children has a more specific structure than in adults. The healing process of the septal cartilage is an important factor to consider in planning surgical procedures. Children's noses are smaller, shorter and have a larger nasolabial angle. Children also have a flatter tip and short columella. The nasal septum is the main structure that supports the nasal framework. ⁵

Nasal growth will continue after puberty, during adolescence the process will end at the age of 18-20 years in men and 16-18 years in women. There are two phases of nasal growth, in the first year of life where the endochondral ossification process occurs in the anterior part of the skull base and during puberty the nose grows faster than other periods in life. ⁵

Physiology Nose

Based on theory structural, theory evolutionary And theory functional, physiological functions of the nose and paranasal sinuses are: ^2,3,6

1. Function respiration : For arrange condition air ( water conditioning ), filter air, humidification And balancer in exchangepressure and local immunological mechanisms. Inspired air enters the nose towards the respiratory system through the anterior nares, then rises upwards to the level of the middle concha and then descends downwards towards the nasopharynx. The airflow in the nose is curved or arch. The inhaled air will be humidified by the mucous membrane. In summer, the air is almost saturated with water vapor so that there is little evaporation of inspired air by the mucous membrane, while in winter the opposite will occur. The temperature of the air passing through the nose is regulated so that it is around 37 degrees Celsius. This temperature regulating function is made possible by the large number of blood vessels under the epithelium and the presence of a wide surface area of the concha and septum. Dust particles, viruses, bacteria and fungi inhaled with the air will be filtered in the nose by hairs (vibrissae) in the nasal vestibule, cilia and mucous membranes.

2. Olfactory function: the true olfactory organ is located in the upper part of the nasal septum and the lateral walls of the nose on each side. The olfactory mucosa has receptor cells whose axons form the olfactory fila that lead to the olfactory center in the central nervous system. The cells sensory the catch sensation smell And depends on the air supply. If there is a blockage, the function of the olfactory organ is also greatly hampered which clinically usually also causes taste disorders.

3. Phonetic function: the shape and function of the nose form the characteristics of each person. The nose is included in the rigid components of the canal that forms voice And articulation. When nose clogged, Lots secretions and other disorders, the voice quality will change and the voice will become nasal.

4. Nasal reflex: the nasal mucosa is a reflex receptor related to the digestive, cardiovascular and respiratory tracts. Irritation of the nasal mucosa will cause a sneeze reflex and stop breathing. Certain odor stimuli will cause secretion of the salivary glands, stomach and pancreas.

5. Function static And Mechanic : For lighten up burden head and protection against trauma and heat protection.

Etiopathogenesis vestibular stenosis

Vestibular stenosis is a narrowing of the nasal cavity in the vestibule. Causes include congenital abnormalities, nasal trauma, infection and iatrogenic. Nasal bone deformity is recognized as the main cause of airway obstruction in newborns. Apert syndrome is often found with manifestations of bilateral nasal cavity narrowing with choanal atresia. Fraser syndrome is a rare autosomal recessive disorder, manifested by cryptophthalmos and nasal abnormalities in the form of a wide nose, anterior nares hypoplasia and choanal stenosis. In Binder syndrome, abnormalities are often found in the form of anterior nasal cavity hypoplasia, short columella, and half-moon shaped nostrils. This occurs as a result of failure of canalization of the epithelial plug between the lateral and medial nasal processes . ⁷

In addition to being caused by congenital abnormalities, vestibular stenosis is also often caused by nasal trauma. The incidence of nasal bone fractures worldwide ranks third after clavicle fractures and antebrachial fractures. Nasal bone fractures usually occur in bone trauma. face. Nasal bone fractures in children are an important type of fracture because nasal trauma during growth has a greater impact than nasal trauma experienced in adulthood. Pediatric patients often cannot remember incidents that occurred long ago, and may have caused anatomical changes that cause significant nasal obstruction. Inadequate diagnosis or inappropriate treatment of nasal bone fractures can trigger various complaints. good local on nose or oropharynx Which due to by changes in the physiological conditions of the airways. These complaints can include cosmetic problems, airway obstruction, sinusitis, and synechiae to cause stenosis vestibule. Specifically on children, fracture Nasal os can cause delays in growth and development of the face. ⁸

Trauma to the alanine or vestibular lining usually occurs due to complex wounds or lacerations. The caudal and lateral parts of the alanine are composed of network fibrofatty or fibromuscular Which very easy injury And contracture occurs. Direct trauma to the alanation such as root wounds and chemical wounds cause tissue damage and cause scar tissue contracture which causes the alanation to become flat. As a result of tissue damage and scar tissue contracture, the negative pressure that occurs during inspiration further causes the injured vestibule to become increasingly contracted. ⁸

Reason other the occurrence stenosis vestibule that is infection And inflammation including chicken pox, leprosy, syphilis, which in the healing process causes scar tissue, resulting in vestibular stenosis. ¹

Vestibular stenosis can also be caused by previous medical procedures. Some medical procedures that can cause vestibular stenosis include rhinoplasty and septoplasty, inferior concha conchotomy using cauterization, intranasal intubation, trauma during nasal examination, tampon insertion as a treatment for epistaxis, use of CPAP in neonates, and use of nasogastric tubes. ¹

Diagnosis

1. Anamnesis

The diagnosis of vestibular stenosis can be determined only by the patient's clinical picture. However, it is very important to know the patient's age, patient complaints such as nasal congestion and a history of trauma or previous nasal surgery. The most common symptom of vestibular stenosis is nasal congestion. Nasal congestion is said to be persistent and can occur unilaterally or bilaterally. Complaints of nasal congestion will worsen if the patient suffers from rhinitis so that the patient has to breathe through the mouth and can cause snoring symptoms. ¹⁰

1. Inspection physique

The purpose of physical examination in patients with vestibular stenosis is to establish a diagnosis and assessment for case management. External and internal inspection is performed to look for changes in shape, deviation or abnormal shape. In patients with vestibular stenosis caused by nasal trauma, bimanual palpation examination can be performed. inspection with bimanual palpation on nose can evaluated Is there crepitation, palpable nasal bone indentation and irregular bone ? ¹¹

Anterior rhinoscopy and endoscopic examinations are performed to determine the location and severity of stenosis. front must supported with lighting Which Enough And cooperative patient condition. Use of nasal speculum and headlamp will expand the field of view. Areas that may experience stenosis covering the base of the nose, roof, and lateral walls of the vestibule. In some cases, vestibular stenosis can be accompanied by damage to the nasal conchae. Furthermore, stenosis can spread to affect the entire cavity. Nasi. ¹¹

2. Inspection support

Supporting examinations can be used to determine the extent where the damage occurs, the location of the stenosis and also the complications that can arise due to vestibular stenosis. The recommended supporting examination is a CT Scan. CT-Scan can be used to confirm the diagnosis stenosis vestibule after done inspection clinical previously or if there is a suspicion of complications arising. ¹¹

Management vestibular stenosis

The goal of treating vestibular stenosis is to restore nasal airway patency and restore the shape of the nose. Although there are several actions taken to treat vestibular stenosis, treatment of this case can be difficult because it causes network scar and have number relapse Which high. ^13,14 Management of nasal vestibular stenosis is by surgery. There are several methods that can be done to repair nasal vestibular stenosis. These methods include removing scars and installing stents , using local flaps from the surrounding area, split and full thickness skin graft with installation stents , as well as graft composite Which can be taken from the earlobe. ³ The choice of surgical procedure depends on the location of the stenosis, the thickness of the obstructed tissue wall, the condition of the surrounding tissue, the degree of external deformity, and the condition of the alanation. ^5,6

Approach Which general that is excision cicatricial Which obstruct, replacing damaged tissue with new lining , and using stents post-operatively to prevent stenosis from returning. ¹¹ In this case, the stent functions to keep the vestibule always expanded. or as a support. Stents can also be used temporarily while waiting for surgery, especially in incomplete stenosis and congenital abnormalities. ³

Myocutaneous flap from the tissue around the nose, in addition to correcting stenosis vestibule, also For repair malposition alarm base. Technique This is sometimes combined with the use of composite grafts. ³

The most commonly used local flaps are Z plasty and W plasty. Z plasty was first reported by Horner in 1837, who moved the excess lateral skin transversely to lengthen the area along the scar line, thereby eliminating contracture. The Z plasty procedure has been widely used to correct nasal valve stenosis as well as correct cleft lip and nasal deformity. Z plasty can significantly reduce subjective nasal obstruction complaints experienced by patients and has minimal effect on the external appearance of the nose. ^3,6

Split and full thickness skin grafts are performed by transforming tissue from outside the nasal area to correct the narrowing after release. This technique requires an intranasal stent to support and facilitate healing and is usually removed after 3 weeks. Complications of using skin grafts are frequent contractures after the stent is removed and failure to correct the actual stenosis. ³

Graft composite can done with use graft from leaf ear. Hard cartilage is used for support so that stent no longer needed. Cartilage grafts are recommended to prevent re- stenosis, but cannot compensate for collapsed allanation. The disadvantage of this technique is that scars are left in the donor area. ^3,10

There is also literature discussing the use of Mitomycin C solution in post-operative wounds to prevent restenosis due to the emergence of fibrotic tissue. Mitomycin C is an antibiotic-antyneoplastic agent isolated from Streptomyces caespitosus . Works as an agent alkali with in a way selective hinder synthesis DNA And cross linking DNA. At high concentrations it can also suppress RNA and protein synthesis. Mitomycin C works by inhibiting fibroblast proliferation and collagen synthesis. ^2,5,11

Complications

The most common complication of nasal vestibular stenosis correction is failure to relieve the obstruction. This is usually caused by the surgical technique used not being adapted to the anatomical shape of the patient's nose. Thick columella and holes A very small nose can cause failure, resulting in synechiae and even restenosis if not assisted by the use of a stent. Other complications include epistaxis, infection, scarring, contracture and asymmetrical nose shape. The donor area also sometimes becomes a problem such as imperfect wound healing and the emergence of keloids. ¹⁷

REFERENCE

1. Arun Kumar JS, Santosh S, Anchan S. Iatrogenic stenosis of front nares : a case report. Journal of Clinical and Diagnostic Research. 2018;8:01-02.

2. Hilger PA. Nose: applied anatomy and physiology. In: Adam GL, Boies LR, Higler PA, editors. Textbook of ENT diseases. 6th edition. Jakarta: EGC; :173-89.

3. Soetjipto D, Mangunkusumo E, Wardani RS. Nasal obstruction. In: Soepardi EA, Iskandar N, Bashiruddin J, Restuti RD, editors. Textbook knowledge health ear, nose, throat, head And neck. Edition to- 7. Jakarta: FKUI; 2012:96- 100.

4. Barsova GK, Nikolovski N. Justification for rhinoseptoplasty in children- our 10 year overview. Macedonian Journal of Medical Sciences. 2018;080.

5. Gurkov R. Nose and paranasal sinuses. In: Nagel P, Gurkov R, editors. Fundamentals of otolaryngology. 2nd edition. Jakarta: EGC; 2012:33-58.

6. Abdollahifakhim S, Mousaviagdas M. Association of nasal nostril stenosis with bilateral choanal atresia : A case report. Iranian Journal of Otorhinolaryngology. 2019;26(1)

7. Chan J, Sam P. Diagnosis and management of nasal fractures. Operative Techniques in Otolaryngology. 2018; 19:263-66.

8. Bassam W, Bhargava D, Al-abri R. A novel v-silicone vestibular stent : preventing vestibular stenosis and preserving nasal valves. Omani Medical Journal. 2019;27:60-62.

9. Smith LP, Roy S. Treatment strategies for iatrogenic nasal vestibular stenosis in young children. International Journal of Pediatric Otorhinolaryngology. 2017;70:1369-73.

10. Yoon BW, Kim DW, Cho KS. Iatrogenic nasal vestibular stenosis after maxillofacial reconstructive surgery. Brazilian Journal of Otorhinolaryngology. 2018;84(1):126-130.

11. Dennis S, Shandilaya M, Nolst GJ. Open rhinoplasty in children. Facial Plastic Surgery. 2017;23(4):259-66.

12. Bozkurt M, Kapi E, Kuvat SV, Selcuk CT. Repair of nostril stenosis using a triple flap combination : Boomerang, nasolabial, and vestibular rotation flap.

    The Cleft Palate-Craniofacial Journal. 2016;49:753- 758.